RISK FACTORS OF ISCHEMIC STROKE IN YOUNG ADULTS OF PAKISTAN

Main Article Content

Yasir Akbar Jamali
Jamshed Warsi
Zulfiqar Ali Laghari

Keywords

Ischemic Stroke, Cerebral infarction, Young adults, risk factors, Pakistan

Abstract

Background: Although most stroke patients are above the age of 65, 10% of stroke victims are estimated to be under the age of 45. There is evidence that young individuals are experiencing an increasing rate of ischemic stroke, while the reasons for this rise are unclear. Stroke in younger people calls for different research and treatment than in older people. Neurosonology aids in the diagnosis and post-interventional assessment of carotid artery disease in patients having carotid revascularization procedures.


Objective: This study aimed to study the incidence and risk factors of ischemic stroke in young adults.


Patients and Methods: We recruited patients with ischemic stroke older than 18 years and younger than 45 years admitted to medical wards I, II, and III, PUMHS Hospital, within the first week of the acute event.


Results: Analysis was done for 151 (72.2%) ischemic strokes out of 209 young stroke patients. The most common risk factors for ischemic stroke included hypertension in 75 (49.7%), followed by diabetes mellitus in 32 (21.2%). Cardiac disease, smoking, and previous stroke were found in 18 (11.9%), 14 (9.3%), and 21 (13.9%) patients, respectively. The mean GCS score of ischemic stroke patients was 10.6 ± 3.7. The mean GCS score indicated mild ischemic stroke.


Conclusion: The findings of this study showed that predominant risk factors for ischemic stroke among young people in the local area include hypertension, diabetes mellitus, cardiac disease, and smoking.

