Stroke mortality and its determinants in a resource-limited setting: A prospective cohort study in Yaounde, Cameroon

Epidemiology, clinical features and outcome of stroke in rural versus urban hospitals in Cameroon

OBJECTIVES

Stroke is a major public health problem worldwide with disparities between urban and rural areas. The aim of this study was to compare the epidemiological, clinical features and outcomes of stroke between rural and urban hospitals in Cameroon.

MATERIALS AND METHODS

We conducted a retrospective cohort study at the Douala General Hospital (urban) and Ad Lucem Hospital of Banka (rural) from January 1st, 2014, to December 31st, 2019. The medical records of all patients admitted for stroke, and meeting the inclusion criteria were reviewed. Diagnosis of stroke was based on brain imaging and/or the World Health Organization definition. Data were analyzed using SPSS version 20.0.

RESULTS

Among the 15277 files reviewed, 752 were included with 623 cases (82.80%) in urban areas. The percentage of patients hospitalized for stroke were 9.06% and 2.85% in urban and rural hospitals respectively. The frequency of patients admitted for severe stroke (Glasgow coma scale ≤ 8) was higher in the rural hospital (p = 0.004). In-hospital mortality (p = 0.010), cumulative mortality at one-month (p = 0.018), poor functional recovery (p = 0.002), one-year stroke recurrence (p = 0.020) were significantly higher in rural setting. Undefined stroke was predictor of mortality in the rural hospital, while hemorrhagic stroke was predictor of mortality at one-month in the urban hospital.

CONCLUSIONS

Stroke cases were significantly more severe with poor outcomes in the rural hospital. Efforts are needed to improve prevention, and access to stroke care for communities, especially in rural setting.

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.

Risk Factors Associated With Exclusion of Obese Patients Ischemic Stroke With a History of Smoking From Thrombolysis Therapy

The objective of this study is to determine risk factors that may contribute to exclusion decision from recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke (AIS) with a combined current or history of smoking and obesity. This study was conducted on data from 5469 patients with AIS collected from a regional stroke registry. Risk factors associated with inclusion or exclusion from rtPA were determined using multivariate logistic regression analysis. The adjusted odds ratios and 95% confidence interval for each risk factor were used to predict the increasing odds of an association of a specific risk factor with exclusion from rtPA. In the adjusted analysis, obese patients with AIS with a history of smoking (current and previous) excluded from rtPA were more likely to present with carotid artery stenosis (OR = 0.069, 95% CI 0.011-0.442), diabetes (OR = 0.604, 95% CI 0.366-0.997), higher total cholesterol (OR = 0.975, 95% CI 0.956-0.995), and history of alcohol use (OR = 0.438, 95% CI 0.232-0.828). Higher NIHSS score (OR = 1.051, 95% CI 1.017-1.086), higher triglycerides (OR = 1.004, 95% CI 1.001-1.006), and higher high-density lipoprotein (OR = 1.028, 95% CI 1.000-1.057) were associated with the inclusion for rtPA. Our findings reveal specific risk factors that contribute to the exclusion of patients with AIS with a combined effect of smoking and obesity from rtPA. These findings suggest the need to develop management strategies to improve the use of rtPA for obese patients with AIS with a history of smoking.

Stroke in Africa: A systematic review and meta-analysis of the incidence and case-fatality rates

BACKGROUND

The burden of stroke (a leading cause of disability and mortality) in Africa appears to be increasing, but a systematic review of the best available data to support or refute this observation is lacking.

AIM

To determine the incidence and 1-month case-fatality rates from high-quality studies of stroke epidemiology among Africans.

SUMMARY OF REVIEW

We searched and retrieved eligible articles on stroke epidemiology among indigenous Africans in bibliographic databases (MEDLINE, ScienceDirect, Google Scholar, and Cochrane library) using predefined search terms from the earliest records through January 2022. Methodological assessment of eligible studies was conducted using the Newcastle-Ottawa scale. Pooling of incidence and case-fatality rates was performed via generalized linear models (Poisson-Normal random-effects model). Of the 922 articles retrieved, 14 studies were eligible for inclusion. The total number of stroke cases was 2568, with a population denominator (total sample size included in population-based registries or those who agreed to participate in door-to-door community studies) of 3,384,102. The pooled crude incidence rate of stroke per 100,000 persons in Africa was 106.49 (95% confidence interval (CI) = 58.59-193.55), I2 = 99.6%. The point estimate of the crude incidence rate was higher among males, 111.33 (95% CI = 56.31-220.12), I2 = 99.2%, than females, 91.14 (95% CI = 47.09-176.37), I2 = 98.9%. One-month case-fatality rate was 24.45 (95% CI = 16.84-35.50), I2 = 96.8%, with lower estimates among males, 22.68 (95% CI = 18.62-27.63), I2 = 12.9%, than females, 27.57 (95% CI = 21.47-35.40), I2 = 51.6%.

CONCLUSION

The burden of stroke in Africa remains very high. However, little is known about the dynamics of stroke epidemiology among Africans due to the dearth of high-quality evidence. Further continent-wide rigorous epidemiological studies and surveillance programs using the World Health Organization STEPwise approach to Surveillance (WHO STEPS) framework are needed.

A Spatial Variation Analysis of In-Hospital Stroke Mortality Based on Integrated Pre-Hospital and Hospital Data in Mashhad, Iran

BACKGROUND

Despite significant advances in the quality and delivery of specialized stroke care, there still persist remarkable spatial variations in emergency medical services (EMS) transport delays, stroke incidence, and its outcomes. Therefore, it is very important to investigate the possible geographical variations of in-hospital stroke mortality and to identify its associated factors.

METHODS

This historical cohort study included suspected stroke cases transferred to Ghaem Hospital of Mashhad by the EMS from March 2018 to March 2019. Using emergency mission IDs, the pre-hospital emergency data were integrated with the patient medical records in the hospital. We used the Bayesian approach for estimating the model parameters.

RESULTS

Out of 301 patients (142 (47.2%) females vs. 159 (52.8%) males) with a final diagnosis of stroke, 61 (20.3%) cases had in-hospital mortality. Results from Bayesian spatial log-logistic proportional odds (PO) model showed that age (PO=1.07), access rate to EMS (PO=0.78), arrival time (evening shift vs. day shift, PO=0.09), and sequelae variables (PO=9.20) had a significant association with the odds of in-hospital stroke mortality (P<0.05). Furthermore, the odds of in-hospital stroke mortality were higher in central urban areas compared to suburban areas.

CONCLUSION

Marked regional variations were found in the odds of in-hospital stroke mortality in Mashhad. There was a direct association between age and odds of in-hospital stroke mortality. Hence, the prognosis of in-hospital stroke mortality could be improved by better control of hypertension, prevention of the occurrence of sequelae, increasing the access rate to EMS, and optimizing shift work schedule.

Patient-level and system-level determinants of stroke fatality across 16 large hospitals in Ghana and Nigeria: a prospective cohort study

BACKGROUND

Every minute, six indigenous Africans develop new strokes. Patient-level and system-level contributors to early stroke fatality in this region are yet to be delineated. We aimed to identify and quantify the contributions of patient-level and system-level determinants of inpatient stroke fatality across 16 hospitals in Ghana and Nigeria.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicentre study involving 16 sites in Ghana and Nigeria. Cases include adults (aged ≥18 years) with clinical and radiological evidence of an acute stroke. Data on stroke services and resources available at each study site were collected and analysed as system-level factors. A host of demographic and clinical variables of cases were analysed as patient-level factors. A mixed effect log-binomial model including both patient-level and system-level covariates was fitted. Results are presented as adjusted risk ratios (aRRs) with respective 95% CIs.

FINDINGS

Overall, 814 (21·8%) of the 3739 patients admitted with stroke died as inpatients: 476 (18·1%) of 2635 with ischaemic stroke and 338 (30·6%) of 1104 with intracerebral haemorrhage. The variability in the odds of stroke fatality that could be attributed to the system-level factors across study sites assessed using model intracluster correlation coefficient was substantial at 7·3% (above a 5% threshold). Stroke units were available at only five of 16 centres. The aRRs of six patient-level factors associated with stroke fatality were: low vegetable consumption, 1·19 (95% CI 1·07-1·33); systolic blood pressure, 1·02 (1·01-1·04) for each 10 mm Hg rise; stroke lesion volume more than 30 cm3, 1·48 (1·22-1·79); National Institutes of Health Stroke Scale (NIHSS) score, 1·20 (1·13-1·26) for each 5-unit rise; elevated intracranial pressure, 1·75 (1·31-2·33); and aspiration pneumonia, 1·79 (1·16-2·77).

INTERPRETATION

Studies are needed to assess the efficacy of interventions targeting patient-level factors such as aspiration pneumonia in reducing acute stroke fatality in this region. Policy directives to improve stroke unit access are warranted.

