Abstract
Aim and background: Stroke remains a major cause of mortality and morbidity, with substantial heterogeneity in risk factors and outcomes by subtype. This study aimed to compare the prevalence and clinical profiles of ischemic and hemorrhagic strokes and to evaluate the distribution of demographic, neurological, clinical, and metabolic variables among adults presenting within 24 hours of symptom onset.
Materials and methods: A cross-sectional observational study was conducted at a tertiary care hospital in Lahore from June 2023 to July 2024. A total of 800 adults diagnosed with ischemic or hemorrhagic stroke were enrolled using non-probability consecutive sampling. Demographic, clinical, and laboratory parameters, including body mass index (BMI), Glasgow Coma Scale (GCS), blood pressure, lipid profile, glycated hemoglobin (HbA1c), and renal function, were recorded within 24 hours of admission.
Results: In this study of 800 patients, ischemic stroke was identified in 565 (70.6%) and hemorrhagic stroke in 235 (29.4%). Patients aged 50 years or younger had significantly lower odds of ischemic stroke compared to those above 50 years (OR = 0.515, p < 0.001). No significant association was observed between gender and stroke type. High socioeconomic status was associated with a greater proportion of hemorrhagic stroke (χ² = 19.69, p < 0.001). Ever smokers had higher odds of ischemic stroke (OR = 1.405, 95% CI: 1.027-1.921, p = 0.033). Hypertension (HTN) was significantly more frequent in hemorrhagic stroke (OR = 1.453, 95% CI: 1.055-2.000, p = 0.022), while diabetes mellitus (DM) and dyslipidemia showed no significant association with stroke type. Chronic kidney disease was not significantly associated with hemorrhagic stroke (OR = 1.678, 95% CI: 0.996-2.826, p = 0.050). Presentation within 4.5 hours of symptom onset was significantly associated with hemorrhagic stroke (OR = 2.993, 95% CI: 2.034-4.405, p < 0.001). Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly higher in hemorrhagic stroke (SBP mean difference (MD) = -31.30, 95% CI: -36.02 to -26.58, p < 0.001; DBP MD = -10.01, 95% CI: -14.74 to -5.28, p < 0.001). Ischemic stroke patients had higher total cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglycerides, while hemorrhagic stroke patients had higher high-density lipoprotein cholesterol (HDL-C) and blood urea. In-hospital mortality occurred in 74 (13.1%) of the ischemic stroke group and 57 (24.3%) of the hemorrhagic stroke group, with significantly higher mortality associated with hemorrhagic stroke (OR = 2.17, 95% CI: 1.47-3.20, p < 0.001). Mortality was also associated with advanced age, lower Glasgow Coma Scale score, higher systolic blood pressure, and elevated cholesterol and triglyceride levels.
Conclusion: This study highlights distinct demographic, clinical, and metabolic profiles between ischemic and hemorrhagic stroke. Hypertension, high socioeconomic status, and early hospital presentation were associated with hemorrhagic stroke, while ischemic stroke was more prevalent among older patients and smokers. In-hospital mortality was significantly higher in hemorrhagic stroke and was linked to advanced age, reduced Glasgow Coma Scale score, and adverse metabolic parameters.
Keywords: hemorrhagic cva, ischemic cva, mortality, prevalence studies, risk factor stroke, stroke
Introduction
Stroke, also referred to as cerebrovascular accident (CVA), remains one of the foremost causes of mortality and long-term disability across the globe, exerting a substantial burden on healthcare resources. Clinically, strokes are classified into two major categories: ischemic stroke, caused by arterial occlusion leading to cerebral infarction, and hemorrhagic stroke, which results from spontaneous rupture of cerebral vessels, manifesting as intracerebral or subarachnoid hemorrhage [1,2]. Globally, ischemic stroke constitutes approximately 76% of all stroke cases, with hemorrhagic subtypes, including intracerebral and subarachnoid hemorrhages, accounting for the remainder. In 2019, there were an estimated 101.5 million individuals living with stroke worldwide - 77.2 million with ischemic stroke and 20.7 million with intracerebral hemorrhage [3]. This pattern is reflected in Pakistan, where hospital-based data indicate that approximately 71% of strokes among older adults are of the ischemic type [4]. Despite slight reductions in age-standardized stroke incidence rates, the absolute prevalence continues to escalate, driven largely by increasing age and the rising prevalence of modifiable risk factors such as hypertension, dyslipidemia, and physical inactivity [5-7].
Although ischemic and hemorrhagic strokes share several risk factors, their clinical and metabolic profiles often diverge. Ischemic strokes are more commonly associated with atherosclerotic and cardiometabolic abnormalities, including elevated low-density lipoprotein cholesterol, total cholesterol, and triglyceride levels [6,7]. Conversely, hemorrhagic strokes are more frequently linked to chronic hypertension, alcohol use, and underlying vascular fragility, particularly in younger individuals [8]. Previous studies from a range of regional and international settings have consistently demonstrated these distinctions, with ischemic stroke patients typically exhibiting higher lipid parameters and hemorrhagic stroke patients presenting with more severe hypertension and greater neurological impairment at the time of admission, as evidenced by higher scores on established clinical severity scales and increased early mortality [5,6,9]. Additionally, poorer functional outcomes and increased short-term mortality have been documented more often following hemorrhagic stroke, despite its lower overall incidence [10].
With the continued rise in diabetes (DM), hypertension (HTN), sedentary lifestyles, and other risk factors, cardiovascular diseases such as stroke are increasing in prevalence [5]. Therefore, it is necessary to provide updated data on the prevalence of stroke subtypes in the current population. In addition, differences in risk factors, clinical presentation, and metabolic profiles have a significant impact on the type of stroke and on in-hospital mortality. This study provides contemporary data by examining the distribution of key demographic, clinical, and metabolic characteristics in both ischemic and hemorrhagic stroke, and evaluates the relationship of these variables with clinical outcomes. The results contribute important insights for optimizing risk assessment and management in acute stroke.
Materials and methods
Study design, duration and setting
A cross-sectional observational study was conducted in the Department of Medicine at Lahore General Hospital, Lahore. The study period extended from June 2023 to July 2024. Ethical approval was obtained from the Institutional Review Board (IRB # 106/06/2023), and written informed consent was acquired from all participants or their legally authorized representatives prior to enrollment. Non-probability consecutive sampling was used to enroll eligible patients presenting to the emergency and inpatient departments.
Inclusion and exclusion criteria
A total of 800 adult patients aged 18 years or above, presenting within 24 hours of the onset of acute neurological symptoms, were included. Diagnosis of ischemic or hemorrhagic stroke was established using clinical assessment and neuroimaging [11]. Ischemic stroke was defined as infarction in a vascular territory confirmed on repeat non-contrast computed tomography (CT) brain after 24 hours, following initial exclusion of hemorrhage. Hemorrhagic stroke was confirmed by identification of hyperdense blood on non-contrast CT in parenchymal, ventricular, or subarachnoid spaces. Exclusion criteria comprised transient ischemic attack without radiological evidence, stroke mimics (such as hypoglycemia, trauma, postictal paralysis, brain tumors, migraine with aura, and conversion disorder), incomplete clinical or laboratory data, inadequate imaging, pregnancy, and those leaving against medical advice.
