Research Article
Clinical and Neuroimaging Characteristics of Acute Stroke Patients Admitted to Adult Medical In-Patient Service of a Tertiary Teaching hospital in Addis Ababa Ethiopia, A Cross-sectional Study
- Andualem Endrias Yesuf 1*
- Rekik Abebe Degef 1
- Samson Zegeye Endale
- Binyam Jemaneh Batu 3
- Biruk Demisse Ayalew 4
St Paul’s Hospital Millennium Medical College, Department of Internal Medicine, Addis Ababa, Ethiopia.
*Corresponding Author: Andualem Endrias Yesuf,St Paul’s Hospital Millennium Medical College, Department of Internal Medicine, Addis Ababa, Ethiopia.
Citation: Andualem E. Yesuf, Rekik A. Degef, Samson Z. Endale, Binyam J. Batu, Biruk D. Ayalew. (2025). Clinical and Neuroimaging Characteristics of Acute Stroke Patients Admitted to Adult Medical In-Patient Service of a Tertiary Teaching hospital in Addis Ababa Ethiopia, A Cross-sectional Study. Journal of Clinical Medicine and Practice, BioRes Scientia Publishers. 2(1):1-8. DOI: 10.59657/3065-5668.brs.25.012
Copyright: : © 2025 Andualem Endrias Yesuf, this is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: November 18, 2024 | Accepted: December 04, 2024 | Published: January 19, 2025
Abstract
Background: Stroke is one of the primary causes of illness and mortality on a global scale. In both industrialized and developing nations, stroke is one of the main health issues. Additionally, stroke continues to be the major cause of disability in the adult population worldwide. In sub-Saharan nations, there is still a need for improved stroke diagnosis and care. In Ethiopia, data on the clinical and neuroimaging characteristics of stroke patients in outpatient and inpatient settings is scarce or, in some cases, out of date. Because of these, hospitals have been unable to allocate healthcare resources in accordance with the best available research. For the detection and treatment of stroke, Ethiopia has insufficient resources and capabilities. Therefore, this study aimed to assess clinical and neuroimaging Characteristics of Acute Stroke Patients Admitted to Adult Medical In-Patient Service of a Tertiary Teaching hospital in Addis Ababa Ethiopia.
Methods: A descriptive hospital-based cross-sectional study of clinical records during the period from September 1, 2024, to September 1, 2024, was conducted and used data collection form to abstract data from medical charts/records of sampled patients. The quantitative data was collected using pre-tested questionnaires. Descriptive statistics such as frequencies, means, and standard deviations were performed. Data was entered using EPI info version 6.0 and SPSS statistical packages. Study data was analyzed by IBM SPSS for Widow 20.0.
Results: Of the total of 2103 admissions in the medical adult inpatient service of St. Paul’s hospital millennium medical college, 103 of them were stroke patients, giving an in-hospital prevalence of 4.89%. The most frequent age of stroke patients was (60-69) which accounts for 47.6%. The mean age of the patients is 64 years. The majority (61.2%) of the study participants were male.72.8% were urban residents and the majority were government workers (27.2%). The in-hospital fatality rate was 26.2%. Additionally, 66.0 % of patients were improved and 1.9 % of them were referred for further treatment and investigation. The most frequent Subtype of stroke was ischemic stroke (90.3 %) followed by hemorrhagic strokes with Imaging findings of Intracranial Hemorrhage (31.1%) and Subarachnoid Hemorrhage (5.8 %).
Conclusion: Stroke prevalence at the hospital was 4.89%. The type of stroke with the highest prevalence was ischemic stroke. Hypertension and hyperlipidemia were the leading identified risk factors for stroke. In-hospital stroke case mortality was greater than in other studies done in northern Ethiopia and sub-Saharan Africa. Aspiration Pneumonia was the most common complication identified. Federal minster of health and hospitals should objectively allocate resources and plan strategic interventions that meaningfully improve stroke care and stroke prevention including introduction of IV thrombolytic (alteplase) therapy in the hospitals.
