(Stroke. 1997;28:1702-1709.)
© 1997 American Heart Association, Inc.
Articles |
Epidemiology and Etiology of Ischemic Stroke in Young Adults Aged 18 to 44 Years in Northern Sweden
From the Departments of Neurology (B.K., J.M.), Medicine (B.C., B.S., T.O.), Clinical Physiology (C.B.), and Neuroradiology (M.F.), University Hospital, Umeå, Sweden.
Correspondence to Bo Kristensen, MD, Department of Neurology, University Hospital, S-901 85 Umeå, Sweden. E-mail Bo.Kristensen{at}neuro.umu.se
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Abstract |
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Background and Purpose The aim of this study was to conduct a population-based epidemiological survey among young adults aged 18 to 44 years in Northern Sweden and furthermore to gain further insight into the etiology of ischemic stroke in this age group.
Methods Two studies were done. In the first part, epidemiological data were collected to calculate incidence and mortality from 1991 through 1994. This was based on the World Health Organization Northern Sweden MONICA register of acute stroke events. Eighty-eight first-ever ischemic stroke patients were identified during that period. In the second part, 107 consecutive patients aged 18 to 44 years with ischemic stroke referred to a university hospital were studied prospectively during a 5-year period and were extensively evaluated according to a standardized protocol. On the basis of modified Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria, the patients were classified into eight subtypes of ischemic stroke.
Results The average population-based annual incidence rate for ischemic stroke (cases per 100 000 per year) was 11.3 (95% confidence interval, 6.7 to 16.1). The case-fatality rate was 5.7%. According to the modified TOAST criteria, a probable cause of ischemic stroke was identified in 36% and remained unexplained in 21% of cases. Spontaneous cervical arterial dissection was the leading probable etiology (13%). Patent foramen ovale or atrial septal aneurysm was a possible cause of stroke in 28% of cases. The percentages of ischemic stroke attributed to IgG anticardiolipin antibodies (4.7%), atherothrombotic vasculopathy (3.7%), oral contraceptive use (7%), and migraine (1%) were lower than reported in recent clinical series.
Conclusions The incidence rate for ischemic stroke was higher than previously reported from most countries in Western Europe. The higher incidence was not explained by a higher prevalence of premature atherosclerotic vasculopathy. Without the additional diagnostic information derived from advanced cardiac imaging, the proportion of indeterminate cases would have constituted 37% of the patients.
Key Words: cerebral infarction • epidemiology • stroke classification • Sweden • young adults
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Introduction |
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Ischemic stroke in young adults has been considered a relatively rare event, with fewer than 5%1 of all cerebral ischemic infarctions occurring below the age of 45 years, although more than 10% has been reported.2 The age-specific incidence of stroke among individuals in this young age group has been reported by community and hospital surveys from various geographic areas. However, hardly any population-based data have been reported.3
The causes of stroke among young adults are more diverse than in the elderly and require a thorough diagnostic workup. A major problem has thus been that previous studies addressing the etiology of ischemic cerebral infarction in the young have often been retrospective and nonstandardized, with highly variable investigational techniques and sets of diagnostic criteria being applied.4 In addition, advances in technology, including transesophageal investigation and new biochemical assays, have introduced new potential causes of ischemic stroke that still need to be substantiated. Finally, without the acknowledgment of cases not referred for investigation, a biased pattern of the causes of the disease may be present in hospital-based studies from third-level facility hospitals.
The objectives of the present study were to evaluate a true age-specific incidence and furthermore to delineate the causes of ischemic stroke in young adults. The study was thus undertaken in two parts. First, a prospective population-based epidemiological survey was conducted to provide data on the incidence and mortality rates of ischemic stroke in young adults from northern Sweden. Second, in a series of patients admitted to our university hospital, an accurate hierarchy of causes of ischemic stroke was established on the basis of the TOAST classification modified for ischemic stroke in young adults.5
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Subjects and Methods |
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Epidemiological Study
Acute stroke events in the two northernmost counties of our catchment area (Fig 1
) have been
monitored since 1985 by the WHO Northern Sweden MONICA
project.6 The case finding and validation of data
quality have been described in detail earlier.7
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The total population in the MONICA surveillance area was 518 669 on January 1, 1991, and 527 423 on December 31, 1994. The target population considered to be at risk included all residents aged 18 to 44 years in this area. They represented 37% (194 194 and 193 113, respectively) of the total population at the beginning and at the end of the epidemiological survey period.