FUNDING

US National Institutes of Health.

TRANSLATIONS

For the Twi, Yoruba and Hausa translations of the abstract see Supplementary Materials section.

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 profile, clinical presentation, and determinants of stroke subtypes among patients with stroke admitted to public referral hospitals, Northwest Ethiopia in 2021: A cross-sectional study

Background

Stroke is the second leading cause of death worldwide, with a significant increase in stroke burden over the last two and half decades, especially in developing countries. African countries are undergoing an epidemiological transition from being dominated by infectious diseases to being double-burdened by non-communicable diseases, with existing infectious diseases driven by sociodemographic and lifestyle changes and a weak healthcare system. Data on the risk profile, clinical presentation, and predictors of stroke subtypes are still limited. Therefore, the main aim of this study was to assess the risk profile, clinical presentation, and predictors of stroke in public referral hospitals of Northwest Ethiopia.

Methods

For this study, 554 patients with stroke admitted to three public referral hospitals were prospectively followed up. Data were collected using a pre-tested interviewer-administered questionnaire. STATA version 16 was used for data analyses. Candidate variables significant in bivariate analysis were selected for multivariate binary logistic regression, and statistical significance was set at a p &lt; 0.05.

Results

Of the 554 patients with stroke, 60.3% had an ischemic stroke. The mean age of the participants was 61 ± 12.85 years, and more than half (53.25%) of them were women. The most common risk factor identified was hypertension (29.7%), followed by congestive heart failure. The most common clinical presentation was hemiparesis, which was reported by 57.7% of the patients, followed by loss of consciousness (20.7%) and aphasia (9%). Through multivariable logistic regression, age (AOR = 1.03, 95% CI:1.01–1.05), sedentary physical activity level (AOR = 6.78, 95% CI:1.97–23.32), absence of a family history of chronic illness (AOR = 3.79, 95% CI:2.21–6.48), hypertension (AOR=0.51, 95% CI:0.31–0.85), and past stroke (AOR = 3.54, 95% CI:0.93–13.49) were found to be independent determinants of the stroke subtype.

Conclusion

Age, the level of sedentary physical activity, absence of a family history of chronic illness, hypertension, and past stroke were independent determinants of stroke subtype.

Case fatality rate and its determinants among admitted stroke patients in public referral hospitals, Northwest, Ethiopia: A prospective cohort study

According to the global burden of disease 5.5 million deaths were attributable to stroke. The stroke mortality rate is estimated to be seven times higher in low-income countries compared to high-income countries. The main aim of the study was to assess the 28 days case fatality rate and its determinants among admitted stroke patients in public referral hospitals, in Northwest Ethiopia. A hospital-based prospective cohort study was conducted from December 2020 to June 2021. The study population was 554 stroke patients. Based on Akakian Information Criteria, the Gompertz model was fitted to predict the hazard of death. The study included admitted stroke patients who were treated in the general medical ward and neurology ward. The mean age of the participants was 61 ± 12.85 years and 53.25% of the patients were female. The 28-days case fatality rate of stroke was 27.08%. The results from Gompertz parametric baseline hazard distribution revealed that female sex adjusted hazard rate (AHR = 0.27, 95% CI:0.18–0.42), absence of a family history of chronic disease (AHR = 0.50, 95%CI:0.29–0.87), good GCS score (AHR = 0.21, 95% CI:0.09–0.50) and the absence of complication during hospital admission (AHR = 0.16, 95% CI:0.08–0.29) were factors which decrease hazard of 28 days case fatality rate. While, hemorrhagic stroke sub-type (AHR = 1.38, 95% CI:1.04–3.19), time from symptom onset to hospital arrival (AHR = 1.49, 95% CI:1.57–2 .71), time from confirmation of the diagnosis to initiation of treatment (AHR = 1.03, 95% CI:1.01–1.04), a respiratory rate greater than 20 (AHR = 7.21, 95% CI:3.48–14.9), and increase in NIHSS score (AHR = 1.16, 95% CI:1.10–1.23) were factors increasing hazard of 28 days case fatality rate of stroke. At 28-days follow-up, more than one-fourth of the patients have died. The establishment of separate stroke centers and a network of local and regional stroke centers with expertise in early stroke evaluation and management may address challenges.

Predictors of stroke favorable functional outcome in Guinea, results from the Conakry stroke registry

Low- to middle-income countries (LMICs) now bear most of the stroke burden. In LMICs, stroke epidemiology and health care systems are different from HICs. Therefore, a high-income country (HIC)-based predictive model may not correspond to the LMIC stroke context. Identify the impact of modifiable variables in acute stroke management in Conakry, Guinea as potential predictors of favorable stroke outcome. Data were extracted from the Conakry stroke registry that includes 1018 patients. A logistic regression model was built to predict favorable stroke outcomes, defined as mRS 0–2. Age, admission NIHSS score, mean arterial blood pressure and capillary glycemia were chosen as covariates. Delay to brain CT imaging under 24 h from symptom onset, fever, presence of sores and abnormal lung auscultation were included as factors. NIHSS score on admission, age and ischemic stroke were included in the null model as nuisance parameters to determine the contribution of modifiable variables to predict stroke favorable outcome. Lower admission NIHSS, brain CT imaging within 24 h of symptoms onset and lower mean arterial blood pressure emerged as a significant positive predictors of favorable stroke outcome with respective odd ratios (OR) of 1.35 [1.28–1.43], 2.1 [1.16–3.8] and 1.01 [1.01–1.04]. The presence of fever or sores impacted negatively stroke favorable outcomes with OR of 0.3 [0.1–0.85] and 0.25 [0.14–0.45]. The area under receiver operating characteristic curves (AUC) of the model was 0.86. This model explained 44.5% of the variability of the favorable stroke outcome with 10.2% of the variability explained by the modifiable variables when admission NIHSS, and ischemic stroke were included in the null model as nuisance parameter. In the Conakry stroke registry, using a logistic regression to predict stroke favorable outcome, five variables that led to an AUC of 0.86: admission NIHSS, early brain CT imaging, fever, sores and mean blood pressure. This paves the way for future public health interventions to test whether modulating amendable variables leads to increased favorable stroke outcomes in LMICs.

Cardiovascular risk and stroke mortality in persons living with HIV: a longitudinal study in a hospital in Yaounde

Introduction

HIV infection is a well-known risk factor for stroke, especially in young adults. In Cameroon, there is a death of data on the outcome of stroke among persons living with HIV (PLWH). This study aimed to assess the cardiovascular risk profile and mortality in PLWH who had a stroke.

Methods

this was a retrospective cohort study of all PLWH aged ≥18 years admitted for stroke between January 2010 and December 2019 to the Cardiology Unit of the Yaoundé Central Hospital, Cameroon. Cardiovascular risk was estimated using the modified Framingham score, with subsequent dichotomization into low and intermediate/high risk. Mortality was assessed on day 7 during hospitalization (medical records), at one month, and one year by telephone call to a relative.

Results

a total of 43 PLWH who had a stroke were enrolled. Their mean age was 52.1 (standard deviation 12.9) years, most of them were female (69.8%, n = 30). There were 25 (58.1%) patients on concomitant antiretroviral therapy. The Framingham cardiovascular risk score at admission was low in 29 patients (67.4%) and intermediate to high in 14 patients (32.6%). Ischemic stroke was the most common type of stroke in 36 persons (83.7%). The length of hospital stay was 11.4 (interquartile range 9.2-13.7) days. Mortality at 1 year was 46.5% (n = 20).

Conclusion

stroke mortality was high in this population of PLWH. Most patients had a low Framingham score, suggesting that this risk estimation tool underestimates cardiovascular risk in PLWH.

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.

Recurrent Ischemic and Hemorrhagic Stroke in Cameroon: A Case-Control Study

Introduction

Stroke recurrence accounts for a great percentage of catastrophic complications, yet no comprehensive study has analyzed the factors associated with stroke recurrence in Cameroon. We carried out this case-control study to better understand the factors associated with the stroke recurrence in Cameroon.

Methods

We collected sociodemographic, clinical, neuroimaging, laboratory, and therapeutic data of eligible patients who consulted the neurology and cardiology department of the Yaounde Central Hospital in Cameroon. We included all patients at least five years removed from their first stroke event who consulted the authors' institution as of January 15, 2019. Wilcoxon signed-rank and Fisher's exact tests were used. Also, a Cox regression model was used to identify confounders.

