International Journal of Laboratory Hematology

The Official journal of the International Society for Laboratory Hematology

ORIGINAL ARTICLE INTERNAT IONAL JOURNAL OF LABORATO RY HEMATO LOGY

Association of mean platelet volume and platelet count with the

development and prognosis of ischemic and hemorrhagic stroke
J. DU* ,† , Q. WANG*, B. HE † , P. LIU † , J.-Y. CHEN † , H. QUAN*, X. MA*

*Department of Neurology, The S U M M A RY

Nuclear Industry 416 Hospital,
Chengdu, Sichuan, China
†
Department of Health and
Social Behavior, West China
School of Public Health,
Sichuan University, Chengdu,
Sichuan, China
Correspondence:
Prof. Xiao Ma, Ph.D., Depart-
ment of Health and Social
Behavior, 17 South Renmin
Road, Section 3, West China
School of Public Health,
Sichuan University, Chengdu,
Sichuan 610041, China.
Tel.: +862885422114;
Fax: +862885501295;
E-mail: maxiao8293846@
163.com
doi:10.1111/ijlh.12474
Received 26 July 2015; accepted
for publication 31 December
2015
Keywords
Ischemic stroke, hemorrhagic
stroke, mean platelet volume,
platelet count, prognosis
Introduction: Mean platelet volume (MPV) and platelet (PLT) count
are the two major parameters that reflect the functions and activ-
ities of PLTs. The associations of MPV and PLT count with the
occurrence and prognosis of stroke have not been fully clarified.
This study aimed to investigate the association of MPV and PLT
count with the development and prognosis of first-ever ischemic
and hemorrhagic stroke in order to provide evidence for early diag-
nosis and treatment of both strokes.
Methods: This study included 281 first-ever ischemic stroke and 164
first-ever hemorrhagic stroke patients between 2010 and 2012. All
participants received routine blood tests within 2 h after admission
and were categorized into good or poor prognosis group based on
the Modified Rankin Scale (mRS) score. MPV and PLT counts were
transformed into categorical variables and their association with
the occurrence and prognosis of both strokes was evaluated by
multivariate logistic regression.
Results: The risk of ischemic and hemorrhagic stroke in MPV group
(>13 fL) was 22.17 and 5.21 times higher compared with normal
MPV group. The PLT count was positively correlated with the risk
of ischemic stroke, but negatively correlated with the risk of
hemorrhagic stroke. MPV and PLT count was not correlated with
the prognosis of either stroke.
Conclusions: Increased MPV is an independent risk factor for both
strokes. Elevated PLT count increases the risk for ischemic stroke,
but decreases the risk for hemorrhagic stroke. However, neither
MPV nor PLT count has significant association with the prognosis
of either stroke.

is crucial in the development of ischemic stroke due

INTRODUCTION
to its participation in thromboemboli that may initiate
As a major component of the blood-vascular axis the symptoms of stroke [1, 2]. Activated PLTs initiate
responsible for preventing hemorrhage, platelet (PLT) the formation of a hemostatic plug and provide a scaf-

