The document explores the role of homocysteine as a risk factor for stroke, analyzing data from 451 patients over two years. It identifies elevated homocysteine as an independent risk factor, particularly prevalent in males, younger patients, and those with high LDL cholesterol. The study concludes that homocysteine is a significant modifiable risk factor for ischemic and recurrent strokes, with implications for vitamin supplementation in reducing stroke risk.

1. HOMOCYSTEINE AS
A RISK FACTOR OF
STROKE
DR SUDHIR KUMAR MD DM (Neurology)
Neurologist, Apollo Hospitals, Hyderabad

2. AIMS & OBJECTIVES
• To study the risk factors of stroke, with a special
emphasis on the role of homocysteine,
• To study the effect of homocysteine in : 1.
Ischemic vs hemorrhagic strokes, 2. Men vs
women stroke patients, 3. Younger vs older stroke
patients

3. PATIENTS & METHODS
• Setting: Apollo hospitals, Jubilee Hills, a JCI-
accredited stroke center,
• Patients admitted with stroke (ischemic or
hemorrhagic), presenting within 24 hours of
symptom onset were included,
• Risk factors for stroke were assessed, within 24
hours of admission,
• Duration of study: April 2013 to March 2015

4. RESULTS (1)
• Total number of patients- 451
• Mean age: Ischemic stroke (57.5 years),
hemorrhagic stroke (58.1 years)
• Stroke type: Ischemic (330; 73%), Hemorrhagic
(121; 27%)
• Gender: Male Female
Ischemic 236 (71.5% 94 (28.5%)
Hemorrhagic 87 (71.9%) 34 (28.1%)

5. RESULTS (2)
Risk
factor
Ischemic
(no.)
Ischemic
(%)
H’gic
(no.)
H’gic (%) P value
HT 207 63% 86 71% 0.079
DM 121 37% 38 31% 0.326
Smoking 71 21% 18 15% 0.116
Alcohol 72 22% 27 22% 0.91
Homocysteine 102 31% 40 33% 0.663
Low HDL 258 78% 88 73% 0.294
High LDL 160 49% 35 29% 0.001*
High TG 88 27% 19 16% 0.013*
High Chol 90 27% 22 18% 0.111

6. RESULTS (3)
Mean homocysteine concentration
Ischemic stroke (n=330): 13.77
Hemorrhagic stroke (n=121): 14.98
Overall (n=451): 14.09
P=0.527

7. RESULTS (4)
Distribution of patients with elevated homocysteine
in stroke risk categories:
1. Gender
Male: 118/323
Female: 22/128 p: 0.000*

8. RESULTS (5)
Age groups and elevated homocysteine
Age Patients High Hcy
(n)
High Hcy (%)
<44 years 67 33 49%
44-58 years 148 52 35%
58-72 years 169 47 28%
>72 years 67 10 15%
P=0.000*
Younger patients with stroke had significantly higher homocysteine

9. RESULTS (6)
1. Hypertension
Yes: 95/293; No: 47/158 p=0.588
2. Diabetes
Yes: 41/159; No: 100/292 p=0.061
3. Smoking
Yes: 32/89; No: 110/362 p=0.311
4. Alcohol
Yes: 40/99; No: 102/352 p=0.031*

11. RESULTS (7)
Significant association of elevated Homocysteine with LDL and total cholesterol
1. HDL
<40: 110/333; >40: 37/118 p=0.972
2. LDL
<100: 61/256; >100: 81/195 p=0.001*
3. TG
<150: 100/340; >150: 46/111 p=0.057
4. Total Cholesterol
<200: 90/340; >200: 47/111 p=0.029*

12. RESULTS (8)
Mean serum values of homocysteine
Males: 15.81; Females: 10.17 p=0.003*
<44 years: 20.94
44-58 years: 13.96
58-72 years: 13.22
>72 years: 9.7 p=0.003*
Homocysteine values did not differ between those with or
without DM, HTN, Smoking or alcohol.

13. DISCUSSION (1)
• Elevated homocysteine level is an independent risk
factor of stroke. (Lancet 1995)
• Mechanisms: endothelial cell damage, smooth muscle cell proliferation, lipid
peroxidation, upregulation of prothrombotic factors, downregulation of
antithormbotic factors
• About 30% of patients with stroke have elevated
homocysteine levels.
• Elevated homocysteine as a risk factor for stroke is
more common in males, younger patients, those
actively drinking, pure vegetarians, and in those with
high LDL/total cholesterol.

14. DISCUSSION (2)
• Meta-analysis of nine studies with >13,000
patients (NMCD 2014)
• Correlation between homocysteine levels and
stroke was studied.
• Significant association with elevated
homocysteine levels and ischemic/recurrent
stroke
• No association with hemorrhagic stroke.

15. DISCUSSION (3)
• Patients with hyperhomocysteinemia have lesions
typical of cerebral microangiopathy and tend to have
multiple infarctions. (Arch Neurol 1997)
• In an MRA brain based study, patients with 2- or 3-
vessel stenosis were found to have higher
homocysteine levels than those with 1-vessel stenosis.
(Stroke 1998)
• Stroke risk increases in proportion to the increase in
homocysteine levels.
• High homocysteine levels at admission can be a useful
test to pick up patients who are actively drinking.
(Alcohol Alcohol 2004)

16. DISCUSSION (4)
• High homocysteine levels in acute phase of
ischemic stroke (measured within 24 hours) can
predict mortality. (Stroke 2015)
• Patients with Hcy>18.6 had 1.6 times higher
mortality, as compared to those with Hcy<10.
• This correlation was significant only in large-artery
atherosclerosis; and not significant in small vessel
ischemic disease.

17. DISCUSSION (5)
• Long term daily treatment with vitamins (folic acid 2.5
mg, pyridoxine 50 mg and vitamin B12 1 mg) reduces
homocysteine levels (HOPE 2 study, Stroke 2009)
• Vitamin therapy reduced the risk of incident stroke, as
well as nonfatal stroke.
• Lowering homocysteine, however, had no effect on
stroke severity (at 24 hours) and disability (at 90 days)
• Optimal level of homocysteine is 10-12; those with >15
are considered to have elevated homocysteine.

18. CONCLUSIONS
• Elevated homocysteine is an important, strong, graded
and modifiable risk factor for ischemic and recurrent
strokes.
• Elevated homocysteine at baseline also predicts
higher long term mortality.
• Association is stronger in males, younger patients,
those with elevated LDL/cholesterol; vitamin B12
deficiency and regular alcohol consumers.
• Vitamin supplementation reduces the recurrence of
stroke.

19. QUERIES/COMMENTS
Contact
M: 9866193953
Email: drsudhirkumar@yahoo.com