European Journal of Cardiovascular Medicine

Ischemic stroke continues to be a major contributor to long-term disability and global mortality. The event results from an abrupt reduction in cerebral blood flow, culminating in neuronal damage[1]. While well-recognized vascular risk factors such as hypertension, diabetes, dyslipidemia, smoking, and older age contribute substantially to stroke burden, metabolic determinants have received increasing attention for their role in vascular integrity and thrombosis. Among these, homocysteine has emerged as an important biochemical marker and a potential modifiable risk factor for cerebrovascular disease[2].

Homocysteine is formed during methionine metabolism, and its clearance requires adequate Vitamin B12 and folate availability. Deficiencies in either of these micronutrients impair remethylation pathways, resulting in elevated circulating homocysteine[3]. Elevated homocysteine has been implicated in endothelial dysfunction, heightened oxidative stress, increased vascular smooth muscle proliferation, and a pro-thrombotic tendency, collectively fostering an environment conducive to ischemic injury. Several large cohort studies have demonstrated that low dietary intake or reduced plasma levels of folate and Vitamin B12 are associated with a higher risk of stroke, supporting the role of one-carbon metabolism in cerebrovascular health [1–3].

Regional studies have reinforced these observations, particularly in populations where nutritional insufficiency is prevalent. For example, work from the Middle East and South Asia has reported a notable association between hyperhomocysteinemia and ischemic stroke, with a significant proportion of patients exhibiting concurrent Vitamin B12 or folate deficiency [4]. Such findings underscore the relevance of dietary and metabolic evaluation in stroke prevention strategies, especially in regions where plant-based diets may limit natural Vitamin B12 intake.

Advancements in laboratory techniques have improved the precision of homocysteine and vitamin assays, facilitating their integration into clinical practice when appropriate [5]. Despite this, homocysteine and related micronutrient assessments are not routinely emphasized in stroke workups. Recognizing and correcting these biochemical abnormalities may provide an accessible and cost-effective opportunity to reduce recurrent stroke risk, complementing standard vascular risk management.

In the present study, we evaluated serum homocysteine, Vitamin B12, and folate levels in patients presenting with first-episode ischemic stroke. The aim was to determine the extent of metabolic imbalance in this population and explore the relationship between elevated homocysteine and coexisting micronutrient deficiencies. This assessment may help strengthen the understanding of nutritional-metabolic influences in stroke and encourage more comprehensive risk factor evaluation in clinical care.

This observational, cross-sectional study was carried out at the Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, in collaboration with Vishnu Dental College, Bhimavaram. The study period extended from June 2024 to August 2024. A total of 50 patients who presented with a first-episode ischemic stroke were enrolled.

Study Population and Inclusion Criteria:
Patients aged 18 years and above with a confirmed first ischemic stroke on clinical evaluation and neuroimaging (CT/MRI) were included. All participants were admitted within the acute phase of stroke onset.

Exclusion Criteria:
Patients with recurrent stroke, hemorrhagic stroke, chronic kidney disease, known malignancy, chronic liver disease, thyroid dysfunction, or those already on Vitamin B12 or folate supplementation were excluded to avoid confounding biochemical variation.

Data Collection:
Demographic details, clinical history, vascular risk factors (hypertension, diabetes, dyslipidemia, smoking, alcohol use), and relevant medical records were documented using a structured proforma.

Sample Collection and Laboratory Analysis:
Fasting venous blood samples were collected within 24 hours of admission.

Serum homocysteine levels were measured using an enzymatic immunoassay method.

• Serum Vitamin B12 and serum folate concentrations were estimated by chemiluminescence assay.
• Reference cut-off values applied in this study:
• Elevated homocysteine: >15 µmol/L
• Vitamin B12 deficiency: <200 pg/mL
• Low folate: <4 ng/mL

Statistical Analysis:
Data were entered in Microsoft Excel and analyzed using descriptive statistics. Continuous variables were expressed as mean ± standard deviation, and categorical variables were presented as frequencies and percentages. No inferential tests were applied, as the primary objective was descriptive assessment of biomarker patterns in the study cohort.

Ethical Considerations

The study was conducted after obtaining approval from the Institutional Ethics Committee of Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram. All participants were informed about the study purpose and procedures, and written informed consent was obtained prior to enrolment. Confidentiality of patient data was maintained, and no identifying information was disclosed at any stage. Laboratory investigations and clinical assessments were carried out as part of routine patient care, ensuring no additional risk or discomfort to participants.

