Epidemiology, Risk Factors, and Predictors of Disability in a Cohort of Jordanian Patients with the First Ischemic Stroke

Majdi Al Qawasmeh, Belal Aldabbour, Aiman Momani, Deema Obiedat, Kefah Alhayek, Raid Kofahi, Ahmed Yassin, Khalid El-Salem, Majdi Al Qawasmeh, Belal Aldabbour, Aiman Momani, Deema Obiedat, Kefah Alhayek, Raid Kofahi, Ahmed Yassin, Khalid El-Salem

Abstract

Objective: To identify the risk factors, etiologies, length of stay, severity, and predictors of disability among patients with the first ischemic stroke in Jordan.

Methods: A retrospective cohort study of 142 patients who were admitted to the Neurology Department at King Abdullah University Hospital between July/2017 and March/2018 with a first ischemic stroke. Etiology was classified according to the TOAST criteria. Severity was represented by NIHSS score, disability by mRS score, and prolonged length of stay as hospitalizations more than 75th percentile of the cohort's median length of stay. Analysis of the sample demographics and descriptive statistics were done, including frequencies of prevalence of independent variables (risk factors) and frequencies of stroke and etiology work-up. Chi-square and univariate analysis of variance "ANOVA" were used to investigate the relationship between risk factors and type of stroke. Finally, logistic regression analysis was used to measure the contribution of each of the independent variables. IRB approval was obtained as necessary.

Results: The mean age for the cohort was 66.5 years. The most common risk factors were hypertension (78.8%), diabetes mellitus (60.5%), and ischemic heart disease (29.4%). The most common stroke etiology was small-vessel occlusion (54.2%). Median length of stay was 4 days. Prolonged length of stay was observed in 23.23% of patients, which was associated with several factors, the most common of which were persistent dysphagia (57.5%), nosocomial infection (39.3%), and combined dysphagia and nosocomial infection (21.2%). The mean admission NIHSS score was 7.94, and on discharge was 5.76. In-hospital mortality was 2.81%, while 50% of patients had a favorable outcome on discharge (mRS score between 0-2). The mean discharge mRS score for the cohort was 2.47 (SD ± 1.79). Large artery atherosclerosis was associated with the highest residual disability with a mean score of 3.67 (SD ± 1.88), while the stroke of undetermined etiology was associated with the lowest residual disability with a mean score of 1.60 (SD ± 1.78). Significant predictors of mRS score were smoking (t 3.24, P < 0.001), age (t 1.98, P < 0.049), and NIHSS score (t 9.979, P 0.000).

Conclusion: Ischemic strokes have different etiologies that are associated with different levels of impact on the patient's clinical status and prognosis. Large artery atherosclerosis was associated with the highest residual disability. Regarding predictors of prognosis, current smoking status, age above 50, gender, and NIHSS on admission appear to be the strongest predictors of prognosis. Finally, higher NIHSS score on admission resulted in a longer hospital stay.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Copyright © 2020 Majdi Al Qawasmeh et al.