© 2016 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2016, 38, 233–239 233
234 J. DU ET AL. | MPV AND PLT COUNT IN STROKE
fold for the activation of coagulation [3, 4]. Moreover,
PLT dysfunction has been found to be associated with
spontaneous intracerebral hemorrhage [5, 6]. The
importance of abnormal PLT for the onset of acute
cerebrovascular disorders has recently received
increasingly more attention [2, 7].
Mean platelet volume (MPV) and PLT count are
the two major parameters that reflect the functions
and activities of PLTs. MPV, which describes the mean
volume (size) of platelets, is an indicator that repre-
sents megakaryocytic hyperplasia and metabolism,
and platelet production in bone marrow, and indicates
the age of circulating platelets. MPV has been identi-
fied as an independent risk factor for cerebral infarc-
tion [8], and a higher MPV is detected in patients
with acute stroke, myocardial infarction, diabetes,
hypercholesterolemia as well as smokers compared
with normal subjects [8, 9]. PLT count is a parameter
reflecting the production and aging of platelets [10].
As two indicators that demonstrate platelet functions,
MPV and PLT count have been reported to play
important roles in the development and prognosis of
ischemic and hemorrhagic stroke [11, 12]. However,
the associations of MPV and PLT count with the
occurrence, severity and prognosis of stroke have not
been fully clarified.
In this case–control study, we evaluated the associ-
ation of MPV and PLT count with the development
and prognosis of first-ever ischemic and hemorrhagic
stroke to provide evidence for early diagnosis and
treatment of ischemic and hemorrhagic stroke, and to
improve their prognosis.
SUBJECTS AND METHODS
Study subjects
Patients with first-ever ischemic or hemorrhagic stroke
who were admitted to our hospital between October
2010 and January 2012 were enrolled in this study.
The average time elapsed from stroke onset to admis-
sion was 6 h. Subjects without any cardiovascular or
cerebrovascular diseases who were admitted to our
hospital during the same time period were selected as
controls. Any subject with pregnancy, infection, reac-
tive airway diseases, tumor, cerebral trauma, arteriove-
nous malformation or bleeding caused by other factors,
inflammation, hematologic disease, or undergoing
treatment with lipid-lowering drugs, angiotensin-con-
verting enzyme inhibitors or anticoagulant drugs was
excluded from the study. All participants signed the
informed consent, and the study was approved by the
ethical review committee of the hospital.
Collection of baseline characteristics, medical history,
and disease-related data
The demographic and clinical characteristics were col-
lected via a questionnaire, including the risk factors for
cardiovascular and cerebrovascular diseases, previous
disease history (hypertension, hyperlipemia, diabetes,
and heart disease), and therapy. The cause of ischemic
stroke was categorized based on the Trial of Org 10172
in Acute Stroke Treatment (TOAST) rating system [13].
The cerebral infarct size was measured at 3 days after
enrollment by computed tomography (CT) [14] or mag-
netic resonance imaging (MRI) scan [15]. Those with
the largest diameter of ≥3 cm were defined as large
infarcts, whereas those with the largest diameter of
<3 cm were considered as small infarcts. The intracere-
bral hemorrhage volume was determined using the for-
mula ABC/2 [16]. While a hemorrhage volume of
≥30 mL indicated a large hemorrhage, while a volume
of <30 mL was defined as a small hemorrhage. All mea-
surements were performed with a blind method.
Blood investigation
All subjects received routine blood testing within 2 h
after admission to the hospital. MPV and PLT count
were measured within 30 min after venipuncture with
a Sysmex XS-2000i autoanalyzer (Sysmex Corporation,
Kobe, Japan). The parameters were set according to
the index of adults in Sichuan province described in
National Guideline for Clinical Laboratory Procedures
(Third Edition) [17].
Treatment of stroke
The acute ischemic stroke patients without indications
for thrombolysis were given aspirin at 300 mg/d for
3 days, and 100 mg/d 3 days afterward. Those with
indications for thrombolytic therapy were given an
intravenous injection of recombinant tissue-type plas-
minogen activator (rTPA, 0.9 mg/kg) and long-term
aspirin therapy (100 mg/d) at 24 h after thrombolysis.
© 2016 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2016, 38, 233–239

