Global Differences in Risk Factors, Etiology, and Outcome of Ischemic Stroke in Young Adults-A Worldwide Meta-analysis: The GOAL Initiative

Jacob MA; Ekker MS; Allach Y; Cai M; Aarnio K; Arauz A; Arnold M; Bae HJ; Bandeo L; Barboza MA; Bolognese M; Bonardo P; Brouns R; Chuluun B; Chuluunbatar E; Cordonnier C; Dagvajantsan B; Debette S; Don A; Enzinger C; Ekizoglu E; Fandler-Höfler S; Fazekas F; Fromm A; Gattringer T; Hora TF; Jern C; Jood K; Kim YS; Kittner S; Kleinig T; Klijn CJM; Kõrv J; Kumar V; Lee KJ; Lee TH; Maaijwee NAM; Martinez-Majander N; Marto J; Mehndiratta MM; Mifsud V; Montanaro V; Pacio G; Patel VB; Phillips MC; Piechowski-Jozwiak B; Pikula A; Ruiz-Sandoval J; von Sarnowski B; Swartz RH; Tan KS; Tanne D; Tatlisumak T; Thijs V; Viana-Baptista M; Vibo R; Wu TY; Yesilot N; Waje-Andreassen U; Pezzini A; Putaala J; Tuladhar AM; de Leeuw FE

doi:10.1212/WNL.0000000000013195

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Global Differences in Risk Factors, Etiology, and Outcome of Ischemic Stroke in Young Adults-A Worldwide Meta-analysis: The GOAL Initiative

Jacob MA ¹ , Ekker MS ¹ , Allach Y ¹ , Cai M ¹ , Aarnio K ¹ , Arauz A ¹ Show all authors , Arnold M ¹ , Bae HJ ¹ , Bandeo L ¹ , Barboza MA ¹ , Bolognese M ¹ , Bonardo P ¹ , Brouns R ¹ , Chuluun B ¹ , Chuluunbatar E ¹ , Cordonnier C ¹ , Dagvajantsan B ¹ , Debette S ¹ , Don A ¹ , Enzinger C ¹ , Ekizoglu E ¹ , Fandler-Höfler S ¹ , Fazekas F ¹ , Fromm A ¹ , Gattringer T ¹ , Hora TF ¹ , Jern C ¹ , Jood K ¹ , Kim YS ¹ , Kittner S ¹ , Kleinig T ¹ , Klijn CJM ¹ , Kõrv J ¹ , Kumar V ¹ , Lee KJ ² , Lee TH ² , Maaijwee NAM ¹ , Martinez-Majander N ¹ , Marto J ¹ , Mehndiratta MM ¹ , Mifsud V ¹ , Montanaro V ¹ , Pacio G ¹ , Patel VB ¹ , Phillips MC ¹ , Piechowski-Jozwiak B ¹ , Pikula A ¹ , Ruiz-Sandoval J ¹ , von Sarnowski B ¹ , Swartz RH ¹ , Tan KS ¹ , Tanne D ¹ , Tatlisumak T ¹ , Thijs V ¹ , Viana-Baptista M ¹ , Vibo R ¹ , Wu TY ¹ , Yesilot N ¹ , Waje-Andreassen U ¹ , Pezzini A ¹ , Putaala J ¹ , Tuladhar AM ¹ , de Leeuw FE ²