Data collection procedure
Baseline demographic characteristics recorded at admission included age, gender, residence (urban/rural), socioeconomic status (categorized as low: <25,000 PKR, middle: 25,000-75,000 PKR, high: >75,000 PKR monthly income), and body mass index (BMI, kg/m²), calculated from measured weight and height. Smoking status was categorized as ever smoker (current/former) or non-smoker. Clinical history was evaluated for comorbidities, including hypertension (systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or current antihypertensive use), DM (glycated hemoglobin (HbA1c) ≥6.5%), dyslipidemia (total cholesterol ≥200 mg/dL, low-density lipoprotein cholesterol (LDL-C) ≥130 mg/dL, high-density lipoprotein cholesterol (HDL-C) <40 mg/dL for males and <50 mg/dL for females, triglycerides ≥150 mg/dL, or lipid-lowering therapy) and chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m² for at least three months or documented diagnosis). Clinical characteristics assessed included stroke type, anatomical site of lesion on imaging, level of consciousness using the Glasgow Coma Scale (GCS), and neurological signs (loss of consciousness, seizures). Blood pressure (systolic and diastolic) was measured within one hour of admission. Laboratory investigations were performed within 24 hours of admission, including total cholesterol, LDL-C, HDL-C, triglycerides, non-HDL cholesterol, fasting and random glucose, HbA1c, serum creatinine, blood urea, uric acid and sodium. All results were recorded in standard units. In-hospital mortality was defined as any death occurring prior to hospital discharge. Data recorded using data collection proforma.
Statistical analysis
Continuous variables were expressed as mean and standard deviation. Categorical variables were reported as frequencies and percentages. Group comparisons were conducted using the chi-square test for categorical variables and the independent samples t-test for continuous variables. Univariate analysis was performed to assess the association of demographic, clinical, and metabolic variables with in-hospital mortality, presenting odds ratios with 95% confidence intervals. Statistical significance was set at p < 0.05. Data analysis performed through SPSS version 26.0 (IBM Corp., Armonk, NY, USA).
Results
A total of 800 patients were included, with ischemic stroke identified in 565 (70.6%) and hemorrhagic stroke in 235 (29.4%). The mean age was 63.91 ± 13.40 years, and most patients were older than 50 years. Males comprised nearly two-thirds of the patients. The majority had low or middle socioeconomic status and an urban background. The mean BMI was 26.57 ± 4.88 kg/m², with the majority of the patients in the overweight category. HTN and DM were observed in about one-third and one-fourth of patients, respectively. Most patients arrived at the hospital after 4.5 hours from symptom onset, with a mean arrival time of 8.98 ± 4.80 hours. The basal ganglia was the most frequent lesion site. The mean GCS score was 9.82 ± 2.49, with mean systolic and diastolic blood pressures of 163.19 ± 34.07 mmHg and 101.71 ± 31.36 mmHg, respectively. In-hospital mortality occurred in 131 (16.4%) patients (Table 1).
Table 1. Baseline Demographic, Clinical, and Neurological Characteristics of Study Participants (n=800).
| Variable | Frequency (%) |
| Age Group | |
| ≤50 years | 174 (21.8%) |
| >50 years | 626 (78.3%) |
| Gender | |
| Male | 515 (64.4%) |
| Female | 285 (35.6%) |
| Socioeconomic Status | |
| Low | 364 (45.5%) |
| Middle | 295 (36.9%) |
| High | 141 (17.6%) |
| Residence | |
| Rural | 341 (42.6%) |
| Urban | 459 (57.4%) |
| Body Mass Index (kg/m²) | |
| <18.5 (Underweight) | 35 (4.4%) |
| 18.5–24.9 (Normal) | 266 (33.3%) |
| 25.0–29.9 (Overweight) | 285 (35.6%) |
| ≥30.0 (Obese) | 214 (26.8%) |
| Smoking Status | |
| Ever smoker | 339 (42.4%) |
| Never smoker | 461 (57.6%) |
| Hypertension | |
| No | 544 (68.0%) |
| Yes | 256 (32.0%) |
| Diabetes Mellitus | |
| No | 606 (75.8%) |
| Yes | 194 (24.3%) |
| Dyslipidemia | |
| No | 596 (74.5%) |
| Yes | 204 (25.5%) |
| Chronic Kidney Disease | |
| No | 735 (91.9%) |
| Yes | 65 (8.1%) |
| Arrived within 4.5 hours of symptom onset | |
| No | 671 (83.9%) |
| Yes | 129 (16.1%) |
| Lesion Site | |
| Cortical (cerebral cortex) | 170 (21.3%) |
| Subcortical (white matter, internal capsule) | 178 (22.3%) |
| Basal ganglia | 201 (25.1%) |
| Thalamus | 104 (13.0%) |
| Brainstem | 83 (10.4%) |
| Cerebellum | 33 (4.1%) |
| Multifocal | 31 (3.9%) |
| Seizures at Presentation | |
| No | 712 (89.0%) |
| Yes | 88 (11.0%) |
| Stroke Subtype | |
| Ischemic | 565 (70.6%) |
| Hemorrhagic | 235 (29.4%) |
| In-hospital Mortality | |
| No | 669 (83.6%) |
| Yes | 131 (16.4%) |
Age group was significantly associated with stroke subtype, as patients aged ≤50 years were less likely to have ischemic stroke compared to those over 50 years (OR = 0.515, 95% CI: 0.363-0.731, p < 0.001). Gender distribution did not differ significantly between ischemic and hemorrhagic stroke (OR = 1.007, 95% CI: 0.733-1.384, p = 0.964). Ever smokers had higher odds of ischemic stroke than never smokers (OR = 1.405, 95% CI: 1.027-1.921, p = 0.033). Presentation within 4.5 hours was significantly associated with hemorrhagic stroke (OR = 2.993, 95% CI: 2.034-4.405, p < 0.001). Hypertension was more common in hemorrhagic stroke (OR = 1.453, 95% CI: 1.055-2.000, p = 0.022), while dyslipidemia and diabetes mellitus were not significantly associated with stroke subtype (dyslipidemia: OR = 0.798, 95% CI: 0.558-1.142, p = 0.217; diabetes: OR = 0.876, 95% CI: 0.611-1.256, p = 0.470). Seizures at presentation were significantly more common in hemorrhagic stroke (OR = 2.209, 95% CI: 1.408-3.468, p < 0.001). Ischemic stroke patients had higher BMI, longer time to hospital arrival, and better Glasgow Coma Scale scores. They also exhibited significantly higher total cholesterol, low-density lipoprotein, triglycerides, serum uric acid, and sodium levels. In contrast, hemorrhagic stroke patients had significantly elevated systolic and diastolic blood pressures, higher high-density lipoprotein, and increased blood urea levels. HbA1c showed no significant difference (Table 2).
