Clinical and neuroimaging factors associated with 30-day fatality among indigenous West Africans with spontaneous intracerebral hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is associated with a high case fatality rate in resource-limited settings. The independent predictors of poor outcome after ICH in sub-Saharan Africa remains to be characterized in large epidemiological studies. We aimed to determine factors associated with 30-day fatality among West African patients with ICH.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study conducted at 15 sites in Nigeria and Ghana. Adults aged ≥18 years with spontaneous ICH confirmed with neuroimaging. Demographic, cardiovascular risk factors, clinical features and neuroimaging markers of severity were assessed. The independent risk factors for 30-day mortality were determined using a multivariate logistic regression analysis with an adjusted odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Among 964 patients with ICH, 590 (61.2%) were males with a mean age (SD) of 54.3(13.6) years and a case fatality of 34.3%. Factors associated with 30-day mortality among ICH patients include: Elevated mean National Institute of Health Stroke Scale(mNIHSS);(OR 1.06; 95% CI 1.02-1.11), aspiration pneumonitis; (OR 7.17; 95% CI 2.82-18.24), ICH volume > 30mls; OR 2.68; 95% CI 1.02-7.00)) low consumption of leafy vegetables (OR 0.36; 95% CI 0.15-0.85).

CONCLUSION

This study identified risk and protective factors associated with 30-day mortality among West Africans with spontaneous ICH. These factors should be further investigated in other populations in Africa to enable the development of ICH mortality predictions models among indigenous Africans.

Challenges to Thrombolysis in A Resource-Poor Setting- A Case Report

A major complication of acute ischemic stroke is death and disability. The emergence of reperfusion therapy in form of thrombolysis and endovascular thrombectomy has led to the reversal of this trend in high-income countries. Low- and middle-income countries are yet to benefit maximally from these time-bound treatment options due to some limitations. We intend to highlight some of these in this report. We report an 80-year-old male patient with hypertension and firstdegree AV block admitted 3 hours after the onset of stroke with National Institutes of Health Stroke Scale (NIHSS) score of 13 and Medical Research Council (MRC) muscle power grade 3 in both the left upper and lower limb. Urgent non-contrast brain CT revealed no evidence of hemorrhage. Intravenous tissue plasminogen activator (tPA) was administered at a dose of 0.6 mg/kg 9 hours after symptom onset. He made significant improvement afterward and was discharged. The challenges encountered in his management include prehospital and intrahospital delay, and unavailability of tissue plasminogen activator. There is a need for an improved healthcare delivery system in order to reduce the morbidity associated with acute ischemic stroke.

Neurocritical Care in Nigeria

Nigeria is the most populous country in Africa with an estimated 206 million inhabitants served by less than 300 neurologists and 131 neurosurgeons. Neurological conditions account for approximately 18% of all medical emergencies. Neurocritical care challenges in Nigeria are as complex as they are in other low-to-middle-income countries (LMICs). These include high burden of neurological diseases, poor pre-hospital care, delays in transfer, lack of neurocritical care equipment, and inadequate rehabilitative capacity. Neurocritical care units in Nigeria offer mostly limited multimodal monitoring due to out-of-pocket payment, and the success of repeat radiological imaging and blood work is low. Data gathering and outcome research in neurocritical conditions can help in clinical decision-making and enhance cost-effective clinical care. The concept of allocation requires that when medical resources are scarce, they must be efficiently utilized in the most judicious way so as to achieve the greatest possible benefit. A high degree of transparency is needed with regard to the principles, values and criteria employed to facilitate such triage decisions. Proper funding will help improve availability of equipment and drugs resulting in a higher quality of care and, subsequently, improvement in mortality. There is ample evidence that neurocritical care improves overall prognosis in neurocritically-ill patients. Neurocritical care units (NCCUs) are mostly unavailable in Nigeria, often resulting in poorer prognosis for patients. What is already known: Nigeria has an unacceptably huge deficit in the overall capacity for neurocritical care. The inadequacies affect a wide range of components - facilities, quantity and quality of personnel, and the unbearably high cost, among others. What this study adds: This article attempts to condense the challenges in one piece while highlighting previously obscure ones, with the aim of providing possible solutions to the lingering challenges in neurocritical care in Nigeria and, invariably, other LMICs. How this study might affect practice, policies or research: We envisage this article will stimulate the initial steps in a multipronged and data-driven approach to bridging the gap by government and relevant healthcare administrators.

