Cerebrovascular diseases in Nigeria: what do we know and what do we need to know?

Clinical Outcomes of Primary Subarachnoid Hemorrhage: An Exploratory Cohort Study from Sudan

Background

Although Subarachnoid Hemorrhage (SAH) is an emergency condition, its epidemiology and prognosis remain poorly understood in Africa. We aim to explore the clinical presentations, outcomes, and potential mortality predictors of primary SAH patients within 3 weeks of hospitalization in a tertiary hospital in Sudan.

Methods

We prospectively studied 40 SAH patients over 5 months, with 3 weeks of follow-up for the symptomatology, signs, Glasgow coma scale (GCS), CT scan findings, and outcomes. The fatal outcome group was defined as dying within 3 weeks.

Results

The mean age was 53.5 years (SD, 6.9; range, 41–65), and 62.5% were women. One-third (30.0%) were smokers, 37.5% were hypertensive, two-thirds (62.5%) had elevated blood pressure on admission, 37.5% had >24 hours delayed presentation, and 15% had missed SAH diagnosis. The most common presenting symptoms were headache and neck pain/stiffness, while seizures were reported in 12.5%. Approximately one-quarter of patients (22.5%) had large-sized Computed Tomography scan hemorrhage, and 40.0% had moderate size. In-hospital mortality rate was 40.0% (16/40); and 87.5% of them passed away within the first week. Compared to survivors, fatal outcome patients had significantly higher rates of smoking (50.0%), hypertension (68.8%), elevated presenting blood pressure (93.8%), delayed diagnosis (56.2%), large hemorrhage (56.2%), lower GCS scores at presentation, and cerebral rebleeding ( P < 0.05 for each). The primary causes of death were the direct effect of the primary hemorrhage (43.8%), rebleeding (31.3%), and delayed cerebral infarction (12.5%).

Conclusions

SAH is associated with a high in-hospital mortality rate in this cohort of Sudanese SAH patients due to modifiable factors such as delayed diagnosis, hypertension, and smoking. Strategies toward minimizing these factors are recommended.

A preliminary spatial analysis of diagnosed stroke disease in Osun state, Nigeria

INTRODUCTION

There have been a number of clinical studies on diagnosed Stroke disease. However, there have been few studies on the geographical disparities for stroke. This study investigates the spatial pattern of stroke disease reflecting socio-demographic characteristics in the State.

METHODS

Stroke patients' admissions for 22 years (from 1990 to 2012) were examined. Their socio-demographic characteristics were extracted from their health records and analyzed. The location of the stroke patients were categorized by Local Governments Areas (LGAs). Spatial maps were generated and produced in a Geographical Information System (GIS) environment. It involves the analysis of the distribution of stroke cases in relation to their underlying population to determine the areas of high and low density of diagnosed cases across the state.

RESULTS

The result highlighted the spatial distribution of diagnosed stroke cases and also highlighted the areas of concern regarding their spatial distribution within the state. Social inequalities in stroke were persistent as incidence rates in urban areas (North) were around 3 times higher than in the rural areas (South). However, this could be due to better healthcare access in the urban areas than in the rural areas as there were disparities in the distribution of healthcare facilities involved in administering care to stroke patients in Osun State.

CONCLUSION

The outcome of this study appears to indicate that spatial inequalities in the access to Stroke healthcare is a concern that needs to be addressed in order to manage the disease adequately.

Stroke Subtypes in Black Tanzanians: A Retrospective Study of Computerized Tomography Scan Diagnoses at Muhimbili National Hospital, Dar es

Limited data are available on the stroke subtypes in Tanzania and sub-Saharan Africa. The present study was aimed at determining retrospectively the pattern of confirmed strokes in all patients in our hospital who had been given a computerized tomography (CT) brain scan during the study period (April 2001 to May 2002). Over the 12-month period 371 CT brain scans were taken, of which 148 showed stroke, 89 (60.1%) showed haemorrhage and 59 (39.9%) showed infarcts ( P<0.05). Among the haemorrhagic group 48 (53.9%) were men and 41 (46.1%) women, while 31 (52.5%) men and 28 (47.5%) women had infarction. We concluded that there were relatively more cases of cerebral haemorrhage than infarction. Hypertension and diabetes mellitus were common risk factors in both subtypes of stroke.

Factors associated with death and predictors of one-month mortality from stroke in Kano, Northwestern Nigeria

BACKGROUND

In resource-poor setting, identification of predictors of death is of paramount importance for clinicians, so that specific therapies and management strategies can be applied to patients at high risk of dying. This study aims to determine the factors associated with death and predictors of in-patient mortality for stroke among a cohort of stroke patients in two tertiary centers in Northwestern Nigeria.

MATERIALS AND METHODS

This was a prospective study of consecutive patients with acute stroke who were admitted to tertiary hospitals in northwestern Nigeria. A single observer, using pre-defined diagnostic criteria, recorded the information of interest including length of stay, outcome (dead or alive all through 30 days), time of death.