References

    1. Feigin V. L., Norrving B., Mensah G. A. Global Burden of Stroke. Circulation Research. 2017;120(3):439–448. doi: 10.1161/CIRCRESAHA.116.308413.
    1. Katan M., Luft A. Global Burden of Stroke. Seminars in Neurology. 2018;38(2):208–211. doi: 10.1055/s-0038-1649503.
    1. Feigin V. L., Lawes C. M., Bennett D. A., Barker-Collo S. L., Parag V. Worldwide stroke incidence and early case fatality reported in 56 population- based studies: a systematic review. Lancet Neurology. 2009;8(4):355–369. doi: 10.1016/S1474-4422(09)70025-0.
    1. The GBD 2016 Lifetime Risk of Stroke Collaborators. Global, Regional, and Country-Specific Lifetime Risks of Stroke, 1990 and 2016. New England Journal of Medicine. 2018;379(25):2429–2437. doi: 10.1056/nejmoa1804492.
    1. Boehme A. K., Esenwa C., Elkind M. S. Stroke Risk Factors, Genetics, and Prevention. Circulation Research. 2017;120(3):472–495. doi: 10.1161/CIRCRESAHA.116.308398.
    1. O'Donnell M. J., Xavier D., Liu L., et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376(9735):112–123. doi: 10.1016/S0140-6736(10)60834-3.
    1. Jordan. Institute for Health Metrics and Evaluation. 2017. October 2019, .
    1. Bahou Y., Hamid H., Hadidi A. Ischaemic stroke in Jordan: a 2-year hospital-based study of subtypes and risk factors. Eastern Mediterranean Health Journal. 2004;10(1-2):138–146.
    1. Bahou Y. A. M., Jaber M. Ischemic stroke at Jordan University Hospital: a one-year hospital-based study of subtypes and risk factors. SM Journal of Neurology and Neuroscience. 2015;1(1):p. 1003.
    1. Estimated Population of the Kingdom by Governorate and Sex. Department of Statistics-Jordan. 2017. October 2019, .
    1. Sacco R. L., Kasner S. E., Broderick J. P., et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(7):2064–2089. doi: 10.1161/STR.0b013e318296aeca.
    1. Adams H. P., Jr., Bendixen B. H., Kappelle L. J., et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35–41. doi: 10.1161/01.STR.24.1.35.
    1. White H., Boden-Albala B., Wang C., et al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics. Circulation. 2005;111(10):1327–1331. doi: 10.1161/01.CIR.0000157736.19739.D0.
    1. George M. G. Risk Factors for Ischemic Stroke in Younger Adults. Stroke. 2020;51(3):729–735. doi: 10.1161/STROKEAHA.119.024156.
    1. James P. A., Oparil S., Carter B. L., et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) Journal of the American Medical Association. 2014;311(5):507–520. doi: 10.1001/jama.2013.284427.
    1. American Diabetes Associations. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2009;33(Suppl 1):S62–S69.
    1. Nayor M., Vasan R. S. Recent Update to the US Cholesterol Treatment Guidelines. Circulation. 2016;133(18):1795–1806. doi: 10.1161/CIRCULATIONAHA.116.021407.
    1. Bath P. M., Lees K. R., Schellinger P. D., et al. Statistical analysis of the primary outcome in acute stroke trials. Stroke. 2012;43(4):1171–1178. doi: 10.1161/STROKEAHA.111.641456.
    1. Krell R. W., Girotti M. E., Dimick J. B. Extended length of stay after surgery: complications, inefficient practice, or sick patients? JAMA Surgery. 2014;149(8):815–820. doi: 10.1001/jamasurg.2014.629.
    1. Gyalai-Korpos I., Ancusa O., Dragomir T., Tomescu M. C., Marincu I. Factors associated with prolonged hospitalization, readmission, and death in elderly heart failure patients in western Romania. Clinical Interventions in Aging. 2015;10:561–568.
    1. Ueno Y., Okuzumi A., Watanabe M., et al. Cerebral small artery diseases may be associated with aortic arch calcification in stroke patients. Journal of Atherosclerosis and Thrombosis. 2014;21(10):1011–1021. doi: 10.5551/jat.22483.
    1. Lee A. H., Fung W. K., Fu B. Analyzing hospital length of stay: mean or median regression? Medical Care. 2003;41(5):681–686. doi: 10.1097/01.MLR.0000062550.23101.6F.
