ORIGINAL ARTICLE Comment [i-[1]: MAJOR REVISION IS

RECOMMENDED.
FREQUENCY OF DEEP VEIN THROMBOSIS AMONG PATIENTS WITH ACUTE
STROKE Comment [i-[2]: Many studies published in last
8 issues of this journal on frequency & distribution
may be of help to you. Links for 2 are given.
1.http://www.gjms.com.pk/ojs24/index.php/gjms/
article/view/2076/1267
ABSTRACT 2.http://www.gjms.com.pk/ojs24/index.php/gjms/
article/view/2106/1316
Background: Stroke is a devastating public health problem worldwide, considered as the third
leading cause of death in developed countries, and the leading cause of disability among adults.
Deep vein thrombosis (DVT), including pulmonary embolism (PE) as a sequel, is a serious
complication of various medical conditions including stroke. The purpose of this study was to
determine frequency of deep vein thrombosis among patients presented with stroke.
Materials and methods: This study was descriptive (cross-sectional) study, conducted in the
Department of Neurology, Lady Reading Hospital, Peshawar over 6 months. In the study a total
of 196 patients were observed. Base line investigations were done and ultrasound was carried out
to diagnose deep vein thrombosis. All the laboratory investigations and ultrasound were done by
single experience pathologist and sonologist having minimum of five years of experience
respectively. Observation and examination was done by neurologist who was not aware about the
study and data was recorded in a predesigned proforma. To control confounders and bias in the
study results, strict exclusion criteria had been followed.
Results: In this study mean age was 63 years with standard deviation ± 28.34. Forty two percent
patients were male and 58% patients were female. More over 8% patients had deep vein
thrombosis. Comment [i-[3]: The frequency of DVT was 16
(8%).
Conclusion: Our study concludes that the frequency of deep vein thrombosis was 8% among
patients presented with stroke.
KEY WORDS: Pulmonary embolism, deep vein thrombosis, acute stroke, thromboembolism.

INTRODUCTION Comment [i-[4]: First give some background i.e.

prevalence of stroke and prevalence of DVT in
Stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in stroke form global, regional, national & lastly local
literature/ studies
a corresponding loss of neurologic function.1 Also previously called cerebrovascular accident
(CVA) or stroke syndrome, stroke is a nonspecific term encompassing a heterogeneous group of
pathophysiologic causes, including thrombosis, embolism, and hemorrhage.2 Venous
thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism
(PE), is a potentially life-threatening complication in surgical and nonsurgical patients. Deep
venous thrombosis has been reported to develop in 10% to 75% of immobilized post stroke
patients.3 It remains common cause of morbidity and mortality in bedridden or hospitalized
patients, as well as generally healthy individuals. The exact incidence of DVT is unknown
because most studies are limited by the inherent inaccuracy of clinical diagnosis. Stroke has
potentially enormous emotional and socioeconomic results for patients, their families, and health
services.2, 4
Stroke is a devastating public health problem worldwide, considered as the third leading cause of
death in developed countries, and the leading cause of long-term disability.2,4 Stroke is currently
the second leading cause of death in the Western world, ranking after heart disease and before
cancer,39 and causes 10% of deaths worldwide.5 Medical complications after ischemic stroke
contribute substantially to poor stroke outcomes.6 Although most DVT is occult and resolves
spontaneously without complication, death from DVT-associated massive pulmonary embolism
(PE) causes as many as 300,000 deaths annually in the United States.2 Existing data that
probably underestimate the true incidence of DVT suggest that about 80 cases per 100,000
population occur annually. Approximately 1 person in 20 develops a DVT in the course of his or
her lifetime. About 600,000 hospitalizations per year occur for DVT in the United States.7
Deep vein thrombosis (DVT), including pulmonary embolism (PE) as a sequel, is a serious
complication of various medical conditions including stroke. It is considered to develop mostly
within 2 weeks post-stroke. Frequency of DVT in acute stroke patients admitted to medical ICU
was 8.93%.2 There is large variation in incidence among different clinical studies, with clinically
confirmed DVT and PE in patients with ischemic stroke without thromboprophylaxis.
Prophylaxis with low-molecular-weight heparins (LMWHs) and unfractionated heparin (UFH)
reduces the risk of DVT in patients after acute ischemic stroke (AIS). Treatment options for
DVT include Anticoagulation with Heparins, Unfractionated heparin (UFH), warfarin, factor Xa
inhibitors like Fondaparinux and Rivaroxaban. Endovascular therapy and surgical interventions
can be performed to reduce the severity and duration of lower extremity symptoms. Physical
measures like elastic compression stockings and ambulation also helps. 8
The role of deep vein thrombosis as a risk factor for vascular disease causing stroke is
controversial and there is little information about it. The aim of this study was to establish the
incidence of early stroke-related deep vein thrombosis and identify as risk factors for the Comment [i-[5]: To determine the frequency/
prevalence ----.
development of the stroke. Once we found the higher proportion as that of literature than the Comment [i-[6]: Where these factors are
identified in methods, results & discussion?
guideline may be recommended for such patients by giving additional attention and proper deep
vein thrombosis prophylaxis in order to avoid thrombotic complications of life-threatening
potential. Moreover the results of the study will help to conduct the randomized control trial to
prove the deep vein thrombosis as risk factor for stroke patients.
MATERIALS AND METHODS
The study was a descriptive cross-sectional study conducted in Department of Neurology, Lady
Reading Hospital, Peshawar for 6 months from to . Patients were selected by Consecutive (non- Comment [i-[7]: D-M-Y to D-M-Y.