Table 2. Association of Demographic and Clinical Variables with Stroke Subtype (n=800).
For each variable and subgroup, the table presents the absolute frequency and column-wise percentage of ischemic and hemorrhagic stroke patients, as well as the mean and standard deviation (SD) for continuous variables. The odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) quantifies the association. The relevant t-test or Pearson’s chi-square (χ²) statistic and p-value are shown, with p < 0.05 considered statistically significant.
Abbreviations: BMI, body mass index; GCS, Glasgow Coma Scale; LDL, low-density lipoprotein; HDL, high-density lipoprotein; HbA1c, glycated hemoglobin.
Percentages are column-wise for each stroke type.
| Variable | Subgroup | Ischemic n (%) (n=565) | Hemorrhagic n (%) (n=235) | OR/MD (95% CI) | t-test/ χ² | p-value |
| Age (continues) years | 65.68 ± 12.58 | 59.65 ± 14.35 | 6.03 (4.03 to 8.03) | 5.923 | < 0.001 | |
| Age Group (years) | ≤50 | 103 (18.2%) | 71 (30.2%) | 0.515 (0.363–0.731) | 14.00 | < 0.001 |
| >50 | 462 (81.8%) | 164 (69.8%) | ||||
| Gender | Male | 364 (64.4%) | 151 (64.3%) | 1.007 (0.733–1.384) | 0.002 | 0.964 |
| Female | 201 (35.6%) | 84 (35.7%) | ||||
| Socioeconomic Status | Low | 260 (46.0%) | 104 (44.3%) | - | 19.69 | < 0.001 |
| Middle | 226 (40.0%) | 69 (29.4%) | ||||
| High | 79 (14.0%) | 62 (26.4%) | ||||
| Residence | Rural | 253 (44.8%) | 88 (37.4%) | 1.355 (0.992–1.850) | 3.65 | 0.056 |
| Urban | 312 (55.2%) | 147 (62.6%) | ||||
| BMI (mean±SD) kg/m² | 27.12 ± 4.71 | 25.26 ± 5.05 | 1.86 (1.13 to 2.60) | 4.994 | < 0.001 | |
| BMI (kg/m²) | <18.5 (Underweight) | 22 (3.9%) | 13 (5.5%) | - | 13.15 | 0.004 |
| 18.5–24.9 (Normal) | 168 (29.7%) | 98 (41.7%) | ||||
| 25.0–29.9 (Overweight) | 213 (37.7%) | 72 (30.6%) | ||||
| ≥30.0 (Obese) | 162 (28.7%) | 52 (22.1%) | ||||
| Smoking Status | Ever smoker | 253 (44.8%) | 86 (36.6%) | 1.405 (1.027–1.921) | 4.55 | 0.033 |
| Never smoker | 312 (55.2%) | 149 (63.4%) | ||||
| Time to Hospital Arrival (mean±SD) hours | 10.01 ± 4.94 | 6.52 ± 3.36 | 3.49 (2.79 to 4.18) | 9.906 | < 0.001 | |
| Arrived ≤4.5 hours | No | 501 (88.7%) | 170 (72.3%) | 2.993 (2.034–4.405) | 32.73 | < 0.001 |
| Yes | 64 (11.3%) | 65 (27.7%) | ||||
| Hypertension | No | 398 (70.4%) | 146 (62.1%) | 1.453 (1.055–2.000) | 5.27 | 0.022 |
| Yes | 167 (29.6%) | 89 (37.9%) | ||||
| Dyslipidemia | No | 414 (73.3%) | 182 (77.4%) | 0.798 (0.558–1.142) | 1.52 | 0.217 |
| Yes | 151 (26.7%) | 53 (22.6%) | ||||
| Diabetes Mellitus | No | 424 (75.0%) | 182 (77.4%) | 0.876 (0.611–1.256) | 0.52 | 0.470 |
| Yes | 141 (25.0%) | 53 (22.6%) | ||||
| Chronic Kidney Disease | No | 526 (93.1%) | 209 (88.9%) | 1.678 (0.996–2.826) | 3.85 | 0.050 |
| Yes | 39 (6.9%) | 26 (11.1%) | ||||
| Lesion Site | Cortical (cerebral cortex) | 166 (29.4%) | 4 (1.7%) | - | 140.4 | < 0.001 |
| Subcortical (white matter, IC) | 131 (23.2%) | 47 (20.0%) | ||||
| Basal ganglia | 134 (23.7%) | 67 (28.5%) | ||||
| Thalamus | 46 (8.1%) | 58 (24.7%) | ||||
| Brainstem | 36 (6.4%) | 47 (20.0%) | ||||
| Cerebellum | 21 (3.7%) | 12 (5.1%) | ||||
| Multifocal | 31 (5.5%) | 0 (0.0%) | ||||
| Seizures at Presentation | No | 517 (91.5%) | 195 (83.0%) | 2.209 (1.408–3.468) | 12.32 | < 0.001 |
| Yes | 48 (8.5%) | 40 (17.0%) | ||||
| GCS Score on Admission | 10.04 ± 2.46 | 9.27 ± 2.47 | 0.77 (0.39 to 1.15) | 4.025 | < 0.001 | |
| Systolic Blood Pressure (mmHg) | 154.00 ± 31.60 | 185.30 ± 29.36 | -31.30 (-36.02 to -26.58) | -13.023 | < 0.001 | |
| Diastolic Blood Pressure (mmHg) | 98.77 ± 30.83 | 108.78 ± 31.56 | -10.01 (-14.74 to -5.28) | -4.156 | < 0.001 | |
| Total Cholesterol (mg/dL) | 193.94 ± 36.48 | 180.45 ± 34.70 | 13.49 (8.01 to 18.97) | 4.831 | < 0.001 | |
| LDL Cholesterol (mg/dL) | 126.65 ± 18.16 | 117.33 ± 24.86 | 9.32 (6.22 to 12.42) | 5.898 | < 0.001 | |
| HDL Cholesterol (mg/dL) | 42.20 ± 4.90 | 43.43 ± 4.91 | -1.23 (-1.97 to -0.48) | -3.224 | 0.001 | |
| Triglycerides (mg/dL) | 153.24 ± 35.09 | 139.11 ± 27.42 | 14.13 (9.10 to 19.16) | 5.513 | < 0.001 | |
| HbA1c (%) | 7.13 ± 2.14 | 6.95 ± 2.06 | 0.18 (-0.14 to 0.50) | 1.085 | 0.278 | |
| Blood Urea (mg/dL) | 49.41 ± 59.86 | 61.37 ± 86.56 | -11.96 (-22.44 to -1.48) | -2.241 | 0.025 | |
| Serum Uric Acid (mg/dL) | 7.11 ± 1.22 | 5.92 ± 1.08 | 1.18 (1.00 to 1.36) | 12.917 | < 0.001 | |
| Serum Sodium (mEq/L) | 136.33 ± 8.68 | 133.50 ± 9.91 | 2.82 (1.44 to 4.20) | 4.016 | < 0.001 | |
In-hospital mortality occurred in 16.4% of patients overall, with a significantly higher rate among hemorrhagic stroke patients (26.0%) compared to ischemic stroke patients (12.4%) (OR=2.48, 95% CI: 1.69-3.64; p<0.001). In-hospital mortality was consistently higher among hemorrhagic stroke patients compared to ischemic stroke across most demographic, socioeconomic, clinical, and radiological categories. Younger age, male gender, lower and middle socioeconomic status, rural or urban residence, overweight or obese BMI, and history of smoking all showed significantly higher odds of mortality with hemorrhagic stroke (OR range: 1.7-6.2, p < 0.05). Clinical comorbidities such as hypertension, diabetes, dyslipidemia, and chronic kidney disease further increased the risk of mortality in hemorrhagic stroke, with seizures at presentation associated with the highest odds (OR = 10.6, 95% CI: 3.27-34.57, p < 0.001). Mortality also varied significantly by lesion site, being particularly elevated in the basal ganglia for hemorrhagic stroke. Early arrival within 4.5 hours and adverse clinical features such as low Glasgow Coma Scale, hypertension, and seizures further amplified mortality risk in the hemorrhagic group, consistently supported by statistically significant odds ratios and confidence intervals (Table 3).