    1. Arboix A. Cardiovascular risk factors for acute stroke: Risk profiles in the different subtypes of ischemic stroke. World Journal of Clinical Cases. 2015;3(5):418–429. doi: 10.12998/wjcc.v3.i5.418.
    1. Rukn S. A., Mazya M. V., Hentati F., et al. Stroke in the Middle-East and North Africa: A 2-year prospective observational study of stroke characteristics in the region—Results from the Safe Implementation of Treatments in Stroke (SITS)-Middle-East and North African (MENA) International Journal of Stroke. 2019;14(7):715–722. doi: 10.1177/1747493019830331.
    1. Hsieh F. I., Chiou H. Y. Stroke: morbidity, risk factors, and care in Taiwan. Journal Stroke. 2014;16(2):59–64. doi: 10.5853/jos.2014.16.2.59.
    1. Turin T. C., Kita Y., Rumana N., et al. Ischemic stroke subtypes in a Japanese population: Takashima Stroke Registry, 1988-2004. Stroke. 2010;41(9):1871–1876. doi: 10.1161/STROKEAHA.110.581033.
    1. Al-Hashel J. Y., Al-Sabah A.-A., Ahmed S. F., et al. Risk Factors, Subtypes, and Outcome of Ischemic Stroke in Kuwait: A National Study. Journal of Stroke and Cerebrovascular Diseases. 2016;25(9):2145–2152. doi: 10.1016/j.jstrokecerebrovasdis.2016.05.038.
    1. Zafar A., al-Khamis F. A., al-Bakr A. I., Alsulaiman A. A., Msmar A. H. Risk factors and subtypes of acute ischemic stroke. A study at King Fahd Hospital of the University. Neurosciences. 2016;21(3):246–251. doi: 10.17712/nsj.2016.3.20150731.
    1. Marulanda-Londono E., Chaturvedi S. Stroke due to large vessel atherosclerosis: Five new things. Neurology: Clinical Practice. 2016;6(3):252–258. doi: 10.1212/CPJ.0000000000000247.
    1. Murtagh B., Smalling R. W. Cardioembolic stroke. Current Atherosclerosis Reports. 2006;8(4):310–316. doi: 10.1007/s11883-006-0009-9.
    1. Ferro J. M. Cardioembolic stroke: an update. Lancet Neurology. 2003;2(3):177–188. doi: 10.1016/S1474-4422(03)00324-7.
    1. Krishnamurthi R. V., Barker-Collo S., Parag V., et al. Stroke Incidence by Major Pathological Type and Ischemic Subtypes in the Auckland Regional Community Stroke Studies. Stroke. 2018;49(1):3–10. doi: 10.1161/STROKEAHA.117.019358.
    1. Khader Y., Batieha A., Jaddou H., et al. Hypertension in Jordan: Prevalence, Awareness, Control, and Its Associated Factors. International Journal of Hypertension. 2019;2019:8. doi: 10.1155/2019/3210617.3210617
    1. Alghadir A., Alghwiri A. A., Awad H., Anwer S. Ten-year Diabetes Risk Forecast in the Capital of Jordan. Medicine. 2016;95(12, article e3181) doi: 10.1097/MD.0000000000003181.
    1. Marnane M., Duggan C. A., Sheehan O. C., et al. Stroke subtype classification to mechanism-specific and undetermined categories by TOAST, A-S-C-O, and causative classification System. Stroke. 2010;41(8):1579–1586. doi: 10.1161/STROKEAHA.109.575373.
    1. Tsivgoulis G., Katsanos A. H., Köhrmann M., et al. Embolic strokes of undetermined source: theoretical construct or useful clinical tool? Therapeutic Advances in Neurological Disorders. 2019;12:p. 175628641985138. doi: 10.1177/1756286419851381.
    1. Kissela B. M., Khoury J. C., Alwell K., et al. Age at stroke: temporal trends in stroke incidence in a large, biracial population. Neurology. 2012;79(17):1781–1787. doi: 10.1212/WNL.0b013e318270401d.
    1. Seminog O. O., Scarborough P., Wright F. L., Rayner M., Goldacre M. J. Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults. BMJ. 2019;365:p. l1778.
    1. Mossuto-Agatiello L. Caudal paramedian midbrain syndrome. Neurology. 2006;66(11):1668–1671. doi: 10.1212/01.wnl.0000218180.03127.11.
    1. Al-Shammri S., Shahid Z., Ghali A., et al. Risk factors, subtypes and outcome of ischaemic stroke in Kuwait--a hospital-based study. Medical Principles and Practice. 2003;12(4):218–223. doi: 10.1159/000072287.
    1. Deleu D., Inshasi J., Akhtar N., et al. Risk factors, management and outcome of subtypes of ischemic stroke: a stroke registry from the Arabian Gulf. Journal of the Neurological Sciences. 2011;300(1-2):142–147. doi: 10.1016/j.jns.2010.08.023.
