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ORIGINAL ARTICLE  
Year : 2011  |  Volume : 4  |  Issue : 1  |  Page : 25-28
A study on profile and risk factors of stroke in young adults (15-45 years) from coastal South India


Department of Community Medicine, Kasturba Medical College, Mangalore, Karnataka, India

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Date of Web Publication7-May-2011
 

   Abstract 

Background : Stroke among young adults (15-45 years) is an important problem worldwide. Most of the studies done in India are on ischemic stroke among young adults. There is paucity of information on all subtypes of strokes among young adults in India. So, this study was undertaken. Materials and Methods: This was a retrospective, record-based study. Cases of stroke identified from hospital records starting form January 1998 to June 2008 were considered for the study. There were 109 cases between 15 and 45 years, the information about which were recorded in a pre-tested semi-structured proforma. Analysis: The data were analyzed using SPSS version 12. Chi-square was used. " P" value of <0.05 was considered to be significant. Results: Ischemic stroke was the most common (56%), followed by hemorrhagic (22.9%) and embolic (22.1%). Age (>31 years), males, smoking, and hypertension were found to have significant association. Role of diabetes and homocysteine requires further investigation. The numbers were not adequate to test association with lipid profiles.

Keywords: Risk factors, stroke, young adults

How to cite this article:
Harsha Kumar H N, Kalra B, Goyal N, Jayaram S, Kumar S G. A study on profile and risk factors of stroke in young adults (15-45 years) from coastal South India. Ann Trop Med Public Health 2011;4:25-8

How to cite this URL:
Harsha Kumar H N, Kalra B, Goyal N, Jayaram S, Kumar S G. A study on profile and risk factors of stroke in young adults (15-45 years) from coastal South India. Ann Trop Med Public Health [serial online] 2011 [cited 2014 Sep 2];4:25-8. Available from: http://www.atmph.org/text.asp?2011/4/1/25/80517

   Introduction Top


Stroke is an important cause of disability among adults and one of the leading causes of death worldwide. [1] Younger individuals suffer form stroke among developing countries as compared to developed countries. [2] Data form India on stroke among the young are mostly limited to ischemic stroke. [3],[4],[5] There is paucity of information on stroke in young individuals, covering all types of stroke in India. [6] So, we conducted a study to determine the profile of stroke cases among young adults admitted in one of the tertiary referral centers of Karnataka state.


   Materials and Methods Top


This was a retrospective, record-based study of patients of stroke, in the age group of 15-45 years, admitted to two referral hospitals of Kasturba Medical College, Mangalore. The patients were identified form the medical records starting form January 1998 to June 2008. Consent was sought for accessing medical records. One hundred and nine patients fulfilled the World Health Organization (WHO) definition of stroke. [7] Stroke of all types were included (i.e., ischemic, hemorrhagic, embolic). Patients who presented with drop attacks and loss of consciousness due to other causes were excluded. The following information was noted in a semi-structured proforma: the socio-demographic patient characteristics (like age, sex, and occupation), presenting symptoms, risk factors present (like diabetes mellitus, hypertension, smoking, alcoholism, family history, cardiac disease, and dyslipidemias), investigations performed and outcome following stroke.

Definitions

Arterial hypertension: 1. Diagnosed by a physician or known case; 2. blood pressure of ≥140 mmHg systolic and or diastolic of ≥90 mmHg on two separate occasions [8] before or after admission to hospital; 3. already on treatment.

Diabetes mellitus: 1. Diagnosed by a physician or known case; 2. in whom fasting venous blood sugar is more than 126 mg/dl [9] during the acute phase of stroke (during first 7 days of stroke); 3. already on treatment.

Hypercholesterolemia

1. Diagnosed by a physician or a known case; 2. already on treatment; 3. total cholesterol of ≥240 mg/dl, or low density lipoprotein of ≥160 mg/dl. [10]

Hypertriglyceridemia

1. Diagnosed by a physician or a known case; 2. triglycerides of ≥150 mg/dl; 3. high density lipoprotein of ≤40 for women and ≤50 for women. [10]

Serum homocysteine

Levels above 9.9 μmol/l were considered to be abnormal.

