Cardiovascular disease is the primary global cause of death, accounting for more than 17.3 million deaths per year, a number that is expected to grow to more than 23.6 million by 2030. In 2013, cardiovascular deaths represented 31% of all global deaths, with 80% of those deaths taking place in low- and middle-income countries (LMICs) [
First-time incidence of stroke occurs almost 17 million times a year worldwide, one every two seconds. Black people are twice as likely to have a stroke compared to white people [
Although age-standardized rates of stroke mortality have decreased worldwide in the past two decades, the absolute number of people who have a stroke every year, stroke survivors, and related deaths are high and sharply increasing in LMICs [
According to WHO report of 2014 including all ages and sexes, in Ethiopia from the total cases of deaths, 30% were attributed to noncommunicable diseases (NCDs) and of these NCDs one-third of mortality was accounted by cardiovascular disease (CVD) [
As patients usually present late and the standard of care is poor compared to hospitals in developed countries, the in-hospital mortality is expected to be higher [
The study was conducted at stroke unit of Jimma University Medical Center (JUMC), a tertiary hospital found in Jimma city, southwest Ethiopia. Jimma is located 357km South West of the capital city of Ethiopia, Addis Ababa. JUMC has endured time as one of the oldest public hospitals in Ethiopia. Its history is traced back to the short-lived Italian occupation of the country, when it served as a medical center for soldiers. Shortly after, it was renamed as Ras Desta Damtew Hospital by the Imperial regime and then Jimma Hospital by the Derg. It has a total bed capacity around 555 with nearly 1600 hospital staffs.
The prospective observational study was carried out for 4 consecutive months from March 10 to July 10, 2017. All 116 stroke patients ≥ 18 years having either clinical diagnosis or confirmed by imaging as per WHO criteria for diagnosis of stroke [
A semistructured questionnaire containing the variables to be measured was designed, developed, and utilized based on the previous literature and using the WHO step wise approach to stroke surveillance along with different modifications and incorporations [
Checked data was cleaned and entered to Epidata version 3.1. Then, the data was exported and analyzed using SPSS version 20.0 for windows. Descriptive statistics such as percent, frequency, mean, and medians were used to summarize categorical variables of patients’ characteristics and stroke event factors. The data analysis and correlation were done based on the selected variables for addressing all specific objectives adequately. The result was interpreted and presented using appropriate tables. Predictors with probability value less than 0.05 were considered statistically significant.
a history of a previous stroke event at some time in the past which meets the WHO definition or a history of a new stroke event occurring more than 1 month after onset of a stroke event already registered.
Good GCS (13-15): mild brain injury (alert). Moderate GCS (9-12): moderate brain injury (drowsy). Poor GCS (≤8): severe brain injury (unconscious).
NIHSS 0–6 (mild). NIHSS 7–12 (moderate). NIHSS 13–20 (severe). NIHSS ≥ 21 (very severe).
The mean age of stroke patients was 55.1±14.0 years, ranging from 23 to 96 years. Stroke occurred at a mean age of 56.7 ±14.9 years in males and at 52.5 ±12.1 years in females. Stroke in the young, defined as age less than 45 years, accounted for 22.4% of the total patients, while 78.4% of the total patients were below 65 years of age. The majority of stroke patients were males (62.9%) and from rural areas (72.4%). Majority of the participants had informal education (able to read and write) 49 (42.2%) followed by no basic education (unable to write and read) 42 (36.2%). The mean body mass index (BMI) of the patient was 21.22±3.38 kg/m2 [
Sociodemographic characteristics of stroke among adult patients admitted to stroke unit of JUMC from March 10 to July 10, 2017.
|
|
|
|
---|---|---|---|
|
< 45 | 26 | 22.4% |
45-65 | 65 | 56.0% | |
>65 | 25 | 21.6% | |
|
|||
|
|
73 | 62.9% |
|
43 | 37.1% | |
|
|||
|
|
84 | 72.4% |
|
32 | 27.6% | |
|
|||
|
|
104 | 89.7% |
|
11 | 9.5% | |
|
1 | 0.9% | |
|
|||
|
|
42 | 36.2% |
|
49 | 42.2% | |
|
17 | 14.7% | |
|
3 | 2.6% | |
|
5 | 4.3% | |
|
|||
|
|
44 | 37.9% |
|
41 | 35.3% | |
|
11 | 9.5% | |
|
6 | 5.2% | |
|
5 | 4.3% | |
|
5 | 4.3% | |
|
4 | 3.4% | |
|
|||
|
|
24 | 20.7% |
|
74 | 63.8% | |
|
18 | 15.5% | |
|
|||
|
|
20 | 17.2% |
|
46 | 39.7% | |
|
25 | 21.6% | |
|
25 | 21.6% |
The median time elapsed between the onset of stroke symptoms and arrival to the hospital was 27 hours (range 0 to 377 hours). The median time of arrival for IS and HS patients was 44 hours and 18.25 hours, respectively. Only nine patients presented within 3 hours of symptom onset and 14 patients (12.1%) presented within 4.5 hours (window period). Almost half (47.4%) of the patients presented within 24 hours and 26 (22.4%) patients presented to hospital beyond 72 hours. Compared to patients with ischemic stroke, patients with hemorrhagic stroke presented more often within 24 hours, 36.7% and 58.9%, respectively. There was no significant difference in terms of sex of the patient for hospital arrival. Additionally, the estimated median time of hospital arrival for urban residents was 18.25 hours and for rural residents 32.13 hours (P=0.953) (Table
Stroke event factors among adult stroke patients admitted to stroke unit of JUMC from March 10 and July 10, 2017.