    1. Jordan. Overview of tobacco use, tobacco control, legislation and taxation, World Bank Group. May 2019, .
    1. Weimar C., Roth M. P., Zillessen G., et al. Complications following acute ischemic stroke. European Neurology. 2002;48(3):133–140. doi: 10.1159/000065512.
    1. Johnston K. C., Li J. Y., Lyden P. D., et al. Medical and neurological complications of ischemic Stroke. RANTTAS Investigators Stroke. 1998;29(2):447–453. doi: 10.1161/01.STR.29.2.447.
    1. Grau A. J., Buggle F., Schnitzler P., Spiel M., Lichy C., Hacke W. Fever and infection early after ischemic stroke. Journal of the Neurological Sciences. 1999;171(2):115–120. doi: 10.1016/S0022-510X(99)00261-0.
    1. Heuschmann P. U., Kolominsky-Rabas P. L., Misselwitz B., et al. Predictors of in-hospital mortality and attributable risks of death after ischemic stroke: the German Stroke Registers Study Group. Archives of Internal Medicine. 2004;164(16):1761–1768. doi: 10.1001/archinte.164.16.1761.
    1. Hamidon B. B., Raymond A. A., Norlinah M. I., Jefferelli S. B. The predictors of early infection after an acute ischaemic stroke. Singapore Medical Journal. 2003;44(7):344–346.
    1. Grabska K., Gromadzka G., Czlonkowska A. Infections and ischemic stroke outcome. Neurology Research International. 2011;2011:8. doi: 10.1155/2011/691348.691348
    1. Davenport R. J., Dennis M. S., Wellwood I., Warlow C. P. Complications after acute stroke. Stroke. 1996;27(3):415–420. doi: 10.1161/01.STR.27.3.415.
    1. Westendorp W. F., Nederkoorn P. J., Vermeij J. D., Dijkgraaf M. G., van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMC Neurology. 2011;11(1):p. 110. doi: 10.1186/1471-2377-11-110.
    1. Langhorne P., Stott D. J., Robertson L., et al. Medical complications after Stroke. Stroke. 2000;31(6):1223–1229. doi: 10.1161/01.STR.31.6.1223.
    1. Vargas M., Horcajada J. P., Obach V., et al. Clinical consequences of infection in patients with acute stroke: is it prime time for further antibiotic trials? Stroke. 2006;37(2):461–465. doi: 10.1161/01.STR.0000199138.73365.b3.
    1. Jaradat R. W., Lahlouh A. B., Alshogran O. Y., Aldabbour B. A., Balusha A. A. Nosocomial Infections among Patients with Intracranial Hemorrhage: A Retrospective Data Analysis of Predictors and Outcomes. Clinical Neurology and Neurosurgery. 2019;182:158–166. doi: 10.1016/j.clineuro.2019.05.016.
    1. Wouters A., Nysten C., Thijs V., Lemmens R. Prediction of Outcome in Patients With Acute Ischemic Stroke Based on Initial Severity and Improvement in the First 24 h. Frontiers in Neurology. 2018;9:p. 308. doi: 10.3389/fneur.2018.00308.
    1. Sato S., Toyoda K., Uehara T., et al. Baseline NIH Stroke Scale Score predicting outcome in anterior and posterior circulation strokes. Neurology. 2008;70, Issue 24, Part 2:2371–2377. doi: 10.1212/01.wnl.0000304346.14354.0b.
    1. Sablot D., Belahsen F., Vuillier F., et al. Predicting acute ischaemic stroke outcome using clinical and temporal thresholds. ISRN Neurology. 2011;2011:9. doi: 10.5402/2011/354642.354642
    1. Rost N. S., Bottle A., Lee J. M., et al. Stroke Severity Is a Crucial Predictor of Outcome: An International Prospective Validation Study. Journal of the American Heart Association. 2016;5(1) doi: 10.1161/jaha.115.002433.
    1. Shrestha S., Poudel R. S., Khatiwada D., Thapa L. Stroke subtype, age, and baseline NIHSS score predict ischemic stroke outcomes at 3 months: a preliminary study from Central Nepal. Journal of Multidisciplinary Healthcare. 2015;8:443–448. doi: 10.2147/JMDH.S90554.
    1. Caso V., Paciaroni M., Agnelli G., et al. Gender differences in patients with acute ischemic stroke. Womens Health. 2010;6(1):51–57. doi: 10.2217/WHE.09.82.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe