Analysis of Risk Factors in Stroke Patients [1]

The analysis of data from the study indicates several key points

regarding the demographics and risk factors associated with ischemic stroke patients:

1. *Gender Predominance: *

 The study shows a higher incidence of stroke in males compared to females. This male predominance is consistent with many other epidemiological studies on stroke.

2. *Age Distribution: *

-             The highest risk group for ischemic stroke is individuals aged 60 to 80 years. The second highest risk group is individuals aged 40 to 60 years.

 -            The second highest risk group is individuals aged 40 to 60 years.

 -            The 20 to 40 years age group has the lowest risk among the studied age ranges.

*Risk Factors: *

-             *Hypertension [7] is identified as the most significant risk factor for ischemic stroke. This is consistent with global data indicating hypertension as a major modifiable risk factor for stroke.

-             *Diabetes Mellitus [8] is the second most significant risk factor. Diabetes is known to increase the risk of stroke through various mechanisms, including accelerated atherosclerosis.

-             The combination of *hypertension and diabetes mellitus* presents a higher risk than either condition alone, highlighting the compounded risk in patients with both conditions.

-             *Thrombophilia [9] is also identified as a significant risk factor. Specific cases in the study include:

One patient with *protein C deficiency*.

One patient with *protein S deficiency*.

One patient with *hyperhomocysteinemia*.

Implications for the Management

Based on the identified risk factors, the management strategies for ischemic stroke patients in the study are as follows:

*Anti platelets vs. Anticoagulants: *

-             *Anti platelets* are generally indicated for most patients with ischemic stroke, especially those with hypertension and diabetes mellitus. These medications help prevent platelet aggregation and subsequent thrombus formation in the arteries.

-             *Anticoagulants* are specifically required for patients with thrombophilia. Conditions such as protein C deficiency, protein S deficiency, and hyperhomocysteinemia warrant the use of anticoagulants to prevent thrombus formation in the venous system and the heart. In addition, the patients with cardioembolic stroke needs to be treated with anticoagulants.

When once the patient enters the hospital the stroke team' will start working.

Fast history along with risk factors are taken and simultaneously all hematological investigations like blood sugar RFT, LFT, ECG, 2 D ECHO X-ray chest and PT with INR are done and immediately subjected for MRI or CT scan brain. when once the haemorrhage is ruled out and other investigations are normal we thrombolyse with Tenacteplase 0.25 mg per kg body weight except in 2 cases who were thrombolysed with,0.1 mg per kg body weight as they crossed 4.5 hrs [10]     and the exact time could not be assessed.Taking the radiological picture( MRI) into consideration we have thrombolysed with 0.1mg dose basing on other studies where they found equally good results and the incidence of haemorrhagic transformation is very low.

Various studies showed that the lower dose is equally effective and younger patients, small infarcts, high risk individuals can be given this low dose got good results with least complications

All the patients who were thrombolysed are followed up in the stroke unit and followed the stroke protocol in monitoring the vitals. CT scan was done after 24 hrs and monitored the sensorium. If there is any bleed and there is altered sensorium, Neurosurgeon was alerted and if necessary, the patient will be subjected for surgery. In our study we didn't come across such situations.

We have followed the stroke protocol as given by SMART Criteria [3].

The earlier criteria laid down were very stringent and very few cases were thrombolysed. The present SMART guidelines show the only

contraindication for THROMBOLYSIS is Intracerebral haemorrhage. Leave alone the age, high or low blood sugar, previous head injury, previous

UGI or urethral bleed and size of infarct or seizures will not come in the way of THROMBOLYSIS.

Patients with accelerated hypertension are also taken for THROMBOLYSIS after reducing the blood pressure to normal range. Even if the patients are on anticoagulants we can correct the INR by giving the concerned antidote and thrombolyse. Patients who are on antiplatelets are not a contraindication for THROMBOLYSIS. Here in our study, we could thrombolyse two cases who were on oral anticoagulants. Warfarin in one case for Double valve replacement and another for Mitral valve replacement. Their INR was less than 1.7 and we could thrombolyse. Though patients on anticoagulants were an absolute contraindication for THROMBOLYSIS, taking INR into consideration of more than 1.7 corresponding antidote can be given along with FFP and thrombolyse but the time constraint is very important and to be done very fast. With the present guidelines the number of patients who can undergo THROMBOLYSIS have been increased. We have followed all the cases for more than 3 months except the last 2 cases who left the hospital on the third day because of financial constraints. All the other cases showed good improvement. They regained grade 3 power in the first week and at end of three months. Patients could do their normal activities without any support. Now the crux of the problem is why we are not able to get all eligible cases for THROMBOLYSIS and help them. Now our main aim is to identify the ways and means by which we can increase THROMBOLYSIS in eligible patients. We will discuss about this at the end of the study. Further evaluation was done with angiogram along with MRI for further management. We have not done thrombectomy in any patient.

Two patients came from outside after THROMBOLYSIS and thrombectomy. One patient showed good improvement at the end of three months and doing the normal activities. We lost one patient with large infarct who underwent THROMBOLYSIS and thrombectomy as they refused for surgical intervention. Along with THROMBOLYSIS, management of blood pressure and Diabetes mellitus were carried out. If any problem like ICH plan for surgical management was considered and the Neurosurgeon was alerted. In our study we didn't have any such problems and all the patients who were thrombolysed were discharged in good condition. All these patients were followed up and most of them showed good improvement in the first few days and the remaining at the end of three months showed good improvement. This shows the value of THROMBOLYSIS in the window period and the time is brain concept well established. Those patients who came after the window period we have tried for THROMBOLYSIS plus thrombectomy but none of them could get it done because of the financial burden, fear of improvement, and refusal from the supporting caregivers. Those patients who came after a day or two we have evaluated by imaging, identification of risk factors and their management was done along with the physiotherapy.

Evaluation of the causes of non Thrombolysed patients who came after the window period:
These patients are subjected for imaging for diagnosing haemorrhagic or ischemic stroke, hematological evaluation for diabetes mellitus, lipid profile, viral markers, RFT, LFT, CBC, ECG, X RAY CHEST, SICKELING, and coagulopathies. All the ischemic strokes are managed with anti-platelets, lipid lowering agents, anti-hypertensives and anti-diabetic drugs along with physiotherapy. If there is evidence of raised intracranial pressure either Mannitol or 3% saline infusion were given. If there is midline shift or deterioration in the sensorium surgical intervention was sought and managed.

All the patients after recovery were discharged with required advice and follow up was done. If there is evidence of carotid stenosis more than 70 percent the interventional radiologist opinion was taken and followed accordingly. Any evidence of coronary artery disease association if noticed Cardiologist consultation was taken and followed accordingly.