Risk factors, clinical outcomes and predictors of stroke mortality in Sierra Leoneans: A retrospective hospital cohort study

Predictors of 30-day mortality following the first episode of stroke among patients admitted at referral hospitals in Dodoma, central Tanzania: A prospective longitudinal observational study

Background and Aims

Stroke is the leading cause of disability and the second most common cause of death after ischemic heart disease worldwide. Understanding predictors of early poststroke mortality provides opportunities for interventions and favorable outcomes. This study aimed to determine the incidence and predictors of 30-day mortality among patients admitted with the first stroke at referral hospitals in Dodoma.

Methods

A prospective longitudinal observational design enrolled patients with acute stroke confirmed by CT scan or MRI admitted at referral hospitals in Dodoma. The National Institute of Health Stroke Scale was used to assess stroke severity at baseline. A comparison of risk factors, clinical profiles, and mortality was done using the Chi-square test. A logistic regression model was used to determine the predictors of 30-day mortality in patients with the stroke while the 30-day probability of survival was estimated using Kaplan-Meier analysis.

Results

Out of 226 patients with first-ever stroke, 121(54%) were males, and the population mean age was 63(15) years. The 140(62%) had Ischemic stroke, and 154(68%) survived at the 30th day. Patients with a history of smoking 2.4 [95% confidence interval (CI) (1.0-5.6), p = 0.048], loss of consciousness 2.7 [95% CI (1.2-6.4; p = 0.019] and unequal pupil size 13.7 [95% CI (4.1-58.1, p < 0.001 were significantly more associated with mortality within 30 days. The median survival was 7 (3-9) days, whereas alcohol drinkers and those aged above 60 years had a shorter time to mortality compared to non-alcohol drinkers and those aged <60 years.

Conclusion

The study showed a high incidence of mortality within 30 days after the first stroke episode, with the highest proportion dying within 7 days of being hospitalized. Advanced age of ≥60 years, smoking, alcohol use, and severe stroke at admission warrant special attention.

Exploring the Epidemiology of Atrial Fibrillation in Nigeria: A Focus on Atrial Fibrillation in Heart Failure Patients and Its Association With Stroke

Atrial fibrillation (AF) represents a significant global public health concern, particularly due to its association with adverse health outcomes such as stroke and heart failure. In Nigeria, where the burden of cardiovascular diseases is rising, understanding the prevalence and impact of AF is crucial for effective healthcare planning and intervention strategies. This review examines the epidemiology of AF in Nigeria, comparing it with global and African data. It explores demographic and regional variations, comorbidity factors, and the impact of AF on the healthcare system, mortality, and quality of life. Notably, the prevalence of AF in Nigeria generally falls just under 5%, but this figure rises to approximately 9% in stroke patients and 11-20% among those with heart failure (HF). Rheumatic heart disease (RHD) is identified as a significant AF risk factor within Africa, affecting around 20% of AF patients - a stark contrast to the 2% in North America. AF's association with higher mortality rates and functional deterioration highlights the urgent need for improved diagnostic and therapeutic approaches, alongside broader public health measures. In conclusion, the review emphasises the significant public health concern AF represents in Nigeria, especially among HF and stroke patients, and stresses the importance of tailored healthcare policies and interventions to mitigate AF's impact and improve patient outcomes.

30-day in-hospital stroke case fatality and significant risk factors in sub-Saharan-Africa: A systematic review and meta-analysis

Existing studies investigating 30-day in-hospital stroke case fatality rates in sub-Saharan Africa have produced varying results, underscoring the significance of obtaining precise and reliable estimations for this indicator. Consequently, this study aimed to conduct a systematic review and update of the current scientific evidence regarding 30-day in-hospital stroke case fatality and associated risk factors in sub-Saharan Africa. Medline/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), APA PsycNet (encompassing PsycINFO and PsychArticle), Google Scholar, and Africa Journal Online (AJOL) were systematically searched to identify potentially relevant articles. Two independent assessors extracted the data from the eligible studies using a pre-tested and standardized excel spreadsheet. Outcomes were 30-day in-hospital stroke case fatality and associated risk factors. Data was pooled using random effects model. Ninety-three (93) studies involving 42,057 participants were included. The overall stroke case fatality rate was 27% [25%-29%]. Subgroup analysis revealed 24% [21%-28%], 25% [21%-28%], 29% [25%-32%] and 31% [20%-43%] stroke case fatality rates in East Africa, Southern Africa, West Africa, and Central Africa respectively. Stroke severity, stroke type, untyped stroke, and post-stroke complications were identified as risk factors. The most prevalent risk factors were low (<8) Glasgow Coma Scale score, high (≥10) National Institute Health Stroke Scale score, aspiration pneumonia, hemorrhagic stroke, brain edema/intra-cranial pressure, hyperglycemia, untyped stroke (stroke diagnosis not confirmed by neuroimaging), recurrent stroke and fever. The findings indicate that one in every four in-hospital people with stroke in sub-Saharan Africa dies within 30 days of admission. Importantly, the identified risk factors are mostly modifiable and preventable, highlighting the need for context-driven health policies, clinical guidelines, and treatments targeting these factors.

