Risk Factors and Etiological Classification of Ischemic Stroke Subtypes in Southwest Iran
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Abstract
Precise categorization of the causes of ischemic stroke (IS) is crucial for optimizing stroke treatment and assessing the prognosis of patients. This cross-sectional study aimed to determine the risk factors and various subcategories of IS in Iranian patients. The study included all patients with IS referred to Golestan Hospital (Ahvaz, Iran) for one year. Their demographics and clinical data were collected. The etiology of IS was classified based on the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria. A total of 1100 patients with IS were evaluated, 658 were male and 442 were female. They had an average age of 66 years (ranging between 20 and 99 years). The majority of them were in the 61-80 age group. The prevalence of risk factors for IS included hypertension (HTN) (71.4%), diabetes (50.4%), smoking (42.4%), history of previous stroke (28%), dyslipidemia (15.4%), and cardiovascular disease (22.5%). Three months after admission, the mortality rate was 10.7% and the majority of patients exhibited a lower level of disability based on the modified Rankin Score (mRS) compared to the time of admission. The frequency of all risk factors, except for HTN, differed significantly between genders (P<0.05). Furthermore, the prevalence of risk factors varied significantly among different stroke etiologic subgroups (P<0.05). The most common etiological factors identified by TOAST classification were associated with large artery atherosclerosis (LAA) and small artery occlusion (SAO). Significant variations were observed in the prevalence of different etiologic subtypes of stroke among genders and across different age groups.
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11. Zhang H, Li Z, Dai Y, Guo E, Zhang C, Wang Y. Ischaemic stroke etiological classification system: the agreement analysis of CISS, SPARKLE and TOAST. Stroke and vascular neurology. 2019;4(3).
12. Jamali S, Jamali B, Yagoubi H. Evaluation of serum level of homocysteine in patients with ischemic stroke. medical journal of mashhad university of medical sciences. 2018;60(6):767-78.
13. Karimi AM, Nia JM, Farhoodi M, Hosseini SRA. Relationship between smoking status, vitamin B12 and folic acid, with homocysteine in patients with ischemic Stroke. Medical Journal of Tabriz University of Medical Sciences. 2011;33(2):81-6.
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15. Khatri P, Conaway MR, Johnston KC, Investigators ASAPS. Ninety-day outcome rates of a prospective cohort of consecutive patients with mild ischemic stroke. Stroke. 2012;43(2):560-2.
16. Zafar F, Tariq W, Shoaib RF, Shah A, Siddique M, Zaki A, et al. Frequency of Ischemic Stroke Subtypes Based on Toast Classification at a Tertiary Care Center in Pakistan. Asian J Neurosurg. 2018;13(4):984-9.
17. Aghdam A, Vatan K, Kameli A. Investigating the distribution of risk factors for ischemic stroke and its relationship with involvement site and duration of hospitalization in Imam Khomeini Hospital in Urmia: a cross sectional descriptive study. Urmia Medical Journal. 2019;30(4):329-34.
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19. Aronow WS. Hypertension-related stroke prevention in the elderly. Current Hypertension Reports. 2013;15:582-9.
20. Guo J, Guan T, Shen Y, Chao B, Li M, Wang L, et al. Lifestyle factors and gender-specific risk of stroke in adults with diabetes mellitus: a case-control study. Journal of Stroke and Cerebrovascular Diseases. 2018;27(7):1852-60.
21. O'donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. The Lancet. 2010;376(9735):112-23.
22. Lipska K, Sylaja P, Sarma P, Thankappan K, Kutty V, Vasan R, et al. Risk factors for acute ischaemic stroke in young adults in South India. Journal of Neurology, Neurosurgery & Psychiatry. 2007;78(9):959-63.
23. Khorvash F, Khalili M, Rezvani Habibabadi R, Sarafzadegan N, Givi M, Roohafza H, et al. Comparison of acute ischemic stroke evaluation and the etiologic subtypes between university and nonuniversity hospitals in Isfahan, Iran. International Journal of Stroke. 2019;14(6):613-9.
24. Li L, Yiin GS, Geraghty OC, Schulz UG, Kuker W, Mehta Z, et al. Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: a population-based study. The Lancet Neurology. 2015;14(9):903-13.
25. Morovatdar N, Thrift AG, Kapral MK, Behrouz R, Saber H, Amiri A, et al. Long-term outcomes of ischemic stroke of undetermined mechanism: a population-based prospective cohort. Neuroepidemiology. 2017;49(3-4):160-4.