Affiliations

¹ From Donders Institute for Brain, Cognition and Behaviour (M.A.J., M.S.E., Y.A., M.C., C.J.M.K., A.M.T., F.-E.d.L.), Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands; Neurology (K.A., N.M.-M., T.T., J.P.), Helsinki University Hospital and University of Helsinki, Finland; National Institute of Neurology and Neurosurgery of Mexico (A.A.), Manuel Velasco Suárez, Mexico City; Department of Neurology (M.A.), Inselspital, University Hospital, University of Bern, Switzerland; Cerebrovascular Disease Center (H.-J.B., K.-J.L.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea; Neurology Department (L.B., P.B., G.P.), Hospital Británico de Buenos Aires, Argentina; Neurosciences Department (M.A.B.), Hospital Dr. Rafael A. Calderon Guardia, CCSS, San Jose, Costa Rica; Neurocenter (M.B., N.A.M.M.), Department of Neurology and Neurorehabilitation, Lucerne Cantonal Hospital, Luzern, Switzerland; The Faculty of Medicine and Pharmacy (R.B.), Vrije Universiteit Brussel, Jette, Belgium; Department of Neurology (R.B.), ZorgSaam Hospital, Terneuzen, the Netherlands; International School of Traditional Medicine (B.C.) and Department of Neurology, School of Medicine (B.D.), Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; Department of Global Health (E.C.), School of Public Health, Taipei Medical University, Taiwan; U1172-LilNCog-Lille Neuroscience & Cognition (C.C.), Univ Lille, Inserm, CHU Lille; Team VINTAGE (S.D.), Bordeaux Population Health Research Center, Inserm, University of Bordeaux, France; School of Medicine (A.D.) and Department of Epidemiology and Preventive Medicine, School of Public Health (D.T.), Sackler Faculty of Medicine, Tel Aviv University, Israel; Department of Neurology (C.E., S.F.-H., F.F., T.G.) and Division of Neuroradiology, Department of Radiology (C.E., T.G.), Medical University of Graz, Austria; Department of Neurology (E.E., N.Y.), Istanbul University, Istanbul Faculty of Medicine, Turkey; Center for Neurovascular Diseases, Department of Neurology (A.F., U.W.-A.), Haukeland University Hospital, Bergen, Norway; SARAH Hospital of Rehabilitation (T.F.H., V. Montanaro), Brasilia, Brazil; Department of Laboratory Medicine, Institute of Biomedicine (C.J.), and Institute of Neuroscience and Physiology (K.J.), the Sahlgrenska Academy, University of Gothenburg; Departments of Clinical Genetics and Genomics (C.J.) and Neurology (K.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurology (K.Y.S.), College of Medicine, Hanyang University, Seoul, South Korea; Department of Neurology (S.K.), Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore; Department of Neurology (T.K.), Royal Adelaide Hospital, Australia; Department of Neurology and Neurosurgery (J.K., R.V.), University of Tartu, Estonia; Neurological Institute (V.K., V. Mifsud, B.P.-J.), Cleveland Clinic Abu Dhabi, United Arab Emirates; Department of Neurology (T.-H.L.), Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine (T.-H.L.), Chang Gung University, Guishan, Taoyuan, Taiwan; Department of Neurology (J.P.M., M.V.-B.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental and CEDOC, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal; Department of Neurology (M.M.M.), G.B. Pant Institute of Medical Education and Research (GIPMER), New Delhi, India; Department of Neurology (V.B.P.), Nelson R. Mandela School of Medicine, Inkosi Albert Luthuli Central Hospital, Mayville, South Africa; Department of Neurology (M.C.P.), Waikato Hospital, Hamilton, New Zealand; Department of Medicine (Neurology), University Health Network (A. Pikula), and Department of Medicine (Neurology) (R.H.S.), Sunnybrook Health Sciences Center, University of Toronto, Canada; Department of Neurology (J.R.-S.), Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico; Department of Neurology (B.v.S.), University Medicine, Greifswald, Germany; Department of Medicine (K.-S.T.), University of Malaya, Kuala Lumpur; Rambam Healthcare Campus (D.T.), Haifa, Israel; Stroke Theme (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne; Department of Neurology (V.T.), Austin Health, Melbourne, Victoria, Australia; Department of Neurology (T.Y.W.), Christchurch Hospital, New Zealand; and Department of Clinical and Experimental Sciences (A. Pezzini), Neurology Clinic, University of Brescia, Italy
² From Donders Institute for Brain, Cognition and Behaviour (M.A.J., M.S.E., Y.A., M.C., C.J.M.K., A.M.T., F.-E.d.L.), Department of Neurology, Radboud University Medical Center, Nijmegen, the Netherlands; Neurology (K.A., N.M.-M., T.T., J.P.), Helsinki University Hospital and University of Helsinki, Finland; National Institute of Neurology and Neurosurgery of Mexico (A.A.), Manuel Velasco Suárez, Mexico City; Department of Neurology (M.A.), Inselspital, University Hospital, University of Bern, Switzerland; Cerebrovascular Disease Center (H.-J.B., K.-J.L.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea; Neurology Department (L.B., P.B., G.P.), Hospital Británico de Buenos Aires, Argentina; Neurosciences Department (M.A.B.), Hospital Dr. Rafael A. Calderon Guardia, CCSS, San Jose, Costa Rica; Neurocenter (M.B., N.A.M.M.), Department of Neurology and Neurorehabilitation, Lucerne Cantonal Hospital, Luzern, Switzerland; The Faculty of Medicine and Pharmacy (R.B.), Vrije Universiteit Brussel, Jette, Belgium; Department of Neurology (R.B.), ZorgSaam Hospital, Terneuzen, the Netherlands; International School of Traditional Medicine (B.C.) and Department of Neurology, School of Medicine (B.D.), Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia; Department of Global Health (E.C.), School of Public Health, Taipei Medical University, Taiwan; U1172-LilNCog-Lille Neuroscience & Cognition (C.C.), Univ Lille, Inserm, CHU Lille; Team VINTAGE (S.D.), Bordeaux Population Health Research Center, Inserm, University of Bordeaux, France; School of Medicine (A.D.) and Department of Epidemiology and Preventive Medicine, School of Public Health (D.T.), Sackler Faculty of Medicine, Tel Aviv University, Israel; Department of Neurology (C.E., S.F.-H., F.F., T.G.) and Division of Neuroradiology, Department of Radiology (C.E., T.G.), Medical University of Graz, Austria; Department of Neurology (E.E., N.Y.), Istanbul University, Istanbul Faculty of Medicine, Turkey; Center for Neurovascular Diseases, Department of Neurology (A.F., U.W.-A.), Haukeland University Hospital, Bergen, Norway; SARAH Hospital of Rehabilitation (T.F.H., V. Montanaro), Brasilia, Brazil; Department of Laboratory Medicine, Institute of Biomedicine (C.J.), and Institute of Neuroscience and Physiology (K.J.), the Sahlgrenska Academy, University of Gothenburg; Departments of Clinical Genetics and Genomics (C.J.) and Neurology (K.J.), Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Neurology (K.Y.S.), College of Medicine, Hanyang University, Seoul, South Korea; Department of Neurology (S.K.), Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore; Department of Neurology (T.K.), Royal Adelaide Hospital, Australia; Department of Neurology and Neurosurgery (J.K., R.V.), University of Tartu, Estonia; Neurological Institute (V.K., V. Mifsud, B.P.-J.), Cleveland Clinic Abu Dhabi, United Arab Emirates; Department of Neurology (T.-H.L.), Chang Gung Memorial Hospital, Linkou Medical Center; College of Medicine (T.-H.L.), Chang Gung University, Guishan, Taoyuan, Taiwan; Department of Neurology (J.P.M., M.V.-B.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental and CEDOC, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal; Department of Neurology (M.M.M.), G.B. Pant Institute of Medical Education and Research (GIPMER), New Delhi, India; Department of Neurology (V.B.P.), Nelson R. Mandela School of Medicine, Inkosi Albert Luthuli Central Hospital, Mayville, South Africa; Department of Neurology (M.C.P.), Waikato Hospital, Hamilton, New Zealand; Department of Medicine (Neurology), University Health Network (A. Pikula), and Department of Medicine (Neurology) (R.H.S.), Sunnybrook Health Sciences Center, University of Toronto, Canada; Department of Neurology (J.R.-S.), Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico; Department of Neurology (B.v.S.), University Medicine, Greifswald, Germany; Department of Medicine (K.-S.T.), University of Malaya, Kuala Lumpur; Rambam Healthcare Campus (D.T.), Haifa, Israel; Stroke Theme (V.T.), Florey Institute of Neuroscience and Mental Health, University of Melbourne; Department of Neurology (V.T.), Austin Health, Melbourne, Victoria, Australia; Department of Neurology (T.Y.W.), Christchurch Hospital, New Zealand; and Department of Clinical and Experimental Sciences (A. Pezzini), Neurology Clinic, University of Brescia, Italy. frankerik.deleeuw@radboudumc.nl