probability) sampling. Sample size was 196 patients using 8.93% proportion of deep vein Comment [i-[8]: Research is a problem solving
activity for a specified/ defined population. Please
1 tell the count of the population from which this
thrombosis , 95% confidence level and 4% margin of error under WHO software for sample size
sample was drawn & to which the results from
sample will be inferred? As any formula will require
determination. All patients with stroke, of either gender, between the age of 30 to 70 years population size.

presented after 12 hours of onset of symptoms were included in the study. The patients with Comment [i-[9]: Add reference.

history of previous stroke, peripheral artery disease, blood dyscrasias, active infections,
neoplasia, gout, renal or liver disease, thyroid dysfunction, chronic obstructive pulmonary
disease and chronic inflammatory bowel disease were excluded from the study because they act Comment [i-[10]: How these were evaluated?
What protocol was adapted to diagnose such patients
as confounders and if introduced will develop bias in the study results. from population & then to exclude them?

DATA COLLECTION PROCEDURE Comment [i-[11]: The unit of research is

Variable. Researcher should talk in terms/
The study was conducted after approval from hospital ethical and research committee. terminologies of research. What were demographic
and what were your research variables? What were
their attributes? What were their data type?
Demographic data, including age, sex and complete history was recorded based on medical
records of the patients. Smoking history and its duration was asked from the patients. Baseline
blood pressure of the patients was recorded (in supine position). Informed written consent was
obtained from all patients after diagnosing stroke. Base line investigation was done and
ultrasound was carried out to diagnosed deep vein thrombosis. All the laboratory investigations
and ultrasound were done by single experience pathologist and sonologist having minimum of
five years of experience respectively. Observation and examination was done by neurologist who
was not be aware about the study and data was recorded in a predesigned Proforma. To control
confounders and bias in the study results, strict exclusion criteria had followed.
Comment [i-[12]: As our objective is to
DATA ANALYSIS: determine the prevalence in population. You have
drawn a sample & observed it & collected data from
Data was entered using SPSS version 10.0. Categorical variables like gender and deep vein it. Now give the data analysis plan for your sample
for all variables as per your objective, then infer
thrombosis was described as frequencies and percentages. Quantitative variables like age, sample results on to the population from where you
have drawn your sample as confidence interval (CI)
at certain confidence level (CL). Then tell us if your
Weight, height and BMI were described as Mean ± Standard deviation. Deep vein thrombosis sample observed data match to population expected
data through hypothesis testing.
was stratified among age, gender and BMI to see the effect modifications. Post stratification chi
square test was applied by keeping p-value<0.05 as significant. All results were presented as
tables and graphs.
RESULTS
In this study age distribution among 196 patients was analyzed as 21(11%) patients were in age Comment [i-[13]: Age groups.
Comment [i-[14]: It is not distribution. It is
range 31-40 years, 41(21%) patients were in age range 41-50 years, 65(33%) patients were in sample description. A sample of 196 subjects with
stroke included 82 (42%) men and 114 (58%)
age range 51-60 years, 69(35%) patients were in age range 61-70 years, Mean age was 63 years women, 21 (11%) in age group 31-40 years, 41
(21%) in 41-50 years, 65 (33%) in 51-60 years and
with standard deviation ± 28.34. (Table 1).Gender distribution among 196 patients was analyzed 69 (35%) in age group 61-70 years.

as 82(42%) patients were male and 114(58%) patients were female. (Table 1) BMI among 196
patients was analyzed as 74(38%) patients had BMI ≤25 while 122(62%) patients had BMI >25.
Mean BMI was 25 with SD ±3.21. Mean height was 6.5 ft with SD ±2.86 and Mean weight was
72 Kg with SD ±7.341. (Table 1)
TABLE NO. 1: Demographic characteristics of patients with post stroke DVT (n=196).
Demographic characteristics Frequency Percentage
Age 30-40 years 21 11%
41-50 years 41 21%
51-60 years 65 33%
61-70 years 69 35%
Gender Male 82 42%
Female 114 58%
BMI ≤ 25 74 38%
>25 122 62%