Results

We recruited 100 patients; seven out of ten patients had hypertension, while six out of 10 had a sedentary lifestyle. Half of the patients consumed alcohol regularly, while one patient out of five had diabetes. Most patients presented with their first stroke event, and a quarter had a stroke recurrence. Stroke recurrence was associated with right handedness (OR = 0.23, 95% CI = 0.16–0.33), congestive heart failure (OR = 3.45, 95% CI = 1.16–10.28), gout (OR = 4.34, 95% CI = 1.09–18.09), dysarthria (OR = 4.34, 95% CI = 1.30–14.54), and facial palsy (OR = 3.96, 95% CII = 1.49 – 10.51), as well as modifiable factors such as elevated abdominal circumference (P < 0.01), systolic blood pressure (P < 0.01), blood glucose level (PI <I 0.01), LDL cholesterol (P < 0.01), and triglyceride levels (P < 0.01). The mulitvariable regression model only identified laterality (B = –1.48, P = 0.04) as a statistically significant explanatory varibale for stroke recurrence.

Conclusion

We mapped the landscape of recurrent strokes in Cameroon. There is a need to evaluate the causes of suboptimal drug adherence rates and both the role and adherence to nonpharmacologic interventions.

Treatment Outcome and Its Determinants among Patients Admitted to Stroke Unit of Jimma University Medical Center, Southwest Ethiopia

Background

Stroke is a public health problem in Ethiopia. Despite the high prevalence of stroke in Ethiopia, there is a paucity of data with regard to drug treatment, treatment outcome, and risk factors of poor treatment outcome of stroke. Hence, this study is aimed at assessing treatment outcome and its determinants among patients admitted to stroke unit of Jimma University Medical Center (JUMC).

Methods

A two-year hospital-based retrospective cross-sectional study was employed to analyze the medical records of patients admitted with stroke to stroke unit of Jimma University Medical Centre from February 1^st, 2016 to March 30^th, 2018. Data was entered by Epidata manager version 4.0.2 and analyzed by SPSS version 24. Multivariable logistic regression analysis with the backward stepwise approach was done to identify independent predictors of poor treatment outcome of stroke. Variables with P value less than 0.05 were considered as statically significant determinants of poor treatment outcome.

Results

Of 220 patients with stroke admitted to the Jimma University, 67.30% were male. Nearly two thirds (63.18%) of them had poor treatment outcomes. Dyslipidimics were administered to 60% of the patients, and the most popular antiplatelet used was aspirin, which was prescribed to 67.3% the patients. Age ≥ 65 adjusted odd ratio ((AOR): 2.56; 95% CI: 1.95-9.86, P = 0.001), presence of comorbidity (AOR: 5.25; 95% CI: 1.08-17.69, P < 0.001), admission with hemorrhagic stroke (AOR: 18.99; 95% CI: 7.05-42.07, P < 0.001), and admission to the hospital after 24 hour of stroke onset (AOR: 4.98; 95% CI: 1.09-21.91, P = 0.03) were independent predictors of poor treatment outcomes.

Conclusion

Substantial numbers of stroke patients had poor treatment outcomes. Elderly patients, patients diagnosed with hemorrhagic stroke, patients with comorbidity, and those with delayed hospital admission were more likely to have poor treatment outcome. Hence, frequent monitoring and care should be given for the aforementioned patients. Awareness creation on the importance of early admission should be delivered particularly for patients who have risk factors of stroke (cardiovascular diseases).

Clinical Characteristics, Treatment Outcomes, and its Predictors Among Hospitalized Stroke Patients in Ambo University Referral Hospital, West Ethiopia: A Retrospective Hospital-Based Study

Background

Stroke is becoming a leading cause of death and adult disability in the developing world.

Objective

The objective of the study was to assess the clinical characteristics, treatment outcomes, and its predictors among stroke patients admitted to Ambo University Referral Hospital (AURH), West Ethiopia.

Methods

All 111 stroke patients hospitalized from April 2016 to May 2019 were included using a hospital-based retrospective study. Socio-demographic profile, past medication history, clinical presentation, drugs prescribed for comorbid condition and stroke treatment, and outcomes data were collected using data abstraction formats and results were summarized using both descriptive and inferential statistics.

Key Findings

According to WHO clinical criteria, 89 (80.2%) were diagnosed with ischemic stroke, and 20 (18.0%) were diagnosed with hemorrhagic stroke. The majority of the patients 94 (84.7%) had at least one antecedent risk factor in which hypertension accounted for 44.1%. More than half, 69 (62.2%), of hospitalized stroke patients had good treatment outcomes while 42 (37.8%) had a poor outcome. The overall case-fatality rate was 18 (16.2%), 12 (13.5%) from ischemic stroke, and 6 (30.0%) from hemorrhagic stroke. Acetyl salicylic acid (ASA) with atorvastatin/simvastatin, 67 (73.5%) in ischemic stroke and 12 (60.0%) in hemorrhagic stroke, was the most frequent medications prescribed for stroke during admission while it was frequently prescribed for 48 (53.6%) of ischemic stroke and 10 (50.0%) of the hemorrhagic stroke on discharge. Overall, ceftriaxone + metronidazole 32 (28.8%) was frequently prescribed concomitant medications during admission. The major predictors identified for poor stroke outcomes were substance abuse (AOR=2.839, P=0.024) and have had not received any medication for stroke treatment during admission (AOR=12.503, P≤0.001).

Conclusion

A significant number of the admitted stroke patients had poor treatment outcome in which the case-fatality rate was relatively high. Substance abuse and having not received medication for stroke were the significant predictors for poor treatment outcome. Hence, a well-established stroke unit setup at AURH is required for accurate diagnosis and management of stroke to overcome stroke-related mortality and/or poor treatment outcome.

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.

Insights in the pathophysiology of haemorrhagic strokes in a sub-Sahara African country, an epidemiological and MRI study

OBJECTIVE

Intra-cerebral Haemorrhage (ICH) seems more prevalent in sub-Saharan Africa (SSA) than in High-Income Countries (HIC) with poorer clinical outcome. Higher impact of hypertension and/or amyloid angiopathy could account for this disproportion. Here, we sought to (i) retrospectively compare ICH clinical and imaging patterns in Belgium and Guinea and in a subsequent cohort (ii) prospectively compare brain MRI characteristics to seek evidence for a different proportion of amyloid angiopathy patterns.

METHODS

Ninety one consecutive patients admitted for spontaneous ICH at Brussels Erasme-ULB Hospital and at Conakry Ignace Deen-UGANC were retrospectively compared in terms of ICH volume estimated with the ABC/2 method, clinical characteristics and modified ranking (mRS) score at 30 days. mRS was dichotomised as good outcomes (≤3) and poor outcomes (>3). A prospective cohort of 30 consecutive patients with ICH admitted at CHU Conakry Ignace Deen-UGANC was prospectively included to undergo brain MRI. Results of the Guinean MRI were compared to 30 patients randomly selected from Brussels' initial cohort. Paired Student's t-test and Mann-Whitney u-test were used for group comparisons.

RESULTS

Age of ICH onset was higher in Belgium (68 ± 17 years vs. 56 ± 14 years, P < 0.01) while ICH volume and 30-day mortality rate were higher in Guinea (20 ml vs. 11 ml, P < 0.01 and mortality 33% vs. 10 %, P < 0.01). ICH burden in survivors in Conakry and Brussels showed respectively good outcomes in 56.7% and 60.4% (P = 0.09) and poor outcomes in 10.3% vs. 29.6% (P < 0.001). MRI analysis of the prospective cohort failed to disclose significant differences regarding brain MRI characteristics.

CONCLUSIONS

Intra-cerebral Haemorrhage affected patients 15 years younger in Guinea with larger haematoma volumes and higher mortality than in Belgium. MRI findings did not show more prevalent amyloid angiopathy pathology suggesting that better primary prevention of hypertension could positively impact ICH epidemiology in Guinea.

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

Background

Stroke data from Sierra Leone is limited, despite the increase in global burden of the disease. The aim of this study was to assess the risk factors, clinical outcomes and predictors of stroke mortality at a tertiary hospital in Freetown, Sierra Leone.

Methods

This retrospective cohort study was conducted on stroke patients admitted at the Connaught Teaching Hospital between 1st January to December 31, 2018. Clinical data related to stroke, with variables including patients’ demographics, stroke subtype, vascular risk factors, modified Rankin Scale (mRS), and outcomes were documented. In-hospital mortality, associated risk factors and predictors of stroke were determined. The study was approved by the Sierra Leone Ethics and Scientific Review Committee. It was registered under Research Registry https://www.researchregistry.com/browse-the-registry#home/with the unique identifying number researchregistry6009.

