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Neurology India, Vol. 54, No. 1, January-March, 2006, pp. 51 Invited Comments Invited Comments Pezzini Alessandro Clinica Neurologica, Università degli Studi di Brescia, P.le Spedali Civili, 1, 25125 - Brescia Code Number: ni06011 Related article: ni06010, ni06012 Over the last decade, convincing evidence has been gathered on the relation between moderate elevation of plasma total homocysteine (tHcy) and ischemic stroke. If a causal association really exists, then the practical implication is that the intervention of increasing folate intake at a population level could lead to a decrease in stroke risk. However, causality has yet to be established. At least theoretically, the tHcy-stroke association might be a spurious epidemiological finding and elevated tHcy could be interpreted as an epiphenomenon secondary to the vascular disease itself.[1] Recently, evidence that tHcy may be a causal risk factor for ischemic stroke was provided by a large meta-analysis of literature, based on the principle of Mendelian randomization.[2] However, most of the studies included in this meta-analysis were from Europe or North America and focused on subjects with mean age of 40 years or older, with relatively few data from studies conducted in other continents and from younger groups. In this issue of Neurology India, Panigrahi et al[3] report on a hospital-based, case-control study including a group of 1- to 42- year-old patients (median age: 12 years) with ischemic stroke and no history of major "traditional" cardiovascular risk factors. Among the 32 patients who were recruited over one year, these investigators found a higher prevalence of hyperhomocysteinemia in comparison to the group of 60 controls, and a trend toward a significant association between the TT677 MTHFR genotype and disease. Such findings were independent on clinical phenotype (single infarct vs recurrent infarcts). Furthermore, given the inclusion criteria, the influence of a confounding effect on the reported association seems negligible. Although the small sample size precludes extensive analysis, this study highlights the role of homocysteine as a potential risk factor for ischemic stroke at young age in this specific ethnic group. Whether increased tHcy is as a causal risk factor for ischemic stroke remains to be proven. However, while awaiting for conclusive evidence from powered randomized trials of multi-vitamin supplementation,[4] the implication of these findings may be that measuring tHcy levels and screening of MTHFR genotypes in stroke patients of this ethnic group is warranted, since the benefits of the empirical practice of treating selected high-risk patients (such as those included in Panigrahi et al study) with folic acidbased multivitamin therapy, outweigh the potential risks. References
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