The cardiogenic ischemic stroke patients with interna-
tional normalized ratio (INR) of 2–3 were given war-
farin, and those rejecting determination of INR were
given aspirin (100 mg/d). Mannitol or furosemidum
was given to lower the intracranial pressure. The hemor-
rhagic stroke patients with brainstem hemorrhage, cere-
bral hemorrhage of <30 mL, or cerebellar hemorrhage
of <10 mL were intravenously injected with citicoline
sodium (0.75 mg/d) for 10 days, and those with cerebral
hemorrhage of >30 mL, cerebellar hemorrhage of
>10 mL or subarachnoid hemorrhage underwent surgi-
cal therapy, mannitol or furosemidum treatment to
lower the intracranial pressure, and an intravenous
injection of citicoline sodium (0.75 mg/d), and vitamin
C (3 g/d) for 10 days. All patients with acute ischemic
stroke were intravenously administered with edaravone
at a daily dose of 60 mg 12 h apart for successive
10 days following admission. The patients with carotid
artery plaques and/or low-density lipoprotein choles-
terol (LDL-C) concentration of >3.12 mmol/L were
orally given rosuvastatin at a daily dose of 10 mg. Anti-
hypertensive agents and antidiabetic drugs were given
to lower blood pressure and blood glucose level.
Assessment of neurological impairment and clinical
outcomes
Neurological impairment at presentation was assessed
by the National Institutes of Health Stroke Scale
(NIHSS) [17], and the clinical outcomes were evalu-
ated with the Modified Rankin Scale (mRS) at 30 days
after treatment [18].
Statistical analysis
Categorical variables were expressed as frequency and
percentage, and analyzed by chi-square tests. Mea-
Table 1. Clinical characteristics of patients and control subjects
Control group
No. 200
Age (years) 65.76  12.95
Male, n (%) 112 (56)
Diabetes, n (%) 39 (19.5)
Hyperlipidemia, n (%) 52 (26)
Heart disease, n (%) 34 (17)
Hypertension, n (%) 91 (45.5)
© 2016 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2016, 38, 233–239
J. DU ET AL. | MPV AND PLT COUNT IN STROKE 235
surement data were presented as mean  standard
deviation (SD), and compared by t-tests. To evaluate
the associations of MPV and PLT count with the
development and clinical outcome of stroke, MPV and
PLT count were transformed into categorical variables
using the normal ranges of MPV (9.4–12.5 fL) and
PLT (100–300 9 109/L) as the cutoff value [17], and
then included in a multivariate logistic regression
model. All statistical analyses were performed using
SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). A P
value <0.05 was considered statistically significant.
R E S U LT S
General characteristics
Based on the selection criteria, a total of 445 cases
were selected for the study including 281 cases of first-
ever ischemic stroke and 164 cases of first-ever hemor-
rhagic stroke. The general information of study sub-
jects was summarized in Table 1. The mean age of the
controls was similar to that of ischemic and hemor-
rhagic stroke patients (both P values >0.05). A higher
incidence of diabetes, hyperlipemia, and heart disease
was observed in ischemic stroke patients compared
with the controls (P < 0.05), whereas the prevalence
of hypertension was significantly higher in hemor-
rhagic stroke patients (75.6%) than that (45.5%) in
the controls (v2 = 21.22, P < 0.001). Therefore, the
history of diabetes, hyperlipemia, and heart disease
was involved as confounding variables in the multi-
variate logistic regression model to evaluate the associ-
ation of MPV and PLT count with the development of
ischemic stroke, whereas history of hypertension was
used as a confounding variable in the regression analy-
sis to assess the association of MPV and PLT count with
the development of hemorrhagic stroke.
Ischemic group P Hemorrhagic group P
281 164
66.33  11.02 0.005 65.66  10.39 0.002
146 (52) 0.416 85 (51.8) 0.300
117 (41.6) 0.000 39 (23.8) 0.412
123 (43.8) 0.007 43 (26.2) 0.368
92 (32.7) 0.000 31 (18.9) 0.389
121 (43.1) 0.323 124 (75.6) 0.008
236 J. DU ET AL. | MPV AND PLT COUNT IN STROKE

