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I read with interest the article by Lipska et al1 evaluating the risk factors for young stroke in South India . This study could have also looked at the possible association of an elevated serum Homocysteine level
as a risk factor for stroke .There are data supporting even mild to moderate hyperhomocysteinemia as a possible risk factor for ischemic strokes 2, 3
Elevated levels of Homocys...
Elevated levels of Homocysteine can be primary - the commonest cause being due to Cystathionine beta synthase deficiency. Also Methylene tetrahydro-folate reductase (MTHFR) gene polymorphism can increase the homocysteine level especially in the presence of low serum levels of folic acid. Secondary causes include low B12, B6 levels many lifestyle factors and a host of systemic diseases.
It is interesting to note hyperhomocysteinemia has been found to be an independent risk factors for Coronary artery disease in Indian Asians residing in the UK 4 also Indian Asian residing in the United States have significantly high plasma homocysteine levels compared with Caucasians 5 Finding a strong association between an elevated Homocysteine levels and stroke in a given geographical area can open up new avenues for
epidemiological studies looking for genetic mutations causing primary hyperhomocysteinemia. This can have strong implications in the health care for that population as the treatment is simple and cheap.
1. K Lipska1, P N Sylaja2, P S Sarma3, K R Thankappan3, V R Kutty4, R S Vasan5 and K Radhakrishnan2 Risk factors for acute ischaemic stroke in young adults in South India J Neurol Neurosurg Psychiatry.2007; 78: 959-
2. P. J. Kelly, J. Rosand, J. P. Kistler, V. E. Shih, S. Silveira, A. Plomaritoglou, and K. L. Furie Homocysteine, MTHFR 677C T polymorphism, and risk of ischemic stroke: Results of a meta-analysis: Neurology, Aug 2002; 59: 529 - 536.
3. Eikelboom JW, Lonn E, Genest J Jr, Hankey GJ, Yusuf S. Homocyst(e)ine and cardiovascular disease. A critical review of the epidemiological evidence. Ann Intern Med. 1999; 131: 363–375
4. Chambers JC, Obeid OA, Refsum H, Ueland P, Hackett D, Hooper J, Turner RM, Thompson SG, Kooner JS. Plasma homocysteine concentrations and risk of coronary heart disease in UK Indian Asian and European men Lancet.
2000 Feb 12;355(9203):523-7.
5. Chandalia M, Abate N, Cabo-Chan AV Jr, Devaraj S, Jialal I, Grundy SM. Hyperhomocysteinemia in Asian Indians living in the United States. J Clin Endocrinol Metab. 2003 Mar;88(3):1089-95.
Dr Sanjith Aaron, Alexander M, Maya Thomas, Mathew Vivek.
Dept Of Neurological Sciences Christian Medical College & Hospital Vellore, Tamil Nadu India
Individual with an ischemic or hemorrhagic stroke accounts for about 5 % of all stroke if younger than 45 years of age. The cause of stroke in young differs dramatically compared to the elderly. The most common causes for stroke in young are: cardiac disease, hematological, and dissection.
The stroke risk factors more complex. Lee, et.al, (2002) found the 4 most common risk factors were hyp...
The stroke risk factors more complex. Lee, et.al, (2002) found the 4 most common risk factors were hyperlipidemia (53.1%), smoking (49.8%), hypertension (45.8%), and family history of stroke (29.3%). The other important risk factor is hyperhomocysteine that may cause embolism and
dissection in young adults (Kelly, 2003). Sometimes we need genetic study for finding CADASIL (Viswanathan, 2007). The doctors also have to find the history of migraine (Cuadrado, 2000). The other important risk factor is antiphospholipid antibodies syndrome (Mehndiratta, 1999)
In the article of Dr. Chan (2000) mentioned that about one in five young patients was inadequately investigated by a stroke-oriented group of neurologists. A battery of extensive examinations is indicated to elucidate the etiology for further stroke prevention.
Leys, et.al (2002) studied 287 young onset ishemic stroke and found that annual mortality rate of 4.5% during the first year and then of 1.6%. Some patients do not regain independence. What does it mean? The stroke in young adults is more complex. The doctors have to find the risk factors, and commonly the risk factors are not traditional risk factors. We have to investigate homocysteine, Lp(a),
cardiac doopler, or the marker of vasculitis. More efforts is needed.
The article of Dr. Lipska, et.al is very interesting. This article measure the novel risk factors for stroke (example: metabolic syndrome). In the future we need more research with more risk factors. There is a need of
more studies in the etiology and stroke subtype of young ischemic stroke.
Chan MTY, Nadareishvili ZG, Norris JW, Diagnostic Strategies in Young Patients with Ischemic Stroke in Canada,Can. J. Neurol. Sci. 2000; 27: 120-124
Cuadrado, M.J. Khamashta M.A. HughesG.R.V. Migraine and stroke in young women, Q J Med 2000; 93: 317-318
Kelly, PJ, Furie, KL, Kistler JP, Stroke in young patients with hyperhomocysteinemia due to cystathionine beta-synthase deficiency, Neurology 2003;60:275-279
Lee, TH, Hsu WC, Etiologic Study of Young Ischemic Stroke in Taiwan, Stroke. 2002;33:1950
Tsong-Hai Lee, MD, PhD; Wen-Chuin Hsu Leys, D, Henon H, Clinical outcome in 287 consecutive young adults (15 to
45 years) with ischemic stroke,Neurology 2002;59:26-33
Mehndiratta MM, Bhattacharya A, Gupta M, Khawaja GK, Puri V, Antiphospholipid antibodies syndrome in 'Stroke in young'. Neurol India 1999;47:122-6
Viswanathan, A. Gschwendtner, J. Lacunar lesions are independently associated with disability and cognitive impairment in CADASIL, Neurology 2007; 69: 172-179