A Prospective Study of Stroke Characteristics, Risk Factors, and Mortality in a Tertiary Hospital of Northern Ethiopia

Background

As developing countries experience the epidemiologic transition to chronic diseases, morbidity and mortality from stroke is expected to rise. Stroke and other non-communicable diseases are increasing in Ethiopia but prospective data are scarce and there are not enough data regarding the characteristics, risk factors and mortality of stroke.

Objective

Aimed at determining the risk factors, clinical profiles and treatment outcomes of stroke admissions in Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia.

Methods

This is a prospective cross-sectional study of all adult stroke patients admitted over consecutive 12 months period in medical ward and ICU of Ayder Comprehensive sSpecialized Hospital, northern Ethiopia. Medical residents through a pre-designed questionnaire collected data. Monovariate analysis, bivariate analysis and multivariate analysis to control for confounder variables were done using software SPSS version 26. P < 0.05 was considered statistically significant.

Results

There were 272 stroke admissions to medical ward and ICU over the 1-year period. Stroke comprised 13.05% of total medical admissions. Ischemic stroke accounted for 62.9% of stroke admissions. Stroke in the young accounted for 14.7% of all stroke admissions. Hypertension was the most common risk factor identified, found in 51.8%. Diabetes mellitus and atrial fibrillation were the other common risk factors. The in-hospital mortality was 13.6%. The only independent predictor of mortality identified was presence of complications, AOR [95% CI] of 2.4 [1.4, 5.3], P-value of 0.028. Aspiration pneumonia was the most common complication.

Conclusion

This study showed a high burden of stroke among medical admissions in northern Ethiopia. Being the most common risk factor for stroke, the high burden of undiagnosed and untreated hypertension needs special attention and efforts on community awareness should be enhanced. The relatively higher mortality illustrates the need to establish stroke centers to enhance the quality of stroke care.

A comprehensive analysis of stroke admissions at a rural Nigerian tertiary health facility: Insights from a single-center study

Objectives

This research intended to examine the demographic and clinical attributes of stroke admissions in a rural Nigerian hospital.

Materials and Methods

A retrospective analysis of stroke admissions was conducted over 1 year. All necessary data were obtained from patients' records and SPSS was employed for data analysis. P < 0.05 was deemed significant.

Results

There were 52 stroke cases, accounting for 5.9% of medical admissions. The patients' mean age was 62.81 ± 12.71 years, while females constituted 51.9% of cases. Common risk factors included hypertension (76.9%), hyperlipidemia (38.5%), alcohol (26.9%), and diabetes mellitus (26.9%). Clinical manifestations included hemiparesis/plegia (84.6%), altered consciousness (63.5%), slurred speech (61.5%), cranial nerve deficit (61.5%), aphasia (42.3%), and headache (34.6%). Ischemic stroke (71.2%) predominated over hemorrhagic stroke (28.8%). The average hospitalization duration was 17.62 ± 8.91 days, and the mean onset to arrival time was 121.31 ± 136.06 h. Discharge and mortality rates were 82.7% and 13.5%, respectively. The association between stroke subtypes and mortality was significant (P = 0.001).

Conclusion

Stroke constitutes a significant portion of medical admissions in Nigeria, with ischemic stroke being more prevalent. High mortality rates underscore the urgent need to manage risk factors to prevent stroke.

Stroke in Sierra Leone. the stroke risk factors for people with HIV: A prospective case-control study

BACKGROUND

HIV infection rates are relatively low in Sierra Leone and in West Africa but the contribution of HIV to the risk factors for stroke and outcomes is unknown. In this study, we examined stroke types, presentation, risk factors and outcome in HIV stroke patients compared with controls.

METHODS

We used data from the Stroke in Sierra Leone Study at 2 tertiary hospitals in Freetown, Sierra Leone. A case control design was used to compare stroke type, presentation, risk factors and outcome in sero-positive HIV patients with HIV negative stroke controls. Controls were matched for age and gender and a 1:4 ratio cases to controls was used to optimize power. Analysis was performed using the Pearson x2 for categorical variable, Paired-T test and Mann-Whitney U test for continuous variables. A p-value of less than 0.05 was taken as the level of statistical significance.