Of the 281 patients with ischemic stroke, 200 cases
were classified according to the TOAST system,
including 82 cases (41%) caused by large-artery
atherosclerosis, 42 cases (21%) caused by small-vessel
occlusion, 44 cases (22%) caused by cardioembolism,
18 cases (9%) of other determined etiology, and 14
cases (7%) of undetermined etiology. Cerebral infarct
size was measured in 183 cases, including 114 cases
(62.3%) with small infarcts and 69 cases (37.7%)
with large infarcts. Among the 164 hemorrhagic
stroke patients, intracerebral hemorrhage volume was
determined in 57 cases, including 27 cases (47.4%)
with large hemorrhages and 30 cases (52.6%) with
small hemorrhages.
Association of MPV and PLT count with the development
of ischemic and hemorrhagic stroke
After the confounding factors were controlled, multi-
variate logistic regression analysis revealed a reduction
in the risk of ischemic (OR = 0.06; 95% CI, 0.02–
0.18) and hemorrhagic stroke (OR = 0.05; 95% CI,
0.01–0.2) in subjects with MPV of <9.4 fL than those
with normal range of MPV and an increase in the risk
of ischemic (OR = 22.17; 95% CI, 7.86–62.53) and
hemorrhagic stroke (OR = 5.21; 95% CI, 1.62–16.74)
in subjects with MPV of >12.5 fL as compared to those
with normal range of MPV. In addition, the rise of
PLT count was found to increase the risk of ischemic
stroke (OR = 4.49; 95% CI, 1.49–13.53; P = 0.008),
whereas the decrease of PLT count reduced the risk of
hemorrhagic stroke (OR = 1.97; 95% CI, 1.08–3.62;
P = 0.03) (Table 2).
Changes of MPV, PLT count, and NIHSS score in ischemic
and hemorrhagic stroke patients with good and poor
prognosis
The clinical outcomes were evaluated using the Modi-
fied Rankin Scale (mRS) at 30 days after treatment. Of
the 281 ischemic stroke patients, 66 had no mRS scores,
129 had good prognosis (<4), and 86 had poor prognosis
(≥4). Among the 164 patients with hemorrhagic stroke,
31 had no mRS scores, 78 had good prognosis (<4), and
55 had poor prognosis (≥4). There were no significant
differences in gender, previous history of diabetes,
hyperlipidemia, hypertension, and heart diseases, alco-
hol consumption, or smoking between the subjects with

Table 2. Association of MPV and PLT count with the risk of ischemic and hemorrhagic stroke detected by
multivariate logistic regression analysis

No. cases No. cases

No. detected detected in
cases in ischemic hemorrhagic
in stroke stroke
Parameter controls subjects OR (95% CI)† P value subjects OR (95% CI)‡ P value

MPV (fL) Normal 109 128 1.00 – 88 1.00 –

range
(9.4–12.5)
Reduction 57 40 0.06 (0.02–0.18) <0.001 40 0.05 (0.01–0.20) <0.001
(<9)
Elevation 34 113 22.17 (7.86–62.53) <0.001 36 5.21 (1.62–16.74) 0.006
(>13)
PLT Normal 137 190 1.00 – 90 1.00 –
(9109/L) range
(100–300)
Reduction 29 31 0.76 (0.43–1.36) 0.36 42 1.97 (1.08–3.62) 0.03
(<100)
Elevation 34 60 4.49 (1.49–13.53) 0.008 32 1.42 (0.29–6.96) 0.66
(>300)

MPV, mean platelet volume; PLT, platelet.

†The controlled variables involve history of hyperlipidemia, diabetes, and heart diseases.
‡The controlled variable is history of hypertension.

