Characterization of Demographic, Clinical, and Laboratory Risk Factors for Stroke in a Tertiary Hospital in Riyadh, Saudi Arabia

Background Stroke is a major cause of death and long-term disability worldwide, with varying incidence and risk factors across different populations. This study aims to analyze demographic, clinical, and laboratory risk factors for stroke among the Saudi Arabian population to enhance the understanding of its behavior and associated mortality. Methods In this retrospective cohort study, we analyzed data from 3586 patients diagnosed with hemorrhagic or non-hemorrhagic stroke at King Fahad Medical City from January 1, 2020, to November 11, 2022. We collected data on demographic variables, past medical history, social history, nationality, and laboratory components. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 27.0. (Armonk, NY: IBM Corp.), with significance set at p<0.05. Results The study population was predominantly male (57.86%) and within the age group of 51 to 80 years (58.8%). A significant portion of patients were Saudi nationals (99.6%), with hypertension (50.2%) and diabetes (40.4%) being the most common comorbidities. Laboratory abnormalities related to sodium and potassium levels were strongly linked to mortality rates. Notably, ischemic stroke was the most common type across all age groups, except for patients under age 16, where hemorrhagic stroke was more prevalent. Conclusions Our findings reveal significant associations between stroke risk factors and mortality within the Saudi Arabian population, highlighting the impact of hypertension, diabetes, and electrolyte imbalances. The study underscores the need for targeted stroke prevention and management strategies in Saudi Arabia, aligning with global trends to mitigate the burden of this disease.


Introduction
Stroke ranks as the second most common cause of mortality globally.[1].Recent years have seen a significant increase in the incidence of stroke and the associated mortality and burdens [2].In 2020, the United States reported 795,000 stroke cases, with 610,000 being first-time incidents [3].Stroke remains the primary cause of long-term disability among the elderly population (i.e., those aged 65 and older).Similarly, Europe reported 1.1 million stroke cases and 460,000 deaths in 2017.An epidemiological model predicts a 27% increase in stroke cases for the same region [4].
In comparison, Saudi Arabia reports fewer stroke cases than Western countries, likely due to its generally younger population on average [5].The incidence of stroke in Saudi Arabia was reported as 29 per 100,000, significantly lower than the 219 per 100,000 reported in the United States by the American Heart Association [6,7].Nevertheless, a model by Al Senani et al. predicts an increase in first-time stroke incidence among Saudis over the next decade [8].Our research aims to analyze demographic, clinical, and laboratory risk factors for stroke among Saudis to understand the relationship between laboratory results, clinical history, and mortality.

Materials And Methods
This retrospective cohort study included patients diagnosed with hemorrhagic or non-hemorrhagic stroke (n=3586) at King Fahad Medical City (KFMC) from January 1, 2020, to November 11, 2022.We excluded patients not diagnosed with stroke or those without a complete personal file.We extracted data using the Epic research module and the Slicer Dicer tool (Epic Systems Corporation, Verona, USA), compiling it in a Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA) spreadsheet.We collected variables including demographic data (gender and age), past medical history (diabetes, hypertension, atherosclerotic diseases, and seizure disorders), social history (smoking, marital status), nationality, and laboratory components which were taken after the diagnosis (venous pH, sodium, potassium, albumin, non-high-density lipoprotein (HDL) cholesterol, hemoglobin, platelet count, red blood cell count, sodium bicarbonate in venous blood, and chloride), family history (diabetes, hypertension, stroke, hyperlipidemia, seizure disorder, and no known problems).We also assessed the mortality rate or current patient status (alive, deceased) during the hospital stay, which was defined as the proportion of individuals who died while admitted to the hospital.Patients were divided into four age groups: Group 1 (younger than 16 years), Group 2 (16 to 50 years), Group 3 (51 to 80 years), and Group 4 (older than 80 years).
We received ethical approvals from the Institutional Review Boards of King Fahad Medical City (FWA00018774) and Dar Al Uloom University (PRO23020008), adhering to the Declaration of Helsinki.All personal identifiers were removed for privacy.Data cleaning and editing were performed using Microsoft Excel 2010.We compared our findings with current literature and conducted statistical analyses using IBM SPSS Statistics for Windows, Version 27.0.(Armonk, NY: IBM Corp.).A Chi-square test measured significant differences at a 5% level.We calculated descriptive statistics, inferential statistics, standard deviation, and mean.A p-value of less than 0.05 was considered significant.To control for multiple comparisons, we applied the Bonferroni correction by dividing the significance level by the number of comparisons conducted.

