| Background:Review of nearly 20 years research reports on acute ischemic stroke in young adults at home and abroad,Data from European population-based studies represented by the Helsinki series show that according to TOAST classification,other determined and undetermined etiology were more common,while stroke caused by large-artery atherosclerosis was only about 7%.In assessing stroke recurrence in young adults,the results from the Helsinki study database showed that statins can significantly reduce the recurrence of stroke.We know that statins are the basic drugs for the secondary prevention of atherosclerotic cerebrovascular disease,which vaguely suggests that the Helsinki research may weaken the proportion of large arteriosclerosis type.Since the Helsinki study was obtained from a European population and the imaging assessment method was rough,we believe that the situation of young stroke in the Asian population may be different from the European population.The reason for this speculation is that small artery occlusion was more common from Japan(2020)study;Another Chinese high-resolution magnetic resonance vascular wall imaging technology to study the vessel wall of young intracranial artery stenosis from Professor Xu Weihai(2017)showed that 80%of them were arteriosclerosis vascular stenosis.Identify the etiology is crucial for the selection of treatment methods,prognosis evaluation and secondary prevention of ischemic stroke in young adults.We therefore believe that the study on clinical characteristics of risk factors,etiology,imaging,complication and prognosis will help us obtain data on young stroke in northern China,especially the proportion of TOAST types,to take more effective prevention and treatment measures to improve the prognosis of young stroke patients.Objectives:We first constructed a database of acute ischemic stroke in young adults.We aimed to:(1)Explicit the proportion of etiology classification in the young stroke cohort in this center;(2)Investigate the risk factors related to prognosis at one year after stroke;(3)Subgroup analysis:Explore the incidence of young ischemic stroke patients with middle cerebral artery stenosis and analyse the risk factors affecting their short-term outcome.Methods:(1)A total of 515 young adults with acute ischemic stroke admitted to the First Affiliated Hospital of Shandong First Medical University between January 2013 and September 2018,were retrospectively recruited.The baseline data and follow-up data at one year after stroke were collected.The database of acute ischemic stroke in young adults was established.(2)Etiology was classified by TOAST(Trial of Org 10172 in acute stroke treatment criteria).WASID method was used to measure and calculate the rate of cerebral artery stenosis.Modified Rankin Scale(mRS)was used for evaluating functional prognosis at discharge and one year(unfavorable outcome:mRS≥2).Binary logistic regression was performed to determine independent risk factors of unfavorable functional prognosis.(3)Baseline data:according to gender and age,included subjects were categorized as male group and female group.And they were also categorized as age 18-49 years group and age 50-55 years group.The baseline data characteristics were compared between groups.(4)Prognosis at one year after stroke:include functional prognosis,stroke recurrence and adherence to secondary preventive medication in patients with atherosclerotic stroke.(5)Subgroup analysis:young adults with MCA territory infarction were recruited.Subjects were defined as stenosis group(MCA stenosis≥50%)and no-stenosis group(MCA stenosis<50%or no stenosis)by the degree of MCA stenosis.For patients in stenosis group,they were categorized as uni-MCA stenosis subgroup and multiple stenosis subgroup.Clinical characteristics of patients between groups were compared and risk factors affecting short-term outcomes of stroke patients were also analyzed.Results:1.Baseline data of young adults with ischemic stroke(1)Demographic data:515 young ischemic stroke patients were included in our study,with a mean age of 48.2±5.8 years.In those included patients,367(71.3%)were male,148(28.7%)were female.The ratio of male to female was 2.46:1.245 patients were aged 18-49 years and 270 patients were aged 50-55 years.(2)Risk factors:78.4 percent of patients had 2 or more traditional vascular risk factor,the most five common traditional vascular risk factors were hypertension(61.9%),smoking(44.3%),alcoholconsumption(38.9%),hyperhomocysteinemia(37.9%)and diabetes(35.3%).Traditional vascular risk factors differ between gender and age groups.The most commom traditional vascular risk factors in the male group was smoking(61.9%),in female group was hypertension(64.2%).Diabetes mellitus(P=0.004),hyperhomocysteinemia(P<0.001),smoking(P<0.001)and drinking(P<0.001)were more common in the male group than in female group.Hyperhomocysteinemia(P=0.010)was more common in the age 18-49 years group than in the 50-55 years group.Diabetes mellitus(P=0.020),history of ischemic stroke/TIA(P<0.001)were more common in the 50-55 years group than in the 18-49 years group.In rare risk factors,autoimmune disease(36.9%)was the most common,most of them were female(7.4%vs 2.2%,p=0.004).(3)TOAST distribution:Classification proportion from high to low were large artery atherosclerosis(LAA,43.1%),small artery occlusion(SAO,30.7%),stroke of other undemonstrated etiology(SUE,15.3%),stroke of other demonstrated etiology(SOE,7.8%),cardiogenic embolism(CE,3.1%).Moyamoya disease was the most common among the SOE,followed by vasculitis.SUE was more commom in the female group than the male group(20.9%vs 13.1%,p=0.025).LAA was more common in the 50-55 years age group than in the 18-49 years age group(48.9%vs 36.7%,p=0.005).