Abstract 227 | Pdf Downloads 106

References

[1] M. S. Ekker et al., “Epidemiology, aetiology, and management of ischaemic stroke in young adults,” Lancet Neurol., vol. 17, no. 9, pp. 790–801, 2018.
[2] V. L. Feigin, “Stroke epidemiology in the developing world,” The Lancet, vol. 365, no. 9478, pp. 2160–2161, 2005.
[3] A. Kulshreshtha, L. M. Anderson, A. Goyal, and N. L. Keenan, “Stroke in South Asia: a systematic review of epidemiologic literature from 1980 to 2010,” Neuroepidemiology, vol. 38, no. 3, pp. 123–129, 2012.
[4] United Nations Statistics Division. 2011 [cited 2012]., “Composition of macro geographical (continental) regions, geographical sub-regions, and selected economic and other groupings [database on the Internet]. Available from: http:// millenniumindicators.un.org/unsd/methods/m49/m49regin.htm.”.
[5] K. Anand, D. Chowdhury, K. B. Singh, C. S. Pandav, and S. K. Kapoor, “Estimation of mortality and morbidity due to strokes in India,” Neuroepidemiology, vol. 20, no. 3, pp. 208–211, 2001.
[6] M. Wasay et al., “Ischemic stroke in young Asian women: risk factors, subtypes and outcome,” Cerebrovasc. Dis., vol. 30, no. 4, pp. 418–422, 2010.
[7] S. Banerjee, R. Biram, J. Chataway, and D. Ames, “South Asian strokes: lessons from the St Mary’s stroke database,” QJM Int. J. Med., vol. 103, no. 1, pp. 17–21, 2010.
[8] R. De Silva et al., “Young strokes in Sri Lanka: an unsolved problem,” J. Stroke Cerebrovasc. Dis., vol. 18, no. 4, pp. 304–308, 2009.
[9] Y. Béjot, H. Bailly, J. Durier, and M. Giroud, “Epidemiology of stroke in Europe and trends for the 21st century,” Presse Médicale, vol. 45, no. 12, pp. e391–e398, 2016.
[10] R. Ji, L. H. Schwamm, M. A. Pervez, and A. B. Singhal, “Ischemic stroke and transient ischemic attack in young adults: risk factors, diagnostic yield, neuroimaging, and thrombolysis,” JAMA Neurol., vol. 70, no. 1, pp. 51–57, 2013.
[11] N. A. Syed et al., “Ischemic stroke subtypes in Pakistan: the Aga Khan University stroke data bank,” J. Pak. Med. Assoc., vol. 53, no. 12, p. 584, 2003.
[12] E. A. Vohra, W. U. Ahmed, and M. Ali, “Aetiology and prognostic factors of patients admitted for stroke.,” JPMA J. Pak. Med. Assoc., vol. 50, no. 7, pp. 234–236, 2000.
[13] K. Hussain, B. Nusheen, and S. Javed, “MORBIDITY PATTERN IN PATIENTS WITH ISCHEMIC STROKE AT A TERTIARY CARE HOSPITAL,” 2020.
[14] A. Ahmad, F. Usman, and A. Hassan, “Risk factors and pattern of stroke in Islamabad, Pakistan,” Rawal Med. J., vol. 34, no. 1, pp. 47–47, 1970.
[15] D. Smajlović, “Strokes in young adults: epidemiology and prevention,” Vasc. Health Risk Manag., pp. 157–164, 2015.
[16] B. W. Van Tassell, S. Toldo, E. Mezzaroma, and A. Abbate, “Targeting interleukin-1 in heart disease,” Circulation, vol. 128, no. 17, pp. 1910–1923, 2013.
[17] P. Chand, S. Ibrahim, M. Matloob Alam, F. Arain, and B. Khealani, “Acute childhood ischemic stroke: a Pakistani tertiary care hospital experience,” Pak. J. Neurol. Sci. PJNS, vol. 11, no. 1, pp. 3–6, 2016.
[18] M. Tibæk, C. Dehlendorff, H. S. Jørgensen, H. B. Forchhammer, S. P. Johnsen, and L. P. Kammersgaard, “Increasing incidence of hospitalization for stroke and transient ischemic attack in young adults: a registry-based study,” J. Am. Heart Assoc., vol. 5, no. 5, p. e003158, 2016.
[19] G. Mathew et al., “STROCSS 2021: strengthening the reporting of cohort, cross-sectional and case-control studies in surgery,” Int. J. Surg. Open, vol. 37, p. 100430, 2021.
[20] M. J. Lang, V. David, and J. Giese-Davis, “The age conundrum: a scoping review of younger age or adolescent and young adult as a risk factor for clinical distress, depression, or anxiety in cancer,” J. Adolesc. Young Adult Oncol., vol. 4, no. 4, pp. 157–173, 2015.
[21] L. Amaya Pascasio et al., “Stroke in Young Adults in Spain: Epidemiology and Risk Factors by Age,” J. Pers. Med., vol. 13, no. 5, p. 768, 2023.