|
|
|
|
|
|
---|---|---|---|---|---|
|
|
|
|
||
|
|
27 (11.13-70.63) | 44 (12.46-92.00) | 18.25 (9.00-49.05) | 0.059 |
≤ |
14 (12.1%) | 9 (15.0%) | 5 (8.9%) | - | |
|
21 (18.1%) | 6 (10.0%) | 15 (26.8%) | 0.042 | |
|
20 (17.2%) | 7 (11.7%) | 13 (23.2%) | 0.098 | |
|
21 (18.1%) | 12 (20.0%) | 9 (16.1%) | 0.693 | |
|
40 (34.5%) | 26 (43.3%) | 14 (25%) | 0.962 | |
|
|||||
|
|
15.71±7.52 | 14±7.15 | 17.54±7.54 | 0.013 |
|
12 (10.3%) | 11 (18.3%) | 1 (1.8%) | - | |
|
31 (26.7%) | 17 (28.3%) | 14 (25.0%) | 0.046 | |
|
47 (40.5%) | 23 (38.3%) | 24 (42.9%) | 0.024 | |
|
26 (22.4%) | 9 (15.0%) | 17 (30.4%) | 0.007 | |
|
|||||
|
|
12.12±3.35 | 13.07±2.56 | 11.11±3.80 | 0.002 |
|
17 (14.7%) | 3 (5.0%) | 14 (25.0%) | 0.004 | |
|
33 (28.4%) | 17 (28.3%) | 16 (28.6%) | 0.389 | |
|
66 (56.9%) | 40 (66.7%) | 26 (46.4%) | - | |
|
|||||
|
|
150 (130-180) | 150 (124.25-170) | 157 (130.75-189.25) | 0.049 |
|
21 (18.1%) | 14 (23.3%) | 7 (12.5%) | - | |
|
19 (16.4%) | 9 (15.0%) | 10 (17.9%) | 0.221 | |
|
76 (65.5%) | 37 (61.7%) | 39 (69.6%) | 0.149 | |
|
|||||
|
|
98.50 (80-110) | 90 (70.25-108.75) | 100 (88-110) | 0.047 |
|
2 (1.7%) | 2 (3.3%) | 0 (0%)) | 0.999 | |
|
33 (28.4%) | 21 (35.0%) | 12 (21.4%) | - | |
|
8 (6.9%) | 4 (6.7%) | 4 (7.1%) | 0.999 | |
≥ |
73 (62.9%) | 33 (55.0%) | 40 (71.4%) | 0.999 | |
|
|||||
|
|
86.34±13.23 | 88.85±13.70 | 83.66±12.27 | 0.037 |
|
104 (89.7%) | 52 (86.7%) | 52 (92.9%) | - | |
|
12 (10.3%) | 8 (13.3%) | 4 (7.1%) | 0.281 | |
|
|||||
|
|
23.5 (20-24) | 23.50 (20.25-24) | 23.50 (20-26) | 0.516 |
|
33 (28.4%) | 15 (25.0%) | 18 (32.1%) | - | |
|
83 (71.6%) | 45 (75.0%) | 38 (67.9%) | 0.704 | |
|
|||||
|
|
36.6 (36.5-36.8) | 36.6 (36.5-36.9) | 36.6 (36.43-36.80) | 0.666 |
|
3 (2.6%) | 2 (3.3%) | 1 (1.8%) | 0.588 | |
|
97 (83.6%) | 49 (81.7%) | 48 (85.7%) | - | |
|
16 (13.8%) | 9 (15.0%) | 7 (12.5%) | 0.739 | |
|
|||||
|
|
34 (29.3%) | 14 (23.3%) | 20 (35.7%) | 0.321 |
|
38 (32.8%) | 23 (38.3%) | 15 (26.8%) | 0.103 | |
|
28 (24.1%) | 14 (23.3%) | 14 (25.0%) | 0.488 | |
|
16 (13.8%) | 9 (15.0%) | 7 (12.5%) | - | |
|
|||||
|
|
25 (21.6%) | 16 (26.7%) | 9 (16.1%) | - |
|
22 (19.0%) | 11 (18.3%) | 11 (19.6%) | 0.897 | |
|
27 (23.3%) | 14 (23.3%) | 13 (23.2%) | 0.377 | |
|
35 (30.2%) | 16 (26.7%) | 19 (33.9%) | 0.632 | |
|
2 (1.7%) | 1 (1.7%) | 1 (1.8%) | 0.960 | |
|
5 (4.3%) | 2 (3.3%) | 3 (5.4%) | 0.628 | |
|
|||||
|
|
4 (3.4%) | 4 (6.7%) | 0 (0%) | 0.999 |
|
24 (20.7%) | 13 (21.7%) | 11 (19.6%) | 0.645 | |
|
88 (75.9%) | 43 (71.7%) | 45 (80.4%) | - | |
|
|
107 (92.2%) | 52 (86.7%) | 55 (98.2%) | - |
|
9 (7.8%) | 8 (13.3%) | 1 (1.8%) | 0.048 |