RESULTS

Of 511 (51.8%) stroke patients tested for HIV, 36 (7.1%) were positive. Univariate unmatched analysis showed a stroke mean age of 49 years in HIV-positive versus 58 years in HIV-negative population (p = <0.001). In the case-control group, ischaemic stroke is the major type reported in both populations, HIV-negative population: 77 (53.5%) versus HIV-positive: 25 (69.4%) (p = 0.084). Hypertension is the most prevalent risk factor in both groups, HIV-positive: 23 (63.9%) versus HIV-negative: 409 (86.1%) (p = 0.001). Lower CD4+ count is associated in-hospital mortality (p = <0.001).

CONCLUSION

These findings support the current call for timely management of stroke and HIV through integrated care.

Survival status and predictors of mortality among adult Stroke patients admitted to Jimma University Medical Center, South west Ethiopia: A retrospective Cohort study

Background

Stroke is the leading cause of cardiovascular disease death in sub-Saharan Africa and the second leading cause of mortality worldwide. In 2016, 6.23% of all fatalities in Ethiopia were stroke-related.

Objective

To assess survival status and predictors of mortality among adult stroke patients admitted to Jimma University Medical Center from April 1/2017 to March 31/2022.

Methods

A retrospective cohort study was conducted on 480 adult stroke patients selected by simple random sampling from patients admitted to the Jimma University Medical Center Stroke Unit from April 1, 2017 to March 31, 2022. Data were extracted from May to June 2022 and entered Epi-data v.3.1 and analyzed by R v.4.2. The Kaplan-Meier curve with Log rank test was used to estimate survival time and to compare survival experience between categories of explanatory variables. The Cox regression model was computed to identify predictors of survival status in stroke patients. Then the 95% CI of the hazard ratio was set with corresponding p-value < 0.05 to declare statistical significance.

Results

During 4350 person-days of follow-up; 88 (18.33%) patients died; resulting in an incidence mortality of 20.23 per 1000 person-days, with a median survival time of 38 days. Glasgow coma score <8 on admission (AHR = 7.71; 95% CI: 3.78, 15.69), dyslipidemia (AHR = 3.96; 95% CI: 2.04, 7.69), aspiration pneumonia (AHR 2.30; 95% CI: 1.23-4.26), and increased intracranial pressure (AHR = 4.27; 95% CI: 2.33, 7.81), were the independent predictors of the time until death.

Conclusion

The incidence of stroke mortality was higher at the seven and fourteen days. Glasgow Coma Scale, increased intracranial pressure, dyslipidemia, and aspiration pneumonia were independent predictors of mortality.

Incidence and Predictors of Aspiration Pneumonia Among Stroke Patients in Western Amhara Region, North-West Ethiopia: A Retrospective Follow Up Study

Background

Aspiration pneumonia is one of the major complications among hospitalized stroke patients, with global incidence ranging from 5-83% and hospital mortality rate of up to 70%. This study aimed to assess the incidence and identify predictors of aspiration pneumonia among stroke patients in Western Amhara region, North-West Ethiopia.

Methods

An institution-based retrospective follow-up study was conducted on a simple random sample of 568 stroke patients in Western Amhara region admitted at Felege Hiwot Referral Hospital. Log binomial regression model, a generalized linear model with log link, was applied to identify significant predictors of aspiration pneumonia.

Results

Cumulative incidence of aspiration pneumonia among the 568 sampled patients was 23.06%. Males were 1.71 times more at risk to acquire aspiration pneumonia than females (ARR = 1.71, 95% CI 1.07-2.74). Patients with vomiting and dysphagia were at more risk of acquiring aspiration pneumonia as compared with patients without vomiting and dysphagia (ARR = 1.81, 95% CI 1.04-3.14 and ARR = 1.95, 95% CI 1.10-3.48, respectively). Patients who received antibiotic prophylaxis and patients with Glasgow Coma Scale greater than 12 had less risk of acquiring aspiration pneumonia as compared with those who did not receive antibiotic prophylaxis and patients with Glasgow Coma Scale less than 8 (ARR = 0.10, 95% CI 0.04-0.28 and ARR = 0.45, 95% CI 0.22-0.94, respectively).

Conclusion

The cumulative incidence of aspiration pneumonia among sampled patients was 23.06%. Vomiting, dysphagia, antibiotic treatment and Glasgow Coma Scale showed significant correlation with the acquiring of aspiration pneumonia. Therefore, we recommend health-care providers should give special attention for patients with these risk factors to prevent aspiration pneumonia.

Development and internal validation of a clinical risk score for in-hospital mortality after stroke: a single-centre retrospective cohort study in Northwest Ethiopia

OBJECTIVE

To develop and validate a clinical risk score for in-hospital stroke mortality.

DESIGN

The study used a retrospective cohort study design.

SETTING

The study was carried out in a tertiary hospital in the Northwest Ethiopian region.

