Comparative Analysis of Risk Factors and Clinical Outcomes in Young Patients with Acute Ischemic and Hemorrhagic Stroke

doi:10.21203/rs.3.rs-4917141/v1

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Comparative Analysis of Risk Factors and Clinical Outcomes in Young Patients with Acute Ischemic and Hemorrhagic Stroke

https://doi.org/10.21203/rs.3.rs-4917141/v1

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Background

Stroke is a leading cause of death and disability worldwide and has significant socioeconomic impacts, particularly among young adults. This study focused on young adults (18–55 years) who experienced acute ischemic (AIS) or hemorrhagic stroke (HS) in Zanjan, Iran.

Methods

A retrospective registry-based analysis was conducted using data from the Vali-e-Asr Hospital Stroke Center. A total of 5345 stroke patients were recorded between March 2016 and June 2023, and 616 young stroke survivors were included. Baseline demographic data, stroke risk factor data, functional status (modified Rankin scale (mRS) score, stroke severity (NIHSS score), treatment history, and mortality were analyzed. The statistical analyses included chi-square tests, independent t tests, and logistic regression.

Results

The cohort comprised 525 AIS (85.23%) and 91 HS (14.77%) patients. Significant differences were observed between groups in terms of atrial fibrillation incidence, antiplatelet treatment history, hypertension, previous smoking, and recent stroke history. HS patients had a higher baseline NIHSS score (12.90 ± 6.04 vs. 7.69 ± 8.56, p < 0.05). In-hospital and three-month mortality rates were significantly greater in the HS group. Factors significantly associated with in-hospital mortality included hemorrhagic stroke, female sex, higher NIHSS score, and current smoking status. Lower odds of achieving excellent functional outcomes and functional independence at three months were noted for HS patients, influenced by NIHSS scores and prior health conditions.

Conclusion

Young stroke patients, particularly those with hemorrhagic stroke, have higher mortality and poorer outcomes. The key risk factors included stroke type, NIHSS score, smoking status, and sex. Identifying and managing these factors could improve patient outcomes.

Ischemic stroke

Hemorrhagic stroke

Clinical outcomes

Risk factors

Young adults

In 2019, strokes caused 12.2 million incidents, 143 million disability-adjusted life years (DALYs), and 6.55 million deaths. Worldwide, it is the second leading cause of death and the third leading cause of disability(1). It is estimated that 10–14% of all strokes occur in individuals under 50 years of age(2–4). Among young adults, stroke incidence and hospitalization rates are increasing, while the average onset age is decreasing(5, 6). Considering that young adults are in their early years of productive activity and start families, stroke has a greater socioeconomic impact on young people than on older individuals(7, 8).

Despite the high chance of stroke survival at a young age, young survivors are at an increased risk of recurrence(9). Therefore, identifying stroke risk factors and causes is crucial for preventing recurrences, which occur at a rate of 9% among young adults(8, 10, 11). Atrial fibrillation, diabetes, high blood pressure, family history, dyslipidemia, and prior dyslipidemia are among these risk factors(12, 13). It seems necessary to determine the most significant risk factors in each region and ethnicity based on lifestyle variations.

In low-income groups, stroke-related mortality rates were three times greater than those in high-income groups, and DALYs were three times greater than those in high-income groups(1, 14). In addition, low socioeconomic status is associated with greater stroke severity and worse stroke outcomes(15). Notably, the incidence of stroke varies widely from 5 to 15 strokes per 100,000 persons-years in European studies to 40 strokes per 100,000 persons-years in some Middle Eastern and North African (MENA) countries(16, 17). Based on these findings, a comprehensive assessment of regional stroke incidence, especially in Iran, a country in the MENA region, could be beneficial for reducing stroke incidence and reducing its consequences and recurrence. The aim of this study was to investigate and compare risk factors and their effects on the clinical outcomes of young stroke patients in two groups: acute ischemic stroke and hemorrhagic stroke.

Study Design and Population

This retrospective, registry-based study included young adults aged 18 to 55 years who were admitted to the Stroke Center at Vali-e-Asr Hospital in Zanjan, Iran, for acute ischemic or hemorrhagic stroke. Data were obtained from the Safe Implementation of Treatments in Stroke (SITS) registry. All patients underwent computed tomography (CT) brain scans, with or without magnetic resonance imaging (MRI), as part of the admission process. From a total of 5345 stroke patients registered in the database between March 2016 and June 2023, 1067 (19.9%) were identified as young stroke survivors. Of these, 616 patients were included in the final analysis: 525 (85.2%) with acute ischemic stroke (AIS) and 91 (14.8%) with hemorrhagic stroke (HS) (Fig. 1).

