Epidemiology and Prognostic Factors of Stroke In Intensive Care Unit at the National University Hospital Hubert Koutoukou Maga (CNHU-HKM) of Cotonou

Article Information

Hounkpè Pierre Claver1*, Ahounou Ernest1, Adjagba Philippe2, Kiatti Enoch1, Oke Luc3

1Anesthesia and Critical Care Service, National University Hospital Hubert Koutoukou MAGA (CNHU-HKM) of Cotonou, Bénin

2Service of Cardiology, National University Hospital Hubert Koutoukou MAGA (CNHU-HKM) of Cotonou, Bénin

3American Center for Investigative Cardiology (ACIC), USA

*Corresponding Author: Hounkpe Pierre Claver, Department of Anesthesia and Critical Care, Service of Anesthesia and Critical Care, National University Hospital Hubert K. MAGA (CNHU-HKM), Cotonou, Bénin Republic, West Africa 

Received: 10 January 2020; Accepted: 28 January 2020; Published: 31 January 2020

Citation: Hounkpè Pierre Claver, Ahounou Ernest, Adjagba Philippe, Kiatti Enoch, Oke Luc. Epidemiology and Prognostic Factors of Stroke In Intensive Care Unit at the National University Hospital Hubert Koutoukou Maga (CNHU-HKM) of Cotonou. Anesthesia and Critical Care 2 (2020): 001-007.

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Abstract

Introduction: Strokes are serious neurovascular pathologies and constitute a public health problem due to their high frequency and high mortality rate. The research aim was to assess the prognostic factors of stroke in the intensive care unit of the National University Hospital Hubert Koutoukou Maga (CNHU-HKM) of Cotonou.

Materials and Methods: This was a cross-sectional, descriptive and analytical research with retrospective data collection. It took place in the intensive care unit of the CNHU/HKM at Cotonou over a period of 30 months from January 1, 2015 to June 30, 2017. The cases of stroke confirmed by a brain scanner/ MRI were included.

Results: A total of 109 stroke cases were included in our research and the prevalence was 5.5%. Hemorrhagic strokes were more representative (59.6%). The mean age was 59 ± 14 years, the sex ratio was 1.22. The HBP was the most common risk factor (81.7%). Mortality was 80.07% and length of stay 8 ± 9 days. The poor prognostic factors were GCS ≤ 8, the presence of neurological and respiratory complications or sepsis.

Conclusions: Strokes in intensive care unit at CNHU/HKM are burdened with a high mortality rate (80.07%). The poor prognostic factors were GCS ≤ 8, the presence of neurological and respiratory complications or sepsis.

Keywords

Stroke; Epidemiology; Prognostic factors; Mortality; Strengthening the technical platform

Stroke articles, Epidemiology articles, Prognostic factors articles, Mortality articles, Strengthening the technical platform articles

Article Details

1. Introduction

Stroke is a sudden deficit in focal brain function with no other apparent cause than a vascular cause [1]. Because of its frequency and severity, it is a public health problem [2]. In fact, it is the leading reason for hospitalization in neurology units, the third cause of death and the first cause of disability in adults worldwide [3, 4]. In Africa, because of changes in eating habits and stress, strokes are becoming more frequent and could be the leading cause of death in 2020 according to the WHO [5]. When the vital prognosis is engaged, its monitoring is done in intensive care units and its management is multidisciplinary, involving the critical care physician, the neurologist, the cardiologist but also the radiologist and sometimes the neurosurgeon. The aim of our work was to determine the prevalence and assess the prognostic factors of stroke in the intensive care unit of the National University Hospital Hubert Koutoukou Maga (CNHU/HKM) at Cotonou.

The specific objectives were to determine the prevalence of stroke in the intensive care unit of the CNHU/HKM, to describe their epidemiological profile and to identify the prognostic factors

2. Materials and Methods

It was a cross-sectional, descriptive and analytical research with retrospective data collection. It took place in the anesthesia and critical care service of the CNHU/HKM at Cotonou over a period of 30 months running January 1, 2015 through June 30, 2017. The source population consisted of all stroke cases admitted to intensive care unit during the research period. The inclusion criteria were: any patient whose clinical diagnosis of stroke was confirmed by brain CT/MRI. The non-inclusion criteria were: any patient whose clinical diagnosis of stroke was not confirmed on brain imaging. The exclusion criteria were: any patient whose diagnosis of stroke was documented but whose record was unusable. The variables studied were: prevalence, socio-demographic, clinical and paraclinical data, evolutionary data and prognostic factors.

