Stroke is undoubtedly one of the leading global health challenges, causing significant morbidity and mortality around the world. According to recent statistics, stroke was responsible for about 6.17 million deaths in 2017, accounting for 11% of all global deaths. In India, it contributes to 7.3% of total deaths, which signifies its critical role in public health [1]. In addition to mortality, stroke is one of the leading causes of long-term disability. In India, for example, stroke contributes to 3.5% DALYs. This increasingly evolving health crisis calls for attention, especially considering that incidence and prevalence of stroke have increased in low- and middle-income countries. It is here, in these regions, where two-thirds of global stroke burden are borne [2].

Acute ischemic stroke (AIS) is an important subtype of stroke characterized by the interruption of the blood supply to brain tissue, leading to a cascade of ischemic injury that continues with free radical production, oxidative stress, and endothelial damage. The reason for the wide variability in the clinical presentations of AIS lies in the complicated anatomy and vascular structure of the brain [3]. Timely diagnosis and treatment can make a great difference in the outcome. There is evidence to demonstrate that two interventions, intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rtPA) and mechanical thrombectomy (MT), have provided efficacy in reducing long-term disability in appropriately selected patients. These therapies, however, are very time-sensitive and require rapid diagnosis and intervention [4].

Neuroimaging is, in essence, a central element in diagnosing and managing stroke cases. CT remains the most widely used first imaging tool due to its availability, low cost, and ability to identify ischemic and hemorrhagic strokes. Scanning with CT shows very useful information about the localization and severity of the lesion, and advanced techniques like CT perfusion give useful supplementary information, primarily outlining the limits between ischemic penumbra and infarct core. Despite increasing availability of MRI, CT remains the bedrock of acute stroke care, and markedly its use is prevalent in resource-poor locations [5-6].

The carotid arteries are frequently involved in ischemic stroke; it is indeed one of the major suppliers of cerebral blood. Atherosclerotic changes within the carotid arteries such as plaque or stenosis and ulceration lead to either embolization or hypoperfusion, thereby causing ischemic events. Due to being non-invasive and having good sensitivity, Doppler ultrasonography through carotid Doppler will be indispensable for assessing carotid artery stenosis [7]. Carotid Doppler, while measuring blood flow velocities and characterizing plaque morphology, will identify high-risk lesions and thus guide the clinical decision-making process. This is specifically on account of the rising incidence of stroke in India and the sparse availability of advanced imaging modalities in many regions. Hence, a very important assessment of the relationship between clinical neurological dysfunction, CT findings, and carotid Doppler studies is warranted [9-10].

Thus, this study bridges this knowledge gap by investigating the prevalence of carotid artery stenosis and its association with risk factors such as hypertension, diabetes, hyperlipidemia, smoking, and age of patients who have acute ischemic stroke. It also intends to assess the utility of CT imaging in diagnosing stroke and correlating the nature, site, and severity of brain lesions with clinical presentations. Understanding the interplay between neurological dysfunction, imaging findings, and vascular pathology will not only enhance diagnostic accuracy but also inform strategies for risk stratification and management. Studies like this are very important as India sets a goal to reduce premature mortality from NCDs by 25% by 2025, thereby advancing stroke care and reducing its economic and social effects.

Study Population

Raipur Institute of Medical Sciences admitted 100 patients who gave a history of neurological deficits and thus were suspected of being subjected to cerebrovascular accidents (CVAs). The age considered was >40 years to <60 years. Data collection has been done over a period of two years based on the acquisitions made considering patients with acute onset of neurological symptoms during this time period.

Study Design

This study was conducted in a hospital-based cross-sectional survey. The nature of the study design allowed evaluating clinical and investigative parameters regarding cerebrovascular accidents within the focused population.

