Introduction

Stroke has increasingly become a global health concern. It is the sixth main cause of disease burden and the second commonest cause leading to death globally. Previously seen to be affecting the elderly population, however, presently, researchers have revealed that the frequency of Stroke in younger individuals has increased significantly.¹ An outcome of a systematic review anticipates that Stroke will become a burden in the Middle East as the younger population is increasingly suffering from it.

In recent years, the incidence of Stroke in women between the age of 45-54 years has increased, in addition to various studies, affirming that the recurrence of Stroke within five years (from the first episode) is more commonly seen amongst women than men.

Amongst the Arab population, Stroke has emerged recently as a growing health problem. Due to the rising number of stroke cases annually, it is expected that the mortality rate due to Stroke will be doubled by the year 2030, as per a study held in the Middle East.²

A high occurrence of risk factors such as Hypertension, Diabetes, and Dyslipidemia in the Bahraini population is believed to be the cause of rising stroke cases. Therefore, this needs to be properly identified, and understood.3 According to a report published in 2015, the incidence of Stroke has nearly doubled among the Bahraini population during the last 16 years.⁴

A high prevalence of the aforementioned risk factors amongst the elderly Bahraini population also is indicative of a disturbing outcome inevitably leading to a continuing rise in Stroke cases.² It has also been noted that the incidence of Stroke in the younger Bahraini population is about ten times higher than their western counterparts.

The aim of this study was to perform a descriptive analysis of female stroke patients, understanding the risk factors contributing to its development. The study included all the female patients diagnosed with Stroke in a tertiary medical center in Bahrain during 2016-2019. It assessed sex-specific risk factors linked with Stroke in the female population and discussed how to avoid these in the future.

Methods

This retrospective study was conducted at a tertiary setting in Bahrain. Specific data on all stroke cases (Total number of cases 108) was collected via Convenience sampling from the hospital electronic medical records system with the below-mentioned criteria from 2016 to 2019.The study was approved by the Institutional review board at King Hamad University Hospital. Patients signed an informed consent form prior to voluntary participation in the study.

Inclusion Criteria included women, 18 years and above with or without co-morbidities, diagnosed with Stroke. Exclusion Criteria included unclear data/missing data and stroke mimics, e.g., Hypoglycemia, Seizures.

The primary outcome was to look into the risk factors leading to Stroke in the female population of all ages, including Diabetes mellitus, Hypertension, Dyslipidemia, Coronary artery disease, Smoking, Hormonal therapies, Peripheral arterial disease, and previous stroke/transient ischemic attack.

The following data was also collected: demographic data such as age, sex, and co-morbidities, clinical data such as the severity of symptoms, stroke type, and underlying etiology, radiographic imaging data, and patient outcome.

The statistical analysis formula used was Z_(1-α/2)² p (1-p)/d²

Statistical Package for Social Sciences (SPSS) Version 25 was used to analyze the data.

Results

(Tables and figures can be referred to in the PDF).

A total of 108 female Stroke patients were identified. The study population’s mean age was 67.89 ± 13.12 years, Table 1.

The study revealed that the majority (94%) of the stroke patients were diagnosed to have an ischemic stroke, with only 6% having had suffered from intracranial hemorrhage (Figure 1).

Atherothrombotic and large artery disease was the most prevalent underlying etiologies (n= 36, 33.3 %), with 13 (12.0%) patients having both Artherothrombotic & large arteries.

Nine out of thirteen patients who had all four risk factors (Diabetes mellitus, Hypertension, Dyslipidemia, coronary artery disease/atrial fibrillation) had underlying etiology of “large artery.” “Sixteen out of thirty-six patients who had all the three risk factors (Diabetes mellitus, Hypertension, Dyslipidemia) had underlying etiology of “large artery.” Sixteen out of twenty-three patients who had diabetes mellitus and Hypertension had underlying etiology of “large artery,” thereby indicating that large artery was the most prevalent underlying etiology associated with the risk factors (p= 0.003).

Upon investigating the underlying risk factors, Hypertension was found to be the predominant cause (80.6%) either alone or in association with other factors. On the other hand, 65 patients (60.18 %) out of the total 108 had both, Diabetes mellitus and Hypertension.

Interestingly 31 out of 36 patients (86.11%) with large arteries and 30 out of 36 patients (83.33%) with the atherothrombotic condition were Hypertensive.

Discussion

This is the first study to our knowledge focusing on the risk factor profiling and demographic contribution for stroke cases amongst the female population in the kingdom of Bahrain.

