Epidemiology and etiology of young stroke

Clinical Characteristics, Functional Outcome, and Socioeconomic Impact of Ischemic Stroke among Young Egyptian Adults

BACKGROUND

Stroke in young patients results in disproportionately high societal cost given the productive life-years lost. Little is known about stroke in young Egyptian patients. We aimed to analyze clinicodemographic characteristics, functional outcome, and socioeconomic impact of ischemic stroke among young Egyptian adults.

METHODS

This is a prospective, observational cohort study of consecutively recruited patients with acute ischemic stroke (AIS), 18-50 years, between September 2022 and September 2023 at a tertiary stroke center in the south of Egypt. We recorded baseline demographic and cardiovascular risk factors, stroke severity, stroke subtype according to the TOAST classification, intravenous thrombolysis, employment, and ambulation status pre- and post-stroke, post-stroke complications, and 90-day functional outcome measured by the modified Rankin Scale (mRS).

RESULTS

Our cohort comprised 210 patients, 38.0 (±7.8) years, 89 (42%) females. Mean NIHSS score was 11.2 (±4.8); in-hospital case fatality was 9% (19 patients). Dyslipidemia (n = 105, 50%), smoking (n = 105, 50%), and hypertension (n = 67, 32%) were the most prevalent cardiovascular risk factors. At 90 days, 58 (29%) patients had a 90-day mRS 0-1 and 53 (26%) met criteria for depression diagnosis. Sixty-nine of the 116 employed individuals (59%) remained out of work after 90 days of stroke, 61 of whom were single earners in their household. 36/60 (60%) thrombolysis-eligible patients received it; an additional 98 otherwise thrombolysis-eligible patients presented >4.5 h from symptom onset. Patients receiving IV thrombolysis were significantly more likely to have resumed full-time work at 90 days (32% vs. 11%, p = 0.006) but with no significant difference in 90-day mRS.

CONCLUSIONS

Young adult AIS patients in Egypt experience high rates of post-stroke depression and face challenges in their ability to work and provide for their families. Since most patients have treatable cardiovascular risk factors and only about two-thirds of eligible patients receive thrombolysis, reinforcing primary prevention, education about early stroke signs, and benefits of acute can improve outcomes and have significant potential societal benefit.

An international perspective on young stroke incidence and risk factors: a scoping review

BACKGROUND

Stroke among younger age groups is increasing globally. While there is a focus on research conducted on people under 65 years who have had a stroke, there is a paucity of data on the incidence and risk factors of stroke among younger people (≤ 30 years). This scoping review examines evidence on incidence and risk factors for perinatal, paediatric and young adult stroke globally.

METHODS

The review was guided by the Joanna Briggs Institute's scoping review methodology. A systematic search was conducted on 23rd March 2022 across Medline Ovid, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The eligibility criteria included all study designs providing information on the incidence and risk factors of stroke among young people (≤ 30 years) in the last ten years.

RESULTS

A total of 5750 articles were identified. After screening, 471 articles (224 cohort studies (47.6%), 164 case studies/case series (34.8%), 35 reviews (7.4%), 30 case-control (6.4%) and 18 combinations of designs (3.8%) were included. There was data from 50 different countries, 199 studies were from high-income countries, upper and middle income (n = 38), lower middle-income (n = 39), low-income (n = 3) countries, international study (n = 7) and a further 185 articles did not state the country of research. Most of the studies (63%) focused on risk factors while incidence constituted 37%. Incidence data were reported heterogeneously across studies, leading to an inability to synthesise data. The three most frequently reported risk factors for perinatal stroke were infections, cardiac conditions, and intrapartum factors. Vasculopathies, infection and cardiac conditions accounted for most reported risk factors for paediatric stroke, while chronic conditions such as diabetes mellitus, vasculopathies and cardiac conditions accounted for the most reported risk factors among young adults.

CONCLUSION

This review has highlighted different stroke risk factors for each age cohort of people under 30 years. The low number of epidemiological studies suggests that further research of this type is needed to fully understand the incidence and risk factors in young stroke. A standardised reporting of age groupings of incidence data is imperative to enable the comparison of data from different geographical locations.

Characterisation of young stroke presentations, pathways of care, and support for 'invisible' difficulties: a retrospective clinical audit study

Background Young stroke survivors are likely to be discharged home from acute hospital care without rehabilitation more quickly than older survivors, but it is not clear why. File-audit studies capturing real-world clinical practice are lacking for this cohort. We aimed to compare characteristics and care pathways of young and older survivors and describe stroke presentations and predictors of pathways of care in young survivors (≤45years), including a focus on care received for 'invisible' (cognitive, psychological) difficulties. Methods A retrospective audit of 847 medical records (67 young stroke survivors, mean age=36years; 780 older patients, mean age=70years) was completed for stroke survivors admitted to an Australian tertiary hospital. Stroke characteristics and presence of cognitive difficulties (identified through clinician opinion or cognitive screening) were used to predict length of stay and discharge destination in young stroke survivors. Results There were no differences in length of stay between young and older survivors, however, young stroke survivors were more likely to be discharged home without rehabilitation (though this may be due to milder strokes observed in young stroke survivors). For young stroke survivors, stroke severity and age predicted discharge destination, while cognitive difficulties predicted longer length of stay. While almost all young survivors were offered occupational therapy and physiotherapy, none received psychological input (clinical, health or neuropsychology). Conclusions Cognitive and psychological needs of young stroke survivors may remain largely unmet by a service model designed for older people. Findings can inform service development or models of care, such as the new Australian Young Stroke Service designed to better meet the needs of young survivors.

Mounting Stroke Crisis in India: A Systematic Review

Stroke, a neurological disorder, has emerged as a formidable health challenge in India, with its incidence on the rise. Increased risk factors, which also correlate with economic prosperity, are linked to this rise, including hypertension, diabetes, obesity, sedentary lifestyle, and alcohol intake. Particularly worrisome is the impact on young adults, a pivotal segment of India's workforce. Stroke encompasses various clinical subtypes and cerebrovascular disorders (CVDs), contributing to its multifaceted nature. Globally, stroke's escalating burden is concerning, affecting developing nations. To combat this trend effectively and advance prevention and treatment strategies, comprehensive and robust data on stroke prevalence and impact are urgently required. In India, these encompass individuals with elevated BMIs, and those afflicted by hypertension, diabetes, or a familial history of stroke. Disparities in stroke incidence and prevalence manifest across India, with differences in urban and rural settings, gender-based variations, and regional disparities. Early detection, dietary changes, effective risk factor management, and equitable access to stroke care are required to address this issue. Government initiatives, like the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) 2019, provide guidelines, but effective implementation and awareness campaigns are vital. Overcoming barriers to stroke care, especially in rural areas, calls for improved infrastructure, awareness campaigns, and support systems. Data standardization and comprehensive population studies are pivotal for informed public health policies.

Age at Menopause and the Risk of Stroke: Observational and Mendelian Randomization Analysis in 204 244 Postmenopausal Women

Background Observational studies have shown that women with an early menopause are at higher risk of stroke compared with women with a later menopause. However, associations with stroke subtypes are inconsistent, and the causality is unclear. Methods and Results We analyzed data of the UK Biobank and EPIC-CVD (European Prospective Investigation Into Cancer and Nutrition-Cardiovascular Diseases) study. A total of 204 244 postmenopausal women without a history of stroke at baseline were included (7883 from EPIC-CVD [5292 from the subcohort], 196 361 from the UK Biobank). Pooled mean baseline age was 58.9 years (SD, 5.8), and pooled mean age at menopause was 47.8 years (SD, 6.2). Over a median follow-up of 12.6 years (interquartile range, 11.8-13.3), 6770 women experienced a stroke (5155 ischemic strokes, 1615 hemorrhagic strokes, 976 intracerebral hemorrhages, and 639 subarachnoid hemorrhages). In multivariable adjusted observational Cox regression analyses, the pooled hazard ratios per 5 years younger age at menopause were 1.09 (95% CI, 1.07-1.12) for stroke, 1.09 (95% CI, 1.06-1.13) for ischemic stroke, 1.10 (95% CI, 1.04-1.16) for hemorrhagic stroke, 1.14 (95% CI, 1.08-1.20) for intracerebral hemorrhage, and 1.00 (95% CI, 0.84-1.20) for subarachnoid hemorrhage. When using 2-sample Mendelian randomization analysis, we found no statistically significant association between genetically proxied age at menopause and risk of any type of stroke. Conclusions In our study, earlier age at menopause was related to a higher risk of stroke. We found no statistically significant association between genetically proxied age at menopause and risk of stroke, suggesting no causal relationship.