Discussion
In our study, we conducted a detailed analysis of laboratory components, medical history, and demographic data related to stroke, aiming to better understand stroke risk factors and behavior within the Saudi Arabian population.Demographically, our findings resonate with current literature, indicating that male patients constitute a larger portion of the stroke population at 57.86% than female patients [9].The dominance of the Saudi population in our sample at 99.6% could be attributed to the eligibility criteria at KFMC.The mortality rate post-stroke was 6.1%, marginally lower than international figures [10].Possible explanations include the relatively younger average age of the Saudi population [11], advanced medical facilities reducing mortality rates [12], and the discharge of stabilized patients.Regarding marital status, our data aligns with current trends, showing a slightly higher stroke incidence in unmarried individuals at 53.4% compared to married ones at 46.6% [13].
Our medical history analysis reveals a strong link between stroke and known risk factors such as hypertension, diabetes, and dyslipidemia, aligning with global observations of stroke behavior [14].Smoking was a risk factor for only 5% of our sample, suggesting potential underreporting, especially in emergencies or when patients could not provide their history [15].A history of previous strokes was significant in 37.1% of cases, underlining it as a major risk factor [16], whereas only 1.3% reported a history of seizure disorders.Nonetheless, late-life seizures significantly elevate stroke risk [17].Family history showed no clear patterns.
Regarding laboratory findings, chloride abnormalities were present in 24.7% of patients, mainly within the 51 to 80 age group.This suggests a potential link between chloride imbalance and stroke in the elderly, possibly due to increased rates of acute kidney injury [18,19].Albumin discrepancies were noted in 63.2% of cases, indicating potential neuroprotection deficits and an elevated inflammatory state [20].Similarly, sodium and potassium level abnormalities were observed in 63.3% and 63.1% of cases, respectively, and were significantly associated with mortality.Specifically, hypernatremia was present in 37.6% of deceased patients, hyponatremia in 14.9%, hyperkalemia in 16.3%, and hypokalemia in 20.5%.Potassium plays a crucial role in nerve conduction and neurotransmitter release.Hypokalemia can impair these processes, leading to worsened neurological symptoms in stroke patients.This can result in reduced functional recovery and increased disability, which can indirectly contribute to higher mortality rates; similarly, hypernatremia can have detrimental effects on the central nervous system.High sodium levels can disrupt the normal functioning of brain cells by altering osmotic balance and causing cellular shrinkage.This can lead to neurological complications such as seizures, altered mental status, and even cerebral edema.As these complications can increase the risk of mortality in stroke patients, it is safe to say that hypernatremia and hypokalemia propose a lethal combination in stroke patients [21,22].Thus, we recommend regular electrolyte monitoring, upon admission and after the diagnosis.Moreover, we recommend optimizing fluid therapy in stroke patients and adopting a multidisciplinary approach to stroke care, involving neurologists, nephrologists, intensivists, and other specialists.
HCO 3 and venous blood gas pH levels were normal in 37.3% and 37.4% of cases, respectively.Although these alterations suggest a metabolic acidotic state impacting cerebrovascular blood flow [23], HCO 3 levels did not significantly affect mortality, aligning with existing evidence but indicating potential as a prognostic predictor [24].The serum lipid profile showed a 36.3%rate of non-HDL cholesterol abnormalities, which did not influence mortality rates.
Stroke types varied with age; hemorrhagic strokes accounted for nearly one-third of cases in patients under 16 years (36.8%),shifting progressively from hemorrhagic to ischemic with increasing age, a pattern which is observed within the literature [25,26].

Limitations
This study faces several limitations that warrant consideration.Firstly, its retrospective, single-center design may limit the generalizability of our findings to the broader Saudi Arabian population or other regions.The study's reliance on existing medical records introduces potential biases, including incomplete documentation and social desirability bias, particularly concerning self-reported behaviors like smoking.Additionally, excluding non-Arabic speaking participants or those without a comprehensive medical record may introduce selection bias.Another significant limitation is the lack of detailed analysis of the impact of lifestyle factors, socioeconomic status, and access to healthcare services, which are known to influence stroke risk and outcomes.Furthermore, the study did not account for genetic factors that could be crucial in stroke susceptibility and recovery.The cross-sectional nature of the data collection limits our ability to establish causality between the identified risk factors and stroke occurrence.Lastly, potential advancements in stroke management and healthcare access during the study period were not analyzed, which could affect the interpretation of the results concerning temporal trends in stroke care and outcomes.

Conclusions
Our research provides a robust overview of stroke risk factors and behaviors among the Saudi Arabian population.We found that patients with hypokalemia or hypernatremia faced higher mortality risks.Additionally, hypertension, diabetes, and a history of previous strokes emerged as significant risk factors.These findings align with global trends and enrich the knowledge base for stroke prevention, management, and future research in Saudi Arabia.This research highlights the necessity of implementing specific strategies for stroke prevention and management in Saudi Arabia, in line with worldwide efforts to reduce the impact of this condition.
interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

TABLE 2 : Chi-square tests of gender and disease association
Abbreviation: AHD, atherosclerotic heart disease.* Bonferroni difference is statistically significant at p<0.05

TABLE 3 : Chi-square tests of gender and family history association
* Bonferroni difference is statistically significant at p<0.05

TABLE 4 : Chi-square tests of gender and laboratory data association
Abbreviations: HCO 3 , bicarbonate; HDL, high-density lipoprotein.*Bonferroni difference is statistically significant at p<0.05Ischemic stroke was the most common stroke type across all age groups, except in the pediatric population, where 36.8% of patients (n=28) under 16 experienced hemorrhagic strokes.The prevalence of hemorrhagic stroke decreased with age, being replaced by ischemic stroke in older patients (

TABLE 5 : Type and incidence of stroke by age group 2024
khalil Hussien et al.Cureus 16(4): e58266.DOI 10.7759/cureus.58266FIGURE2: Type of stroke and corresponding age group in percentage (arranged in line chart)