© 2016 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2016, 38, 233–239

poor and good prognoses (P > 0.05). MPV in the
ischemic stroke patients with poor prognosis was signifi-
cantly higher compared with those with good prognosis
(P < 0.01). However, no association was detected
between PLT count and the prognosis of ischemic stroke
(P = 0.051). In the hemorrhagic stroke patients, no cor-
relation was observed between MPV and PLT, and the
prognosis (P = 0.14 and 0.15, respectively). The
ischemic and hemorrhagic stroke patients with higher
pretreatment NIHSS scores were found to have a signifi-
cantly poorer prognosis (P < 0.001) (Table 3). There-
fore, NIHSS score, as a confounding variable, was
included in the multivariate logistic regression model to
assess the associations of MPV and PLT count with the
prognosis of ischemic and hemorrhagic stroke.
Association of MPV and PLT count with the prognosis of
ischemic and hemorrhagic stroke
After NIHSS score was controlled, no significant associa-
tion was detected between MPV and PLT count, and the
prognosis of ischemic and hemorrhagic stroke
(P > 0.05). No analyses were performed due to too few
cases with declined MPV or increased PLT count
(Table 4).
DISCUSSION
It has been known that platelets play an important
role in the pathophysiology of ischemic stroke by
developing intravascular thrombus after erosion or
rupture of atherosclerotic plaques [1], while thrombo-
cytopenia occurs concurrently with cerebral hemor-
rhage [19]. MPV and PLT count have been considered
an index of the functions of platelets. In this study,
281 patients with first-ever ischemic stroke and 164
patients with first-ever hemorrhagic stroke were ran-
Table 3. Comparison of MPV, PLT count, and NIHSS score in ischemic and hemorrhagic stroke patients with good
or poor prognoses
Ischemic stroke
Parameter Good prognosis Poor prognosis
MPV 13.05  1.10 13.87  1.27
PLT 174.89  75.49 151.13  64.83
NIHSS score 11.66  4.58 21.52  2.64
MPV, mean platelet volume; PLT, platelet; NIHSS, National Institutes of Health Stroke Scale.
© 2016 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2016, 38, 233–239
J. DU ET AL. | MPV AND PLT COUNT IN STROKE 237
domly chosen for the known risk factors and com-
pared with the control subjects with the same risk
factors but without any defined vascular diseases.
Our findings showed that a decline in MPV reduced
the risk of ischemic stroke (OR = 0.06), whereas an ele-
vated MPV increased the risk of ischemic stroke
(OR = 22.17). The elevation of MPV has been found to
significantly increase the risk of ischemic stroke [20].
As an important indicator that describes platelet func-
tion and activity, MPV is found to be positively associ-
ated with platelet reactivity. Large platelets, which
contain more high-density granules and have higher
activity, are much easier to form thrombi [21, 22]. The
size of platelets is determined during the production of
progenitor cells and does not change after being
released into the circulatory system. Therefore, the
hypercoagulable state caused by large platelets occurs
before the onset of ischemic stroke [1]. Therefore, it
seems plausible to infer that the elevation of MPV may
increase the risk of ischemic stroke.
To our knowledge, there are few reports evaluating
the role of MPV in hemorrhagic stroke. Currently, the
association of MPV alteration with hemorrhagic stroke
remains controversial. No clear association between
MPV and the risk of hemorrhagic stroke has been
detected in some studies [20, 23, 24]. Our findings
showed that the reduction of MPV may decrease the risk
of hemorrhagic stroke (OR = 0.05), whereas elevated
MPV may increase the risk of hemorrhagic stroke
(OR = 5.214). It has been shown that the patients with
reduced MPV have a higher likelihood of bleeding than
those with elevated MPV, suggesting that MPV may be
used to measure the tendency of bleeding, and serve as
a parameter for assessing early-stage recovery of the
hematopoietic function of bone marrow [25]. Neverthe-
less, it is possible that raised MPV is a response to bleed
in the hemorrhagic cohort. In addition, the measure-
Hemorrhagic stroke
t P Good prognosis Poor prognosis t P
4.32 <0.001 12.23  1.25 12.63  0.75 1.50 0.14
1.96 0.051 148.93  83.83 126.18  49.74 1.47 0.15
17.96 <0.001 12.48  5.07 20.41  3.62 7.16 <0.001
238 J. DU ET AL. | MPV AND PLT COUNT IN STROKE

Table 4. Association of MPV and PLT count with the prognosis in patients with ischemic and hemorrhagic stroke
assessed by multivariate logistic regression analysis

Ischemic stroke Hemorrhagic stroke

Good Poor OR Good Poor OR

Parameter prognosis prognosis (95% CI) P value prognosis prognosis (95% CI) P value