Ischemic Infarction in Young Adults

Ischemic strokes in young adults are increasing in incidence and have emerged as a public health issue. The radiological features are not only diagnostic in identifying ischemic infarctions but also provide important clues in the investigation of the underlying causes or in the identification of risk factors. According to the different imaging patterns associated with ischemic stroke in young adults, the causes can be classified into 5 categories: cardioembolism, large vessel vasculopathy, small vessel vasculopathy, toxic-metabolic, and hypercoagulable disorders. The radiological features of each category and cause are described and summarized in this review.

Global disease burden of stroke attributable to high fasting plasma glucose in 204 countries and territories from 1990 to 2019: An analysis of the Global Burden of Disease Study

BACKGROUND

High fasting plasma glucose (HFPG) is the leading risk factor contributing to the increase of stroke burden in the past three decades. However, the global distribution of stroke burden specifically attributable to HFPG was not studied in depth. Therefore, we analyzed the HFPG-attributable burden in stroke and its subtypes in 204 countries and territories from 1990 to 2019.

METHODS

Detailed data on stroke burden attributable to HFPG were obtained from the Global Burden of Disease Study 2019. The numbers and age-standardized rates of stroke disability-adjusted life years (DALYs), deaths, years lived with disability, and years of life lost between 1990 and 2019 were estimated by age, sex, and region.

RESULTS

In 2019, the age-standardized rate of DALYs (ASDR) of HFPG-attributable stroke was 354.95 per 100 000 population, among which 49.0% was from ischemic stroke, 44.3% from intracerebral hemorrhage, and 6.6% from subarachnoid hemorrhage. The ASDRs of HFPG-attributable stroke in lower sociodemographic index (SDI) regions surpassed those in higher SDI regions in the past three decades. Generally, the population aged over 50 years old accounted for 92% of stroke DALYs attributable to HFPG, and males are more susceptible to HFPG-attributable stroke than females across their lifetime.

CONCLUSIONS

Successful key population initiatives targeting HFPG may mitigate the stroke disease burden. Given the soaring population-attributable fractions of HFPG for stroke burden worldwide, each country should assess its disease burden and determine targeted prevention and control strategies.

Association of Sugar-Sweetened Beverages and Cardiovascular Diseases Mortality in a Large Young Cohort of Nearly 300,000 Adults (Age 20-39)

(1) Background: The association of sugar-sweetened beverages (SSBs) with cardiovascular disease (CVD) mortality in younger adults (age 20−39) is rarely mentioned in the literature. Younger adults are less vulnerable to CVDs, but they tend to consume more SSBs. This prospective study aimed to assess the association between CVD mortality and SSBs in younger adults between 1994 and 2017. (2) Methods: The cohort enrolled 288,747 participants consisting of 139,413 men and 148,355 women, with a mean age 30.6 ± 4.8 years, from a health surveillance program. SSBs referred to any drink with real sugar added, such as fructose corn syrup or sucrose. One serving of SSB contains about 150 Kcal of sugar in 12 oz of drink. Cox models were used to estimate the mortality risk. (3) Results: There were 391 deaths from CVDs in the younger adults, and the positive association with CVD mortality started when SSB intake was ≥2 servings/day (HR: 1.59, 95% CI: 1.16−2.17). With mortalities from diabetes and kidney disease added to CVDs, the so-called expanded CVD mortality risk was 1.49 (95% CI: 1.11−2.01). By excluding CVD risk factors (hypertension, diabetes, and smoking), the CVD mortality risk increased to 2.48 (95% CI: 1.33−4.62). The dose−response relationship persisted (p < 0.05 for trend) in every model above. (4) Conclusions: Higher intake of SSBs (≥2 servings/day) was associated with increased CVD mortality in younger adults. The younger adults (age 20−39) with SSB intake ≥2 servings/day had a 50% increase in CVD mortality in our study, and the mortality risk increased up to 2.5 times for those without CVD risk factors. The dose−response relationship between the quantity of SSB intake and the mortality risk of CVD in younger adults discourages SSB intake for the prevention of CVD mortality.

"Incidence, characteristics and prognosis of cervical artery dissection-induced ischemic stroke in central Iran"

OBJECTIVES

Ischemic stroke is the most common presentation of cervical artery dissection (CAD). Information regarding CAD-induced stroke is scarce, especially in the Middle East. Here we investigated the incidence of CAD-induced stroke, its characteristics, and the clinical course in central Iran.

METHODS

This is an observational study conducted in the city of Isfahan, Iran. We recruited patients with ischemic stroke during 2017-2019. We analyzed characteristics of the CAD-induced stroke patients with regards to the involved vessel (internal carotid artery dissection (ICAD) or vertebral artery dissection (VAD)). We assessed functional outcome (modified Rankin Scale [mRS]) and recanalization status after 1 year of follow-up.

RESULTS

Among 3630 ischemic stroke patients, 51(1.4%) had CAD-induced stroke (mean age: 41.8 ± 12.6; 40.4% female; 28 and 19 ICAD and VAD cases, respectively). The crude incidence rate of CAD-induced stroke was 1.20/100,000/year (0.66/100,000/year and 0.45/100,000/year for strokes due to ICAD and VAD, respectively). mRS ≤ 2 was present in 63.8% of the patients after 1 year of follow-up. History of exercise during the last days before stroke occurrence was associated with a better follow-up mRS (β = -3.1, p-value: 0.037). Administration of anticoagulant or double-antiplatelets was related neither to mRS nor recanalization results. Trauma (27.7%), smoking (21.3%), and headache disorders/migraine (21.3%) were the most common reported factors.

CONCLUSION

We found a crude incidence rate of 1.20/100,000/year for CAD-induced stroke. Trauma, smoking, and headache disorders were the most common reported factors among our patients. CAD-induced stroke had a favorable long-term prognosis regardless of the type of the involved vessel or the used medication.

Risk Factors of Ischemic Stroke in Young Adults: A Chinese Single-Center Study

Introduction

The etiology and risk factor profile of ischemic stroke in young adults are different from those in older patients. However, current etiological classifications are more applicable for the older adults, posing a challenge to the diagnosis of young patients with ischemic stroke. In this study, we applied a modified risk factor categorization previously used in the International Pediatric Stroke Study (IPSS) to describe the risk factor profiles of Chinese young patients with ischemic stroke and explore the sex and age differences in the distribution of risk factors.

Methods

This is a single-center retrospective study. Patients aged 18–50 years with a first-ever ischemic stroke admitted to the Peking Union Medical College Hospital between 2013 and 2020 were consecutively included. The risk factors of patients were collected and divided into 10 categories according to the modified IPSS criteria and the sex and age differences were explored.

Results

A total of 538 patients were enrolled in this study. The median age was 39 years and 62.6% were men. At least one IPSS risk factor category was identified in the 93.3% of all patients. The most common IPSS subtype was atherosclerosis-related risk factors (61.7%), followed by prothrombotic states (27.3%), chronic systemic conditions (24.7%), arteriopathy (16.2%), and cardiac disorders (10.4%). Chronic systemic conditions were more prevalent in patients aged &lt;35 years (34.0 vs. 19.6%, p &lt; 0.05) and women (43.3 vs. 13.6%, p &lt; 0.0001). Atherosclerosis-related risk factors were more dominant in patients aged ≥35 years (72.6 vs. 41.9%, p &lt; 0.0001) and men (77.2 vs. 35.8%, p &lt; 0.0001).

