Stroke is a major cause of morbidity and mortality worldwide [
In spite of the huge socioeconomic impact of stroke in this age group, there is a scarcity of data regarding stroke in young adults in the northwestern Nigeria. Most of the data available originated from southwestern Nigeria; they were obtained over two decades ago and were retrospective. Moreover, stroke in adult below 45 yrs of age was reported to be uncommon [
It was against this background that we embarked on this multicentre prospective study aimed at reviewing the pattern, types, and case fatality of stroke in the young adults in the northwestern part of Nigeria.
In this prospective study, consecutive patients aged 18–40 years who were admitted to the medical wards of the two tertiary hospitals; Aminu Kano Teaching Hospital (AKTH), Kano, and Murtala Muhammad Specialist Hospital, (MMSH) Kano, from June 2008 to August 2010 were recruited in the study. Eligibility for the study was in accordance with the World Health Organization (WHO) definition of stroke as ‘rapidly developing clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than vascular origin’ (WHO 1989) [
A questionnaire was designed to extract relevant clinical data from the patients. The questionnaire recorded the age, sex, date of admission, delay before presentation, reasons for delay, time of death, accompanying symptoms, stroke type, and the predisposing factors. Only those who had complete information and met the World Health Organization criteria for the clinical diagnosis of stroke were included. The survivors were followed up in neurology clinics for 6 months, status of disability on admission and at discharge was recorded using modified Rankin disability scale [
Management of the patients in these centres was in accordance with Aminu Kano Teaching Hospital guideline on stroke management, which is a modification of American Heart Association/American stroke association (AHA/ASA) guidelines [
The case fatality at 24 hours and 72 hours was recorded. Analysis of data was done using the statistical software package SPSS version16. Descriptive statistics were depicted using absolute numbers, simple percentages, range, and measures of central tendency (mean, median) as appropriate. The Chi-square test was used to test the significance of associations between categorical groups. Statistical significance was fixed at probability level of 0.05 or less.
A total of seventy-one stroke patients aged 18–40 yrs, comprising fifty-two (73%) males and 19 (23%) females, were enrolled; mean age was
Distribution of stroke type and sex by age group.
Age group | Infarctive | Haemorhagic | Total | ||
Male | Female | Male | Female | ||
10–20 | 3 | — | — | — | 3 |
21–30 | 16 | 2 | 8 | 1 | 27 |
31–40 | 10 | 11 | 15 | 5 | 41 |
Total | 29 | 13 | 23 | 6 | 71 |
Delay before presentation in hours.
Delay before presentation (Hours) | Frequency | Percent |
---|---|---|
<3 | 6 | 8.5 |
3–6 | 6 | 8.5 |
7–24 | 23 | 32.4 |
25–48 | 33 | 46.2 |
>48 | 3 | 4.2 |
Total | 71 | 100 |
Traditional risk factors*.
Risk factors | Frequency | Percentage |
---|---|---|
Hypertension | 53 | 74.7 |
Smoking | 36 | 50.7 |
Hypercholesterolemia | 7 | 9.9 |
Cardiac diseases** | 6 | 8.5 |
HIV | 6 | 8.5 |
Previous stroke and or transient ischaemic attack | 4 | 5.6 |
Diabetes | 3 | 4.2 |
Alcohol | 3 | 4.2 |
Migraine | 3 | 4.2 |
Drug of addiction (cocaine, amphetamine) | 2 | 2.8 |
Sickle cell disease | 2 | 2.8 |
Connective tissue disease | 1 | 1.4 |
Unidentified | 6 | 8.5 |
Status of patients on modified ranking scale on discharge and at 6-month followup.
Ranking disability scale | Frequency at discharge from hospital | Frequency at 6-month followup* |
---|---|---|
0 (no symptoms) | — | 2 |
1 (no significant disability) | 1 | 4 |
2 (slight disability) | 11 | 11 |
3 (moderate disability) | 16 | 10 |
4 (moderately severe disability) | 11 | 6 |
5 (severe disability) | 9 | 4 |
Total | 48 | 37 |
Stroke is not uncommon among young people, as was previously assumed in early reports [
Male preponderance in this study is similar to the findings elsewhere [
Similar to other studies [
In the present paper, only 8.5% and 17% of the patients presented before 3 and 6 hours, respectively at the emergency unit. In view of the short time window (3–6 hours) for thrombolytic therapy, this finding has a significant implication for thrombolytic therapy in the management of infarctive stroke in our setting. Therefore, provision of facilities for thrombolytic therapy without adequate education on early presentation and infrastructural support for early presentation may not necessarily make much difference.
Regarding risk factors, as previously reported by other studies [
Similar to some previous studies [
HIV is commonly a disease of the young adult who, among other things, engages in high-risk behaviors, such as unprotected heterosexual contact and intravenous drug abuse. Few of our patients that consented to HIV screening were reactive. Incidentally, the two patients with cocaine and amphetamine use also had HIV. HIV is increasingly becoming a common risk factor for stroke in Sub-Saharan Africa [
Sickle cell disease and connective tissue diseases should also be given consideration when dealing with stroke in young adult in developing countries as shown in the present study to have accounted for (2.8%) of cases of stroke recruited.
Mortality and case fatality in the present study are comparable to what was reported in the other geopolitical zones of Nigeria [
Aspiration pneumonitis being a common finding associated with death is worthy of note; this is in conformity with a study by Hassan et al. reported that 23% of patients with stroke developed stroke-associated pneumonia, of which 34% died during hospital stay [
Regarding disability in survivors, comparing the degree of disability at discharge to disability at 6-month followup, some improvement was recorded. This can be largely ascribed to intensive and qualitative physiotherapy and secondary prevention of stroke.
Nevertheless, it suffices to state that this study suffers from some limitations, being a hospital-based study limits its external validity. Moreover, error of misclassification cannot be completely ruled out as neuroimaging was done in all the patients. However, the findings provide some clues as to the pattern, clinical characteristics, and case fatality of stroke in young adult in Kano. Besides, it generated a background data and impetus for a larger community-based study on stroke in the young in Kano.
Our data suggests that stroke in young adults is not as uncommon as previously suggested, and that hypertension, smoking, hypercholesterolemia, cardiac diseases and HIV are the most common risk factors. Infarctive stroke was commoner than haemorhagic stroke, and the overall case fatality was high (19.7%) in the first seventy-two hours. The study also showed increasing frequency of HIV as a risk factor for stroke among young adults in the study area.