Background: Stroke is a frequent medical problem and a leading cause of death and disability worldwide. Several conditions and lifestyle factors have been associated with stroke. Aim: To evaluate risk factors in stroke patients in Sulaimani city. Results: 110 patients with stroke were included in this study, hypertension was found to be the most common risk factor in current study. Out of 110 cases, 83 (75.5%) were hypertensive. Peak stroke-prone age was (60 - 69) year for male, (70 - 79) year for female. We found a statistically significant relation between level of TSC, LDL with ischemic stroke (r = 0.4047, P < 0.0001) and (r = 0.4052 P < 0.0001) respectively. While there was a significant inverse relation between HDL and ischemic stroke (Correlation coefficient = ?0.4862, P < 0.0001). On the other hand, there was no significant relation between level of TG and ischemic stroke (r = 0.2403, P < 0.0114). Also correlation statistic between TSC/HDL, LDL/HDL and result of CT scan, showed that there is statistical significance correlation between infarction and value of atherogenic index, (r = 0.5301, P < 0.0001, r = 0.4990, P < 0.0001) respectively, but there is no correlation between haemorhage & the index. Conclusion: Hypertension is the leading risk factor of stroke. It is therefore essential to detect and treat hypertension at its outset. High value of atherogenic index mostly associated with ischemic stroke .while no relation found with haemorhagic stroke.
Cerebrovascular diseases include disorders in which there is a disturbance of blood supply to the brain. Stroke occurs when an artery supplying blood to a part of the brain suddenly becomes blocked (ischaemic stroke) or bleeds (haemorrhagic stroke), accounting for about 85% & 15% of cases respectively [
Stroke is classified into two major types: Brain ischemia due to thrombosis, embolism, or systemic hypoperfusion. Brain hemorrhage due to intracerebral hemorrhage or subarachnoid hemorrhage [
This cross sectional study was approved by the scientific committee of the directory of health in sulaimani city and was conducted to evaluate risk factors for stroke in those patients admitted to the General Teaching Hospital in Sulaimani city-Iraq, from November 2009 to November 2010. The total sample size was 110 patients.
All patient with proven stroke by CT-scan included in this study, those who have no CT-scan & having space occupying lesion on CT where excluded from study. Transthoracic echocardiography performed using PHILIPS EnVisor C machine combines real-time two-dimensional imaging of the heart and cardiac valves. All patients in the study had a C.T scan (SOMATOM AR.SP, version B41A) of the brain (without contrast) to confirm the clinical diagnosis of stroke and the results was read by expert radiologists within 24 hours of presentation [
Data were translated into codes using a specially designed coding sheet, and then converted to computerized database. An expert statistical advice was sought and statistical analyses were done using (SPSS) (Statistical Package for Social Science) version 17 computer software. The degree of association between the variables (lipid profile and CT scan results) calculated using Rank correlation i.e. Spearman’s rho and/or Kendall’s tau rank correlation coefficients. P-value < 0.05 regarded as statistically significant.
A total of 110 patients with stroke were enrolled in the study; 73 ischemic strokes and 27 hemorrhagic ones (
Ischemic stroke | 73% |
---|---|
Hemorrhagic stroke | 27% |
Age | No. (n = 110) | Male (%) | Female (%) | P value |
---|---|---|---|---|
30 - 39 | 3 | 1 (33.3) | 2 (66.7) | 0.9935 |
40 - 49 | 12 | 6 (50) | 6 (50) | 0.6831 |
50 - 59 | 17 | 13 (76.5) | 4 (23.5) | 0.0085 |
60 - 69 | 40 | 27 (67.5) | 13 (32.5) | 0.0002 |
70 - 79 | 32 | 18 (56.2) | 14 (43.7) | 0.4777 |
80 - 89 | 5 | 1 (20) | 4 (80) | 0.2059 |
90 - 99 | 1 | 0 (0) | 1 (100) | 0.0001 |
Risk factors | No. {n = 110} (%) |
---|---|
Hypertension | 83 (75.5) |
Smoking | 58 (52.7) |
Ischemic heart disease | 41 (37.3) |
History of prior stroke | 40 (36.4) |
Family history of stroke | 33 (30.8) |
Diabetes mellitus | 24 (21.8) |
Atrial fibrillation | 21 (19.1) |
Valvular heart disease | 7 (6.2) |
Oral contraceptive pills | 9 (8.2) |
Increased hematocrit | 8 (7.3) |
Alcohol | 7 (6.4) |
On Anticoagulants | 2 (1.8) |
