|Year : 2017 | Volume
| Issue : 4 | Page : 155-159
Stroke admissions in Kubwa General Hospital: A 30-month review
Osaze Ojo1, Chukwuebuka Udo Onyegiri2
1 Department of Medicine, Medicine Unit, Kubwa General Hospital, Kubwa, Nigeria
2 Department of Family & Specialty Medicine, Nisa Premier Hospital, Abuja, Nigeria
|Date of Web Publication||17-Apr-2018|
Dr. Osaze Ojo
Kubwa General Hospital, Kubwa, Abuja
Background: Stroke is a common neurological disorder that contributes significantly to the morbidity and mortality of medical admissions. Objectives: To review the types, risk factors, hemispheric involvement, and outcomes of admitted stroke patients in Kubwa General Hospital, Abuja, Nigeria. Subjects and Methods: We carried out a retrospective study of patients who had a clinical diagnosis of stroke in Kubwa General Hospital, Abuja, Nigeria, between January 2013 and June 2015. Results: A total of 60 patients who had stroke were admitted during this period, accounting for 4.25% of medical admissions. Men and women accounted for 68.3% and 31.7%, respectively, with a male-to-female ratio of 2:1. Their mean age was 54.9 ± 13.5 years while the median age was 52.5 years. The mean hospital stay for these patients was 8.4 ± 5.5 days. Ischemic stroke occurred more frequently (65%) compared with hemorrhagic stroke (35%). Hypertension (65%), alcohol (25%), previous stroke (18.3%), diabetes mellitus, and hypercholesterolemia (18.3%) were the common identifiable risk factors for stroke. Ten patients (16.7%) had two risk factors for stroke, whereas 8 patients (13.3%) had three risk factors for stroke. The mean systolic and diastolic blood pressures on admission were 171.5 ± 41.6 mmHg and 103.3 ± 24.0 mmHg, respectively. The left hemisphere (53.3%) was more often affected than the right hemisphere in these patients. Majority of the patients (48.3%) were discharged following improvement while the case fatality was 11.7%. Conclusion: Stroke is not uncommon as a cause of medical admission in Kubwa General Hospital. Ischemic stroke occurred more commonly and the left hemisphere was more often involved compared with the right hemisphere. Hypertension was the most common risk factor for stroke in these patients.
Keywords: Hemispheric involvement, outcomes, risk factors, stroke
|How to cite this article:|
Ojo O, Onyegiri CU. Stroke admissions in Kubwa General Hospital: A 30-month review. Sahel Med J 2017;20:155-9
| Introduction|| |
Stroke is a common neurological disorder. The incidence of stroke is increasing worldwide and it is the third leading cause of death in most industrialized countries.,, The frequency of stroke in hospital populations in Nigeria varies from 0.9% to 4.0%; with a higher frequency in the context of neurological admissions (0.5%–45%). Stroke is the most common cause of neurological admission at the Lagos University Teaching Hospital  (LUTH) but third most common in Ogun State University Teaching Hospital  (OSUTH). At the University College Hospital, Ibadan, LUTH, and OSUTH, stroke accounted for 5%, 8%, and 17%, respectively, of medical deaths. Conventionally, modifiable and nonmodifiable risk factors have been identified as causes of stroke in these patients. The rise in the incidence and prevalence of hypertension and diabetes has been closely followed by a rise in noncommunicable disorders such as stroke. The HIV pandemic has led to developing countries such as Nigeria contending with a rise in both communicable and noncommunicable disorders.
In a study  in a Nigerian tertiary hospital, 120 stroke patients were involved with a male preponderance (61.7%). Hypertension, central obesity, and diabetes mellitus were the most common risk factors with ischemic stroke occurring more commonly (68.3%). There was no reference of the hemisphere of the brain which was more commonly affected. The lipid profile was not determined as a risk factor in admitted stroke patients. The outcomes of these admissions were not determined also.
Desalu et al. in a review of stroke admissions at a tertiary hospital in rural Southwestern Nigeria observed that women accounted for a slight majority of admitted cases with stroke (52.5%). As in the previously cited study, hypertension and diabetes mellitus were the most common risk factors. The 30-day case fatality was 23.8%. This was higher in men than in women. The case fatality was also higher in patients with hemorrhagic stroke than those with ischemic stroke (34.3% vs. 18.5%). As with the previous study, the more commonly affected hemisphere was not mentioned. This study was designed to determine the pattern and outcomes of admitted stroke patients as well as the risk factors for stroke in them.
| Subjects and Methods|| |
This was a 30-month retrospective study (January 2013–June 2015) conducted in Kubwa General Hospital: a district hospital in Abuja, the Federal Capital Territory of Nigeria. The Kubwa community is one of the major suburban districts in Abuja.