In many studies prior, it was observed that stroke incidence was higher amongst the male population. However, a certain meta-analysis showed a 1:1 female to male ratio in the middle east.⁵ Whereas, on the other hand, some studies have revealed increased stroke incidence amongst the female population.^6,7

In recent years, the incidence of Stroke in women between the age of 45-54 years has increased, in addition to various studies, affirming that the recurrence of Stroke within five years (from the first Stroke) is more commonly seen amongst women than men, both; in younger ages (40–69 years old, 22% vs. 33%), as well as in elderly (>70 years old, 28% vs. 33%) patients.⁸

A multitude of risk factors lead to a high occurrence of Stroke in women, including Hypertension (75%), Diabetes (54%), and Hyperlipidemia (34%).⁹ Although both diabetes and metabolic syndrome are recognized causes of ischemic stroke in both sexes; a meta-analysis revealed that women are affected more than men due to these risk factors.¹⁰ Framingham cohort study concluded that compared to men, women had an increased lifetime risk of Stroke.10Few risk factors specifically affect women, for example, Migraine.¹¹

The range of age for patients who developed Stroke was from 54 to 80 years, similar to a study showing an average age between 59 and 63 years.^12-14The increased incidence in advanced age is believed to be secondary to multiple risk factors and atherothrombotic changes in vessels that progress with older age.

A study in Korea showed increased stroke prevalence amongst women between the age of 75 to 84 years.¹⁵

The majority of stroke cases were ischemic in nature (98 out of 108 = 94%), resembling other studies conducted in the middle east.^16,17 While intracerebral hemorrhage was found to be affecting only eight patients (4.6%), subarachnoid hemorrhage (0.9%) being the least common form of Stroke. In the current study, atherothrombosis was the main underlying etiology leading to ischemic Stroke either alone (21.3%) or in association with the large artery (12.0%) followed by cardioembolic cause (11.2%). This was in concordance with other retrospective analytical studies.¹⁸

We also found a significant correlation between large artery disease with nearly all risk factors, including Diabetes mellitus, Hypertension, Dyslipidemia, Coronary artery disease/atrial fibrillation (p=0.003).

The study revealed that Hypertension was a predominant risk factor in all types of strokes. About 86.9% of patients with atherothrombotic conditions, 82.6% patients with underlying large artery disease, and 69.2% with both atherothrombotic and large artery were hypertensive. This factor was consistent with studies conducted on the general population (irrespective of gender differences followed by diabetes (76%) and dyslipidemia (46%).¹⁹

About 30.6% of the total sample size had atrial fibrillation with or without coronary artery disease contributing to cardioembolic Stroke. Moreover, 26 patients (24.7%) with coronary artery disease/atrial fibrillation had associated Hypertension.

A study conducted in Turkey on the gender difference in stroke patients suggested a higher number of atrial fibrillation and hypertension cases amongst the female population.²⁰A study revealed females as an independent predictor of a negative outcome in the form of disability or death at the time of discharge for patients with Ischemic stroke.²¹

A meta-analysis included a few other relevant causes which are common to both male and female populations, for example, hypercoagulable states like acquired hyperhomocysteinemia, which is the most common abnormality (18%), followed by protein C or S deficiency (8%), methyl-tetrahydro-folate-reductase C677T mutation (5%) and factor V Leiden mutation (5%). Other findings included the positive anticardiolipin antibodies (3%), presence of lupus anticoagulant (2%), thrombocytosis (3%), and G20210A prothrombin gene mutation (3%).

Stroke incidence is also seen to be high in sickle cell patients secondary to vaso-occlusive crises.²² Another case-control study revealed low magnesium levels linked with a high risk of ischemic Stroke among women.²³ Although these factors were not looked into in our study, however, future studies could focus on other possible parameters to be considered with Stroke.

Yet another prospective - observational analysis revealed an increased risk of stroke (27% to 39%) amongst postmenopausal women who were regular users of oral estrogens with or without progestin, compared with nonusers.24In our study, 0.9% of patients used hormonal therapy and had cerebrovascular accident, whereas 99.1% were not users of any hormonal therapies.

It has been studied that non-communicable diseases are quite prevalent in the Middle East, with 30% of our total population being hypertensive and 11% diabetic.²⁵

In addition to the above-mentioned risk factors, lack of self-awareness, sedentary lifestyle, and poor control of non-communicable diseases, dispose our elder and the younger population at risk of developing stroke.²⁶Additionally, the middle eastern population lacks the awareness of cerebrovascular events; their leading risk factors, causes, and symptoms, as seen in a survey study conducted in Oman which concluded that intensive health education is required to improve understanding of Stroke, especially among the most vulnerable groups.²⁷

Smoking is yet another strong risk factor contributing highly to Stroke and is a leading cause of death in both genders. A study including 10,382 male and female participants revealed a larger absolute risk difference of Stroke, attributable to smoking in women than in men.²⁸

In this study, 0.9% of patients who had Stroke were smokers, whereas the remaining 99.1% didn’t have a smoking history.

Outcome

In our study, 75% of patients went home, and 10% mortality was observed. This could be attributed to timely presentation resulting in intervention done and the role played by physical therapy.

Conclusion

The study emphasizes the contribution of metabolic syndrome in the causation of stroke cases in the female Bahraini population. This implies an increased need for public awareness regarding risk factors with an understanding of their impact on the quality of life, and therefore, measures should be taken to prevent it. It is worth conducting future studies on a larger scale and possibly in comparison with the male population.

Acknowledgment

The authors would like to thank the patients who participated in this study and would like to acknowledge the support by the Research department of King Hamad University Hospital. Funding for the study was done by King Hamad University Hospital.

Conflicts of Interest

Nil.