Sahel Medical Journal

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 18  |  Issue : 4  |  Page : 177--181

A clinical study of ischemic stroke from capital of Gujarat, India


Chirayu Vijaykumar Vaidya1, Drusty Krishnasevak Majmudar2,  
1 Department of Medicine, Gujarat Medical Education Research Society Medical College and Hospital, Gandhinagar, Gujarat, India
2 Department of Radio Diagnosis, AMC MET Medical College, L. G. Hospital Campus, Maninagar, Ahmadabad, Gujarat, India

Correspondence Address:
Chirayu Vijaykumar Vaidya
“Safalya”, Plot No. 1371/2, Sector-2/B, Gandhinagar - 382 002, Gujarat, India
India

Abstract

Background: Cerebrovascular diseases rank first in frequency and importance among all neurologic diseases. Acute ischemic stroke, a subtype of acute stroke is one of the leading causes of death and major cause of morbidity and mortality throughout the world. The incidence is increasing with a gradual increase in obesity, diabetes mellitus, dyslipidemia, hypertension, and some other cardiac problem. Aims: The aim of the study was to identify the risk factors, assess various clinical and radiological features with patients attending Gujarat Medical Education Research Society (GMERS) Medical College and General Hospital in capital city Gandhinagar in Gujarat state. Subjects and Methods: This is a retrospective study of all patients managed for ischemic stroke at GMERS Medical College and Hospital, Gandhinagar, Gujarat from January 1, 2012 to December 31, 2013. Results were analyzed with SPSS version 21 software. Results: The mean age was 60.20 years. Majority (32%) were in age group of 61–70 years young ischemic stroke (age ≤45 years) comprised of 17.14% of all patients. The male to female ratio was 1.6:1 with male predominance. Most of the patients (50.3%) were having right hemiplegia followed by left hemiplegia (40%). The common clinical presentation was hemiplegia (49.1%) followed by speech involvement (29.1%), altered sensorium (9.4%). Most common risk factor was hypertension (30.1%) followed by previous history of stroke (16.1%), dyslipidemia (15.6%), and smoking (15.1%). The frequent site of the infraction was parietal (33.3%) followed by frontal (16.2%) and basal ganglia (10.7%). Conclusion: Incidence of ischemic stroke was more in the age group of 61–70 years with male predominance and hypertension was the most common risk with affection of middle cerebral artery territory.



How to cite this article:
Vaidya CV, Majmudar DK. A clinical study of ischemic stroke from capital of Gujarat, India.Sahel Med J 2015;18:177-181


How to cite this URL:
Vaidya CV, Majmudar DK. A clinical study of ischemic stroke from capital of Gujarat, India. Sahel Med J [serial online] 2015 [cited 2019 Sep 23 ];18:177-181
Available from: http://www.smjonline.org/text.asp?2015/18/4/177/176591


Full Text

 Introduction



Stroke is the second leading cause of death worldwide and one of the leading causes of disability. With increasing life expectancy, the burden of stroke is likely to increase worldwide with middle and low-income countries particularly affected. In a country like India, the cases are also increasing with gradual increase in obesity, diabetes mellitus, hyperlipidemia, hypertension, and some other cardiac problems. The incidence of stroke increases