Data collection was carried out using a collection form, from the critical care register and patient files. Data was entered into Epi Data software version 3.1 and analyzed using Epi Data analysis version 2.2.2.182. Statistical analysis was carried out using the Pearson Chi2 test with significance threshold for a p value ≤ 0.05. The confidence interval was set at 95%.

3. Results

3.1 Prevalence: We had collected during the research period 168 cases of stroke out of 1967 hospitalizations; only 109 cases of stroke were confirmed by a brain scan, which corresponds to a prevalence of 5.5%.

3.2 Stroke Mechanism: The stroke mechanism was hemorrhagic in 65 patients (59.6%), ischemic in 44 patients (40.4%) including one case of ischemic stroke with secondary bleeding.

3.3 Age: The average age of our patients was 59 ± 14 years with the extremes of 26 and 91 years. Patients under 65 represented 68% of our sample.

3.4 Sex: Sixty patients were male (55%) and forty-nine were female (45%). The sex ratio was then 1.22. In the male population, thirty-nine (65%) had a hemorrhagic stroke, compared to twenty-one (35%) who had an ischemic stroke. Twenty-six (53.1%) of the women had a hemorrhagic stroke and twenty-two (44.9%) had an ischemic stroke. A case of ischemic stroke with secondary bleeding was found in a woman.

3.5 Risk factors: HBP was the most representative risk factor; it is found in 81.7% of our patients. Table 1 shows the general characteristics of stroke patients in intensive care and the risk factors associated with the disease.

3.6 Clinical data of stroke cases in intensive care

3.6.1 Neurological signs: The neurological signs found in our patients are presented in Table 2. 

3.6.2 Therapeutic data: The time taken to perform a brain scan in our series exceeded 24 hours in all patients. No case of ischemic stroke benefited for thrombolysis. The treatment of our patients consisted in the management of vital distress and secondary cerebral aggressions of systemic origin (SCASO). Eighty-four patients (77.1%) benefited from mechanical ventilation either for the treatment of respiratory distress or because they are in a profound impairment of consciousness with GCS ≤ 8.

3.6.3 Progressive data: The evolution was favorable in 06 of our patients (5.6%) who were discharged without post-effects. 14 patients (12.8%) had neurological post-effects such as hemiplegia, facial paralysis and dysarthria. They were transferred to the neurology department for further care. 01 patient had left intensive care against medical advice.

3.6.4 Mortality: 88 patients (or 80.07%) of stroke cases had died. The causes of death are summarized in Table 3. The length of stay was on average 8 ± 9 days, with the extremes of 1 and 69 days.

3.6.5 Factors associated with death: The factors associated with death are summarized in Table 4.

Characteristics

Size (n=109)

Percentage (%)

Sex

Male

60

55

Female

49

45

Age

20-35 years

4

4

36-50 years

26

24

51-65 years

44

40

66-80 years

28

26

> 80 years

7

6

Risk factors

HBP

89

81,7

Diabetes

19

17,4

Stroke

13

11,9

Heart disease

4

3,7

Table 1: General characteristics of stroke cases in the intensive care unit of the CNHU-HKM (2015-2017).

Symptoms

Size

Percentage (%)

GCS

[9 - 14]

40

37

 ≤ 8

64

59

Clear consciousness

5

4

Pupil

Bilateral mydriasis

15

13,8

Anisocoria

13

11,9

Pyramidal syndrome

Facial paralysis

23

21,10

Hemiplegia

80

73,4

Status epilepticus

24

22

Table 2: Neurological signs in cases of stroke in the intensive care unit of CNHU-HKM (2015-2017).

Complications

Size (n=88)

Percentage (%)

HICT + Brain displacement

43

48,86

Respiratory failure

52

59,10

Heart Failure

38

43,18

Severe sepsis

52

59,10

Metabolic disorders

29

32,95

Table 3: Causes of death in cases of stroke in intensive care at CNHU/HKM (2015-2017).

Associated factors

Non-survivors (%)

Survivors (%)

p-value

GCS

normal

2 (40,0)

3 (60,0)

 

[9-14[

28 (70)

12 (30)

0,005

≤ 8

58 (90,6)

6 (9,4)

 

Complications

No

5 (33,3)

10 (66,7)

 

Yes

83 (88,3)

11 (11,7)

0,0001

Type of complication

HICT + brain displacement

     

No

45 (69,2)

20 (30,8)

0,0002

Yes

43 (97,7

1 (2,3)

 

Respiratory failure

No

36 (72,0)

14 (28,0)

0,033

Yes

52 (88,1)

7 (11,9)

 

Sepsis

No

36 (70,6)

15 (29,4)

0,011

Yes

52 (89,7)

6 (10,3)

 

Table 4: Factors associated with death in strokes in intensive care unit of CNHU / HKM (2015-2017).