PARTICIPANTS

The study included 912 patients who had a stroke admitted to a tertiary hospital between 11 September 2018 and 7 March 2021.

MAIN OUTCOME MEASURES

Clinical risk score for in-hospital stroke mortality.

METHODS

We used EpiData V.3.1 and R V.4.0.4 for data entry and analysis, respectively. Predictors of mortality were identified by multivariable logistic regression. A bootstrapping technique was performed to internally validate the model. Simplified risk scores were established from the beta coefficients of predictors of the final reduced model. Model performance was evaluated using the area under the receiver operating characteristic curve and calibration plot.

RESULTS

From the total stroke cases, 132 (14.5%) patients died during the hospital stay. We developed a risk prediction model from eight prognostic determinants (age, sex, type of stroke, diabetes mellitus, temperature, Glasgow Coma Scale, pneumonia and creatinine). The area under the curve (AUC) of the model was 0.895 (95% CI: 0.859-0.932) for the original model and was the same for the bootstrapped model. The AUC of the simplified risk score model was 0.893 (95% CI: 0.856-0.929) with a calibration test p value of 0.225.

CONCLUSIONS

The prediction model was developed from eight easy-to-collect predictors. The model has excellent discrimination and calibration performance, similar to that of the risk score model. It is simple, easily remembered, and helps clinicians identify the risk of patients and manage it properly. Prospective studies in different healthcare settings are required to externally validate our risk score.

The Burden and In-Hospital Mortality of Stroke Admissions at a Tertiary Level Hospital in Namibia: A Retrospective Cohort Study

Background

Despite stroke being a leading cause of morbidity and mortality globally, there is a dearth of information on the burden and outcomes of stroke in sub-Saharan Africa and Namibia in particular.

Methods

A hospital-based, retrospective cohort study was conducted to analyse non-electronic medical records of all consecutive stroke patients who were admitted to one of the highest tertiary-level hospitals in Namibia for 12 months (2019-2020). The primary outcome of the study was to establish the in-hospital mortality, stroke subtypes, and associated complications.

Results

In total, 220 patients were included in the study, their mean age was 53 (SD13.8) years, and 55.5% were males. 61.0% had an ischaemic stroke (IS), and 39.0% had a haemorrhagic stroke (HS). The mean age was significantly lower in patients with HS vs. IS (48.2 ± 12.2 vs. 56.1 ± 13.3, p < 0.001). Of the IS patients, the majority (29.0%) had total anterior circulation infarct (TACI), while in the HS group, 34.0% had basal ganglia haemorrhage with or without intraventricular extension. Hypertension (p = 0.015), dyslipidaemia (p = 0.001), alcohol consumption (p = 0.022), and other cardiovascular diseases (p = 0.007) were more prevalent in patients with IS compared to those with HS. The prevalence rate of intravenous thrombolysis was 2.2% in IS and use of intravenous antihypertensives in 25.9% of patients with HS than IS. The in-hospital mortality was 26.4% with complications such as raised ICP, aspiration pneumonia, hydrocephalus, and sepsis significantly high in those that died. Aspiration pneumonia (OR 2.79, 95% CI 1.63-4.76, p < 0.001) and increased ICP (OR 0.30, 95% CI 0.16-057, p < 0.001) were independent predictors of in-hospital mortality on the multivariate analysis.

Conclusion

Our findings showed a younger mean age for stroke and mortality rate comparable to other low- to middle-income countries (LMICs). Hypertension and alcohol consumption were the main risk factors for both stroke subtypes, while aspiration pneumonia and raised intracranial pressure predicted in-hospital mortality.

Risk Factors for Hemorrhagic Stroke among Adults in the Democratic Republic of the Congo: A Hospital-Based Study in a Limited Resource Setting

Background

The prevalence of stroke is increasing in sub-Saharan Africa. The scarcity of hospital-based stroke data in Lubumbashi (in the Democratic Republic of the Congo) led to the study, which was designed to describe the epidemiology of stroke and identify risk factors associated with hemorrhagic stroke among adult patients in Lubumbashi.

Methods

This was a cross-sectional study of 158 adult patients admitted for stroke in the internal medicine department of Lubumbashi University Clinics from January 2018 to December 2020. Sociodemographic and clinical features, cardiovascular risk factors, and hospital mortality were collected. A logistic regression has determined the risk of developing a hemorrhagic stroke.