with age and the number of stroke is projected to increase as the number of the elderly population will increase. Stroke is a medical emergency and needs urgent diagnosis and treatment.[1] It has been defined as a rapidly developing signs of focal (or global) disturbance of cerebral function with symptoms lasting for ≥24 h, or leading to death with no apparent cause other than vascular origin. The clinical manifestations of stroke are highly variable because of the complex anatomy of the brain and its vasculature. Stroke may be broadly classified into ischemic and hemorrhagic stroke. Ischemic stroke occurs due to loss of blood supply to part of the brain initiating the ischemic cascade due to free radical production and damage to endothelial lining. At present, diagnosis of stroke is mostly based on computed tomography (CT) scan or magnetic resonance imaging (MRI).[1] Studies had been conducted on the epidemiology and risk factors of acute stroke in various parts of the world including India. After coronary heart disease (CHD) and cancer of all types, stroke is the third commonest cause of death worldwide. However, unlike the Caucasians, Asians have a lower rate of CHD and a higher prevalence of stroke.[2] Among the Asians, the number who died from a stroke was >3 times that for CHD.[3],[4],[5] In one report, the age-standardized, gender-specific stroke mortality rate was 44–102.6/100,000 for Asian males, compared with only 19.3 for Australian white males.[6] However, it is believed that the average age of patients with stroke in developing countries is 15 years younger than that in developed countries.[7] Indian studies have shown that about 10–15% of strokes occur in people below the age of 40 years.[8] In India, nearly one-fifth of patients with first-ever strokes admitted to hospitals are aged <40 years.[9] Higher proportions of younger individuals are affected in India compared to developed countries. Ischemic stroke is the most common subtype followed by embolic stroke and 21–48% of stroke

in young is caused by atherosclerotic large artery occlusive disease.[10] Men are more likely to have a stroke than women: The male/female sex ratio for India is 7:1.[11] This may be due to differences in risk factors such as smoking and drinking which are more prevalent among men in India compared with women.[12] The mean onset of stroke for men in India ranges from 63 to 65 for men and 57–68 for women.[12],[13],[14] Therefore, this study was carried out to know the demographic and clinical characteristics of the patients with ischemic stroke in our hospital which will provide baseline data to plan future preventive strategies for government and will help young physicians to deal with this disabling disease.

 Subjects and Methods



This is a retrospective study of 175 cases managed for ischemic stroke in the medical ward of Gujarat Medical Education Research Society (GMERS) Medical College and Government Hospital Gandhinagar, Gujarat from January 1, 2012 to December 31, 2013. Due permission from Ethical Committee was taken to retrieve case notes of the patients from the Medical Record Department of the Hospital and relevant data extracted and analyzed. We have only CT scan machine in house, for MRI we have to send patients to higher centers. The definition of stroke given by the World Health Organization (WHO), as rapidly developing clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24 h or longer or leading to death, with no apparent cause other than vascular origin (WHO 1989) were applied to include these cases in this study.

Inclusion criteria:

All patients above age 18 years and whose symptoms and signs were according to WHO definition of stroke with CT confirmed diagnosis of ischemic infarction.

Exclusion criteria:

Age below 18 yearsHemorrhagic strokeHemorrhagic infarctionPatients' medical records not indicating CT confirmed diagnosis of ischemic infarctionMedical records of patients sent for brain MRI with inconclusive or normal CT scan findings.

Methods

The data obtained were analyzed using SPSS version 21.0 software (IBM). Results were expressed in frequencies and percentages.

 Results



One hundred and seventy-five cases of ischemic stroke case records managed in medical ward of GMERS Medical College and Government Hospital, Gandhinagar during a period of January 1, 2012–December 31, 2013 were studied and evaluated for clinical profile and frequency of risk factors.

Age distribution

The age range was from 26 to 97 years with a mean age of 60.20 years. The incidence of ischemic stroke is maximum in the age group of 61–70 years which comprises 32% of total patients, as shown in [Table 1]. Young patients with ischemic stroke (age ≤45 years) comprised of 17.14% of all patients.{Table 1}

Sex distribution of stoke patients

Of 175 patients, 109 (62.3%) were males, and 66 (37.7%) were females as shown in [Table 1]. The male to female ratio was 1.6:1.

From above observation, it can be concluded that the incidence of ischemic stroke is more common in male sex.

As shown in [Table 1], more number of females (26) and more number of males (30) were in 61–70 years age group.

Neurological findings in ischemic stroke patients

In our study, as shown in [Table 2], most common neurological finding was right hemiplegia with (50.3%) followed by left hemiplegia (40%).{Table 2}

Clinical presentation of ischemic stroke patients

In our study as shown in [Table 2], the most common clinical presentation was hemiplegia which was (49.1%) followed by speech involvement (29.1%), altered sensorium (9.4%), convulsions (4.9%), instability of gait (4.5%), vomiting (1.9%), and headache (1.1%).