RESULT

A total of 273 patients comprising 179 male and 94 female stroke patients were recruited. One hundred and seventy-four (63.7%) had infarctive stroke while 99 (36.3%) had hemorrhagic stroke (91 intracerebral and 8 sub-arachnoid hemorrhage). One-month mortality was 37%, and the majority was patients with hemorrhagic stroke (69.6%). About two-third (74.5%) of the mortalities occurred during the first week of the event. Logistic regression showed that severe systolic blood pressure, severe diastolic pressure, second or more episode of stroke, severe GCS, seizures, abnormal pupillary size, hemorrhagic stroke type, presence of aspiration pneumonitis, RBS > 200 mg/dl were independent predictors of mortality in stroke.

CONCLUSION

The present study provides information on factors associated with death in stroke. GCS < 8, seizures, abnormal pupillary size, hemorrhagic stroke, aspiration pneumonitis were independent predictors of mortality.

Stroke in young Nigerian adults

Stroke in adults under the age of 45 results in a greater loss of potential years of life than for other adults. This premature loss of life is associated with a high social and economic burden. Few data are available regarding stroke among young Nigerian adults in the Niger Delta Basin. This study sought to determine the incidence, risk factors, stroke subtypes and case fatality of stroke among young Nigerian adults. The medical records of all 18- to 45-year-old patients admitted with stroke in the medical wards of the University of Port Harcourt Teaching Hospital (UPTH) from January 2003 to December 2008 were retrospectively reviewed. Of the 611 patients admitted with stroke, 54 (8.8%) were aged 18-45 years. There were 26 males and 28 females. Hypertension was responsible for 42 (77.8%) stroke cases. Other important risk factors were excessive alcohol intake (27.8%), heart disease (13%), diabetes mellitus (11.1%), cigarette smoking (11.1%) and HIV infection (7.4%). The total case fatality was 29.6% with intracerebral hemorrhage (ICH) having higher case fatality of 69.2% than cerebral infarction (CI) with a case fatality of 16.7%. Among the young Nigerian adults who presented with stroke, 53.7% survived. The authors conclude from the above information that the incidence of stroke in young patients at UPTH is low. Hypertension is the most important risk factor of stroke; however, other less common but important risk factors in the young adults are cigarette smoking, diabetes mellitus and HIV. Efforts should be made to reduce the impact of stroke in this age group by focusing on these risk factors, which are either preventable or modifiable.

Stroke at the university of port harcourt teaching hospital, rivers state, Nigeria

The case records of 202 consecutive adult Nigerian in-patients with stroke at the University of Port Harcourt Teaching Hospital (UPTH) were retrospectively reviewed. The mean age at presentation was 62.62 +/- 14.2 years. The male to female ratio was 1:1.2. The commonest risk factors were hypertension, diabetes mellitus, hypercholesterolaemia, older age and a previous history of stroke. Clinically, 67.3% had cerebral infarction (CI), while 27.7% had intracerebral haemorrhage (ICH). The peak age of events for both sub-types was the 7th decade. The case fatality was 55.4% for ICH and 23.5% for CI. Thus, stroke is associated with high mortality at the UPTH. Improved emergency care of stroke patients is needed while the setting up of dedicated stroke centres is advocated. A community-based study is necessary to provide more insight into the problem and also highlight the basis for appropriate intervention and policy.

Racial disparity in stroke risk factors: the Berlin-Ibadan experience; a retrospective study

BACKGROUND

Different workers have reported racial disparities in the distribution of risk factors for stroke and stroke subtype (ischemic vs hemorrhagic). No transcultural transnational studies have been conducted to confirm and relate these disparities to one another. Our objective was to identify differences in the distribution of risk factors for stroke and stroke subtypes among urban-dwelling stroke patients in Nigeria, a developing country, and Germany, an industrialized country.

METHODS

Consecutive stroke patients in Ibadan (100) and Berlin (103) were studied. Their hospital records were screened to identify documented vascular risk factors and stroke subtype.

RESULTS

The stroke patients in Ibadan were younger than those in Berlin (t = 4.940, P = 0.000). Hypertension was significantly more common in Ibadan while cigarette smoking, dyslipidemia, atherosclerosis, and cardiac factors were significantly more frequent in Berlin. Cerebral infarction was more common in Berlin (80%) than in Ibadan (63%).

CONCLUSION

The risk factors associated with cerebral infarction were more frequent in Berlin. We suspect that racial disparity in risk factors for stroke may account for the difference in proportions of stroke subtype in black and white populations. Larger prospective community-based multinational multiracial studies are required to confirm these disparities and identify possible underlying genetic, dietary, and socio-economic factors.

Serum lipids in patients with stroke--a cross-sectional case-control study

BACKGROUND

Vascular disease remains the prime contributor to the pathogenesis of stroke, but dyslipidemia has not been clearly established as a risk factor for stroke the same way it has been for coronary artery disease. There is no case-controlled study on the contribution of serum lipids to stroke in Nigerians. This study aimed at assessing the possibility of serum lipids as risk factor for stroke in Nigerian patients.