The diagnoses were made by a consultant physician and dermatologist and medical officers based on the WHO step-wise approach to stroke surveillance.
Data were retrieved from patients' records for the period under review using a structured questionnaire. The following information were obtained: age, sex, duration of hospital stay, occupation, the hemisphere involved, possible risk factor (hypertension, diabetic, previous stroke etc.), type of stroke (ischemic or hemorrhagic), blood pressure at presentation, blood glucose at presentation, lipid profile while on admission, and outcome of care. Outcome variables were subdivided into the following: discharge following improvement, death, referred to other hospitals, left against medical advice, and absconded.
The data collated were analyzed with Statistical Package for the Social Sciences (SPSS®). Descriptive and frequency statistics were obtained for the variables of interest. Approval for the study was obtained from the Federal Capital Territory Health Research Ethics Committee, Abuja.
| Results|| |
During the study period (30 months), 60 patients were clinically diagnosed with stroke, of which 41 (68.3%) were males while females were 19 accounting for 31.7% of patients. The mean age for both sexes was 54.9 ± 13.5 years. The median age for both sexes was 52.5 years. The age of patients ranged from 22 to 88 years. The categorization of the age groups for the patients is shown in [Table 1]. Ischemic stroke occurred in 39 (65%) patients, whereas hemorrhagic stroke was diagnosed in 21 (35%) patients. The left hemisphere was involved in 32 (53.3%) patients, whereas the right hemisphere was involved in 28 (46.7%) patients. Most of the patients were businessmen and women (22, 36.7%) as well as civil servants [15, 25.0%, [Table 2].
Systemic hypertension (39, 65.0%) was the most common modifiable risk factor for stroke. Others include alcohol consumption (15, 25.0%), previous stroke, diabetes mellitus, and hypercholesterolemia (11, 18.3%) each. The identified risk factors are shown in [Table 3].
The duration of stay on admission was 8.4 ± 5.5 days, whereas the duration of stay before death was 4.4 ± 6.3 days. The mean systolic and diastolic blood pressures at presentation were 171.5 ± 41.6 mmHg and 103.3 ± 24.0 mmHg, respectively. Most of the patients were discharged following improvement (29, 48.3%) while the case fatality rate was 11.7%. The other outcomes are shown in [Figure 1].
| Discussion|| |
This study determined the pattern and outcomes of stroke admissions in Kubwa General Hospital. The total number of medical admissions during the review period was 1413, of which 60 patients were admitted with stroke constituting 4.25% of admissions. This is similar to an earlier report by Desalu et al. whose study showed that stroke accounted for 4.5% of medical admissions.
The mean age of the patients was very similar to a study on stroke risk factors among patients in a Nigerian Teaching Hospital. A greater percentage of the patients were middle aged and elderly. This lends credence to the fact that the prevalence of stroke increases with age.,
Males were predominantly more affected (68.3%) than females. This was also in keeping with the previous reports., This was however different from findings by Ogun et al. and Onwuchekwa who reported a marginal preponderance of females., This may be explained by the larger number of patients (708 and 202, respectively) compared to 60 in this study. The other reasons posited for the marginal preponderance in females were the use of oral contraceptive pills, hormone replacement therapy, and pregnancy.
The left hemisphere (53.3%) was more frequently involved than the right hemisphere (46.7%). Hedna et al. reported that left-hemispheric strokes (54%) were more common than right-hemispheric strokes (46%) in a study on hemispheric differences in ischemic stroke. This hemispheric difference in frequency is mainly due to the higher incidence of left hemispheric large-vessel strokes in the middle cerebral artery distribution. More patients had ischemic stroke (65.0%) compared with hemorrhagic stroke (35.0%). This was in consonance with the study by Desalu et al. where ischemic stroke constituted 64.4% and 34.7% had hemorrhagic stroke. This pattern of a preponderance of ischemic stroke is consistent with other reports., On the contrary Njoku and Aduloju  and Ogun et al. reported a higher incidence of hemorrhagic stroke. These studies were largely based on the clinical diagnosis and so could be less reliable by best practices. Hypertension was the most common risk factor in this study (65%). This is evidenced by the mean systolic (171.5 ± 41.6 mmHg) and diastolic (103.3 ± 24.0 mmHg) blood pressures of the patients. This is corroborated by other studies where hypertension was shown to be the predominant risk factor., The other risk factors in descending order were alcohol consumption (25.0%), history of previous stroke (18.3%), diabetes mellitus (18.3%), and hypercholesterolemia (18.3%). The finding of alcohol consumption as the second most common risk factor draws attention to the changing lifestyle patterns of Nigerians. Regular alcohol consumption is associated with hypertension, fatal and nonfatal intracranial hemorrhage, cerebral infarction, and increased risk of death from stroke. About one-fifth (18.3%) of patients had a history of a previous stroke. Recurrence of stroke is frequent and is a major contributor to morbidity and mortality. The immediate period after a stroke carries the greatest risk for recurrence. In the Stroke Data Bank of 1273 patients with infarcts, 3.3% had an early recurrence within 30 days. Diabetes mellitus is a major risk factor for the development of atherosclerosis and the excess risk of stroke in patients with diabetes mellitus is about four times higher when compared with normal individuals in a general population. In a study on stroke risk factors, Alkali et al. reported diabetes mellitus as constituting 23.5% as against 18.3% in this study. This may be due to the larger patient size in their study. The incidence of hyperlipidemia (18.3%) is comparable to 18.4% reported in another study within the same geographical area. Data clearly support the positive relationship between total and low-density cholesterol in extracranial carotid atherosclerosis. The history of tobacco use in this study (8.3%) is in consonance with the finding by Alkali et al. (7.7%). Cigarette smoking increases the risk of ischemic stroke nearly two times  and was reported to be a significant risk factor in a case–control study among Nigerians.
