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Stroke Risk Factors

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Stroke Risk Factor
Hypertension (Systolic or diastolic)	increases risk x 2-4. Hypertension is a major risk factor for ischaemic and even more so for haemorrhagic stroke (x 9) . Hypertension (Each 100 mmHg diastolic or 20 mmHg systolic doubles stroke rate). It is not acute rises but chronic sustained elevations in blood pressures which damage deep penetrating arteries which occlude or bleed and in larger vessels accelerate atherosclerosis as well as causing cardiac damage and atrial fibrillation.
Age	No age group is immune to stroke. There is even a baseline level of strokes in infants and children increasing gradually through all age groups with a steep rise in those over 75. Incidence doubles with every decade over 55. It is uncommon but any medium-sized unit will see several 18-30-year-olds per year with stroke. Stroke is often the cause of death in the frail elderly.
Male gender	Stroke is slightly more common in males ( x 1.2) really until age > 75 when the balance between sexes tends to reduce and equalise in old age.
Diabetes Mellitus	increased by 2-6 times
Race	All types of stroke is commoner in Blacks but especially ICH. Chinese, Asians and Blacks have an increased risk of ICH. Blacks and East Asians have an increased incidence of intracranial atherosclerotic disease
AF/PAF or atrial flutter and sick sinus syndrome	See CHADSVASC scoring for risk assessment
Valvular heart disease	rheumatic mitral stenosis with AF hugely increases cardioembolic risk
Previous stroke or TIA
Carotid stenosis	is itself a direct marker of an atherosclerosis process that can either result in the throwing of emboli or occluding the carotid and causing ipsilateral infarction
Dyslipidaemia	Stroke is commoner with elevated Cholesterol and LDL. The relationship is not as clear cut as with IHD. There may be a relationship between low cholesterol and intracerebral haemorrhage.
Current Cigarette smoking	increases stroke risk by 50% which is far less than the risk related to IHD. Stronger link with ischaemic stroke. Cessation reduces ischaemic stroke.
Oral contraceptive and HRT	Doubles the stroke risk for low oestrogen content and increased by four times for higher oestrogen content. Can increase risk of thromboembolic stroke and cerebral venous thrombosis and subarachnoid haemorrhage though the absolute risk is very low and pregnancy itself has stroke risks. Particularly concerning is the combination of OCP with other risk factors such as smoking and migraine with aura or thrombophilia
Family history
Psychosocial stress	Mild increase in stroke risk by about x 1.3
Physical inactivity	(increased risk by 2.5). Physical activity appears to be protective of both ischaemic ahd haemorrhagic stroke.
Excess alcohol	Increases risk by 50-100% once more than 30 drinks per month or binge drinking. Moderate alcohol appears protective. Relationship stronger for haemorrhage.
Obesity	Often complex and hard to disentangle risks for instance it is suspected now that obesity itself is not a risk of itself but the increased stroke risk is due to the additive risk from the increased diabetes and hypertension associated with obesity. Still management is to address the obesity and lose weight.
Pregnancy and puerperium	risk of stroke in the days before birth and the 6 weeks after is rare it is one of the commoner settings for stroke in young adults related possibly to a hypercoagulable state and vessel wall changes.
Migraine	Record whether migraine with aura or not. Migraine with aura appears to double stroke risk. Increased risk if under 45, smoking and on OCP. Mostly posterior circulation. Migraine also associated with dissections, Antiphospholipid syndrome, CADASIL and MELAS and Essential thrombocythaemia.
Polycythaemia	HCT > 0.5 in males and 0.47 in females is associated with increased stroke risk
Antiphospholipid (aPL) antibodies	found in autoimmune conditions and can be associate with stroke mainly in young females.
Illicit drugs	Drugs with a sympathomimetic effect (amphetamine, cocaine, crack) can cause ischaemic stroke through several mechanisms such as acute hypertension enhanced platelet aggregation, and rarely vasculitis (mainly related to amphetamine intake) of the polyarteritis nodosa or giant cell-granulomatous types.

References

Interstroke Investigators. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010: 376;112-23

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