31.8.1 Clinical Presentation and Evaluation of Risk Factors in Acute Ischeamic Stroke Patients Presented to MMC Mardan

Original Article

 

Risk Factors in Acute Ischeamic Stroke

Clinical Presentation and Evaluation of Risk Factors in Acute Ischeamic Stroke Patients Presented to MMC Mardan

Muhammad Abbas, Shahzeb, Jehandad Khan, Sarmad Raza and Jamal Nasir

ABSTRACT

Objective: Stroke is extremely common in our set up, it is associated with high risk of mortality, morbidity and permanent disability but very little is known about it by the general public in a developing country like Pakistan. So the main objective of the study was to find out the clinical presentation and the risk factors associated with acute ischemic stroke and to know about the general public awareness about stroke.

Study Design: Descriptive /cross-sectional study

Place and Duration of Study: This study was conducted at the Medical Units of Mardan Medical Complex (M.M.C), Mardan from July 2019 to December 2019.

Materials and Methods: Adult 183 male and female patients of acute ischemic stroke admitted through emergency and medical OPD in medical units of MMC were included in study after taking an informed verbal consent from them. Following detailed history and clinical examination they were subjected to relevant investigations and CT brain. Patients with finding of bleed on CT and those having venous infarct were excluded.

Results: Hyperlipidemias, hypertension, diabetes and smoking were the major risk factors causing ischemic stroke in our sample of patients. Other risk factors given in detail below were also present, atrial fibrillation was found to be common risk factor in elderly population. 24% of patients presented with re stroke.

Conclusion: It was concluded that majority of patients were unaware of the risk factors causing stroke, so if we as a professional not only treat them but also educate them the incidence of stroke can be considerably reduced
in society.

Key Words: Ischemic stroke, risk factors of ischemic stroke, stroke and diabetes.

Citation of article: Abbas M, Shahzeb, Khan J, Raza S, Nasir J. Clinical Presentation and Evaluation of Risk Factors in Acute Ischeamic Stroke Patients Presented to MMC Mardan. Med Forum 2020;31(8):3-7.

 

 

INTRODUCTION

Stroke is a leading cause of death and disability throughout the world and causes a considerable burden due to its mortality, morbidity and permanent disability. It is one of the commonest conditions and a serious public health problem encountered in medical units of our set up. Despite the high seriousness of disease ordinary people know very little about the clinical presentation and associated risk factors causing it. So the purpose of this study was to evaluate the risk factors, clinical presentation of ischemic stroke among the adult patients and then to educate them properly regarding their disease so that they can lead a normal life and are prevented from re-stroke. 

 

 

Department of Medical Unit-B, Mardan Medical Complex (MMC), Mardan.

 

 

Correspondence: Dr. Muhammad Abbas, Associate Professor of Medical Unit-B, Mardan Medical Complex (MMC), Mardan.

Contact No: 0300-9053406

Email: docabbas1@hotmail.com

 

 

Received:    April, 2020

Accepted:    May, 2020

Printed:        August, 2020

 

 

 

It not only adversely influences the life of the patients but also has got worse effects on their families and care takers1. Data from global burden of diseases, injuries and risk factors study group (GBD) of 2010 has declared stroke as a major cause of morbidity and mortality in developing countries2. Due to advancement in the management of stroke and control of risk factors causing it mortality from stroke have been reduced3. The advance treatment and management such as the use of intravenous tissue type plasminogen activator and certain other interventional management in certain cases of acute ischemic stroke, the effective prevention still remains the best management of stroke 4.  Greater the duration of exposure to risk factors of stroke higher the chance of getting it3. Effectively controlling these risk factors not only reduces the occurrence or re-occurrence of stroke but also the mortality rates5. 77% of strokes are primary so controlling the risk factors highlights the importance of primary prevention3.  People living a healthy life style have 80% less chance of developing stroke than those who do not6. Risk factors for developing stroke are modifiable which can be controlled and permanent which are uncontrollable. The non-modifiable or permanent risk factors include sex, old age, race, heredity and ethnicity. Modifiable risk factors include hypertension, diabetes, dyslipidemia, atrial fibrillation, smoking, alcohol.

MATERIALS AND METHODS

This was a cross-sectional descriptive study including 183 patients presented to us with acute ischemic stroke of twenty-four hours or of less duration. Adult patients of both genders were included in study, ranging between 15 to 90 years of age. Those who sustained stroke due bleed or venous infarct were excluded. Verbally informed consent was followed by written consent from the patients or their attendants. Approval of the study was taken from local ethical committee of the hospital. Detailed history was followed by clinical examination; history taking was mainly focus on:

Diabetes Mellitus: patients either on oral hypoglycemic drugs / insulin or fasting blood sugar more than 126 mg / dl or random blood sugar of 200 mg /dl or more on two occasions or were having HbA1c 6.5 % or more8, 9, 10, 11.

