Study On Stroke In Young Patient Due To Cardiac Disease in Tertiary Care Hospital in Dhaka City

Objectives: Study of the risk factors associated with stoke due to cardiac disease in age group between 18 to 45 years of age,evaluate the risk factor of hospitalized stroke patients & to search for cardiac disease associated with stroke also appropriate preventive measure applicable for our country. Materials & Methods: Non randomized prospective observational study was carried out in the department of Neurology, Medicine & Cardiology unit of Dhaka Medical College Hospital between the periods of July 2009 to December 2009. Fifty (50) consecutive indoor patients more than 18 years of both sex admitted with suspicion of stroke. Diagnosis of stroke will be made from details clinical history clinical examination and confirmed by CT scan or MRI. Result: Fifty patients were randomly chosen for this study, of which 26 (52%) patients were male, 24 (48%) patients were female & male: female ratio was 1.08:1. Highest incidence of stroke was in between 3rd & 4th decade. The incidence of ischemic stroke 46 (92%) & hemorrhagic stroke 4(8%).Cardio embolism is the major (92%) risk factor for ischemic stroke. Among the cardiac risk factors, valvular disease (64%), MI (16%), &IHD (10%), Atrial fibrillation 8%, Patent foramen ovale 2%.Among the patients 33.33% of women with cerebral infarction were using OCP. Majority of the patients in this study were sedentary worker (45%). Among the stroke patients 8% & 10% had previous H/O stroke & TIA respectively. Conclusion: In this study a number of modifiable risk factors were identified, of which valvular heart disease & HTN are important risk factor next are DM & IHD smoking. Most of the valvular heart diseases are rheumatic in origin, which can be prevented through primary & secondary prevention of rheumatic fever.

Result: Result: Result: Result: Result: Fifty patients were randomly chosen for this study, of which 26 (52%) patients were male, 24 (48%) patients were female & male: female ratio was 1.08:1.Highest incidence of stroke was in between 3rd & 4th decade.The incidence of ischemic stroke 46 (92%) & hemorrhagic stroke 4(8%).Cardio embolism is the major (92%) risk factor for ischemic stroke.Among the cardiac risk factors, valvular disease (64%), MI (16%), &IHD (10%), Atrial fibrillation 8%, Patent foramen ovale 2%.Among the patients 33.33% of women with cerebral infarction were using OCP.Majority of the patients in this study were sedentary worker (45%).1990) studied 50 patients with stroke.Most of the incidence of stroke was between the ages of 50-69 years.In this study (table-1) 52% were male & 48% were female i.e. male incidence is 8% higher than female & ratio is 1.08:1 which coincides with international study.The present study coincides with study of Chowdhuryet a1 10 & is slightly higher than the finding of Kurtzke 11 where showed that frequency of stroke is 30% higher in men than women.CT & MRI findings of the studied patients show (table-3) that 92% had ischemic stroke while 8% had hemorrhagic stroke.This study similar with study of Alam B et a1, 12 they studied 1020 patients of stroke in DMCH.In their study the incidence of ischemic stroke was 93% & hemorrhagic stroke was 7%.Higher rate of hemorrhagic stroke also have been reported in number of hospital series in Asian countries such as Singapore, Malaysia (33%), Thailand (30%), Korea (31%), Taiwan (31 %).Higher rate of hemorrhagic stroke in this present hospital based study may be due to the acute admission is more related to the hemorrhagic stroke.
In this study cardiogenic cerebral embolus is one of the most common causes of ischemic stroke in the young due to cardiac disease accounting for unto 92 % of cases.Among the cardio embolic cause, the mitral valvular disease is the most common.In this study transthoracic echocardiography was done in fifty patients &transoesophageal echocardiography was done in six patients.There was only one patent foramen ovale, detected by doing transoesophageal echocardiography which was missed by transthoracic echocardiography.There might be more patent foramen ovals, if TEE could be done in the young adults group, whose risk factor was not identified.Most of the patients with valvular heart disease had H/O Rheumatic Fever.Mitral valvular heart diseases were more prevalent in this study group.Among them most of the patients were female.Bevan et al 14 13 found in his study that 61% of his study subjects were suffered from acute stressful events before the attack of stroke.
Finally out of 50 patients, the conditions of 38 patients were improved, 8 patients were static & 4 patients were deteriorated.

Conclusion
Stroke is one of the foremost causes of morbidity, mortality & a socioeconomic challenge, more so in Bangladesh where health system including the rehabilitation is not within the reach of ordinary people.It is crystal clear that, this devastating condition not only affects the patient but also their family.There are many risk factors for stroke, some are modifiable & some are not.In this study a number of modifiable risk factors were identified, of which valvular heart disease & HTN are important risk factor next is DM, IHD, smoking.Stroke is more preventable than to cure.In an under developed country like ours, the best policy for combating stroke is primary prevention.Most of the valvular heart diseases are rheumatic in origin, which can be prevented through primary & secondary prevention of rheumatic fever.
Extensive investigations arenecessary to find out etiology ofyoung adults other than cardiac diseases & aggressive treatment & secondary prevention as well as rehabilitation should be considered.
Non randomized prospective observational study was carried out in the department of Neurology, Medicine & Cardiology unit of Dhaka Medical College Hospital between the periods of July 2009 to December 2009.Fifty (50) consecutive indoor patients more than 18 years of both sex admitted with suspicion of stroke.Diagnosis of stroke will be made from details clinical history clinical examination and confirmed by CT scan or MRI.

