Stroke in Young Adults in The Middle East and North Africa (MENA) region: what is the difference from elsewhere? A report from sixteen centers experiences

Amal M Al Hashmi^1*Yahia Imam²Mehdi Farhoudi³Elyar Sadeghi³Andoerza Ghoreishi⁴Abdulkarim Al Mutairi⁵Khaled Mohamed Sobh⁶Atilla Ozcan Ozdemir⁷Erdem Gurkas⁸Hani Humaidan⁹Hosam Al-Jehani¹⁰Faiza Mushtaque¹¹Vinitha Leeleamani¹²Salma Said¹³Hany Helal¹⁴Noora Al Jahwari¹⁵Abeer Sabry Safan²Rasha KM Abumustafa²May Al Hamid¹⁶Farid Aladham¹⁷Ossama Yassin Mansour¹³Haytham Hussein Mohammed Osman¹⁸Sachin Jose¹⁹Ehab Shawky¹⁴

• ¹Ministry of Health (Oman), Muscat, Oman
• ²Hamad Medical Corporation, Doha, Qatar
• ³Tabriz University of Medical Sciences, Tabriz, Iran
• ⁴University of Zanjan, Zanjan, Iran
• ⁵Prince Sultan Military Medical City, Riyadh, Saudi Arabia
• ⁶Al Hussain Hospital , Al Azher University, Cairo, Egypt
• ⁷Eskisehir Osmangazi University, Eskisehir, Türkiye
• ⁸Latfi Hospital, Istanbul, Türkiye
• ⁹Salmaniya Medical Complex, Manama, Bahrain
• ¹⁰Imam Abdurrahman Al Faisal University, Damam, Saudi Arabia
• ¹¹Ministry of Health of Oman, Muscat, Oman
• ¹²Ministry of Health of Oman, Sohar, Oman
• ¹³Alexandria University, Alexandria, Egypt
• ¹⁴Tanta University, Tanta, Egypt
• ¹⁵Ministry of Health of Oman, Muscat, Oman
• ¹⁶King Fahad Hospital, Riyadh, Saudi Arabia
• ¹⁷Specialty Hospital, Amman, Jordan
• ¹⁸The National Rabit University, Khartoum, Sudan, Khartoum, Sudan
• ¹⁹Oman Medical Specialty Board (OMSB), Muscat, Oman

Background: Stroke at a young age is on the rise globally. The diverse range of underlying etiologies and risk factors for stroke in young adults make it challenging. There are very limited papers in this regard from our Middle East and North Africa (MENA) region. Objectives: Identifying risk factors, etiologies and treatment offered to young stroke patients in the MENA region. Method: A five-year multicenter retrospective study across nine MENA countries (2018–2022) was conducted. Multinomial logistic regression was applied to evaluate associations between vascular risk factors and stroke subtypes (adjusted for age, sex, and country). Results: 16 centers participated including 3971 patients, 65.5 % were male. Hypertension (HTN) was the most common risk factor among all stroke subtypes (38%). Diabetes mellitus (DM) and HTN, were the most frequent risk factors for ischemic stroke (IS) and Intracerebral hemorrhage (ICH)). Smoking and HTN were common in subarachnoid hemorrhage (SAH). All patients had either Cerebral Computed topography (CT) angiogram or Carotid Doppler ,32.6% of 67.4% showed positive results. A total of 2441 (61.9%) patients had Transthoracic Echocardiogram (TTE) and /or Transesophageal Echocardiogram (TEE). 11.2% of the patients showed abnormalities. The antiphospholipid screening tests were done in 31.4 % of the patients and were positive only in 3.5 %. IS was the most common stroke subtype 63.6%, followed by (ICH)19.2%. Undetermined etiology (UDE) was the most common underlying etiology of IS in 22.2%. Intravenous thrombolysis therapy (IVT) was given in 8.5% of patients. Mechanical thrombectomy (MT) was performed in 3.7%. Anticoagulation therapy was offered in 20% of patients. Endovascular treatment(EVT) was performed in 5.2% of patients. Surgical intervention including clipping or hemicortectomy or hematoma evacuation was done in 5.6% of patients. Conclusion: This study offers the first regionally coordinated effort to examine the risk factors, and etiologies of stroke in young adults across the (MENA) region. The data clearly reflects not only the high burden of disease but also striking variability in patient profiles and healthcare responses between countries. Emerging non-traditional risk factors, and persistent diagnostic limitations, point to the complexity of tackling stroke in the young. Yet, in this complexity lies opportunity.