High altitude exposure and ischemic stroke: A literature review
Abstract
Despite our understanding of stroke, the risk factors involved and its treatment and prevention, stroke remains the second leading cause of death among humans worldwide. Several risk factors have been associated with higher incidences of stroke, such as hypertension or diabetes, while non-traditional risk factors such as vitamin D deficiency or cardiac valvular thickness have recently been identified. The potential role of hypoxia or high altitude exposure as a risk factor has not been clearly established. This review includes the relationship between acute and chronic high altitude exposure and the possible development of ischemic stroke in high altitude populations. Several risk factors are identified in high altitude dwellers such as polycythemia, increased platelet adhesiveness and greater risk to develop vascular thrombosis. Other conditions such as dehydration, extreme cold and immobilization might lead to increased risk of ischemic stroke in newcomers. Taking into account the limited number of studies, it is argued that high altitude and chronic hypoxia may be risk factors for the development of ischemic stroke. The altitude associated with higher prevalence of ischemic stroke is not clear, but it appears that there is increased risk above 3000m.
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References
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2. Jaillard AS, Hommel M, Mazetti P. Prevalence of stroke at high altitude (3380m) in Cuzco, a town of Peru. A population-based study. Stroke 1995; 26: 562 – 68.
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5. Norton EF. The fight for Everest 1924. New York; 1925: 90 – 119.
6. Cucinell SA, Pitts CM. Thrombosis at mountain altitudes. Aviat Space Environ Med 1987; 58: 1109 – 11.
7. Murdoch DR. Lateral rectus palsy at high altitude. Journal of Wilderness Medicine 1994; 5: 179 – 81.
8. Grotta JC. Cerebral venous thrombosis - a new diagnosis in travel medicine. J Travel Med 1996; 3: 137.
9. Shipton E. Upon that mountain. London: Hodder and Stoughton; 1943: 129 – 30.
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11. Song SY, Asaji T, Tanizaki Y, Fujimaki T, Matsutani M, Okeda R. Cerebral thrombosis at altitude: Its pathogenesis and the problems of prevention and treatment. Aviat Space Environ Med 1986; 57: 71 – 76.
12. Wohns RN. Transient ischemic attacks at high altitude. Crit Care Med 1986; 14: 517 – 18.
13. Sharma A, Sharma PD, Malhotra HS, Kaul J, Pal LS, Das Gupta DJ. Hemiplegia as a manifestation of acute mountain sickness. J Assoc Physicians India 1990; 38:
662 – 63.
14. Basnyat B. Seizure and hemiparesis at high-altitude outside the setting of acute mountain sickness. Wilderness Environ Med 1997; 8: 221 – 22.
15. Dietz TE, McKiel VH. Transient high altitude expressive aphasia. High Alt Med Biol 2000; 1: 207 – 11.
16. Bandyopadhyay S, Singh R, Gupta V, Gupta A. Anterior ischaemic optic neuropathy at high altitude. Indian J. Ophthalmol 2002; 50: 324 – 25.
17. Saposnik G, Del Brutto OH. Stroke in South America: A systematic review of incidence, prevalence, and stroke subtypes. Stroke 2003; 34: 2103 – 07.
18. Heckmann JG, Kolominsky-Rabas PL, Heuschmann P, Erbguth FJ, Neundorfer B, Galeote J. Low incidence of stroke in the chiquitanos tribe in the bolivian lowlands. Stroke 2000; 31: 2266 – 70.
19. Niaz A, Nayyar S. Cerebrovascular stroke at high altitude. J Coll Physicians Surg Pak 2003; 13: 446 – 48.
20. Anand AC, Jha SK, Saha A, Sharma V, Adya CM. Thrombosis as a complication of extended stay at high altitude. Natl Med J India 2001; 14: 197 – 201.
21. Cruz ME, Schoenberg BS, Ruales J, Barberis P, Proano J, Bossano F, Sevilla F, Bolis CL. Pilot study to detect neurologic disease in Ecuador among a population with a high prevalence of endemic goiter. Neuroepidemiology 1985; 4: 108 – 16.