Result

We studied 178 (95 male and 83 female) patients. The mean age was 59.8 ± 14.0 years, median was 58.1years (ranging: 29–88 years). The commonest risk factors were hypertension (84.3%), tobacco smoking (35.9%) and alcohol (31.4%). Ischemic stroke confirmed by CT scan was 76.3%. In-hospital mortality was 34.8% and at discharge, mean modified Rankin Score (mRS) was 3.89 ± 1.62. The independent predictors for stroke mortality were: hypertension [AOR = 2.2; C.I 95%: (1.32–3.80), p = 0.001], previous stroke [AOR = 2.31; C.I 95%: (1.43–5.74), p = 0.001], GCS < 8 [AOR = 6.06; C.I 95%: (3.17–12.79), p < 0.001], clinical diagnosis in the absence of imaging [AOR = 3.11; C.I 95%: (2.1–9.87), p = 0.001], hemorrhagic stroke [AOR = 2.96; C.I 95%: (1.96–9.54), p < 0.001], and aspiration pneumonia [(AOR = 3.03; C.I 95%:(1.44–6.36), p = 0.001]. Women had poorer outcome than men.

Conclusion

This study highlights a high stroke mortality in a resource limited hospital, with some stroke patients having difficulties in accessing Computer Tomogram (CT) scan services. It illustrates the need to establish a stroke care setting to improve the quality of stroke care.

•

Globally, sub-Saharan Africa (SSA) has the highest incidence and case-fatality from stroke.

•

In Sierra Leone, the dearth of stroke data limits the access to evidence-based standards of stroke care.

•

We reported a high in-hospital stroke mortality, with majority of the deaths occurring in the first week, and this is comparable to some reported studies from SSA.

•

The poor control of hypertension and aspiration pneumonia are major but avoidable contributors to poor stroke outcomes in SSA.

Survival of Stroke Patients According to Hypertension Status in Northern Ethiopia: Seven Years Retrospective Cohort Study

Background

Globally, stroke appears as a major cause of preventable deaths and disabilities. In Ethiopia, the intra-hospital mortality of stroke is significant; however, epidemiologic data are scarce whether there is a difference in the overall survival time between hypertensive and non-hypertensive adult stroke patients admitted in specialized hospitals. This study was intended to determine the survival of stroke patients according to their hypertension status admitted in Ayder Comprehensive Specialized Hospital, Northern Ethiopia from March 1, 2012, to February 28, 2019.

Methods and Findings

A hospital-based retrospective cohort study was conducted among all cohorts of confirmed first-ever stroke patients admitted in Ayder Comprehensive Specialized Hospital, Northern Ethiopia. Kaplan–Meier survival analysis was applied to estimate the survival probability of hypertensive and non-hypertensive first-ever stroke patients. Cox proportional hazards regression model was used to determine the adjusted hazard ratio of death for each main baseline predictor variable with 95% CI, and P-value <0.05 was used to declare statistical significance. The assumptions of the Cox proportional hazards regression model assessed by the global test, Schoenfeld residuals. There were 503 (323 were hypertensive, 180 Non-hypertensive) confirmed first, ever adult stroke patients, the overall median age of the patients was 65 years, IQR (53–75) years. Seventy-five (14.9%) of them were dead, with a median survival time of 48 days and 428 (85.1%) of them were censored. At any particular point in time, the hazard of death among hypertensive patients was two times higher than non-hypertensive patients, but this was not found to be a statistically significant (adjusted HR=2.13: 95% CI 0.66–6.81). Glasgow Coma Scale 3–8 at admission (adjusted HR=10.12; 95% CI 2.58–40.68), presence of stroke complications (adjusted HR=7.23; 95% CI 1.86–28.26) and borderline high total cholesterol level (adjusted HR=3.57; 95% CI 1.15–11.1) were the only independent predictors of intra-hospital patient mortality.

Conclusion

The overall survival time difference between hypertensive and non-hypertensive first-ever adult stroke patients was not statistically significant. Early identification and treatment of stroke complications, co-morbidities along strict follow-up of comatose patients may improve the intra-hospital survival of stroke patients, and we also recommend community-based studies using a large sample size.

Predictors of 30-day and 90-day mortality among hemorrhagic and ischemic stroke patients in urban Uganda: a prospective hospital-based cohort study

Background

We report here on a prospective hospital-based cohort study that investigates predictors of 30-day and 90-day mortality and functional disability among Ugandan stroke patients.

Methods

Between December 2016 and March 2019, we enrolled consecutive hemorrhagic stroke and ischemic stroke patients at St Francis Hospital Nsambya, Kampala, Uganda. The primary outcome measure was mortality at 30 and 90 days. The modified Ranking Scale wasused to assess the level of disability and mortality after stroke. Stroke severity at admission was assessed using the National Institute of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS). Examination included clinical neurological evaluation, laboratory tests and brain computed tomography (CT) scan. Kaplan-Meier curves and multivariate Cox proportional hazard model were used for unadjusted and adjusted analysis to predict mortality.

Results

We enrolled 141 patients; 48 (34%) were male, mean age was 63.2 (+ 15.4) years old; 90 (64%) had ischemic and 51 (36%) had hemorrhagic stroke; 81 (57%) were elderly (≥ 60 years) patients. Overall mortality was 44 (31%); 31 (23%) patients died within the first 30 days post-stroke and, an additional 13 (14%) died within 90 days post-stroke. Mortality for hemorrhagic stroke was 19 (37.3%) and 25 (27.8%) for ischemic stroke. After adjusting for age and sex, a GCS score below < 9 (adjusted hazard ratio [aHR] =3.49, 95% CI: 1.39–8.75) was a significant predictor of 30-day mortality. GCS score < 9 (aHR =4.34 (95% CI: 1.85–10.2), stroke severity (NIHSS ≥21) (aHR = 2.63, 95% CI: (1.68–10.5) and haemorrhagic stroke type (aHR = 2.30, 95% CI: 1.13–4.66) were significant predictors of 90-day mortality. Shorter hospital stay of 7–13 days (aHR = 0.31, 95% CI: 0.11–0.93) and being married (aHR = 0.22 (95% CI: 0.06–0.84) had protective effects for 30 and 90-day mortality respectively.

Conclusion

Mortality is high in the acute and sub-acute phase of stroke. Low levels of consciousness at admission, stroke severity, and hemorrhagic stroke were associated with increased higher mortality in this cohort of Ugandan stroke patients. Being married provided a protective effect for 90-day mortality. Given the high mortality during the acute phase, critically ill stroke patients would benefit from early interventions established as the post-stroke- standard of care in the country.

Magnitude of risk factors and in-hospital mortality of stroke in Ethiopia: a systematic review and meta-analysis

Background

The morbidity and mortality of stroke is disproportionately high in developing countries owing to the poor health care system and poor neurologic interventions. Though a number of studies were conducted to estimate the in-hospital mortality rate of stroke in Ethiopia, the lack of a nationwide study that determines the overall magnitude of risk factors and in-hospital mortality rate of stroke is an important research gap. Meta-analysis is key to improve the accuracy of estimates through the use of more data sets. Thus, this study was aimed to determine the overall magnitude of risk factors and in-hospital mortality rate of stroke in Ethiopia.

Methods

This study was conducted following the PRISMA checklist. We searched from Google Scholar, PubMed, Science Direct, Web of Science, CINAHL, and Cochrane Library databases for studies. Each of the original studies was assessed using a tool for the risk of bias adapted for cross-sectional studies. Data were pooled and a random effect meta-analysis model was fitted to provide the overall magnitude of risk factors and in-hospital mortality rate of stroke. Also, the subgroup analyses were performed to examine how the in-hospital mortality rate varies across different groups of studies.

Results

In this study, the overall magnitude of hypertension, diabetes mellitus, and atrial fibrillation among stroke patients were 47% (95%CI: 40–54), 8% (95CI%:6–12), and 10% (95%CI: 5–19), respectively. The overall in-hospital mortality of stroke in Ethiopia was 18% (95%:14–22). The highest magnitude of in-hospital mortality of stroke was observed in SNNPR and the lowest was noted in Tigray region. In addition, the magnitude of the in-hospital mortality rate of stroke was 15.1% (95%CI: 11.3–19.4), and 19.6%(95%CI: 14.1–25.7), among studies published before and after 2016, respectively.

Conclusions

Our pooled result showed that nearly one-fifth of stroke patients have died during hospitalization. The most common risk factor of stroke among the included studies was hypertension followed by atrial fibrillation and diabetes mellitus. There is a need for a better understanding of the factors associated with high blood pressure, especially in countries with a high risk of stroke.

