Health behavior of young patients with ischemic stroke in Estonia: A score of five factors.

BACKGROUND: Behavioral risk factors are common among young patients with stroke. This study aimed to compare the health behavior of patients and healthy controls and develop a combined risk score of health behavior. METHODS: The health behavior of patients aged 18-54 years who suffered an ischemic stroke from 2013 to 2020 in Estonia was compared to the Health Behavior among Estonian Adult Population 2014 study sample. We chose five risk factors for comparison: smoking status, body mass index, physical exercise, diet (salt use and vegetable consumption), alcohol intake (quantity and frequency), and composed a summary score. RESULTS: Comparing 342 patients and 1789 controls, daily smoking (49.0% vs. 22.7%), obesity (33.4% vs. 15.9%), low physical activity (< twice/week) (72.2% vs. 60.5%), excessive salt use (8.6% vs. 4.5%), and frequent alcohol use (≥ weekly) (39.9% vs. 34.0%) were more prevalent among patients. The differences in infrequent vegetable consumption (<6 days/week) and excessive alcohol consumption (7 days, >8 units/females, >16 units/males) were not significant. The observed differences were similar for age groups 18-44 years and 45-54 years. The average Health Behavior Stroke Risk Score (0-10) was 4.6 points (CI 4.4-4.8, SD ± 1.97) for patients and 3.5 points (CI 3.4-3.6, SD ± 1.90) for controls. CONCLUSIONS: Before stroke, young patients displayed significantly worse health behavior than the general population. The largest differences were found for smoking and obesity, and a cumulation of risk factors was observed via the HBSR score.

Estonian young stroke registry: High burden of risk factors and high prevalence of cardiomebolic and large-artery stroke.

BACKGROUND AND AIMS: The aim of the present study was to assess the risk factor burden and stroke etiology of young stroke patients in Estonia and to compare the results with similar cohorts from other countries. METHODS: This study includes ischemic stroke patients aged 18-54 years from the prospective Estonian Young Stroke Registry between 2013 and 2020. All patients were managed in a stroke unit following a prespecified detailed protocol. Data on stroke risk factors, etiology, and stroke severity were analyzed. RESULTS: A total of 437 patients (mean age 44.7 ± 8.3 years; 62% males) were included in the registry during the 8-year study period. A total of 50.2% of patients had ≥ 3 well-documented risk factors (higher for men: odds ratio (OR) 3.8; 95% cardiac index confidence interval (CI) 1.8-8.3; p < .001) and 6.2% of patients had ≥ 3 less well-documented risk factors. While 42% of patients had undetermined cause of stroke (34% of them cryptogenic), the second most frequent etiologies were large-artery atherosclerosis and cardioembolism (both 19%). 60 percent of cardioembolic strokes were due to high-risk causes. Large-artery atherosclerosis was more prevalent in men (OR 1.8; 95% CI 1-3.3; p = .05) and among older patients (OR 6.2; 95% CI 1.8-21.4; p = .008). The median National Institutes of Health Stroke Scale score on admission was 3 (interquartile ranges 2-6), stroke was more severe in men (p = .05). CONCLUSIONS: Our study revealed that young patients with stroke in Estonia have higher burden of well-documented risk factors, higher prevalence of high-risk cardioembolic causes and higher prevalence of large-artery stroke compared to other young stroke cohorts.

Determinants of Long-Term Health-Related Quality of Life in Young Ischemic Stroke Patients.

OBJECTIVES: This study aimed to assess long-term, health-related quality of life (HRQOL) in a young ischemic stroke cohort, and to identify factors associated with poor HRQOL. MATERIALS AND METHODS: We conducted a survey with ischemic stroke survivors in Estonia aged 18-54 years at the time of stroke, measuring HRQOL with the three-level version of the five-dimension EuroQol (EQ-5D-3L). The control group comprised the participants of the Health Behavior among Estonian Adult Population study. A tobit regression model with a backward stepwise analysis was used to identify factors associated with low EQ-5D-3L utility scores. RESULTS: In total, 352 patients with a mean follow-up time from the qualifying event of 5.7 years and 2304 controls were included. The mean EQ-5D-3L utility score in stroke survivors was significantly lower compared with that in the general population (0.71 vs. 0.87, respectively, p<0.001). However, the subgroup with excellent functional outcome had a significantly higher mean EQ-5D-3L utility score compared with non-stroke counterparts (0.91 v 0.87, respectively, p<0.001). The largest differences between stroke survivors and the general population were in the physical domains. Coronary heart disease at the index event, and higher follow-up duration, functional disability, depressive symptoms, recurrent stroke, and not being fully employed at follow-up, were independently associated with lower HRQOL. CONCLUSION: Young ischemic stroke survivors have long-term decreased HRQOL, except for those with excellent functional recovery. Our results prioritize motor rehabilitation and highlight the importance of secondary prevention, treatment of depression, and career counselling as potential ways of increasing HRQOL.

Mortality in young adult patients with acute ischaemic stroke.

