European Journal of Cardiovascular Medicine

Stroke stands as a pervasive public health challenge, holding a significant position in global morbidity and mortality. The World Health Organization (WHO) designates it as the second leading cause of death for individuals aged 60 and above and the fifth leading cause among those aged 15 to 59¹. This issue's gravity is accentuated by the annual occurrence of 750,000 new stroke cases in the United States, resulting in 150,000 fatalities². In 2016, the Global Burden of Disease project estimated a staggering 1,175,778 incident cases of stroke in India³. However, despite systematic reviews estimating the annual incidence of stroke in India, there remains a paucity of data and a lack of standardized research methods^4-5.

Globally, stroke's impact is immense, ranking as the second most common cause of mortality and the third most common cause of disability, following ischemic heart disease. Each year, approximately 15 million people worldwide experience the repercussions of stroke, with one-third losing their lives and two-thirds grappling with disabilities, placing a substantial burden on families, societies, and economies.

The adoption of Western cultural habits, characterized by sedentary lifestyles, tobacco and alcohol consumption, and a high-fat/cholesterol diet, has accelerated risk factors, contributing to the escalating burden of stroke⁶. Existing literature emphasizes traditional risk factors such as obesity, hypertension, diabetes mellitus, and dyslipidemia, with hypertension being the most prevalent. Additional risk factors among the younger population include smoking, excessive alcohol intake, illicit drug use, oral contraceptive use, and migraines⁶. Despite the inherent increase in stroke risk with age, affecting about two-thirds of individuals over 65, stroke is not confined to older age groups but also affects adults and young adults. Recognizing the controllable nature of some risk factors, our study aims to investigate the prevalence of stroke and associated risk factors in individuals under 45 years old.

Prevention of stroke hinges on early modification of specific risk factors, including hypertension, diabetes mellitus, dyslipidemia, heart disease, atrial fibrillation, smoking, obesity, and alcoholism. Hemorrhagic stroke exhibits a stronger association with hypertension, while ischemic stroke is more linked to factors such as smoking, hyperlipidemia, cardiac disease, and atherosclerosis⁷.

Our exploration into the demography and risk factors of stroke in young patients is crucial for understanding long-term disability and the burden on victims and their families. Furthermore, it provides a foundation for implementing preventive measures, with the ultimate goal of mitigating the impact of stroke disability in the younger population. In our study, we aim to unravel the demographic profile and diverse risk factors associated with stroke within our local population, providing valuable insights for the formulation of preventive strategies.

OBJECTIVES:

1. Investigate the demographic profile of young stroke patients admitted to the hospital.

2. Examine the risk factors associated with hospitalization for young stroke patients

This cross-sectional observational study was conducted from October 2022 to October 2023 at PGIMER & Capital Hospital, Bhubaneswar, Odisha. The inclusion criteria encompassed hospitalized patients aged 45 years or younger with a confirmed diagnosis of stroke, and those or their attendants who provided consent for participation. Exclusion criteria involved individuals over 45 years old, patients without a definite stroke diagnosis, outpatient cases, and those unwilling to participate.

The study focused on subjects with a first stroke, diagnosed by the sudden onset of neurological deficit persisting for more than 24 hours, with evidence confirmed by neuroimaging (MRI or Non-contrast CT scan) and assessed by a neurologist. Sixty patients meeting these criteria were enrolled, excluding cases of stroke secondary to infection, structural brain lesions (such as tumors), and connective tissue disorders. A comprehensive proforma collected participant details including name, age, gender, occupation, educational status, lesion site and type, duration of lesion, family history, and any concurrent systemic illnesses. Statistical analysis was carried out using SPSS version 20.

A total of patients with Stroke were enrolled in this study out of which 34 (65%) were male and 18 (35%) were female with a male-female ratio of 1.88:1. The mean age of the patients was in the mid-40s. The mean age was 32.57 ± 9.6 years, in which the mean age of males was 34.21±9.09 whereas the mean age of females was 30.10± 08.48.

Table -1 Type of stroke

The age-wise distribution revealed that ischemic strokes were prevalent across various age groups, with the highest incidence observed in the 41-40 age range. Hemorrhagic strokes were more evenly distributed across age groups, with a slightly higher prevalence in the 41-45 age range.

Figure -1 Clinical Presentation in Stroke Patients

Table -2 Site of Lesion in Ischemic Stroke

Among patients with ischemic strokes, the majority (42.30%) had lesions in the Middle Cerebral Artery, followed by 25% in the Lenticulostriate branches. Lesser occurrences were noted in the Anterior Cerebral Artery (11.53%), Posterior Circulation Stroke (7.69%), and the Anterior Choroidal Artery (1.92%).

Table 3 Site of Lesion in Hemorrhagic Stroke

In patients with hemorrhagic strokes, the majority (84.61%) had lesions classified as Intracerebral Hemorrhage, while 15.38% presented with Subarachnoid Hemorrhage.The study investigated the relationship between various risk factors and the types of strokes, presenting the data in terms of frequency and percentage distribution.