Conclusions

The IPSS classification might be a potential tool to better identify the risk factors of ischemic stroke in young adults.

Neuroimaging Parameters Are Not Associated With Chronic Post-stroke Fatigue in Young Stroke Patients

Introduction

Post-stroke fatigue is frequently present in young adults, but its underlying mechanism is still unclear. The aim of the study was to investigate the association between lesion location, network efficiency and chronic post-stroke fatigue based on voxel-based lesion-symptom mapping and structural network connectivity analysis.

Patients and Methods

One hundred and thirty five young patients, aged 18–50 years, with a first-ever transient ischemic attack or cerebral infarction from the Follow-Up of Transient ischemic attack and stroke patients and Unelucidated Risk factor Evaluation (FUTURE) study, underwent 1.5T MRI and were assessed for fatigue using the self-report Checklist Individual Strength. Stroke lesions were manually segmented, and structural network efficiency was calculated using the diffusion MRI-based brain networks and graph theory for each patient. Univariate and multivariate analyses was performed to study the associations between MRI parameters and chronic post-stroke fatigue. In addition, we used voxel-based lesion-symptom mapping to analyze the relationship between the lesion location and chronic post-stroke fatigue.

Results

Mean age at index event was 39.0 years (SD ± 8.2), and mean follow-up duration was 11.0 years (SD ± 8.0). 50 patients (37%) had post-stroke fatigue. Voxel-based lesion-symptom mapping showed no significant relation between stroke lesions and the presence of chronic post-stroke fatigue. Furthermore, there were no significant associations between the lesion size or network efficiency, and the presence of chronic post-stroke fatigue.

Discussion

We did not find any association between stroke characteristics (lesion location and size) and chronic post-stroke fatigue (CIS20-R), nor associations between structural brain network connectivity and post-stroke fatigue on the long term in young stroke patients.

Age–Period–Cohort Analysis of Long Trend of Mortality for Stroke and Subtypes Attributed to High SBP in Chinese Adults

Stroke has been found as the leading cause of death in China, and high systolic blood pressure (SBP) has been indicated as a critical risk factor of stroke mortality. Accordingly, in this article, the aims were to investigate the long-term trends of mortality in terms of stroke and subtypes arising from high SBP stratified by age and gender among Chinese adults. The data of this article originated from the global burden of disease (GBD) study database. The age, period, and cohort effects were examined with the age–period–cohort model (APC). The age-standardized mortality of stroke attributed to high SBP in China has been significantly declining from 1990 to 2019. As indicated by the result of APC analysis, substantially rising age effects have been exerted on stroke and subtypes from 25 to 84 years of both genders, whereas the age effect on women increased less rapidly than that on men. As opposed to the above result, the period and cohort effects were reported to show similar monotonous decrease trends, and stroke of women more significantly declined than that of men (significantly with p &lt; 0.05 for all). All types of stroke mortality arising from high SBP were indicated to change. The risk of death was identified to be most remarkably reduced in high SBP-attributable subarachnoid hemorrhage (SAH), whereas intracerebral hemorrhage (ICH) and ischemic stroke (IS) decreased at approximately the same rate. People born in the later birth cohorts or living in recent periods had a lower risk of stroke death, whereas men and elder groups were considered as the high-risk populations for stroke mortality due to high SBP. Although the stroke mortality relating to high SBP in China was declining, ICH and IS would continue to be the first and second lethal subtypes of stroke. In contrast to the above finding, SAH accounted for the minimum proportion of deaths and the maximum reduction in period and cohort effects. Thus, it is of high significance to introduce advanced hypertension control technology and knowledge regarding healthy lifestyles.

A Contemporary Review of Epidemiology, Risk Factors, Etiology, and Outcomes of Premature Stroke

PURPOSE OF REVIEW

Recent data identifies increases in young ischemic and hemorrhagic strokes. We provide a contemporary overview of current literature on stroke among young patients or premature stroke along with directions for future investigation.

RECENT FINDINGS

Strokes in the young are highly heterogenous and often cryptogenic. Sex distribution and risk factors shift from women among the youngest age groups (< 35) to men over the age of 45, with a coinciding rise in traditional vascular risk factors. Incidence is higher in minority and socioeconomically disadvantaged populations, and the impact of stroke among these communities may be exaggerated by disparities in symptom recognition and access to care. Special diagnostic work-up may be needed, and a lower threshold for diagnosis is warranted as potential misdiagnosis is a concern and may preclude necessary triage and management. Although "premature strokes" form a relatively small proportion of total incidence, they vary greatly across subgroups and present an outsized impact on quality of life and productivity.

Midbrain infarction in inherited protein S deficiency: a rare association

Inherited thrombophilic disorders are well-established predisposing factors for venous thromboembolism, but their role in arterial ischaemic stroke is uncertain. The exact mechanism of arterial thrombosis in thrombophilias remains elusive. Herein, we report a case of a 30-year-old woman who was admitted to our facility with sudden-onset right-sided ptosis and ophthalmoplegia. Detailed clinical features, neuroimaging and laboratory evaluation clinched the diagnosis of ischaemic stroke in midbrain due to microvascular obstruction associated with isolated protein S deficiency. She was treated with oral anticoagulant (warfarin) and physiotherapy; without any improvement of her symptoms at 2 months of follow-up. A high index of clinical suspicion is needed in any case of young ischaemic stroke in absence of common cardiac and vascular risk factors, to recognise the presence of inherited thrombophilia.

Presentation of cerebral and cervical arterial dissections in Botucatu, Brazil: case series

Spontaneous dissection of the cervical and cerebral arteries is an important cause of stroke and disability in young patients. In this report, the authors present a case series of patients with spontaneous carotid, vertebral, or cerebral artery dissection who underwent digital angiography. A review of the published literature on this subject is also presented.

[Ischemic stroke at a young age on the context of chronic myeloleukosis]

The article describes the clinical search for diagnosis and treatment of a patient who developed a severe ischemic stroke at a young age, when specifying the cause of which chronic myeloleucosis was identified. The unavailability of patient compliance and non-compliance with the recommended examination at the outpatient stage led to the development of severe complications. It would seem that the diagnosis of chronic myeloid leukemia, which does not represent excessive complexity, with the development of an acute condition in a young patient, such as an ischemic stroke, results in a complex diagnostic search, complicated by developing comorbidities due to general decompensation of the body.

Prevalence of and factors associated with stroke in hypertensive patients in Thailand from 2014 to 2018: A nationwide cross-sectional study

Stroke is a significant cause of death and disability. In Thailand, it imposes a major health burden, and the prevalence of stroke is increasing, particularly in patients with hypertension (HT), diabetes mellitus (DM), and dyslipidemia (DLP). We aimed to determine the trends in the prevalence of stroke and the associated factors among Thai patients with HT. Nationwide cross-sectional studies were conducted annually in 2014, 2015 and 2018 based on data obtained from the Thailand DM/HT study. Nationally, representative patients with HT in Thailand were sampled with stratified one-stage cluster sampling. A total of 104,028 participants were included in this study. The prevalence of stroke remained constant, with prevalence rates of 4.0%, 3.8%, and 3.9% in 2014, 2015 and 2018, respectively (p for trend = 0.221). Our findings suggested that the management of stroke patients who are covered by the universal coverage scheme should be evaluated. Effective interventions, including promoting smoking cessation, attenuating cholesterol levels, and controlling blood pressure should be provided to hypertensive patients to prevent ischemic stroke. Young adults with HT should be more concerned about the possibility of stroke. The use of prophylactic low-dose aspirin should be carefully monitored to prevent hemorrhagic stroke.

