European Journal of Cardiovascular Medicine

Cerebrovascular accident (CVA) or stroke is a widespread medical condition that affects one out of every four individuals during their lifetime. It is the second most common cause of death and the third most common cause of disability in adults worldwide. [1] CVA is an acute focal injury of the central nervous system (CNS) caused by a vascular problem, which leads to a neurological deficit. [2] Globally, there are around 9.6 million cases of ischemic stroke and 4.1 million cases of hemorrhagic stroke, which includes intracerebral and subarachnoid hemorrhage, every year. The incidence of strokes is expected to rise with an aging population, making the absolute incidence rate higher. [3]

Ischemic strokes are the most common type of stroke, which occur due to reduced blood flow to the brain, usually caused by a blockage in an artery. However, there is a less common type of ischemic stroke called venous infarction that occurs when a cerebral vein or venous sinus gets blocked. On the other hand, hemorrhagic strokes occur when a cerebral artery ruptures, causing bleeding in the brain. [2] A transient ischemic attack refers to a temporary bout of neurological malfunction that arises due to focal brain, spinal cord, or retinal ischemia but without an acute infarction. [4]

High blood pressure is the most potent risk factor for stroke, but there are other risks, such as smoking, diabetes, hyperlipidemia, physical inactivity, and atrial fibrillation. [5] Interventions are required to alter lifestyle and the environment, as well as individual treatment to address these risks. [6]

The clinical presentation and outcomes of CVAs may be influenced by the distribution of risk factors, which can vary depending on the geographic location and cultural background of the population. Our research aimed to examine the patient characteristics, radiological findings, risk factors, causes, and prognosis of individuals who experienced CVA in and around the region of Ahmedabad in Gujarat state of India.

Study design and sampling:

This cross-sectional study conducted at Smt. Shardaben General Hospital, Ahmedabad, Gujarat, received ethical clearance from the Institutional Review Board (NHLIRB/2023/August/17/No.6). Employing a prospective observational design, data will be collected over a twelve-month period, spanning from August 2023 to July 2024. All patients aged 18 years and above, hospitalized with signs and symptoms suggestive of a new-onset stroke, and whose diagnosis is subsequently confirmed through radiological studies (CT or MRI brain), will be eligible for inclusion. Informed consent will be obtained from all participants or their legally authorized representatives.

Data collection:

Predefined proforma was used to collect data of each individual participant. A thorough medical history was obtained to determine when the symptoms first appeared, how long they have persisted, and any changes that have occurred over time. Additionally, past medical history and family history were reviewed, with a particular focus on stroke risk factors such as hypertension, diabetes mellitus, and ischemic heart disease. All patients underwent a clinical assessment, including general physical and systemic examination, emphasizing the CNS examination. NIHSS score was estimated to assess the severity of stroke symptoms. The observations made by a skilled radiologist regarding CT/MRI brain results were documented.

Data entry and analysis

The data collected was recorded in an MS Excel data collection sheet format. Continuous variables were presented as mean ± SD or median (IQR) for non-normally distributed data. Categorical variables were expressed as frequencies and percentages with a 95% Confidence interval. Statistical testing was conducted with the Statistical Package for the Social Sciences software (SPSS trial version). Student t-tests and Chi-Squared tests were used to compare the continuous and categorical data, respectively. A two-sided P value of <0.05 was considered statistically significant.

In our study, we recruited 100 patients with CVA that fulfilled the inclusion and exclusion criteria. Out of 100 patients, 57 were male and 43 were female. The mean age of the study population was 62.1 (+ 13.88) years.

Among the study participants, 91 were diagnosed with an ischemic stroke and 9 were diagnosed with hemorrhagic stroke, of which all had an intra-cerebral hemorrhage.

Table 1: Association between factors and types of CVA

                   Weakness of limbs was the most common symptom, present in 92% patients and was significantly more prevalent in patients with hemorrhagic stroke compared to those with ischemic stroke. Similarly, change or loss of consciousness and speech, and headache were also significantly associated with hemorrhagic stroke (p<0.05).

Table 2: Clinical features of CVA in the study population.

Table 3: Heart rate and blood pressure of the study population

Table 3 represents that among the study population, 16 patients had bradycardia on admission. Out of 9 patients with hemorrhagic stroke, 4 had bradycardia, whereas as among the 91 patients with ischemic stroke, 12 had bradycardia, and this difference was statistically significant (p<0.05). Similarly, patients with hemorrhagic stroke had significantly higher blood pressure compared to those with ischemic stroke.

Table 4: Glasgow Coma Scale at admission in the study population

Table 4 illustrate that 13 patients had a GCS of less than 9, of which 4(44.4%) had hemorrhagic and 9 (9.9%) had ischemic; 13 patients had a GCS of 9-12, of which 3(33.3%) had hemorrhagic and 10(11.05%) had ischemic; and 74 patients had a GCS 12-15, of which 2(22.2%) had hemorrhagic and 72(79.1%) had ischemic. GCS was significantly lower in patients with hemorrhagic stroke than in those with ischemic stroke (p<0.05).