Baseline demographic information, stroke risk factors, stroke functional status (assessed using the modified Rankin Scale [mRS; score range: 0–6]), stroke severity (assessed using the National Institutes of Health Stroke Scale [NIHSS; score range: 0–42]), drug treatment history, and mortality data were collected for all participants.

Risk factors

The following stroke risk factors were evaluated: hypertension (systolic blood pressure ≥ 130 mm Hg or diastolic blood pressure ≥ 80 mm Hg), diabetes mellitus (fasting blood sugar ≥ 126 mg/dL or 2-hour postprandial glucose ≥ 200 mg/dL), hyperlipidemia (history of high cholesterol or triglycerides, or both), history of smoking (previous or current), previous stroke occurring more than three months prior, previous stroke within the past three months, transient ischemic attack (TIA), and atrial fibrillation.

Outcomes

Stroke severity was categorized based on NIHSS scores as follows: minor stroke (0–4), moderate stroke (5–15), moderate-to-severe stroke (16–20), and severe stroke (21–42). Functional independence was defined as an mRS score ≤ 2, while an excellent outcome was defined as an mRS score ≤ 1 at the three-month follow-up. Mortality rates at discharge and at the three-month follow-up were also recorded.

Statistical analysis

Statistical analysis was performed using SPSS software (version 26; IBM Corporation, Armonk, NY, USA). Quantitative variables were expressed as mean ± standard deviation (SD), and categorical variables as frequency and percentage. Baseline characteristics and outcomes were compared between HS and AIS patients using the chi-square test for categorical variables and the independent t-test for normally distributed quantitative variables. Logistic regression analysis was conducted to determine the odds ratios (ORs) and 95% confidence intervals (CIs) for the associations of outcomes with stroke type and other relevant factors. Separate bivariate models were initially used to compare outcomes between AIS and HS patients. A multivariate logistic regression model was then constructed, adjusting for age, sex, stroke risk factors (hypertension, diabetes mellitus, hyperlipidemia, current smoking, previous smoking, previous stroke > 3 months, previous stroke ≤ 3 months, TIA, atrial fibrillation), and baseline NIHSS score. The goodness-of-fit of the adjusted model was evaluated using the Hosmer–Lemeshow test.

Study population

The study included 616 young stroke patients, of whom 525 (85.23) had AIS and 91 (14.77) had HS. The group characteristics are shown in Table 1. A significant difference was noted between the two groups in terms of the incidence of atrial fibrillation, history of antiplatelet treatment, hypertension, previous smoking, and previous stroke within 3 months. The HS group also had a significantly greater mean NIHSS score at baseline (12.90 ± 6.04 vs. 7.69 ± 8.56). There were no significant differences between the AIS and HS groups in terms of sex, history of anticoagulant treatment, diabetes mellitus, hyperlipidemia, current smoking, previous stroke earlier than 3 months, previous TIA, previous atrial fibrillation, or age. Figure 2 shows a comparison between the two groups based on the frequency of their three-month mRS scores.