Clinical information from discharge records on all subjects in the age range 25 to 45 years with ICD-9 codes 430 to 438 was screened and validated for acute stroke events that met the definition of ischemic stroke. Data from the group aged 18 to 25 years not originally computed in the MONICA register were obtained, adhering to the same guidelines. This part of the study thus contains patients referred to our university hospital (included in the etiological study; see below) as well as patients investigated only at local acute-care hospitals in Northern Sweden. The same inclusion and exclusion criteria as in the etiological study were used.
Etiological Study
Northern Sweden is served by 13 local hospitals and a
third-level university hospital (Fig 1
). The population in the
present study consists of patients aged 18 to 44 years who were
admitted to Umeå University Hospital between January 1991 and May 1996
as a result of ischemic stroke. The inclusion criteria were as
follows: (1) first-ever completed ischemic stroke, defined as a
rapidly developing focal neurological deficit with no apparent cause
other than a vascular origin, that persisted beyond 24 hours in
surviving patients; (2) age from 18 through 44 years; and (3)
evaluation possible within 3 months after stroke onset. Patients were
scheduled for follow-up at 4 and 12 months after admission. Exclusion
criteria were as follows: ischemic stroke due to complications
of subarachnoid hemorrhage, cardiac surgery, and
malignancy in a terminal stage or occurring as an immediate consequence
of trauma.
Clinical and Laboratory Evaluation
Medical history and information regarding cerebrovascular risk
factors such as arterial hypertension, diabetes mellitus,
smoking, alcohol use, illicit drug use, hyperlipidemia,
oral contraceptive use, history of migraine, and occurrence of venous
or arterial thrombosis in the family were obtained
according to a standardized protocol. Hypertension was defined as
systolic blood pressure >160 mm Hg and/or
diastolic pressure >95 mm Hg on two different
occasions measured outside of the acute phase of stroke or treatment
with antihypertensive drugs during the last 2 weeks before recruitment;
diagnosis of diabetes mellitus was documented by medical records or
at recruitment according to the WHO criteria8 ;
hypercholesterolemia was considered present
if fasting blood level was 
6.5 mmol/L at recruitment; and
hypertriglyceridemia was present if
fasting triglyceride levels were >2.2 mmol/L
at recruitment. Current smoking was defined as smoking one or more
cigarettes per day. Migraine was defined according to the criteria of
the International Headache Society.9
Neuroimaging included CT and MRI of the brain, assessment of cerebral blood flow (single-photon emission CT with Tc–hexamethylpropyleneamine oxime), and cerebral angiography including posterior circulation angiography. Furthermore, duplex ultrasonography of the cervical arteries, chest roentgenography, electrocardiography, and 24-hour Holter electrocardiography recording was performed.
In reference to echocardiographic studies, the TTE
studies were performed with the use of standard techniques. Views were
obtained in the parasternal, apical, and subcostal windows. The TEE
images were obtained with a 5-MHz monoplane transducer in 69 patients
and with a multiplane transducer in 28 patients. All examinations were
recorded on videotape and analyzed in a blinded manner
off-line in a random order. ASA was diagnosed when the atrial septum
appeared abnormally redundant and mobile and exhibited an excursion
into the left or right atrium, or both, of >10 mm and a base of
10 mm. For PFO, the echocardiographic detection
of interatrial right-to-left shunting was identified by color-flow
Doppler or by the administration of 5 mL agitated saline in an
antecubital vein. Two to four contrast injections were systematically
performed in each patient, in the resting state and during
provocative maneuvers (Valsalva and cough test) to
transiently reverse the interatrial pressure gradient. The
echocardiographic diagnosis of PFO was based on the
appearance of at least three microcavitations, either spontaneously or
after provocation maneuvers, into the left atrium, not later than four
cycles after the appearance of the microcavitations in the right
atrium. The presence of atheroma of any severity was noted
when detected on echocardiography, occurring
between the aortic valve and the origin of the left subclavian artery.
Mitral valve prolapse was defined on TTE as mitral leaflet thickening
and displacement beyond the plane of the mitral annulus and into the
left atrium in the parasternal long-axis view during systole.
