Clinical Profile of Acute Cerebrovascular Accidents

Background: Acute cerebrovascular disease or stroke is one of the most leading causes of morbidity and mortality. Due to change in dietary habits and life style factors, there is increase in co-morbid conditions like diabetes and hypertension. This in turn increases the risk for developing stroke. Aim: To study the cerebrovascular accident patients by analyzing and comparing their clinical profile. Materials and Methods: A prospective study was conducted in a tertiary care hospital in stroke patients. The type of stroke, associated risk factors and prognosis of the patients were studied. Results: A total of 50 patients were included in the study, for a period of 4 months from January 1, 2021 to April 30, 2021. Both male and female were included in the study. The mean age of the patients was 56.86 years. Thrombotic stroke was the most common (50%) followed by embolic and hemorrhagic stroke. Hypertension was the most commonly associated risk factor (80%), followed by diabetes (60%), smoking (52%), dyslipidemia (34%) and alcohol (28%). The comparatively higher incidence of cerebrovascular accidents in age less than 60 years is attributed to the rise in risk factors in the young age (P<0.05). The average duration of hospitalization was 6.58 days. There is no in-hospital mortality. Conclusion: With prevalence of risk factors on rise, younger individuals are also affected. Proper risk factor management will help in preventing stroke and its recurrence. Original Research Article Ashwathy and Deepthi; JPRI, 33(47B): 966-973, 2021; Article no.JPRI.74897 967


INTRODUCTION
Acute cerebrovascular accident (CVA), also known as stroke, is defined by World Health Organization (WHO), as rapidly developing 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 [1,2,3,4,5,6]. There are two main types of stroke, ischemic stroke and hemorrhagic stroke. Ischemic stroke is further classified as thrombotic stroke and embolic stroke. Stroke is a neurological disorder characterised by blockage of blood vessels [7]. Ischemic stroke may be due to an obstruction within the blood vessel which supplies blood to the brain. Hemorrhagic stroke occurs due to the weakening of blood vessel which would rupture and bleed into the surrounding brain tissues [8]. Ischemic stroke is caused by deficient blood and oxygen supply to the brain. Hemorrhagic stroke is caused by bleeding or leaky blood vessels [7]. Investigations like CT modalities and MRI help to identify the type of stroke (ischemic or hemorrhagic), severity and location of lesion, the patency of the intracranial vessels, the degree of cerebral perfusion, and the presence and size of the ischemic penumbra [9]. CT scan remains the primary imaging modality for the initial evaluation of patients with suspected stroke [10,11]. The incidence of stroke is also influenced by some risk factorsmodifiable and non-modifiable [7,12,13]. Modifiable risk factors include diabetes, hypertension, dyslipidemia, smoking, alcohol, etc [7,2,12,13]. Non-modifiable risk factors include age, gender, etc [7,12,13]. Though stroke is commonly observed in old age, the risk factors tend to increase the chances of CVA in young age. Duration of hospitalization, incidence of nosocomial infection and in-hospital mortality marks the prognosis and quality of patient care.

Aims and Objectives
 To assess the demographic characteristics like age and gender distribution of stroke.  To analyze the type of stroke and site of lesion.  To assess the incidence of other comorbid conditions and risk factors.
 To assess the type and episodes of nosocomial infections.  To assess the duration of hospitalization and in-hospital mortality rate.

MATERIALS AND METHODS
A prospective observational study was conducted in a tertiary care hospital. A total of 50 patients diagnosed with cerebrovascular accident (CVA) in the General Medicine Department, were analysed in this study, from 1 st January, 2021 to 30 th April, 2021. The study was based on the clinical profile of the patients. This study analyzed the type of stroke and the site of lesion in the patients. The risk factors like smoking, alcohol, diabetes, hypertension and dyslipidemia were assessed along with demographic details. The duration of stay in hospital and prognosis of the patients was recorded.

Inclusion Criteria
 All adult patients with the age of eighteen years or more hospitalized with clinical diagnosis suggestive of acute cerebrovascular accident or strokeincluding ischemic and hemorrhagic subtypes.  Patients with recurrent episodes of stroke will also be included.

Exclusion Criteria
 Patients less than 18 years of age and who are not willing to participate in the study  Patient who gets discharged against medical advice before the advised duration of hospitalization.

Statistical Methods
Continuous data was represented as mean ± SD. Categorical data was represented as value (%). Chi-Square test was the statistical tool used in the study. Data were analyzed with SPSS software (version 22.0 for Windows, IBM Corp., Armonk, NY). P value less than 0.05 was considered statistically significant at 95 percent confidence interval [14].

