A stroke or cerebrovascular accident is defined as the sudden loss of blood circulation to an area of the brain, leading to a loss of neurologic function. An Ischemic Stroke occurs due to an obstruction in the blood vessels supplying the brain. This obstruction is either due to deposition of fat along the arterial walls (atherosclerosis), narrowing the lumen, formation of thrombus (blood clot) within the arteries supplying the brain, or due to formation of thrombus at some other site, and its dislodging and moving to the blood vessels of the brain. Occasionally, an ischemic stroke may also result when although the blood supply is normal, but the oxygen capacity of the blood is severely reduced, as in cases of anemia, or carbon monoxide poisoning. Symptoms depend on which part of the brain is affected by the lack of blood supply. Most common symptoms are abnormal sensations or weakness along one side of the body, numbness, blindness in one eye, slurred speech, loss of coordination and balance, vertigo, mood changes, drowsiness, lethargy, and edema in the brain leading to brain swelling. Severe strokes may result in coma. Major risk factors for developing an ischemic stroke include age over 65 years, hypertension, cardiac disease, coagulopathy, alcohol abuse, diabetes, and smoking, among others.
Stroke is suspected based on the history of the patient and results of examination. MRI, and CT scans are used for confirming the diagnosis. These may be followed by cerebral angiography, magnetic resonance angiography, or color Doppler ultrasonography. Symptoms of an ischemic stroke need immediate medical attention, since it is a medical emergency. It is important that the patient gets proper medical treatment within three hours of experiencing the stroke. Thrombolytic medications and drug thinners, such as tissue Plasminogen Activator, heparin, coumarin, or aspirin are administered to break up the clot. Anti-hypertensive medications and pain killers may also be required. Only about 10% of people who suffer a cerebrovascular infarction recover all normal body functions. Most other people suffer from moderate to severe impairments, which may require long term treatments in the form of speech, occupational, and/or physiotherapy.
Benamer and Grosset (2009) conducted a systematic review of all reports of stroke in Arab countries published between 1983 and 2008. Their results indicated that the annual stroke incidence among Arabs ranged from 27.5 to 63 per 100,000, while prevalence was between 42 and 68 per 100,000 population. These rates are lower than those reported in Western populations, and similar to that in the Chinese population. The most common subtype was ischemic stroke. Risk factors were similar to those in the Western countries, including hypertension, diabetes mellitus, hyperlipidemia, and cardiac disease. Some of the studies showed a high rate of lacunar infarction.
In a study on 118 patients and 120 control subjects, Almawi et al. (2009) found that the significant predictors of stroke were hypertension, MTHFR C677T and A1298C genotypes, and hyperhomocysteinemia.
Al-Shammri et al. (2003) studied 62 patients (51 of them Kuwaitis) diagnosed with ischemic stroke between 1995 and 1999 in Kuwait to study the subtypes, risk factors and prognosis of the condition in this population. Apart from a difference in age (Kuwaitis being older at 65.5 years mean age), there was no significant difference between the Kuwaiti and expatriate groups in clinical presentation, management, and prognosis. The most common risk factors identified in this study included hypertension (72.5%), diabetes (69.4%), hyperlipidemia (30.6%), and smoking (1.6%). With regard to location of infarct, the anterior circulation was most commonly affected (58%). Eight patients (six women) died within 30-days of admission, while 10 other patients (seven women) had severe disability. Although the incidence, age range, risk factors, and sub-types did not show any significant difference between men and women, the outcome was significantly worse for women. Patients with advanced age, large artery atherosclerotic and cardio-embolic strokes also had an unfavorable prognosis.
Al Shafaee et al. (2006) conducted the first study in Oman to assess stroke knowledge (warning signs, impending risk factors, treatment, source of information and perceived risk of stroke among them) among Omani patients with an established risk of stroke. Randomly selected patients (with at least one of these risk factors: diabetes, hypertension, heart disease, atrial fibrillation, dyslipidemia, previous stroke or transient ischemia attack, and carotid stenosis), who were attending medical clinics were interviewed by trained family practice residents. Out of 624 patients who were randomly selected, 554 were eligible for enrollment, but only 400 patients (72%) responded. There were 210 (52.5%) men and 190 (47.5%) females, and the mean age was 57 years. Only 24.8% knew that that stroke casualty was due to blood vessel occlusion or hemorrhage, while the majority (56.2%) gave incorrect answer, and 19% were not sure. The brain as the organ involved in stroke was identified by 34.8%, 57% could not name the organ and 8.3% of the patients identified other organs such as the nerves. The most common symptom identified by the patients was weakness and paralysis (65%), followed by speech difficulty (30%), and walking difficulty (25.8%). About 32% did not know a single warning symptom. At least one symptom was correctly mentioned by 68%, 42.7% mentioned two, and 26% mentioned three warning symptoms. The most common risk factor identified by the patients was hypertension (34.5%), followed by diabetes (22.8%), cardiovascular disease (10.8%), and hyperlipidemia (8.5%). Only one risk factor was identified by 43%, two by 28.5%, three or more by 14% of the patients. On the other hand, not a single risk factor was mentioned by 44.3%, and false beliefs such as exposure to cold weather and bad spirits were mentioned by 12.7%. Only 7.2% of the patients knew that they were at increased risk of stroke. Information about stroke in those who had it was acquired from general life experiences and personal acquaintances in 95.5%, and only 4.5% received such information from a health professional. The reaction of the majority (73%) was to go to hospital if they had stroke, 19.5% would try local (indigenous) treatment first and then medical if it failed, and 7.5% said they would like to be treated at home with only indigenous treatment. About 26.5% said they would resort to medical treatment at hospital, 25% to indigenous treatments, while 15.5% said they would resort to both. Interestingly, 32.8% said that there was no appropriate treatment available.