Table 5: NIHSS score in study population

Table 5 represents that no of mild strokes (NIHSS<5) among the study’s patients. 42 patients (NIHSS 5-15) had a moderate stroke, of which 2 had hemorrhagic stroke and 40 had ischemic stroke;32 ischemic patients (NIHSS>20) had a severe stroke, of which 7 had hemorrhagic stroke and 19 had ischemic stroke. Those with hemorrhagic cva were more likely to experience a major stroke.

Table 6: Risk factors for CVA in study population.

Table 6 represents in our study we found that the most common comorbidity observed was hypertension in 51 patients. Out of 9 patients with hemorrhagic CVA, 8 were hypertensive, whereas 43 out of 91 patients with ischemic stroke were hypertensive.

Table 7: Outcomes of CVA in study population according to modified Rankin score for neurological disability.

Outcome analysis

The outcome of patients was analysed using the modified Rankin scale (mRS) for neurological disability. The mRS scale data reveals a distribution across five categories. The most frequent mRS score is 4, which accounts for 36% of the observations (36 individuals). This is followed by mRS score 3, with 29% (29 individuals), and mRS score 5, with 26% (26

individuals). Less common are mRS scores 2 and 6, representing 4% (4 individuals) and 5(5 individuals) of the data, respectively. This distribution indicates that the majority of individuals fall within the moderate to severe range of the mRS scale, with fewer individuals in the lower and highest categories.

Over the past two decades, India has experienced significant changes in its population, economy, and disease patterns. [7] In 2020, the global incidence of stroke was 11.71 million people, and of all strokes, ischemic stroke was approximately 65% of all cases, and ICH was around 29% of all cases. [8] In the present study, we observed that 91% of the subjects had an ischemic stroke, whereas 9% were diagnosed with an intra-cerebral hemorrhage.

The mean age of patients in our study was 62.1 years. About 50% of patients were between 61 and 80 years old, and 9% were over 80 years old. As age increase the risk of experiencing a stroke increases significantly, especially after the age of 55, with about three-quarters of all strokes occurring in individuals 65 years or older. The projected growth in the elderly population is expected to lead to an increase in strokes, creating challenges for healthcare providers and policymakers. [8] The conventional view is that stroke is more common in older individuals. It is concerning that the number of strokes in younger people is increasing, and it has become a significant public health concern. Strokes in individuals under the age of 50 make up about 10% to 14% of all strokes. [9-10] In the present research, 8% of stroke patients were less than 40 years old, and 33% were between the age of 41 and 60. The global incidence of ischemic stroke is increasing among young adults, unlike stroke in older adults. Alarming increases in the occurrence of stroke in young adults in low- and middle-income countries have been observed. According to a study based on the population in India. A recent study by Singla et al. published in 2022, reported an annual stroke incidence of 46 per 1,00,000 individuals aged between 18 and 49 years in an Indian population. [11]

Out of 100 patients of acute CVA participating in this study, 57% were males, while 43% were females. The incidence of ischemic stroke shows gender differences, and there is an increasing number of reports on this. Even though men are more susceptible to vascular diseases, the level of risk is not consistent across all age groups. This discrepancy in stroke risk can be observed in epidemiological studies, with a sharp increase in stroke occurrence in women after the age of 60, surpassing men in their 70s. [10] In stroke survivors, older women typically experience more severe strokes and have less favorable outcomes. [11] The lifetime risk of stroke globally (from the age of 25 and beyond) is 25.1% for females and 24.7% for males. [102] Nonetheless, regional differences exist. The regions with the highest lifetime risks for females are Eastern Europe and East Asia (36.5% and 36.3% respectively).[12]

In this study patients with hemorrhagic stroke had significantly higher incidence of loss of consciousness, loss of speech, dysphagia and headache. These patients also had significantly higher blood pressures and lower heart rates and GCS. Overall, the severity of stroke as assessed by NIHSS scale was significantly higher among patients with hemorrhagic stroke as compared to those with ischemic stroke. The study published by Klaus et al. found similar outcomes, indicating that the likelihood of hemorrhagic stroke increased as stroke severity rose, from 2% in patients with mild strokes to 30% in those with severe strokes. [13] Ojaghihaghighi et al. conducted another study stating that hemorrhagic strokes were more prevalent in cases with lower GCS scale, agitated mood, acute onset headache, seizure, and mydriatic pupil. [7]