Table 1

Baseline characteristics of the study population based on stroke type.
Variables	Total (n = 616)	Acute ischemic stroke (n = 525)	hemorrhagic stroke (n = 91)	P value
Gender [n (%)]
Male	331 (53.7)	278 (53)	53 (58.2)	0.350
Female	285 (46.3)	247 (47)	38 (41.8)
Atrial fibrillation at entry [n (%)]
No	571 (92.7)	482 (91.8)	89 (97.8)	0.043
Yes	45 (7.3)	43 (8.2)	2 (2.2)
History of antiplatelet treatment [n (%)]
No	565 (91.7)	474 (90.3)	91 (100)	0.002
Yes	51 (8.3)	51 (9.7)	0 (0)
History of anticoagulant treatment [n (%)]
No	605 (98.2)	514 (97.9)	91 (100)	0.164
Yes	11 (1.8)	11 (2.1)	0(0)
Hypertension [n (%)]
No	308 (50)	288 (54.9)	20 (22)	< 0.001
Yes	308 (50)	237 (45.1)	71 (78)
Diabetes mellites [n (%)]
No	516 (83.8)	439 (83.6)	77(84.6)	0.812
Yes	86 (16.4)	14 (15.4)	100 (16.2)
Hyperlipidemia [n (%)]
No	579 (94)	493 (93.9)	86 (94.5)	0.824
Yes	37 96)	32 (6.1)	5 (5.5)
Current smoking [n (%)]
No	536 (87)	454 (86.5)	82 (90.1)	0.341
Yes	80 (13)	71 (13.5)	9 (9.9)
Previous smoking [n (%)]
No	589 (95.6)	509 (97)	80 (87.9)	< 0.001
Yes	27 (4.4)	16 (3)	11 (12.1)
Previous stroke earlier than 3 months [n (%)]
No	588 (95.5)	502 (95.6)	86 (94.5)	0.638
Yes	28 (4.5)	23 (4.4)	5 (5.5)
Previous stroke within 3 months [n (%)]
No	549 (89.1)	480 (91.4)	69 (75.8)	< 0.001
Yes	67 (10.9)	45 (8.6)	22 (24.2)
Previous TIA ^a [n (%)]
No	604 (98.1)	516 (98.3)	88 (96.7)	0.313
Yes	12 (1.9)	9 (1.7)	3 (3.3)
Previous atrial fibrillation [n (%)]
No	580 (94.2)	491 (93.5)	89 (97.8)	0.108
Yes	36 (5.8)	34 (6.5)	2 (2.2)
Age, year [mean ± SD ^b]	45.94 ± 7.62	45.84 ± 7.68	46.48 ± 7.25	0.459
NIHSS ^c baseline [mean ± SD]	8.46 ± 6.73	7.69 ± 6.04	12.90 ± 8.56	< 0.001
^a Transient ischemic attack; ^b Standard deviation; ^c National Institutes of Health Stroke Scale.

Clinical outcomes

Among all the young stroke patients, 42 (6.8%) died while in the hospital, 55 (8.9%) died within three months, 456 (74) had excellent functional outcomes within three months, and 489 (79.5%) achieved independence within three months (Table 2). The in-hospital mortality rate (23.5% compared with 4%) and three-month mortality rate (33% compared with 4.7%) were significantly greater for hemorrhagic stroke patients. Furthermore, the HS group was 76% less likely to achieve an excellent functional outcome at three months and 77% less likely to achieve functional independence.

Table 2

Associations between clinical outcomes and stroke types in young adults
Outcomes	Total (n = 616)	Acute ischemic stroke (n = 525)	Hemorrhagic stroke (n = 91)	OR ^a	95% CI ^b	P value
Discharge mortality	42 (6.8)	21 (4)	21 (23.1)	7.200	3.742, 13.854	< 0.001
Three-month mortality	55 (8.9)	25 (4.7)	30 (33)	6.250	3.466, 11.271	< 0.001
Three-month excellent functional outcome ^c	456 (74)	413 (78.7)	43 (47.3)	0.243	0.153, 0.385	< 0.001
Three-month functional independency ^d	489 (79.4)	440 (83.8)	49 (53.8)	0.225	0.140, 0.362	< 0.001
^a Odds ratio; ^b Confidence interval; ^c mRS score 0–1; ^d mRS score 0–2

Discharge mortality

Table 3 presents the relationships between patient factors and mortality at discharge. We assessed the odds of various outcomes based on 13 factors, including type of stroke, sex, age, baseline NIHSS score, hypertension, diabetes status, hyperlipidemia status, prior smoking status, current smoking status, previous strokes within 3 months, previous strokes earlier than 3 months, previous TIAs, and previous atrial fibrillation. According to the multivariate logistic regression analysis adjusted for covariates, in-hospital mortality was significantly associated with hemorrhagic stroke incidence [AOR = 4.578, P = 0.001], female sex [AOR = 2.673, P = 0.042], NIHSS score 16–20 [AOR = 16.530, P < 0.001], NIHSS score 21–42 [AOR = 53.377, P < 0.001], and current smoking status [AOR = 4.943, P = 0.005].