Ten patients (16.7%) had two risk factors of hypertension and diabetes mellitus, whereas eight patients (13.3%) had three risk factors of various combinations. Thus, the total number of patients with multiple risk factors was 18 (30.0%). This is however different from a study in Northern Nigeria that reported that 37.5% of those below 45 years and 81.5% of stroke patients above 45 years had three or more risk factors. This was however a prospective study with a larger number of patients as well as the fact that a greater number of risk factors were determined in the study. Risk factors independently increase the probability of stroke and may also interact to increase the probability of stroke. The realization that the probability of stroke is increased several fold by the presence of multiple risk factors may help both patient and physician to more fully appreciate the need for serious risk factor management.
The mean duration of stay (8.4 ± 5.5 days) was similar (9 ± 7 days) to a study by Ng et al. on predictors of acute rehabilitation and total length of stay in acute stroke. The in-hospital case fatality rate in this study was 7 (11.7%). This is similar to a case fatality rate of 12.0% reported in a study by Sennay et al. The number of those discharged following improvement is 29 (48.3%). This again is similar to 47.9% reported by Sennay et al. A higher number of patients 15 (25.0%) compared with 6 (4.2%) were referred to other facilities. This is not unconnected with the fact that the hospital where the index study was conducted is a secondary care center, hence the need to refer when it was necessary. In this study, 8 patients (13.3%) left against medical advice while Sennay et al. reported that 20.4% of patients in their study left against medical advice. The health-seeking behavior of Nigerians may account for this trend. In a study by Chukwuneke et al., 111 patients (57%) sought health care at the health centers, 121 (62.7%) patent medicine stores, 87 (45%) medicine vendors, 100 (51.8%) private clinics, 56 (29%) prayer houses, and 118 (61.1%) traditional healers. Only one patient (1.7%) absconded from the ward in this study. Financial constraints resulting in inability to offset medical bills might have been responsible for this behavior.
| Conclusion|| |
Stroke is not uncommon and its prevalence increases with age. Ischemic stroke occurred more frequently than hemorrhagic stroke and the left hemisphere was more commonly involved compared with the right hemisphere. The presence of hypertension as the most common risk factor necessitates the need for improved health education for its treatment as well as raises the need for better control by medical practitioners. The presence of multiple risk factors should raise the awareness for the need to prevent modifiable risk factors for stroke.
Limitation of the study
All patients did not have computed tomography scans either due to availability or affordability. Being a retrospective study, it is possible that some of the diagnosis made clinically may be inaccurate.
Financial support and sponsorship
This study was administratively supported by the staff of the medical records unit of Kubwa General Hospital.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sudlow CL, Warlow CP. Comparing stroke incidence worldwide: What makes studies comparable? Stroke 1996;27:550-8.
Wolf PA, Kannel WB, Dawber TR. Prospective investigations: The Framingham study and the epidemiology of stroke. Adv Neurol 1978;19:107-20.
Warlow CP. Epidemiology of stroke. Lancet 1998;352 Suppl 3:SIII1-4.
Ojini FI, Danesi MA. Pattern of neurological admissions at the Lagos University Teaching Hospital. Niger J Clin Pract 2003;5:38-41.
Ogun SA, Adelowo OO, Familoni OB, Jaiyesimi AE, Fakoya EA. Pattern and outcome of medical admissions at the Ogun State University Teaching Hospital, Sagamu – A three year review. West Afr J Med 2000;19:304-8.