Keywords: hemorrhagic stroke; ischemic stroke; risk factors; outcomes; ethiopia
Introduction: Background
A stroke, or cerebrovascular accident, is defined by the abrupt onset of a neurologic deficit that is attributable to a focal vascular cause [1]. Previously it was defined as rapidly developed clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than of vascular origin [2,3]. Although still widely used, this definition relies heavily on clinical symptoms and is now considered outdated by the American Heart Association and American Stroke Association due to significant advances in the ‘nature, timing, clinical recognition of stroke and its mimics, and imaging findings that require an updated definition [4]. the American Heart Association/American Stroke Association updated their endorsed definition of stroke to one that includes silent infarctions (inclusive of cerebral, spinal and retinal) and silent hemorrhages [4]. Central nervous system infarction occurs over a clinical spectrum: Ischemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, while silent infarction by definition causes no known symptoms. Stroke also broadly includes intracerebral hemorrhage and subarachnoid hemorrhage [4]. Thus, the definition of stroke is clinical, and laboratory studies including brain imaging are used to support the diagnosis [5,6]. the clinical manifestations of stroke are highly variable because of the complex anatomy of the brain and its vasculature [6–9]. The incidence of stroke increases with age and is higher in men than women.[10,11] Significant risk factors include hypertension, hypercholesterolemia, diabetes, smoking, heavy alcohol consumption, and oral contraceptive use [12,13].
It is established that acute stroke is a common problem and the reason for most referrals to medical OPD (outpatient department) and admission worldwide. In 2013, approximately 6.9 million people had ischemic and 3.4 million people had a hemorrhagic stroke. In 2015, there were about 42.4 million people who had previously had a stroke and were still alive. Between 1990 and 2010, the number of strokes that occurred each year decreased by approximately 10% in the developed world and increased by 10% in the developing world [14,15]. In 2015, stroke was the second most frequent cause of death after coronary artery disease, accounting for 6.3 million deaths (11% of the total). About 3.0 million deaths resulted from ischemic stroke, while 3.3 million deaths resulted from hemorrhagic stroke. About half of people who have had a stroke live less than one year. Overall, two-thirds of strokes occurred in those over 65 years old [16]. Stroke is one of the major health problems in both developed and developing countries. Globally, stroke is one of the leading causes of morbidity and mortality.[17–19] Besides, stroke remains one of the leading contributors to disability among the adult population in the world. Acute stroke also drains meager resources of the healthcare system, and is an economic burden at individual and societal level. In Africa, the burden of stroke is disproportionately high and unattended [20].
The burden of stroke can be reduced by identification of stroke risk factors and instituting appropriate preventive public health measures [21]. According to the Global Burden of Disease (GBD) 2019 report, 90% of stroke risk is due to high blood pressure, obesity, diabetes hyperlipidemia, and renal dysfunction [22]. The remaining 10% of stroke risk could be due to a family history of stroke, cigarette smoking, obesity, lack of exercise, alcohol consumption, and unhealthy diets. Hemorrhagic stroke is associated with uncontrolled hypertension, and ischemic stroke is mostly related to diabetes mellitus [13]. Preventive strategies may vary depending on the local prevalence of individual risk factors, and may include lifestyle changes and efficient medical management of hypertension, diabetes, and heart diseases [21]. Lifestyle modifications include reduction of salt intake, regular physical exercise, weight reduction and healthy diet eating.[23,24] Blood pressure controlling campaigns, legislation to control the use of tobacco and its products are additional stroke prevention interventions. Currently, community-based stroke prevention programs and the use of community health workers are recommended to increase access to medical information and stroke care [23,24]. Moreover, prompt diagnosis and treatment reduce stroke morbidity and mortality. Clinical evaluation (history and physical examination) remain the pillars in diagnosis of stroke.[5] Focal weakness, speech disturbance, headache, and arm paresis are some of the common clinical presentations of stroke. Neuroimaging studies such as computed tomography scan and magnetic resonance imaging are additionally used for diagnosis and classification of stroke. Acute hemorrhage and areas of infarction on brain CT (Computed Tomography) scan or MRI (Magnetic Resonant imaging) suggest a diagnosis and types of strokes. Nevertheless, stroke diagnosis and treatment capacity are sub-optimal in Sub-Saharan countries. Ethiopia has the limited capacity and resource for diagnosis and treatment of stroke [5].
In Ethiopia, available data are limited or/and outdated on clinical and neuroimaging profiles of stroke patients in outpatient and inpatient settings. These have prevented implementation of evidence-based healthcare resources allocation for optimal stroke care in hospitals, and design of locally relevant continuing professional development programs and medical education in major universities and colleges in the country. SPHMMC (Saint Paul’s Hospital Millennium Medical College) is not an exception in these regards. Stroke prevention strategies also need valid and updated research data on major stroke risk factors in the country. The study describes clinical presentations and brain CT (or brain MRI) scans of the study population. It also identifies major demographic and epidemiological risk factors of stroke and in-hospital stroke complications. Findings of this study will inform policymakers and hospital administrators in their endeavors to improve stroke medical care in hospitals of SPHMMC and in the country at large. In addition, the study provides inputs in designing health professional training targeting improvement of stroke diagnosis and treatment.