Platelets

130,000-400,000/mm 3 was considered to be normal range.

Bleeding time

Simplate: <7 minutes, prothrombin time: 11-15 seconds, activated partial thromboplastin time (APTT): 25-35 seconds.

Smoking

1. Documented from the medical records; 2. more than 3 times a week for more than a year prior to stroke; 3. history elicited after the admission.

Alcoholism

1. Documented from the medical records; 2. more than 3 times a week for more than a year prior to stroke; 3. history elicited after the admission.

Cardiac disease

1. Diagnosed by a physician or a known case; 2. as documented from investigations.

Stroke subtype

Cardio-embolic: presence of potential cardiac sources of embolism as documented from ECHO cardiograph. Hemorrhagic stroke: as documented form the cranial computerized tomography (CT) scan. Ischemic stroke: supported by axial CT or digital subtraction angiography.

Outcome of stroke

The cases were categorized into the following classes based on Activities of Daily Living (ADL). Class 1: No significant disability or can independently perform the ADL; Class 2: slight disability or able to carry out ADL without assistance; Class 3: moderate disability or able to carry out ADL or walk with assistance; Class 4: severe disability or unable to carry out ADL or walk without assistance; Class 5: dead. [11]

Analysis

The data were fed into SPSS version 12 and analyzed. Chi-square test was used to know if differences observed were statistically significant. "P" value of <0.05 was considered to be significant.


   Results Top


Out of 109 cases of stroke, 61 (56%) were ischemic stroke, 25 (22.9%) were hemorrhagic stroke and 23 (21.1%) were embolic stroke. Depending on the subtype, the numbers who underwent various investigations along with the proportion of those with abnormal reports are given in [Table 1].
Table 1: Number of patients who were investigated and numbers with abnormal report


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Demographic characteristics

Overall, there is male preponderance (74 out of 109) in all subtypes of strokes. Stroke is more common (78 out of 109) among 31-45 year category as compared to <30 years. The occupational distribution did not show any pattern: students 3, unskilled 20, semiskilled 24, business 28 and professionals 34. Professionals included bank employees, managers and engineers in private companies.

Symptoms and disability

Cases of embolic stroke mostly presented with loss of power in the limbs. Mostly (12 cases), they woke up in the morning and noticed loss of power. Headache was more common among hemorrhagic stroke and it occurred in the evenings between 4 and 6 p.m. No pattern could be observed in the headache occurring among cases of ischemic stroke. Vomiting and seizures were more common among cases of hemorrhagic stroke than the rest.

The disabilities observed were monoplegia (right lower limb 2, left lower limb 1, right upper limb 4, left upper limb 2) and hemiplegia with upper motor neuron facial palsy (right 16, left 5).

Risk factors

There were 76 (69.7%) smokers, 53 (48.6%) alcoholics, 59 (54.1%) diabetics and 79 (72.5%) hypertensives. Family history of stroke was present in 42 (38.5%) patients. Using Body Mass Index (BMI ≥ 25) criteria, 53 (48.6%) were overweight out of which 20 (18.3%) were males. Abnormal platelets and coagulation parameters were found in four cases, all of which had hemorrhagic stroke. Elevated homocysteine was found in three cases, all of which had ischemic stroke. Single risk factor was present in 57 (52.2%) patients, two risk factors in 68 (62.4%) and three or more risk factors in 79 (72.5%) patients. Twelve cases did not have any known risk factor. Mortality was lower [8 (7.3%)] than disability [60 (55%)], and 41 (37.6%) cases had good outcome. The distribution of patient characteristics/risk factors according to stroke subtype is given in [Table 2].
Table 2: The distribution of patient characteristics/risk factors according to stroke subtype


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Investigation results

ECHO revealed the following abnormalities: hypertensive heart disease 28, rheumatic heart disease 14, cardiomayopathy 4 and aortic stenosis 3. Involvement of mitral valve (regurgitation 6, stenosis 5) was more common among the RHDs.