22. Mahajan SK, Kashyap R, Sood BR, Jaret P, Mokta J, Kaushik NK, Prashar BS. Stroke at moderate altitude. J. Assoc Physicians India 2004; 52: 699 – 702.
23. Wang X, Wu T, Chen Q, Wei C, Zhao G. [Relationship between hematocrit (hct) and cardiac systolic time intervals (sti) in residents at 4300 m altitude]. Space Med Eng (Beijing) 1998; 11: 365 – 67.
24. Winslow RM, Monge CC, Brown EG, Klein HG, Sarnquist F, Winslow NJ, McKneally SS. Effects of hemodilution on O2 transport in high-altitude polycythemia. J Appl Physiol 1985; 59: 1495 – 1502.
25. Kiyohara Y, Ueda K, Hasuo Y, Fujii I, Yanai T, Wada J, Kawano H, Shikata T, Omae T, Fujishima M. Hematocrit as a risk factor of cerebral infarction: Long-term prospective population survey in a japanese rural community. Stroke 1986; 17: 687 – 92.
26. Heath D, Reid Williams D. Transport and release of oxygen to the tissue. In: Heath D, Reid Williams D. High Altitude Medicine and Pathology. Oxford: Oxford University Press; 1995: 55 – 73.
27. Fujimaki T, Matsutani M, Asai A, Kohno T, Koike M. Cerebral venous thrombosis due to high-altitude polycythemia. Case report. J Neurosurg 1986; 64: 148 – 50.
28. Toff WD, Jones CI, Ford I, Pearse RJ, Watson HG, Watt SJ, Ross JA, Gradwell DP, Batchelor AJ, Abrams KR, Meijers JC, Goodall AH, Greaves M. Effect of hypobaric
hypoxia, simulating conditions during long-haul air travel, on coagulation, fibrinolysis, platelet function, and endothelial activation. JAMA 2006; 295: 2251 – 61.
29. Hodkinson PD, Hunt BJ, Parmar K, Ernsting J. Is mild normobaric hypoxia a risk factor for venous thromboembolism? J Thromb Haemost 2003; 1: 2131 – 33.
30. Schobersberger W, Hoffmann G, Gunga HC. [Interaction of hypoxia and haemostasis - hypoxia as a prothrombotic factor at high altitude?]. Wien Med Wochenschr 2005; 155: 157 – 62.
31. Tewari SC, Jayaswal R, Kasthuri AS, Nath CS, Ohri VC. Excessive polycythaemia of high altitude. Pulmonary function studies including carbon monoxide diffusion
capacity. J Assoc Physicians India 1991; 39: 453 – 55.
32. Kryger M, McCullough R, Doekel R, Collins D, Weil JV, Grover RF. Excessive polycythemia of high altitude: Role of ventilatory drive and lung disease. Am Rev Respir Dis 1978; 118: 659 – 66.
33. Berglund B. High-altitude training. Aspects of haematological adaptation. Sports Med 1992; 14: 289 – 303.
34. Blomback M, Kronlund P, Aberg B, Fatah K, Hansson LO, Egberg N, Moor E, Carlsson K. Pathologic fibrin formation and cold-induced clotting of membrane oxygenators during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1995; 9: 34 – 43.
35. Ikeda T, Yanaga K, Lebeau G, Higashi H, Kakizoe S, Starzl TE. Hemodynamic and biochemical changes during normothermic and hypothermic sanguinous perfusion of the porcine hepatic graft. Transplantation 1990; 50: 564 – 67.
36. Saito S, Tanaka SK. A case of cerebral sinus thrombosis developed during a high-altitude expedition to Gasherbrum I. Wilderness Environ Med 2003; 14: 226 – 30.
37. Baumgartner RW, Siegel AM, Hackett PH. Going high with preexisting neurological conditions. High Alt Med Biol 2007; 8: 108 – 16.
38. Dickinson J, Heath D, Gosney J, Williams D. Altitude-related deaths in seven trekkers in the Himalayas. Thorax 1983; 38: 646 – 56.
39. Kotwal J, Apte CV, Kotwal A, Mukherjee B, Jayaram J. High altitude: A hypercoagulable state: Results of a prospective cohort study. Thromb Res 2007; 120: 391–97.
patients living at high vs. low altitudes in yemen. Med Gen Med 2006; 8: 28.