Results

Of 9,919 hospitalized patients, 158 had a stroke with a hospital prevalence of 1.6%; 86 (54.4%) patients had a hemorrhagic stroke while 72 (45.6%) had an ischemic stroke. Of which 41.1% (65/158) were women. The mean age was 60.8 ± 13.3 years. Main clinical signs were hemiplegia (63.3%), headache (48.7%), speech disorders (38.6%), and dizziness (38.6%). Hypertension (82.9%) and hyperglycemia (53.2%) were the most common risk factors. Inhospital mortality was 22.8%. After logistic regression, independent predictors for developing hemorrhagic stroke were hypertension (aOR = 8.19; 95% CI: 2.72–24.66; p < 0.0001) and atrial fibrillation (aOR = 4.89; 95% CI: 1.41–16.89; p = 0.012).

Conclusion

This study highlights the high stroke mortality in a resource-limited hospital and the burden of hypertension in the development of hemorrhagic stroke. It illustrates the need to establish stroke care setting to improve the quality of stroke care.

Proportion of stroke types in Madagascar: A tertiary-level hospital-based case series

BACKGROUND

Like other countries in sub-Saharan Africa, Madagascar has a high burden of stroke. The Malagasy population is unique in sharing both African and Asian ancestry. The proportion of ischemic and hemorrhagic stroke types is unknown for this population.

AIM

Our aim was to establish the proportion of stroke types and known risk factors for the Malagasy population.

METHODS

We conducted a single-center, tertiary-level hospital-based case series. We included all patients with a CT-imaging confirmed stroke who presented at the emergency ward of the study hospital between January 1, 2017, and November 20, 2018.

RESULTS

Of 223 patients with CT-confirmed stroke, 57.4% (128/223, 95% CI: 51-64%) had an ischemic stroke and 42.6% (95/223, 95% CI: 36-49%) had an intracranial hemorrhage. The majority (89.5%; 85/95, 95% CI: 83-96%) of intracranial hemorrhages were intracerebral; 4.2% (4/95, 95% CI: 0-8%) had a subdural hematoma, 5.3% (5/95, 95% CI: 1-10%) had a subarachnoid hemorrhage, there was one isolated intraventricular hemorrhage (1.1%; 1/95, 95% CI: -1-3%). The prevalence of hypertension among stroke patients was high (86.6%; 187/216, 95% CI: 82-91%).

CONCLUSIONS

Our study is the first to report the proportion of stroke types and known risk factors in Madagascar. We find that the proportion of hemorrhagic strokes was unexpectedly higher than that reported from other countries in sub-Saharan Africa. Our findings highlight the need for a country-specific approach to stroke prevention, treatment, and rehabilitation and provide guidance on public health resource allocation in Madagascar.

The Next Frontier in Neurocritical Care in Resource-Constrained Settings

Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS.

Factors associated with stroke associated pneumonia among adult stroke patients admitted to university of Gondar hospital, Northwest Ethiopia

Stroke is the major cause of disability and death in sub-Saharan African countries. The presence and severity of complications play a major role in the outcome of stroke. Stroke associated pneumonia is often noticed post stroke infection that has been linked to an increased risk of hospital mortality, a longer hospital stay and higher healthcare expenses. Report on details of stroke-associated pneumonia has never been documented in countries of sub-Saharan Africa. This study aimed to determine the incidence and risk factors of stroke-associated pneumonia among adult stroke patients in hospital settings, Northwest Ethiopia. The study was undertaken at a stroke care unit, University of Gondar hospital between January 1, 2020 and December 31, 2020. A convenience sampling method was used to recruit study subjects. Relevant clinical history was taken, focused physical examination was done, and brain imaging (CT scan or MRI) was performed to settle the diagnosis of stroke. A modified Centre for Disease Control and Prevention (CDC) criteria was used to diagnose stroke-associated pneumonia. All patients with stroke-associated pneumonia were treated according to the 2016 Infectious Diseases Society of America/American Thoracic Society Clinical Practice Guidelines. The Data were cleaned in Epi Info version 4.6.0.2, and analyzed using SPSS version 26. Variables associated with stroke-associated pneumonia were computed using logistic regression analysis. P value < 0.05 was considered to declare statistical significance. The study comprised a total of 325 adult stroke patients. The mean age of study subjects was 65.2 years (SD ± 15.7). The most prevalent type of stroke was ischemic stroke, which accounted for 68% of all cases. Hemiparesis (94%), facial palsy (87%), and swallowing disturbance (51%) were the frequently noticed neurological findings. Stroke-associated pneumonia complicated 116/325 (36%) of stroke patients. Multi-variate regression analysis revealed that patients who were elderly (age > 75 years) (AOR = 3.910, CI 1.181-12.936, P = 0.026), had swallowing disturbance (AOR = 4.656, CI 2.356-9.202, P-value < 0.001), epileptic seizures (AOR = 2.678, 95% CI 1.253-5.721, P-value < 0.001) and moderate to severe stroke (NIHSS score = 16-21) (AOR = 5.994, 95% CI 2.043-17.585, P-value < 0.001) were at risk of developing stroke-associated pneumonia. SAP was a substantial medical complication among stroke patients. Early identification and prompt intervention measures for the identified risk factors might address the burden of SAP.