Table 3. Analysis of Effect Modifiers and Confounding Variables on In-Hospital Mortality Among Ischemic and Hemorrhagic Stroke Patients (n=800).
For each subgroup, the table presents frequencies and column-wise percentages, with odds ratios (OR) and 95% confidence intervals (CI), chi-square (χ²) statistics, and exact p-values illustrating the strength and significance of associations. The reference category is “No” for binary variables and the first subgroup for variables with more than two levels. OR > 1 indicates higher odds of mortality. Statistical significance is defined by a 95% CI excluding 1 and p < 0.05.
Abbreviations: BMI, body mass index
| Variable (Subgroup) | Stroke Subtype | In-hospital Mortality No (n=669) n (%) | In-hospital Mortality Yes (n=131) n (%) | Odds Ratio (95% CI) | Pearson Chi-square | p-value |
| Age ≤50 years | Ischemic | 95 (92.2%) | 8 (7.8%) | 4.033 (1.643 to 9.900) | 10.226 | 0.001 |
| Hemorrhagic | 53 (74.6%) | 18 (25.4%) | ||||
| Age >50 years | Ischemic | 400 (86.6%) | 62 (13.4%) | 2.293 (1.478 to 3.556) | 14.204 | < 0.001 |
| Hemorrhagic | 121 (73.8%) | 43 (26.2%) | ||||
| Male | Ischemic | 325 (89.3%) | 39 (10.7%) | 3.106 (1.905 to 5.064) | 21.979 | < 0.001 |
| Hemorrhagic | 110 (72.8%) | 41 (27.2%) | ||||
| Female | Ischemic | 170 (84.6%) | 31 (15.4%) | 1.714 (0.911 to 3.222) | 2.836 | 0.092 |
| Hemorrhagic | 64 (76.2%) | 20 (23.8%) | ||||
| Low socioeconomic status | Ischemic | 215 (82.7%) | 45 (17.3%) | 1.937 (1.138 to 3.298) | 6.046 | 0.014 |
| Hemorrhagic | 74 (71.2%) | 30 (28.8%) | ||||
| Middle socioeconomic status | Ischemic | 208 (92.0%) | 18 (8.0%) | 6.163 (3.088 to 12.298) | 31.136 | < 0.001 |
| Hemorrhagic | 45 (65.2%) | 24 (34.8%) | ||||
| Highsocioeconomic status | Ischemic | 72 (91.1%) | 7 (8.9%) | 1.309 (0.434 to 3.952) | 0.229 | 0.632 |
| Hemorrhagic | 55 (88.7%) | 7 (11.3%) | ||||
| Rural | Ischemic | 223 (88.1%) | 30 (11.9%) | 2.788 (1.523 to 5.102) | 11.640 | 0.001 |
| Hemorrhagic | 64 (72.7%) | 24 (27.3%) | ||||
| Urban | Ischemic | 272 (87.2%) | 40 (12.8%) | 2.287 (1.389 to 3.767) | 10.915 | 0.001 |
| Hemorrhagic | 110 (74.8%) | 37 (25.2%) | ||||
| BMI <18.5 (Underweight) | Ischemic | 18 (81.8%) | 4 (18.2%) | 2.813 (0.593 to 13.336) | 1.759 | 0.185 |
| Hemorrhagic | 8 (61.5%) | 5 (38.5%) | ||||
| BMI 18.5-24.9 (Normal) | Ischemic | 145 (86.3%) | 23 (13.7%) | 2.045 (1.082 to 3.865) | 4.962 | 0.026 |
| Hemorrhagic | 74 (75.5%) | 24 (24.5%) | ||||
| BMI 25.0-29.9 (Overweight) | Ischemic | 185 (86.9%) | 28 (13.1%) | 2.641 (1.335 to 5.224) | 8.226 | 0.004 |
| Hemorrhagic | 52 (72.2%) | 20 (27.8%) | ||||
| BMI ≥30.0 (Obese) | Ischemic | 147 (90.7%) | 15 (9.3%) | 2.940 (1.275 to 6.781) | 6.817 | 0.009 |
| Hemorrhagic | 40 (76.9%) | 12 (23.1%) | ||||
| Smoking: Ever | Ischemic | 221 (87.4%) | 32 (12.6%) | 2.993 (1.657 to 5.404) | 13.994 | < 0.001 |
| Hemorrhagic | 60 (69.8%) | 26 (30.2%) | ||||
| Smoking: Never | Ischemic | 274 (87.8%) | 38 (12.2%) | 2.214 (1.331 to 3.681) | 9.679 | 0.002 |
| Hemorrhagic | 114 (76.5%) | 35 (23.5%) | ||||
| Non-hypertensive | Ischemic | 352 (88.4%) | 46 (11.6%) | 1.215 (0.692 to 2.133) | 0.459 | 0.498 |
| Hemorrhagic | 126 (86.3%) | 20 (13.7%) | ||||
| Hypertensive | Ischemic | 143 (85.6%) | 24 (14.4%) | 5.089 (2.792 to 9.279) | 30.790 | < 0.001 |
| Hemorrhagic | 48 (53.9%) | 41 (46.1%) | ||||
| Non-diabetic | Ischemic | 395 (93.2%) | 29 (6.8%) | 2.476 (1.426 to 4.300) | 10.912 | 0.001 |
| Hemorrhagic | 154 (84.6%) | 28 (15.4%) | ||||
| Diabetic | Ischemic | 100 (70.9%) | 41 (29.1%) | 4.024 (2.072 to 7.816) | 17.980 | < 0.001 |
| Hemorrhagic | 20 (37.7%) | 33 (62.3%) | ||||
| Non-dyslipidemic | Ischemic | 387 (93.5%) | 27 (6.5%) | 3.293 (1.920 to 5.648) | 20.346 | < 0.001 |
| Hemorrhagic | 148 (81.3%) | 34 (18.7%) | ||||
| Dyslipidemic | Ischemic | 108 (71.5%) | 43 (28.5%) | 2.608 (1.370 to 4.967) | 8.785 | 0.003 |
| Hemorrhagic | 26 (49.1%) | 27 (50.9%) | ||||
| Chronic Kidney Disease: No | Ischemic | 473 (89.9%) | 53 (10.1%) | 2.178 (1.397 to 3.395) | 12.208 | < 0.001 |
| Hemorrhagic | 168 (80.4%) | 41 (19.6%) | ||||
| Chronic Kidney Disease: Yes | Ischemic | 22 (56.4%) | 17 (43.6%) | 4.314 (1.421 to 13.094) | 7.069 | 0.008 |
| Hemorrhagic | 6 (23.1%) | 20 (76.9%) | ||||
| Arrival >4.5h: No | Ischemic | 447 (89.2%) | 54 (10.8%) | 2.069 (1.293 to 3.311) | 9.473 | 0.002 |
| Hemorrhagic | 136 (80.0%) | 34 (20.0%) | ||||
| Arrival ≤4.5h: Yes | Ischemic | 48 (75.0%) | 16 (25.0%) | 2.132 (1.006 to 4.516) | 3.969 | 0.046 |
| Hemorrhagic | 38 (58.5%) | 27 (41.5%) | ||||
| Seizures at Presentation: No | Ischemic | 469 (90.7%) | 48 (9.3%) | 1.437 (0.859 to 2.403) | 1.924 | 0.165 |
| Hemorrhagic | 170 (87.2%) | 25 (12.8%) | ||||
| Seizures at Presentation: Yes | Ischemic | 26 (54.2%) | 22 (45.8%) | 10.636 (3.272 to 34.571) | 18.942 | < 0.001 |
| Hemorrhagic | 4 (10.0%) | 36 (90.0%) | ||||
| Lesion Site: Cortical | Ischemic | 156 (94.0%) | 10 (6.0%) | 1.400 (1.005 to 1.950) | 45.645 | < 0.001 |
| Hemorrhagic | 4 (100.0%) | 0 (0.0%) | ||||
| Lesion Site: Subcortical | Ischemic | 114 (87.0%) | 17 (13.0%) | 1.588 (0.654 to 3.858) | 1.056 | 0.304 |
| Hemorrhagic | 38 (80.9%) | 9 (19.1%) | ||||
| Lesion Site: Basal ganglia | Ischemic | 116 (86.6%) | 18 (13.4%) | 2.551 (1.233 to 5.278) | 6.625 | 0.010 |
| Hemorrhagic | 48 (71.6%) | 19 (28.4%) | ||||
| Lesion Site: Thalamus | Ischemic | 43 (93.5%) | 3 (6.5%) | 1.352 (0.306 to 5.981) | 0.159 | 0.690 |
| Hemorrhagic | 53 (91.4%) | 5 (8.6%) | ||||
| Lesion Site: Brainstem | Ischemic | 16 (44.4%) | 20 (55.6%) | 0.593 (0.247 to 1.422) | 1.380 | 0.240 |
| Hemorrhagic | 27 (57.4%) | 20 (42.6%) | ||||
| Lesion Site: Cerebellum | Ischemic | 20 (95.2%) | 1 (4.8%) | 10.000 (0.964 to 103.779) | 4.849 | 0.028 |
| Hemorrhagic | 4 (33.3%) | 8 (66.7%) | ||||
| Lesion Site: Multifocal | Ischemic | 30 (96.8%) | 1 (3.2%) | - | - | - |
| Hemorrhagic | 0 (0.0%) | 0 (0.0%) |
In both ischemic and hemorrhagic stroke, lower admission Glasgow Coma Scale (GCS) score and higher systolic blood pressure were strongly associated with increased in-hospital mortality (both p < 0.001). Higher total cholesterol, triglycerides, and HbA1c levels were significant predictors of mortality in both groups (all p < 0.05), as was markedly elevated blood urea (p < 0.001). In ischemic stroke, lower serum sodium was also associated with mortality (p < 0.001), while in hemorrhagic stroke, lower HDL cholesterol (p = 0.006) and higher systolic blood pressure remained significant. No significant differences were found for LDL cholesterol or serum uric acid in either group (Table 4).
Table 4. Comparison of Clinical and Laboratory Variables by In-Hospital Mortality Status Among Ischemic and Hemorrhagic Stroke Patients (n=800).
Means and standard deviations of baseline clinical and laboratory parameters were compared between in-hospital mortality groups for both stroke types using independent samples t-test. Statistical significance was set at p < 0.05. Negative mean differences reflect higher values among survivors.
Abbreviations: CI, confidence interval; SD, standard deviation; BMI, body mass index; GCS, Glasgow Coma Scale; LDL, low-density lipoprotein; HDL, high-density lipoprotein; HbA1c, glycated hemoglobin
| Variable | Stroke Subtype | In-hospital Mortality No, Mean ± SD | In-hospital Mortality Yes, Mean ± SD | Mean Difference (95% CI) | t-test | p-value |
| Age in Years | Ischemic | 64.52 ± 11.81 | 73.91 ± 14.65 | -9.40 (-12.46 to -6.34) | -6.034 | < 0.001 |
| Hemorrhagic | 59.28 ± 14.33 | 60.70 ± 14.49 | -1.43 (-5.64 to 2.78) | -0.668 | 0.505 | |
| BMI (kg/m²) | Ischemic | 27.30 ± 4.64 | 25.86 ± 5.04 | 1.44 (0.27 to 2.62) | 2.409 | 0.016 |
| Hemorrhagic | 25.12 ± 5.15 | 25.64 ± 4.76 | -0.52 (-2.00 to 0.96) | -0.689 | 0.491 | |
| Time to Hospital Arrival (hours) | Ischemic | 10.04 ± 4.80 | 9.75 ± 5.86 | 0.29 (-0.94 to 1.53) | 0.467 | 0.641 |
| Hemorrhagic | 6.72 ± 3.36 | 5.94 ± 3.32 | 0.79 (-0.20 to 1.77) | 1.575 | 0.117 | |
| GCS Score on Admission | Ischemic | 10.25 ± 2.40 | 8.60 ± 2.44 | 1.65 (1.04 to 2.25) | 5.366 | < 0.001 |
| Hemorrhagic | 9.75 ± 2.03 | 7.92 ± 3.08 | 1.83 (1.14 to 2.52) | 5.242 | < 0.001 | |
| Systolic Blood Pressure (mmHg) | Ischemic | 151.45 ± 29.73 | 172.00 ± 38.21 | -20.55 (-28.29 to -12.80) | -5.208 | < 0.001 |
| Hemorrhagic | 180.75 ± 27.96 | 198.28 ± 29.62 | -17.53 (-25.86 to -9.21) | -4.150 | < 0.001 | |
| Diastolic Blood Pressure (mmHg) | Ischemic | 99.35 ± 30.25 | 94.64 ± 34.61 | 4.71 (-3.02 to 12.44) | 1.197 | 0.232 |
| Hemorrhagic | 106.49 ± 27.80 | 115.33 ± 39.94 | -8.84 (-18.04 to 0.36) | -1.893 | 0.060 | |
| Total Cholesterol (mg/dL) | Ischemic | 192.53 ± 36.22 | 203.94 ± 37.06 | -11.42 (-20.53 to -2.31) | -2.462 | 0.014 |
| Hemorrhagic | 173.66 ± 27.08 | 199.82 ± 45.46 | -26.16 (-35.78 to -16.54) | -5.358 | < 0.001 | |
| LDL Cholesterol (mg/dL) | Ischemic | 126.79 ± 18.41 | 125.66 ± 16.35 | 1.13 (-3.43 to 5.69) | 0.486 | 0.627 |
| Hemorrhagic | 116.67 ± 24.94 | 119.21 ± 24.75 | -2.55 (-9.84 to 4.75) | -0.687 | 0.492 | |
| HDL Cholesterol (mg/dL) | Ischemic | 42.32 ± 4.75 | 41.37 ± 5.86 | 0.94 (-0.28 to 2.17) | 1.509 | 0.132 |
| Hemorrhagic | 43.94 ± 4.57 | 41.95 ± 5.53 | 1.99 (0.57 to 3.41) | 2.767 | 0.006 | |
| Triglycerides (mg/dL) | Ischemic | 151.60 ± 33.22 | 164.84 ± 44.78 | -13.24 (-21.98 to -4.50) | -2.976 | 0.003 |
| Hemorrhagic | 136.30 ± 24.67 | 147.11 ± 33.00 | -10.81 (-18.74 to -2.88) | -2.685 | 0.008 | |
| HbA1c (%) | Ischemic | 6.91 ± 1.93 | 8.69 ± 2.83 | -1.77 (-2.29 to -1.26) | -6.730 | < 0.001 |
| Hemorrhagic | 6.45 ± 1.42 | 8.40 ± 2.80 | -1.96 (-2.51 to -1.41) | -7.022 | < 0.001 | |
| Blood Urea (mg/dL) | Ischemic | 43.69 ± 47.28 | 89.84 ± 106.72 | -46.15 (-60.69 to -31.62) | -6.238 | < 0.001 |
| Hemorrhagic | 36.90 ± 28.01 | 131.18 ± 142.37 | -94.28 (-116.61 to -71.95) | -8.319 | < 0.001 | |
| Serum Uric Acid (mg/dL) | Ischemic | 7.12 ± 1.21 | 7.03 ± 1.28 | 0.21 (-0.41 to 0.82) | 0.602 | 0.547 |
| Hemorrhagic | 5.97 ± 1.10 | 5.79 ± 1.01 | 0.18 (-0.14 to 0.49) | 1.101 | 0.272 | |
| Serum Sodium (mEq/L) | Ischemic | 136.82 ± 8.28 | 132.86 ± 10.54 | 3.96 (1.80 to 6.11) | 3.610 | < 0.001 |
| Hemorrhagic | 134.06 ± 9.54 | 131.90 ± 10.84 | 2.16 (-0.74 to 5.06) | 1.469 | 0.143 |
Discussion
The present study found that ischemic stroke constituted 70.6% of all stroke cases, while hemorrhagic stroke accounted for 29.4%, a distribution closely consistent with previous international and regional epidemiological reports [1,4,6]. Globally, ischemic stroke remains the predominant subtype, accounting for 62-88% of all incident strokes, while hemorrhagic stroke comprises 12-38% of cases [12]. European and Middle Eastern cohorts generally report ischemic stroke frequencies of 80-85% and hemorrhagic stroke at 15-20% [13,14]. In Asia, and specifically in East and Southeast Asia, the proportion of hemorrhagic stroke is somewhat higher, yet ischemic stroke still predominates, with large Chinese and South Asian studies indicating ischemic stroke rates around 79-88% and hemorrhagic stroke 12-21% [15,16]. The higher frequency of hemorrhagic and overall stroke cases at this tertiary care hospital likely results from its status as the largest neuroscience referral center, where patients from multiple regions with more severe or complex presentations are concentrated, leading to elevated observed rates compared to non-referral or general hospital settings.
Patients with hemorrhagic stroke were observed to be significantly younger than those with ischemic stroke, consistent with previous reports indicating mean age differences of seven to 10 years between the subtypes [17,18]. This age disparity has been documented across multiple populations and is attributed to differing risk factor profiles, with hypertension and diabetes more frequently observed in hemorrhagic stroke patients, while ischemic stroke is more often linked to atrial fibrillation. Regarding gender, men comprised a higher proportion of both ischemic and hemorrhagic stroke cases, particularly intracerebral hemorrhage [19,20]. Ischemic stroke predominated in both rural and urban populations, with a higher ischemic-to-hemorrhagic ratio in rural (4.3:1) than urban (3.8:1) areas, matching prior registry data [15]. Lower socioeconomic status was significantly linked to increased ischemic stroke risk, poorer outcomes, and higher long-term mortality, whereas this association was weaker for hemorrhagic stroke, consistent with published evidence [21,22]. This disparity may be attributed to differential access to preventive healthcare, delayed presentation, and lower adherence to long-term secondary prevention strategies among lower socioeconomic groups, particularly impacting ischemic stroke outcomes.
Patients with ischemic stroke in this study exhibited significantly higher BMI than those with hemorrhagic stroke, in agreement with prior reports identifying overweight and obesity as key risk factors for ischemic events. Rising BMI correlates with increased ischemic stroke risk, while a U-shaped pattern links both low and high BMI to higher hemorrhagic stroke risk in men, but less so in women. Class 1 obesity is specifically linked to ischemic, not hemorrhagic stroke [9,23].
Hypertension was significantly more frequent among hemorrhagic stroke patients in this study, with an odds ratio of 1.45 (95% CI: 1.05-2.00, p = 0.022), consistent with previous literature describing hypertension rates nearing 100% in hemorrhagic stroke patients and slightly less prevalent in ischemic stroke (60-90%) [6,7]. Diabetes mellitus and dyslipidemia, by contrast, showed higher prevalence among ischemic stroke patients, as supported by studies reporting diabetes in 30-50% of ischemic cases versus 10-30% in hemorrhagic, and dyslipidemia in 35-80% of ischemic versus 10-40% of hemorrhagic strokes [5,6]. While the present study did not observe significant differences in frequency for diabetes or dyslipidemia between groups, ischemic stroke patients exhibited higher mean total and low-density lipoprotein cholesterol, in line with global data highlighting lipid abnormalities as more prominent in ischemic stroke and potentially inversely associated with hemorrhagic stroke [5-7]. Chronic kidney disease was found in 8.1% of cases, and its distribution by stroke subtype indicated that ischemic stroke is more common in chronic kidney disease [24].