[22] M. T. S. Larbi et al., “Ischemic and Non-ischemic Stroke in Young Adults–A Look at Risk Factors and Outcome in a Developing Country,” Cureus, vol. 13, no. 8, 2021.
[23] E. M. Hassan, A. M. Aboulfotooh, Y. G. Yahia, and R. N. Saleh, “Hospital Based Study in Assessment of Risk Factors of Stroke in Young Adults,” Egypt. J. Hosp. Med., vol. 90, no. 2, pp. 2467–2473, 2023.
[24] F. Li et al., “Ischemic stroke in young adults of Northern China: characteristics and risk factors for recurrence,” Eur. Neurol., vol. 77, no. 3–4, pp. 115–122, 2017.
[25] M. Lutski, I. Zucker, T. Shohat, and D. Tanne, “Characteristics and outcomes of young patients with first-ever ischemic stroke compared to older patients: the National Acute Stroke ISraeli Registry,” Front. Neurol., vol. 8, p. 421, 2017.
[26] F. Barinagarrementeria, T. Figueroa, J. Huebe, and C. Cantú, “Cerebral Infarction in PeopleUnder 40 YearsI: Etiologic Analysis of 300 Cases Prospectively Evaluated,” Cerebrovasc. Dis., vol. 6, no. 2, pp. 75–79, 1996.
[27] N. Yesilot Barlas et al., “Etiology of first-ever ischaemic stroke in European young adults: the 15 cities young stroke study,” Eur. J. Neurol., vol. 20, no. 11, pp. 1431–1439, 2013.
[28] H. N. El Tallawy et al., “Epidemiology and clinical presentation of stroke in Upper Egypt (desert area),” Neuropsychiatr. Dis. Treat., pp. 2177–2183, 2015.
[29] J.-J. Ge, Y.-Q. Xing, H.-X. Chen, L.-J. Wang, and L. Cui, “Analysis of young ischemic stroke patients in northeast China,” Ann. Transl. Med., vol. 8, no. 1, 2020.
[30] W. Xu, X. Zhang, H. Chen, Z. Zhao, and M. Zhu, “Prevalence and outcome of young stroke patients with middle cerebral artery stenosis,” BMC Neurol., vol. 21, no. 1, pp. 1–10, 2021.
[31] A. M. S. Sayedahmed and M. S. A. Alkhair, “Comparative study of risk factors in young adults and elderly stroke patients in Sudan,” Interdiscip. Neurosurg., vol. 23, p. 100955, 2021.
[32] P. Siriratnam et al., “Prevalence and risk factors of ischaemic stroke in the young: a regional Australian perspective,” Intern. Med. J., vol. 50, no. 6, pp. 698–704, 2020.
[33] J. M. Ramírez-Moreno et al., “Strength of association of classical vascular risk factors in young patients with ischaemic stroke: A case-control study,” Neurol. Engl. Ed., 2022.
[34] M. S. Ekker et al., “Risk Factors and Causes of Ischemic Stroke in 1322 Young Adults,” Stroke, vol. 54, no. 2, pp. 439–447, 2023.
[35] R. Renna et al., “Risk factor and etiology analysis of ischemic stroke in young adult patients,” J. Stroke Cerebrovasc. Dis., vol. 23, no. 3, pp. e221–e227, 2014.
[36] L. Ramirez et al., “Trends in acute ischemic stroke hospitalizations in the United States,” J. Am. Heart Assoc., vol. 5, no. 5, p. e003233, 2016.
[37] M. Tang et al., “Risk Factors of Ischemic Stroke in Young Adults: A Chinese Single-Center Study,” Front. Neurol., p. 715, 2022.
[38] P. Namaganda, J. Nakibuuka, M. Kaddumukasa, and E. Katabira, “Stroke in young adults, stroke types and risk factors: a case control study,” BMC Neurol., vol. 22, no. 1, p. 335, 2022.
[39] S. Nirhale, P. Dubey, S. Rohatgi, P. Rao, P. Naphade, and A. Gitay, “A study of clinical, aetiological and radiological profile of ischemic stroke in young adults at a tertiary care centre,” J. Popul. Ther. Clin. Pharmacol., vol. 30, no. 14, pp. 211–218, 2023.
[40] R. X. You, J. J. McNeil, H. M. O’Malley, S. M. Davis, A. G. Thrift, and G. A. Donnan, “Risk factors for stroke due to cerebral infarction in young adults,” Stroke, vol. 28, no. 10, pp. 1913–1918, 1997.
[41] A. Chatzikonstantinou, M. E. Wolf, and M. G. Hennerici, “Ischemic stroke in young adults: classification and risk factors,” J. Neurol., vol. 259, no. 4, pp. 653–659, 2012.
[42] T. Sharshar, C. Lamy, and J. L. Mas, “Incidence and causes of strokes associated with pregnancy and puerperium: a study in public hospitals of Ile de France,” Stroke, vol. 26, no. 6, pp. 930–936, 1995.