A detailed laboratory study was performed, including complete blood cell count; electrolytes; serum creatinine; amino-transferases; creatine kinase; urinary analysis; erythrocyte sedimentation rate; serum protein electrophoresis; concentrations of blood glucose and glycosylated hemoglobin; antinuclear antibodies and IgG aCLs; rheumatoid factor; complement factors (C3/C4); serological testing for syphilis, borreliosis, and viral infections, including HIV; serum cholesterol and triglyceride levels; LDL and HDL levels; lipoprotein(a); and prothrombin and activated partial thromboplastin times. Activated partial thromboplastin time was also used as a screening test for the presence of lupus anticoagulants. Levels of protein C, protein S, and antithrombin III were analyzed both in the acute phase and at least 4 months after first admission.
Classification of Subtypes
We used a modified stroke subtype classification for the
etiology of ischemic stroke with the definitions based on the
TOAST classification, accommodated and validated for stroke in the
young.5 The patients were classified independently by two
groups of paired investigators. A consensus approach was applied when
necessary. The main diagnostic criteria are
presented in Fig 2.
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Statistical Analyses
Incidence rate was derived from the number of first episodes of
ischemic stroke among the residents in the two counties during
the study period. The average of the populations living in the area
between January 1, 1991, and December 31, 1994, was the denominator of
the equations for the incidence rates. Case-fatality rate was defined
as the number of subjects who died within 28 days from the onset of
stroke during the same period. Ninety-five percent confidence intervals
were computed according to the Poisson variation for the number of
events within the age groups. Fisher's exact and
2 tests were used when appropriate for
statistical analysis. Probability was two tailed, and
P<.05 was considered significant.
The study was approved by the Research Ethics Committee of Umeå University; data handling procedures were approved by the National Computer Data Inspection Board.
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Results |
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Epidemiological Study
A total of 88 first-ever ischemic strokes in the age range 18 through 44 years from the MONICA surveillance area were recognized during the time period of January 1, 1991, to December 31, 1994. Seventy-one cases (81%) were primarily evaluated or referred from secondary-level care settings for further investigations at the university hospital. These patients are thus included in the etiologic study part. The additional 17 cases, all admitted to local acute-care hospitals, were identified from the MONICA project register. These additional cases had all undergone CT scan or necropsy. No further cases were recognized from death certificates only or from medical discharge records in the group aged 18 to 24 years.
The average annual incidence rate of first-ever ischemic stroke
in the group aged 18 to 44 years was 11.3/100 000. The age- and
sex-specific incidence rates and the 95% confidence intervals are
shown in Table 1. In both sexes the risk
of stroke increased with age, but there was no statistically
significant difference between men and women (2=3.03,
P=.08).
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Five patients died within 28 days, resulting in a case-fatality rate of 5.7%. Deaths resulted from ischemic cerebral edema and herniation in 3 patients and from the effects of severe brain stem cerebellar infarction in 1 patient. One patient died as a result of a myocardial infarction and subsequent congestive heart failure.
Data pertaining to the yearly average of ischemic stroke events in men and women in the group aged 25 to 74 years during the time period 1991 to 1993 were available from the MONICA register.7 On average, 562 first-ever ischemic stroke events occurred yearly during 1991 to 1993. Ischemic stroke in young adults thus represented 3.9% of all ischemic strokes in the group aged 18 to 74 years.
The distribution of the main diagnostic categories for the
71 patients evaluated at the university hospital during the
epidemiological survey period is shown in Fig 2. The mean age of the 17
patients (10 men, 7 women) not evaluated at our university hospital was
40.2±2.3 years (range, 27 to 44 years). Based on information from
local hospital records on admission and on discharge, an apparent
probable diagnosis could be assigned to 3 patients. Because of
incomplete evaluation at the local- level hospitals, it was not
possible to allocate the remaining 14 patients to a particular
etiologic subtype.