Current Management of Acute Ischemic Stroke in Africa: A Review of the Literature

BACKGROUND

Acute ischemic stroke is one of the leading causes of disability and mortality globally, with increasing incidence in Africa, as the continent is already burdened with infectious diseases. Rapid diagnosis and efficient treatment are crucial, as even a slight delay to reperfuse the brain significantly affects the recovery outcome. Neuroimaging is vital for optimal care and thrombolytic or endovascular therapy in specialised stroke care units. This review aims to discuss the burden of acute ischemic stroke in Africa and how healthcare systems have tried to reduce the incidence and improve outcomes for the disease.

METHODOLOGY

Data was collected from online databases and medical journal published on PubMed, Ovid MEDLINE, ScienceDirect and Embase bibliographical data. All articles related to acute ischemic stroke in Africa were considered.

RESULTS

The medical care for acute ischemic stroke in Africa is far from optimal with little adherence to recommended protocols. There is a lack of public awareness of the disease, imaging infrastructure, personnel, stroke care units and recovery facilities, due to poor funding. Poor knowledge of stroke signs and symptoms results in delay in treatment and poor prognosis.

CONCLUSION

We urge African leaders and private entities to invest in stroke care by building appropriate infrastructures, providing medical equipments, implementing guidelines, and sustainable follow-up systems. Telehealth is a suggested strategy to mitigate the scarcity of health personnel, and international and national efforts to increase treatment affordability should be doubled. Further extensive research on the impact of acute ischemic stroke on the African continent population is encouraged.

Predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia

BACKGROUND

Factors associated with stroke mortality are understudied in sub-Saharan Africa but have implications for designing interventions that improve stroke outcomes. We investigated predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia.

METHODS

Data from consecutive adults admitted with stroke at University Teaching Hospital in Lusaka, Zambia between October 2018 and March 2019 were retrospectively reviewed for clinical in-hospital outcomes. Vital status at 90-days post-discharge was determined through phone calls. Factors associated with stroke mortality were included in multivariable logistic regression models utilizing multiple imputation analysis to determine independent predictors of in-hospital and 90-days post-discharge mortality.

RESULTS

In-hospital mortality was 24%, and 90-day post-discharge mortality was 22% among those who survived hospitalization. Hemorrhagic and unknown strokes, ICU care, seizures, and aspiration pneumonia were significantly associated with in-hospital mortality. Among these, hemorrhagic stroke (OR 2.88, 95% CI 1.27-6.53, p = 0.01) and seizures (OR 29.5, 95% CI 2.14-406, p = 0.01) remained independent predictors of in-hospital mortality in multivariable analyses. Ninety-day post-discharge mortality was significantly associated with older age, previous stroke, atrial fibrillation, and aspiration pneumonia, but only older age (OR 1.04, 95% CI 1.01-1.06, p = 0.007) and aspiration pneumonia (OR 3.93, 95% CI 1.30-11.88, p = 0.02) remained independently associated with 90-day mortality in multivariable analyses.

CONCLUSION

This Zambian stroke cohort had high in-hospital and 90-day post-discharge mortality that were associated with several in-hospital complications. Our data indicate the need for improvement in both acute stroke care and post-stroke systems of care to improve stroke outcomes in Zambia.

Osuntokun Award Lecture 2021: Challenges of Measuring the Burden of Stroke in Africa

BACKGROUND

Over recent years non-communicable diseases have dramatically increased in low- and middle-income countries, including those of sub-Saharan Africa. With continuing high levels of infectious disease, these countries now face the double burden of disease. Stroke has emerged as a major cause of hospital admission, disability, and mortality for which the major modifiable risk factor is hypertension, which is often not diagnosed and, even if diagnosed, not treated and, even if treated, not controlled.

METHODS

In this award lecture paper I outline my personal experience of measuring the burden of, and risk factors for, stroke in sub-Saharan Africa, along with the challenges faced. I will specifically describe the measurement of mortality and case fatality, prevalence and incidence as well as commenting on aetiology and risk factors and reflect on future initiatives and directions.

RESULTS

Over the past 5 decades there has been a dramatic increase in numbers of stroke patients admitted to hospital throughout sub-Saharan Africa, with high in hospital mortality rates, also reflected in high case fatality rates in those cohorts followed up following discharge from hospital. Community-based surveys assessing mortality from stroke using verbal autopsy have demonstrated very high age-adjusted rates. Age adjusted prevalence rates assessed by door-to-door surveys have generally shown lower prevalence than high income countries. The Tanzanian stroke incidence study, which incorporated verbal autopsy for those patients dying before reaching hospital, demonstrated some of the highest age-adjusted stroke incidence rates in the world. There were high rates of stroke in younger ages and high rates of intracranial haemorrhage though not as high as previously shown in hospital-based studies. Hypertension is the main modifiable risk factor but other risk factors such as HIV are important while, certainly in rural populations, raised cholesterol remains rare as does carotid artery stenosis and history of transient ischemic attack. Other vascular disease such as ischemic heart disease and peripheral vascular disease is also less common.