Cranial CT scan: Involvement of middle cerebral artery territory in 18 patients was the most common finding. Digital subtraction angiography revealed abnormality in 7 (stenosis 4, occlusion 3) cases.


   Discussion Top


There is one comparable study from India done on all subtypes of stroke in young adults, [1] which also found that ischemic stroke is the most common subtype followed by hemorrhagic and embolic. Overall, there is male preponderance of stroke. Studies done on ischemic stroke among 15-45 year olds form India also report male preponderance. [3],[4] Similar findings have been reported from Denmark in cases of thromboembolic stroke. [12] Higher proportion of males was found among cases of ischemic stroke in studies conducted outside India. [13],[14] The proportion of cases is more in 31-45 year age group and is similar to findings reported by Nayak et al. [3] No pattern could be observed among the occupations, though the proportions (56.8%) in sedentary (professional, business) occupation outnumbered the more physically active occupations (40.3%). No comparable findings were obtained from Indian studies.

Presenting symptoms similar to our study have been reported by Chopra and Prabhakar [15] and Nayak et al. [3] Though day time onset is reported to be more common, [3],[16],[17] we could not find such a difference. The proportion of non-ischemic strokes (44%) is slightly lesser than that of ischemic strokes (56%). Cases of ischemic stroke had day time onset (43 out of 61) and no pattern could be observed in non-ischemic stroke. This could have accounted for the differences.

Smoking, alcoholism and hypertension have been found to be significantly associated with ischemic stroke [3],[4],[18] and in all subtypes of strokes [6] from India, which is similar to our finding. Diabetes mellitus is reported to be risk factor for ischemic stroke form India [4] and Switzerland, [18] which was not found in our study. Diabetes was not found to be a risk factor for ischemic stroke in Sweden [19] and Taiwan. [20] Lipska et al.[4] have reported that diabetes is not a risk factor for stroke when compared with hospital-based controls. Apart from the differences in patient profile (all subtypes, i.e., our study vs. ischemic), there does not seem to be consistent association between diabetes and stroke in studies conducted in various countries. Hypercholesterolemia and hypertriglyceridemia are known to be associated with stroke in young adults. [18],[20] Lipska et al.[4] did not find such an association in South Indian patients. The proportion of patients who did not have abnormal lipid profile was so low in this study that we could not undertake meaningful analysis. Role of elevated homocysteine levels requires further investigation in the Indian setting, though its association was reported from USA. [21] Majority of the investigated cases had normal platelets and coagulation parameters, indicating that it is not an important cause of stroke in young adults. Majority of the cases had good outcome and low mortality which is comparable with other Indian studies. [3],[15]

There are some limitations of our study. Apart from inadequate numbers (in spite of including 10 year records), not all the patients underwent all the investigations, thereby making analysis and interpretations difficult. Being a tertiary care center, the referred patients' profile may not be representative, creating a bias. Because of paucity of information, this study does give an idea of sample size required to undertake more detailed studies with bigger sample sizes to explore associations and risk factors.

 
   References Top

1.Bonita R, Mendis S, Truelsen T, Bogousslavsky J, Toole J, Yatsu F. The Global Stroke Initiative. Lancet Neurol 2004;3:391-3.  Back to cited text no. 1
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2.Truelsen T, Bonita R, Jamrozik K. Surveillance of stroke: A global perspective. Int J Epidemiol 2001;30:11-6.   Back to cited text no. 2
    