A major quota of patients (40.5%) showed severe neurological deficit (NIHSS 13–20) on admission (38.3% for ischemic stroke and 42.9% for hemorrhagic stroke). The mean NIHSS of the patients was 15.71 ± 7.52 and was significantly elevated in hemorrhagic stroke patients (17.54±7.54) compared to patients with ischemic strokes (14±7.15), (P=0.013).
The median time to CT scan imaging after hospital arrival was 4 days. Of the 61 patients with stroke confirmed by CT scan, 34.4 % were scanned within 3 days of hospital arrival, 50.8% between 3 days and 7 days, and 13.1% between 7 days and 14 days. Only 1 patient had CT scan 2 weeks after the hospital arrival [
The mean GCS of all stroke patients hospital arrival was moderate 12.12±3.35, for IS 13.07±2.56 and for HS 11.11±3.80 (P=0.002). About two-thirds (66.7%) of ischemic stroke patients had good GCS compared to 46.4% of HS patients. One-fourth of HS patients had severe brain injury as compared to 5% of IS patients (P=0.004) (Table
The median systolic blood pressure and diastolic blood pressure of patients was 150 mmHg and 98.5 mmHg, respectively. The median SBP of IS and HS was 150 mmHg and 157 mmHg, respectively, and the median diastolic blood pressure of IS and HS was 90 mmHg and 100 mmHg, respectively. On hospital arrival majority of patients (65.5%) had systolic blood pressures (SBP) that was highly elevated (≥140 mm Hg), in particular 69.6% in hemorrhage stroke patients. The diastolic blood pressure was elevated (≥ 90 mm Hg) upon hospital arrival in 73 (62.9%) of the patients, in particular 71.4% of HS patients.
Majority of patients, 89.7%, presented with heart rate within normal range (60–100 bpm) and 10.3% had >100 bpm upon hospital arrival. The mean heart rate was 86±13 bpm for total patients and it was higher for IS as compared to HS patients (89±14 bpm versus 84±12 bpm) (P=0.037). A majority (71.6%) of patients presented with elevated respiratory rate (RR) (> 20 breath/min). The median RR was 24 breath/min for both ischemic and hemorrhagic stroke patients up on hospital arrival. Majority of the patients (83.6%) had normal temperature (36.0-37.1°C) up on hospital arrival.
The circadian pattern of stroke onset indicates that majority of stroke attack occur in the afternoon (32.8%) and in the morning (29.3%). This circadian pattern showed a significant peak in morning for hemorrhagic stroke (35.7%) and afternoon for ischemic stroke (38.3%). Out of total patients, stroke occurred in 35 (30.2%) while doing sedentary (nonsquatting) activities and in 27 (23.3%) while squatting. Majority of strokes occurred mostly in awake state (78.4%), particularly 83.9% of hemorrhagic stroke patients (P= 0.033).
