Total Antioxidant Capacity Predicts Outcome in Acute Ischemic Stroke Subtypes in Egyptian Patients Nesma A.M. Ghonimi, MD,* Mohamed E. Mahdy, MD,* and Osama A. Abdel Salam, MD† Background: Oxidative stress after ischemic stroke contributes to neuronal cell injury. We tried to demonstrate an association between total antioxidant capacity (TAC) lev- els and outcomes after acute ischemic stroke (AIS). Methods: We enrolled 60 patients (36 females and 24 males) who were admitted to our hospital due to AIS, in addition to 30 age and sex-matched healthy controls. TAC levels were measured on day 1 of stroke onset, the relationships between TAC levels, stroke subtypes, and clinical out- comes based on the National Institutes of Health Stroke Scale and modified Rankin scale upon discharge were evaluated. Results: TAC levels were significantly lower in AIS patients than control (P < .001) being much lower in patients with large-vessel cerebral infarction than in those with small-vessel infarction. We investigated whether TAC concentrations reflected the severity and outcome of ischemic stroke and we found a significantly lower concentration of TAC in the poor outcome group than in the good outcome group (P < .001). Conclusions: Our findings suggested that the biochemical changes related to TAC and oxidative stress may be considered a marker of ischemic brain injury and clinical outcome of ischemic stroke. Key Words: TAC—acute ischemic stroke—stroke subtypes—clinical outcome © 2019 Elsevier Inc. All rights reserved. Introduction Acute ischemic stroke (AIS) is a common cause of per- manent disability in adults worldwide. Ischemia leads to increased production of free radicals and reactive oxygen species (ROS) in tissue and plasma through several mech- anisms. 1 In healthy individuals, antioxidant activity coun- terbalances free radical production, but in the case of ischemia, the balance between ROS and antioxidant activ- ity is shifted toward free radicals causing oxidative stress that potentially leads to cellular lipids, proteins, and DNA damage. 2 Oxidative stress is a pivotal event in the setting of AIS and may contribute to stroke outcome. 3,4 The antioxidant defense system has been studied in stroke patients with regard to enzymes, including superoxide dismutase and glutathione peroxidase 5,6 and nonenzymatic antioxidants such as ascorbic acid, a-tocopherol, carote- noids, and uric acid 7-9 ; however, total antioxidant capacity (TAC) measurement provides better indicator of antioxidant activity rather than individual antioxidants levels. 10 Circulating TAC in AIS patients and its relation to stroke subtypes and outcome has been scarcely studied, and the findings are conflicting. In some studies, circulating TAC levels in AIS patients were lower than in healthy control subjects, 9,7,11 while in another study no differences were found. 12 Finally, higher circulating TAC was reported by Lorente et al. 13 Only 1 study tried to find the relation between TAC and stroke subtypes. 14 Thus, the objective of this study was to determine whether there is an association between circulating TAC levels, stroke subtypes, and out- come in patients with AIS. Subjects and Methods Sixty patients with AIS were enrolled in this study in the Department of Neurology, Zagazig University Hospital, from November 2016 to June 2017. Diagnosis was based on clinical presentation, neurologic examination, and results of brain imaging either computed tomography (CT) or mag- netic resonance imaging (MRI) with diffusion-weighted imaging. Patients aged 18-80 years with acute From the *Department of Neurology, Faculty of Medicine, Zagazig University, Zagazig, Egypt; and †Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura, Egypt. Received January 8, 2019; accepted March 30, 2019. Financial Disclosure: The authors declare no financial or other con- flict of interests. Address correspondence to Nesma A.M. Ghonimi, Department of Neurology, Faculty of Medicine, Zagazig University, Zagazig, Egypt. E-mail: nesma_neuro@yahoo.com. 1052-3057/$ - see front matter © 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.03.053 Journal of Stroke and Cerebrovascular Diseases, Vol. 28, No. 7 (July), 2019: pp 1911À1917 1911