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(Stroke. 1996;27:838-841.)
© 1996 American Heart Association, Inc.

Articles

Stroke in the Young in Israel

Incidence and Outcomes

Naomi Rozenthul-Sorokin, MD; Revital Ronen, MA; Ada Tamir, DrPH; Hana Geva, MD, MMHS Reuben Eldar, MD, DPH

From the Fleischman Unit for the Study of Disability, Loewenstein Hospital, Rehabilitation Center, Raanana, and the Unit for Improvement of Quality of Care, Rambam Medical Center (H.G.), Haifa, Israel.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose Data on stroke in the young in Israel are fragmentary. To obtain an overall perspective and to assess the nature and magnitude of the problem, a study was conducted on stroke occurrence in the young population during 1 year. Incidence and outcomes are reported in this communication.

Methods We conducted a prospective ascertainment of first stroke in all permanent residents of Israel aged 17 to 49 years who were referred to all acute-care hospitals in the country or died before reaching them.

Results We identified 253 first stroke victims in the studied population; 62.8% were male. The age- and sex-adjusted incidence rate for all types of stroke was 10.36/100 000 per year (males, 13.00; females, 7.71). The majority of strokes (80.6%) were cerebral infarctions, with 9.9% intracerebral hemorrhages, 7.9% subarachnoid hemorrhages, and 1.6% strokes of unspecified type. The case-fatality rate for all types of stroke was 9.9% (mortality within the first 4 weeks after the event, on average 6 days). The survival rate was 95% for cerebral infarctions, 64% for intracerebral hemorrhages, and 80% for subarachnoid hemorrhages; 86.7% of all survivors remained with an impairment resulting in a disability.

Conclusions Incidence rates were similar to those reported from developed Western countries. The case-fatality rate of 9.9% and the considerable percentage of survivors with a disability in a population at the beginning of their family, professional, and social lives indicate the magnitude of the problem.

Key Words: epidemiology • incidence • stroke outcome • young adults

	Introduction

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Data regarding stroke among the young have been reported from developed^{1 2 3 4} and less developed^{5 6} countries. In Israel, information on stroke in the young is fragmentary. During 7 years (1960 to 1967), 69 patients younger than 45 years were admitted after an acute first stroke to three hospitals in Jerusalem. The annual incidence per 100 000 was estimated to be 2.5 for those younger than 34 years and 22.2 for the group aged 35 to 44 years and was higher in females.⁷ From 1971 to 1974, 59 first stroke patients younger than 54 years were registered prospectively in the Ramle-Rechovot district, with an annual incidence rate of 10/100 000.⁸ In 600 000 Jewish residents in the north of Israel during 1 year, 15 strokes in patients younger than 45 years were identified prospectively.⁹ During 15 years (1974 to 1988), 171 females aged 17 to 45 years were referred to a rehabilitation institution after a first stroke.¹⁰

To obtain an overall perspective and to assess the nature and magnitude of stroke in the young population of Israel, a study was conducted during 1 year. The present report will describe basic features of the study population, incidence, and outcomes. Further communications will address risk factors and causes of stroke in this population and a long-term follow-up.

	Subjects and Methods

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The study included all permanent residents of Israel aged 17 to 49 years who sustained a first stroke between November 1, 1992, and October 31, 1993. Stroke and its types were defined according to criteria of the World Health Organization,¹¹ a definition that includes cerebral infarction and intracerebral and subarachnoid hemorrhage.

Specially briefed investigators (physicians and nurses) in all 23 acute-care hospitals in Israel prospectively identified stroke patients aged 17 to 49 years in emergency departments and hospital wards. They administered a structured questionnaire by interviewing the patients and/or family, speaking with the team caring for the patient, and reviewing the medical record in the department in which the patient was hospitalized. The questionnaire contained 88 questions pertaining to demographic and socioeconomic variables, medical and family history, and clinical and ancillary findings on admission to and discharge from an acute-care hospital. Systematic reviews of documents in the medical record departments and emergency wards of the hospitals were made concomitantly to detect any missed cases as well as strokes that occurred in hospitals (after admission for diagnosis other than stroke). To identify nonfatal cases treated out of hospitals, retrospective checks were made in all rehabilitation facilities as well as in samples of primary care clinics and neurological outpatient departments. Constant weekly reviews of death certificates and autopsy reports in all six district offices of the Ministry of Health served to identify stroke victims who died before reaching a hospital.

The occurrence of stroke was categorized as follows: 4:31 AM to 11:30 AM, morning; 11:31 AM to 3:30 PM, midday; 3:31 PM to 7:30 PM, afternoon; 7:31 PM to 11:30 PM, evening; and 11:31 PM to 4:30 AM, night. When a person awakened in the morning with a deficit, the stroke was registered as having occurred at night.