May Measurement Month 2018: blood pressure screening results in Cameroon

Hypertension is a global public health challenge, but awareness, treatment, and control rates remain low. May Measurement Month (MMM) creates a platform for awareness creation and opportunistic screening which can identify significant numbers with raised blood pressure (BP). We present results of the 2018 edition of MMM in Cameroon. A cross-sectional survey of self-selected volunteers aged ≥18 years was conducted in May 2018. The definition of hypertension and statistical analyses followed the standard protocol. Data were collected from 28 public (indoors and outdoors) and private locations which were assigned unique site identification numbers, over a 30-day period. Of the 8883 participants screened, 53.8% were male and the median age was 35 (interquartile range 21) years, and 30.0% reported not having a previous BP measurement. After imputation, 1867 (21.0%) were hypertensive, 645 (34.5%) were aware of their diagnosis, and 507 (27.2%) were on antihypertensive medication, among whom 242 (47.8%) had controlled BP. In linear regression models adjusting for age, sex, and the use of antihypertensive medication, systolic and diastolic BP were significantly higher in participants aware of their diagnosis, those on antihypertensive medication, and who reported alcohol intake of 1-3 times per month and, one or more times per week. Hypertension prevalence is the lowest, and awareness, treatments, and control rates the highest reported in epidemiological studies in Cameroon in the last two decades. Further surveys will be useful in evaluating the impact, if any, of the MMM campaign on the burden of hypertension in the Cameroon.

30-day and 60-day rates and predictors of mortality among adult stroke patients: Prospective cohort study

Stroke is one of the most common medical emergencies and the leading cause of preventable death and long-term disability worldwide. A prospective cohort study was conducted at the stroke unit of Jimma university medical center for four consecutive months (from March 10 to July 10, 2017). Of the total 116 study patients, 60 (51.7%) had an ischemic stroke. At 30-day follow-up, 81 (69.8%) patients were alive, 34 (29.3%) were died, and one patient (0.9%) was lost to follow-up. Elevated alanine aminotransferase (ALT) level (AHR: 3.77, 95% CI: 1.34-10.57), diagnosis of stroke clinically alone (AHR: 3.90, 95 CI: 1.49-10.26), brain edema (AHR: 4.28, 95% CI: 1.61-11.37), and National Institute of Health Stroke Scale (NIHSS) ≥ 13 during hospital arrival (AHR: 6.49, 95% CI: 1.90-22.22) were the independent predictors of 30-day mortality. At 60-day follow-up, 68 (58.6%) patients were alive, 46 (39.7%) were died, and 2 (1.7%) were lost to follow-up. Discharge against medical advice (AHR: 6.40, 95% CI: 2.31-17.73) and severe modified Rankin score/mRS (4-5) at discharge (AHR: 3.64, 95% CI: 1.01-13.16) were the independent predictors of 60-day mortality. The median (IQR) length of survival after hospital admission for patients died within 30 and 60 days were 4.65 (2.34-11.80) and 9.3 (3.93-33) days, respectively. Stroke significantly affects the morbidity and mortality in Ethiopia. There is a need to provide better care and future planning for stroke patients as an emergency diagnosis and treatment to minimize mortality and disability.

Post-stroke Complications and Mortality in Burkinabè Hospitals: Relationships with Deglutition Disorders and Nutritional Status

Stroke frequently causes deglutition disorders, leading to a decline in nutritional status and complications, and increasing mortality. Sub-Saharan data are scarce. The objectives of this study were to assess complications and mortality among hospitalized patients in Burkina Faso during the first two weeks after stroke, and to investigate associated factors. Patients with stroke were followed prospectively in Ouagadougou and Bobo-Dioulasso hospitals. Deglutition disorders and nutritional parameters were assessed at baseline (D0) and on Days 8 (D8) and 14 (D14). Complications and mortality were recorded up to D14. Factors associated with complications and mortality were investigated using multivariate analysis. Of the 222 patients included, 81.5% developed at least one complication, and mortality was 17.1%. At D0, D8, and D14, the rate of deglutition disorders was 37.4%, 28.4%, and 15.8%, respectively, and that of undernourishment 25.2%, 29.4%, and 31.0%, respectively. In multivariate analysis, only the presence of deglutition disorders was a risk factor for developing at least one complication (OR = 5.47, 95% CI 1.81-16.51). Factors predicting death were the presence of deglutition disorders at D0 (OR = 7.19, 95% CI 3.10-16.66), and at least one seizure during follow-up (OR = 3.69, 95% CI 1.63-8.36). After stroke, the rates of complications, death, and undernourishment were high compared to Western countries. Prevention and management of deglutition disorders, and specific follow-up of patients with seizures could reduce post-stroke mortality.

Magnitude, risk factors and outcomes of stroke at Debre Markos Referral Hospital, Northwest Ethiopia: a retrospective observational study

Background

Stroke is one of the leading causes of death and disability in developing countries. The burden of stroke has varied widely in different areas, and there is a paucity of information about stroke in the selected study area.

Objectives

To assess the burden, risk factors, and outcomes of stroke at Debre Markos Referral Hospital, Northwest Ethiopia

Patients and methods

A hospital-based retrospective observational study was conducted in the medical ward of Debre Markos Referral Hospital from March 2017 to April 2019. A pretested checklist was used to extract relevant data from the chart of stroke patients. All statistical analyses were performed in the SPSS version 20 software.

Results

From a total of 2100 admissions in the medical ward, 162 of them were stroke patients, giving the in-hospital magnitude of 7.7%. The in-hospital case fatality rate was 8.6%. Additionally, 27.2% of patients were improved and 39.5% of them were referred. There was a significant association between types of stroke and risk factors such as sex, comorbid hypertension, hyperlipidemia, and atrial fibrillation (P ≤ 0.05).

Conclusion

The in-hospital period prevalence of stroke was 7.7%. Ischemic stroke was the most common type of stroke. Hypertension and hyperlipidemia were the leading identified risk factors for stroke. The overall in-hospital mortality was lower than previous studies in sub-Saharan African countries. Therefore, effective strategies and guidelines for the prevention and control of stroke and its risk factors are needed.

Long-Term Mortality of Stroke Survivors in Parakou: 5-Year Follow-Up

BACKGROUND

The burden of stroke is high in Africa, but few data are available on the long-term outcome of strokes in this area.

AIM

We aimed to study the long-term outcome of stroke survivors in Parakou from 2012 to 2018.

METHODS OF STUDY

It was a cohort study and included 247 stroke patients admitted to the University Hospital of Parakou from January 1, 2012 to April 30, 2018. Each patient was followed up for at least 1 year. The modified RANKIN scale was used to evaluate patients. Verbal autopsy was used to ascertain the cause of death. The survival probability was estimated using the Kaplan-Meier method. Predictors of mortality were estimated using the Cox proportional model and the hazard ratio (HR) and their 95% confidence intervals were determined. The data were analyzed using Stata Software.

RESULTS

The mean age was 58.1 ± 13.4 years with a sex ratio of 1.12. Among stroke survivors, the mortality was 10.1% at 3 months, 11.7% at 6 months, 15.4% at 1 year, 21.5% at 3 years, and 23.5% at 5 years. The probability of survival after a stroke was 66.5% at 5 years. Factors associated with mortality were age with adjusted HR 1.4 (1.2-1.7) for each 10 years, male sex with aHR 2.3 (1.2-4.6), history of hypertension with aHR 2.0 (1.0-4.1) and the severity of the initial neurological impairment National Institute of Health Stroke Scale with aHR 1.1 (1.0-1.2) for each 1 point. The main causes of death were recurrent stroke, infectious diseases, and cardiac disease. The proportion of patients with functional disability was 53.8% at 1 year. The quality of life was generally impaired in terms of physical health, personal environment, and finances.

CONCLUSIONS

The long-term prognosis of stroke patients in Parakou is poor. It requires urgent action to reduce this burden.

Clinical characteristics and treatment outcomes among stroke patients hospitalized to Nekemte referral hospital, western Ethiopia

OBJECTIVES

Stroke is the brain equivalent of a heart attack. It is one of the most common causes of morbidity and mortality worldwide and is a prominent cause of death, disability and dementia in sub-Saharan Africa (SSA). Hence, the purpose of this study was to assess the clinical characteristics and treatment outcomes among hospitalized stroke patients at Nekemte referral hospital (NRH).

PATIENTS AND METHODS

Retrospective cross sectional study design was conducted on randomly selected stroke patients admitted to medical wards of NRH from 2013 to 2017.

RESULTS

Among 364 patients included in the study, 208 (57.1%) were males and the mean age of the patients was 59.66 ± 13.4 years. Regarding types of stroke, 192 (52.7%) were diagnosed as having ischemic stroke. During admission 132 (36.3%) patients complained left side body weakness (hemiparesis) and the major risk factor identified was hypertension 230 (63.2%). Overall, 65.4% of patients had poor outcome while 34.6% of patients had good out comes (improved). Being illiterate /unable to read and write (AOR = 3.94, 95% CI: 1.31-11.76, P = 0.01), attending secondary school (AOR = 3.6, 95% CI: 1.4-9.17, P = 0.007) and length of hospital stay >5 days (AOR = 2, 95% CI: 1.04-3.86, P = 0.037) were independent predictors of poor treatment outcome.