[43] J.-S. Jeng, S.-C. Tang, and P.-K. Yip, “Stroke in women of reproductive age: comparison between stroke related and unrelated to pregnancy,” J. Neurol. Sci., vol. 221, no. 1–2, pp. 25–29, 2004.
[44] A. H. James, C. D. Bushnell, M. G. Jamison, and E. R. Myers, “Incidence and risk factors for stroke in pregnancy and the puerperium,” Obstet. Gynecol., vol. 106, no. 3, pp. 509–516, 2005.
[45] M. P. Aguilera-Pena, A. F. Cardenas-Cruz, I. Baracaldo, E. Garcia-Cifuentes, M. I. Ocampo-Navia, and E. J. Coral, “Ischemic stroke in young adults in Bogota, Colombia: a cross-sectional study,” Neurol. Sci., vol. 42, pp. 639–645, 2021.
[46] X. Wu, Y. Zou, S. You, and Y. Zhang, “Distribution of risk factors of ischemic stroke in Chinese young adults and its correlation with prognosis,” BMC Neurol., vol. 22, no. 1, p. 26, 2022.
[47] H. Naess, H. I. Nyland, L. Thomassen, J. Aarseth, and K.-M. Myhr, “Etiology of and risk factors for cerebral infarction in young adults in western Norway: a population-based case-control study,” Eur. J. Neurol., vol. 11, no. 1, pp. 25–30, 2004.
[48] R. J. Adams et al., “Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: a scientific statement for healthcare professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association,” Circulation, vol. 108, no. 10, pp. 1278–1290, 2003.
[49] M. S. Dhamoon, R. R. Sciacca, T. Rundek, R. L. Sacco, and M. S. V. Elkind, “Recurrent stroke and cardiac risks after first ischemic stroke: the Northern Manhattan Study,” Neurology, vol. 66, no. 5, pp. 641–646, 2006.
[50] E. Touzé, O. Varenne, G. Chatellier, S. Peyrard, P. M. Rothwell, and J.-L. Mas, “Risk of myocardial infarction and vascular death after transient ischemic attack and ischemic stroke: a systematic review and meta-analysis,” Stroke, vol. 36, no. 12, pp. 2748–2755, 2005.
[51] C.-A. Cheng et al., “Pregnancy increases stroke risk up to 1 year postpartum and reduces long-term risk,” QJM Int. J. Med., vol. 110, no. 6, pp. 355–360, 2017.
[52] G. Too, “Postpartaler Schlaganfall: Oft fehlen die typischen Risikofaktoren,” stroke, vol. 131, pp. 70–78, 2018.
[53] T. R. van Veen, R. B. Panerai, S. Haeri, A. C. Griffioen, G. G. Zeeman, and M. A. Belfort, “Cerebral autoregulation in normal pregnancy and preeclampsia,” Obstet. Gynecol., vol. 122, no. 5, pp. 1064–1069, 2013.
[54] D. J. Lanska and R. J. Kryscio, “Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis,” Stroke, vol. 31, no. 6, pp. 1274–1282, 2000.
[55] A. G. Witlin, F. Mattar, and B. M. Sibai, “Postpartum stroke: a twenty-year experience,” Am. J. Obstet. Gynecol., vol. 183, no. 1, pp. 83–88, 2000.
[56] W. Cai et al., “Correlation analysis between post-stroke constipation and brain injury,” Nan Fang Yi Ke Da Xue Xue Bao, vol. 33, no. 1, pp. 117–120, 2013.
[57] S. T. Kim, H. Cloft, K. D. Flemming, D. F. Kallmes, G. Lanzino, and W. Brinjikji, “Increased prevalence of cerebrovascular disease in hospitalized patients with Ehlers–Danlos syndrome,” J. Stroke Cerebrovasc. Dis., vol. 26, no. 8, pp. 1678–1682, 2017.
[58] A. Aslam, U. Khan, F. Niazi, and I. Anwar, “Etiology and risk factors of stroke in young adults: A multicentric study,” Ann. Med. Surg., vol. 82, p. 104647, 2022.
[59] C.-Y. Chen et al., “Etiology and risk factors of intracranial hemorrhage and ischemic stroke in young adults,” J. Chin. Med. Assoc., vol. 84, no. 10, pp. 930–936, 2021.
[60] A. I. Qureshi et al., “Ischemic events associated with unruptured intracranial aneurysms: multicenter clinical study and review of the literature,” Neurosurgery, vol. 46, no. 2, p. 282, 2000.
[61] E. C. Raps et al., “The clinical spectrum of unruptured intracranial aneurysms,” Arch. Neurol., vol. 50, no. 3, pp. 265–268, 1993.
[62] D. O. Wiebers, J. P. Whisnant, T. M. Sundt, and W. M. O’Fallon, “The significance of unruptured intracranial saccular aneurysms,” J. Neurosurg., vol. 66, no. 1, pp. 23–29, 1987.