Table - I
All the data were analyzed and presented by simple statistical percentage and tabulated form by SPSSsystem.Informed consent was taken from the patient or from the attendant of the patient for participation in the study.Patients were followed up during their stay in the hospital to observe the outcome.Ethical Clearance was taken from local medical ethical committee of Dhaka Medical College Hospital.Demographic variation of stroke Among the stroke patients 8% & 10% had previous H/O stroke & TIA respectively.Conclusion: Conclusion: Conclusion: Conclusion: Conclusion: In this study a number of modifiable risk factors were identified, of which valvular heart disease & HTN are important risk factor next are DM & IHD smoking.Most of the valvular heart diseases are rheumatic in origin, which can be prevented through primary & secondary prevention of rheumatic fever.ds:ds:Stroke,Cardiacdisease,Tertiarylevel hospital, Young patientIntroductionStroke is a clinical syndrome consisting of a constellation of neurological findings.Sudden or rapid in onset which persists for more than 24 hours & whose vascular origins are limited to thrombotic or embolic occlusion of a cerebral artery resulting in infraction or spontaneous rupture of a vessel resulting in intracerebral or subarachnoid hemorrhage.Stroke in young adults may be devastating & frequently no cause can be found.Though there are some overlapping in the risk factors between the some clearly distinct risk factors for ischemic & hemorrhagic stroke in young adults, e.g.Materials & MethodThis is a non randomized prospective observational study was carried out in the department of Neurology, Medicine & Cardiology unit of Dhaka Medical College Hospital between the period of July 2009 to December 2009.Fifty (50) consecutive patients 18 -45 years of age both sex admitted in Dhaka Medical College Hospital suspicion of stroke was included in the study.All routine investigation were done including TC, DC, ESR, Hb%, total platelet count Urine for R/M/E, S. Creatinine, FBS& 2HABF,CXR P/A view,ECG, Fasting Lipid profile, Anti Phospholipids antibody, Protein C & S confirmed by CT scan or MRI of brain & evaluation of cause due to cardiac diseases through appropriate relevant investigation like Echocardiography (Color Doppler/Trans esophageal).History of head injury, ICSOL, any demyelinating disease, bleeding disorder evident by history or by brain imaging & Patients who die immediate after admission were excluded from the study.ResultStroke incidence rises exponentially with increasing age.In this present study, all the patients were grouped in five age groups.Majority of the study subjects were above 41 years of age (44%) were suffering from stroke.Urban population was more vulnerable.The study shows that the stroke incidence high in low income group (64%) then middle income group (32%).

Table - II
In this study, all the patients were grouped in five age groups.Majority of the study subjects were above 41 years of age.Bevan etal 8 in his study of stroke in young adults also found similar picture Bell et al ( 17ows that about 35.4% cerebral infarcts are due to cardioembolic source.Among 24 mitral valvular heart diseases,19 patient had left atrial mural thrombus with vegetation& only 4 patient had atrial fibrillation most likely due to rheumatic valvular heart disease.In this study there were cardiac risk factors, other than valvular heart disease.Anterior ventricular wall & inferior wall was found hypokinetic in 1 & 4 patients respectively on transthoracic echocardiography.Among them 16% patients had H/O MI & 10% patients had IHD.This study shows that coronary artery disease in earlier age is also a risk factor ischemic stroke.Present study shows that 16.67% of stroke patients were suffering from HTN. Bevan et al14in "Stroke in young adults" showed that 31% of the patient with cerebral infarction had HTN.This present study correlates with this western study.This study shows that 33.33% stroke patients did not aware that they were hypertensive & 25% were on irregular treatment.This present study is almost similar with the study of Chowdhury et al,10who studied 74 hypertensive patients who suffered stroke & had shown that 34% of the patients were not aware that they were hypertensive & 60.7% were on irregular treatment.You canary et al15showed in his study that the percentage of ischemic stroke was similar with normal tensile patients but the incidence was higher in untreated cases of HTN.So elective control of HTN is essential.The present study shows 20% patients were smoker.Physical activity has inverse relationship with the stroke.Exercise is effective in the prevention of cardiovascular disease & stroke.The benefits are largely manifested through the role that exercise plays an important role in control of certain modifiable risk factors such as blood lipid abnormalities, diabetes & obesity.This study shows that 20 % of the study subjects were heavy workers, 35% were moderate workers, 45% sedentary workers.This study indicates that, those who were hard worker were affected less.Herman et al17suggested that physical activity reduces the risk of stroke.In this present study sedentary workers form the major percentage of stroke.The present study shows, only 8% patients had previous H/O of stroke & only 10% had previous H/O TIA.An western study shows that 18% (Aho et al) & 26% (walker et al 1 ) patients suffered acute stroke had past H/O one or more episode of stroke which is higher than this present study.In this study, only 16% of the patients were in sleep, 56% were resting state during attack & the rest of the patients were awake.It suggested acute mental stress is either a precipitant of stroke or an important underlying cause.Hayeeet al