MPV (fL) Normal 64 49 1.00 – 39 21 1.00 –

range
(9.4–12.5)
Reduction 64 37 1.68 0.39 39 34 0.70 0.64
(<9) (0.51–5.54) (0.15–3.21)
Elevation 1 0 – – 0 0 – –
(>13)
PLT Normal 101 36 1.00 0.70 28 17 1.00 –
(9109/L) range
(100–300)
Reduction 26 48 1.41 47 38 1.03 0.97
(<100) (0.24–8.39) (0.28–3.81)
Elevation 2 2 – – 3 0 – –
(>300)

MPV, mean platelet volume; PLT, platelet.

ment of immature platelet fractions might provide addi-
tional value to this study. Further studies are needed to
investigate the role of MPV in hemorrhagic stroke and
the underlying mechanisms.
The present study demonstrated that a higher PLT
count increased the risk of ischemic stroke (OR = 4.49),
whereas lower PLT count reduced the risk of hemor-
rhagic stroke (OR = 1.97). Aberrant elevation of PLT is
found to promote thrombus formation, thereby
increasing the risk of ischemic stroke, while the aber-
rant PLT reduction causes the impairment of coagula-
tion function, thereby resulting in cerebral
hemorrhage. It has been shown that increased capillary
fragility and thrombocytopenia may occur concurrently
with cerebral hemorrhage despite that the exact mech-
anism of hemorrhage is unclarified [19].
The role of MPV and PLT count in the prognosis of
stroke has not been elucidated. Elevated MPV has been
shown to be associated with poor prognosis in patients
with acute ischemic stroke [2, 26], but other studies
identified no significant correlation between MPV and
the prognosis of stroke [27]. PLT count has been identi-
fied as a good predictor for hemorrhagic stroke-induced
death within 24 h of stroke onset, and significantly
reduced PLT count is detected in ischemic stroke
patients with poor prognosis or subjects who died of
ischemic stroke [28]. Our findings showed that MPV
was correlated with the prognosis in patients with
ischemic stroke, and those with elevated MPV had
poorer outcomes. In addition, there was a significant dif-
ference in the degree of pretreatment neurological defi-
cit between the patients with good and poor prognoses,
and more severe neurological deficit was observed in
patients with poor prognosis, as shown by greater pre-
treatment NIHSS score found in patients with poor prog-
nosis. A higher NIHSS score indicates a more severe
neurological deficit. It is therefore speculated that the
association between elevated MPV and prognosis in
patients with ischemic stroke may be affected by the
severity of pretreatment stroke. Our findings revealed
no significant associations of MPV and PLT count with
the prognosis of ischemic and hemorrhagic stroke, after
the variable pretreatment NIHSS score was controlled.
This study was primarily limited by its small sample
size of some subgroups (e.g., subjects with elevated
MPV or PLT count). A larger sample with more evenly
distributed subjects across subgroups would have bene-
fited our results. Furthermore, this study did not detect
the associations of MPV and PLT count with stroke
prognosis, which might be due to the limitation of sam-
ple size. Further large scale, multicenter studies are
required to assess the role of MPV and PLT count in the
prognosis of stroke. Patients without any cardiovascular
or cerebrovascular diseases who were admitted to our

© 2016 John Wiley & Sons Ltd, Int. Jnl. Lab. Hem. 2016, 38, 233–239
 J. DU ET AL. | MPV AND PLT COUNT IN STROKE 239

hospital during the same time period were selected as
controls. Another possible improvement to the study
could have been mentioning the details for the reasons
of their hospitalization and the treatment they received
before blood sample collection. In addition, MPV and
PLT counts were transformed into categorical variables
in this study. It could be useful to find out whether the
results are unchanged if continuous variables of MPV
and PLT count are used instead of categorical variables.
In summary, elevated MPV is an independent risk
factor of both ischemic and hemorrhagic stroke. Ele-
vated PLT count is a risk factor of ischemic stroke,
and reduced PLT count is a risk factor of hemorrhagic
stroke. Further studies are required to investigate the
associations of MPV and PLT count with the prognosis
of ischemic and hemorrhagic stroke.
CONFLICT OF INTERESTS
The authors declare no conflict of interests.
FUNDING
Scientific Research Projects funded by the Department
of Public Health of Sichuan Provine (Project No.
100182).

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