Methods of Data Collection

After proper explanation of the aim and methodology of the study, informed and written consent was taken from all the participants or their legal guardians. Detailed neurological symptoms and systemic findings were recorded through a medical history for each patient. A very meticulous general and neurological examination had been conducted which involved tests to evaluate the motor, sensory, autonomic, and higher mental functions. The neurological deficits were assessed through established clinical methods that included the MRC grading system to evaluate the motor power and the mini-mental scale to assess cognition. Systematic analysis of lobar functions along with frontal, parietal, temporal, and occipital lobe specific tests were carried out. When ataxia, vertigo, oculomotor palsies, and hemiplegia occurred, brain stem function was also assessed.

The clinical nature of the lesion was evaluated using symptomatology. In patients presenting with severe headache, vomiting, seizures, and altered sensorium; more so those with a past history of hypertension, hemorrhagic strokes were suspected. On the other hand, infarcts were suspected in cases of isolated motor hemiplegia, progressive signs, relative preservation of consciousness, and partial recovery. These clinical impressions were confirmed by neuroimaging and other diagnostic tests.

Inclusion and Exclusion Criteria

The study recruited all patients aged >40 to <60 years presenting with neurological deficits believed to be caused by suspected cerebrovascular accidents with symptoms less than a week. Patients excluded from the study were those with hemorrhagic stroke, stroke-like syndromes, systemic illnesses, metabolic emergencies, malignancies, infections such as tuberculosis, or poor general condition. All patients with a history of head injury and stroke more than one week were also excluded from the study.

Investigations Conducted

Extensive diagnostic analysis was conducted in all patients. Evaluation procedures included random sugar level estimation, blood urea and creatinine level, serum electrolyte, and lipid profile studies along with urine analysis. Electrocardiography was done in all patients to identify rhythm abnormalities, ischemic changes, or chamber hypertrophy. Echocardiography was conducted in a subset of patients with significant findings in ECG to identify valvular function, left ventricular ejection fraction, and regional wall motion abnormalities.

Neuroimaging was the key study for demonstrating cerebrovascular events. CT of the brain was performed in 24–48 hours post-admission. This was also used to identify the type of CVA as hemorrhage or infarct. In cases where the first scan was negative or there was a sudden change in status, repeat scan was performed. Imaging was useful to identify lesions and the extent of damage; conversely, it can be ruled out by other conditions like neoplasms or abscesses. Carotid Doppler ultrasonography was performed in 75 patients to assess the integrity of the carotid artery. This prospective study measured the velocity of systole, diastole, intima-media thickness, and the level of arterial stenosis.

Statistical Analysis

The statistical analysis was performed using SPSS version 13.0 and Microsoft Excel 2007 software. A retrospective analysis of the patient demographics, like age, the history of diabetes mellitus, hypertension, smoking, alcohol abuse, and hyperlipidemia, in relation to carotid artery stenosis was done. Statistical association was studied using a Chi-square test at a significance level of p < 0.05 p<0.05. The findings were systematically documented and then made and interpreted to pick out patterns and associations pertinent to the research question.

The study included 100 patients aged 40–60 years, admitted with ischemic strokes at the Raipur Institute of Medical Sciences from 2022 to 2024. Of these, 61 (61%) were male, and 39 (39%) were female, with a male-to-female ratio of approximately 1.56:1. The demographic distribution highlights a slightly higher prevalence of ischemic strokes in males compared to females.

CT Scan Findings

CT imaging of the brain revealed distinct patterns in patients with ischemic strokes. Among the 100 scans, 6 patients (6%) presented with massive infarcts accompanied by a midline shift, while 69 (69%) had infarcts without midline shifts. Lacunar infarcts were observed in 9 patients (9%), and 16 patients (16%) had normal CT scans. The findings underscore that the majority of lesions were subcortical, with cortical involvement being less frequent.

Table 1: CT Scan Findings in Stroke Patients

Figure 1: Distribution of CT Findings in Stroke Patients.