CONCLUSIONS

There is already a large burden relating to stroke in sub-Saharan Africa and this will only escalate further as the population ages. Hypertension is the biggest risk factor for mortality worldwide and in sub-Saharan Africa prevalence rates are very high with the majority of people suffering with stroke not being diagnosed with their hypertension prior to their stroke. The most important challenge is to improve primary prevention for which improving diagnosis and control rates for hypertension is the number one priority. For those who do have stroke there is a need to increase the number of suitably staffed stroke units as these have been shown to have a very large impact on improving both mortality and morbidity in high income countries. There are still many unanswered questions and a need for more research throughout sub-Saharan Africa on risk factors, and treatment, for stroke.

Five-year analysis of clinical presentations and predictors of stroke mortality in rural Southwestern Nigeria: A retrospective observational study

Introduction

Stroke mortality and its predictors are important outcome measures in stroke epidemiological studies and clinical trials. There is an observed paucity of data regarding the clinical presentations and predictors of stroke mortality in Southwestern Nigeria. Few available related studies have centred on hospitals in the urban and sub-urban areas; however, none in the rural settings. This study, therefore, focuses on the clinical presentations and predictors of stroke mortality at the adult Emergency Centre of a tertiary hospital situated in rural Southwestern Nigeria.

Methods

A retrospective survey, using data form and standardized questionnaire, was used to study the patients admitted for stroke between January 2015 and December 2019. The data were analysed using SPSS Version 22.0. The results were presented in descriptive and tabular formats.

Results

A total of 276 patients were studied. Their mean age was 67.3 ± 11.1 years. The most common clinical presentations were hemiparesis and cranial nerve deficit. The case of fatality was 10.1%. The predictors of stroke mortality were age ≥65 years [(AOR = 12.752; 95% CI: (1.022–159.190), p = 0.048)], Glascow coma score <8 [(AOR = 50.348; 95% CI: (7.779–325.866), p < 0.001)], uncontrolled blood pressure [(AOR = 23.321; 95% CI: (2.449–221.927), p = 0.006)], presence of atrial fibrillation [(AOR = 16.456; 95% CI: (2.169–169.336), p = 0.009)], convulsion [(AOR = 25.889; 95% CI: (2.374–282.296), p = 0.008)], heart failure [(AOR = 30.284; 95% CI: (3.265–256.347), p < 0.001)], and a repeat stroke [(AOR = 32.617; 95% CI: (2.410–441.381), p = 0.009)].

Conclusion

The 7-day fatality was 10.1%. The predictors of stroke mortality were poor Glascow coma score, uncontrolled blood pressure, atrial fibrillation, heart failure, convulsion and a repeat stroke. This study strengthens the argument on the higher prevalence of stroke and its mortality in rural Southwestern Nigeria. Our findings may provide an impetus for prospective research on this outcome.

Influence of hypertension classification on hypertensive intracerebral hemorrhage location

The authors sought to explore whether hypertension classification was risk factor for lobar and non‐lobar hypertensive intracerebral hemorrhage (HICH) and the prognosis in patients with hematoma. This retrospective cohort study was conducted on HICH patients admitted at the First Affiliated Hospital of Soochow University. Observations with first‐ever intracerebral hemorrhage (ICH) were recruited. The authors divided the brain image into three groups according to the location of ICH to predict whether there were significant differences between lobar and non‐lobar ICH. A Mann‐Whitney U test was used and this retrospective trial also compared the operation and mortality rates. Our cohort included 209 patients (73.7% male; median age:60.5±16.7). The overall incidence of lobar HICH was less than non‐lobar HICH (24.4% vs. 68.4%), 7.2% cases of mixed HICH was included in this analysis. In a Mann‐Whitney U test analyze, it indicated that there were significant differences in hypertension classification between lobar and non‐lobar HICH (Z = ‐3.3, p<.05). And the percentage of hematoma in lobar areas with relatively slightly high blood pressure (BP) (high normal and grade 1 hypertension) accounts for 52.9% versus 30.1% in non‐lobar areas. The increasing trends of the prevalent rate of lobar ICH with BP rising were not remarkable. The non‐lobar HICH showed a sharper increase in the condition of grade 3 hypertension compared with lobar HICH. During the period of research, the fatality of lobar hemorrhage was 2.9% versus 7.7% (non‐lobar). Besides, the fatality incidence of HICH with relatively slightly high BP (high normal and grade 1 hypertension) was lower than poorly controlled hypertensive patients (grade 2 and grade 3 hypertension). (8.0% vs. 15.7%). The increase of hypertension classification will aggravate the occurrence of non‐lobar ICH and positively corrected with BP, but not in lobar areas. It is essential to understand the distinction influence of hypertension classification between lobar and non‐lobar ICH.