Risk factors in ischemic stroke patients

In our study, most common risk factor was hypertension with (30.1%) incidence. It is followed by previous history of cerebrovascular disease (16.1%), dyslipidemia (15.6%), smoking (15.1%), diabetes mellitus (10.8%), alcohol (6.5%), history of previous coronary artery disease with 5.4% and 1 case of rheumatic heart disease as shown in [Table 2].

Topographic distribution of cerebral infarction

In our study, most common site of infraction was parietal (33.3%) followed by frontal (16.2%), basal ganglia (10.7%), temporal (7.9%), occipital (7.6%), and paraventricular (4.8%). Other affected areas of the brain are shown in [Table 3].{Table 3}

 Discussion



In our study, mean age was of 60.20 years. Similar observations were noticed in the studies done by Misbach and Wendra [15] Qari [16] Naik et al.,[17] and Eapen et al.,[18] in which mean ages were (58.8 + 13.3 vs. 63 vs. 58.27 vs. 57 years), respectively. The incidence of ischemic stroke was maximum in the age group of 61–70 years which comprises 32% of total patients. This trend was seen in the studies done by Misbach and Wendra [15] Shah et al.,[19] and Zhang et al.,[20] with 35.8% patients were ≥65 years, 61.25% patients in 60–69 years and 6.48% patients in 65–85 years, respectively. In a study done by Baidya et al.,[21] acute ischemic stroke was found most commonly in 50–75 age group. Young patients with ischemic stroke (age ≤45 years) comprised of 17.14% of all patients. It correlated with the studies done by Misbach and Wendra [15] Eapen et al.,[18] and Shah et al.[19] with incidences of young patients with ischemic stroke were (12.9% vs. 20% vs. 15.4%), respectively.

In our study, 62.3% were males and 37.7% were females with male to female ratio of 1.6:1. Similar trend was seen in study by Abu Naser et al.,[22] in which male to female ratio was 1.35:1. Incidence of ischemic stroke was more common in male sex. In study by Naik et al.,[17] most (69.33%) were males with ischemic stroke. Similarly, in studies by Eapen et al.,[18] Zhang et al.[20] and Baidya et al.,[21] there was male predominance in ischemic stroke.

In our study, most common presentation was right hemiplegia with (50.3%) followed by left hemiplegia (40%). Similarly, in the study by Abu Naser et al.,[22] right hemiplegia with (51.25%) was predominant. This was also seen in the study by Baidya et al.,[21] in which most common presentation was right hemiplegia with (48%) followed by left hemiplegia (32%).

In our study, most common clinical presentation was hemiplegia (49.1%) followed by speech involvement (29.1%), altered sensorium (9.4%). Similar trend was seen in the study by Misbach and Wendra [15] in which most common clinical presentation was hemiplegia which was (90%) followed by speech involvement (50%). In the study of Baidya et al.,[21] (80%) hemiplegia, (60%) speech involvement, and (54%) altered sensorium. In a study by Abu Naser et al.,[22] most common clinical presentation was hemiplegia (80%), speech involvement (60%), altered sensorium (53.75%) in ischemic stroke. In a study by Qari,[16] most common feature was hemiplegia with 69%, equal speech involvement and altered sensorium of 32%.