between haemorhage and the index. Trans-thoracic echocardiography showed that 56.4% of the patients have hypertensive heart disease and that 27.3% of the patients demonstrated evidence of ischemic heart disease; the study was unremarkable in 15.5% of the patients (
The patients included in the present study representa random sample of patients hospitalized in medical department with acute stroke with variable duration of in-patient care. The frequency of these risk factors in our study distributed as follows (in decreasing order):
Lipid profile | No. | % |
---|---|---|
Normal TSC | 93 | 84.5 |
High TSC | 17 | 15.4 |
Low HDL | 86 | 78.2 |
High HDL | 24 | 21.8 |
Normal LDL | 82 | 74.5 |
High LDL | 28 | 25.4 |
Normal TG | 96 | 87.3 |
High TG | 14 | 12.7 |
TTE finding | No. of patients (n = 110) | Percentage of patients |
---|---|---|
Hypertensive heart disease | 62 | 56.4 |
Ischemic heart disease | 17 | 27.3 |
Normal | 13 | 15.5 |
Aortic sclerosis | 9 | 8.2 |
Valvular heart disease | 7 | 6.3 |
Atrial septal defect (secondum type) | 1 | 0.9 |
Atrial myxoma (left-sided) | 1 | 0.9 |
Hypertension is the commonest risk for stroke (75%), smoking (52%), ischemic heart disease (37%), history of prior stroke (36%), family history of stroke (30%), diabetes mellitus (21%), atrial fibrillation (19%), valvular heart disease (8%), oral contraceptive pills (8%), increased hematocrit (7%), alcohol (6%), and anticoagulant use (1%).
Stroke rates increase dramatically with age. About two thirds of all strokes occur after the age of 65. in our study the most affected age group was between (60 - 70) years of age [
Stroke is more common in male sex than female’s one according to many series [
Stroke subtype: Ischemic stroke had been reported to be more frequent than hemorrhagic stroke and accounted for 73% versus 27% of that of haemorrhagic stroke in our study. This percentage of hemorrhagic stroke (27%) is a slightly higher than the western figures (especially in USA, which is around (10% - 15%), but coincides with the results of studies done on Asian populations [
Hypertension: The above findings indicate that hypertension is the commonest risk factor identified and is the most important risk factor for stroke, and this observation is consistent with other studies. For people of all ages and both sexes, higher levels of both systolic and diastolic blood pressure have been associated with an increased incidence of ischemic and hemorrhagic stroke [
Smoking: Smoking has been seen as a risk factor for stroke incidence in some studies [
Diabetes mellitus: In our study most cases were of type 2 diabetes, and its contribution to stroke (21%) was a little bit higher than many other studies (5% - 10%)]. This difference might be explained by the fact that some cases were previously undiagnosed and many others were poorly controlled. Many studies have observed an independent association―in both men and women―of diabetes with an elevated risk of stroke [
Dyslipidemia: The relation between serum cholesterol levels and the risk of stroke is not clear. A U-shaped relation between the serum level of total cholesterol and the risk of stroke of all types has been proposed, derived from an inverse association with hemorrhagic stroke and a direct association with ischemic stroke. The inverse relation with hemorrhagic stroke has been observed in numerous studies of populations of Japanese origin [
In our study, we found that patients with high total serum cholesterol (Correlation coefficient r = 0.4047; P < 0.0001; 95% Confidence interval for r = 0.2353 to 0.5503) and low HDL cholesterol (Correlation coefficient r = −0.4862; P < 0.0001; 95% Confidence interval for r = −0.6173 to −0.3289) were mostly associated with ischemic stroke; we measured the atherogenic index (LDL/HDL cholesterol) and the atherogenic ratio (total serum cholesterol/HDL cholesterol) and found that a statistically significant association was established between high atherogenic index (Correlation coefficient r = 0.4990; P < 0.0001; 95% Confidence interval for r = 0.3439 to 0.6276) and high atherogenic ratio (Correlation coefficient r = 0.5301; P < 0.0001; 95% Confidence interval for r = 0.3807 to 0.6526) with ischemic stroke. Also we found that a normal total serum cholesterol does not confirm a protection against stroke, because 28 patients had a high LDL (more than 160 mg/dl; n = 110) and 86 patients had a low HDL cholesterol (less than 40 mg/dl; n = 110) within the normal total cholesterol range.