A total of 50 patients with first-episode ischemic stroke were analyzed. The mean age of the study group was 58.4 ± 9.6 years, and males constituted a larger proportion (62%). The average BMI fell within the overweight range. The detailed demographic characteristics are presented in Table 1.

Table 1: Demographic Profile of Study Participants (n = 50)

Hypertension emerged as the most frequent associated clinical condition (56%), followed by Type 2 diabetes mellitus (42%). History of smoking was noted in 38% of the participants, while dyslipidemia and alcohol use were present in smaller proportions. These clinical risk factors are summarized in Table 2,Figure 1.

Table 2: Clinical Risk Factors

Figure 1.Clinical Risk Factors in study Participants

Biochemical assessment showed a noticeable rise in serum homocysteine levels among many patients. The mean homocysteine level was 19.8 ± 6.7 µmol/L, which exceeds the upper limit of the reference range. Vitamin B12 levels were on the lower side, and serum folate also showed mild reduction in several cases. The mean values of these biomarkers are provided in Table 3.

Table 3: Serum Biomarker Levels

When applying standard cut-off values, elevated homocysteine was observed in 64% of the study population. Vitamin B12 deficiency was identified in 56% of patients, and low folate levels were present in 36%. These proportions highlight a clear pattern of altered one-carbon metabolism in a substantial segment of the cohort. The distribution of deranged biomarkers is outlined in Table 4.

Table 4: Prevalence of Deranged Biomarkers

In this study, a large proportion of patients with first-episode ischemic stroke demonstrated elevated serum homocysteine along with reduced Vitamin B12 and folate levels, suggesting a disturbance in one-carbon metabolism that may influence vascular integrity. Hyperhomocysteinemia is known to induce endothelial dysfunction and promote a pro-thrombotic state, thereby increasing stroke susceptibility. Recent literature reinforces the association between high homocysteine levels and ischemic stroke risk, with homocysteine emerging as an independent and modifiable vascular risk factor [7].

Vitamin B12 and folate deficiencies were also frequently observed, and these micronutrients play essential roles in homocysteine metabolism. When their levels are inadequate, homocysteine accumulates, amplifying vascular injury. Studies from South and Northeast Indian populations similarly report high rates of Vitamin B-complex deficiency among stroke patients, aligning with our findings and highlighting nutritional influences in these regions [8].

Low Vitamin B12 levels in particular have been associated with increased ischemic stroke risk, suggesting that early biochemical evaluation may help in risk stratification [9]. Dietary patterns, limited intake of animal-derived foods, and unrecognized malabsorption issues could contribute to these deficiencies. Furthermore, systematic reviews and meta-analyses have consistently shown that homocysteine-lowering strategies through B-vitamin supplementation may reduce stroke incidence, especially in individuals with elevated baseline homocysteine levels [10–12]. Such evidence supports early nutritional assessment and timely correction as practical preventive measures.

Although laboratory methodologies and assay precision continue to evolve and improve reliability of these metabolic markers [6], routine screening for homocysteine, Vitamin B12, and folate is still not widely integrated into standard stroke evaluation. Our findings indicate that incorporating these biochemical assessments, particularly during the first stroke presentation, may provide valuable opportunities to address modifiable metabolic imbalances.

Limitations

This study was limited by its relatively small sample size and short duration, which may restrict the generalizability of the findings. As an observational, cross-sectional design, it cannot establish a direct causal relationship between elevated homocysteine, micronutrient deficiency, and stroke occurrence. Dietary intake patterns and lifestyle influences were not quantified, which may have contributed to biochemical variations. Additionally, follow-up assessment after supplementation or treatment was not performed, preventing evaluation of long-term outcomes and recovery trends.

This study highlights a clear metabolic disturbance among patients presenting with first-episode ischemic stroke, characterized by elevated homocysteine and frequent deficiencies of Vitamin B12 and folate. These findings indicate that beyond conventional vascular risk factors, abnormalities in one-carbon metabolism may play an important contributory role in stroke pathogenesis. Early detection of these biochemical changes offers a practical opportunity for intervention, as both Vitamin B12 and folate deficiencies are correctable through diet or supplementation. Incorporating routine assessment of these markers in stroke evaluation may support more comprehensive risk reduction strategies and potentially improve long-term outcomes. Further studies with larger cohorts and extended follow-up are encouraged to validate these observations.

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