Ischemic Stroke at Jordan University Hospital: A One-Year Hospital-Based Study of Subtypes and Risk Factors

Keywords

Stroke; Hypertension; Jordan

Abstract

Objective: To study the ischemic stroke subtypes and risk factors in 100 patients observed at Jordan University Hospital (JUH) over a one-year-period, and to compare the results with another 100 age-and –sex matched controls as well as with studies from other Arab countries.

Methods: One hundred patients with first-ever ischemic stroke admitted to JUH over a one-year period (between January 2013 to January 2014) were studied.

Results: There were 62 males and 38 females (M/F ratio=1. 6), with a mean age of 66 years (range 22-90 years), the majority (80/100) between the age 51-80 years. The most common stroke subtype was lacunar infarcts (36 patients). Fourty-two out of 51 patients had intracranial atherosclerosis. The most common risk factor was hypertension (85%) followed by hyperlipidemia (71%) and diabetes mellitus (65%).

Conclusion: In accordance with other Arab studies and controls, hypertension was the predominant risk factor but lacunar infarcts were more common than in most reports from other Arab countries . This shows the importance of appropriate management of hypertension to reduce the incidence of stroke in Jordan.

Introduction

Stroke is a common neurological disorder, the second commonest cause of death and a major cause of disability in survivors. Cerebrovascular disease is globally the 6th commonest cause of an ongoing disease burden, but is expected to move to the 4th place by 2020 [1]. Over 65% of stroke deaths are reported from developing countries [2,3]. Stroke is largely preventable, so that knowledge of risk factors, which vary within populations, is essential to achieve eductions in the stroke rate and resulting disease burden. An examination of stroke subtypes and risk factors is an important foundation for evidence-based prevention programmes [4]. We have already published 2 studies on ischemic stroke in Jordan [5,33].

The aim of this study is to assess the ischemic stroke subtypes and risk factors in 100 patients observed at Jordan University Hospital over a one-year-period (January 2013 to January 2014), and to compare the results with 100 age- and -sex matched controls, as well as with our previous studies and those from other Arab countries.

Methods

The Jordan University Hospital is a 600-bed tertiary care teaching hospital providing health care to a large proportion of the middle class medically insured Jordanian population. One hundred consecutive patients with first-ever ischemic stroke admitted to the hospital through the emergency department between January 2013 and January 2014 were reviewed. We applied the definition of stroke given by the World Health Organization [6]: rapidly evolving clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than vascular origin.

All patients had an initial Computed Tomography (CT) brain scan to exclude intracerebral hemorrhage followed afterward by a second CT and/or Magnetic Resonance (MRI) scan to confirm the infarct location and size, as well as a Magnetic Resonance Angiography (MRA) of the neck and brain vessels to rule out arterial stenosis or occlusion. Some patients had carotid Doppler ultrasound to assess the degree of stenosis. Most patients had 2-D-transthoracic echocardiography to rule out a valvulopathy or left atrial/ventricular clot. Tests for hypercoagulable state or vasculitis were done when clinically indicated. Each patient was assessed for risk factors for stroke. Hypertension, diabetes mellitus and hyperlipidemia were defined by standard guidelines [7-9]. Ischemic heart disease; myocardial infarction and atrial fibrillation were confirmed by a 12-lead Electrocardiogram (ECG) and with a cardiology consultation. History of prior transient ischemic attacks and smoking were also noted. Obesity was diagnosed if the body mass index (BMI) was above 25.

An assessment was made of the cause(s) of the stroke and these were classified into subtypes using the TOAST criteria [10] and according to whether the cause was determined or undetermined(2 or more possible causes). The National Institute of Health Stroke Scale (NIHSS) was assessed for all patients. Risk factors for stroke were also assessed in another 100 age -and -sex -matched controls.

Results

There were 100 patients (62 males, 38 females; M/F ratio 1. 6) with a mean age of 66 years (range 22-90 years). The age and sex distribution of the patients is shown in Table 1, which demonstrates that the majority (80 patients) were between the age of 51 and 80 years. The ischemic stroke subtypes are shown in Table 2 which shows that, among those with a determined cause, lacunes were more common than large artery atherosclerosis (36 and 28 patients respectively). Strokes related to large artery atherosclerosis were noted in 51 patients(alone in 28 patients and with lacunes in 23) (see Table 2), predominantly in the anterior circulation (carotid territory) in 33/51 patients and only 18/51 in the vertebrobasilar region. Among the 33 patients with atherosclerotic strokes in the anterior circulation, 29 had intracranial atherosclerotic lesions (either stenosis or occlusion), 25 in the territory of the middle cerebral artery and 4 in the anterior cerebral artery, and only 4 had extracranial lesions (stenosis or occlusion of the internal carotid artery). Among the 18 patients with atherosclerotic strokes in the posterior circulation, 13 had intracranial lesions (stenosis or occlusion of the posterior cerebral artery) and only 5 had extracranial lesions (stenosis or occlusion of the vertebral artery). Thus the majority (42 out of 51 patients) had intracranial atherosclerotic lesions.

