European Journal of Cardiovascular Medicine

The occurrence of stroke among individuals has become a subject of significant attention in recent times. However, there is a lack of uniformity in the available data, as various studies include different age groups in their analyses. The majority of published reports focus on individuals between the ages of 15 and 45 when addressing strokes in the young. A hospital-based study conducted in India revealed that the proportion of stroke cases in the young population ranged from 15% to 30% [1]. In a population-based study, 8.8% of participants with stroke were found to be young [2]. In the United States, statistics indicate that 532,000–852,000 individuals aged 18–44 years have experienced a stroke, with approximately 50% being ischemic strokes, 20% intracerebral haemorrhages (ICH), and 30% subarachnoid haemorrhages (SAH) among those aged 15–44 years [3]. The study of stroke in individuals holds significant importance for several reasons. The aetiology and risk factors associated with strokes in this demographic are more diverse and distinct compared to the elderly population. Consequently, these differences may suggest the need for separate therapeutic approaches. Notably, there is a paucity of studies on stroke in individuals from the northeastern part of India, which is home to a unique ethnic entity. The tribal communities of Odisha region are predominately are suffering from communicable diseases be but now they are also suffering from non-communicable diseases like stroke. Therefore, the objective of this study is to examine the profile of stroke cases among individuals in the Ganjam district of Odisha.

This retrospective hospital-based study on stroke in individuals was conducted at the Department of Neurology of MKCG Medical College and Hospital, Ganjam, a tertiary care centre in the region. The study spanned a period of one year, from February 2019 to February 2020. Patient identification was based on medical records, and appropriate consent was obtained for record access. The study protocol received approval from the institutional review board.

Inclusion criteria:

- Patients aged 18 years and above admitted to the hospital, meeting the WHO definition of stroke.

Exclusion criteria:

- Patients aged 18 years and above with a history of previous stroke or head trauma preceding admission.

- Patients with secondary causes of intracerebral bleed, such as bleeding in a tumour.

Data collection followed a predefined protocol, encompassing demographic characteristics, family history, risk factors, neurological examination, and diagnostic information. Neuroimaging, including computed tomography (CT) scans and subsequent magnetic resonance imaging (MRI), magnetic resonance venography (MRV), CT angiography, and digital subtraction angiography (DSA) when necessary, were performed. Additional tests included blood coagulation profiles, routine hemograms, blood glucose tests, serum lipid profiles, viral markers, blood Venereal Disease Research Laboratory (VDRL), electrocardiograms (ECG), echocardiography, carotid Doppler, and chest X-rays. Detailed coagulation and vasculitis profiles were conducted when deemed appropriate, and cerebrospinal fluid (CSF) analysis for CSF VDRL was performed in two patients.

Stroke classification included cerebral infarction, intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH), and cerebral venous thrombosis (CVT).

A total of 120 patients were included in the study, representing 32.4% of all stroke cases during the study duration (370 cases in total). The mean age of onset was 33 years, with a male-to-female ratio of 1.5:1, indicating a male preponderance. Diagnostic procedures included CT scans for all patients on admission, MRI for 85 patients, and DSA for seven patients. ECG and echocardiography were conducted for all patients, carotid Doppler for cerebral infarction cases, and MRV for suspected CVT.

Figure 1: Distribution of Stroke in study participants

Hemiparesis was the most common presenting symptom (83.3%), while headache predominated in haemorrhagic stroke. Seizures were observed in 36.6% of haemorrhagic and 7.3% of ischemic stroke cases. CVT patients presented with seizures in 33.3% of cases. SAH cases universally presented with headache, and neck rigidity was noted in all SAH patients, as well as 26.5% of ICH with intraventricular extension and 4.0% of intraventricular haemorrhage cases.

Figure 2: Types of Ischemic stroke

Cerebral infarction accounted for 50.8% of cases, with atherosclerotic (52.4%) being the most common subtype. Alcohol abuse was the leading risk factor (68.8%), followed by smoking (44.3%). Hypertension was detected in 11.5%, and diabetes mellitus in 3.3% of cases. ICH constituted 41.6% of cases, predominantly affecting the basal ganglia (71.4%), with alcohol abuse as the primary risk factor (66.8%). SAH was observed in 4.2% of cases, with a 1.3:1 male-to-female ratio, and DSA revealed aneurysms in 42.3% of cases. CVT occurred in 3.1% of cases, exclusively in females, with risk factors including anti-phospholipid antibody syndrome, Protein S deficiency, and undetermined causes.