[63] W. DO, “International Study of Unruptured Intracranial Aneurysms Investigators: Unruptured intracranial aneurysms: Natural history, clinical outcome, and risks of surgical and endovascular treatment,” Lancet, vol. 362, pp. 103–110, 2003.
[64] M. Nagashima, M. Nemoto, H. Hadeishi, A. Suzuki, and N. Yasui, “Unruptured aneurysms associated with ischaemic cerebrovascular diseases. Surgical indication,” Acta Neurochir. (Wien), vol. 124, pp. 71–78, 1993.
[65] M. M. Przelomski, M. Fisher, R. I. Davidson, H. R. Jones, and E. M. Marcus, “Unruptured intracranial aneurysm and transient focal cerebral ischemia: a follow-up study.,” Neurology, vol. 36, no. 4, pp. 584–587, 1986.
[66] A. I. Qureshi et al., “Magnetic resonance angiography in patients with brain infarction,” J. Neuroimaging, vol. 8, no. 2, pp. 65–70, 1998.
[67] M.-G. Bousser and J. M. Ferro, “Cerebral venous thrombosis: an update,” Lancet Neurol., vol. 6, no. 2, pp. 162–170, 2007.
[68] J. M. Coutinho, “Cerebral venous thrombosis,” J. Thromb. Haemost., vol. 13, pp. S238–S244, 2015.
[69] P. Beighton, A. D. Paepe, B. Steinmann, P. Tsipouras, and R. J. Wenstrup, “Ehlers-Danlos syndromes: revised nosology, Villefranche, 1997,” Am. J. Med. Genet., vol. 77, no. 1, pp. 31–37, 1998.
[70] A. De Paepe and F. Malfait, “The Ehlers–Danlos syndrome, a disorder with many faces,” Clin. Genet., vol. 82, no. 1, pp. 1–11, 2012.
[71] S. T. Kim, W. Brinjikji, and D. F. Kallmes, “Prevalence of intracranial aneurysms in patients with connective tissue diseases: a retrospective study,” Am. J. Neuroradiol., vol. 37, no. 8, pp. 1422–1426, 2016.
[72] S. T. Kim, W. Brinjikji, G. Lanzino, and D. F. Kallmes, “Neurovascular manifestations of connective-tissue diseases: a review,” Interv. Neuroradiol., vol. 22, no. 6, pp. 624–637, 2016.
[73] J. M. Coutinho, J. J. Gerritsma, S. M. Zuurbier, and J. Stam, “Isolated cortical vein thrombosis: systematic review of case reports and case series,” Stroke, vol. 45, no. 6, pp. 1836–1838, 2014.
[74] J. M. Ferro, P. Canhão, M.-G. Bousser, J. Stam, and F. Barinagarrementeria, “Cerebral vein and dural sinus thrombosis in elderly patients,” Stroke, vol. 36, no. 9, pp. 1927–1932, 2005.
[75] D. Aulia, “Ischemic Stroke, Aortic Stenosis, Heart Failure with Complications Anemia and Hyponatremia,” Influ. Int. J. Sci. Rev., vol. 5, no. 1, pp. 265–279, 2023.
[76] J. Stam, “Thrombosis of the cerebral veins and sinuses,” N. Engl. J. Med., vol. 352, no. 17, pp. 1791–1798, 2005.
[77] J. M. Coutinho, S. M. Zuurbier, M. Aramideh, and J. Stam, “The incidence of cerebral venous thrombosis: a cross-sectional study,” Stroke, vol. 43, no. 12, pp. 3375–3377, 2012.
[78] S. Devasagayam, B. Wyatt, J. Leyden, and T. Kleinig, “Cerebral venous sinus thrombosis incidence is higher than previously thought: a retrospective population-based study,” Stroke, vol. 47, no. 9, pp. 2180–2182, 2016.
[79] M. Janghorbani, M. Zare, M. Saadatnia, S. A. Mousavi, M. Mojarrad, and E. Asgari, “Cerebral vein and dural sinus thrombosis in adults in Isfahan, Iran: frequency and seasonal variation,” Acta Neurol. Scand., vol. 117, no. 2, pp. 117–121, 2008.
[80] B. A. Khealani et al., “Cerebral venous thrombosis: a descriptive multicenter study of patients in Pakistan and Middle East,” Stroke, vol. 39, no. 10, pp. 2707–2711, 2008.
[81] Y. Sidhom et al., “Cerebral venous thrombosis: clinical features, risk factors, and long-term outcome in a Tunisian cohort,” J. Stroke Cerebrovasc. Dis., vol. 23, no. 6, pp. 1291–1295, 2014.
[82] L. Maali, S. Khan, F. Qeadan, M. Ismail, D. Ramaswamy, and V. S. Hedna, “Cerebral venous thrombosis: continental disparities,” Neurol. Sci., vol. 38, pp. 1963–1968, 2017.
[83] M. Capecchi, M. Abbattista, and I. Martinelli, “Cerebral venous sinus thrombosis,” J. Thromb. Haemost., vol. 16, no. 10, pp. 1918–1931, 2018.

Most read articles by the same author(s)