Etiology
In this part of the study, 63 men and 44 women referred to our
hospital from January 1, 1991, through May 31, 1996, fulfilled the
inclusion criteria. The mean age of the patients was 36.5±6.2 years
(range, 19 to 44 years); age and sex distribution is shown in Table 2. Unwillingness to participate in
certain procedures, technical problems, pregnancy, and early death
explained why scheduled investigations were not accomplished in all
cases. Selective angiography of both carotids and at least one
vertebral artery was performed in 95 patients (89%), and abnormalities
related to clinical symptoms were found in 58 patients (61%). In
addition, 3 patients underwent MRI angiography. All patients were
investigated by CT, and 80 patients (75%) were investigated by MRI of
the brain. The carotid territory was involved in 56%, the posterior
circulation was affected in 41%, and multiple territories were
involved in 3%. Six patients did not display any visible
ischemic lesions on neuroimaging. One hundred five patients
(98%) underwent either a TTE or TEE investigation.
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After completion of the etiologic workup, assessment of a probable or
possible etiology led to classification of the patients into one or
more of eight diagnostic groups subdivided into
higher-priority (I to IV) and lower-priority (V to VIII) diagnoses (Fig 2). The distribution of diagnoses relating to the specific age groups
of 18 to 34 years and 35 to 44 years is shown in Table 3. The main finding was an increased
occurrence of nonatherosclerotic vasculopathy in the older age
group.
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Risk factors were distributed as reported in Table 4. There were no statistically
significant differences between sexes with regard to atherosclerotic
risk factors, whereas migraine history was more frequently associated
with female sex (P=.041).
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Higher-Priority Diagnoses
Ninety higher-priority diagnoses were identified in 76 patients.
In 14 patients two higher-priority diagnoses coexisted. Atherosclerotic
vasculopathy was diagnosed as the cause of cerebral infarction in 13
patients (11%). Atherogenic risk factors were present in all of
these patients except 1. All patients with a possible diagnosis of
atherothrombotic vasculopathy demonstrated only discrete plaque
formation in the carotid arteries without any signs of flow
abnormalities. In addition, TEE revealed a simple aortic arch
atheroma in 3 patients.
The main cause for nonatherosclerotic vasculopathy was nontraumatic cervicocerebral arterial dissection. The carotid arteries were affected in 9 patients and the vertebral arteries in 10 patients. One patient with fibromuscular dysplasia as an underlying cause had bilateral carotid dissections. Isolated intracranial arteritis was diagnosed in 1 patient. Coexistent higher-priority diagnosis was found in 7 patients with probable or possible arterial dissection, 5 with a PFO/ASA, 1 with low positive IgG aCL titer, and 1 patient with a simple aortic arch atheroma, in which case priority in the final classification was given to the diagnosis of arterial dissection.
A cardioembolic etiology was presumed in 35 patients (33%). The most frequent abnormality was right to left cardiac shunts consistent with PFO, which became evident in 32 of 97 patients (33%) investigated with TEE. In one patient PFO was associated with pulmonary arteriovenous fistulas. Atrial septum aneurysm was detected in 9 patients (9%), isolated in 5 patients, and associated with PFO in 4 patients. Angiographic lesions compatible with intracranial embolic occlusion were detected in 16 of 30 patients (53%) with PFO/ASA as the possible cause of stroke. Coexistent higher-priority diagnoses was found in 6 patients with PFO/ASA, 1 with a low positive IgG aCL titer and 5 with a possible atherothrombotic vasculopathy, including 1 patient with a simple aortic arch atheroma, but in the final classification priority was given to the cardioembolic diagnosis. Additionally, 6 patients with PFO/ASA had coexisting lower-priority diagnoses (lacunar infarction [n=2], migraine-induced infarction [n=2], and oral contraceptive use [n=2]). Mitral valve prolapse was observed in 1 patient. In 4 patients a probable source of cardiac embolism was present (congenital heart disease [n=2], ischemic dilated cardiomyopthy with left ventricular thrombus and PFO [n=1], and atrial septum defect with left atrial thrombus [n=1]). There was no evidence of potential emboligenic arrhythmias from electrocardiography or Holter monitoring.
With respect to hematological causes of stroke, natural anticoagulant levels were determined for 102 patients at admission and for 97 patients at follow-up. One patient had an inherited protein S deficiency. Seven patients (7%) had low positive readings for IgG aCL. Other laboratory features such as ANA titers, VDRL tests, complement C4, thrombocytes, and aPPT were negative or within normal range in all IgG aCL–positive patients, and no valve abnormalities were detected by echocardiographic investigation. A history of heavy alcohol ingestion within the preceding 24 hours was elicited in 1 patient. Ischemic stroke occurred in the postpartum state in 1 patient.