Bilateral cerebral infarction in diabetic ketoacidosis and bilateral internal carotid artery occlusion: A case report and review of literature

BACKGROUND

Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus (T1DM). Very rarely does DKA lead to cerebral edema, and it is even rarer for it to result in cerebral infarction. Bilateral internal carotid artery occlusion (BICAO) is also rare and can cause fatal stroke. Moreover, case reports about acute cerebral infarction throughout both internal carotid arteries with simultaneous BICAO are very scarce. In this study, we present a patient with BICAO, T1DM, hypertension, and hyperlipidemia, who had a catastrophic bilateral cerebral infarction after a DKA episode. We briefly introduce BICAO and the mechanisms by which DKA results in cerebral infarction.

CASE SUMMARY

A 41-year-old woman presented with ischemic stroke that took place 3 mo prior over the left corona radiata, bilateral frontal lobe, and parietal lobe with right hemiplegia and Broca’s aphasia. She had a history of hypertension for 5 years, hyperlipidemia for 4 years, hyperthyroidism for 3 years, and T1DM for 31 years. The first brain magnetic resonance imaging not only revealed the aforementioned ischemic lesions but also bilateral internal carotid artery occlusion. She was admitted to our ward for rehabilitation due to prior stroke sequalae. DKA took place on hospital day 2. On hospital day 6, she had a new massive infarction over the bilateral anterior cerebral artery and middle cerebral artery territory. After weeks of aggressive treatment, she remained in a coma and on mechanical ventilation due to respiratory failure. After discussion with her family, compassionate extubation was performed on hospital day 29 and she died.

CONCLUSION

DKA can lead to cerebral infarction due to several mechanisms. In people with existing BICAO and several stroke risk factors such as hypertension, T1DM, hyperlipidemia, DKA has the potential to cause more serious ischemic strokes.

Proposed definition for young-onset ischemic stroke according to its cause

OBJECTIVE

Young-onset stroke has a greater social impact than does stroke in older persons, indicating the importance of its prevention. Although there have been studies comparing stroke risk factors in young versus older individuals, no definition of young-onset ischemic stroke has been established. Large extracranial and intracranial atheroma, small vessel disease and atrial fibrillation have a major role in cases of stroke in the elderly, while these disorders are much less frequent in young adults. The purpose of this study was to determine the optimal cut-off point for defining young-onset ischemic stroke according to its cause.

METHODS

We identified 203 patients aged 65 years or less who had been admitted to our hospital between 2010 and 2017 with ischemic stroke, and we divided them into two groups according to the causes of the stroke. We allocated patients with strokes caused by small vessel occlusion, large artery atherosclerosis, atrial fibrillation, or aortic atheroma to Group A and those with strokes of other causes to Group B which included dissection, Trousseau syndrome and cerebral sinus thrombosis. We then used receiver operating characteristics curve analysis by the above groups and by sex to determine the cut-off age for defining young-onset.

RESULTS

Group A comprised 131 patients (58 ± 7 years, 92 men, 39 women) and Group B 72 (45 ± 15 years, 47 men, 25 women). Receiver operating characteristics curve analysis to differentiate Group B from Group A in all participants indicated a cut-off value of 53 years of age (area under curve: 0.78 [0.71-0.85], P < 0.001), which we therefore considered should define young-onset ischemic stroke. After dividing all patients by their sex, ROC analyses identified a cut-off for age of between 53 and 54 years for men (AUC: 0.75, 95% CI: 0.65-0.85, P < 0.001). In comparison, ≤ 48 years was the cut-off for young ischemic stroke in women (AUC: 0.83, 95% CI: 0.71-0.94, P < 0.001).

CONCLUSIONS

The age of 53 years may be the optimal cut-off point for young-onset ischemic stroke. Of note, the cut-off point between young- and non-young-onset stroke was 48 years for women, whereas it was 53 years for men. It is therefore important to carefully examine and treat female patients with this sex difference in mind.

Low prevalence of atrial fibrillation in ischaemic stroke: Underestimating a modifiable risk factor

INTRODUCTION

Cerebrovascular disease remains one of the leading causes of morbidity and mortality globally. In South Africa, it was the fourth leading cause of death in 2016, responsible for 5.1% of all deaths - the leading cause of death in individuals 65 years and older. Atrial fibrillation accounts for 15% of all strokes and 25% are diagnosed when patients present with a stroke. We set out to determine the prevalence of atrial fibrillation in patients with confirmed ischaemic strokes in a district level hospital in the Western Cape, South Africa.

METHODS

This descriptive study was conducted at Mitchells Plain Hospital in Cape Town and data was collected over a one-year period. Patients diagnosed with a stroke were identified from an electronic patient register and relevant radiology and clinical data were sourced retrospectively. The diagnosis of ischaemic stroke was confirmed by a CT scan report and ECGs were independently screened by two Emergency Physicians. Ethical approval was granted by the University of Cape Town Human Research Ethics Committee [790/2018].

RESULTS

The proportion of adult patients with a stroke diagnosis was 2%. Of the included cases, 80% had ischaemic strokes and 11% had haemorrhagic strokes. 11% of all patients with ischaemic strokes had atrial fibrillation, 67% of those presumed new. A total of 60 (15%) of all patients with ischaemic stroke were aged 45 years or younger. The inpatient mortality rate was statistically higher in patients who had atrial fibrillation (26% vs 7%, p < 0.001).

CONCLUSION

With the increasing population life expectancy, and prevalence of cardiovascular disease the prevalence of atrial fibrillation and its complications will increase. Since the risk of stroke related to atrial fibrillation can be reduced significantly by oral anticoagulation, further studies should aim to explore barriers and challenges to effective screening.

From an aging person to an elegant senior: a humanistic approach to viewing older adults

The continuing growth in the number of adults aged 60-plus has raised global alertness of population restructuring. This demographic change, on the one hand, reduces productivity and increases public expenditure due to aging, resulting in prejudice, bias, misrepresentation, and discrimination against them. On the other hand, it develops a specific consumer market segment and extends the availability and accessibility of the elderly through employment, volunteering, or grandparenting. This study argues against the stigmatization of this age group from a functional perspective that damages social cohesion. It advocates a humanistic view toward seniors to eradicate marginalization and promotes the manageability of the senior population. With the aid of advanced technology and health equity, senior adults can retain everyday competence for self-care with dignity, as well as gracefully attain physical and psychological health, autonomy, and well-being in their later life. All these considerations give medical and nursing professionals insight into how to take care of the elderly.

Sex differences of ischemic stroke in young adults-A single-center Chinese cohort study

BACKGROUND AND OBJECTIVE

Stroke at a young age is a societal challenge with a rising incidence. Our aim was to investigate sex differences in risk factors, etiology, and diagnostic process of ischemic stroke in Chinese young adults.

METHODS

We retrospectively recruited 411 consecutive patients with first-ever ischemic stroke who were 18 to 50 years of age (mean age, 38.2 ± 8.1 years, women 31.4%), admitted to Peking Union Medical College Hospital from 2007 to 2018. Sex differences in demographics, risk factors, etiology, and diagnostic testing were analyzed.

RESULTS

Females were significantly younger than males (36.9 versus 38.7 years, P<0.05). Hypertension (43.0%), smoking (41.1%), hyperlipidemia (37.2%), and hyperhomocysteinemia (27.9%) were common risk factors, statistically higher among males than females (P<0.05). Stroke etiology showed a significant sex difference that large-artery atherosclerosis and small-vessel diseases were more common among males than females (48.6% versus 19.4%, P<0.001; 9.9% versus 3.1%, P<0.05, respectively). Stroke of other determined etiology was more common among females (50.4% versus 19.1%, P<0.001). Relevant abnormality rates were higher among females on screening for autoimmune diseases and thrombophilia (23.3% versus 11.1%, P<0.05 and 50.0% versus 16.7%, P<0.001, respectively).

CONCLUSIONS

A high rate of the traditional stroke risk factors and etiological subtype of large artery atherosclerosis in males were found, as well as prominent sex differences in relevant diagnostic testing abnormality rates, providing useful information for developing sex-specific strategies in stroke evaluation and prevention in young adults.