Clinical Features and Lesion Distribution

Clinical features were correlated with CT findings to assess lesion distribution and severity. Among the 100 patients, 27 (27%) presented with pure motor hemiplegia, primarily associated with infarctions in the capsulo-ganglionic area. These lesions were non-cortical, with no cerebellar involvement. Motor hemiplegia accompanied by cortical deficits, such as aphasia and visual neglect, was noted in 26 (26%) patients, with 17 confirmed capsulo-ganglionic lesions. Additionally, 12 (12%) patients exhibited brainstem deficits, most of whom had normal CT findings. Cerebellar and frontal lobe features were noted in a smaller subset, with 4 patients showing frontal lobe dysfunctions.

Table 2: Clinical Features and CT Correlation in Stroke Patients

Prevalence and Severity of Carotid Stenosis

Carotid Doppler studies were performed on 75 patients to evaluate the prevalence and severity of carotid stenosis. Out of these, 44 patients (58.7%) were found to have carotid stenosis, while 31 (41.3%) showed no evidence of stenosis. Mild stenosis was observed in 20 patients (27%), moderate stenosis in 16 patients (21%), and severe stenosis in 8 patients (11%). This data indicates that mild-to-moderate stenosis is more prevalent in ischemic stroke patients compared to severe stenosis.

Table 3: Prevalence and Severity of Carotid Stenosis

Figure 2: Severity of Carotid Stenosis in Stroke Patients.

Risk Factor Analysis

A detailed analysis of patient risk factors revealed significant associations between carotid stenosis and comorbid conditions such as diabetes mellitus, hypertension, smoking, and hypercholesterolemia. Diabetic patients showed a higher prevalence of carotid stenosis (63.6%) compared to non-diabetic patients (29%). Similarly, hypertensive patients exhibited a significantly higher prevalence of carotid stenosis (68.2%) compared to normotensive individuals (38.7%). Smoking was identified as a strong risk factor, with 59.1% of smokers showing carotid stenosis compared to 25.8% of non-smokers. Patients with elevated cholesterol levels had a higher prevalence of carotid stenosis (72.7%) than those with normal cholesterol levels (41.9%).

Table 4: Risk Factors Associated with Carotid Stenosis

Age and Sex Distribution

The prevalence of carotid stenosis increased significantly with age, indicating an age-related progression in the condition. A higher prevalence was noted in male patients compared to females. These findings highlight the need for targeted screening in older adults, particularly males with comorbid risk factors.

Figure 3: Age and Sex Distribution of Carotid Stenosis.

This present study has attempted to elucidate the clinical correlation, diagnostic accuracy and underlying risk factors of stroke patients as assessed through clinical evaluation, CT scans, and carotid Doppler studies. The basic backbone of this research has been carried out through basic detailed history-taking, thorough examination, and diagnostic imaging with all 100 patients undergoing CT scanning and a subset of 75 patients undergoing carotid Doppler studies. In significant variations between clinical presentations and imaging results, this study underlines how difficult it is to make the diagnosis and management of stroke [11].

This study has made an important observation in the fact that clinical and CT scans had different diagnoses. Out of 100 patients clinically diagnosed with stroke, 84 showed lesions on CT, and 16 showed normal brain imaging. Ironically, out of these 16 patients, 8 patients were clinical features of posterior circulation strokes involving the brain stem [12].  This indicates that CT imaging is not very sensitive for the detection of small lacunar infarcts, particularly in the posterior fossa. Such cases may necessitate the use of MRI to enhance sensitivity. In addition, some patients with motor hemiplegia and cortical deficits presented with normal CT imaging findings. This once again raises questions about the correlation between clinical presentations and imaging [13].

The present study also provided insight into the nature and site of lesions diagnosed on CT scans. Among the patients clinically suspected to have hemorrhagic strokes, 6 were confirmed to have massive infarcts with midline shifts on imaging. That finding depicts the invaluable role of CT scans in differentiating between ischemic and hemorrhagic strokes, which determines the onset of appropriate therapies like antiplatelet agents. Localization of the lesion was also variable according to clinical presentation [14]. For instance, in pure motor hemiplegia, 27 out of 48 patients had lesions localized in the capsulo-ganglionic area as visualized with CT scans; this indicates a good correlation between the clinical syndrome and subcortical localization of the lesion. In other cases, the discrepancies in the localization of the lesions were because of cortical and subcortical interaction, as explained by the phenomenon of cortical-subcortical diaschisis [15].

