A CLINICAL STUDY OF STROKE IN YOUNG

: INTRIDUCTION : Stroke is one of the important causes of morbidity and mortality all over the world. Incidence of stroke steadily increases with age. Experts are concerned of the emerging stroke epidemic in India. Stroke affecting the young has potentially devastating consequence son the individual and his family. Certain risk factors are unique to the young. It needs more studies for identification and modification of risk factors. The study aims to evaluate clinical features, risk factors, etiology and mortality of stroke in young patients. METHODS: 74 young patients satisfying the inclusion criteria were included in this study. A detailed history was taken from young stroke patients, systemic examination and required investigations were done. Data was collected in standardized proforma and analysed. RESULTS: Stroke in young accounts for 7.95% of stroke cases of all age groups. The mean age of the patients was 34.66 ± 7.48 years. Among 74 patients, 47(63.51%) were male and 27(36.49%) were female. Seizures, decreased consciousness, speech involvement and motor deficit were observed in 33.78%, 44.59%, 22.97% and 100% of cases respectively. 82.43% patients had ischemic and 17.57% patients had hemorrhagic stroke. Among ischemic stroke, large artery atherosclerosis was 16.21%, tuberculous meningoencephalitis with vasculitis was 16.21%, lacunar stroke was 10.81%, CVT was 10.81% and cardio embolic stroke was 6.76%. Smoking (59.45%), alcoholism (58.10%), hypertension (43.24%), coronary artery disease (8.10%), diabetes mellitus (10.81%), elevated total cholesterol (25.67%), elevated low density lipoproteins (22.97%), elevated triglycerides (27.02%) and low HDL (22.97%) were important risk factors. Carotid doppler was abnormal in 9.45% of patients. 6.76% patients had mitral stenosis in echocardiogram. Low protein C and protein S were found in 1.35% of patients. Eight (10.81%) patients died during the hospital stay. INTERPRETATION AND CONCLUSIONS: The major risk factors for stroke were hypertension, dyslipidemia, smoking, alcoholism and diabetes mellitus. Ischemic stroke was more common than hemorrhagic stroke. CVT was common in postpartum women. 58% of TB meningoencephalitis patients have AIDS. Mortality was higher in hemorrhagic stroke. informed consent was taken from all patients. Patients who satisfied the inclusion criteria were included in this study. A proforma was prepared which include detailed history, clinical examination and required investigations. History includes all symptoms pertaining to the stroke in detail with emphasis on all risk factors. A complete clinical examination is done for neurological deficit. Relevant investigations like hemoglobin, total white cell count, erythrocyte sedimentation rate, blood sugar, blood urea, serum creatinine, test for HIV, CT scan brain were performed in all patients. Coagulation profile, ANA, anti-dsDNA, antiphospholipid antibodies, CSF analysis, carotid doppler and echocardiogram were performed in selected patients. Data was collected in standardized proforma from all the subjects. Data collected in a predesigned proforma was managed using Excel 2007. All the entries were double-checked for any possible error. Descriptive statistics for the categorical variables were performed by computing the frequencies (percentage) in each category Epi info software was used to calculate P value for statistical significance. P


INTRODUCTION:
Stroke is a global health problem. It is one of the important causes of morbidity and mortality all over the world. Stroke causes long-term disability and has tremendous emotional and socioeconomic consequences in patients, their families and society. In the last four decades, there is more than 100% increase in stroke incidence in low to middle income countries, but a 42%decrease in high-income countries. 1 Stroke mortality rates are declining or stabilizing in developed countries, experts are concerned of the emerging stroke epidemic in India. 2 As life expectancy is increasing, India will likely face a significant socioeconomic burden to meet the costs of managing stroke. 2 Recent study identified that 7% of medical and 45% of neurological admissions were due to stroke with a fatality rate of 9% at hospital discharge. 3