Regarding stroke onset majority of the disease was associated with sudden onset in 88 (75.9%) patients. The fluctuating type of stroke was solely presented in 4 (6.7%) ischemic stroke patients. Of the 116 individuals with stroke, 107 (92.2%) suffered from first-event stroke episode, and the remaining 9 (7.8%) exhibited the recurrent/ previous stroke. The recurrent stroke was more significant in IS, 13.3% versus 1.8% (P=0.048). Two-thirds of patients with recurrent stroke were on treatment along with life style modification and the remaining were on life style modification only 3 (33.3%) (Table
The mean age of the patients (55.14±14.04 years) was in line with other studies in developing countries where the mean age of the patients diagnosed for stroke was between 50 and 60 years [
The median time elapsed between the onset of stroke symptoms and the arrival to the hospital was 27 hours (IQR: 11.13-70.63 hours), which was delayed as compared to study in Gambia 8 hours [
The fact that the majority of our patients come late creates management difficulties as these first hours are important to avoid secondary insults to the brain and preserve the ischemic penumbra. Considering the concept that “time is brain” these subsets of patients should have the acute treatment option with IV rTPA if available for them. The contraindication for this thrombolytic therapy was high because average delay in time of presentation to hospital was more than the intended window period in our study setting. Although thrombolytic treatment is currently not available in our country, significant delays during the prehospital or in-hospital phases of care create management difficulties and would make such advanced treatments difficult in the future even if rTPA is available in the local hospital. In addition to delayed presentation, brain imaging was delayed to a median of four days. Therefore, the prerequisite of receiving thrombolytic is not achieved and consequently rTPA was not given even to eligible patients.
Majority of patients (40.5%) showed severe neurological deficit on admission which was similar to study by Kuriakose et al. in India [
During hospital arrival of the majority of patients (65.5%) systolic blood pressures (SBP) were highly elevated (≥140 mm Hg) that complies with another study by Gebremariam et al. [
The circadian pattern of stroke onset indicates that majority of stroke attacks occur in the afternoon and in the morning which was consistent with study by Sarkar et al. in India [
Majority of strokes occurred while patients were doing sedentary (nonsquatting) activities and while the patients were squatting which was unlike a study by Sarkar et al. in which majority of strokes occurred just after patients were awakening and while being involved in outdoor activities [
Regarding stroke onset majority of the disease was associated with sudden onset in agreement with study by Ghandehari et al. in Iran [
The major strength of this study was its prospective study design and the enrollment of consecutive patients. We have performed a detailed initial assessment including a NIHSS stroke scale in the hospital in a series of patients with stroke.
Regarding weaknesses of the study first, this was a hospital-based study rather than population based and hence may be subjected to referral bias. As our study ascertained events over a 4-month period, we acknowledge the possibility of a contribution of seasonal variation in stroke rates to our findings and were unable to analyze trends in stroke rates over time, as our study did not run for a complete 1-year period.
The level of poor blood pressure control in hypertensive patients we observed in this study was alarming because in more than two-third of the patients, blood pressure was elevated (≥140/90 mm Hg) on hospital arrival. The delay of hospital arrival and imaging were challenges similar to other developing countries for early management and recovery of the patients. There was diurnal variation and close relationship of stroke events with variation of activity in this study. The circadian pattern onset of stroke showed a significant peak in morning for hemorrhagic stroke and afternoon for ischemic stroke. Majority of stroke onset was associated with sudden onset and first-ever stroke episode.
There should be aggressive propaganda from every social, media, and political level of the country in the purpose of increasing the awareness of risk factors and stroke events by making the people understand the devastating effect of the disease on human health and economy of the country. Additional studies that attempts to assess delays for treatment and to determine some of the factors that impede timely presentation in patients with strokes are advisable to address those issues further. Finally a prospective community based stroke incidence and prevalence studies are required to identify stroke event factors.
Cerebrovascular accident
Cardiovascular diseases
Global Burden of Diseases
Glasgow coma scale
Hemorrhagic stroke
Hypertension
Intracerebral hemorrhage
Ischemic heart disease
Ischemic stroke
Jimma University Medical Center
Low- and middle-income countries
Noncommunicable diseases
National Institute of Health Stroke Scale
Recombinant tissue plasminogen activator
Sub-Saharan Africa
Stroke unit
World Health Organization.
The data used to support the findings of this study are included within the article.
Ethical clearance was obtained from the Institutional Review Board (IRB) of Jimma University, Institute of health.
Verbal consent was obtained from responsible bodies of the hospital and stroke unit of the hospital prior to the interview and reviews of the patient data. At hospital patients were informed about the study and verbal consent was obtained. For patients that have altered level of consciousness or severe aphasias an appropriate substitute decision maker (i.e., close family member, relatives/ proxy/caregiver) was given the consent. When needed the consent was given to them with an information sheet or read/explained to them (for those who could not read). The data from the case records and interview was handled with strong confidentiality. Neither the case records nor the data extracted was used for any other purpose.
No conflicts of interest exist.
We thank Jimma University for funding and supporting the study. We are grateful to staff members of stroke unit of JUMC, data collectors, and study participants for their cooperation in the success of this study.