2. Jaillard AS, Hommel M, Mazetti P. Prevalence of stroke at high altitude (3380m) in Cuzco, a town of Peru. A population-based study. Stroke 1995; 26: 562 – 68.
3. Jha SK, Anand AC, Sharma V, Kumar N, Adya CM. Stroke at high altitude: Indian experience. High Alt Med Biol 2002; 3: 21 – 27.
4. Roverovsky V. The central asian expedition of capt. Roberovsky and lt. Kkozloff. Geogr J 1896; 8: 161.
5. Norton EF. The fight for Everest 1924. New York; 1925: 90 – 119.
6. Cucinell SA, Pitts CM. Thrombosis at mountain altitudes. Aviat Space Environ Med 1987; 58: 1109 – 11.
7. Murdoch DR. Lateral rectus palsy at high altitude. Journal of Wilderness Medicine 1994; 5: 179 – 81.
8. Grotta JC. Cerebral venous thrombosis - a new diagnosis in travel medicine. J Travel Med 1996; 3: 137.
9. Shipton E. Upon that mountain. London: Hodder and Stoughton; 1943: 129 – 30.
10. Clarke CRA. Cerebral infarction at extreme altitude. In: Hypoxia, Exercise and Altitude. Sutton JR, Houston CS, Jones NL; eds. New York: Liss; 1983: 453 – 54.
11. Song SY, Asaji T, Tanizaki Y, Fujimaki T, Matsutani M, Okeda R. Cerebral thrombosis at altitude: Its pathogenesis and the problems of prevention and treatment. Aviat Space Environ Med 1986; 57: 71 – 76.
12. Wohns RN. Transient ischemic attacks at high altitude. Crit Care Med 1986; 14: 517 – 18.
13. Sharma A, Sharma PD, Malhotra HS, Kaul J, Pal LS, Das Gupta DJ. Hemiplegia as a manifestation of acute mountain sickness. J Assoc Physicians India 1990; 38:
662 – 63.
14. Basnyat B. Seizure and hemiparesis at high-altitude outside the setting of acute mountain sickness. Wilderness Environ Med 1997; 8: 221 – 22.
15. Dietz TE, McKiel VH. Transient high altitude expressive aphasia. High Alt Med Biol 2000; 1: 207 – 11.
16. Bandyopadhyay S, Singh R, Gupta V, Gupta A. Anterior ischaemic optic neuropathy at high altitude. Indian J. Ophthalmol 2002; 50: 324 – 25.
17. Saposnik G, Del Brutto OH. Stroke in South America: A systematic review of incidence, prevalence, and stroke subtypes. Stroke 2003; 34: 2103 – 07.
18. Heckmann JG, Kolominsky-Rabas PL, Heuschmann P, Erbguth FJ, Neundorfer B, Galeote J. Low incidence of stroke in the chiquitanos tribe in the bolivian lowlands. Stroke 2000; 31: 2266 – 70.
19. Niaz A, Nayyar S. Cerebrovascular stroke at high altitude. J Coll Physicians Surg Pak 2003; 13: 446 – 48.
20. Anand AC, Jha SK, Saha A, Sharma V, Adya CM. Thrombosis as a complication of extended stay at high altitude. Natl Med J India 2001; 14: 197 – 201.
21. Cruz ME, Schoenberg BS, Ruales J, Barberis P, Proano J, Bossano F, Sevilla F, Bolis CL. Pilot study to detect neurologic disease in Ecuador among a population with a high prevalence of endemic goiter. Neuroepidemiology 1985; 4: 108 – 16.
22. Mahajan SK, Kashyap R, Sood BR, Jaret P, Mokta J, Kaushik NK, Prashar BS. Stroke at moderate altitude. J. Assoc Physicians India 2004; 52: 699 – 702.
23. Wang X, Wu T, Chen Q, Wei C, Zhao G. [Relationship between hematocrit (hct) and cardiac systolic time intervals (sti) in residents at 4300 m altitude]. Space Med Eng (Beijing) 1998; 11: 365 – 67.