Hyperlipidemia:  either patient was already on statins / fibrates, or total cholesterol equal to or more than 200 mg /dl, LDL cholesterol equal to or more than 100 mg /dl, HDL cholesterol less than 40 mg /dl in men or less than 50 mg / dl in women or serum triglyceride equal to or more than 150 mg / dl 9, 12.

Hypertension: patients were already on anti-hypertensive or BP > 140/90 on two measurements 8,9,10,11.

Obesity: BMI > 30 kg/m2, while central obesity was taken as waist circumference of more than 102 cm in men and 88 cm in women10.

Smoker: current smokers were who smoked two cigarettes / day for men and for women it was one cigarette / day since 1 year and ex- smokers were taken as patients who were not smoking since 1 year13.

Routine base line investigations including FBC, LFTs, RFTs, PT/INR, daily FBS, RBS, HbA1c, ECG, LIPID PROFILE were done on all patients, Radiological assessment of the patients included CT brain, echocardiogram, carotid Doppler and certain immunological test such as ANF, Anti ds DNA, antiphospholipid, protein s and c, anti thrombin111, and factor v Leiden were also done in few selected cases.

RESULTS

These were the different clinical presentation of stroke depending upon the area of brain involved. Headache, hemi paresis /hemiplegia and speech disturbance were the common clinical presentation of acute ischemic stroke. Facial palsy was also presented in 87 cases and was mainly of UMN type though LMN type also occurs in few cases of brainstem infarct. Elderly patients presented with convulsion along with stroke.

In this study majority of patients were male mainly illiterate belonging to lower socioeconomic groups, it
 

 

was less common in educated people and younger age group of less than 45 years of age as evident in tables.

HTN, DM, hyperlipidemias, smoking and atrial fibrillation (mainly in elderly) were the common risk factors to be found associated with stroke in this study. Relative percentage of other risk factors is given in table.

Table No.1: Clinical Presentation of Stroke

Particulars

No. of Patients (N=183)

%Age

Headache

131

71.58%

Speech disturbance

104

56.83%

Hemiparesis / Hemiplegia

99

54.10%

Unconsciousness/Coma

15

8.20%

Confessional State

71

38.80%

Facial Palsy

87

47.54%

Convulsion/Seizure

19

10.38%

Visual Field Defect

6

3.28%

Ataxia/Gait abnormality

24

13.11%

Vertigo/dizziness

24

13.11%

Diplopia

10

5.46%

Monoparesis/Monoplegia

4

2.19%

Dysphagia

36

19.67%

     

Figure No.1: Clinical presentation of stroke

Table No.2: Individual Characteristics of Stroke Patients

Particulars

Numbers

%Age

Age

< 45

13

7.10%

45 – 60

122

66.67%

> 60

48

26.23%

Sex

Male

129

70.49%

Female

54

29.51%

Educational Qualification

Illiterate

87

47.54%

Only able to Read & Write

77

42.08%

Higher Secondary School (10-12 Classes)

11

6.01%

Graduation or Above

8

4.37%

 

 

Table No.3: Risk Factors in Individuals with Stroke (N=183)

Risk Factor

Number

%Age

Hyperlipidemia

112

61.20%

HTN

110

60.11%

DM

76

41.53%

Smoking

69

37.70%

Atrial Fibrillation

52

28.42%

Re-Stroke

44

24.04%

Obesity

25

13.66%

History of T I A

13

7.10%

Family History

11

6.01%

Carotid Stenosis

10

5.46%

Cardiac Emboli

9

4.92%

Stress

7

3.83%

Pregnancy

3

1.64%

 

Figure No.2: Risk factors in individuals with stroke

DISCUSSION

This study included 183 adult patients ranging from 15 years to 90 years of age with mean age of 57.40. 129 male and 54 female patients making 70.49% and 29.5% respectively of the sample studied. This is in accordance with the several studies in the past which also demonstrated high prevalence of stroke in males than in females 14. Protective role of female hormones, high level of exposure to stressful conditions and also higher incidence of smoking in males may account for this.