Adetuyibi A, Akisanya JB, Onadeko BO. Analysis of the causes of death on the medical wards of the University College Hospital, Ibadan over a 14-year period (1960-1973). Trans R Soc Trop Med Hyg 1976;70:466-73.
Ekeh BC, Ogunniyi AO, Isamade EL. Stroke risk factors among patients in a Nigerian teaching hospital. J Med Trop 2013;15:33-6.
Desalu OO, Wahab KW, Fawale B, Olarenwaju TO, Busari OA, Adekoya AO, et al.
A review of stroke admissions at a tertiary hospital in rural Southwestern Nigeria. Ann Afr Med 2011;10:80-5.
] [Full text]
Farooq MU, Chaudhry AH, Amin K, Majid A. The WHO STEPwise Approach to stroke surveillance. J Coll Physicians Surg Pak 2008;18:665.
Njoku CH, Aduloju AB. Stroke in Sokoto, Nigeria: A five year retrospective study. Ann Afr Med 2004;3:73-6.
Imarhiagbe FA, Ogbeide E, Ogunrin AO. Adult stroke registry in West Africa: Profile of 334 in-patients in the University of Benin Teaching Hospital, Benin City, Nigeria. Sahel Med J 2016;19:12-5. [Full text]
Ogun SA, Ojini FI, Ogungbo B, Kolapo KO, Danesi MA. Stroke in south west Nigeria: A 10-year review. Stroke 2005;36:1120-2.
Onwuchewa A, Bellgam H, Asekomeh G. Stroke at the university of Port Harcourt teaching hospital, Rivers state, Nigeria. Trop Doct 2009;39:150-2.
Hedna VS, Bodhit AN, Ansari S, Falchook AD, Stead L, Heilman KM, et al.
Hemispheric differences in ischemic stroke: Is left-hemisphere stroke more common? J Clin Neurol 2013;9:97-102.
Bwala SA. Stroke in a Subsaharan Nigerian hospital – A retrospective study. Trop Doct 1989;19:11-4.
Gorelick PB. Alcohol and stroke. Stroke 1987;18:268-71.
Sacco RL, Benjamin EJ, Broderick JP, Dyken M, Easton JD, Feinberg WM, et al.
American Heart Association Prevention Conference. IV. Prevention and rehabilitation of stroke. Risk factors. Troke 1997;28:1507-17.
Sacco RL, Foulkes MA, Mohr JP, Wolf PA, Hier DB, Price TR. Determinants of early recurrence of cerebral infarction. The Stroke Data Bank. Stroke 1989;20:983-9.
Hasan SR, Khan GA. Frequency of known risk factors of stroke and its outcome in patients' admitted in Sindh Government Qatar hospital Karachi. Pak J Med Sci 2007;23:634-6.
Alkali NH, Bwala SA, Akano AO, Osi-Ogbu O, Alabi P, Ayeni OA. Stroke risk factors, subtypes, and 30-day case fatality in Abuja, Nigeria. Niger Med J 2013;54:129-35.
] [Full text]
Heiss G, Sharrett AR, Barnes R, Chambless LE, Szklo M, Alzola C. Carotid atherosclerosis measured by B-mode ultrasound in populations: Associations with cardiovascular risk factors in the ARIC study. Am J Epidemiol 1991;134:250-6.
Shinton R, Beevers G. Meta-analysis of relation between cigarette smoking and stroke. BMJ 1989;298:789-94.
Walker R. Hypertension and stroke in Sub-Saharan Africa. Trans R Soc Trop Med Hyg 1994;88:609-11.
Karaye KM, Nashabaru I, Fika GM, Ibrahim DA, Maiyaki BM, Ishaq NA, et al.
Prevalence of traditional cardiovascular risk factors among Nigerians with stroke. Cardiovasc J Afr 2007;18:290-4.
Ng YS, Tan KH, Chen C, Senolos GC, Chew E, Koh GC. Predictors of acute, rehabilitation and total length of stay in acute stroke: A prospective cohort study. Ann Acad Med Singapore 2016;45:394-403.
Sennay AG, Hannah SY. Types, risk profiles, and outcomes of stroke patients in a tertiary teaching hospital in Northern Ethiopia. eNeurologicalSci 2016;3:41-7.
Chukwuneke FN, Ezeonu CT, Onyire BN, Ezeonu PO, Ifebunandu N, Umeora MC. Health seeking behaviour and access to health care facilities at the primary level in Nigeria: Our experience. Ebonyi Med J 2012;11:51-7.
[Table 1], [Table 2], [Table 3]