Hemorrhagic stroke patients in this study presented to the hospital significantly earlier than ischemic stroke patients, mirroring registry data that report a median arrival time of 248 minutes for hemorrhagic stroke versus 483 minutes for ischemic stroke, and a 42% rate of early (≤4.5 hours) arrival for hemorrhagic cases compared to 30% in ischemic stroke [7,18]. Early presentation is especially crucial for timely intervention in ischemic stroke, where treatment efficacy is time-dependent. Lesion analysis revealed ischemic stroke was most frequently localized to the basal ganglia (25.1%), subcortical (22.3%), and cortical (21.3%) regions, whereas hemorrhagic stroke more often affected deep structures such as basal ganglia, thalamus, brainstem, and cerebellum, corroborating previous findings that deep brain involvement predominates in hemorrhagic events [10,25]. Regarding neurological status, hemorrhagic stroke was associated with lower mean GCS scores at admission (9.27 ± 2.47) compared to ischemic stroke (10.04 ± 2.46), supporting previous observations of greater initial severity and higher mortality in hemorrhagic stroke [25,26]. Admission blood pressure was also significantly higher in the hemorrhagic group, with systolic averaging 185.3 mmHg and diastolic 108.8 mmHg, consistent with published data [27].
A previous study reported that serum uric acid level consistently found higher in ischemic stroke compared to hemorrhagic stroke, reporting mean of 303 μmol/L in ischemic versus 269 μmol/L in hemorrhagic stroke [28]. For serum sodium, findings are heterogeneous; several studies indicate lower sodium levels and less frequent hyponatremia in ischemic stroke, whereas hyponatremia is more common and sodium values higher in hemorrhagic stroke, with some studies reporting a significant difference (129.4 ± 3.1 mEq/L in ischemic versus 134.4 ± 3.5 mEq/L in hemorrhagic, p < 0.0001) [29,30]. These metabolic disturbances have important prognostic implications, particularly for acute management and outcome prediction.
Consistent with previous large multicenter and registry-based studies, the present study demonstrated a significantly higher in-hospital mortality rate for hemorrhagic stroke (26.0%) compared to ischemic stroke (12.4%), with the odds of mortality being more than twice as high in hemorrhagic cases (OR=2.48, 95% CI: 1.69-3.64; p<0.001). In-hospital mortality for ischemic stroke typically ranges from 3.5% to 6.7%, whereas mortality for hemorrhagic stroke spans from 15.1% to 22.5% and can reach up to 39% in critically ill populations [10,18,24,25]. Early mortality is particularly pronounced in hemorrhagic stroke, with the risk of death within the first week being nearly four times greater than that of ischemic stroke [23,25]. Lower Glasgow Coma Scale scores, especially in the context of hemorrhagic stroke and deep brain involvement, are powerful predictors of mortality [5,10,25]. Although overall lesion-specific mortality is higher in hemorrhagic stroke, current literature lacks detailed site-by-site mortality data for each subtype, underscoring the importance of further research in this area.
This study's major strengths include its large sample size and the detailed assessment of key demographic, metabolic, and neurological variables. The consecutive enrollment and broad inclusion of acute stroke presentations from a high-volume tertiary care center enhance generalizability to similar referral settings. However, several limitations must be acknowledged. The cross-sectional design restricts the ability to establish temporal or causal relationships between risk factors and stroke subtypes. Moreover, the study was conducted at a single tertiary care center in Pakistan, which may limit ethnic and regional generalizability. As such, the findings may not fully represent the broader diversity of stroke presentations across different ethnic and socioeconomic groups. Future studies employing multicenter, prospective designs and incorporating long-term outcomes are needed to clarify causal pathways, identify modifiable risk factors, and optimize acute and post-stroke care strategies tailored to regionally diverse patient populations.
Conclusions
This study demonstrates that ischemic and hemorrhagic strokes have distinctly different clinical and metabolic profiles among adults presenting to a tertiary care center. Ischemic stroke was more frequently observed, particularly in older adults and those with a history of smoking, while hemorrhagic stroke was associated with higher blood pressure, greater representation among individuals of higher socioeconomic status, and more rapid hospital arrival after symptom onset. The findings also highlight that hypertension remains a key risk factor for hemorrhagic stroke, whereas elevated cholesterol and triglyceride levels are more closely related to ischemic stroke. Importantly, in-hospital mortality was substantially higher in the hemorrhagic stroke group, with mortality risk amplified by advanced age, reduced consciousness at admission, and unfavorable metabolic findings. These insights emphasize the need for risk factor modification and tailored acute management strategies, with particular focus on blood pressure control and early intervention, to reduce adverse outcomes in both stroke subtypes within the local population.
Acknowledgments
Tayyaba Arooj Mufti and Muhammad Irfan Jamil contributed equally to the work and should be considered co-first authors.
Disclosures
Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Post Graduate Medical Institute/Amer-Ud-Din Medical College/Lahore General Hospital Lahore issued approval 106/06/2023.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an 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.