In our study, dyslipidemia and hypertension were the most prevalent risk factor for CVA, seen in 67% and 51% of patients, respectively. Obesity, diabetes, family history and smoking were other important risk factors. The risk factors for hemorrhagic and ischemic stroke share similarities, but there are also significant differences. Additionally, there are variations in risk factors among the different causes of ischemic stroke. Hypertension plays a crucial role as a risk factor for hemorrhagic stroke while also contributing to atherosclerotic disease, which can lead to ischemic stroke. [13] Conversely, hyperlipidemia is a key risk factor for strokes resulting from. Atrial fibrillation, on the other hand, is specifically linked to cardioembolic stroke [14]. In our study, too, hypertension was more common in patients with ICH, whereas raised cholesterol was significantly associated with an ischemic stroke. The most significant changeable risk factor for stroke is hypertension, which has a clear, direct, consistent, and unbroken link between blood pressure and the risk of stroke. [14] Hypertension was the most significant risk factor for stroke in the INTERSTROKE study. [15]

In the past few decades, multiple studies in India have investigated the risk factors associated with stroke. In the 1990s, a case-control study conducted across multiple hospitals found that diabetes mellitus, hypertension, tobacco use, and low hemoglobin levels were more significant risk factors for ischemic stroke than cholesterol levels. [15] In a study from Northern India, the main risk factors identified were high blood pressure (diastolic blood pressure >95 mmHg), high blood sugar levels, smoking, and low levels of hemoglobin (<10 g%). [16] One more community-driven research on biological risk factors in North India has revealed increased levels of fasting blood sugar, cholesterol, triglycerides, and low HDL in conjunction with urbanization among urban, rural, and semi-urban populations. [17] A study comparing cases and controls from the identical area has yielded comparable findings and recorded reduced intake of fruits and vegetables, inactive routines, and emotional tension as contributing elements. [18]

The study analyzed the outcomes of patients with stroke using the modified Rankin scale (mRS) to measure neurological disability. The distribution of mRS scores indicated that most patients experienced moderate to severe disability. Specifically, the majority of patients fell into the mRS score categories of 3, 4, and 5, which signify moderate disability, moderately severe disability, and severe disability, respectively. These findings suggest that a substantial portion of the stroke patients in this study required significant assistance with daily activities and had considerable impairments. Comparing these results with previous research, it aligns with the general consensus that stroke often results in significant disability. Prior studies have also shown a high prevalence of moderate to severe disability in stroke survivors, emphasizing the profound impact of stroke on individuals' functional abilities. For instance, research by Kwon et al. found that about 30-40% of stroke survivors fall into the moderately severe to severe disability range on the mRS scale, which is consistent with the findings of this study. [19] Similarly, a study by Bamford et al. reported that a significant proportion of stroke patients experienced moderate to severe disability, highlighting the long-term challenges faced by these individuals. [20] Furthermore, the study highlights that ischemic stroke generally resulted in better outcomes compared to hemorrhagic strokes. This is supported by previous literature indicating that hemorrhagic strokes tend to have worse prognoses due to factors like increased intracranial pressure and more extensive brain damage. For instance, a study by Weimar et al. reported similar findings, with hemorrhagic strokes associated with higher mortality and disability rates compared to ischemic strokes. [21] Conversely, a study by Paolucci et al. better long-term prognosis for hemorrhagic stroke patients compared to ischemic stroke, suggesting that other factors such as comorbidities and access to care might play a crucial role. [21].

The study also examined the correlation between initial stroke severity, measured by the NIH Stroke Scale (NIHSS), and outcomes. Higher NIHSS scores, indicating more severe strokes, were associated with poorer outcomes. This is a well-established finding in stroke research, with numerous studies corroborating that higher NIHSS scores are predictive of worse functional outcomes and higher mortality. For instance, a study by Adams et al. demonstrated that patients with NIHSS scores above 20 had a markedly higher risk of severe disability or death. [22] It has been widely accepted that CVA is the most debilitating and life-threatening neurological disease. Despite advances in risk stratification, diagnosis and management, the population characteristics and risk factors for stroke have been evolving. Moreover, there have been very limited study done in the Gujarati population in India, to assess the profile of patients developing stroke and to identify important risk factors. The current study was thus conducted to fill this gap of knowledge and provide recent evidence for clinicians managing patients with CVA.

It has been widely accepted that CVA is the most debilitating and life-threatening neurological disease. Despite advances in risk stratification, diagnosis and management, the population characteristics and risk factors for stroke have been evolving. Moreover, there have been very limited study done in the Gujarati population in India, to assess the profile of patients developing stroke and to identify important risk factors. The current study was thus conducted to fill this gap of knowledge and provide recent evidence for clinicians managing patients with CVA.

Limitations

The current research was carried out using robust methodology, yet we encountered specific constraints when interpreting the findings.

·         Small sample size: While we managed to reach the intended sample size outlined in the protocol, the 100-patient sample size is inadequate for producing robust, high- quality evidence.

·         The present study only followed up with participants until they were discharged from the hospital, so it was not possible to assess long-term outcomes.

·         This research was conducted at a single center and therefore had challenges in reaching a suitable number and geographic variety of participants.

·         The patients for this study were recruited from a tertiary care hospital, which generally caters to more severe cases compared to the community; thus, the general applicability of these results is a concern.

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