Fig. 8.1
Disease burden on the neurology unit in Mulago Hospital, 2012 (Matovu et al. 2012 data unpublished)
Risk Factors for Stroke
In a study carried out in Uganda’s Mulago National Referral hospital, in Kampala, Nakibuuka et al. [3] investigated the main risk factors for ischemic and hemorrhagic stroke. The parameters noted were past medical history, physical examination findings, key laboratory investigations and Ultrasonography investigations. Table 8.1 below shows the main findings.
Table 8.1
Risk factors of stroke among patients admitted to Mulago National Referral Hospital in 2012
Risk factor | Percentage of patients | Percentage of patients |
|---|---|---|
With ischemic stroke (N = 66) | With hemorrhagic stroke (N = 19) | |
I. Past medical history | ||
Hypertension | 57.6 | 68.4 |
Physical inactivity | 40.9 | 36.8 |
Diabetes mellitus | 12.1 | 5.2 |
Current smoking | 7.6 | 5.2 |
Alcohol | 18.2 | 21.1 |
II. Examination findings | ||
Irregularly irregular pulse | 22.7 | 5.3 |
Systolic BP >140 mmHg | 47.0 | 73.7 |
Diastolic BP >90 mmHg | 36.4 | 68.4 |
III. Laboratory findings | ||
Total cholesterol >200 mg/dl | 31.0 | 39.0 |
LDL cholesterol >110 mg/dl | 43.1 | 33.3 |
HDL cholesterol <40 mg/dl | 38.0 | 17.0 |
Triglycerides >150 mg/dl | 23.1 | 33.3 |
FBS >126 mg/dl | 43.1 | 55.6 |
Reactive TPHA | 26.2 | 50.0 |
Reactive HIV serology | 7.7 | 0 |
IV. Ultrasound findings | ||
Atherosclerosis on CUS | 46.0 | 46.7 |
For both types of stroke (ischemic and hemorrhagic), the outstanding risk factors for stroke were Hypertension (BP > 140/90 mmHg), physical inactivity, alcoholism, dyslipidemias, Diabetes Mellitus, arthrosclerosis and a positive syphilis serology.
Hypertension
More than 50 % of patients with either ischemic or hemorrhagic stroke reported a history of hypertension, in which more than half of the patients were found to have a blood pressure greater than 140/90 mmHg. Of these patients, however, 27 (32 %) patients reported sporadic use of anti-hypertensive medications, with only 7 patients (8 %) reporting regular medication use. Only 3 patients reported regular use of aspirin prophylaxis for stroke, and these all presented with ischemic stroke.
Cardiac Causes: Embolic Source, Atrial Fibrillation and Stenosis
In Nakibuuka’s study, 18 patients had a suspected cardio-embolic stroke, with 18.8 % patients found to have an irregularly irregular pulse. However, none of these patients were aware of a previous diagnosis of atrial fibrillation or were taking any medications. Two of these patients were found to have severe valvular heart disease, suggesting that atrial fibrillation could be an important under-recognized cause of stroke in African populations [3–5]. Atherosclerosis in the carotid arteries and cardiac left ventricular hypertrophy were commonly found on physical examination.
Diabetes Mellitus, Dyslipideamias and Lifestyle
Thirty eight patients were found to have a Fasting Blood Sugar (FBS) greater than 126 mg/dl, consistent with a diagnosis of Diabetes Mellitus, but only nine of these patients had a known previous diagnosis of the diabetes. Commonly recognized risk factors, such as hypercholesterolemia, physical inactivity, current smoking and alcohol were frequently found in this stroke victim population.
Syphilis and Human Immunodeficiency Virus
Twenty six patients were found to have reactive serology for syphilis, and only five patients were found to have HIV diagnosed by Abbot test. All these patients were on treatment for these disorders.
Socio-demographic Associations of the Stroke Victims Seen at Mulago Hospital
In terms of their sociodemographic characteristics, Nakibuuka et al. [3] found that the stroke victims were almost of equal gender representation with 51.8 % females but they had a bimodal age distribution with a peak in the 40–49 year age group (22.4 %) and in those aged 60–80 years (37.6 %). Generally, stroke was more common in older individuals and the mean age for all stroke patients was 62.2 years with the vast majority of them being above 40 years old (83.5 %). Most were married (61.2 %), had primary school education or below (54.1 %) and were employed (52.9 %) as shown in Table 8.2 below. These findings were similar to the findings of studies done in other African countries in Zimbabwe [6, 7].
Table 8.2
Socio demographic characteristics of stroke patients admitted to Mulago National Referral Hospital
Characteristics | Number (N = 85) | Percentage (%) |
|---|---|---|
Age (years) | ||
20–29 | 8 | 9.4 |
30–39 | 6 | 7.1 |
40–49 | 19 | 22.4 |
50–59 | 11 | 12.9 |
60–69 | 16 | 18.8 |
70–79 | 16 | 18.8 |
80+ | 9 | 10.6 |
Gender | ||
Female | 44 | 51.8 |
Highest education level attained | ||
Never been to school | 14 | 16.5 |
0–7 years | 32 | 37.6 |
8–12 years | 23 | 27.1 |
More than 12 years | 16 | 18.8 |
Marital status | ||
Never married | 6 | 7.1 |
Married | 52 | 61.2 |
Divorced | 17 | 20.0 |
Widowed | 10 | 11.8 |
Occupation | ||
Student | 3 | 3.5 |
Unemployed | 37 | 43.5 |
Employed | 45 | 52.9 |
Stroke Types
Strokes are divided into two very broad groups namely hemorrhagic strokes and ischemic strokes. In ischemia, there is not enough blood supply to allow continued normal functioning of the affected brain tissue. Brain ischemia is much more common in these than in those due to hemorrhage. About four strokes out of every five are ischemic. In hemorrhage, there are several different subtypes characterized by their locations inside of the skull. Hemorrhages within the brain substance (inside of the pia mater) are called intracerebral hemorrhages. Those between the pia mater and arachnoid are called subarachnoid hemorrhages. Regarding stroke types in Mulago National Referral hospital, 77.6 % were ischemic while 22.4 % were hemorrhagic stroke as confirmed by Computed Tomography scan of the brain. The incidence of both ischemic and hemorrhagic stroke increased with age as seen in Table 8.3 [3]. Mukisa et al. [8] in a separate study done in Mulago National referral hospital, had the same findings with the majority of patients admitted with stroke having ischemic stroke (82.4 %) and those with hemorrhagic stroke were 17.6 %. The observed ratio of ischemic to hemorrhagic stroke of 4:1 was similar to other studies among African populations [9–11]. Atherosclerotic stroke was the commonest ischemic stroke in etiology, being observed in 43.5 % patients with ischemic stroke. Intraparenchymal hemorrhage was the most common hemorrhagic stroke in etiology, in 78.9 % of patients with hemorrhagic stroke [3]. Table 8.3 summarizes these findings.
Table 8.3
Incidence of ischemic and hemorrhagic stroke according to gender and age group as seen at Mulago Hospitala
Ischemic stroke | Hemorrhagic stroke | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
Male N = 35 | Female N = 31 | Male (n = 9) | Female N = 10 | |||||||
Age (years) | AS | CE | O | AS | CE | O | IPH | SAH | IPH | SAH |
21–30 | 0 | 3 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
31–40 | 1 | 0 | 0 | 0 | 0 | 3 | 1 | 0 | 0 | 0 |
41–50 | 2 | 1 | 0 | 1 | 2 | 0 | 1 | 1 | 1 | 1 |
51–60 | 7 | 1 | 1 | 1 | 2 | 2 | 1 | 0 | 1
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