Hamad et al. (2001) conducted a retrospective study of 217 patients (157 men and 60 women) with ischemic stroke diagnosed between January to December 1997. The overall incidence rate was 41 per 100,000 inhabitants per year (95% CI, 30.2-52.4/100,000/year) and 238/100,000/year for the population over 45 years old. The age standardized incidence was 57.5 per 100,000 inhabitants per year (95% CI, 43.1-73.8). The crude incidence for native Qataris was 75 per 100,000 inhabitants per year. The mean age of patients experiencing their first stroke was 57 years. Thirty-nine (18%) patients were younger than 45 years. Clinical subtypes of stroke were ischemic (80%), intracerebral hemorrhage (19%), and subarachnoid hemorrhage (1%). Risk factors included hypertension (63%), diabetes mellitus (42%), ischemic heart disease (17%), and atrial fibrillation (4.5%). The overall patient fatality rate at 30 days was 16%.
A cohort study was carried out by Bener et al. (2005) on patients hospitalized in Qatar between the years 1999 and 2003 to find the association between stroke and acute myocardial infarction. During this period, 166 Qatari patients were hospitalized with stroke. Interestingly, the incidence of stroke was higher among Qatari females than Qatari males. Diabetes mellitus was found to be the most common risk factor in stroke patients. Of the 166 patients, 91 (38.9%) had AMI, the incidence of which was higher in males than in females. The prevalence of AMI was higher in subjects <50-years of age. A stepwise logistic regression analysis showed that smoking and hypercholesterolemia were strong predictors for AMI in patients with stroke. Bener et al. (2005) concluded that a strong association exists between stroke, AMI, and related risk factors.
Deleu et al. (2006) studied the risk factor profiles, subtypes and recurrence of non-cardioembolic ischemic stroke in Arabs and South Asians, at the only stroke-admitting hospital in Qatar for the period between January through December 2001. A total of 303 patients with ischemic non-cardioembolic stroke were included in the study. Sixty seven percent of the overall patient population (sex ratio 2:6, M/F) was of Arab origin, and 32% were South Asians. Hypertension was the most commonly encountered risk factor followed by dyslipidemia, diabetes mellitus, and obesity. Carotid artery stenotic lesions, ventricular wall motion abnormalities and stroke recurrence were observed with a higher frequency in the Arab subgroup of patients compared with the South Asians. The majority of strokes were lacunar hemispheric strokes (68%), followed by lacunar brainstem strokes (15%) and large-vessel hemispheric infarctions (10%). Patients with a previous history of stroke had a higher frequency of carotid artery stenosis (p = 0.05) and risk of stroke recurrence (p = 0.04).
Khan (2007a) studied the risk factors and subtypes of young ischemic stroke among Qatari and non-Qatari residents in all young adults (15-45 years of age) admitted to Hamad General Hospital with first-ever ischemic stroke from September 2004 to September 2005. Stroke was confirmed in 40 (32 males and 8 females). Their ages ranged from 17 to 44 years (mean 37.1+/-13.27). Thirty (75%) of the patients were non-Qatari. The most common risk factors were hypertension 16 (40%), diabetes mellitus 13 (32.5%), hypercholesterolemia 11 (27.5%), smoking 11 (27.5%), and alcohol intake 9 (22.5%). Regarding stroke subtypes, lacunar stroke syndrome (LACS) was diagnosed in 17 (42.5%), total anterior circulation stroke syndrome (TACS) in 16 (40%), partial anterior circulation stroke syndrome (PACS) in 5 (12.5%) and posterior circulation stroke syndrome (POCS) in 2 (5%). Partial anterior circulation stroke syndrome (PACS) was observed with a higher frequency in Qatari patients compared with non-Qataris (p=0.009). In a separate study, Khan (2007b) carried out the first prospective hospital-based study on the risk factors, subtypes, and short-term functional outcome of cerebral infarction among young adults in Qatar. A total of 40 patients, including 10 Qataris (five males and five females), with ischemic stroke between the ages of 15 and 45-years were included in the study. Clinical subtypes and risk factors were assessed for all patients and statistically analyzed. Among the Qatari patients, the most common risk factors were found to be hypertension (three patients), diabetes mellitus, hypercholesterolemia, smoking, alcohol intake (two patients each), antipohospholipid syndrome, patent foramen ovale, and sickle cell anemia (one patient each). In five of the cases, the risk factor remained undetermined. With regard to the stroke subtype, partial anterior circulation stroke syndrome and lacunar stroke syndrome were the most common types among Qataris (four patients each), followed by total anterior and posterior circulation stroke syndrome (one patient each). One of the Qatari male patients developed treatment complication in the form of deep vein thrombosis. Of the 10 patients, three were discharged with neurological deficit. No cases of inherited deficiency of coagulation inhibitors were noticed. There was no fatality among any of the Qatari patients.
One year later, Khan et al. (2008) studied 270 patients with first-ever stroke diagnosed between September 2004 and September 2005. Of these patients 217 (80.4%) had ischemic stroke and 53 (19.6%) had hemorrhagic stroke. Male patients predominated in all types of stroke. The main risk factors for stroke were hypertension and diabetes, whereas lacunar infarct was the most common subtype of ischemic stroke. Risk factor profiles were similar between Qatari and non-Qatari patients except for hypercholesterolemia, which was observed with a higher frequency in Qatari compared with non-Qatari patients with ischemic stroke.
Benamer and Grosset (2009) in their review of all reports of stroke in Arab countries noticed that unlike all other countries, Sudan had a high rate of intracerebral hemorrhage (41%), which was statistically similar to that reported from East Asian countries.
[See also: Arab > Benamer and Grosset, 2009].