Table 3

Multivariate logistic regression of discharge mortality in young stroke patients according to risk factors
	AOR ^a	95% CI ^b	P value
Hemorrhagic vs. ischemic	4.578	1.871, 11.202	0.001
Female vs. male	2.673	1.036, 6.894	0.042
Age
26–35 vs. 18–25	0.289	0.028, 3.016	0.300
36–45 vs. 18–25	0.273	0.035, 2.152	0.218
46–55 vs. 18–25	0.176	0.022, 1.440	0.105
NIHSS ^c score baseline
5–15 vs. 0–4	2.781	0.707, 10.947	0.143
16–20 vs. 0–4	16.530	3.556, 76.836	< 0.001
21–42 vs. 0–4	53.377	13.489, 244.057	< 0.001
Hypertension. Yes vs. no	0.989	0.403, 2.429	0.981
Diabetes mellitus. Yes vs. no	1.373	0.461, 4.093	0.570
Hyperlipidemia. Yes vs. no	0.615	0.097, 3.891	0.606
Current smoking. Yes vs. no	4.943	1.625, 15.030	0.005
Previous smoking. Yes vs. no	0.247	0.024, 2.508	0.237
Previous stroke earlier than 3 months. Yes vs. no	0.578	0.085, 3.912	0.574
Previous stroke within 3 months. Yes vs. no	1.212	0.395, 3.718	0.737
Previous TIA ^d. Yes vs. no	2.576	0.264, 25.118	0.415
Previous atrial fibrillation. Yes vs. no	N/A	N/A	N/A
^a Adjusted odds ratio; ^b Confidence interval; ^c National Institutes of Health Stroke Scale; ^d Transient ischemic attack.

Three-month excellent functional outcome

According to the related results, excellent functional outcome was significantly influenced by the following factors: hemorrhagic stroke [AOR = 0.349, P < 0.001], NIHSS score 5–15 [AOR = 0.342, P < 0.001], NIHSS score 16–20 [AOR = 0.039, P < 0.001], NIHSS score 21–42 [AOR = 0.031, P < 0.001], hyperlipidemia [AOR = 3.406, P = 0.044], and previous smoking [AOR = 0.267, P = 0.012] (Table 4).

Table 4

Multivariate logistic regression of three-month excellent functional outcome of young stroke patients according to risk factors.
	AOR ^a	95% CI ^b	P value
Hemorrhagic vs. ischemic	0.349	0.193, 0.631	< 0.001
Female vs. male	1.170	0.725, 1.888	0.520
Age
26–35 vs. 18–25	2.251	0.500, 10.136	0.291
36–45 vs. 18–25	2.951	0.749, 11.624	0.122
46–55 vs. 18–25	2.002	0.519, 7.726	0.314
NIHSS ^c score baseline
5–15 vs. 0–4	0.342	0.192, 0.608	< 0.001
16–20 vs. 0–4	0.039	0.016, 0.092	< 0.001
21–42 vs. 0–4	0.031	0.013, 0.077	< 0.001
Hypertension. Yes vs. no	1.436	0.887, 2.325	0.141
Diabetes mellitus. Yes vs. no	0.580	0.324, 1.041	0.068
Hyperlipidemia. Yes vs. no	3.406	1.033, 11.228	0.044
Current smoking. Yes vs. no	0.558	0.292, 1.067	0.078
Previous smoking. Yes vs. no	0.267	0.096, 0.747	0.012
Previous stroke earlier than 3 months. Yes vs. no	0.621	0.240, 1.606	0.326
Previous stroke within 3 months. Yes vs. no	0.747	0.373, 1.496	0.411
Previous TIA ^d. Yes vs. no	0.505	0.122, 2.096	0.346
Previous atrial fibrillation. Yes vs. no	0.741	0.316, 1.733	0.489
^a Adjusted odds ratio; ^b Confidence interval; ^c National Institutes of Health Stroke Scale; ^d Transient ischemic attack.

Three-month functional independence

Functional independence (at three months) was strongly associated with hemorrhagic stroke (AOR = 0.333, P = 0.001), NIHSS score 5–15 (AOR = 0.279, P < 0.001), NIHSS score 16–20 (AOR = 0.034, P < 0.001), NIHSS score 21–42 (AOR = 0.027, P < 0.001), diabetes mellitus (AOR = 0.525, P < 0.042), and previous stroke earlier than 3 months (AOR = 0.377, P < 0.043) (Table 5).