Data from all questionnaires were analyzed with Statistix Analytical Software; findings were compared with data of the Central Bureau of Statistics (Statistical Abstract of Israel, 1994, No. 45, Jerusalem) and with results of studies performed in Israel and elsewhere.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Initially 290 patients were registered, but 37 were subsequently excluded from the study when they were diagnosed with recurrent strokes (19), transient ischemic attacks (11), benign tumors (3), metastases to the brain (3), and multiple sclerosis (1). Thus, 253 persons who sustained a confirmed first-ever stroke, as defined, were enrolled in the study; 159 were males (62.8%), 94 females (37.2%), 202 Jews (79.8%), and 51 non-Jews (20.2%).

All of the patients were admitted to one of the 23 hospitals, except 8 who died before reaching one. Two hundred forty-five patients arrived alive at a hospital, and 242 were admitted as inpatients (45.3% to neurology, 40.7% to internal medicine, 7.6% to neurosurgery, and 6.4% to other departments).

During the year of the study, the population of Israel aged 17 to 19 years numbered 2 441 900 persons (1 223 000 males, 1 218 900 females). Comparison with this at-risk population shows a higher proportion of males (62.8%) and a lower proportion of females (37.2%) in the study population than in the at-risk population (50.1% and 49.9%, respectively), a difference found to be statistically significant (²=0.06, P=.05) (Table 1).

View this table: [in this window] [in a new window]   Table 1. Characteristics of Study Subjects Compared With Population at Risk

Types of stroke were defined according to World Health Organization recommendations¹¹ and based on findings of ancillary examinations, following criteria described in the literature.¹²

CT of the brain was performed in 239 patients (94.5%) and showed a hypodense area in 146, intracerebral hemorrhage in 19, subarachnoid hemorrhage in 17, generalized atrophy in 3, sinus thrombosis in 1, and no abnormality in 53. Additional investigations performed were angiography of cerebral blood vessels (in 31 patients), MRI (in 23), and autopsy (in 9). In 4 subjects none of these investigations were carried out.

Based on the findings of these investigations, strokes were divided into cerebral infarctions in 204 subjects (80.6%), intracerebral hemorrhage in 25 (9.9%), subarachnoid hemorrhage in 20 (7.9%), and unspecified type in 4 (1.6%). The stroke occurred at night in 7.1% of subjects, during the morning in 45.6%, during midday in 19.2%, in the afternoon in 9.2%, and in the evening in 18.6%. Almost half of cerebral infarctions (47.5%) occurred during the morning, and 42% of subarachnoid and 36% of intracerebral hemorrhages occurred during the night (without correlation to existence or absence of high blood pressure). No seasonal differences were found in the onset of strokes, irrespective of the type of stroke.

The annual age- and sex-adjusted incidence rate for all types of stroke was 10.36/100 000. It was higher in males (13.00) than in females (7.71) (P<.0001, z=4.06; 95% confidence interval, 10.98 to 15.08 in males, 6.15 to 9.27 in females) (Table 2). The incidence rate was not statistically significantly lower in Jews (10.11) than in non-Jews (11.49).

View this table: [in this window] [in a new window]   Table 2. Incidence Rates for All Strokes According to Age and Sex (per 100 000)

The incidence rate rose with age (Table 2) except in females, in whom a higher rate (3.68) was found in the group aged 20 to 24 years than in the two subsequent age groups (25 to 29 and 30 to 34 years). In all age groups the rate was higher in males, except in the group aged 20 to 24 years, in which it was higher in females.

To compare the incidence in the study population with that from 1960 to 1967,⁷ subjects were divided into two groups: group A (34 subjects aged 17 to 34 years) and group B (219 subjects aged 35 to 49 years). The incidence rate was 2.30 in group A (males, 2.27; females, 2.33) and 22.68 in group B (males, 29.86; females, 15.72) compared with 2.5 in the group younger than 34 years and 22.2 in the group aged 35 to 44 years from 1960 to 1967.

Twenty-five patients died: 10 had a cerebral infarction, 9 an intracerebral hemorrhage, 4 a subarachnoid hemorrhage, and 2 a stroke of unspecified type. This is a case-fatality rate of 9.9% (4.9% ischemic, 36% intracerebral hemorrhage, 20% subarachnoid hemorrhage, and 50% unspecified stroke). Eight died before reaching a hospital and 17 within 4 weeks after the event (on average, 6 days). Except for two subjects in the group aged 17 to 34 years, all other fatal cases occurred in the group aged 35 to 49 years (13 males, 10 females).

Two hundred twenty-eight survivors were discharged from the acute-care hospital after an average stay of 11.75 days (median, 8 days), a short-term (4 weeks) survival of 90.1% (95% for cerebral infarctions, 64% for intracerebral hemorrhages, 80% for subarachnoid hemorrhages, and 50% for unspecified types of strokes).

Table 3 shows the outcome of ischemic stroke in the studied population (because of the small number of hemorrhagic and unspecified types, these are not shown). Seven patients recovered completely, 15 had a minimal impairment that did not interfere with their return to all prestroke activities, and 172 (84.3%) had an impairment that resulted in disability (minor in 96, moderate in 38, and severe in 38). Fifty-three patients (26%) were referred to inpatient rehabilitation.