Lower-Priority Diagnoses
Thirteen patients met the criteria for lacunar infarct, ie, a
lacunar syndrome and small deep infarction compatible with small-artery
disease. In 8 patients a coexistent higher-order diagnosis
was present (possible cardiac embolism [n=2], possible
atherothrombotic vasculopathy [n=5], and IgG aCL low-positive reading
[n=1]).
Eighteen percent of men and 35% of women had a history of migraine, but only 1 woman fulfilled the criteria of the International Headache Society for a probable migraine-induced stroke.9 Migraine-induced stroke was possible in an additional 3 patients with higher-priority diagnosis (possible cardiac embolism [n=2] and probable arterial dissection [n=1]).
Oral contraceptive use was the likely cause of stroke in 3 female patients with additional risk factors (smoking and migraine [n=1], smoking [n=1], and hypertension [n=1]). Five women qualified for another diagnosis (possible cardiac embolism [n=2], probable arterial dissection [n=2], and possible atherothrombotic vasculopathy [n=1]).
The etiology of cerebral infarction was indeterminate in 22 patients (21%). The evaluation was "truly negative" except for 1 patient who did not have an angiography and 1 patient who was unable to endure TEE but had a normal TTE investigation. In this subgroup of patients, angiographic investigations were abnormal in 12 patients (52%) with unexplained intracranial occlusion of a major artery or a branch cortical artery. Overall, there was a preponderance of ischemic lesions in the vertebrobasilar system (57%). Fourteen patients (61%) with an indeterminate diagnosis had at least one risk factor for atherosclerosis (6 with one and 8 with two or more atherogenic risk factors).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The present study is one of the largest reported series of young adults with ischemic stroke investigated by a group of physicians at a single medical center and the first study of stroke in young individuals in which a clear population-based strategy for case finding has been combined with a very extensive diagnostic workup.
By international standards, the crude incidence rates for
ischemic stroke in the present study are higher than those
reported earlier from most countries in Western
Europe3 10 11 12 (Table 5) and
similar to those among whites in Baltimore, Md.13 One
study from Israel has provided information from this decade with an
estimated incidence for ischemic stroke of 5/100 000 in the
group aged 17 to 44 years.14 Our rates are only lower than
the unusually high rates of stroke among males and females aged 15 to
40 years of age in Benghazi, Libya,15 and among blacks in
Baltimore, Md.13 The reported 50% higher incidence rates
for ischemic stroke in the elderly population of the Northern
Sweden MONICA study compared with available data from the MONICA study
of Gothenburg, Sweden,10 together with older limited data
from the Stockholm region11 may suggest a south to north
"stroke gradient" in Sweden. The explanation for such a possible
geographic variation is currently unclear.
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Similar to reports from other countries, incidence rates for both men
and women were found to rise steeply after the age of 35
years.16 In our study this increase was mainly explained
by an increase in the number of arterial dissections and
cardioembolic cases, but it was influenced to only a minor degree by an
increase in premature atherosclerosis (Table 3).
A case-fatality rate of 5.7% in the present study is considerably lower, as expected, in comparison with elderly stroke patients but corresponds to case-fatality rates reported for similar age groups in epidemiological studies3 10 and case series.17 18
The topography of cerebral infarctions in young adults with ischemic stroke has rarely been detailed in previous studies. The proportion of patients with involvement of the vertebrobasilar territory has varied from 25% to 34%.2 19 The relatively high proportion of involvement of the vertebrobasilar territory in our study (41%) may at least partially be due to the extensive use of MRI investigations. Thus, quite a few cases with ischemic lesions in this territory, including cerebellar strokes, may have gone undetected in studies mainly relying on CT scanning.