METHOD

The demography, blood pressure, fasting plasma glucose and fasting serum lipids of 87 consecutive patients with first-ever stroke managed at the University of Benin teaching hospital between January and December 2005 were analyzed and compared with those of age- and sex-matched controls.

RESULTS

Eighty-seven stroke patients (55 males and 32 females; mean age 61.25 +/- 14.77 years) were compared with age- and sex-matched controls. Ischemic stroke constituted 64.37%, while the rest had hemorrhagic stroke. There were no significant differences in the serum cholesterol, HDL-C and LDL-C levels of stroke patients and controls (p > 0.05), but the serum triglyceride level was higher among the stroke patients (p < 0.001) with a significant relative risk (RR = 1.77; p < 0.01).

CONCLUSION

In this cross-sectional case-control study, there is no significant difference in the serum lipids of Nigerian patients with stroke with the exception of serum triglyceride, which seems to confer significant stroke risk.

Determinants of health-related quality of life in Nigerian stroke survivors

Stroke is a leading cause of disability in developing countries. It is crucial to identify factors influencing health-related quality of life (HRQOL) in stroke survivors in this setting so that such factors can be efficiently manipulated in order to maximize HRQOL improvement. This is the first study of these determinants in Nigerian stroke patients. One hundred consecutive consenting stroke survivors were studied in Ibadan. The stroke levity scale (SLS) was used to assess stroke severity. HRQOL was assessed using the psychometrically robust HRQOL in stroke patients (HRQOLISP) questionnaire. HRQOL determinants were sought among variables such as age, gender, socio-economic class (SEC), post-stroke duration, side, type and number of strokes, SLS, modified Rankin scale (mRS), social support, and Likert-graded responses to laughter and negative feelings frequencies. Gender, aphasia, handedness, stroke side, type and frequency as well as SEC had no significant impact on HRQOL. The determinants of HRQOL were SLS, mRS, social support, laughter and negative feelings frequencies. Aside from stroke levity and disability, psychosocial factors such as emotional responses and social support determine HRQOL in stroke survivors. Both neuroscience and clinical management of stroke might benefit from a corresponding broader integrative conceptual framework for life after stroke.

The epidemiology, diagnosis and treatment of subarachnoid haemorrhage in Nigeria: what do we know and what do we need to know?

Our goal was to review published literature on the epidemiology, diagnosis and treatment of subarachnoid haemorrhage (SAH) in Nigeria. With an estimated population of 126 million, roughly 6 million persons in Nigeria have or will develop an intracranial aneurysm in their lifetime. This study should highlight the areas requiring research and development, and facilitate future health care planning. A Medline and Embase literature review of reports on the management of SAH in Nigeria was conducted. The search terms were as follows: stroke, subarachnoid haemorrhage, intracerebral haemorrhage, brain, Nigeria, Nsukka, Ibadan, Lagos, Kaduna, Jos, Benin, Port Harcourt, Africa. All identified abstracts were reviewed for inclusion in the study. Only papers dealing with the study objectives were obtained for review of the bibliography and further analysis. Thirty articles have now been published about stroke in Nigerians. Fifteen of these either discussed SAH specifically or, in general, with other stroke subtypes (ischaemic stroke and intracerebral haematoma) or reviewed vascular intracranial anomalies such as aneurysms. The most detailed paper on this issue was published in 1970 and according to that report SAH is more common in males and prevalent in young people below the age of 40 years (68% of the patients reviewed). Worldwide improvements in medical and surgical management have not been reflected in the literature on SAH. Neurologists, stroke physicians and not neurosurgeons, treat patients with SAH in Nigeria. The results presented in this study reflect the current status of the medical and surgical management of SAH in Nigeria. Conclusive data relating to epidemiology, incidence, diagnosis, current treatment modalities and outcome of SAH in Nigeria have not been published. There is, therefore, a pressing need for further study in these areas and improvements in the management of patients with SAH.

Ear Diseases in Elderly Hospital Patients in Nigeria

BACKGROUND

Little information is available about the pattern of ear diseases in the elderly population. Therefore, the present study aims to determine the pattern of ear diseases among elderly Nigerians, so as to provide an objective basis for cost-effective health care planning for the emerging geriatric population.

METHODS

A retrospective study of 320 patients aged 60 years or older presenting with ear diseases at the University of Ilorin Teaching Hospital, Ilorin, Nigeria, between January 1996 and December 2001 was carried out.

RESULTS

Impacted cerumen was the most common ear disease, occurring in 110 (34.4%) patients of the study population. Chronic suppurative otitis media (CSOM) was the most common infectious disease, affecting 28 (8.8%) patients. Of the 88 patients with hearing loss, 63 (71.6%) had sensorineural, 20 (22.7%) had presbycusis, 1 (1.1%) had conductive, and 4 (4.6%) had mixed hearing loss.

CONCLUSION

Our data suggest that impacted cerumen, hearing loss, and infections (notably CSOM), are the common ear diseases among elderly Nigerians.