(4)Imaging:There were more the anterior circulations infarcts(58.3%)and lacunar infarction(42.1%).Large territorial infarction was 27.6%.50.1%patients had moderate and severe responsible vascular stenosis(≥50%).The incidence of moderate and severe vascular stenosis was higher in the 50-55 years age group than in the 18-49 years age group(p=0.025).(5)Complications:The prevalence of complications during hospitalization was low(65 cases,12.6%),with the most was pulmonary infection(33cases,6.4%).LAA had the highest prevalence of complication(72.3%).In logistic regression,NIHSS scores at admission(p<0.001,OR=1.168),serum uric acid(p=0.040,OR=0.997)and infarct size(p=0.006,OR=1.965)were independent risk factors for early complications.(6)The short-term outcome:Patient had a relatively low neurological defect severity at baseline(The median NIHSS score at admission:4 points,at discharge:2 points)and favourable short-term outcome(mRS<2 at discharge:75.7%).There were no significant differences of mRS score between the different age groups and the gender groups.Hypertension(P=0.011,OR=2.023),admissionNIHSSscore(P<0.001,OR=1.309)were independent risk factors for the short-term unfavourable outcome.2.Prognosis at one year after the index stroke(1)Functional prognosis:400 young ischemic stroke patients were included in our prognosis analysis.Functional prognosis at one year was favourable in 87.0%.LAA type had the high incidence of unfavourable functional prognosis(69.2%).Previous stroke or TIA(p<0.001,OR=5.915),NIHSS score on admission(p<0.001,OR=1.303),complications(p=0.013,OR=3.789)and mRS score on discharge(p=0.001,OR=6.264)were independent risk factors for unfavourable functional prognosis.(2)Recurrent stroke:Stroke recurrence at one year was 8.9%,most of them were ischemic stroke(93.1%).Based on TOAST classification,LAA type(55.2%)and SAO type(41.4%)were more prone to stroke recurrence.All the recurrent stroke had traditional vascular risk factors.The traditional vascular risk factors predicted stroke recurrence(P=0.006,OR=2.208).The higher the number of traditional vascular risk factors(>3.5),the higher the risk of stroke recurrence.(3)Drug compliance:The proportion of patients applied to antihypertensive and hypoglycemic drugs were 90%at one year.70 percent of LAA type and SAO type patients adhered to antiplatelet and statin drugs,and it was higher in LAA type and the 50-55 age group than those in SAO type and the 18-49 age group.3.Subgroup analysis:young stroke adults with MCA stenosis(1)249 young patients with acute infarction in the MCA territory were included in our study and 110(44.2%)patients were defined as stenosis group,139(55.8%)patients were defined as no-stenosis group.For patients in stenosis group,55(50%)patients were categorized as uni-MCA stenosis subgroup and 55(50%)were multiple stenosis subgroup.(2)Risk factors:For young patients with MCA territory infarction,the most five common traditional vascular risk factors included hypertension(58.6%),hyperlipemia(55.0%),smoking(41.0%),hyperhomocysteinemia(36.1%)and alcohol consumption(33.7%).Among the rare risk factors,autoimmune diseases(3.6%)were the most common.Prevalence of the number of traditional vascular risk factors≥2 or 3 increased with age,but not incidence of MCA stenosis.(3)Etiology:According to TOAST classification in young patients with MCA territory infarction,102(41.0%)patients were defined as LAA,84(33.7%)patients were SAO,6(2.4%)patients were CE,23(9.2%)patients were SOE and 34(13.7%)patients were SUE.Patent foramen ovale was the most common cause in patients with CE.Moyamoya disease was the most common etiology of SOE,which was followed by dissection.(4)Compared with patients in no-stenosis group,patients in stenosis group were more likely to have large territorial infarct(p<0.001)and presented with higher NIHSS score at admission(p<0.001).Regarding the clinical outcome,patients in stenosis group had higher risk of developing complications(p=0.006)and presenting with poor functional outcome at discharge(p<0.001).In comparison between subgroups of patients with MCA stenosis,patients in multiple stenosis subgroup were more likely to have history of stroke/TIA(p<0.001)and higher incidence of the number of traditional vascular risk factors≥3(p<0.001).No significant difference was found between two subgroups in stroke severity,complications and functional outcome.(5)Short-term prognosis:64(25.7%)patients had unfavorable functional prognosis at discharge(mRS>2).In order to investigate independent risk factors for unfavorable functional prognosis,binary logistic regression was performed.Hypertension(p=0.004;OR=3.561),NIHSSscores at admission(p<0.001;OR=1.438)and infarct size(p=0.015)independently predicted unfavorable short-term functional prognosis.Conclusions:1.In young adults with acute ischemic stroke in our center,Large-artery atherosclerosis and small-artery occlusion were the most frequent etiologic subgroups.The most common disease of SOE was moyamoya disease,followed by vasculitis.2.Young ischemic stroke patients had good functional prognosis at one year.Previous stroke or TIA,NIHSS score on admission,complications and mRS score on discharge were independent risk factors for unfavourable functional progosis.Stroke recurrence at one year was 8.9%.All recurrent patients had traditional vascular risk factors.The higher the number of traditional vascular risk factors,the higher the risk of stroke recurrence.LAA and SAO patients were more prone to stroke recurrence,but we found only 70%adherence to secondary preventive medication,which suggests that the education of secondary prevention in young atherosclerotic stroke patients should be strengthened in clinical work.3.44.2%young adults with MCA territory infarction in this study had MCA stenosis.Young stroke patients with MCA stenosis had worse clinical outcome,however,only hypertension,NIHSS scores at admission and infarct size were independent predictors. |
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