In our study, most common risk factor was hypertension with (30.1%) incidence. Other major risk factors were previous history of cerebrovascular disease (16.1%), dyslipidemia (15.6%), smoking (15.1%), diabetes mellitus (10.8%), alcohol (6.5%), history of previous coronary artery disease was 5.4%, and 1 case of rheumatic heart disease (0.5%). Similar trend was seen in study by Misbach and Wendra [15] in which the most common risk factors for stroke was hypertension (73.9%) with other major risk factors such as smoking (20.47%), prior stroke, ischemic heart disease (IHD), and diabetes mellitus (19.9%, 19.9%, and l7.3%, respectively). In study by Abu Naser et al.,[22] hypertension was most common with (86.25%), (55%) smokers, (26.25%) diabetes mellitus, and (10%) of cerebral infarction had previous history of stroke or transient ischemic attack. In a study of Baidya et al.,[21] most common risk factor of acute ischemic stroke was hypertension (68%). In study by Palm et al.,[23] in both men and women, most common risk factor was hypertension (86.9% vs. 85.1%), dyslipidemia (64% vs. 67.1%), and smoking (53.6% vs. 36.2%). In a study by Qari [16] hypertension was the most important risk factor for ischemic stroke, as other risk factors were hyperlipidemia, diabetes mellitus, IHD, atrial fibrillation, and smoking. In study by Maskey et al.,[24] major risk factors were hypertension (61.2%), cigarette smoking (59.4%), dyslipidemia (30%), and diabetes mellitus (9.3%). In study by Alam et al.,[25] major risk factors in order of frequency were hypertension (60%), diabetes mellitus (28%), dyslipidemia (28%), smoking (22%), IHD (18%). In study by Marwat et al.,[26] hypertension was the most common risk factor (75%) followed by diabetes mellitus (54.5%), IHD (36.3%), hyperlipidemia (13.6%), smoking (13.6%), and valvular heart disease (6.8%). In studies done by Banerjee et al.[27] and Shah et al.,[19] most common risk factor of ischemic stroke was hypertension. All above-mentioned studies showed hypertension as the most common risk factor of ischemic stroke.

In our study, most common site of infarction was parietal (33.3%) followed by frontal (16.2%), basal ganglia (10.7%), temporal (7.9%), occipital (7.6%), and periventricular (4.8%). Hence, most common area was lobar in distribution of middle cerebral artery (MCA). Similar trend was seen in the study by Naik et al.[17] and Eapen et al.,[18] in which most patients had infarction in MCA territory (77% vs. 83%). This was seen in the study by Shah et al.[19] Baidya et al.[21] and Abu Naser et al.,[22] in which most common area of infarction was cortical (77.1% vs. 59% vs. 58.75%), respectively.

 Conclusion



Incidence of ischemic stroke was maximum in the age group of 61–70 years and the mean age of 60.20 years. Young ischemic stroke (age ≤45 years) comprised of 17.14% of all patients. Male to female ratio was 1.6:1 with male predominance. Most common neurological presentation was right hemiplegia. Most common clinical presentation was hemiplegia followed by speech involvement and altered sensorium. Most common risk factor was hypertension. Other major risk factors were previous history of cerebrovascular disease, dyslipidemia, diabetes mellitus, and alcohol intake. Most common site of the infraction was parietal followed by frontal and basal ganglia.

 Acknowledgments



Sincerely thankful to Mr. Sanjay Makwana, data entry operator for helping in data analysis.

