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Background and aims There seems to be a U-shaped relation between hemoglobin level and ischemic stroke severity. We aimed to explore possible causes of this relation.

Methods All patients with ischemic stroke between 2006 and 2016 admitted within 3 hours of onset were included. Hemoglobin and NIHSS score were obtained on admission. Modified Rankin Scale (mRS) score was obtained day 7. Locally weighted scatterplot smoothing (lowess smoother) curves displaying the frequencies of M1 occlusion and complications according hemoglobin level on admission and lowess smoother curves displaying mRS day 7 in patients with and without middle cerebral artery (M1) occlusion according to hemoglobin level on admission were obtained.

Results This study includes 905 ischemic stroke patients. Low hemoglobin was associated with pneumonia and urinary tract infection. Neurological worsening was not associated with hemoglobin level. Increasing mRS day 7 was strongly associated with increasing high hemoglobin in patients with M1 occlusion (correlation factor=.61, P=.02).

Conclusions Poor outcome in ischemic stroke patients with low hemoglobin is associated with complications during the hospital stay whereas poor outcome in ischemic stroke patients with increasing high hemoglobin levels is associated with occlusion of the middle cerebral artery.