Alcohol: The relation of moderate alcohol consumption to the risk of stroke has not been conclusively determined. Several methodologic problems have hampered research, including the contamination of the reference group of lifelong abstainers with former drinkers, which may contribute to the J-shaped relation observed in many studies. Only 6% patients in our study were drinkers; this small number is consistent with other studies about alcohol and stroke [
Oral contraceptive pill: Higher-dose formulations of oral contraceptives were found to increase the risk of stroke in some subgroups of women, including women over 35 years of age, cigarette smokers, women with hypertension, and women with a history of migraine headaches [
In our study 9 cases (8%) had history of taking oral contraceptive pills, six of them were ischemic stroke, which can be explained by its adverse effects, such as increased thrombosis and three cases were haemorrhagic stroke which might be related to its effect on raising blood pressure [
Atrial fibrillation: Abnormal contraction of the atria may result in thrombus formation. The risk of stroke secondary to thromboembolism related to atrial fibrillation is approximately 3% to 5% per year [
Ischemic heart disease: People with coronary heart disease or heart failure have a higher risk of stroke than those with hearts that work normally [
In the present study 41 cases (37%) had previous history of coronary heart disease and also 17 cases (27%) by transthoracic echocardiography had this disease.
12-Increased hematocrit: A high hematocrit is expected to be associated with an increased risk of thrombosis or embolism. Numerous reports from patients with polycythemia vera and pseudopolycythemia confirm a correlation of elevated hematocrit levels and the incidence of thrombosis [
Transthoracic echocardiography: Echocardiography is the investigation of choice when a cardiac source of embolism is suspected. However, debate persists about which patients with a stroke or thromboembolism requires imaging. This is in part a result of the increasing pressure on already overloaded echo services and a need for prioritization, but it also reflects considerable variation in physicians [
Echocardiographic finding in our patients was like that: Hypertensive heart disease (56%), Ischemic heart disease (27%), Normal (15%), Aortic sclerosis (8%), Valvular heart disease (6%), Atrial septal defect (0.9%), atrial myxoma (0.9%). According to the above findings, hypertensive heart disease (left ventricular hypertrophy (LVH) + diastolic dysfunction) was the main echocardiographic finding among our patients. This observation is consistent with other studies: LVH and abnormal LV geometry are independently associated with increased stroke risk [
Aortic sclerosis: The early build-up of calcium deposits that causes the valve to be thicker and more rigid than normal. Aortic sclerosis is diagnosed on echocardiography as focal areas of increased echogenicity on the valve leaflets with normal valve motion and a normal, or only mildly increased, antegrade velocity across the valve [
Atrial septal defect: The association of ASD with cerebral embolic events has been less well studied. In one series of 103 patients (mean age 52 years) with a presumed paradoxical embolism and an atrial septal abnormality undergoing percutaneous closure, a PFO alone was present in 81, an ASD alone in 12, and both a PFO and ASD in 10 [
Atrialmyxoma: The most common benign cardiac tumour, is found more commonly in young adults with stroke or transient ischemic attack (1 in 250) than in older patients with these problems (1 in 750). Strokes are often recurrent, and may be embolic or hemorrhagic, the presentation ranging from progressive multi-infarct dementia, to massive embolic stroke causing death. Because tumour fragments or adherent thrombus may embolize [
・ Hypertension is the leading risk factor of stroke. It is therefore essential to detect and treat hypertension at its outset.
・ Stroke incidence increases with age and it is more common in male gender.
・ Echocardiography is a useful test as it is cheap, non-invasive and available, to find risk factors for stroke or a complication of these risk factors on the heart.
・ Normal total serum cholesterol (TSC) does not exclude the absence of dyslipidemia, as most of our patients have low serum HDL, and or high LDL.
・ High TSC and low serum HDL are mostly associated with ischemic stroke.
1) Hypertension is the main risk factor for stroke, so early diagnosis and prompt management of it is the main stay in preventing stroke.
2) Inpatient stroke unit operational under the direction of stroke director.
3) Stroke clinic to provide outpatient consultations for stroke care.
4) Ongoing program for primary and secondary stroke prevention.
5) Stroke nurse-coordinator.
Mohamed, A.S. and Alshekhani, M.A.M. (2016) Risk Factors for Stroke in Sulaimaniyah Iraqi Kurdistan Region-Iraq. International Journal of Clinical Medicine, 7, 639-651. http://dx.doi.org/10.4236/ijcm.2016.79070