Table 4- Various risk factors with Stroke

The presence of hypertension was observed in 73.07 % of the total cases, with 51.92 % associated with ischemic stroke and 21.15 % with hemorrhagic stroke. The p-value for this relationship was 0.129, indicating a non-significant association. The presence of diabetes mellitus showed an association with 16 cases, with 14 cases related to ischemic stroke and 2 to hemorrhagic stroke. The p-value for this association was 0.293, indicating a non-significant relationship. Physical inactivity showed a significant association with stroke types. Of the 26 cases related to physical inactivity, 26.92 % were associated with ischemic stroke and 23.07 % with hemorrhagic stroke. The p-value for this association was 0.001, indicating a significant relationship. The presence of dyslipidemia showed an association with 16 cases, with 14 cases related to ischemic stroke and 2 to hemorrhagic stroke. The p-value for this association was 0.079, indicating a non-significant relationship. Central obesity showed a significant association with stroke types. Of the 24 cases related to central obesity, 21 were associated with ischemic stroke and 3 with hemorrhagic stroke. The p-value for this association was 0.005, indicating a significant relationship.

The study explored the association between smoking, alcohol intake, and heart disease with the types of strokes among patients. The data is presented in terms of frequency and percentage distribution.

Table No. 5 - Relation of Smoking, Alcohol Intake, and Heart Disease with Stroke

Non-smokers comprised 12 cases, with 11 linked to ischemic stroke and 1 to hemorrhagic stroke. Among non-significant smokers, there were 1 case associated with hemorrhagic stroke. Significant smokers represented 39 cases, with 27 linked to ischemic stroke and 12 to hemorrhagic stroke.

Non-alcoholic individuals presented 17 cases, with 14 associated with ischemic stroke and 3 with hemorrhagic stroke. In instances of non-significant alcohol consumption, 6 cases were recorded, including 5 related to ischemic stroke and 1 to hemorrhagic stroke. Significant alcohol consumption constituted 29 cases, with 21 (40.38%) associated with ischemic stroke and 8 (15.38 %) with hemorrhagic stroke.

Among individuals without heart disease, 34 cases were identified, with 27 associated with ischemic stroke and 7 with hemorrhagic stroke. Rheumatic heart disease (RHD) was linked to 5 cases, all related to ischemic stroke. Left ventricular hypertrophy (LVH) accounted for 13 cases, with 9 associated with ischemic stroke and 4 with hemorrhagic stroke.

Stroke is a global public health concern, contributing significantly to morbidity and mortality. It exhibits a predilection for males, particularly in older age groups. This study explores the prevalence and implications of various risk factors associated with stroke, shedding light on both modifiable and non-modifiable factors. The age distribution of stroke patients in this study ranged from 21 to 45 years, with majority of cases occurring in individuals between 41-45 years old. The mean age was 32.57 ± 9.6 years, aligning closely with previous studies. Notably, the incidence of stroke increases with age, emphasizing the impact of aging on stroke susceptibility^8-10.

Gender distribution in acute stroke patients varies across countries, with Asian countries showing a higher preponderance of males due to fewer female smokers. Ischemic stroke was more prevalent (75%) than hemorrhagic stroke (25%), consistent with studies in Nepal and China. However, variations exist globally, as demonstrated by Joseph R. Shiber's study, indicating the need for region-specific insights. Ischemic strokes commonly affected the Middle Cerebral Artery (MCA) territory (42.30 %), while hemorrhagic strokes often occurred in the intracerebral space. The distribution of stroke types and affected vascular territories parallels findings in other studies, reflecting the complexity of stroke pathophysiology^11-15.

Hypertension emerged as a prominent risk factor, associated with 51.92 % of ischemic strokes and 21.15 % of hemorrhagic strokes¹⁶. Comparable studies in Russia and India highlight the pervasive influence of hypertension on ischemic stroke incidence. Cigarette smoking was prevalent in both stroke subtypes, although not statistically significant. Alcohol consumption, diabetes, and physical inactivity were also identified as potential risk factors, underscoring the multifactorial nature of stroke etiology¹⁷. The study noted a low prevalence of atrial fibrillation in both ischemic and hemorrhagic strokes. This finding aligns with studies in Senegal and emphasizes the need for nuanced understanding, as risk factors may exhibit regional disparities. Notably, physical inactivity demonstrated a significant association with ischemic stroke. Family history of stroke and obesity emerged as additional risk factors, further emphasizing the intricate interplay of genetic and lifestyle influences.

In conclusion, this study provides a comprehensive examination of stroke risk factors, acknowledging the intricate interplay of various elements. The findings underscore the importance of regional considerations in understanding stroke epidemiology and developing tailored preventive strategies. The multifaceted nature of risk factors necessitates ongoing research to refine our understanding and inform targeted interventions for young stroke prevention. Ischemic stroke was more common than hemorrhagic stroke. The most common modifiable risk factors for stroke in young patients were hypertension, smoking, diabetes, physical inactivity, dyslipidemia, obesity, and alcohol consumption.

Acknowledgment: None

Conflicting Interest: None

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