Examining data from systematic reviews of population-based stroke incidence studies, the total stroke rate for those aged <45 years ranged from 0.1 to 0.3/1000 person-years [4]. In Indian hospital-based studies, stroke in individuals constituted a high proportion, ranging from 15% to 30% [1], while population-based studies, including those in western countries, reported a lower incidence of 8.8% [2]. Our study observed stroke in individuals at 31.3%, potentially elevated due to the inclusion of patients with cerebral venous thrombosis (CVT) and subarachnoid haemorrhage (SAH).

A consistent male preponderance was evident in our study, aligning with findings from both Indian [5,6] and western studies [7,8]. However, the literature presents varied insights, with some population-based studies suggesting increased stroke incidence among women under 30 years old [9], and others reporting a higher risk of haemorrhagic stroke in men, without a significant sex difference in infarct or SAH risk [10]. Notably, all patients with CVT in our study were female.

Cerebral infarction emerged as the most common stroke type in individuals (Figure 1), paralleling findings from different studies [10], which reported 45% infarcts with causes including intracranial atherosclerosis, cardio embolism, cryptogenic cases, and other determinants. Our data align with previous studies, indicating that 21%–48% of strokes in individuals result from atherosclerotic large artery disease, 13%–35% from cardio embolism, and 7%–40% are cryptogenic [11]. Ischemic stroke classification hinged on investigation intensity.

Traditional risk factors such as hypertension, diabetes mellitus, and abnormal lipid profiles were identified, with only hypertension significantly associated with ischemic stroke. This aligns with most studies, although the association of diabetes mellitus with ischemic stroke varies across different regions. High alcohol consumption, a modifiable risk factor, demonstrated a significant association with ischemic stroke in our study, even among female patients. The impact of alcohol on ischemic stroke risk was notably higher than reported in other studies, possibly due to the reversal of the beneficial effects of light alcohol consumption on lipid metabolism and its role in elevating blood pressure, inducing cardiac arrhythmias, and promoting hypercoagulability [15].

There were different cases particularly, there were two cases each, surpassing reported occurrences in an Indian study [6]. Rheumatic heart disease emerged as the leading cause of cardioembolic stroke in individuals, consistent with other studies [11], although infective endocarditis, a common association, was notably absent in our cases. Atrial fibrillation was infrequent. The prevalence of haemorrhagic stroke and SAH among the young (40%–55%) surpassed that in older subgroups (15%–20%), a trend similarly observed in our study. The male preponderance in haemorrhagic stroke aligns with other studies, with hypertension and alcohol abuse identified as significant risk factors. The synergistic effect of alcohol and hypertension heightens the risk of haemorrhage [18], possibly exacerbated by alcohol-related cirrhosis of the liver with hypoprothrombinaemia.

CVT prevalence in India appears notably higher than in western countries [2], ranging from 2% to as high as 16.3% [19]. Our study reported CVT in 12% of cases, primarily affecting postpartum patients. Infection, a common cause of CVT in individuals, was absent in our cases.

Limitations of our study include the inability to investigate various causes of stroke in individuals, such as migraine, homocysteine levels, nonatherosclerotic large artery occlusive disease, and mitochondrial disorders. Family history documentation was incomplete, and a potential referral bias may exist as a result of the hospital-based nature of the study.

Stroke in individuals demands a distinct investigative and therapeutic approach due to its divergent aetiology compared to older age groups. While traditional risk factors like hypertension, diabetes, and smoking are associated with stroke in both the elderly and young, our study emphasizes the prevalence of other modifiable risk factors, particularly alcohol consumption. Behavioural patterns contributing to well-documented risk factors underscore the need for comprehensive population-based studies on stroke in individuals to elucidate underlying aetiology and incidence rates across diverse populations.

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