Table 1: Age and sex Distribution

Table 2: Ischemic stroke subtypes

The risk factors according to subtypes are shown in Table 3 which clearly indicates that the most common was hypertension (85%) followed by hyperlipidemia (71%) and diabetes mellitus (65%). A comparison of risk factors between patients and controls is shown in Table 4, which also indicates that the main risk factors in controls were similar to stroke patients (hypertension in 78% of patients followed by diabetes mellitus in 67% and hyperlipidemia in 49%).

Table 3: Risk Factors* .

Table 4: Comparison of risk factors between patients and controls.

The comparison between risk factors in our study and those in other recent studies from Arab countries (published since 2000) is shown in Table 5 which clearly demonstrates that hypertension was the most common risk factor, found in 40-85% of patients in all the studies. The most common clinical manifestations were hemiparesis/ plegia, dysarthria and aphasia, noted in 81,43 and 16 patients. The mean NIHSS score was 6 (range 1-14).

Table 5: Comparison with risk factors from other Arab countries* .

Discussion

Several points emerge from this study of 100 patients with first ever ischemic stroke observed at Jordan University hospital over a 1-year period. Regarding age and sex distribution, there was a predominance of males (62 %) (see Table 1). This is in full agreement with studies from other Arab countries where the range for males was 55. 9% to 75% [4,5,11-25]. Only one study from Kuwait showed a slightly higher female preponderance at 51. 7% [27].

The mean age of our patients (66 yrs) was slightly higher than in other series where it ranged from 58. 5 to 63 yrs [4,12,17,19,20,23,24,28]. Regarding ischemic stroke subtypes, there was a slight predominance of lacunar infarcts in our patients compared to atherosclerotic lesions (36 and 28 patients respectively),which was however much less than in our previous study on 200 patients with ischemic stroke from Jordan where lacunar infarcts were noted in 64% of patients [5]. Al-Shammri et al. [27] reported 62 patients from Kuwait,of which 59. 7% had lacunar infarcts. Khan et al found that lacunar infarcts were the most common subtype among 217 patients significant(more than 70% narrowing) or occlusion of extracranial carotid and/or vertebral arteries. This is in accordance with one of our previous studies about ischemic stroke which reported a striking absence of severe extracranial carotid and/or vertebral atherosclerosis in all of the patients [33]. This is also similar to Qari’s study,in which only 4 out of 71 Saudi Arabian patients had severe carotid stenosis [15]. Other Middle Eastern reports [34] found a higher frequency of lacunar infarcts and a less frequent prevalence of extracranial large artery disease.

The major risk factor in our patients with non-cardioembolic strokes was hypertension (85%). This is in agreement with all studies from other Arab countries, where hypertension was the most frequent risk factor, and it was reported in 24. 9-76% [5,11-29,31,35- 38]. In addition Khan reported from Qatar that hypertension was a major risk factor in a study of 40 patients with young ischemic stroke, where it was found in 40% of patients followed by diabetes mellitus in 32. 5%, hypercholesterolemia and smoking (27. 5% each) [39]. Hypertension was also a major risk factor for lacunar infarcts, similar to a population-based study done by Sacco in Minnesota which reported that hypertension was found in 81% of patients with lacunar infarcts [40]. Diabetes mellitus was found in 65% of our patients,similar to reports from other Arab countries where the range was 11. 6-69. 4%. [5,11,12,14-16,19-25,27]. However hyperlipidemia was higher in our study (71%) compared with other Arab countries where it was reported in 4-61% of patients [5,15,17,18,20,21,23-25,27,28].

Other risk factors found in our patients were cardiac diseases (ischemic heart disease and atrial fibrillation) which occurred in 43% of patients, smoking in 40% and transient ischemic attacks (TIAs) in 44% of patients. These risk factors fell within the range of those reported from other Arab countries where cardiac diseases were found in 5-50% [5,11-28], cigarette smoking in 1.6 to 44% [5,11,12,14,15,17,18,20,22-25,27,28,34], and previous TIAs in 2. 1-46% [11-13,18,20,24-28,35]. We also noticed that obesity was a significant risk factor of ischemic stroke, being found in 53% of our patients. Akhtar et al reported that obesity and hypertension were major risk factors of ischemic posterior circulation stroke in Qatar, being found in 66% and 61% of patients respectively [31].

Table 4 demonstrates that these same risk factors were also noted in controls where hypertension, diabetes mellitus and hyperlipidemia were noted in 78%, 67% and 49% respectively. This shows the high prevalence of these modifiable risk factors of atherosclerosis in Jordan, and the importance of their prevention and treatment.

Conclusion

This study has shown,first a higher mean age compared to other Arab countries; second a predominance of lacunar infarcts with the rarity of severe extracranial atherosclerotic disease, in contradistinction with most studies from other Arab countries where large artery atherosclerosis was the predominant type; and third that hypertension was the major risk factor for non-cardioembolic stroke, in accordance with all reports from other Arab countries. Although this study has the limitations associated with being a small hospital-based study, our results suggest that the morbidity and mortality of stroke would be reduced by appropriate management of hypertension. The lacunar stroke and hypertension rate is higher than most regions, and should be a focus of public health in Jordan and the Arab world. Future community-based stroke registry and clinical trials in the region would further elucidate the health needs of the population.

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Citation

Bahou Y, Ajour M and Jaber M. Ischemic Stroke at Jordan University Hospital: A One-Year Hospital-Based Study of Subtypes and Risk Factors. SM J Neurol Neurosci. 2015; 1(1): 1003.