Tramadol-Induced Acute Seizures: A Report of Three Cases

There is a rise in substance abuse in Nigeria and prescription drugs, particularly opioid analgesics, which are increasingly becoming a target of abuse. Abuse of the opiod tramadol has the potential to precipitate seizures. We present 3 cases of tramadol-induced seizures presenting at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. The three patients were men, aged 22-40 years and abused other drugs including alcohol, cannabis and Rohypnol. This report illustrates the fact that tramadol abuse may be associated with acute seizures and it is reasonable to consider drug/opiod-induced seizure in every case of unexplained first episode of seizure in a young adult.

Clustering of cardiovascular risk factors in semi-urban communities in south-western Nigeria

BACKGROUND

In addition to poor socio-economic indices and a high prevalence of infectious diseases, there have been various reports of a rising prevalence of cardiovascular diseases, with associated morbidity and mortality in developing countries. These factors co-exist, resulting in a synergy, with serious complications, difficult-to-treat conditions and fatal outcomes. Hence this study was conducted to determine the clustering of cardiovascular disease risk factors and its pattern in semi-urban communities in south-western Nigeria.

METHODS

This was a cross sectional study over seven months in 11 semi-urban communities in south-western Nigeria.

RESULTS

The total number of participants was 1 285 but only 1 083, with 785 (65%) females, completed the data. Participants were 18 years and older, and 51.2% were over 60 years. The mean age was 55.12 ± 19.85 years. There were 2.6% current cigarette smokers, 22% drank alcohol and 12.2% added salt at the table, while 2% had been told by their doctors they had diabetes, and 23.6% had hypertension. The atherogenic index of plasma was at a high-risk level of 11.1%. Elevated total cholesterol and low-density lipoprotein cholesterol, and low high-density lipoprotein cholesterol levels were seen in 5.7, 3.7 and 65.1%, respectively. Prevalence of hypertension was 44.9%, diabetes was 5.2%, obesity with body mass index (BMI) > 30 kg/m2 was 5.7%, and abdominal circumference was 25.7%. Prevalence of clusters of two, three, and four or more risk factors was 23.1, 15.5 and 8.4%, respectively. Increasing age 2.94 (95% CI: 1.30-6.67), BMI 1.18 (95% CI: 1.02-1.37), fasting plasma glucose level 1.03 (95% CI: 1.00-1.05), albuminuria 1.03 (95% CI: 1.00-1.05), systolic blood pressure 1.07 (95% CI: 1.04-1.10), diastolic blood pressure 1.06 (95% CI: 1.00-1.11) and female gender 2.94 (95% CI: 1.30-6.67) showed increased odds of clustering of two or more cardiovascular risk factors.

CONCLUSION

Clustering of cardiovascular risk factors is prevalent in these communities. Patterns of clustering vary. This calls for aggressive and targeted public health interventions to prevent or reduce the burden of cardiovascular disease, as the consequences could be detrimental to the country.

Stroke risk factors among participants of a world stroke day awareness program in South-Western Nigeria

INTRODUCTION

Stroke is a major cause of death and disability in population across the world. Hypertension is the most common stroke risk factor globally as well as in the Nigerian population, however other modifiable risk factors such as obesity are becoming increasingly prevalent due to unhealthy diets and sedentary lifestyle.

MATERIALS AND METHODS

We screened 224 volunteers from Ile-Ife during the 2011 and 2012 world stroke day commemorative activities. Blood pressures (BP) were measured and body mass index (BMI) was determined from weight and height measurements. The data from 40 (18%) were incomplete and were excluded from further analysis.

RESULTS

The 184 subjects eligible for analysis comprised 85 males (46.2%) and 99 females (53.8%), with a male to female ratio of 0.85:1. Their ages ranged from 16 to 95 years (mean, 53±16 years). 25% of the study population had stage 1 or 2 hypertension (mean systolic blood pressure: 127±27 mmHg, mean diastolic blood pressure: 78±16 mmHg), while 34.8% and 14.7% were overweight and obese, respectively (mean BMI: 25.8±5.0 kg/m2).

CONCLUSION

Stroke risk factors such as hypertension and obesity were common among the participants of the world stroke day awareness program in an urban area of Nigeria. Community screening and modification of these risk factors should be intensified in order to reduce stroke morbidity and mortality.

Bell's palsy in pregnancy and the puerperium: a report of five cases

The incidence of idiopathic facial nerve palsy is higher during pregnancy and the puerperium than in nonpregnant women of childbearing age. An important association also exists between Bell's palsy and hypertensive disorders of pregnancy. We describe three patients with idiopathic facial nerve palsy in pregnancy and two in the puerperium. Two of these were associated with hypertensive disorder of pregnancy. This case report illustrates the fact that Bell's palsy is common in pregnancy and in the peurperium and often associated with hypertensive disorders of pregnancy.