OBJECTIVES: This study aimed to determine short- and long-term mortality, clinical determinants and causes of death in young patients with ischaemic stroke. MATERIALS AND METHODS: We performed a hospital-based study of 18- to 54-year-old consecutive patients with ischaemic stroke, who were treated in the two largest hospitals in Estonia from 2003 to 2012. All cases were reviewed by the authors. Survival data and causes of death were obtained from the Estonian Population Registry and the Causes of Death Registry, respectively. Logistic regression and Cox proportional hazard models with backwards stepwise analysis were used to identify determinants of mortality. RESULTS: We identified 738 patients, of whom 124 died during the 5-year follow-up. Cumulative mortality rates at 30 days and 5 years were 4.5% (95% confidence interval [CI], 3.0%-6.0%) and 16.8% (95% CI, 14.1%-19.5%), respectively. The proportion of deaths due to vascular causes was 87.9% at 1 month and 54.6% at 5 years. Thirty-day mortality was independently associated with severe stroke, with a National Institutes of Health Stroke Scale (NIHSS) score >15, and post-stroke infections. The determinants of 5-year mortality were post-stroke infections, structural cardiac diseases and moderate stroke severity with NIHSS score of 7-15. CONCLUSION: The mortality rate among young patients with ischaemic stroke in Estonia is higher than that reported in previous studies and is associated with increased stroke severity, post-stroke infections and structural cardiac diseases. These results emphasize the need for more effective preventive strategies in these patient groups.

Risk Factors and Etiology of Young Ischemic Stroke Patients in Estonia.

OBJECTIVES: Reports on young patients with ischemic stroke from Eastern Europe have been scarce. This study aimed to assess risk factors and etiology of first-ever and recurrent stroke among young Estonian patients. METHODS: We performed a retrospective study of consecutive ischemic stroke patients aged 18-54 years who were treated in our two hospitals from 2003 to 2012. RESULTS: We identified 741 patients with first-ever stroke and 96 patients with recurrent stroke. Among first-time patients, men predominated in all age groups. The prevalence of well-documented risk factors in first-time stroke patients was 83% and in the recurrent group 91%. The most frequent risk factors were hypertension (53%), dyslipidemia (46%), and smoking (35%). Recurrent stroke patients had fewer less well-documented risk factors compared to first-time stroke patients (19.8 versus 30.0%, P = 0.036). Atrial fibrillation was the most common cause of cardioembolic strokes (48%) and large-artery atherosclerosis (LAA) was the cause in 8% among those aged <35 years. Compared to first-time strokes, recurrent ones were more frequently caused by LAA (14.3 versus 24.0%, P = 0.01) and less often by other definite etiology (8.5 versus 1.0%, P = 0.01). CONCLUSIONS: The prevalence of vascular risk factors among Estonian young stroke patients is high. Premature atherosclerosis is a cause in a substantial part of very young stroke patients.

Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Triggers, Causes, and Outcome (SECRETO): Rationale and design.

BACKGROUND: Worldwide, about 1.3 million annual ischaemic strokes (IS) occur in adults aged <50 years. Of these early-onset strokes, up to 50% can be regarded as cryptogenic or associated with conditions with poorly documented causality like patent foramen ovale and coagulopathies. KEY HYPOTHESES/AIMS: (1) Investigate transient triggers and clinical/sub-clinical chronic risk factors associated with cryptogenic IS in the young; (2) use cardiac imaging methods exceeding state-of-the-art to reveal novel sources for embolism; (3) search for covert thrombosis and haemostasis abnormalities; (4) discover new disease pathways using next-generation sequencing and RNA gene expression studies; (5) determine patient prognosis by use of phenotypic and genetic data; and (6) adapt systems medicine approach to investigate complex risk-factor interactions. DESIGN: Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO; NCT01934725) is a prospective multi-centre case-control study enrolling patients aged 18-49 years hospitalised due to first-ever imaging-proven IS of undetermined etiology. Patients are examined according to a standardised protocol and followed up for 10 years. Patients are 1:1 age- and sex-matched to stroke-free controls. Key study elements include centralised reading of echocardiography, electrocardiography, and neurovascular imaging, as well as blood samples for genetic, gene-expression, thrombosis and haemostasis and biomarker analysis. We aim to have 600 patient-control pairs enrolled by the end of 2018. SUMMARY: SECRETO is aiming to establish novel mechanisms and prognosis of cryptogenic IS in the young and will provide new directions for therapy development for these patients. First results are anticipated in 2019.

Stroke awareness in two Estonian cities: better knowledge in subjects with advanced age and higher education.

OBJECTIVES: This study was undertaken to assess stroke awareness of the Estonian population. METHODS: Investigators were asked to fill in an original, closed-ended multiple-choice questionnaire about the definition, risk factors, symptoms and behavior at the onset of stroke by randomly selected subjects in public places of the two biggest cities in Estonia (Tallinn and Tartu). RESULTS: The study included 355 persons. Most of the respondents knew that stroke is an acute disease and that one should call the ambulance at the onset of a stroke. Speech disorder and paresis were the best known symptoms, while hypertension was the best known risk factor. There were no differences between the sexes, but advanced age and higher level of education were related to higher awareness. CONCLUSIONS: The overall knowledge was better compared to many other studies. Future awareness campaigns should be addressed to younger subjects with lower education.

Neoplastic meningitis as the presenting manifestation of gastric adenocarcinoma.

A middle aged man presented with clinical signs of chronic meningitis, including bilateral hearing loss and progressive blindness. Lumbar puncture revealed a mild elevation in lymphocyte number, an elevation in protein levels, and diminished glucose levels, without malignant cells. Magnetic resonance imaging (MRI) T2 weighted seqeunces showed bilateral enhancement of the acoustic nerves. The aetiology of the chronic meningitis was revealed gastric cancer by gastroscopy, and micrometastasis by bone marrow trephine biopsy. Although cerebrospinal fluid (CSF) cytology was negative, neoplastic meningitis (NM) was diagnosed based on clinical and MRI data. The patient's condition worsened rapidly and he died shortly thereafter. Autopsy confirmed the presence of advanced gastric cancer (adenocarcinoma of signet-ring cell type) with pancreatic involvement, and NM with cancer cells on the meninges, but without infiltration tumour cells into underlying brain parenchyma. We conclude that NM as an initial symptom of gastric cancer is rare and ultimately fatal.