View this table: [in this window] [in a new window]   Table 3. Outcomes of Ischemic Strokes According to Age Groups1 (n=204)

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
This study confirmed findings of previous reports from Israel^{7 8 9} that all first stroke cases are referred to hospitals. Systematic efforts have not detected cases not referred to hospitals (except the 8 who died before reaching them), and all 23 acute-care hospitals were covered by the study. We are therefore confident that the study included all first stroke cases that occurred during the year of the study in the population aged 17 to 49 years in Israel. The preponderance of males in the study population can be explained by the higher incidence rates for males.

Similar to other studies,¹³ a high percentage of strokes in young adults were ischemic. Only 71% of the infarctions were visualized on CT of the brain (compared with 91% reported by another study¹⁴ ), probably because in most cases the investigation was done on the day of onset and was not repeated systematically.^{14 15}

Incidence rates in the present study are similar to those estimated almost three decades ago in Jerusalem. Rates found in our study are similar to those among young subjects in Shibata, Japan¹⁶ ; subjects in Auckland, New Zealand¹⁷ ; whites in Baltimore, Md⁴ ; and subjects in most countries of Western Europe^{1 2 3 18 19} (Table 4) except Finland, which has a high incidence of stroke in all age groups, including groups aged 25 to 34 and 35 to 44 years.^{20 21} Our rates are lower than those found in countries of Eastern Europe, such as Poland^{22 23} and Lithuania,²⁴ and in some less developed countries^{5 6} and blacks in Baltimore, Md,⁴ and South Africa.²⁵ The incidence rates for stroke among young adults in Nigeria were reported to be similar to those found in the West.²⁶

View this table: [in this window] [in a new window]   Table 4. Incidence of Stroke in Young Adults

Similar to reports from other countries,^{17 18 19} incidence was found to rise with age, except in the group of females aged 20 to 24 years, in which the rate was higher than in the two subsequent age groups.

Reports from most countries show higher rates for males, except in Denmark² ; Baltimore, Md (where in whites they were the same in both sexes)⁴ ; Florence, Italy³ ; and Oxfordshire, England (where they were higher in females in the younger groups [15 to 24 and 25 to 34 years] and higher in males in the older groups).¹⁹ In our study, rates were significantly higher in males in all age groups, except in the group aged 20 to 24 years, in which they were higher in females. Ten females in our study population sustained strokes associated with oral contraception, pregnancy, or the postpartum period, and 8 of these cases (80%) occurred in those belonging to the group aged 20 to 24 years.

Twenty-five stroke victims in our study died, resulting in a fatality rate of 9.9%, which was higher for hemorrhagic than for ischemic strokes. The case-fatality rate was reported to be between 1.5% and 5% in those younger than 30 years²¹ and 3.3% for males and 1.7% for females younger than 45 years^{2 13} ; however, the latter two reports did not include hemorrhagic strokes.

The 9.9% rate (9.3% for males, 10.6% for females) found in our study is lower than that (23.7%) found in Florence, Italy,⁴ or in Finland,²⁷ where in some areas it reached 40% in the young population. The case-fatality rate was 30% in 16 European populations aged 35 to 64 years ²¹ and was 33.5% in Auckland, New Zealand.¹⁷ In Jewish stroke victims younger than 65 years, the case-fatality rate was 16.8% (males) and 27.4% (females).⁹ It was also somewhat higher in females in our young population.

Similar to other reports,^{3 18 27} the survival rate in our study was higher for ischemic than for hemorrhagic strokes. The majority of survivors (86.7%) in our study were disabled (moderate in 20.6% and severe in 19%). In terms of ischemic strokes only, these rates were 18.6% and 18.6%, respectively. A previous study reported a similar outcome: 30% of 202 patients younger than 45 years were moderately disabled and 16% were severely disabled.¹³

Incidence and case-fatality rates and outcomes of stroke found in young adults in our study are similar to those reported from most Western countries. The case-fatality rate of 9.9% and the considerable percentage of survivors (almost 40%) with a disability in a population at the beginning of their family, professional, and social lives indicate the magnitude of the problem. Further study of the risk factors and causes of stroke is needed to design a strategy for stroke prevention.

	Acknowledgments

 
This study was supported by a research grant from the Pinchas Sapir Fund of Mifal Ha-Payis (the Israel Lottery). We are grateful to directors of all 23 acute-care hospitals and their department heads for their cooperation and for allowing us to study their patients as well as to all investigators/liaison persons at these hospitals.

	Footnotes

 
Reprint requests to Dr R. Eldar, Loewenstein Hospital, Rehabilitation Center, PO Box 3, Raanana, Israel 43100.

Received August 29, 1995; revision received January 24, 1996; accepted February 1, 1996.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rozenthul-Sorokin, N. Articles by Eldar, R. Search for Related Content PubMed PubMed Citation Articles by Rozenthul-Sorokin, N. Articles by Eldar, R.