4. Discussion

Our research focused on 109 cases of stroke hospitalized in the intensive care unit of CNHU/HKM. The prevalence of stroke compared to admissions is low and was 5.5%. Many studies on stroke in critical care carried out in Sub-Saharan Africa have reported higher prevalence ranging between 11% and 19% [6-8]. The low prevalence rate in our work is due to the very selective inclusion criteria which include the performance of a brain scan, which was not the case in the aforementioned research. In neurology departments in Sub-Saharan Africa, stroke is the leading cause of hospitalization [9, 10].

We noted a male predominance in our stroke patients with a sex ratio of 1.22. This male predominance has been found in the works of Ngomahobet et al, Babo et al as well as Boukougou et al; these authors respectively reported the sex ratio of 1.6; 1.4 and 1.8 [6-8]. Is this tendency of men to have more strokes than women linked to the African culture in which men are much more stressed because they are forced to provide for the whole family? Other studies will help us confirm or not this finding.

The mean age was 59 ± 14 years, 28% of the patients were less than 50 years old and almost 40% between 50 and 65 years old. This trend is confirmed in most African research, with average ages varying between 50 and 60 years [11, 8, and 12]. Stroke in Africa affects young adults who make up the workforce, with serious socio-economic consequences. In developed countries of Europe and the United States, on the other hand, stroke affects older people more, with an average age around 77.5 years [13].

The most common stroke mechanism in our research was hemorrhagic stroke (59.6%). It is described that black Africans are more likely to develop hemorrhagic strokes by hypertension [14]. Worldwide, the trend is towards a predominance of ischemic stroke [15].

The overall mortality from stroke in our research was very high (80.7%), that is, more than 8 out of 10 stroke patients hospitalized, who die in intensive care at the CNHU/HKM. In the African research on stroke, only Diouf et al in 2007 in Dakar had a mortality rate of 82.9%, which was higher than ours [16]. Agnon A. et al in 2016 at the CHU-Campus of Lomé, Mapoure Yacouba N. et al of the Hôpital Général de Douala, reported mortality rates of 72.6% and 69.2% respectively [17.18]. In developed countries where stroke is increasingly followed in neurovascular care units, much lower mortality rates have been reported, varying between 33% and 52% [19]. The reasons for this very high mortality rate in our research in particular and in Sub-Saharan Africa in general were:

- Severe initial neurological state of stroke patients admitted to intensive care;

- delay in taking care of patients, who do not come to the hospital at the first sign.

- inadequate resuscitation technical platform

- low number of skilled health personnel

- very low purchasing power of the population, most often deprived of health insurance cover.

The factors associated with death in our research were: a GCS score ≤ 8 (p=0.005), the presence of a HICT + brain displacement (p=0.0001), a respiratory complication (p=0.033) and sepsis (p=0.011). The GCS ≤ 8 has been found as a factor of poor prognosis in several studies [Adoukonou]; it indeed reflects the severity of the initial neurological lesion. Intracranial pressure (ICP) is not monitored in our intensive care unit; the diagnosis of HICT is made on little reliable clinical criteria and the non-optimal care, which further worsens the condition of our patients. As for respiratory and infectious complications, they constitute secondary cerebral aggressions of systemic origin with poor prognosis. Infectious and pulmonary complications have been identified as having a poor prognosis in the work of Sellars et al, and Westendorp et al [20, 21].

5. Conclusions

Strokes are serious neurovascular pathologies managed in intensive care when the life prognosis is engaged. Their prevalence in intensive care of CNHU/HKM was low, 5.5%. The epidemiological profile is that of an adult male (55%), 59 years on average, presenting mainly as a risk factor high blood pressure (81.6%) and whose stroke mechanism is mainly hemorrhagic (59.6%). Mortality is too high, 08 out of 10 patients will die in intensive care and the factors associated with death were a GCS ≤ 08, the presence of neurological, respiratory or sepsis complications. To reduce this high mortality rate, emphasis should be placed on taking care of risk factors, strengthening the technical platform for resuscitation, training sufficient number of health deliverers and health insurance coverage for the population.

Conflicts of Interest

None

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