Neurology, 2022 Feb 08;98(6):e573-e588.

PMID: 34906974 DOI: 10.1212/WNL.0000000000013195

Abstract

BACKGROUND AND OBJECTIVES: There is a worldwide increase in the incidence of stroke in young adults, with major regional and ethnic differences. Advancing knowledge of ethnic and regional variation in causes and outcomes will be beneficial in implementation of regional health care services. We studied the global distribution of risk factors, causes, and 3-month mortality of young patients with ischemic stroke, by performing a patient data meta-analysis from different cohorts worldwide.

METHODS: We performed a pooled analysis of individual patient data from cohort studies that included consecutive patients with ischemic stroke aged 18-50 years. We studied differences in prevalence of risk factors and causes of ischemic stroke between different ethnic and racial groups, geographic regions, and countries with different income levels. We investigated differences in 3-month mortality by mixed-effects multivariable logistic regression.

RESULTS: We included 17,663 patients from 32 cohorts in 29 countries. Hypertension and diabetes were most prevalent in Black (hypertension, 52.1%; diabetes, 20.7%) and Asian patients (hypertension 46.1%, diabetes, 20.9%). Large vessel atherosclerosis and small vessel disease were more often the cause of stroke in high-income countries (HICs; both p < 0.001), whereas "other determined stroke" and "undetermined stroke" were higher in low and middle-income countries (LMICs; both p < 0.001). Patients in LMICs were younger, had less vascular risk factors, and despite this, more often died within 3 months than those from HICs (odds ratio 2.49; 95% confidence interval 1.42-4.36).

DISCUSSION: Ethnoracial and regional differences in risk factors and causes of stroke at young age provide an understanding of ethnic and racial and regional differences in incidence of ischemic stroke. Our results also highlight the dissimilarities in outcome after stroke in young adults that exist between LMICs and HICs, which should serve as call to action to improve health care facilities in LMICs.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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