3.Nayak SD, Nair M, Radhakrishnan K, Sarma PS. Ischemic stroke in the young adult: Clinical features, risk factors and outcome. Natl Med J India 1997;10:107-12.  Back to cited text no. 3
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4.Lipska K, Sylaja PN, Sarma PS, Thankappan KR, Kutty VR, Vasan RS, et al. Risk factors for acute ischaemic stroke in young adults in South India. J Neurol Neurosurg Psychiatry 2007;78:959-63.  Back to cited text no. 4
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5.Srinivasan K. Ischemic cerebrovascular disease in the young: Two common causes in India. Stroke 1984;15:733-5.  Back to cited text no. 5
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6.Mehindiratta MM, Agarwal P, Sen K, Sharma B. Stroke in young adults: A study from a university hospital in north India. Med Sci Monit 2004;10:535-41.  Back to cited text no. 6
    
7.Hatano S. Experience form a mulit centre stroke register: A preliminary report. Bull WHO 1976;54:541-3.  Back to cited text no. 7
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8.Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003;289:2560-72.  Back to cited text no. 8
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9.American Diabetes Association. All about Diabetes. Available at: http://www.diabetes.org/about-diabetes.jsp. [Accessed on 2008 January 4].  Back to cited text no. 9
    
10.Executive summary of The Third Report of National Cholesterol Education Program (NCEP) Expert panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adults Treatment Panel III). JAMA 2001;285:2486-97.  Back to cited text no. 10
    
11.Department of Health and Ageing, Government of Australia. Available at: http://www.health.gov.au/internet/main/publishing.nsf/content/ [Accessed 2008 January 4].  Back to cited text no. 11
    
12.Lidegard O, Soe M, Andersen NM. Cerebral thromboembolism among young women and men from Denmark 1977 - 1982. Stroke 1986;17:670-5.  Back to cited text no. 12
    
13.Lisovoski F, Rousseaux P. Cerebral infarction in young people: A study of 148 patients with cerebral angiography. J Neurol Neurosurg Psychiatry 1991;54:576-7.   Back to cited text no. 13
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14.Bogousslavsky J, Regli F. Iscemic stroke in adults younger than 30 years of age: Cause and prognosis. Arch Neurol 1987;44:479-82.  Back to cited text no. 14
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15.Chopra JS, Prabhakar S. clinical features and risk factors in stroke in young. Acta Neurol Scand 1979;60:289-300.  Back to cited text no. 15
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16.Wroe SJ, Sandercock P, Bamford J, Dennis M, Slattery J, Warlow C. Diurnal variation in incidence of stroke: Oxfordshire community stroke project. BMJ 1992;304:155-7.  Back to cited text no. 16
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17.Kelly-Hayes M, Wolf PA, Kase CS, Brand FN, McGuirk JM, D′Agostino RB. Temporal patterns of stroke onset: The Framingham study. Stroke 1995;26:1343-7.  Back to cited text no. 17
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18.Arnold M, Halpern M, Meier N, Fischer U, Haefeli T, Kappeler L, et al. Age dependent differences in demographics, risk factors, co-morbidity, etiology, management and clinical outcome of acute ischeamic stroke. J Neurol 2008;255:1503-7.  Back to cited text no. 18
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19.Kristensen B, Malm J, Carlberg B, Stegmayr B, Backman C, Fagerlund M, et al. Epidemiology and Etiology of Ischemic Stroke in Young Adults Aged 18 to 44 Years in Northern Sweden. Stroke 1997;28:1702-9.  Back to cited text no. 19
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20.Lee TH, Hsu WC, Chen CJ, Chen ST. Etiologic Study of Young Ischemic Stroke in Taiwan. Stroke 2002;33:1950-5.  Back to cited text no. 20
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21.Kittner SJ, Giles WH, Macko RF, Hebel JR, Wozniak MA, Wityk RJ, et al. Homocyst(e)ine and Risk of Cerebral Infarction in a Biracial Population. Stroke 1999;30:1554-60.  Back to cited text no. 21
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Correspondence Address:
H N Harsha Kumar
Department of Community Medicine, Kasturba Medical College, Near Hampanakatta, Mangalore 575001, Karnataka
India
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DOI: 10.4103/1755-6783.80517

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