CONCLUSION

About two third of the patients had poor treatment outcome. Educational status and mean length of hospital stays were independent predictors of poor treatment out-comes. An emergency care setup capable of early patient evaluation, identification and management of stroke complications is crucial to overcome early stroke related mortality.

Risk factors, clinical presentations and predictors of stroke among adult patients admitted to stroke unit of Jimma university medical center, south west Ethiopia: prospective observational study

Background

Stroke is the second-leading global cause of death behind heart disease in 2013 and is a major cause of permanent disability. The burden of stroke in terms of mortality, morbidity and disability is increasing across the world. It is currently observed to be one of the commonest reasons of admission in many health care setups and becoming an alarming serious public health problem in our country Ethiopia. Despite the high burden of strokes globally, there is insufficient information on the current clinical profile of stroke in low and middle income countries (LMICs) including Ethiopia. So, this study was aimed to assess risk factors, clinical presentations and predictors of stroke subtypes among adult patients admitted to stroke unit of Jimma university medical center (JUMC).

Methods

Prospective observational study design was carried out at stroke unit (SU) of JUMC for 4 consecutive months from March 10–July 10, 2017. A standardized data extraction checklist and patient interview was used to collect data. Data was entered into Epi data version 3.1 and analyzed using SPSS version 20. Multivariable logistic regression was used to identify the predictors of stroke subtypes.

Result

A total of 116 eligible stroke patients were recruited during the study period. The mean age of the patients was 55.1 ± 14.0 years and males comprised 62.9%. According to world health organization (WHO) criteria of stroke diagnosis, 51.7% of patients had ischemic while 48.3% had hemorrhagic stroke. The most common risk factor identified was hypertension (75.9%) followed by family history (33.6%), alcohol intake (22.4%), smoking (17.2%) and heart failure (17.2%). The most common clinical presentation was headache complained by 75.0% of the patients followed by aphasia 60.3% and hemiparesis 53.4%. Atrial fibrillation was the independent predictor of hemorrhagic stroke (AOR: 0.08, 95% CI: 0.01–0.68).

Conclusion

The clinical characteristics of stroke in this set up were similar to other low- and middle-resource countries. As stroke is a high priority chronic disease, large-scale public health campaign should be launched focusing on public education regarding stroke risk factors and necessary interventions.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1409-0) contains supplementary material, which is available to authorized users.

Minimal Setting Stroke Unit in a Sub-Saharan African Public Hospital

Introduction: Sub-Saharan Africa (SSA) has the highest stroke prevalence along with a case fatality that amounts to 40%. We aimed to assess the effect of a minimal setting stroke unit in SSA Public hospital on stroke mortality and main medical complications.

Materials and Methods: The study was set in Conakry, Guinea, Ignace Deen public referral hospital. Clinical characteristics, hospital mortality and main medical stroke complications rates (pneumonia, urinary tract infections, sores and venous thromboembolism) of admitted stroke patients after the installation of a minimal stroke unit equipped with heart rate, blood pressure and blood oxygen saturation monitoring and portable oxygen concentrator (POST) were compared to a similar number of stroke patients admitted before the stroke unit creation (PRE).

Results: PRE (n = 318) and POST (n = 361) stroke, patients were comparable in term of age (61 ± 14 vs. 60 ± 14.8 years, p = 0.24), sex (56 vs. 50% males, p = 0.09), High blood pressure rate (76.7 vs. 79%, p = 0.44), stroke subtype (ischemic in 72 vs. 78% of cases, p = 0.05) and NIHSS (11 ± 4 vs. 11 ± 4, p = 0.85). Diabetes was more frequent in the PRE group (19 vs. 9%, p < 0.001). Mortality was significantly lower in the POST group (7.2 vs. 22.3%, p < 0.0001) as well as medical complications (4.1 vs. 27.7%, p < 0.001) and lower pneumonia rate (3.3 vs. 14.5%, p < 0.001).

Conclusions: Minimally equipped stroke units significantly reduce stroke mortality and main medical complications in SSA.

Risk factors, clinical presentations and predictors of stroke among adult patients admitted to stroke unit of Jimma university medical center, south west Ethiopia: prospective observational study

Background

Stroke is the second-leading global cause of death behind heart disease in 2013 and is a major cause of permanent disability. The burden of stroke in terms of mortality, morbidity and disability is increasing across the world. It is currently observed to be one of the commonest reasons of admission in many health care setups and becoming an alarming serious public health problem in our country Ethiopia. Despite the high burden of strokes globally, there is insufficient information on the current clinical profile of stroke in low and middle income countries (LMICs) including Ethiopia. So, this study was aimed to assess risk factors, clinical presentations and predictors of stroke subtypes among adult patients admitted to stroke unit of Jimma university medical center (JUMC).

Methods

Prospective observational study design was carried out at stroke unit (SU) of JUMC for 4 consecutive months from March 10–July 10, 2017. A standardized data extraction checklist and patient interview was used to collect data. Data was entered into Epi data version 3.1 and analyzed using SPSS version 20. Multivariable logistic regression was used to identify the predictors of stroke subtypes.

Result

A total of 116 eligible stroke patients were recruited during the study period. The mean age of the patients was 55.1 ± 14.0 years and males comprised 62.9%. According to world health organization (WHO) criteria of stroke diagnosis, 51.7% of patients had ischemic while 48.3% had hemorrhagic stroke. The most common risk factor identified was hypertension (75.9%) followed by family history (33.6%), alcohol intake (22.4%), smoking (17.2%) and heart failure (17.2%). The most common clinical presentation was headache complained by 75.0% of the patients followed by aphasia 60.3% and hemiparesis 53.4%. Atrial fibrillation was the independent predictor of hemorrhagic stroke (AOR: 0.08, 95% CI: 0.01–0.68).

Conclusion

The clinical characteristics of stroke in this set up were similar to other low- and middle-resource countries. As stroke is a high priority chronic disease, large-scale public health campaign should be launched focusing on public education regarding stroke risk factors and necessary interventions.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1412-5) contains supplementary material, which is available to authorized users.

Stroke distribution patterns and characteristics in Kenya's leading public health tertiary institutions: Kenyatta National Hospital and Moi Teaching and Referral Hospital

Background

Cardiovascular diseases are the second leading cause of morbidity and mortality in Kenya. However, there is limited clinico-epidemiological data on stroke to inform decision making. This study sought to establish stroke distribution patterns and characteristics in patients seeking care at Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH), with the ultimate aim of establishing the first national stroke registry in Kenya.

Methods

This was a prospective multicentre cohort study among stroke patients. The study used a modified World Health Organisation STEP-wise approach to stroke surveillance tool in collecting data on incidence, major risk factors and mortality rate. The Cochran’s Mantel–Haenszel chisquared test of conditional independence was used with p-value set at 0.05.

Results

A total of 691 patients with confirmed stroke were recruited [KNH 406 (males: 40.9%; females: 59.1%); MTRH 285 (males: 44.6%; females: 55.4%)] and followed over a 12-month period. Overall, ischaemic stroke accounted for 55.6% of the stroke cases, with women being the most affected (57.5%). Mortality rate at day 10 was 18.0% at KNH and 15.5% at MTRH, and higher in the haemorrhagic cases (20.3%). The most common vascular risk factors were hypertension at 77.3% (males: 75.7%; females: 78.5%), smoking at 16.1% (males: 26.6%; females: 8.3%) and diabetes at 14.9% (males: 15.7%; females: 14.4%). Ischaemic stroke was conditionally independent of gender after adjusting for age.

Conclusions

To our knowledge this is the first pilot demonstration establishing a stroke registry in sub-Saharan Africa and clearly establishes feasibility for this approach. It also has utility to both inform and potentially guide public policy and public health measures on stroke in Kenya. Important and unexpected observations included the preponderance of women affected by cerebrovascular disease and that cigarette smoking was the second most common risk factor. The latter, over time, will further impact on the clinico-epidemiological profile of cerebrovascular disease in Kenya.

Stroke Event Factors among Adult Patients Admitted to Stroke Unit of Jimma University Medical Center: Prospective Observational Study

Background

The fact that the majority of patients come late creates management difficulties as these first hours are important to avoid secondary insults to the brain and preserve the ischemic penumbra. Although thrombolytic treatments are currently not available in our hospital, significant delays during the prehospital or in-hospital phases of care create management difficulties and would make such advanced treatments impossible in the future in Ethiopia.

Methods

Prospective observational study was carried at stroke unit of Jimma University Medical Center for 4 consecutive months from March 10 to July 10, 2017. Data was cleaned and entered to Epidata version 3.1 and then exported and analyzed using SPSS version 20.0.