References

1Smith WS, English JD, Johnson SC. Cerebrovascular diseases. In: Favei AS, Bravnald E, Kasper DL, Hsusor SL, Longo DL, Joneson J, et al., editors. Harrison's Principles of Internal Medicine. 18th ed. USA: McGraw Hills; 2012. p. 2513-35.
2Li SC, Schoenberg BS, Wang CC, Cheng XM, Bolis CL, Wang KJ. Cerebrovascular disease in the People's Republic of China: Epidemiologic and clinical features. Neurology 1985;35:1708-13.
3World Health Organization. World Health Statistics Manual 1993. Geneva, Switzerland: World Health Organization; 1994.
4Wu YK. Epidemiology and community control of hypertension, stroke and coronary heart disease in China. Chin Med J (Engl) 1979;92:665-70.
5Wu Z, Yao C, Zhao D, Wu G, Wang W, Liu J, et al. Sino-MONICA project: A collaborative study on trends and determinants in cardiovascular diseases in China, Part i: Morbidity and mortality monitoring. Circulation 2001;103:462-8.
6Menzies Centre for Population Health Research. Profile of Cardiovascular Diseases, Diabetes Mellitus and Associated Risk Factors in the Western Pacific Region. Manila: World Health Organization; 1999.
7Tripathy A, Jeemon P, Ajay V, Prabhakaran D, Reddy K. CVD profile of India. IC Health and WHO 2007:226-43.
8Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: A systematic review. Lancet Neurol 2009;8:355-69.
9Pandian JD, Jaison A, Deepak SS, Kalra G, Shamsher S, Lincoln DJ, et al. Public awareness of warning symptoms, risk factors, and treatment of stroke in northwest India. Stroke 2005;36:644-8.
10KMPG Emerging Trends in Health Care Report India. A Journey from Bench to Bedside. Feb, 2011.
11Sethi P. Stroke-incidence in India and management of ischemic stroke. Neurosciences 2002;4:139-41.
12Das SK, Banerjee TK. Stroke: Indian scenario. Circulation 2008;118:2719-24.
13Bhattacharya S, Saha SP, Basu A, Das SK. A 5 years prospective study of incidence, morbidity and mortality profile of stroke in a rural community of Eastern India. J Indian Med Assoc 2005;103:655-9.
14Sridharan SE, Unnikrishnan JP, Sukumaran S, Sylaja PN, Nayak SD, Sarma PS, et al. Incidence, types, risk factors, and outcome of stroke in a developing country: The Trivandrum Stroke Registry. Stroke 2009;40:1212-8.
15Misbach J, Wendra A. Clinical pattem of hospitalized strokes Clinical pattern of hospitalized strokes in 28 hospitals in Indonesia. Med J Indones 2000;9:29-34.
16Qari FA. Profile of stroke in a teaching university hospital in the western region. Saudi Med J 2000;21:1030-3.
17Naik M, Rauniyar RK, Sharma UK, Dwivedi S, Karki DB, Samuel JR. Clinico-radiological profile of stroke in eastern Nepal: A computed tomographic study. Kathmandu Univ Med J (KUMJ) 2006;4:161-6.
18Eapen RP, Parikh JH, Patel NT. A study of clinical profile and risk factors of cerebrovascular stroke. Gujarat Med J 2009;64:48-54.
19Shah PA, Bardi GH, Naiku BA, Khaliq A, Kaul RK. Clinico-radiological profile of strokes in Kashmir valley, North-West India: A study from a university hospital. Neurol Asia 2012;17:5-11.
20Zhang J, Wang Y, Wang GN, Sun H, Sun T, Shi JQ, et al. Clinical factors in patients with ischemic versus hemorrhagic stroke in East China. World J Emerg Med 2011;2:18-23.
21Baidya OP, Chaudhuri S, Devi KG. Clinico-epidemiological study of acute ischemic stroke in a tertiary hospital of Northeastern state of India. Int J Biomed Adv Res 2013;4:661-5.
22Abu Naser S, Nur N, Shahriar M, Alam B, Miah T. Clinical presentation and epidemiology of stroke – A study of 100 cases. J Med 2009;10:86-9.
23Palm F, Urbanek C, Wolf J, Buggle F, Kleemann T, Hennerici MG, et al. Etiology, risk factors and sex differences in ischemic stroke in the Ludwigshafen Stroke Study, a population-based stroke registry. Cerebrovasc Dis 2012;33:69-75.
24Maskey A, Parajuli M, Kohli SC. A study of risk factors of stroke in patients admitted in Manipal Teaching Hospital, Pokhara. Kathmandu Univ Med J (KUMJ) 2011;9:244-7.
25Alam I, Haider I, Wahab F. Risk factors stratification in 100 patients of acute stroke. J Postgrad Med Inst 2004;18:583-90.
26Marwat MA, Usman M, Hussain M. Stroke and its relationship to risk factors. Gomal J Med Sci 2009;7:17-21.
27Banerjee TK, Mukherjee CS, Sarkhel A. Stroke in the urban population of Calcutta – An epidemiological study. Neuroepidemiology 2001;20:201-7.