The author of this research, believes that this study will be the first of its kind in providing our set up an updated data on clinical and neuroimaging Characteristics of Acute Stroke Patients. Using this data and defining local clinical and radiologic patterns of acute stroke is relevant to adapt locally appropriate clinical guidelines for management of stroke. The study done in a large institution like SPHMMC which serves as tertiary hospital for many populations with very diversified ethnic groups makes it somewhat representative to the population of the country. This will improve clinical competency and capacity of practicing clinicians in diagnosis and treatment of acute stroke. Medical educators will be able to gear their course contents for medical students and residents to improve diagnostic, treatment and monitoring of stroke and stroke complications relevant to the local patient population. Health managers and planners will have important data to objectively allocate resources and plan strategic interventions that meaningfully improve stroke care and stroke prevention including introduction of IV (intravenous) thrombolytic (alteplase) therapy in the hospital. This study will also serve as a reference for many similar future researches in Ethiopia. It will also help in designing health education for the community to improve awareness of acute stroke symptoms.
Specific Objectives
To determine the prevalence of acute stroke among patients admitted to adult inpatient service of SPHMMC during the study period. To determine most common presenting complaint as well complication of acute stroke among patients admitted to adult inpatient service of SPHMMC during the study period. To determine neuroradiologic findings of acute stroke patients admitted to adult inpatient service of SPHMMC during the study period. To identify risk factors for acute stroke among acute stroke patients admitted to adult inpatient service of SPHMMC during the study period.
Methods
We followed the STROBE cross-sectional reporting recommendations.[25]
Study design
A descriptive hospital based cross-sectional study of clinical records during the period from September 1, 2023 to September 1, 2024 was done.
Setting
this study was a hospital-based study conducted at St. Paul's Hospital Millennium Medical College tertiary hospital in Addis Ababa, Ethiopia. The study involved collection of secondary data in the mentioned hospital from September 1, 2023 to September 1, 2024.
Eligibility Criteria
Inclusion criteria was adult patients aged 40-80 who presented with stroke at SPHMMC’s Medical ward were included. Exclusion criteria were patients with other CNS commodities (CNS tumors, infection, Epilepsy) and CNS trauma. One Hundred three (103) participants selected by using systematic random sampling were taken as the study participants.
Variables
both quantitative and qualitative variables were collected in this study. Quantitative variable was age and qualitative variables collected were Stroke risk factors, Presenting acute stroke brain imaging findings and In-hospital stroke complications.
Study Size
One Hundred three (103) participants selected by using systematic random sampling were
taken as the study participants. There was not incomplete data.
Quantitative variables
Age was the only quantitative variable which was collected from the hospital charts.
Statistical methods
The collected data was coded and checked for completeness and consistency before entry to the computer software. Then the data entered to the computer was analyzed using SPSS software, version 20. descriptive statistics like frequencies and cross tabulations was used for describing the study population in relation to relevant variables.
Results
Socio-demographic characteristics
A total of 2103 patients were admitted to the medical ward of St Paul's Millennium Medical College from September 2023 to September 2024. Of these, 103 (4.89 %) patients were admitted with the diagnosis of stroke. The most frequent age of stroke patients was (60-69) which accounts for 47.6% and the mean age of the patients is 64 years. The majority (61.2%) of the study participants were male.72.8% were urban residents. Additionally, 44.7% of the study participants had a history of alcohol intake and about 34.0% were cigarette smokers (Table 1).