24. Winslow RM, Monge CC, Brown EG, Klein HG, Sarnquist F, Winslow NJ, McKneally SS. Effects of hemodilution on O2 transport in high-altitude polycythemia. J Appl Physiol 1985; 59: 1495 – 1502.
25. Kiyohara Y, Ueda K, Hasuo Y, Fujii I, Yanai T, Wada J, Kawano H, Shikata T, Omae T, Fujishima M. Hematocrit as a risk factor of cerebral infarction: Long-term prospective population survey in a japanese rural community. Stroke 1986; 17: 687 – 92.
26. Heath D, Reid Williams D. Transport and release of oxygen to the tissue. In: Heath D, Reid Williams D. High Altitude Medicine and Pathology. Oxford: Oxford University Press; 1995: 55 – 73.
27. Fujimaki T, Matsutani M, Asai A, Kohno T, Koike M. Cerebral venous thrombosis due to high-altitude polycythemia. Case report. J Neurosurg 1986; 64: 148 – 50.
28. Toff WD, Jones CI, Ford I, Pearse RJ, Watson HG, Watt SJ, Ross JA, Gradwell DP, Batchelor AJ, Abrams KR, Meijers JC, Goodall AH, Greaves M. Effect of hypobaric
hypoxia, simulating conditions during long-haul air travel, on coagulation, fibrinolysis, platelet function, and endothelial activation. JAMA 2006; 295: 2251 – 61.
29. Hodkinson PD, Hunt BJ, Parmar K, Ernsting J. Is mild normobaric hypoxia a risk factor for venous thromboembolism? J Thromb Haemost 2003; 1: 2131 – 33.
30. Schobersberger W, Hoffmann G, Gunga HC. [Interaction of hypoxia and haemostasis - hypoxia as a prothrombotic factor at high altitude?]. Wien Med Wochenschr 2005; 155: 157 – 62.
31. Tewari SC, Jayaswal R, Kasthuri AS, Nath CS, Ohri VC. Excessive polycythaemia of high altitude. Pulmonary function studies including carbon monoxide diffusion
capacity. J Assoc Physicians India 1991; 39: 453 – 55.
32. Kryger M, McCullough R, Doekel R, Collins D, Weil JV, Grover RF. Excessive polycythemia of high altitude: Role of ventilatory drive and lung disease. Am Rev Respir Dis 1978; 118: 659 – 66.
33. Berglund B. High-altitude training. Aspects of haematological adaptation. Sports Med 1992; 14: 289 – 303.
34. Blomback M, Kronlund P, Aberg B, Fatah K, Hansson LO, Egberg N, Moor E, Carlsson K. Pathologic fibrin formation and cold-induced clotting of membrane oxygenators during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1995; 9: 34 – 43.
35. Ikeda T, Yanaga K, Lebeau G, Higashi H, Kakizoe S, Starzl TE. Hemodynamic and biochemical changes during normothermic and hypothermic sanguinous perfusion of the porcine hepatic graft. Transplantation 1990; 50: 564 – 67.
36. Saito S, Tanaka SK. A case of cerebral sinus thrombosis developed during a high-altitude expedition to Gasherbrum I. Wilderness Environ Med 2003; 14: 226 – 30.
37. Baumgartner RW, Siegel AM, Hackett PH. Going high with preexisting neurological conditions. High Alt Med Biol 2007; 8: 108 – 16.
38. Dickinson J, Heath D, Gosney J, Williams D. Altitude-related deaths in seven trekkers in the Himalayas. Thorax 1983; 38: 646 – 56.
39. Kotwal J, Apte CV, Kotwal A, Mukherjee B, Jayaram J. High altitude: A hypercoagulable state: Results of a prospective cohort study. Thromb Res 2007; 120: 391–97.
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Published
2017-05-29
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Ortíz Prado E, Dunn JF. High altitude exposure and ischemic stroke: A literature review. Rev Fac Cien Med (Quito) [Internet]. 2017 May 29 [cited 2024 Nov. 22];36(1):64-71. Available from: https://revistadigital.uce.edu.ec/index.php/CIENCIAS_MEDICAS/article/view/1082
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