A Prospective Stroke Register in Sierra Leone: Demographics, Stroke Type, Stroke Care and Hospital Outcomes

Introduction: Stroke is the second most common cause of adult death in Africa. This study reports the demographics, stroke types, stroke care and hospital outcomes for stroke in Freetown, Sierra Leone. Methods: A prospective observational register recorded all patients 18 years and over with stroke between May 2019 and April 2020. Stroke was defined according to the WHO criteria. Pearson's chi-squared test was used to examine associations between categorical variables and unpaired t-tests for continuous variables. Multivariable logistic regression, to explain in-hospital death, was reported as odds ratios (ORs) and 95% confidence intervals. Results: Three hundred eighty-five strokes were registered, and 315 (81.8%) were first-in-a-lifetime events. Mean age was 59.2 (SD 13.8), and 187 (48.6%) were male. Of the strokes, 327 (84.9%) were confirmed by CT scan. Two hundred thirty-one (60.0%) were ischaemic, 85 (22.1%) intracerebral haemorrhage, 11 (2.9%) subarachnoid haemorrhage and 58 (15.1%) undetermined stroke type. The median National Institutes of Health Stroke Scale on presentation was 17 [interquartile range (IQR) 9-25]. Haemorrhagic strokes compared with ischaemic strokes were more severe, 20 (IQR 12-26) vs. 13 (IQR 7-22) (p < 0.001), and occurred in a younger population, mean age 52.3 (SD 12.0) vs. 61.6 (SD 13.8) (p < 0.001), with a lower level of educational attainment of 28.2 vs. 40.7% (p = 0.04). The median time from stroke onset to arrival at the principal referral hospital was 25 hours (IQR 6-73). Half of the patients (50.4%) sought care at another health provider prior to arrival. One hundred fifty-one patients died in the hospital (39.5%). Forty-three deaths occurred within 48 hours of arriving at the hospital, with median time to death of 4 days (IQR 0-7 days). Of the patients, 49.6% had ≥1 complication, 98 (25.5%) pneumonia and 33 (8.6%) urinary tract infection. Male gender (OR 3.33, 1.65-6.75), pneumonia (OR 3.75, 1.82-7.76), subarachnoid haemorrhage (OR 43.1, 6.70-277.4) and undetermined stroke types (OR 6.35, 2.17-18.60) were associated with higher risk of in-hospital death. Discussion: We observed severe strokes occurring in a young population with high in-hospital mortality. Further work to deliver evidence-based stroke care is essential to reduce stroke mortality in Sierra Leone.

In-hospital mortality and its predictors among stroke patients in sub-Saharan Africa: A systemic review and meta-analysis

Objective

To assess the in-hospital mortality from acute stroke and its predictors in sub-Saharan Africa.

Method

The literature search was conducted in the databases of PubMed/Medline, Embase, CINAHL, and Google Scholar. The retrieved studies were screened by titles and abstracts, and then full texts were assessed for eligibility. The methodological quality of the included studies was assessed using the Joanna Briggs Institute's critical appraisal checklist. The publication bias was assessed using the funnel plot asymmetry and the Egger tests. Data were analyzed using Stata software version 15.0 in a random-effect model.

Result

A total of 27 studies with a total sample size of 6331 were included in this systematic review and meta-analysis. The pooled estimated prevalence of in-hospital mortality due to stroke was 22% (95% confidence interval = 0.17-0.27). Stroke mortality in Western Africa (37%, 95% confidence interval = 0.24-0.50) was higher than in Eastern Africa (15%, 95% confidence interval = 0.12-0.19) and Southern Africa (18%, 95% confidence interval = 0.06-0.19). In three studies, mortality was higher in hemorrhagic stroke (25%) than ischemic stroke (14%). Risk factors associated with higher mortality were admission Glasgow Coma Scale, stroke severity, age, sex, presence of hypertension, and declined renal function.

Conclusion

The in-patient mortality of stroke in sub-Saharan Africa was high. Therefore, there is an urgent need for further stroke epidemiology studies in stroke subtypes and the performance of patient-level meta-analysis to understand the risk factors associated with mortality and herald appropriate intervention to curb the high mortality rate in the region.

Stroke in Africa: profile, progress, prospects and priorities

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.