European Journal of Cardiovascular Medicine

After ischemic heart disease and cancer, stroke is the leading cause of mortality in the developed world. It is also the leading cause of physical impairment. In wealthy nations, stroke ranks as the third most common cause of death. A frequent medical emergency is a stroke. Because to the adoption of less healthy lifestyles, the incidence is sharply increasing in many developing nations. Treatment is still ineffective and difficult to achieve. The best course of action is prevention, however it is difficult to predict a stroke, necessitating a thorough analysis of risk factors. The sudden death of brain cells as a result of insufficient blood flow is known as a stroke or cerebral vascular accident. WHO defines stroke as rapidly developing clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death ,with no apparent cause other than vascular origin¹.

In 2017, the number of individuals experiencing stroke increased to more than 104.2 million².  0.7 million deaths by stroke in India in 2016, 1.1million incidence, 16.54million DALY³. It is a significant health issue in India. Both communicable and non-communicable diseases are a double burden on developing nations like India. Stroke prevalence rates are expected to range from 84 to 262/100,000 in rural areas and from 334 to 424/100,000 in urban areas⁴. The incidence rate is 119 to 145/100,000 based on the recent population studies^5,6.

Age, smoking, dyslipidemia, Hyperhomocysteinemia,diabetes, hypertension, atherosclerosis, and other uncommon causes are some of the risk factors. There is strong proof that changing risk factors will lower the risk of stroke. Recent research indicates that high Homocysteine levels are a significant risk factor for cerebrovascular accidents.

Stroke admissions account for 9.2–30% of admissions to neurological wards and 0.9%–4.5% of all medical admissions, according to research⁷. According to studies, between 10 and 15 percent of strokes in India occur in people under the age of 40. According to WHO predictions, low- and middle-income nations, including India and China, would account for 80% of all stroke cases worldwide by 2054. Because of insufficient blood flow, brain cells suddenly die in a stroke. It is one of the main factors in severe long-term impairment. The severity and location of a stroke's brain damage dictate its repercussions, although the clinical symptoms of a stroke may not always accurately indicate its underlying cause or causes. The acute onset of unilateral paralysis, loss of vision, speech impairment, memory loss, impaired reasoning, coma, or death are all common stroke symptoms^8,9.

OBJECTIVES:

1) To study Homocysteine levels in Cerebrovascular patients.

2) To look for association between serum Homocysteine levels and cerebrovascular accidents.

Study design: Cross sectional study

Study period: For a period of one and a half year.

Place of study: Department of General Medicine, Shri Chamarajendra Hospital, HIMS Hassan

Inclusion Criteria

1. Subjects with valid consent.
2. Age more than 18 years.
3. Subjects with New onset or recurrent Cerebro-vascular accidents validated by CT/MRI brain.

Exclusion Criteria

1. Patients with Renal diseases, Hypothyroidism, since they could affect the serum homocysteine levels.
2. Patients on Vit B12 suppliments.
3. Patients with anemia
4. Hereditary stroke disorder
5. Not validated by CT/MRI brain
6. Extreme age group-more than 80 years
7. Any other confounding factor found incidentally during study.

METHOD OF STUDY

The participants were clearly explained about the objectives of the study and informed consent was obtained in local language (Kannada) prior to the study. All participants fulfilling the inclusion criteria were interviewed as per proforma and a detailed clinical examination was done. Participant’s demographic, social and medical details were recorded in proforma sheet and patients were subjected to necessary blood investigations. Data obtained from these patients were systematically recorded and analyzed using statistical package. The blood samples for the following biochemical parameters will be sent on admission, routine investigations like CBC, LFT, RFT, S/E, RBS and Imaging are studies done.

Statistical analysis

Data obtained from the study will be entered in excel sheets and it will be double checked. Data analyzed using SPSS software version 22.0 and will be presented as descriptive statistics in the form of frequency tables, figures and graphs .Association between variables will be done using chi-square test and unpaired t test for qualitative and quantitative variables. Results will be expressed as mean ± SD.ANOVA test will be used for testing the significance between the groups. Correlation of parameters is done by Pearson’s correlation formula. A p value of <0.05 is considered statistically significant.