Deep vein thrombosis among 196 patients was analyzed as 16 (8%) patients had deep vein
thrombosis while 180 (92%) patients didn’t have deep vein thrombosis (Table 2).
TABLE 2: Frequency of deep venous thrombosis in patients with acute stroke (n=196)

Deep vein thrombosis Frequency Percentage Comment [i-[15]: Add two columns for CI at
95% CL.

Yes 16 8%
No 180 92%
Total 196 100%
Stratification of deep vein thrombosis with age, gender and BMI shows the p value of more than Comment [i-[16]: This study is an
epidemiological enquiry/ investigation/ research,
0.05, which is insignificant (Table 3). which includes frequency of DVT in stroke & its
distribution by sex, age groups and BMI. Here
stratification has no place. Here you have to
TABLE 3: Stratification of deep venous thrombosis with respect to age, gender and BMI distribute the positive cases of DVT by sex, age
groups and BMI. Out of 16 cases of DVT in stroke,
(n=196) seven (43.75%) were men and nine (56.25%) were
women. Add CI to both. Add for age groups and
Demographic characteristics Deep venous thrombosis BMI. The two studies cited above & many more
studies in last 8 issues of this journal will help you a
lot. Age groups are too many. Only two are
Yes No Total sufficient to give some meaningful interpretation,
say 31-60 years and more than 60 years .
Age 30-40 years 2 19 21
(P value 0.987) 41-50 years 3 38 41
51-60 years 5 60 65
61-70 years 6 63 69
Total 16 180 196
Gender Male 7 75 82
(P value 0.871) Female 9 105 114
Total 16 180 196
BMI ≤ 25 6 68 74
(P value 0.982) >25 10 112 122
Total 16 180 196

DISCUSSION Comment [i-[17]: Re-write discussion,

conclusion & add references after corrections are
Stroke is a devastating public health problem worldwide, considered as the third leading cause of made in introduction, methods and results.

death in developed countries, and the leading cause of disability among adults. Stroke is also a
major cause of long-term disability and has potentially enormous emotional and socioeconomic
results for patients, their families, and health services.2, 4
Our study shows that mean age was 63 years with standard deviation ± 28.34. Forty two percent
patients were male and 58% patients were female. More over 8% patients had deep vein
thrombosis.
Abdel-Aziz A had reported that frequency of deep venous thrombosis was found to be 10% to
75% in immobilized post stroke patients. Such a wide range of results may be attributed to
methodological differences between particular studies.9
Bembenek JP had reported that deep vein thrombosis (DVT), including pulmonary embolism
(PE) as a sequel, is a serious complication of various medical conditions including stroke. It is
considered to develop mostly within 2 weeks post-stroke. Frequency of DVT in acute stroke
patients admitted to medical ICU was 8.93%.10
Similar results were observed in another study conducted by Bembenek JP et al11 in which a total
of 323 consecutive patients with acute stroke were enrolled. We performed ultrasound imaging
within 7 days after stroke. Deep venous thrombosis was found in 8.7% of patients, only in those
with ischemic stroke. Patients with DVT were more frequently female (71.4% vs 49.5%), had
prestroke Modified Rankin scale (mRS) 3 to 5 (42.9% vs 15.3%), elevated C-reactive protein
(CRP) serum level (65.4% vs 32.5%), and a trend toward elevated serum fibrinogen level (85.7%
vs 70.1%; P = .08). In a multivariate analysis, elevated CRP (odds ratio [OR] 3.15) and prestroke
disability (OR 2.89) were independent risk factors for DVT. Deep venous thrombosis occurs in
<10% of patients with acute stroke and does not significantly affect the 3-month outcome.
Prestroke dependency and elevated CRP level at baseline are independent risk factors for DVT.
Similar results were observed in another study conducted by Kelly J et al 12 in which mean age
was 60 years with standard deviation ± 28.34. Forty percent patients were male and 60% patients
were female. More over the frequency of deep vein thrombosis in acute stroke was 9%.
CONCLUSION
Our study concludes that the frequency of deep vein thrombosis was 8% among patients
presented with stroke.
REFERENCES Comment [i-[18]: Please add on references.
Almost all references require major &/ or minor
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medical intensive care unit zagazig university hospitals, Egypt. ZUMJ 2014
Jan;20;(1):88-96.
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