AGE AND STROKE INCIDENCE:
Age is an independent risk factor for stroke. It has strong association with the incidence of stroke. It steadily increases with age. Indian studies have estimated that the prevalence rates Increase from 0.1-0.3/1000 in the <45 year age group to 12-20/1000 in the 75-84 year age group. 4 Similarly, the incidence rates increase from 27-34/100,000 in the 35-44 age groups to 822-1116/100,000 in the 75+ age group. 2,5 In India, the prevalence of stroke in younger individuals is high (18-32% of all stroke cases) compared with high-income countries. 2 Most of the studies of stroke in young included subjects from second to fourth or fifth decade, in general, stroke in young imply people in between the age group of 15-45 years. The average age of patients with stroke in developing countries is 15 years younger than that in the developed countries. The etiology may vary with different age groups, but most of the risk factors are common to all age groups. Still, certain factors are confined and unique to the young. Stroke affecting the young has potentially devastating consequences on the individual, his family and society. Several studies have analyzed the risk factors of stroke in young, but considering its impact on younger generation, it needs more studies for identification and modification of risk factors.

MATERIAL AND METHODS:
This is a hospital based prospective study conducted in Six medical wards and acute medical care ward in department of general medicine, SVRRGGH, S. V. Medical College, Tirupati during the period of November 2011 to July 2013.

INCLUSION CRITERIA INCLUDED:
Age between 15-45 years, Patients with focal or global neurological deficit attributable to vascular cause and persist for more than 24 hours.

EXCLUSION CRITERIA INCLUDED:
Age <15 and >45 years, Traumatic cause of focal deficits, Patients whose radiological workup does not confirm stroke, Patients unwilling to participate in the study. Written informed consent was taken from all patients. Patients who satisfied the inclusion criteria were included in this study. A proforma was prepared which include detailed history, clinical examination and required investigations. History includes all symptoms pertaining to the stroke in detail with emphasis on all risk factors. A complete clinical examination is done for neurological deficit. Relevant investigations like hemoglobin, total white cell count, erythrocyte sedimentation rate, blood sugar, blood urea, serum creatinine, test for HIV, CT scan brain were performed in all patients. Coagulation profile, ANA, anti-dsDNA, antiphospholipid antibodies, CSF analysis, carotid doppler and echocardiogram were performed in selected patients. Data was collected in standardized proforma from all the subjects. Data collected in a predesigned proforma was managed using Excel 2007. All the entries were double-checked for any possible error. Descriptive statistics for the categorical variables were performed by computing the frequencies (percentage) in each category Epi info software was used to calculate P value for statistical significance. P value <0.05 -Significant. P value>0.05 -Not significant.

RESULTS:
In the study period from November 2011 to July 2013, 930 stroke cases of all age groups were admitted in acute medical care ward and medical wards. Among them 74 young patients satisfying the inclusion criteria were included in this study. Stroke in young accounts for 7.95% of total stroke patients admitted. 23 of them were admitted in acute medical care ward.   ECHOCARDIOGRAPHY AND CAROTID DOPPLER: Echocardiography for looking Regional wall motion abnormalities (RWMA), screening for valvular heart disease was performed in 60 patients. Echocardiography showed regional wall motion abnormality suggestive of coronary artery disease in 6(8.10%) patients and rheumatic heart disease with mitral valve involvement in 5(6.76%) patients. Doppler of carotid vertebral arteries was done in 52 patients in study population. Abnormal carotid doppler was reported in 7(9.45%) patients. . Free protein C and S were done in selected patients (n=31) with ischemic stroke. Low protein C was found in 1(1.35%) patient and 1(1.35%) patient ha d low protein S. Antiphospholipid antibodies were present in 2(2.70%) patients.
MORTALITY: Eight (10.81%) patients in study population died during the hospital stay are shown in figure 23. Deaths in male and female patients were 5 and 3 respectively is shown in figure 24. Among 8 expired patients, 6 patients had hemorrhagic stroke, 1 patient had HIV positive serology with tuberculoma and 1 patient had cerebral venous sinus thrombosis. Mortality in hemorrhagic stroke patients was 46.15%. Mortality in ischemic stroke patients was 3.27%.