Table 5

Multivariate logistic regression of three-month functional independence of young stroke patients according to risk factors
	AOR ^a	95% CI ^b	P value
Hemorrhagic vs. ischemic	0.333	0.179, 0.619	0.001
Female vs. male	0.994	0.587, 1.685	0.983
Age
26–35 vs. 18–25	4.149	0.828, 20.794	0.084
36–45 vs. 18–25	3.632	0.881, 14.975	0.074
46–55 vs. 18–25	3.733	0.913, 15.259	0.067
NIHSS ^c score baseline
5–15 vs. 0–4	0.279	0.137, 0.567	< 0.001
16–20 vs. 0–4	0.034	0.014, 0.085	< 0.001
21–42 vs. 0–4	0.027	0.011, 0.070	< 0.001
Hypertension. Yes vs. no	1.479	0.869, 2.517	0.149
Diabetes mellitus. Yes vs. no	0.525	0.282, 0.976	0.042
Hyperlipidemia. Yes vs. no	2.237	0.657, 7.610	0.198
Current smoking. Yes vs. no	0.500	0.246, 1.018	0.056
Previous smoking. Yes vs. no	0.472	0.160, 1.385	0.172
Previous stroke earlier than 3 months. Yes vs. no	0.377	0.146, 0.970	0.043
Previous stroke within 3 months. Yes vs. no	0.658	0.312, 1.385	0.270
Previous TIA ^d. Yes vs. no	1.093	0.165, 7.226	0.927
Previous atrial fibrillation. Yes vs. no	0.799	0.323, 1.972	0.626
^a Adjusted odds ratio; ^b Confidence interval; ^c National Institutes of Health Stroke Scale; ^d Transient ischemic attack.

Three-month mortality

The three-month mortality rate was significantly related to hemorrhagic stroke [AOR = 4.131, P = 0.001], NIHSS score 16–20 [AOR = 7.345, P = 0.001], NIHSS score 21–42 [AOR = 33.55, 101.438, P < 0.001], and current smoking status [AOR = 3.171, P < 0.016] (Table 6).

Table 6

Multivariate logistic regression of three-month mortality in young stroke patients according to risk factors
	AOR ^a	95% CI ^b	P value
Hemorrhagic vs. ischemic	4.131	1.856, 9.193	0.001
Female vs. male	1.447	0.672, 3.116	0.346
Age
26–35 vs. 18–25	0.493	0.059, 4.148	0.515
36–45 vs. 18–25	0.363	0.053, 2.465	0.300
46–55 vs. 18–25	0.390	0.058, 2.637	0.334
NIHSS ^c score baseline
5–15 vs. 0–4	1.842	0.685, 4.954	0.226
16–20 vs. 0–4	7.345	2.219, 24.316	0.001
21–42 vs. 0–4	33.551	11.097, 101.438	< 0.001
Hypertension. Yes vs. no	0.733	0.341, 1.579	0.428
Diabetes mellitus. Yes vs. no	1.858	0.767, 4.502	0.170
Hyperlipidemia. Yes vs. no	0.406	0.067, 2.455	0.326
Current smoker. Yes vs. no	3.171	1.241, 8.100	0.016
Previous smoker. Yes vs. no	0.671	0.138, 3.268	0.621
Previous stroke earlier than 3 months. Yes vs. no	0.613	0.132, 2.844	0.532
Previous stroke within 3 months. Yes vs. no	1.216	0.445, 3.323	0.704
Previous TIA ^d. Yes vs. no	1.364	0.146, 12.750	0.785
Previous atrial fibrillation. Yes vs. no	0.239	0.029, 2.008	0.188
^a Adjusted odds ratio; ^b Confidence interval; ^c National Institutes of Health Stroke Scale; ^d Transient ischemic attack.

This study investigated young strokes documented in the SITS Registry among the Iranian population, focusing on four key domains: mortality, achievement of excellent functional status (measured by mRS ≤ 1), functional independence (measured by mRS ≤ 2), and mortality. According to the scope of this article, "young stroke" refers to individuals aged 18 to 55 years. The incidence of stroke doubles with every decade of age after these cutoff points fall below 55 years(23).

Strokes of various types exhibit significant regional variation, with ischemic strokes ranging from 22–80% and hemorrhagic strokes ranging from 5–50% (24–28). Approximately 85% of strokes in our study were ischemic, and 15% were hemorrhagic, which is lower than in other East Asian regions (29–33). Among young AIS patients, 53% were males, similar to the findings of other studies conducted in Western countries (44.1–58.9%) compared to Korea (75%), Taiwan (71%), and India (76%) (34–38).