26. Hart RG, Diener H-C, Coutts SB, Easton JD, Granger CB, O'Donnell MJ, et al. Embolic strokes of undetermined source: the case for a new clinical construct. The Lancet Neurology. 2014;13(4):429-38.
27. Kamel H, Healey JS. Cardioembolic stroke. Circulation research. 2017;120(3):514-26.
28. Saver JL. Cryptogenic stroke. New England Journal of Medicine. 2016;374(21):2065-74.
29. Amarenco P, Bogousslavsky J, Caplan L, Donnan G, Hennerici M. Classification of stroke subtypes. Cerebrovascular diseases. 2009;27(5):493-501.
30. Lee JS, Chang P-Y, Zhang Y, Kizer JR, Best LG, Howard BV. Triglyceride and HDL-C dyslipidemia and risks of coronary heart disease and ischemic stroke by glycemic dysregulation status: the strong heart study. Diabetes care. 2017;40(4):529-37.
31. Markus A, Valerie S, Mira K. Promising biomarker candidates for cardioembolic stroke etiology. A brief narrative review and current opinion. Frontiers in Neurology. 2021;12:624930.
32. Teo K, Lear S, Islam S, Mony P, Dehghan M, Li W, et al. Prevalence of a healthy lifestyle among individuals with cardiovascular disease in high-, middle-and low-income countries: The Prospective Urban Rural Epidemiology (PURE) study. Jama. 2013;309(15):1613-21.
2. Feigin VL, Krishnamurthi RV, Parmar P, Norrving B, Mensah GA, Bennett DA, et al. Update on the global burden of ischemic and hemorrhagic stroke in 1990-2013: the GBD 2013 study. Neuroepidemiology. 2015;45(3):161-76.
3. Phipps MS, Cronin CA. Management of acute ischemic stroke. Bmj. 2020;368.
4. Tan Y-f, Zhan L-x, Chen X-h, Guo J-J, Qin C, Xu E. Risk factors, clinical features and prognosis for subtypes of ischemic stroke in a Chinese population. Current medical science. 2018;38:296-303.
5. Azarpazhooh MR, Etemadi MM, Donnan GA, Mokhber N, Majdi MR, Ghayour-Mobarhan M, et al. Excessive incidence of stroke in Iran: evidence from the Mashhad Stroke Incidence Study (MSIS), a population-based study of stroke in the Middle East. Stroke. 2010;41(1):e3-e10.
6. Fahimfar N, Khalili D, Mohebi R, Azizi F, Hadaegh F. Risk factors for ischemic stroke; results from 9 years of follow-up in a population based cohort of Iran. BMC neurology. 2012;12(1):1-7.
7. Iyadurai EAR, Vardhan AH, Manivannan M. TOAST CLASSIFICATION AND NIHSS SCORE IN ACUTE ISCHAEMIC STROKE IN A TERTIARY CARE HOSPITAL–A PROSPECTIVE STUDY. Int J Acad Med Pharm. 2023;5(3):983-6.
8. Aurangzeb F, Meraj L, Arif M, Rasool MQ, Ahmad M. Subtypes of Acute Ischemic Stroke. Journal of Rawalpindi Medical College. 2016;20(3).
9. Dash D, Bhashin A, kumar Pandit A, Tripathi M, Bhatia R, Prasad K, et al. Risk factors and etiologies of ischemic strokes in young patients: a tertiary hospital study in north India. Journal of stroke. 2014;16(3):173.
10. Tian D-Y, Fan D-S. Risk factors, regional disparity and trends of ischemic stroke etiologic subtypes. Chinese Medical Journals Publishing House Co., Ltd. 42 Dongsi Xidajie …; 2018. p. 127-9.
11. Zhang H, Li Z, Dai Y, Guo E, Zhang C, Wang Y. Ischaemic stroke etiological classification system: the agreement analysis of CISS, SPARKLE and TOAST. Stroke and vascular neurology. 2019;4(3).
12. Jamali S, Jamali B, Yagoubi H. Evaluation of serum level of homocysteine in patients with ischemic stroke. medical journal of mashhad university of medical sciences. 2018;60(6):767-78.
13. Karimi AM, Nia JM, Farhoodi M, Hosseini SRA. Relationship between smoking status, vitamin B12 and folic acid, with homocysteine in patients with ischemic Stroke. Medical Journal of Tabriz University of Medical Sciences. 2011;33(2):81-6.
14. Saver JL, Goyal M, Van der Lugt A, Menon BK, Majoie CB, Dippel DW, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. Jama. 2016;316(12):1279-89.