The burden and outcomes of stroke in young adults at a tertiary hospital in Tanzania: a comparison with older adults

Background

Stroke burden in young adults is growing associated with unique risk factors and devastating outcomes. We aimed to investigate the magnitude, risk factors and outcomes of first ever stroke in young adults ≤45 years compared to older adults > 45 years.

Methods

All patients with a World Health Organization clinical definition of stroke at a tertiary hospital in Tanzania were enrolled. The National Institute of Health Stroke Scale and Modified Rankin Scale were used to assess admission stroke severity and outcomes respectively. Kaplan-Meier analysis was used to describe survival and Cox-proportional hazards model was used to examine predictors of fatality.

Results

We enrolled 369 first ever stroke participants over 8 months. First strokes accounted for one quarter of the medical admissions in both younger and older groups, 123/484 {(25.4%) [95% CI 21.5–29.3%]} and 246/919 {(26.8%) [95% CI 23.9–29.6%]} respectively. Hemorrhagic stroke occurred in 47 (42.3%) vs 62 (27.2%) for the young and old respectively p = 0.005. Factors associated with stroke in the young were: a new diagnosis of hypertension in 33 (26.8%) vs 23 (9.3%) p < 0.001, HIV infection 12 (9.8%) vs 7 (2.8%) p = 0.005, use of hormonal contraception in females 33 (48.5%) vs 13 (9.4%) p < 0.001, elevated serum low density lipoproteins 28 (27.7%) vs 29 (16.4%) p = 0.024, hypercholesteremia 34 (31.2%) vs 40 (20.2%), p = 0.031, sickle cell disease 11 (9.7%) vs 9 (4.2%) p = 0.047 and thrombocytosis 12 (16.9%) vs 8 (5.6%) p = 0.007. The overall 30-day fatality rate was 215 (61.3%); 57 (49.1%) vs 158 (67.2%) in the young and old respectively. Independent predictors of fatality were: severe stroke {HR 10.35 (95% CI: 1.397–76.613)}, leukocytosis {HR 2.23 (95% CI: 1.448–3.419)} and fever {HR 1.79 (95% CI: 1.150–2.776)}.

Conclusions

There is a high burden of stroke in young adults that is coupled with a high 30-day fatality rate. Screening and management of hypertension is crucial in the prevention of stroke. More research is needed to identify factors which cause death, allowing the development of sustainable interventions to reduce early post stroke fatality in this group.

Young ischaemic stroke incidence and demographic characteristics - The Norwegian stroke in the young study - A three-generation research program

INTRODUCTION

Norwegian Stroke in the Young Study (NOR-SYS) is a three-generation research program of young ischaemic stroke. In this study, we assessed ischaemic stroke incidence, education and work status among young stroke patients. Furthermore, we evaluated the participation of family members for future validated information on hereditary cardiovascular events.

PATIENTS AND METHODS

Patients aged 15-60 years with radiologically verified acute ischaemic stroke, admitted to Haukeland University Hospital in Bergen, Norway from 2010 to 2015, were included. Patients' partners, common offspring ≥ 18 years and biological parents of patients and partners were invited to participate. Ischaemic stroke incidence was analysed with respect to year, age and sex using multiple logistic regression.

RESULTS

A total of 385 patients, 260 partners (80.0%) and 414 offspring (74.6%) were clinically examined. The mean annual ischaemic stroke incidence rate was 30.2 per 100,000. Incidence was higher in men, and the difference was accentuated with increasing age (p = 0.008). There was no sex difference in educational status (p = 0.104) in contrast to work status (p < 0.001) for patients. In all, 84.1% of men worked, and of these, 80.3% are fulltime. In all, 74.4% of women worked, and of these, 52.9% are fulltime. Parents participated by returning a questionnaire. For patients, 91 fathers (55.2%) and 142 mothers (57.3%) participated. For partners, 48 fathers (38.4%) and 68 mothers (40.2%) participated.

CONCLUSION

The mean annual incidence rate of young stroke was 30.2 per 100,000, and the incidence rate was higher in men. Work status was high among both sexes. Active participation rates were high for patients, partners and offspring.

Global Outcome Assessment Life-long after stroke in young adults initiative-the GOAL initiative: study protocol and rationale of a multicentre retrospective individual patient data meta-analysis

INTRODUCTION

Worldwide, 2 million patients aged 18-50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis and optimal secondary prevention in young stroke patients are limited. This limits evidence-based treatment and hampers the provision of appropriate information regarding the causes of stroke, risk factors and prognosis of young stroke patients.

METHODS AND ANALYSIS

The Global Outcome Assessment Life-long after stroke in young adults (GOAL) initiative aims to perform a global individual patient data meta-analysis with existing data from young stroke cohorts worldwide. All patients aged 18-50 years with ischaemic stroke or intracerebral haemorrhage will be included. Outcomes will be the distribution of stroke aetiology and (vascular) risk factors, functional outcome after stroke, risk of recurrent vascular events and death and finally the use of secondary prevention. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and climate of residence.

ETHICS AND DISSEMINATION

Ethical approval for the GOAL study has already been obtained from the Medical Review Ethics Committee region Arnhem-Nijmegen. Additionally and when necessary, approval will also be obtained from national or local institutional review boards in the participating centres. When needed, a standardised data transfer agreement will be provided for participating centres. We plan dissemination of our results in peer-reviewed international scientific journals and through conference presentations. We expect that the results of this unique study will lead to better understanding of worldwide differences in risk factors, causes and outcome of young stroke patients.

Clinical characteristics and outcomes of methamphetamine-associated intracerebral hemorrhage

OBJECTIVE

To compare the clinical characteristics and outcomes of primary intracerebral hemorrhage (ICH) with and without methamphetamine exposure.

METHODS

We performed a retrospective analysis of patients diagnosed with spontaneous, nontraumatic ICH over a 3-year period between January 2013 and December 2016. Demographics, clinical measures, and outcomes were compared between ICH patients with positive methamphetamine toxicology tests vs those with negative methamphetamine toxicology tests.

RESULTS

Methamphetamine-positive ICH patients were younger than methamphetamine-negative ICH patients (52 vs 67 years, p < 0.001). Patients with methamphetamine-positive ICH had higher diastolic blood pressure (115 vs 101, p = 0.003), higher mean arterial pressure (144 vs 129, p = 0.01), longer lengths of hospital (18 vs 8 days, p < 0.001) and intensive care unit (ICU) stay (10 vs 5 days, p < 0.001), required more days of IV antihypertensive medications (5 vs 3 days, p = 0.02), and had more subcortical hemorrhages (63% vs 46%, p = 0.05). The methamphetamine-positive group had better premorbid modified Rankin Scale (mRS) scores (p < 0.001) and a greater change in functional ability as measured by mRS at the time of hospital discharge (p = 0.001). In multivariate analyses, methamphetamine use predicted both hospital length of stay (risk ratio [RR] 1.54, confidence interval [CI] 1.39-1.70, p < 0.001) and ICU length of stay (RR 1.36, CI 1.18-1.56, p < 0.001), but did not predict poor outcome (mRS 4-6).

CONCLUSIONS

Methamphetamine use is associated with earlier age at onset of ICH, longer hospital stays, and greater change in functional ability, but did not predict outcome.

[Indicators of homeostasis, inflammation and homocysteine in ischemic stroke in the young age]

AIM

To determine indicators of homeostasis, inflammation and homocysteine in the young-aged patients with ischemic stroke (IS) of different genesis in the subacute and chronic stages.

MATERIAL AND METHODS

Out of 218 patients with IS (mean age 34.7±8.7 years), 55 had stroke due to dissection of the inner carotid or the spinal artery, 28 due to cardioembolia, 38 due to antiphospholipid syndrome (APS), 16 due to cerebral arteritis; 85 patients were classified as having cryptogenic stroke, including 23 with noncerebral thrombosis (coagulopathy of unknown etiology) and 62 with no thrombosis. The control group included 28 healthy people matched for age and sex.