Like in Chen’s study and in contrast to the findings of Tan Young Stroke Study, hypertension was significantly different between AIS and ICH(28, 30). Like in Tan patients, there was no significant difference in the incidence of AF between AIS patients and ICH patients. However, in other studies conducted across stroke populations, not exclusively among young individuals, a history of AF has been shown to lead to significant differences between stroke subtypes (28, 39–42). We found no significant difference in diabetes incidence between the two groups, in contrast with similar young studies. Nevertheless, Salvadori reported similar results in adult patients(28, 30, 43). We categorized smokers into former and current smokers. The prevalence of former smokers was significantly different between AIS and ICH patients, consistent with findings from young studies; however, previous smoking status was not significantly different between adult patients (28, 30, 39, 41, 43). Even with a larger sample size, we did not find a significant difference between stroke subtypes, such as Namaganda(31). Despite the findings of Zhang's stroke study, there were no significant differences in the incidence of TIAs (39). Compared to young studies, hyperlipidemia incidence did not significantly differ (28, 30). To our knowledge, no other article has categorized previous strokes into within and before three months. A history of stroke earlier than 3 months was not significantly different. Previous studies by Young and colleagues showed that previous strokes were significant despite the other findings in adult population studies(28, 30, 40, 41, 43).

Discharge mortality rates of 4% for ischemic stroke patients and 23% for hemorrhagic patients were observed in our study, which are comparable to previously reported ranges of 2–12% for AIS and 12–40% for ICH (44–55). Our three-month mortality rate aligns with the literature, with 4.7% for AIS (vs. 3–8%) and 33% for ICH (vs. 17%) (4, 50, 56–59). This variation may stem from differences in the age ranges considered within studies on young stroke incidence, differences in healthcare access, treatment protocols, and the prevalence of certain risk factors (60, 61). Furthermore, some studies did not separate TIA patients from AIS patients, so mortality due to ischemic stroke was reduced.

Compared with males, females exhibit greater discharge and non-six-month mortality rates, which is consistent with the findings of Abdel-Fattah (62). Several studies have shown that males exhibit higher mortality rates than females(63–65), and other studies suggest that there is no association between sex and increased mortality rates(66, 67). Indeed, the association between sex and mortality rate in young strikes remains an area of ongoing research and debate. Stroke subtype, risk factors, age, hormonal influences, treatment approaches, socioeconomic factors, and study design can all contribute to the complexity of this relationship.

According to Waje-Andreassen, we found no significant differences in mortality risk according to age (68). However, a young patient aged older than 35 years with ischemic stroke was a predictive variable for increased mortality risk, likely reflecting the greater prevalence of well-defined vascular risk factors (66, 69).

The adjusted multivariate regressions revealed that patients with NIHSS scores ≤ 4 at baseline had lower discharge and 3-month mortality rates than patients with higher NIHSS scores. These results are consistent with previous studies indicating that the NIHSS score at baseline is a significant predictor of mortality in young adults (70, 71). Severe stroke disrupts vital brain functions that control essential processes such as breathing, heart rate, and consciousness. This can lead to complications and increase the risk of death (72).

We found no significant association between hypertension or diabetes and mortality rates, as did Bernardo(45). Conversely, it was shown to predict mortality by Smajlović (24). The disparity in results could be partly explained by Iran's government efforts to enhance public health through the implementation of a nationwide screening programme focusing on diabetes and hypertension (73).

The association between smoking and stroke yielded mixed findings. According to our analysis, current smokers had higher mortality. A 2022 systematic review and dose‒response meta-analysis supported our findings (74). Paradoxically, several recent studies suggest a possible link between smoking and better early outcomes in stroke patients, including lower mortality rates or similar overall mortality(75, 76). In these studies, smokers were significantly younger than nonsmokers. Further investigation of the association between various smoking characteristics and stroke incidence is warranted, as smoking dosage is closely correlated with stroke incidence (74).

In our study, in accordance with the findings of others, patients with ICH had worse outcomes than did those with AIS. This might be because more patients were admitted to the severe acquired brain injury ward, had a greater burden of clinical deficits (particularly motor deficits and neglect), required assistance with nutrition, and remained in the rehabilitation setting for longer periods than patients with AIS. Among hemorrhagic stroke patients, mRS scores were significantly different at admission, with hemorrhagic patients having significantly greater disability. Additionally, ICH patients are usually younger, need longer and more intensive hospitalization both in acute and rehabilitation settings, and suffer from more severe initial stroke than AIS patients(43, 77–80).