The high prevalence of capsulo-ganglionic lesions in patients who presented with motor hemiplegia and cortical deficits was confirmed in 19 of the 26 cases. This further goes to support the theory of subcortical diaschisis whereby damage to the cortex brings on a functional deficit in the connected regions of the subcortex. The review alleged that it is even difficult to clinically diagnose lesions of the brainstem [16]. Most of the patients who suffered from strokes on the posterior circulation presented with normal CT findings. This limitation, most likely due to the presence of bony artifacts as well as an intrinsic lower sensitivity of CT for posterior fossa lesions, highlights the need for advanced imaging modalities, such as MRI, for full assessment. Cerebellar strokes, although less common, were well correlated with clinical findings in the two patients whose cerebellum was affected [17].

Another dimension of complexity in the relationship between clinical severity and lesion size or extent as seen on CT scans is illustrated here. Some patients with dense motor hemiplegia and marked neurological impairment had only the smallest of lesions, often minimal even in "vulnerable" regions, such as within the internal capsule. This underlines that the clinical severity of stroke doesn't often directly correlate with the size of the lesions seen on imaging, reflecting the intricate interplay between structural and functional impairments of the brain [18].

The carotid Doppler study revealed key information on the number and risk factors of carotid stenosis in ischemic stroke patients. There was a prevalence of carotid stenosis in about 58% of the patients, with significant stenosis in 16%. Carotid stenosis was more common in men at 69%, as compared to women at 37%, and increased as age advanced with up to 65% in people above the age of 60 years and to 33% in patients less than 40 years. Such findings are consistent with previous investigations, thereby emphasizing that age and sex are significant risk factors for carotid stenosis and resultant stroke [19].

Among the factors tested in this research, diabetes mellitus, hypertension, smoking, and hyperlipidemia were found to have a very significant association with carotid stenosis. The diabetic patients showed a remarkably higher prevalence of carotid artery stenosis compared to the non-diabetic control subjects and have been found to support earlier findings on the acceleration of atherosclerosis due to diabetes. Hypertension has also been well established as an independent risk factor for endothelial dysfunction and arterial stiffness. In addition, smoking was the other major risk factor that could possibly be modified. Indeed, smokers had a considerably higher prevalence of carotid stenosis compared to non-smokers. Apart from this, hyperlipidemia further increased the load of risk factors, and the patients with abnormal cholesterol levels had more of a tendency to have carotid stenosis [20].

This study is therefore important in underlining the critical role of imaging in complementing clinical evaluations toward accurate stroke diagnosis and in teasing out this association with modifiable risk factors for reducing the burden of ischemic stroke. Although a CT scan remains a key component of the initial evaluation, extensive use of advanced imaging along with detailed vascular assessments, including carotid Doppler, forms the backbone of comprehensive management for stroke. These results strengthen the rationale for targeted interventions in a manner that addresses underlying comorbidities in such high-risk populations, potentially improving outcome and reducing recurrence of stroke.

In summary, this study indicates that in the diagnosis and management of acute ischemic stroke, CT brain imaging is critical, and alongside a thorough clinical examination, its utility cannot be overstated. Although clinical localization of stroke relates very well with CT findings in most cases, discrepancies do prevail in some cases about the size, extent, and nature of the lesions. This study thus highlights the capsule-ganglionic region as the most commonly involved site, which corresponded with the area of involvement within the MCA territory. Carotid stenosis is another crucial cause of ischemic stroke, and its occurrence is very closely related to advancing age, male gender, smoking, diabetes, hypertension, and hyperlipidemia. The results of this study underscore the need for the use of non-invasive tools for screening such as Doppler sonography for early stroke detection and prevention in higher-risk populations. Despite such limitations, this study reconfirms the need to integrate clinical assessments with imaging modalities for proper diagnosis and efficient stroke management.

CONFLICT OF INTEREST: There is no conflict of interest/ sponsorship.

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