RESULTS
A total of 50 stroke patients were included in this study. Demographic details were analyzed for each patient. Among them 32 (64%) were male and 18 (36%) were female. The mean age was 56.86 years with a range, 25-82 years. The age wise and gender wise distribution of the study subjects is given in Fig. 1.
The clinical profile studied for each patient included age, gender, type of stroke, site of lesion from CT and MRI reports, risk factors, duration of stay in the hospital, incidence of nosocomial infection and prognosis. The investigations for diagnosis of stroke included MRI and CT scan -stating the type of stroke and affected areas in the brain and the vessels involved.
In this study, 5 major risk factors were studied in the patients -smoking, alcohol, diabetes, hypertension and dyslipidemia. Among them hypertension was the most important risk factor in majority (80%) of the stroke patients. The second commonly associated risk factor was diabetes (60%) followed by smoking (52%), dyslipidemia (34%) and alcohol (28%). This has been illustrated in Fig. 5.
The incidence of cerebrovascular accidents is comparatively higher in age group of 40-59 years. This is attributed to the rise in risk factors in the young age. (P<0.05).
During the stay in the hospital, bed sores was evident in 1(2%) out of the 50 patients. No other nosocomial infection occurred. The average days of hospitalization were 6.58 in the stroke patients. There is no incidence of in-hospital mortality.

DISCUSSION
Cerebrovascular accidents are most commonly seen in old age above 60 years. But that doesn't make the young adults to not develop stroke. Other than age, there are many other factors which predispose to cerebrovascular accidents.
The mean age of the study subjects is 56.86 years. Majority are of age group 50-59 years (32%) followed by age group 60-69 years (24%).
This correlates to study reports of Jebasingh et al., [6] where the mean age is 56 years and the incidence was higher in the age group of 51-60 years. The reports of Sayyed et al., [16] showed the majority of the patients were in the age group of 50-60 years (38%).On the other hand, the study reports of Patne et al., [1] and Kuriakose et al., [2] showed majority of patients affected were above the age of 60 years. In our study, 11% of stroke patients were <40 years of age. It was 14% in reports of Sayyed et al., [16] and Iqubal et al., [8]. The findings from these study reports show the start of rise in incidence of cerebrovascular accidents in younger age group.
Among the 50 subjects of our study, thrombotic stroke was the most common type of stroke followed by embolic and hemorrhagic stroke. This makes ischemic type of cerebrovascular accident most common in this study.  [16] and Iqubal et al., [8].
In our study, the most common site of lesion was corona radiata followed by parietal lobe, frontal lobe, thalamus and temporal lobe. The study reports of Patne et al., [1], Kuriakose et al., [2], Vaidya et al., [4] and Jebasingh et al., [6] showed parietal lobe followed by frontal lobe were the commonly affected sites in stroke patients. Middle cerebral artery followed by posterior cerebral artery and anterior cerebral artery were the commonly involved blood vessels in our study. This is similar to study reports of Lakshmikumar et al., [13].
Diabetes was the second most common risk factor in our study subjects. In this study both type 1 and type 2 diabetes were included. The reports of Chitrambalam et al., [5], Lakshmikumar et al., [13], Jebasingh et al., [6] and Iqubal et al., [8] also signify the role of diabetes as one of the major risk factor in developing stroke.
Overall smoking was the third common risk factor (52%), though it was the most common one in the male subjects in our study. Smoking is reported to have a strong association with cerebrovascular accidents by Shah et al., [18] and Lakshmikumar et al., [13].
Dyslipidemia increases the risk of stroke much more when associated with other risk factors like diabetes, smoking, etc. In our study alcohol was the fourth common risk factor in male stroke patients (28%). This correlates with reports of Lakshmikumar et al., [13], where alcohol constituted as risk factor in 27% of subjects.
The study of Ahangar et al., [17] and Jebasingh et al., [6], report diabetes and dyslipidemia to the common risk factors after hypertension. The reports of Patne et al., [1], Kuriakose et al., [3] and Vaidya et al., [4] show smoking and dyslipidemia to be commonly involved in stroke patients following hypertension. In the study of Sayyed et al., [16], following hypertension, both smoking and alcohol were equally (34%) involved. The risk factor prevalence in our study is similar to that of Iqubal et al., [8] , where hypertension is the most common risk factor, followed by dyslipidemia, smoking, diabetes and lastly alcohol. Moreover these risk factors also have strong association with each other.
On statistical analysis of the current study results, P value is less than 0.05 (P<0.05). Risk factors like hypertension, diabetes, smoking, dyslipidemia and alcohol have a major role in developing stroke and also tend to increase the disability and slow the recovery. Hence there is significant association of the risk factors with the rise in incidence of cerebrovascular accidents, not only the older age group but also the younger age group, necessitating the effective control of these risk factors to prevent stroke and its recurrence.
Cerebrovascular accidents being one of the major causes of mortality raise a concern. In our study there was no in-hospital mortality. Also patients, with or without the risk factors like diabetes, admitted in the hospital tend to develop nosocomial infections. In this study only one patient out of 50 subjects had developed bed sores and was treated appropriately. Overall this shows a good prognosis and quality of patient care.

CONCLUSION
Cerebrovascular accidents are in the phase of rise these days. The incidence of stroke is becoming relatively more common in the young age groups, though old aged individuals are also affected. This is not only attributed by age and male predominance but also risk factors like hypertension, diabetes, dyslipidemia, smoking and alcohol. Though hypertension is the most common risk factor associated with stroke, smoking, diabetes, dyslipidemia and alcohol are also of major concern in the young individuals. They not only predispose to stroke but also affect the patient recovery and recurrence of stroke. Hence proper treatment, lifestyle modifications and management of these risk factors is advised to prevent mortality and morbidity caused by cerebrovascular accidents.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s). Written consent form was obtained from all patients.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.