The three-month mRS was used to evaluate the functional outcome of the patients. In addition to providing appropriate information regarding patient prognosis, this score can also be used to identify patients who would benefit from a particular treatment(81). We demonstrated that hemorrhagic patients have poorer functional outcomes than ischemic patients. This can be attributed to the effectiveness of thrombolysis treatment, as well as the lower baseline severity and influence of other factors in ischemic patients. In our study, three-month excellent functional outcome was significantly associated with increasing disease severity, hyperlipidemia and smoking. Liang suggested that smoking is associated with greater stroke severity, more modifiable risk factors, and poor three-month functional outcomes (82). Functional independence was predicted by a higher NIHSS score, diabetes status and previous stroke. In the young population, only baseline stroke severity (NIHSS > 5) was associated with poor outcome at discharge.(83) This difference might be explained by the fact that previous studies focused on discharge outcomes rather than three-month outcomes. In the Nedeltchev study, stroke in the anterior circulation, age, and stroke severity were associated with three-month unfavorable outcomes and death (4). However, in the Goeggel Simonetti trial, the severity of stroke and diabetes were reported to predict three-month unfavorable outcomes (84). These various findings indicate that identifying the factors affecting favorable outcomes requires additional research in different populations and the performance of meta-analyses to determine the appropriate treatment strategies to optimize clinical outcomes.

Finally, we found that stroke type, even after adjustment for covariates, was a predictor of outcome in young adults. In addition, among the adjusted factors, the NIHSS baseline score was the strongest predictor of poor outcomes and mortality. According to our study, hemorrhagic stroke and a high NIHSS score are the most important factors associated with poor outcomes and death in young adults.

A strength of this study lies in the large sample size of young stroke patients and the reliability of the data collected from the SITS registry, one of the largest stroke databases. To our knowledge, this was the first study to comprehensively investigate the effect of different types of stroke and associated risk factors on clinical outcome in young adult patients.

This study has several limitations, including incomplete information on the three-month mRS score in some patients; these patients were also excluded because of a lack of complication data. In addition, several risk factors, such as a history of vascular disease, congestive heart failure, and contraception usage, were not considered in this study. The lower incidence of hemorrhagic diseases than of ischemic diseases also limits the number of hemorrhagic patients.

The impact of ethnicity, race, and lifestyle factors on patient outcomes should be investigated in other regional studies. These studies can significantly assist in the management of first and second prevention programs.

The present study revealed that young hemorrhagic stroke patients had significantly worse outcomes than young acute ischemic stroke patients. Several factors, including sex, diabetes mellitus status, hyperlipidemia status, previous smoking status, and previous stroke history, contributed to poor outcomes within 3 months. Current smoking status was another key factor related to mortality both in the hospital and three months after discharge. Among the related factors, the NIHSS score was associated with the highest odds of poor clinical outcome and mortality. As a result, the NIHSS score at baseline was the most significant predictor of clinical outcomes in young adult patients.

Conflict of interest

Not applicable.

Ethical approval and consent to participate

This study was also approved by the ethical committee (number IR.ZUMS.REC.1400.095). The Declaration of Helsinki was followed in the study. Regarding ethical considerations, all patients provided informed consent prior to being used in clinical studies, and all correspondence information was stored in SITS.

Funding

Not applicable.

Author Contribution

AGH conceived the study and developed its protocol. Data collection was conducted by FM. Data analysis was performed by HN. The initial manuscript draft was created by MA, MAs, and HN. All the authors contributed to the manuscript review and edited and approved the final version of the manuscript.

Acknowledgement

We would like to express our sincere gratitude to the SITS Registry for providing the comprehensive and invaluable data that formed the foundation of our study. The meticulous documentation and extensive database have significantly contributed to our understanding of stroke outcomes in young adults.We also extend our heartfelt thanks to the Vali-e-Asr Hospital Stroke Center and its dedicated team for their unwavering support and collaboration throughout this research. Their commitment to patient care and excellence in clinical practice has been instrumental in the successful completion of this study. The insights and expertise provided by the clinicians at the Stroke Center have enriched our analysis and interpretation of the findings.

Data Availability

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

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No competing interests reported.

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Comparative Analysis of Risk Factors and Clinical Outcomes in Young Patients with Acute Ischemic and Hemorrhagic Stroke

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