Results

A total of 116 eligible stroke patients were recruited during the study period with mean age of 55.1±14.0 years, ranging from 23 to 96 years. The majority of stroke patients were males (62.9%) and from rural areas (72.4%). The median time elapsed between the onset of stroke symptoms and arrival to the hospital was 27 hours. Almost half (47.4%) of the patients presented within 24 hours and 26 (22.4%) patients presented to hospital beyond 72 hours. Majority of patients (40.5%) showed severe neurological deficit on admission and the mean National Institute of health stroke scale (NIHSS) was 15.71 ± 7.52. The mean Glasgow coma scale (GCS) was moderate (12.12±3.35). On hospital arrival systolic blood pressure (SBP) was highly elevated (≥140 mm Hg) in 65.5% of the patients. The circadian pattern showed a significant peak in morning for hemorrhagic stroke (35.7%) and afternoon for ischemic stroke (38.3%).

Conclusions

The delay of hospital arrival was a challenge similar to other high income countries for early management of the patients. Studies that attempt to determine some of the factors that impede timely presentation in patients with strokes are advisable to address those issues further.

Stroke Mortality in Kenya's Public Tertiary Hospitals: A Prospective Facility-Based Study

Background

Despite the increasing global burden of stroke, there are limited data on stroke from Kenya to guide in decision-making. Stroke occurrence in sub-Saharan Africa has been associated with poor health outcomes. This study sought to establish the stroke incidence density and mortality in Kenya's leading public tertiary hospitals for purposes of informing clinical practice and policy.

Methods

This is a prospective study conducted at Kenya's leading referral hospitals, namely, Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH). Adult patients with confirmed cases of stroke were recruited from February 2015 to January 2016 and followed up for a minimum period of 1 year. The WHO 2006 Stroke STEPS instrument was used to collect data on incidence and mortality at days 10 and 28 and every 3 months for 24 months. The person-time of follow-up was computed from admission to death, loss to follow-up, or the end of the study. A survival regression analysis was done using the Cox proportional hazards model.

Results

A total of 719 patients were recruited (KNH: n = 406 [56.5%]; MTRH: n = 313 [43.5%]). The mean age was 58.6 ± 18.7 years, and the male-to-female ratio was 1: 1.4. Ischemic stroke accounted for 56.1% of the stroke cases. The peak age for stroke was between 50 and 69 years, when 36.3% of the cases occurred. Mortality at day 10 and day 28 was 18.4 and 26.7%, respectively. The inpatient mortality rate was 21.6%. The stroke incidence density was 507 deaths per 1,000 person-years of follow-up. The mean survival time was significantly different between inpatients (13.9 months; 95% CI: 13.0–14.7) and outpatients (18.6 months; 95% CI: 17.2–19.9) (p < 0.001). A 1-year increase in age increased the hazard by 1.8%. Inpatients had a 3.9-fold increase in hazard compared to outpatients.

Conclusions

Mortality due to stroke is high, with poor survival observed in the first year after stroke. The risk of death increases with increasing age and duration of hospital stay. There is need for attention to quality of care and long-term needs of stroke patients to mitigate the high mortality rates observed. Public health initiatives aimed at early screening and diagnosis should be enhanced. Further research is recommended to establish the true burden of stroke at the community level to inform appropriate mitigation measures.

In Hospital Stroke Mortality: Rates and Determinants in Southwestern Saudi Arabia

Objectives: The present study analyzed in-hospital first-time stroke mortality in southwestern Saudi Arabia over one-year to assess the in-hospital stroke case fatality rate, mortality rate and explore the factors associated with in-hospital stroke mortality. Study Design: Hospital based follow-up study. Methods: First-time stroke patients admitted to all hospitals in Asser region over one-year period (January through December 2016) were included in the study. Data about personal characteristics, pre-stroke history and clinical criteria, on admission clinical criteria, in-hospital complications and survival status were collected. The last reported Aseer region population was used to calculate age and sex stroke mortality rate per 100,000 population/year. Hazard ratios (HR) and concomitant 95% confidence intervals (95% CI) were computed using multivariate Cox regression survival analysis. Kaplan-Meier curve survival analysis for stroke patients were plotted. Results: A total of 121 in-hospital deaths out of 1249 first-time stroke patients giving an overall case fatality rate (CFR) of 9.7%. Non-significant difference with gender and age were observed in CFR. Overall, in-hospital stroke mortality rate was 5.58 per 100,000/year. Males and elders showed a significantly higher mortality rates. Multivariable Cox regression analyses revealed pre-stroke smoking (HR = 2.36), pre-stroke hypertension (HR = 1.77), post-stroke disturbed consciousness (HR = 6.86), poor mobility (HR = 2.60) and developing pulmonary embolism (HR = 2.63) as significant predictors of in-hospital stroke mortality. Conclusions: In Southwestern Saudi Arabia, the in-hospital stroke mortality rate is higher in men and increases with aging. The prognosis of acute stroke could be improved by smoking cessation, better control of hypertension and prevention of in hospital complication particularly pulmonary embolism.

Association between platelet distribution width and poor outcome of acute ischemic stroke after intravenous thrombolysis

PURPOSE

The platelet distribution width (PDW) reflects the status of platelet activity and may be useful for early predictions of the clinical outcome of stroke patients. The purpose of the study was to determine the associations between PDW and clinical outcomes after intravenous thrombolysis in stroke patients.

PATIENTS AND METHODS

Acute ischemic stroke patients who received intravenous treatment with recombinant tissue-type plasminogen activator were selected for inclusion in the retrospective cohort of this study. The relations between PDW at admission and clinical outcomes were analyzed, including a poor outcome as assessed using the modified Rankin Scale at 3 months, early neurological improvement, and any hemorrhage. The effect of PDW at admission on a poor outcome at 3 months was analyzed using a multivariable logistic regression model with adjustment for potential confounders. The optimal PDW cutoff for predicting poor outcome at 3 months was determined by analyzing the receiver operating characteristics curve.

RESULTS

PDW was significantly higher for a good outcome than a poor outcome (p=0.005), with median (interquartile range) values of 16.2 (13.2-17.2) and 13.6 (12.5-15.9), respectively. PDW was also higher in patients with early neurological improvement than in patients without improvement (p=0.020) and did not differ between hemorrhage and nonhemorrhage patients. The association between PDW <16.05% and poor outcome remained in a multivariable logistic regression analysis, with an OR of 6.68 and a 95% CI of 1.69-26.49 (p=0.007).

CONCLUSION

Results suggest a novel hypothesis that a lower PDW may be related with a poor outcome at 3 months after intravenous thrombolysis in acute ischemic stroke patients.

The epidemiology of stroke in Africa: A systematic review of existing methods and new approaches

Accurate epidemiological surveillance of the burden of stroke is direly needed to facilitate the development and evaluation of effective interventions in Africa. The authors therefore conducted a systematic review of the methodology of stroke epidemiological studies conducted in Africa from 1970 to 2017 using gold standard criteria obtained from landmark epidemiological publications. Of 1330 articles extracted, only 50 articles were eligible for review grouped under incidence, prevalence, case-fatality, health-related quality of life, and disability-adjusted life-years studies. Because of various challenges, no study fulfilled the criteria for an excellent stroke incidence study. The relatively few stroke epidemiology studies in Africa have significant methodological flaws. Innovative approaches leveraging available information and communication technology infrastructure are recommended to facilitate rigorous epidemiological studies for accurate stroke surveillance in Africa.

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review

Background: The burden of stroke in low- and middle-income countries (LMICs) is large and increasing, challenging the already stretched health-care services. Aims and Objectives: To determine the quality of existing stroke-care services in LMICs and to highlight indigenous, inexpensive, evidence-based implementable strategies being used in stroke-care. Methods: A detailed literature search was undertaken using PubMed and Google scholar from January 1966 to October 2015 using a range of search terms. Of 921 publications, 373 papers were shortlisted and 31 articles on existing stroke-services were included. Results: We identified efficient models of ambulance transport and pre-notification. Stroke Units (SU) are available in some countries, but are relatively sparse and mostly provided by the private sector. Very few patients were thrombolysed; this could be increased with telemedicine and governmental subsidies. Adherence to secondary preventive drugs is affected by limited availability and affordability, emphasizing the importance of primary prevention. Training of paramedics, care-givers and nurses in post-stroke care is feasible. Conclusion: In this systematic review, we found several reports on evidence-based implementable stroke services in LMICs. Some strategies are economic, feasible and reproducible but remain untested. Data on their outcomes and sustainability is limited. Further research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs should be a priority.

Clinical Parameters, Routine Inflammatory Markers, and LTA4H Genotype as Predictors of Mortality Among 608 Patients With Tuberculous Meningitis in Indonesia

Background

Damaging inflammation is thought to contribute to the high morbidity and mortality of tuberculous meningitis (TBM), but the link between inflammation and outcome remains unclear.

Methods

We performed prospective clinical and routine laboratory analyses of a cohort of adult patients with TBM in Indonesia. We also examined the LTA4H promoter polymorphism, which predicted cerebrospinal fluid (CSF) leukocyte count and survival of Vietnamese patients with TBM. Patients were followed for >1 year.