RESULTS

There were 1) an increase in von Willebrand factor and coagulation factor VIII as well as a decrease in plasminogen and an increase in plasmin-inhibitor in IS caused by thrombosis (APS, cardioembolia, coagulopathy of unknown etiology); 2) alterations in erythrocyte aggregation and deformity in cryptogenic stroke; 3) mild or moderate hyperhomocysteinemia, with the exception of patients with APS and arteritis. Linear regression analysis confirmed these relationships. Discriminant analysis identified the clusters of parameters characteristic of APS (an increase in (aPTT), plasminogen, blood sedimentation rate, C-reactive protein) and cardioembolia (decreased protein C and increased hematocrit).

CONCLUSION

The laboratory markers associated with cerebral thrombosis can be used for identification of a prothrombotic state as a cause of IS in the young age. Moderate hyperhomocysteinemia is a risk factor but not a cause of IS. The increase of inflammatory markers in APS suggests a role of infection in its development.

A Hospital-Based Study of Stroke in Young from North East India

Introduction:

A study of stroke among young adults and children has recently become a subject of interest. This is because it has a major impact on the individual and society. Studies of stroke in young can lead to therapeutical results affecting both short- and long-term outcomes.

Methods:

This paper is based on a hospital-based retrospective study, of stroke in young, for a duration of 1 year.

Results:

The study revealed stroke in young in 31.38% of all strokes, with cerebral infarction in 50.66%, followed by intracerebral hemorrhage in 41.33%, subarachnoid hemorrhage in 4.66%, and cerebral venous thrombosis in 3.33%. The most common presenting symptom was hemiparesis. The most prevalent risk factor for stroke in young was alcohol consumption, followed by traditional risk factors such as hypertension and smoking. Diabetes was detected less in our study.

Conclusion:

Although traditional risk factors are associated with stroke in young, unfavorable behavioral pattern such as alcohol abuse may cause and promote development stroke in young.

Regional differences in the temporal evolution of stroke: a population-based study of Brazil according to sex in individuals aged 15-49 years between 1997 and 2012

Objective

The present study analyzed the temporal trend of stroke mortality according to sex in individuals aged 15–49 years in the different regions of Brazil between 1997 and 2012.

Results

There was progressive reduction in mortality rate due to stroke in Brazil. The reduction trend was the same for both sexes, although mortality remained slightly higher among men. There was a difference in mortality rates according to the administrative region of the country.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3439-x) contains supplementary material, which is available to authorized users.

Prothrombotic factors do not increase the risk of recurrent ischemic events after cryptogenic stroke at young age: the FUTURE study

BACKGROUND

The role of hypercoagulable states and preceding infections in the etiology of young stroke and their role in developing recurrent ischemic events remains unclear. Our aim is to determine the prevalence of these conditions in patients with cryptogenic stroke at young age and to assess the long-term risk of recurrent ischemic events in patients with and without a hypercoagulable state or a recent pre-stroke infection with Borrelia or Syphilis.

PATIENTS AND METHODS

We prospectively included patients with a first-ever transient ischemic attack or ischemic stroke, aged 18-50, admitted to our hospital between 1995 and 2010. A retrospective analysis was conducted of prothrombotic factors and preceding infections. Outcome was recurrent ischemic events.

RESULTS

Prevalence of prothrombotic factors did not significantly differ between patients with a cryptogenic stroke and with an identified cause (24/120 (20.0%) and 32/174 (18.4%) respectively). In patients with a cryptogenic stroke the long-term risk [mean follow-up of 8.9 years (SD 4.6)] of any recurrent ischemic event or recurrent cerebral ischemia did not significantly differ between patients with and without a hypercoagulable state or a recent infection. In patients with a cryptogenic stroke 15-years cumulative risk of any recurrent ischemic event was 24 and 23% in patients with and without any prothrombotic factor respectively.

CONCLUSIONS

The prevalence of prothrombotic factors and preceding infections did not significantly differ between stroke patients with a cryptogenic versus an identified cause of stroke and neither is significantly associated with an increased risk of recurrent ischemic events after cryptogenic stroke.

Sex as a Biological Variable in Emergency Medicine Research and Clinical Practice: A Brief Narrative Review

The National Institutes of Health recently highlighted the significant role of sex as a biological variable (SABV) in research design, outcome and reproducibility, mandating that this variable be accounted for in all its funded research studies. This move has resulted in a rapidly increasing body of literature on SABV with important implications for changing the clinical practice of emergency medicine (EM). Translation of this new knowledge to the bedside requires an understanding of how sex-based research will ultimately impact patient care. We use three case-based scenarios in acute myocardial infarction, acute ischemic stroke and important considerations in pharmacologic therapy administration to highlight available data on SABV in evidence-based research to provide the EM community with an important foundation for future integration of patient sex in the delivery of emergency care as gaps in research are filled.

Challenges of stroke management in resource-limited settings: A case-based reflection

A 19-year-old man presented with a 1-year history of headache, generalised body weakness, progressive memory loss, and disorientation. One month prior to admission, there was aggravation of the weakness of the right upper limb, with new-onset difficulty with mastication, speech impairment, apathy, and urinary incontinence. On clinical examination, the patient had a motor aphasia and a right-sided hemiparesis with increased muscle tone and hyperreflexia. A noncontrast computed tomography (CT) scan of the brain revealed large ischaemic strokes extending beyond the classical vascular territories. Cerebrospinal fluid analysis showed a mildly increased protein level. The electrocardiogram revealed an irregular sinus bradycardia. The remainder of the cardiovascular and laboratory workup was unremarkable. Considering a working diagnosis of central nervous system vasculitis, the patient was treated with aspirin, prednisolone, and physiotherapy. However, he died suddenly a few weeks later. Based on this case, we discuss the challenges of stroke management in resource-limited settings, provide practical tips for general practitioners, reflect on the potential avenues for short- and long-term action, and introduce the budding collaboration platform between the University College London, the University of Liverpool, the Queen Elizabeth Central Hospital, and the Malawi-Liverpool-Wellcome Trust Clinical Research Programme.

Viral and parasitic pathogen burden and the association with stroke in a population-based cohort

Background Higher cumulative burden of viral and bacterial pathogens may increase the risk of stroke, but the contribution of parasitic infections in relation to cumulative pathogen burden and risk of stroke has rarely been examined. Aim To estimate the association of multiple persistent viral and parasitic infections with stroke in a representative sample of adults in the United States. Methods Serological evidence of prior infection was categorized as positive for 0-1, 2, 3, or 4-5 infections based on immunoglobulin G seropositivity to cytomegalovirus, hepatitis A virus, hepatitis B virus, Toxoplasma gondii, and Toxocara spp. in 13,904 respondents from the National Health and Nutrition Examination Survey III. Regression analysis was used to estimate the cross-sectional association between serological evidence of prior infection and history of stroke adjusting for demographic risk factors, and potential mediators of stroke. Results Age-adjusted models that included serological evidence of prior infection to cytomegalovirus, hepatitis A virus, hepatitis B virus, Toxoplasma gondii, and Toxocara spp. showed that adults in the highest serological evidence of prior infection category (4-5 infections) had a higher prevalence of stroke (5.50%, 95% confidence interval 2.44-10.46%) than those in the lowest serological evidence of prior infection categories (1.49%, 95% confidence interval 1.01-2.11%), and a trend test suggested a graded association between serological evidence of prior infection and stroke ( p = 0.02). In multivariable logistic regression models, the positive association of serological evidence of prior infection with stroke prevalence remained significant after adjustment for other significant risk factors (odds ratio = 1.4, p = 0.01) but was only significant among those aged 20-59 (odds ratio = 2.0, p = 0.005) and not among those aged 60-69 ( p = 0.78) or 70 and older ( p = 0.43). Conclusion We found support for a connection between serological evidence of prior infection to cytomegalovirus, hepatitis A virus, hepatitis B virus, Toxoplasma gondii, and Toxocara spp. and stroke among those aged 20-59. There may be a need to consider common parasitic infections in addition to viral and bacterial pathogens when calculating serological evidence of prior infection in relation to cerebrovascular disease.

