Document Type : Original Article
Authors
- . Ehsan Sarbazi
- . Parvin Sarbakhsh
- . Daryoush Savadi Oskooei 1
- . Mohammad Yazdchi 1
- . Saber Ghaffari‑Fam 2
- . Seyed Morteza Shamshirgaran
1 Department of Neurology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz
2 Miandoab Health Centre, Urmia University of Medical Sciences, Urmia, Iran
Abstract
BACKGROUND AND OBJECTIVE: Stroke is the second leading cause of death worldwide and
the number of stroke cases has increased remarkably over the last 20 years. This study aimed at
identifying predictors of with 6‑month mortality of first‑ever stroke patients and the factors contributing
to it in East Azerbaijan province.
MATERIALS AND METHODS: A closed cohort study was carried out from April 2014 to
December 2014. All cases of first‑ever diagnosed stroke were included in the study. Any transient
ischemic attack, silent brain infarctions, and the stroke cases which were neither associated with
trauma, blood disease nor with malignancy were excluded from the study. The variables of this study
include participants’ demographic characteristics, stroke severity National Institutes of Health Stroke
Scale (NIHSS), and stroke risk factors. Patients were followed up within 6 months. To determine the
survival time, the log‑rank method was applied to compare intergroup differences. The tests include
the univariate and multivariate analysis Cox regression. P < 0.05 were considered as statistically
significant.
RESULTS: A total of 576 cases of stroke were included in this study. Average age of ischemic and
hemorrhagic stroke was 70.15 ± 13.0 and 67.79 ± 12.69, respectively. Case‑fatality rate (CFR)
of stroke patients was 49.2 and 21.7% in hemorrhagic and ischemic stroke types, respectively.
Factors contributing to stroke mortality events include the severity of stroke (NIHSS categories
15–19 and ≥20), age over 65, being female, high body mass index and hyperlipidemia. In the
final model, the severity of stroke (with NIHSS 15–19 with hazard ratio (HR) 4.22 (95% confidence
interval [CI] 2.36–7.56) and NIHSS ≥20 with HR 5.34 (95% CI: 2.81–10.12) and age above 65 with
HR 1.61 (95% CI: 1.02–2.51) were the most important predictors of 6‑month mortality.
CONCLUSION: Severity of stroke by NIHSS was the most prominent factor in stroke patients’
mortality. By increasing the follow‑up time, a better evaluation of the predictors of mortality after
stroke can be achieved.
Keywords
- Ghandehari K. Epidemiology of stroke in Iran. Galen Med J
2016;5:3‑9.
2. Towfighi A, SaverJL. Stroke declines from third to fourth leading
cause of death in the United States: Historical perspective and
challenges ahead. Stroke 2011;42:2351‑5.
3. Béjot Y, Daubail B, Giroud M. Epidemiology of stroke and
transient ischemic attacks: Current knowledge and perspectives.
Rev Neurol (Paris) 2016;172:59‑68.
4. Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ
Res 2017;120:439‑48.
5. Sienkiewicz‑Jarosz H, Głuszkiewicz M, Pniewski J, Niewada M,
Członkowska A, Wolfe C, et al. Incidence and case fatality rates
of first‑ever stroke‑comparison of data from two prospective
population‑based studies conducted in Warsaw. Neurol
Neurochir Pol 2011;45:207‑12.
6. Feigin VL, Lawes CM, Bennett DA, Anderson CS. Stroke
epidemiology: A review of population‑based studies of incidence,
prevalence, and case‑fatality in the late 20th century. Lancet Neurol
2003;2:43‑53.
7. Bank World. Data for Iran, Islamic Rep. Upper Middle Income;
2017. Available from: https://www.data.worldbank.org/
country/iran‑islamic‑rep. [Available date 2018 Jun 30].
8. Sidney S, Rosamond WD, Howard VJ, Luepker RV. The “heart
disease and stroke statistics‑2013 update” and the need for a national
cardiovascular surveillance system. Circulation. 2013;127:21‑3.
9. Di Carlo A, Lamassa M, Baldereschi M, Pracucci G, Consoli D,
Wolfe CD, et al. Risk factors and outcome of subtypes of ischemic
stroke. Data from a multicenter multinational hospital‑based
registry. The European community stroke project. J Neurol Sci
2006;244:143‑50.
10. Hosseini AA, Sobhani‑Rad D, Ghandehari K, Benamer HT.
Frequency and clinical patterns of stroke in Iran – Systematic and
critical review. BMC Neurol 2010;10:72.
11. Daneshfard B, Izadi S, Shariat A, Toudaji MA, Beyzavi Z,
Niknam L, et al. Epidemiology of stroke in Shiraz, Iran. Iran J
Neurol 2015;14:158‑63.
12. Johnson M, Bakas T. A review of barriers to thrombolytic therapy:
Implications for nursing care in the emergency department.
J Neurosci Nurs 2010;42:88‑94. - 13. Appelros P, Stegmayr B, Terént A. Sex differences in stroke
epidemiology: A systematic review. Stroke 2009;40:1082‑90.