The criteria for atherosclerotic disease have varied considerably in previous studies, and several studies included cases defined only by the coexistence of risk factors for atherosclerosis, which may explain why atherosclerosis has been considered to be the cause of stroke in 5% to 50% of patients younger than 50 years.17 20 Using the TOAST classification, we detected 3.7% of patients with a probable atherosclerotic vasculopathy; when similar criteria for probable atherosclerotic vasculopathy were used, the rate of atherosclerotic etiology in recent studies has varied from 5% to 23%.17 18 21 22 23
Several recent studies have demonstrated that the presence of plaques
4 mm in the aortic arch is an important new source of emboli to
the brain in patients older than 60 years.24 However, this
does not seem to be the case in a young stroke population. This is
consistent with the results reported from a few previous
studies including young as well as old stroke
patients.25 26
The use of duplex ultrasonographic and arteriographic evaluation of precerebral and intracerebral vessels resulted in a diagnosis of cervicocerebral arterial dissection in approximately 20% of patients, a proportion considerably higher than reported in most earlier studies.17 20 27 Our routine use of posterior circulation angiography revealed that vertebrobasilar dissection was a common cause of stroke in this age group. This emphasizes that a diagnosis of arterial dissection should be considered in all cases of stroke in young adults and that a thorough angiographic evaluation, including the vertebrobasilar territory, is warranted in most cases.
The prevalence of PFO and ASA is increased in younger adults with stroke,28 29 particularly in patients with otherwise unexplained stroke.21 30 In those younger than 45 years, a prevalence of PFO within the same range as in our study (24% to 50%) has been reported from three previous studies.26 30 31 The mechanism underlying thromboembolic events in patients with interatrial septum abnormalities is not well known.21 32 Angiographic evidence of embolic intracranial arterial occlusions was present in 53% of our patients and gave some evidence of a nidus for thrombus formation. It is of interest to note that 50% of our patients with vertebral dissection had a PFO, an ASA, or both. It is thus important to emphasize that significant vascular pathology must be excluded before these cardiac abnormalities are accepted as the cause of stroke in each individual case.
In our stroke population, hereditary deficiency of natural anticoagulants (protein S, protein C, and antithrombin III deficiency) was very rarely encountered, which is in agreement with results reported by Adams et al33 but at variance with the findings reported from small or selected case series.34 35 Furthermore, the low frequency and low titers of IgG aCL in the present study imply that these antibodies do not account for a significant proportion of strokes in young people, at least not in all young stroke populations. These findings are in agreement with two recent larger prospective studies in which the relevance of aCL for ischemic stroke in unselected stroke populations has been questioned.36 37 However, in respect to other hematologic causes of stroke, it is possible that factor V Leiden gene point mutation could be of interest, although whether activated protein C resistance secondary to this mutation causes arterial vascular disorder is still controversial.38 39
The definition of migraine-induced stroke applied in studies conducted thus far has been inconsistent and probably explains why cerebral infarctions in the young attributed to "migrainous infarction" have varied between 1.2% and 25%.18 40 41 In the present study only 1% of the patients (one patient), based on the criteria of the International Headache Society,9 fulfilled the criteria for migrainous infarction, although the prevalence of migraine with or without aura was higher than might be expected from the background.42 43 Based on data from our epidemiological survey, the incidence of migraine-induced infarction meeting the criteria of the International Headache Society can be estimated at 0.14/100 000 per year and including possible migraine-induced infarction can be estimated at 0.7/100 000 per year in the group aged 18 to 44 years.
The risk increment for cardiovascular disease, including stroke, among users of oral contraceptives is currently a matter of controversy.44 45 46 By ruling out coexistent and more convincing etiologies such as cardioembolism and arterial dissection, we could attribute a probable pathogenetic role to oral contraceptive use in 7% of women.
Conclusions
We report a high incidence of stroke among young adults in
Northern Sweden. This finding is not explained by conventional causes
of stroke, particularly not by a high prevalence of premature
atherosclerotic disease. Without the additional diagnostic
information derived from TEE contrast investigation, the proportion of
indeterminate cases would have constituted 37% of the patients.
Nontraumatic arterial dissection was a leading cause of
ischemic stroke in our study. New exciting data pointing toward
the possibility that spontaneous cervical artery dissections may be due
to an underlying connective tissue disorder warrant further
investigations of this specific subgroup of
patients.47
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This study was supported by the Swedish Medical Research Council (grant K97-19X-12237-01A to Dr Olsson), Karl-Oskar Hansson's Foundation, the Swedish Society of Neurologically Disabled (NHR), 1987 Stroke Foundation, Norrlandsfonden, and the Swedish Heart and Lung Foundation.
Received January 27, 1997; revision received May 15, 1997; accepted May 16, 1997.
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