15. Khatri P, Conaway MR, Johnston KC, Investigators ASAPS. Ninety-day outcome rates of a prospective cohort of consecutive patients with mild ischemic stroke. Stroke. 2012;43(2):560-2.
16. Zafar F, Tariq W, Shoaib RF, Shah A, Siddique M, Zaki A, et al. Frequency of Ischemic Stroke Subtypes Based on Toast Classification at a Tertiary Care Center in Pakistan. Asian J Neurosurg. 2018;13(4):984-9.
17. Aghdam A, Vatan K, Kameli A. Investigating the distribution of risk factors for ischemic stroke and its relationship with involvement site and duration of hospitalization in Imam Khomeini Hospital in Urmia: a cross sectional descriptive study. Urmia Medical Journal. 2019;30(4):329-34.
18. Habibi-Koolaee M, Shahmoradi L, Niakan Kalhori SR, Ghannadan H, Younesi E. Prevalence of Stroke Risk Factors and Their Distribution Based on Stroke Subtypes in Gorgan: A Retrospective Hospital-Based Study-2015-2016. Neurol Res Int. 2018;2018:2709654-.
19. Aronow WS. Hypertension-related stroke prevention in the elderly. Current Hypertension Reports. 2013;15:582-9.
20. Guo J, Guan T, Shen Y, Chao B, Li M, Wang L, et al. Lifestyle factors and gender-specific risk of stroke in adults with diabetes mellitus: a case-control study. Journal of Stroke and Cerebrovascular Diseases. 2018;27(7):1852-60.
21. O'donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. The Lancet. 2010;376(9735):112-23.
22. Lipska K, Sylaja P, Sarma P, Thankappan K, Kutty V, Vasan R, et al. Risk factors for acute ischaemic stroke in young adults in South India. Journal of Neurology, Neurosurgery & Psychiatry. 2007;78(9):959-63.
23. Khorvash F, Khalili M, Rezvani Habibabadi R, Sarafzadegan N, Givi M, Roohafza H, et al. Comparison of acute ischemic stroke evaluation and the etiologic subtypes between university and nonuniversity hospitals in Isfahan, Iran. International Journal of Stroke. 2019;14(6):613-9.
24. Li L, Yiin GS, Geraghty OC, Schulz UG, Kuker W, Mehta Z, et al. Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: a population-based study. The Lancet Neurology. 2015;14(9):903-13.
25. Morovatdar N, Thrift AG, Kapral MK, Behrouz R, Saber H, Amiri A, et al. Long-term outcomes of ischemic stroke of undetermined mechanism: a population-based prospective cohort. Neuroepidemiology. 2017;49(3-4):160-4.
26. Hart RG, Diener H-C, Coutts SB, Easton JD, Granger CB, O'Donnell MJ, et al. Embolic strokes of undetermined source: the case for a new clinical construct. The Lancet Neurology. 2014;13(4):429-38.
27. Kamel H, Healey JS. Cardioembolic stroke. Circulation research. 2017;120(3):514-26.
28. Saver JL. Cryptogenic stroke. New England Journal of Medicine. 2016;374(21):2065-74.
29. Amarenco P, Bogousslavsky J, Caplan L, Donnan G, Hennerici M. Classification of stroke subtypes. Cerebrovascular diseases. 2009;27(5):493-501.
30. Lee JS, Chang P-Y, Zhang Y, Kizer JR, Best LG, Howard BV. Triglyceride and HDL-C dyslipidemia and risks of coronary heart disease and ischemic stroke by glycemic dysregulation status: the strong heart study. Diabetes care. 2017;40(4):529-37.
31. Markus A, Valerie S, Mira K. Promising biomarker candidates for cardioembolic stroke etiology. A brief narrative review and current opinion. Frontiers in Neurology. 2021;12:624930.
32. Teo K, Lear S, Islam S, Mony P, Dehghan M, Li W, et al. Prevalence of a healthy lifestyle among individuals with cardiovascular disease in high-, middle-and low-income countries: The Prospective Urban Rural Epidemiology (PURE) study. Jama. 2013;309(15):1613-21.
| Files | ||
| Issue | Vol 61 No 11 (2023) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/acta.v61i11.16079 | |
| Keywords | ||
| Ischemic stroke Trial of ORG 10172 in acute stroke treatment (TOAST) Stroke etiology Ahvaz Risk factors | ||
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How to Cite
1.
Monjezi S, Rafie S, Behzad E, Mohammadi S. Risk Factors and Etiological Classification of Ischemic Stroke Subtypes in Southwest Iran. Acta Med Iran. 2024;61(11):677-684.