14. O’Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao‑Melacini P,
et al. Risk factors for ischaemic and intracerebral haemorrhagic
stroke in 22 countries (the INTERSTROKE study): A case‑control
study. Lancet 2010;376:112‑23.
15. Center Iranian Statistics. East Azerbaijan Province; 2016. Available
from: https://www.amar.org.ir/. [Available date 2018 Jun 30].
16. Thorvaldsen P, Asplund K, Kuulasmaa K, Rajakangas AM,
Schroll M. Stroke incidence, case fatality, and mortality in the
WHO MONICA project. World Health Organization monitoring
trends and determinants in cardiovascular disease. Stroke
1995;26:361‑7.
17. Timsit S, Nowak E, Rouhart F, Goas P, Merrien FM, Tirel‑Badet A,
et al. High completeness of the brest stroke registry evidenced
by analysis of sources and capture‑recapture method.
Neuroepidemiology 2014;42:186‑95.
18. National High Blood Pressure Education Program. The Seventh
Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. Bethesda (MD):
National Heart, Lung, and Blood Institute (US); 2004.
19. Zimmet P, Alberti K, Shaw J. International diabetes federation: the
IDF consensus worldwide definition of the metabolic syndrome.
Diabetes Voice 2005;50:31‑3.
20. Oveisgharan S, Sarrafzadegan N, Shirani S, Hosseini S,
Hasanzadeh P, Khosravi A. Stroke in Isfahan, Iran: Hospital
admission and 28‑day case fatality rate. Cerebrovasc Dis
2007;24:495‑9.
21. Sagui E, M’Baye PS, Dubecq C, Ba Fall K, Niang A, Gning S,
et al. Ischemic and hemorrhagic strokes in Dakar, Senegal:
A hospital‑based study. Stroke 2005;36:1844‑7.
22. Zandieh A, Kahaki ZZ, Sadeghian H, Fakhri M, Pourashraf M,
Parviz S, et al. A simple risk score for early ischemic stroke
mortality derived from national institutes of health stroke scale:
A discriminant analysis. Clin Neurol Neurosurg 2013;115:1036‑9.
23. Karnik R, Valentin A, Ammerer HP, Hochfelner A, Donath P,
Slany J. Outcome in patients with intracerebral hemorrhage:
Predictors of survival. Wien Klin Wochenschr 2000;112:169‑73.
24. Janes F, Gigli GL, D’Anna L, Cancelli I, Perelli A, Canal G, et al.
Stroke incidence and 30‑day and six‑month case fatality rates in
Udine, Italy: A population‑based prospective study. Int J Stroke
2013;8 Suppl A100:100‑5.
25. Ghandehari K, Izadi Z; Khorasan Stroke Registry. The Khorasan
stroke registry: Results of a five‑year hospital‑based study.
Cerebrovasc Dis 2007;23:132‑9.
26. Delbari A, Salman Roghani R, Tabatabaei SS, Lökk J. A stroke
study of an urban area of Iran: Risk factors, length of stay, case
fatality, and discharge destination. J Stroke Cerebrovasc Dis
2010;19:104‑9.
27. Amini Sani N, Oscoie S, Shamshirgaran SM, Dastgiri S. One
month mortalty rate of storke in Ardabil. J Ardabil Univ Med Sci
2007;7:353‑6.
28. Zhang C, Lan T, Zhe Y, Hu B, Zhang G, He J, et al. Epidemiology
investigation of stroke among Mongolian and Han population
aged over 45 in inner Mongolia. Sci Rep 2017;7:45710.
29. Borhani‑Haghighi A, Safari R, Heydari ST, Soleimani F,
Sharifian M, Yektaparast Kashkuli S, et al. Hospital mortality
associated with stroke in Southern Iran. Iran J Med Sci
2013;38:314‑20.
30. Azarpazhooh MR, Etemadi MM, Donnan GA, Mokhber N,
Majdi MR, Ghayour‑Mobarhan M, et al. Excessive incidence
of stroke in Iran: Evidence from the Mashhad stroke incidence
study (MSIS), a population‑based study of stroke in the Middle
East. Stroke 2010;41:e3‑10.
31. Ghandehari K, MoudZI. Incidence and etiology of ischemic stroke
in Persian young adults. Acta Neurol Scand 2006;113:121‑4.
32. Cheung CM, Tsoi TH, Hon SF, Au‑Yeung M, Shiu KL, Lee CN,
et al. Using the national institutes of health stroke scale (NIHSS) to
predict the mortality and outcome of patients with intracerebral
haemorrhage. Hong Kong Med J 2008;14:367‑70.
33. Dawodu CO, Danesi MA. Relationship of national institute of
health stroke scores [NIHSS] to 90 days mortality in Africa. Niger
Postgrad Med J 2008;15:259‑63.
34. Kawate N, Kayaba K, Hara M, Kotani K, Ishikawa S; Jichi
Medical School Cohort Study Group. Body mass index and stroke
incidence in Japanese community residents: The Jichi medical
school (JMS) cohort study. J Epidemiol 2017;27:325‑30.
35. Ahangar AA, Ashraf Vaghefi SB, Ramaezani M. Epidemiological
evaluation of stroke in Babol, northern Iran (2001‑2003). Eur
Neurol 2005;54:93‑7.
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