Results

We included 608 patients with TBM, of whom 67.1% had bacteriological confirmation of disease and 88.2% had severe (ie, grade II or III) disease. One-year mortality was 43.7% and strongly associated with decreased consciousness, fever, and focal neurological signs. Human immunodeficiency virus (HIV) infection, present in 15.3% of patients, was associated with higher mortality and different CSF characteristics, compared with absence of HIV infection. Among HIV-uninfected patients, mortality was associated with higher CSF neutrophil counts (hazard ratio [HR], 1.10 per 10% increase; 95% confidence interval [CI], 1.04-1.16), low CSF to blood glucose ratio (HR, 1.16 per 0.10 decrease; 95% CI, 1.04-1.30), CSF culture positivity (HR, 1.37; 95% CI, 1.02-1.84), and blood neutrophilia (HR, 1.06 per 109 neutrophils/L increase; 95% CI, 1.03-1.10). The LTA4H promoter polymorphism correlated with CSF mononuclear cell count but not with mortality (P = .915).

Conclusions

A strong neutrophil response and fever may contribute to or be a result of (immuno)pathology in TBM. Aggressive fever control might improve outcome, and more-precise characterization of CSF leukocytes could guide possible host-directed therapeutic strategies in TBM.

Recurrent Stroke and Early Mortality in an Urban Medical Unit in Cameroon

BACKGROUND

Data on stroke mortality in recurrent strokes in the context of limited acute stroke care and secondary stroke prevention within Africa are very scant. We investigated the risk of in-hospital death in patients with recurrent stroke in the medical department of the Yaoundé Central Hospital in Cameroon.

METHODS

Admission and discharge registries, and patient files for the period 1999-2012, were reviewed for evidence of admission for stroke, recurrent stroke, and in-hospital death. Mortality was compared between recurrent and first-ever stroke overall, and heterogeneities across major subgroups were assessed via interaction tests.

RESULTS

Out of 1678 participants included in the final analytic sample, 243 (14.5%) had recurrent stroke. Our first-ever stroke participants were older (median age 65.0 years versus 62.0 years, P = .024), had a worse stroke risk profile (prevalent diabetes 17.5% versus 12.0%, P = .018; atrial fibrillation 3.7% versus 1.1%, P = .002; hypertension 91.7% versus 63.9%, P < .0001), and were smokers. Sixty-five deaths (20.6%) occurred among participants with recurrent stroke and 281 (19.6%) among first-ever stroke participants (P = .013). The adjusted odds ratio of mortality from recurrent stroke was 1.43 (95% CI: 1.03-1.99).

CONCLUSION

Stroke survivors have a 43% higher risk of dying after a recurrent stroke compared to those with first-ever stroke, against a background of unfavorable stroke risk profile.

Diagnosed diabetes mellitus and in-hospital stroke mortality in a major sub-Saharan African urban medical unit

BACKGROUND

Estimates from developed countries show that early mortality after stroke is unaffected by diabetes status. Despite the high burden of both conditions in sub-Saharan Africa, data on the association between diabetes status and early mortality are lacking.

OBJECTIVE

In a major referral hospital in the Capital city of Cameroon, among acute stroke patients diagnosed using the World Health Organization criteria, we compared mortality rates in patents with and without known diabetes.

METHODS

Stroke patients with and without known diabetes were compared for demographic characteristics, risk factors, clinical, radiological, laboratory characteristic, and in-hospital mortality. Heterogeneities in mortality rates across major subgroups were investigated via interaction tests, and logistic regression accelerated failure-time models used to adjust for confounders.

RESULTS

Of the 1667 acute stroke patients included, 213 (12.8%) had diabetes mellitus. In general diabetic patients were older (median age 64.0 vs. 62.0 years, p=0.0006), and were more likely to have other stroke risk factors including a higher triglyceride levels on admission (106 vs. 97mg/dL, p=0.044), a history of stroke (19.7% vs. 13.6%, p=0.022), and a history of hypertension (89.7% vs. 64.8%, p<0.0001). The death rates of diabetic patients and that of non-diabetic patients were similar (22.1% vs. 20.1%. p=0.524). This finding was similar across all pre-specified groups, with no evidence of interaction. Diabetes was unrelated with mortality in adjusted regression models.

CONCLUSION

Diabetes is frequent among stroke patients in this setting, and often co-exists with other stroke risk factors. In-hospital mortality rate is equally high in diabetic and non-diabetic patients.

Delivering neurocritical care in resource-challenged environments

PURPOSE OF REVIEW

Resource-challenged environments of low and middle-income countries face a significant burden of neurocritical illness. This review attempts to elaborate on the multiple barriers to delivering neurocritical care in these settings and the possible solutions to overcome such barriers.

RECENT FINDINGS

Epidemiology of neurocritical illness appears to have changed over time in low and middle-income countries. In addition to neuro-infection, noncommunicable neurological illnesses like stroke, traumatic brain injury, and traumatic spinal cord injury pose a significant neurocritical burden in resource-limited settings. Many barriers that exist hinder effective delivery of neurocritical care in resource-challenged environments. Very little information exists about the neurocritical care capacity. Research and publications are few. Intensive care unit beds and trained personnel are significantly lacking. Awareness about the risk factors of preventable conditions, including stroke, is lacking. Prehospital care and trauma systems are poorly developed. There should be attempts to leverage neurocritical care in these settings with focus on promoting research, local training, capacity building, preventive measures like vaccination, raising awareness, and developing prehospital care.

SUMMARY

Considering the disease burden and potentials to improve outcome, attempts should be made to develop neurocritical care in resource-challenged environments.

VIDEO ABSTRACT

http://links.lww.com/COCC/A11.

Early Mortality and Associated Factors among Patients with Stroke Admitted to a Large Teaching Hospital in Tanzania

BACKGROUND

Stroke is a major cause of death worldwide and 85.5% of stroke deaths occur in low- and middle-income countries due to stroke. The aim of this study was to investigate correlates and predictors of 30-day mortality in stroke patients in urban Tanzania.

METHODS

A prospective 30-day follow-up study was conducted at the Muhimbili National Hospital, Dar es Salaam, Tanzania. We recruited all patients with stroke seen at the Emergency Medicine Department and medical wards. Patients underwent medical history and physical examination including full neurological examination. For those who met the criteria for the diagnosis of stroke according to the World Health Organization, further data were collected, including cholesterol, creatinine, fasting blood glucose, full blood picture, human immunodeficiency virus serology, and electrocardiogram. Patients were followed up at 30 days from the date of stroke onset. The date and the cause of death of those participants who died within 30 days of stroke onset were recorded.

RESULTS

A total of 224 patients were recruited into the study, with follow-up data available on 186 (83.0%). At 30 days post stroke, 124 patients (66.7%) were still alive. Mortality was significantly higher among stroke patients who were over 65 years of age. Of the 62 who died, 54% died of aspiration pneumonia and 21% of septicemia. Patients with infection were 4.4 times more likely to die than thosewithout (P = .001).

CONCLUSIONS

Poststroke mortality rates were high. Many deaths were potentially preventable.

Computed tomography scanning and stroke mortality in an urban medical unit in Cameroon

Background

Despite the increasing availability of head computerized tomography (CT) in resource-limited settings, it is unclear if brain-imaging-based diagnosis of stroke affects the outcomes in the absence of dedicated structures for acute stroke management.

Objectives

In a major referral hospital in the capital city of Cameroon, we compared in-hospital mortality rates in patients with a WHO-based diagnosis of stroke between participants with and without brain imaging on admission.

Methods

Stroke patients with and without admission brain imaging were compared for demographic characteristics, risk factors, clinical and laboratory characteristic, and in-hospital mortality. Heterogeneities in mortality rates (CT vs. No CT) across major subgroups were investigated via interaction tests, and logistic regressions used to adjust for extraneous factors such as age, sex, year of study, residency, history of diabetes and hypertension, history of stroke, Glasgow coma scale, and delay between stroke symptoms onset and hospital admission.

Results

Of the 1688 participants included in the final analysis, 1048 (62.1%) had brain imaging. The median age of the non-CT vs. CT groups was 65 vs. 62 years (p-value < 0.0001%). The death rate of non-CT vs. CT groups was 27.5% vs. 16.4% (p < 0.0001). This difference was mostly similar across major subgroups, and robust to the adjustments for confounders (in spite of substantial attenuation), with excess deaths in those with CT ranging from 65% to 149%.

Conclusion

In this resource-limited environment, the absence of brain imaging on admission was associated with high in-hospital death from stroke, which was only partially explained by delayed hospitalization with severe disease. These results stressed the importance of scaling up acute stroke management in low- and middle-income countries.