Author Contributions
Concept and design: Muhammad Irfan Jamil, Ayesha Farooq, Tayyaba Arooj Mufti, Muhammad Ayoob Memon, Ammar Nawazish, Shiv Priya ., Hafiz Zunair Iqbal, Fatima Shaukat, Iqra Naeem
Acquisition, analysis, or interpretation of data: Muhammad Irfan Jamil, Muhammad Zaryab Haider, Tayyaba Arooj Mufti, Amara Sajjad, Shiv Priya ., Adeel Ahmed, Iqra Naeem
Drafting of the manuscript: Muhammad Irfan Jamil, Ayesha Farooq, Muhammad Zaryab Haider, Tayyaba Arooj Mufti, Ammar Nawazish, Shiv Priya ., Hafiz Zunair Iqbal, Fatima Shaukat, Adeel Ahmed, Iqra Naeem
Critical review of the manuscript for important intellectual content: Muhammad Irfan Jamil, Muhammad Zaryab Haider, Tayyaba Arooj Mufti, Muhammad Ayoob Memon, Amara Sajjad, Fatima Shaukat, Adeel Ahmed, Iqra Naeem
Supervision: Muhammad Irfan Jamil, Ayesha Farooq, Ammar Nawazish, Shiv Priya ., Hafiz Zunair Iqbal, Fatima Shaukat, Adeel Ahmed
References
- 1.Hemorrhagic and ischemic stroke in patients with coronavirus disease 2019: incidence, risk factors, and pathogenesis - a systematic review and meta-analysis. Syahrul S, Maliga HA, Ilmawan M, et al. F1000Res. 2021;10:34. doi: 10.12688/f1000research.42308.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Neuroinflammation in acute ischemic and hemorrhagic stroke. Alsbrook DL, Di Napoli M, Bhatia K, et al. Curr Neurol Neurosci Rep. 2023;23:407–431. doi: 10.1007/s11910-023-01282-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Ischemic stroke of unclear aetiology: a case-by-case analysis and call for a multi-professional predictive, preventive and personalised approach. Golubnitschaja O, Potuznik P, Polivka J Jr, et al. EPMA J. 2022;13:535–545. doi: 10.1007/s13167-022-00307-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Prevalence of ischemic and hemorrhagic stroke among geriatric patients admitted in the public tertiary care hospitals of Peshawar. Haider Z, Sajid Hussain S. J BioMed Res Reports. 2023;2 [Google Scholar]
- 5.Risk factors of ischemic stroke: a literature review. Hanan I, Ardhi MS, Prajitno JH, Setyowatie S. Int J Sci Adv. 2024;5 [Google Scholar]
- 6.Risk and population attributable fraction of stroke subtypes in Japan. Yatsuya H, Yamagishi K, Li Y, et al. J Epidemiol. 2024;34:211–217. doi: 10.2188/jea.JE20220364. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Modifiable risk factors for stroke in Syria: a nationwide multi-centre case-control study. Albitar MM, Maya S, Al Ashabia KK, Hamzeh G, Kakaje A. Sci Rep. 2025;15:115. doi: 10.1038/s41598-024-83569-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Clinical impact of body mass index on outcomes of ischemic and hemorrhagic strokes. Miwa K, Nakai M, Yoshimura S, et al. Int J Stroke. 2024;19:907–915. doi: 10.1177/17474930241249370. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Association of body mass index with ischemic and hemorrhagic stroke. Shiozawa M, Kaneko H, Itoh H, et al. Nutrients. 2021;13 [Google Scholar]
- 10.Hemorrhagic and ischemic strokes compared: stroke severity, mortality, and risk factors. Andersen KK, Olsen TS, Dehlendorff C, Kammersgaard LP. Stroke. 2009;40:2068–2072. doi: 10.1161/STROKEAHA.108.540112. [DOI] [PubMed] [Google Scholar]
- 11.Acute stroke diagnosis. Choi EY, Nieves GA, Jones DE. https://www.aafp.org/pubs/afp/issues/2022/0600/p616.html. Am Fam Physician. 2022;105:616–624. [PubMed] [Google Scholar]
- 12.Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20:795–820. doi: 10.1016/S1474-4422(21)00252-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Age- and sex-specific analysis of stroke hospitalization rates, risk factors, and outcomes from German nationwide data. Kelly DM, Engelbertz C, Rothwell PM, Anderson CD, Reinecke H, Koeppe J. Stroke. 2024;55:2284–2294. doi: 10.1161/STROKEAHA.123.046118. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Stroke incidence, case fatality, and mortality using the WHO International Classification of Diseases 11: the Geneva Stroke Study. Dirren E, Escribano Paredes JB, Klug J, et al. Neurology. 2025;104:0. [Google Scholar]
- 15.[Analysis of the incidence and mortality characteristics of ischemic and hemorrhagic stroke among Chinese residents from 2015 to 2019] Chen XR, Yan LX, Long Z, Hou L, Cai XN, Wang LM, Wu J. Zhonghua Yu Fang Yi Xue Za Zhi. 2025;59:202–208. doi: 10.3760/cma.j.cn112150-20240412-00299. [DOI] [PubMed] [Google Scholar]
- 16.Stroke management and outcomes in low-income and lower-middle-income countries: a meta-analysis of 8535 patients. Aguirre AO, Rogers JL, Reardon T, et al. J Neurosurg. 2023;139:1042–1051. doi: 10.3171/2023.2.JNS222807. [DOI] [PubMed] [Google Scholar]
- 17.Evaluating the coagulation parameters in acute ischemic versus hemorrhagic stroke patients upon hospital admission. Reddy KSS, Varadaraj P, Senthilnathan S, Vivekanandan T, Gunasekaran N. Rom J Med Pract. 2024;19 [Google Scholar]
- 18.Comparison between ischemic and hemorrhagic strokes in functional outcome at discharge from an intensive rehabilitation hospital. Salvadori E, Papi G, Insalata G, et al. Diagnostics (Basel) 2020;11 [Google Scholar]
- 19.Abstract WP171: sex differences in risk factors and outcomes in young patients with intracerebral hemorrhages. Kherani D, Vyas V, Dongarwar D, et al. Stroke. 2024;55 [Google Scholar]
- 20.Sex disparity in stroke outcomes in a multicenter prospective stroke registry in Vietnam. Ton MD, Dao PV, Nguyen DT, et al. Int J Stroke. 2023;18:1102–1111. doi: 10.1177/17474930231177893. [DOI] [PubMed] [Google Scholar]
- 21.Abstract WMP47: neighborhood socio-economic status as a predictor of all-cause long-term post-stroke mortality. Nobel L, Robinson D, Stanton RJ, et al. Stroke. 2024;55 [Google Scholar]
- 22.Socioeconomic status and survival after stroke - using mediation and sensitivity analyses to assess the effect of stroke severity and unmeasured confounding. Lindmark A, Norrving B, Eriksson M. BMC Public Health. 2020;20:554. doi: 10.1186/s12889-020-08629-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Differences in body composition among patients after hemorrhagic and ischemic stroke. Wilczyński J, Mierzwa-Molenda M, Habik-Tatarowska N. Int J Environ Res Public Health. 2020;17 [Google Scholar]
- 24.Epidemiology, thrombolytic management, and outcomes of acute stroke among patients with chronic kidney disease: a systematic review and meta-analysis. Zamberg I, Assouline-Reinmann M, Carrera E, Sood MM, Sozio SM, Martin PY, Mavrakanas TA. Nephrol Dial Transplant. 2022;37:1289–1301. doi: 10.1093/ndt/gfab197. [DOI] [PubMed] [Google Scholar]
- 25.Predictors of in-hospital mortality in stroke patients. Ranasinghe VS, Pathirage M, Gawarammana IB. PLOS Glob Public Health. 2023;3:0. [Google Scholar]
- 26.Risk factor assessment, etiology, clinico-radiological profile and prognosis in CVA. Krishna JT, Kumar P. Int J Sci Res. 2023;37:9. [Google Scholar]
- 27.A1292 The differences between systolic and diastolic blood pressure in ischemic and hemorrhagic stroke patients in Anutapura Hospital Palu, Central Sulawesi, Indonesia. Halim W, Dunggio M. J Hypertens. 2018;36:269. [Google Scholar]
- 28.Decreased uric acid levels correlate with poor outcomes in acute ischemic stroke patients, but not in cerebral hemorrhage patients. Wu H, Jia Q, Liu G, et al. J Stroke Cerebrovasc Dis. 2014;23:469–475. doi: 10.1016/j.jstrokecerebrovasdis.2013.04.007. [DOI] [PubMed] [Google Scholar]
- 29.Frequency of electrolyte imbalance in patients presenting with acute stroke. Mansoor F, Kumar J, Kaur N, et al. Cureus. 2021;13:0. [Google Scholar]
- 30.Electrolyte changes in stroke. Alam MN, Uddin MJ, Rahman KM, et al. https://pubmed.ncbi.nlm.nih.gov/23134903/ Mymensingh Med J. 2012;21:594–599. [PubMed] [Google Scholar]