Sample Size Estimation

• Sample size: 96
• In the present study sample size was calculated using formula- n=Z21-α/2pq /d2
• where Z1-α/2=two failed probability for 95%CI =1.96
• P=80 %
• Q=[100-P]
• d=8% [absolute allowable error]
• n=[1.96]2[10.9][89.1]/62 =95.3 [approx -96]
• thus the sample size required for study is 96

Table 1: Distribution Of The Subjects Based On Gender And Serum

Homocysteine Levels

• Out of 96 subjects, majority of the subjects were males 66(68.8%) and 30(31.2%) were female.
• Among males 40(60.7%) patients had elevated levels of Homocysteine, 26(39.3%) had values within normal range.
• Among Females18(60%) subjects had normal levels and 12(40%) had elevated Homocysteine levels.

Table 2: Distribution Of the Subjects    Based on Comorbidities and Hyperhomocysteinemia

• Among the population with elevated S.Homocysteine levels majority didnot have any Comorbidities (67.3%).
• 4% had Hypertension,1.9% had Recurrent stroke,3.8 % were known case of seizure disorder,5.8 % had Diabetes,1.9 % had IHD,1.9% had both Hypertension and Diabetis,1.9% had both IHD and Old CVA.

Table 3: Correlation Between Cva  And Homocysteine Levels

• Out of 96 subjects, 52 had raised levels of Homocysteine,44 subjects had normal levels.
• 8 out 9 patients with CVT had raised levels of S.Homocysteine.
• Out 70 subjects with Ischemic stroke, 36 had raised levels of S.Homocysteine.
• Only 5 out of 14 subjects with Hemorrhage had raised levels of S.Homocysteine.

TABLE 4: AGE DISTRIBUTION

• Out of 96 subjects, 28 were below the age of 45 and 68 were above the age of 45.
• In subjects below the 45 years age group, 21 out of 28 subjects had elevated levels of Homocysteine.
• Out of 68 subjects above the age 45 years, 31 had elevated levels.

Table No.5:  One way Anova

 Observation

• Anova test shows there’s no significant correlation between RBS and Stroke categories

(‘p’ value-0.765).

It shows the definite correlation between S. Homocysteine and Stroke (‘p’-0.001)

• A Total of 96 patients visiting the Shri Chamarajendra hospital HIMS Hassan were studied.
• Out of 96 cases participated in the study,66 were male,with mean age of 9848 ± 13.93887
• 30 were Females with mean age 7333 ± 16.29879
• Among males 40(60.7%) had elevated levels of Homocysteine,26(39.3%)had values within normal range.
• Among Females 18(60%) subjects had normal levels and 12(40%) had elevated Homocysteine levels.
• CVA was categorised into 3 groups
• Ischemic
• Hemorrhagic
• CVT
• CVT with Hemorrhage
• Out of 96 subjects, 52 had raised levels of Homocysteine, 44 subjects had normal levels.
• 8 out 9 patients with CVT had raised levels of S.Homocysteine.
• Out 70 subjects with Ischemic stroke, 36 had raised levels of S.Homocysteine.
• Only 5 out of 14 subjects with Hemorrhage had raised levels of S.Homocysteine.
• All the patients with both CVT, Hemorrhagic stroke together has high levels of Homocysteine.
• Also it is noted that higher percentage of Young age stroke patients(45years) have Hyperhomocysteinemia.
• There’s no significant correlation between RBS and Stroke.
• In following study serum Homocysteine was estimated using NITRO PAPS TETRAZOLIUM method [colorimetric/spectrophotometric ]
• Serum Zinc levels normal reference range 52-286 μg/dl
• Gold Standard method being Atomic absorption spectrophotometry.
• FBS,PPBS were estimated using Glucose oxidase –peroxidase method [Enzymatic]
• RBS by Hexokinase method [enzymatic].