Characteristics and Outcomes of Young Patients with First-Ever Ischemic Stroke Compared to Older Patients: The National Acute Stroke ISraeli Registry

Background

Nationwide data on the clinical profile and outcomes of ischemic stroke in younger adults are still scarce. Our aim was to analyze clinical characteristics and outcomes of young patients with first-ever ischemic stroke compared to older patients.

Methods

The National Acute Stroke ISraeli registry is a nationwide prospective hospital-based study performed triennially. Younger adults, aged 50 years and younger, were compared with patients, aged 51–84 years regarding risk factors, clinical presentation, stroke severity, stroke etiology, and outcomes. A logistic model for stroke outcome was fitted for each age group.

Results

336 first-ever ischemic strokes were identified among patients aged 50 years and younger and 3,243 among patients 51–84 years. Younger adults had lower rates of traditional vascular risk factors, but 82.7% had at least one of these risk factors. Younger adults were more likely to be male (62.8%), current smokers (47.3%), and to have a family history of stroke (7.4%). They tended to have less common stroke presentation such as sensory disturbances or headache and were more likely to arrive at the hospital independently by car. The majority of young adults (70%) had a favorable outcome (modified Ranking Scale; mRS ≤ 1) at discharge, but 11.7% had poor outcome (mRS > 3) and 18.2% had an in-hospital complication. According to a multivariable regression model, in young adults, only baseline stroke severity (National Institute of Health Stroke Scale > 5) was associated with poor outcome at discharge (p < 0.001), whereas in older adults, stroke severity (p < 0.001), female gender (OR = 1.35, CI 95% 1.03–1.76), older age (OR = 1.08, CI 95% 1.01–1.16), atrial fibrillation (OR = 1.62, CI 95% 1.16–2.26), and anterior circulation territory (OR = 2.10, CI 95% 1.50–2.94) were all significantly associated with poor outcome.

Conclusion

Our findings, in this nationwide registry, demonstrate the relatively high rate of smoking and family history of stroke, and the lower rate of hospital arrival by ambulance among young adults. This calls for increasing awareness to the possibility of stroke among young adults and for better prevention, especially smoking cessation.

Effects of professional rehabilitation training on the recovery of neurological function in young stroke patients

Young stroke patients have a strong desire to return to the society, but few studies have been conducted on their rehabilitation training items, intensity, and prognosis. We analyzed clinical data of young and middle-aged/older stroke patients hospitalized in the Department of Neurological Rehabilitation, China Rehabilitation Research Center, Capital Medical University, China from February 2014 to May 2015. Results demonstrated that hemorrhagic stroke (59.6%) was the primary stroke type found in the young group, while ischemic stroke (60.0%) was the main type detected in the middle-aged/older group. Compared with older stroke patients, education level and incidence of hyperhomocysteinemia were higher in younger stroke patients, whereas, incidences of hypertension, diabetes, and heart disease were lower. The average length of hospital stay was longer in the young group than in the middle-aged/older group. The main risk factors observed in the young stroke patients were hypertension, drinking, smoking, hyperlipidemia, hyperhomocysteinemia, diabetes, previous history of stroke, and heart disease. The most accepted rehabilitation program consisted of physiotherapy, occupational therapy, speech therapy, acupuncture and moxibustion. Average rehabilitation training time was 2.5 hours/day. Barthel Index and modified Rankin Scale scores were increased at discharge. Six months after discharge, the degree of occupational and economic satisfaction declined, and there were no changes in family life satisfaction. The degrees of other life satisfaction (such as friendship) improved. The degree of disability and functional status improved significantly in young stroke patients after professional rehabilitation, but the number of patients who returned to society within 6 months after stroke was still small.

Association of hepatitis B virus infection with decreased ischemic stroke

OBJECTIVES

Inflammatory processes (both infections and autoimmune diseases) may cause endothelial dysfunction and arterial atherosclerosis, subsequently increasing the risk of acute ischemic stroke (AIS). In this investigation, we analyzed the association between hepatitis B virus (HBV) infection and AIS risk.

METHODS

A Taiwan national insurance claims data set of 1,000,000 patients was used to extract 22,303 patients with HBV and 89,212 randomly selected sex- and age-matched controls from the beginning of 2000 to the end of 2006. Both groups were followed up until the appearance of AIS or the end of 2011. AIS risk was measured using the Cox proportional regression model.

RESULTS

After adjusting for the relevant covariates, the HBV group exhibited a lower AIS risk (adjusted hazard ratio [aHR] = 0.77, 95% confidence interval [CI]: 0.66-0.89) compared with the controls at the end of follow-up. Under the condition of no comorbidities, patients with HBV had a lower AIS risk compared with the controls (aHR = 0.65, 95% CI: 0.48-0.87). In 3 age-stratified subgroups, HBV was correlated with a significantly diminished risk of AIS (age ≤ 49 years: aHR = 0.57, 95% CI: 0.39-0.82; age 50-64 years: aHR = 0.65, 95% CI: 0.53-0.80; age ≥ 65 years: aHR = 0.96, 95% CI: 0.76-1.23).

CONCLUSION

HBV was correlated with a reduced risk of AIS development. Although a decrease in AIS risk was noted in the patients with HBV, preventing the development of AIS in this population warrants further attention.

Increased Risk of Stroke in Patients With Fibromyalgia: A Population-BASED Cohort Study

Neuropsychiatric diseases might enhance stroke development, possibly through inflammation and atherosclerosis. Approximately 25% to 40% of patients with stroke, largely younger patients, are not associated with any conventional stroke risk factors. In this research, we explored whether fibromyalgia (FM), a neuropsychosomatic disorder, increases stroke risk.From a claims dataset with one million enrollees sourced of the Taiwan National Health Insurance database, we selected 47,279 patients with FM and randomly selected 189,112 age- and sex-matched controls within a 3-year period from January 1, 2000 to December 31, 2002. Stroke risk was assessed using Cox proportional hazards regression.Comorbidities associated with increased stroke risk, such as hypertension, diabetes, hyperlipidemia, coronary heart disease, irritable bowel syndrome, and interstitial cystitis, were more prevalent in patients with FM and high stroke risk than in the controls. The overall stroke risk was 1.25-fold (95% confidence interval [CI]: 1.21-1.30) higher in the FM group than in the non-FM group. Even without comorbidities, stroke risk was higher in patients with FM than in the controls (adjusted hazard ratio [aHR] = 1.44, 95% CI: 1.35-1.53, P < 0.001). The relative risk of stroke was 2.26-fold between FM and non-FM groups in younger patients (age <35 years, 95% CI: 1.86-2.75).This is the first investigation associating FM with an increased risk of stroke development. The outcomes imply that FM is a significant risk factor for stroke and that patients with FM, particularly younger patients, require close attention and rigorous measures for preventing stroke.

Acupuncture treatment for ischaemic stroke in young adults: protocol for a randomised, sham-controlled clinical trial

INTRODUCTION

Stroke in young adults is not uncommon. Although the overall incidence of stroke has been recently declining, the incidence of stroke in young adults is increasing. Traditional vascular risk factors are the main cause of young ischaemic stroke. Acupuncture has been shown to benefit stroke rehabilitation and ameliorate the risk factors for stroke. The aims of this study were to determine whether acupuncture treatment will be effective in improving the activities of daily living (ADL), motor function and quality of life (QOL) in patients of young ischaemic stroke, and in preventing stroke recurrence by controlling blood pressure, lipids and body weight.