Our study demonstrated that the incidence of ischemic stroke increases with advancing age. It was found in this study that under the age of 45 the incidence of ischemic stroke was 7.1%, between 45-60 years of age it was 66.66% and in patients above 60 years of age it was 26.22%.  A linear relationship between ischemic stroke and age was also demonstrated by marwat et al and Grau et al 15, 16.

Hypertension was found to be a common risk factor for ischemic stroke and was found in 60.1% of patients. Several studies done in the past also demonstrated hypertension as a common risk factor of ischemic stroke 14,16.  This may be mainly due to high prevalence of essential hypertension in our society and also high blood pressure co exists with diabetes mellitus and smoking. This is further compounded by non-compliance with anti-hypertensive drugs mainly due to economic reasons and also due to low literacy rates in our set up. There is a linear relationship between HTN and stroke and a study showed a reduction of 10 mm of Hg in blood pressure was associated with 33% reduction in stroke risk17.

Hyperlipedemia was found to be another common risk factor associated with stroke and was present in 60.2% of cases in our study. This was considerably higher than the study done by Grau et al who found its association with ischemic stroke in 35.1% of cases in his study16, while it was slightly higher than El Tallawi et al who demonstrated it in 54.21% of cases in his study14. Grau et al conducted their study in 2001 at that time the junk fast food was not as common as it is now days that may be the reason for less percentage of hyperlipidemia in his study as compared to El Tallawi et al who conducted their study in 2015 and ours in 2020. The risk of stroke can be reduced by treating hyperlipedemias with statins16,14.

Diabetes was the third common risk factor associated with ischemic stroke in our study and was found in 41.53% of the sample studied. El Tallawi et al found this risk factor in their study in 54.2% of cases14, while Essa et al found this risk factor to be associated in their sample studied in 66.8% of cases19. People becoming more aware of diabetes and its management and this may be the reason for low percentage of diabetes in our study than the above mentioned studies done in past. Coagulation factors, insulin levels are increased in diabetes both of which accounts for causing microangiopathic stroke and is also responsible for accelerating atherosclerotic process in large cerebral arteries and leading to macroangiopathic stroke19.  Diabetes is also associated with HTN in majority of cases and this may have got an additive effect with it in causing ischemic stroke.

Smoking was found in our study in 37.7% of cases. Association of smoking with atherosclerosis is known since long.

Framingham study showed the risk of stroke in male smokers was 2.3 and in female smokers it was 3.1 times more than in nonsmokers. It also concluded that heavy smokers have double risk of stroke when compared with light smokers. When a smoker abstains from smoking for 5 years the risk of stroke returns to that of nonsmokers level20. Shinton found smoking as a risk factor in his study in 55% of cases21, which was considerably higher than our study. This is a good point meaning that people are becoming more aware of hazardous effects of smoking and it is decreasing among them.

Atrial fibrillation was found to be present in 28.41% of cases as a risk factor for ischemic stroke in our study which is comparable to the study done by Soliman
et al3. Majority of stroke patients secondary to atrial fibrillation in our study were elderly and were having lone atrial fibrillation, though few cases of rheumatic heart disease were also found mainly in young patients.

24% of patients in our study presented to us with re-stroke, which is nearly equal to the study done by Altafi who found it in 26% of cases22. Majority of patients with re-stroke were non-compliant with medicines mainly due to socioeconomic reasons and low literacy rates of our country. Overall incidence of stroke in our study was higher among illiterate people than those who have attained higher school/inter level education while it was extremely low among graduates.

CONCLUSION

Clinical presentation of stroke in our study was similar to the other studies done in the past. Common clinical presentation was headache and motor symptoms (speech disturbance and motor weakness of one half of body). Majority of the patients in this study were uneducated middle aged male belonging to lower socioeconomic class. Hypertension, hyperlipidemias, diabetes, smoking and atrial fibrillation were the common risk factors associated with stroke. Most of the patients with diabetes, HTN, were non-compliant with medicines mainly due to illiteracy and socioeconomic reasons. Therefore, a large-scale community based health education should be started, (mainly taking help from social media) in which ordinary people should be educated regarding clinical features of stroke including the warning signs manifested as T.I.A and the risk factors which can cause stroke so that risk factors can be effectively controlled. This will help to control the occurrence and prognosis both of stroke.

Author’s Contribution:

Concept & Design of Study:

Muhammad Abbas

Drafting:

Sarmad Raza

Data Analysis:

Jehandad Khan, Shahzeb, Jamal Nasir

Revisiting Critically:

Muhammad Abbas, Shahzeb

Final Approval of version:

Muhammad Abbas

Conflict of Interest: The study has no conflict of interest to declare by any author.

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