COMPARISION WITH OTHER STUDIES

Mean age group of current study 44.53 years.

Stroke  is  a  major  health  problem  worldwide  and  is  one  of  the  leading  causes of mortality and long-term disability. Ischemic stroke accounts for more than 80% patients of stroke worldwide¹⁰. In the present study, 70 patients had ischemic stroke while only 14 patients presented with Hemorrhagic Stroke.  Primary  and  secondary  prevention  by  managing  the  various  modifiable  risk  factors  for  stroke  is  the  key  to  reducing  the  incidence  of  stroke  and  its  impact  on  health-care  resources¹¹. Hyperhomocysteinemia  is  one  of  the  recently  recognized  modifiable  factors  that  increase  the  risk  of  cardiovascular  and  cerebrovascular  disease.¹²

Mean age group of current study 44.53 years.

Stroke  is  a  major  health  problem  worldwide  and  is  one  of  the  leading  causes of mortality and long-term disability. Ischemic stroke accounts for more than 80% patients of stroke worldwide¹⁰. In the present study, 70 patients had ischemic stroke while only 14 patients presented with Hemorrhagic Stroke.  Primary  and  secondary  prevention  by  managing  the  various  modifiable  risk  factors  for  stroke  is  the  key  to  reducing  the  incidence  of  stroke  and  its  impact  on  health-care  resources¹¹. Hyperhomocysteinemia  is  one  of  the  recently  recognized  modifiable  factors  that  increase  the  risk  of  cardiovascular  and  cerebrovascular  disease.¹²

Out of 96 patients studied, 66 were males, showing male preponderance. Similar male preponderance seen in patients with increased values of serum Homocysteine, where 40 male subjects had elevated serum levels. Similar study by Zongate et al¹³,demonstrated that male gender is linked with higher serum Homocysteine. Similar observations also made in studies by Dinesh chouksey et al¹⁴. and Manoharan S et al.¹⁵

In present study percentage of Hyperhomocysteinemia is more in young stroke patients (below 45 years) (21 out of 28,75%). Similar, results also seen in a study by Gajbhare et al. most of patients with stroke were between 25 to 45 years, which states that Hyperhomocysteinemia appears to be important risk factor for young onset stroke.

• A study by Modi et al.¹³ the levels were significantly high in both younger age group patients (10.85 ± 2.38 vs32 ± 2.89 mmol/l; d.f. 37; 95% CI 0.92-4.14; P= 0.003) and older age group patients.
• In a study conducted by NahidAshjazadeh et al.¹⁵ had taken population of size 171 Showed elevated Homocysteine levels was an independent risk factor for Ischemic stroke and significant relationship between increased Homocysteine levels and risk of cardioembolic stroke.
• Our results are in line with those of Del Ser et al,^16-18who found that tHcy exceeding the 75th percentile 3 months after an ischemic stroke was a predictor of vascular events, including stroke recurrence, acute myocardial infarction, deep venous thrombosis, and peripheral arterial disease. The incidence of each vascular illness, however, was too low to be analyzed separately in that study. By focusing solely on cerebrovascular events, our study clearly identifies elevated tHcy as a risk factor for stroke.

Limitations

• A large scale study is needed to Extrapolate the findings to the whole population
• Study design was a cross sectional observational study. So, it cannot be determined whether elevation in homocysteine was a precursor, or a consequence of stroke.
• Also, we could not measure the B12 and folate levels in our study group, which are co-factors in homocysteine metabolism and have been documented to be strong correlates of tHcy in many studies.
• These stroke patients also had few other risk factors than Hyperhomocysteinemia.

The current study revealed that hyperhomocysteinemia appears to be an important risk factor for Cerebrovascular Accidents. Incidence of Hyperhomocysteinemia is higher in Ischemic stroke and venous stroke. It is therefore important to use serum homocysteine as an important tool to investigate all cases of Cerebrovascualr Accidents. Significant number of young patients with stroke had hyperhomocysteinemia.

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