METHODS AND ANALYSIS

In this randomised, sham-controlled, participant-blinded and assessor-blinded clinical trial, 120 patients between 18 and 45 years of age with a recent (within 1 month) ischaemic stroke will be randomised for an 8-week acupuncture or sham acupuncture treatment. The primary outcome will be the Barthel Index for ADL. The secondary outcomes will include the Fugl-Meyer Assessment for motor function; the World Health Organization Quality of Life BREF (WHOQOL-BREF) for QOL; and risk factors that are measured by ambulatory blood pressure, the fasting serum lipid, body mass index and waist circumference. Incidence of adverse events and long-term mortality and recurrence rate during a 10-year and 30-year follow-up will also be investigated.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of The Third Affiliated Hospital of Zhejiang Chinese Medical University. Protocol V.3 was approved in June 2013. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients by telephone during follow-up calls enquiring on the patient's post-study health status.

TRIAL REGISTRATION NUMBER

ChiCTR-TRC- 13003317; Pre-results.

Hypercoagulability Is a Stronger Risk Factor for Ischaemic Stroke than for Myocardial Infarction: A Systematic Review

Background and Purpose

Hypercoagulability increases the risk of arterial thrombosis; however, this effect may differ between various manifestations of arterial disease.

Methods

In this study, we compared the effect of coagulation factors as measures of hypercoagulability on the risk of ischaemic stroke (IS) and myocardial infarction (MI) by performing a systematic review of the literature. The effect of a risk factor on IS (relative risk for IS, RR_IS) was compared with the effect on MI (RR_MI) by calculating their ratio (RRR = RR_IS/RR_MI). A relevant differential effect was considered when RRR was >1+ its own standard error (SE) or <1−SE.

Results

We identified 70 publications, describing results from 31 study populations, accounting for 351 markers of hypercoagulability. The majority (203/351, 58%) had an RRR greater than 1. A larger effect on IS risk than MI risk (RRE>1+1SE) was found in 49/343 (14%) markers. Of these, 18/49 (37%) had an RRR greater than 1+2SE. On the opposite side, a larger effect on MI risk (RRR<1-1SE) was found in only 17/343 (5%) markers.

Conclusions

These results suggest that hypercoagulability has a more pronounced effect on the risk of IS than that of MI.

Comparison of epidemiology, emergency care, and outcomes of acute ischemic stroke between young adults and elderly in Korean population: a multicenter observational study

Stroke in young adults has been known to show a lower incidence and a better prognosis. Only a few studies have examined the epidemiology and outcomes of ischemic stroke in young adults and compared them with the elderly in Korean population. All consecutive patients with ischemic stroke visiting 29 participating emergency departments were enrolled from November 2007 to October 2009. Patients with less than 15 yr of age and unknown information on age and confirmed diagnosis were excluded. We categorized the patients into young adults (15 to 45 yr) and elderly (46 yr and older) groups. Of 39,156 enrolled all stroke patients, 25,818 with ischemic stroke were included and analyzed (young adult; n=1,431, 5.5%). Young adult patients showed lower prevalence of most chronic diseases but significantly higher prevalence in exercise, current smoking, and alcohol consumption. Hospital mortality was significantly lower in young adults than elderly (1.1% vs. 3.1%, P<0.001). Higher number of patients in elderly group (68.1%) showed worsening change of modified Rankin Scale than young adults (65.2%). Young adults ischemic stroke showed favorable hospital outcomes than the elderly in Korean population.

Development and evaluation of a hospital-based peer support group for younger individuals with stroke

The incidence of stroke in younger individuals is rising, producing unique challenges due to loss of productive roles and long-term impact in the survivor's life. This paper reports the results of a hospital-based program based on occupational therapy principles that was designed to provide support and education for 13 younger individuals (<65) with stroke. Participants demonstrated improved socialization, healthy coping, and role attainment as measured by the Stroke Impact Scale (SIS), the Community Integration Questionnaire (CIQ), and a member satisfaction questionnaire. Key factors for successful implementation and considerations for future programs to meet the needs of younger adults with stroke are discussed.

Does the motor level of the paretic extremities affect balance in poststroke subjects?

Background. Poststroke impairment may lead to fall and unsafe functional performance. The underlying mechanism for the balance dysfunction is unclear. Objective. To analyze the relation between the motor level of the affected limbs and balance in poststroke subjects. Method. A prospective, cross-sectional, and nonexperimental design was conducted in a rehabilitation institute. A convenience sample of 44 patients was assessed for motor level using Brunnstrom recovery stage (BRS) and Fugl-Meyer Assessment: upper (FMA-UE) and lower extremities (FMA-LE). The balance was measured by Berg Balance Scale (BBS), Postural Assessment Scale for Stroke Patients (PASS), and Functional Reach Test (FRT). Results. BRS showed moderate correlation with BBS (ρ = 0.54 to 0.60; P < 0.001), PASS (r = 0.48 to 0.64; P < 0.001) and FRT (ρ = 0.48 to 0.59; P < 0.001). FMA-UE also exhibited moderate correlation with BBS (ρ = 0.59; P < 0.001) and PASS (ρ = 0.60; P < 0.001). FMA-LE showed fair correlation with BBS (ρ = 0.50; P = 0.001) and PASS (ρ = 0.50; P = 0.001). Conclusion. Motor control of the affected limbs plays an important role in balance. There is a moderate relation between the motor level of the upper and lower extremities and balance. The findings of the present study may be applied in poststroke rehabilitation.

Relationship between atherosclerotic risk factors and aortic plaques in patients with first-ever ischaemic stroke

OBJECTIVE

Aortic plaque is considered a risk factor of ischaemic stroke, and both ulceration and plaque thickness are considered important. However, the relative importance of aortic plaque and carotid plaque remains unclear. The purpose of this study is to clarify the relation between aortic and carotid plaque lesions and atherosclerotic risk factors in patients with acute ischaemic stroke.

METHODS

We enrolled 76 patients with first-ever ischaemic stroke, undergoing transoesophageal echocardiography, whose aetiology of ischaemic stroke was unknown. We divided the patients into two groups according to aortic plaque thickness, based on previous reports, i.e., a high-risk group (over 4mm) and a low-risk group (less than 4mm). We also examined several atherosclerotic risk factors.

RESULTS

Mean age, gender and hypertension was not significantly different between the low-risk and high-risk group. HDL-cholesterol (P<0.01), LDL/HDL ratio (P<0.05), non-HDL-cholesterol (P<0.05), HbA1c (P<0.05) and eGFR (P<0.01) were significantly different between the two groups. Max plaque thickness in the carotid artery was correlated with aortic plaque lesions.

CONCLUSION

Multiple atherosclerotic risk factors are associated with greater aortic plaque lesions. Aortic plaque is important not only as an embolic source, but also as one of the atherosclerotic markers.

Are we overestimating the stroke risk related to contraceptive pills?

PURPOSE OF REVIEW

Hormonal contraceptives are used by million of women worldwide. Ischemic stroke is one of the major harmful effects of hormonal contraceptives, but remains a very uncommon disease before menopause. The increased risk of stroke under third and fourth-generation contraceptive pills and nonoral contraceptives has been recently highlighted. Given the benefits associated with combined hormonal contraceptives (COCs), it is important to properly evaluate their risks in order to provide a better benefit/risk balance to young women.

RECENT FINDINGS

Scarce studies addressing the rates of stroke in young women suggest that the fraction attributable to the contraceptive pill remains low. In contrast, there is abundant literature on the relative risks of stroke under COCs. The risk of arterial disease seems to be similar among users of second and third-generation pills, drospirenone-containing pills and nonoral hormonal contraceptives. Progestin-only contraceptives do not appear to be associated with an increased risk of stroke.

SUMMARY

New formulations of hormonal contraceptives are not safer than second-generation COCs. Even if the absolute numbers of strokes attributable to hormonal contraceptives is very low, stringent selection of patients should help to reduce the events still more, and progestin-only contraceptives/nonhormonal methods should be preferred in cases of associated risk factors.