Predictors of short term outcomes among stroke patients admitted at Bugando Medical Centre in Mwanza, Tanzania
- Mwanza, Tanzania: Catholic University of Health and Allied Sciences [CUHAS – Bugando] : 2022
- xii; 75 Pages Includes References and Appendices
Abstract:
Introduction: Globally stroke is the 2nd leading cause of death with highest mortality in Lowmiddle-income countries particularly in sub-Saharan Africa. Little is known about the 30-day outcomes and predictors among stroke patients admitted at Bugando Medical Centre, Northwest Tanzania.
Objective: We aimed to investigate the predictors of 30-day mortality among stroke patients admitted at a tertiary teaching hospital in Northwestern Tanzania.
Methodology: This cohort study recruited patients with a World Health Organization clinical definition for stroke. Baseline data and post-stroke complications were recorded. Head CT-scan and a 12-lead electrocardiography was performed. The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were used to assess stroke severity and outcomes respectively. Kaplan-Meier analysis was used to describe survival and Cox-proportional hazards model was used to examine predictors of mortality.
Results: A total of 135 participants were included in the final analysis. The mean age was 64.5 years, and 64.8% had ischemic stroke. More than one third of the participants (37%) died within 30 days and 25% of patients died within 17 days. Among participants with hemorrhagic stroke 25% died within 5 days vs 23 days for ischemic stroke. Participants with hemorrhagic stroke 25% were located in multiple areas within the cortical and sub-cortical regions followed by the thalamus 22.7% and 63.6% had interventricular extension. 62.9% had ischemic strokes in multiple regions. ECG changes were observed in 54.6% and 46.9% of patients with hemorrhagic and ischemic stroke respectively. The most common ECG patterns was ST changes 29.6% vs 30.9%, T wave inversion 34.1% vs 38.3% and U waves 18.2% vs 1.2% in hemorrhagic and ischemic strokes respectively. Independent predictors for 30-day case fatality were: NIHSS score [aHR 1.09; (95% CI: 1.02-1.18)], mRS score (4-5) [aHR 5.50; (95% CI: 2.02- 15.04)], aspiration pneumonia [(aHR: 3.69; (95% CI: 1.71-13.69) and ECG changes [aHR: (2.28; 95% CI: 1.86, 5.86)].
Conclusion: Stroke is associated with a high 30-day mortality in Northwestern Tanzania. Concerted efforts are warranted in the prevention and management of stroke patients with special attention to individuals with severe strokes, ECG changes, and swallowing difficulties in order to reduce early morbidity and mortality.
= STANDARD DEFINITIONS Abnormal U-wave: Negative U-wave with more than 0.1 mV depth or positive U wave higher than 25% of T-wave visible in more than 2 leads STANDARD DEFINITIONS ASPECT score: (Alberta Stroke Program Early CT Score) is a 10-point quantitative score that measures the extent of early ischemic changes in anterior circulation hyper acute ischemic stroke. The score includes 10 segmental areas of middle cerebral artery territory and each area is given one point. A point is deducted whenever the area is involved. A score of < 7 predicts the poor outcome. STANDARD DEFINITIONS ICH (Intracerebral hemorrhage) score: Is a simple clinical grading scale that allows risk stratification on presentation with Intracerebral Hemorrhage. It contains 5 components which are Glasgow coma scale, Presence of intraventricular hemorrhage, Infratentorial origin of hemorrhage, intracerebral hemorrhage volume and Age. The range of the score is 0-5, with each rise of score associating with progressive increased 30-day mortality. STANDARD DEFINITIONS Large MCA (Middle Cerebral Artery) infarct: Is a form of massive cerebral infarction that is used to describe complete MCA territory infarction resulting in significant space occupying effect. The resulting depression of consciousness terminates in coma and brain death in almost 80% of patients treated with conservative medical therapy alone. The incidence is estimated at 2 to 10% of all ischemic stroke. STANDARD DEFINITIONS Q-waves: Will be significant if they are greater than 0.04 seconds in duration or more than 25% of the height of the R-wave for that lead (unless confined to lead III) STANDARD DEFINITIONS ST segment depression or elevation: Down-sloping ST-segment depression or its flat depression of 1 mm and the elevation of 1.0 mm in extremity and precordial leads (but elevation of 2.0 mm for V1 and V2) STANDARD DEFINITIONS T-wave abnormalities: T-waves that are of low voltage or are flat or inverted in leads that are normally upright or that are abnormally tall and peaked; a T-wave less than 0.1 mV in depth will defined as inverted STANDARD DEFINITIONS Large cerebral hemorrhage: Is defined as those lesions at least 3 cm in largest dimension in the cerebral hemispheres or 1.5 cm in the brain stem. OPERATIONAL DEFINITION Short term outcomes: This was defined as death or survival with and without disability using the modified Rankin Scale from symptom onset and length or duration of hospital stay OPERATIONAL DEFINITION Stroke: Sudden developing clinical signs of focal (or global) neurological impairment, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin. OPERATIONAL DEFINITION Ischemic stroke: Is sudden neurological deficit that results from cerebral ischemia associated with permanent brain infarction. OPERATIONAL DEFINITION Stroke caused by intracerebral hemorrhage: Rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma.
= ABBREVIATIONS ACA Anterior Circulation Artery ASPECTS Alberta Stroke Programme Early CT Score BMC Bugando Medical Centre CE Cardio-Embolic CNS Central Nervous System CT Computed Tomography CUHAS Catholic University of Health and Allied Sciences DALY Disability Adjusted Life Years ECG Electrocardiogram HIC High Income Country ICH Intracranial Hemorrhage IVH Intraventricular Hemorrhage LAA Large Artery Atherosclerosis LIC Low Income Country LMIC Lower Middle-Income Country MCA Middle Cerebral Artery MRS Modified Ranking Scale NIHSS National Institute of Health Stroke Scale OC Stroke of other determined cause PCA Posterior Circulation Artery SAO Small Artery Occlusion SSA Sub Saharan Africa UMIC Upper Middle-Income Country UND Stroke of Undetermined Cause WHO World Health Organization
Wurzburg Road 35, BMC Premises, Post Code: 33102: P. O Box 1464, Mwanza – Tanzania: Phone: +255 28 298 3384: Fax: +255 28 298 3386: Email: vc@bugando.ac.tz : Website: www.bugando.ac.tz