Table 1: Sociodemographic and lifestyle characteristics of stroke patients in St Paul’s millennium medical college, Addis Ababa, Ethiopia 2023–2024
| Variables | Categories | Frequency | Percentage |
Age (years)
Sex
Residency
Lifestyle Alcohol intake
Cigarette Smoking
Physical Exercise | 40-49 50-59 60-69 70-80 Male Female Rural Urban Yes No Yes No Yes No | 15 8 49 31 63 40 28 75 46 57 35 68 25 78 | 14.6 7.8 47.6 30.1 61.2 38.8 27.2 72.8 44.7 55.3 34 66 24.3 75.7 |
Percentage (%) cannot be 100
Discussion
Key results and Interpretation
Acute stroke places a financial strain on both the individual and social levels, draining the healthcare system's scant resources. The prevalence of stroke is disproportionately high and untreated in Africa [16]. One of the most frequent causes of hospital admission in Ethiopia is a stroke. For instance, strokes account for around 24% of all neurological admissions [26]. This study's goal was to evaluate the clinical and neuroimaging characteristics of acute stroke patients admitted to the adult medical inpatient service of a tertiary teaching hospital in Addis Ababa, Ethiopia. In light of this, the prevalence of stroke was 4897/100,000, or 4.89%. This result was almost in line with one from a Kenyan hospital-based investigation [27]. This prevalence, however, was lower than it had been in earlier Ethiopian research [26]. The discrepancy between the research could be caused by the different study periods and environments. Hemorrhagic stroke was the second most frequent kind in this study, following ischemic stroke (90.3%). The results of previous studies support this.[16,26–29] In contrast, hemorrhagic stroke was found to be the most frequently occurring subtype in another research [30, 31]. In 82.5% of individuals who had strokes, hypertension was the most often identified risk factor. This can be the result of sub-Saharan countries' ineffective hypertension management [30]. The rate of concomitant hypertension among stroke patients is also higher, according to other related studies from Ethiopia [29,32]. Additionally, the type of stroke was substantially related to other concomitant diseases such as hyperlipidemia and atrial fibrillation. This result was in line with a Chinese study. Atherosclerosis can lead to impaired fibrinolysis and increased thrombus development in the artery wall, which may be one of the factors contributing to its relationship with stroke [29,32,33]. To maintain cell activity, the brain requires a constant and sufficient flow of blood. Brain cell activities are significantly impacted by changes in blood flow. When there is an ischemic stroke, blood flow to the brain is disrupted as a result of either a thrombus or an embolus. Contrary to an ischemic stroke, a hemorrhagic stroke results in tissue damage because the hematoma compresses nearby tissue. The kind and extent of brain damage determine the clinical signs and symptoms of a stroke. The most frequent clinical manifestation in this particular study was a focal neurologic deficit (100%), followed by a coma or altered mental status (62.1%). Similar results were obtained from a study conducted in a tertiary teaching hospital in northern Ethiopia [29]. In a different hospital-based study at Tikur Anbessa Specialized Hospital in Ethiopia, the most frequent presenting symptoms were altered mental status (48%), hemiparesis (47%), facial palsy (45%), hemiplegia (29%), and aphasia (25%) [30].
The majority of stroke patients in this study (66.0%) have been discharged with improvement, while just 1.9% of stroke patients were referred. This study's in-hospital case fatality rate of 26.2% was comparable to other studies with in-hospital case fatality rates between 11.1% and 30.1% [29, 31, 32]. However, compared to other studies carried out in Ethiopia, this study's in-hospital case fatality rate was lower [26]. The greater availability of diagnostic modalities and expertise in this research may be the cause of the higher rate. As a result, the majority of those with strokes will be referred to the hospital for a more accurate diagnosis and treatment.
Limitations
Explanatory and outcome variables for the study were not causally related to any other variables. An additional analytical investigation will address this issue.
Generalizability
In this study a description of status of a sample population of Acute Stroke Patients whose age was between 40 and 80 and Admitted to Adult Medical In-Patient Service of a Tertiary Teaching hospital in Addis Ababa Ethiopia was performed. Our methodology, which is retrospective medical records review can be replicated elsewhere and the reported results are generalizable to that particular population elsewhere.
Conclusion
The prevalence of acute stroke was lower than in the previous study conducted in Ethiopia; however; in-hospital stroke case fatality was higher compared with previous studies conducted in sub-Saharan Africa and northern Ethiopia. The prevalence of acute stroke among patients admitted to adult inpatient service at St Paul’s hospital millennium medical college A.A, Ethiopia, was 4.89%. Sex (being male), hypertension, hyperlipidemia, and diabetes were the most commonly identified risk factors in patients with stroke. Aspiration Pneumonia was the most commonly identified complication. So, a higher rate of complications was identified in this study. The Federal Minister of health and hospitals should objectively allocate resources and plan strategic interventions that meaningfully improve stroke care and stroke prevention including introduction of IV thrombolytic (alteplase) therapy in the hospital and prevention of in-patient complications like Aspiration Pneumonia and bedsore. Health officials should work on helping professionals in designing health education for the community to improve awareness of acute stroke symptoms, urgent medical attention of possible stroke clinical presentation and importance of relevant lifestyle changes in reducing stroke risks.
Declarations
Ethics statement
I had ethical clearance to conduct the research to SPHMMC wards from IRB and the hospital is a teaching hospital that the patients are aware of. Confidentiality of patient’s information was assured. I had a letter and authority permission from the administrative body of St. Paul’s Hospital Millennium Medical College. And the name of patients was not described in the research paper.
What is Known about this topic
Acute Stroke is Acute stroke is a common problem and reason for most referrals to medical OPD and admission to wards) worldwide; The outcomes of stroke are poor if early diagnosis and treatment are not initiated; The prevalence of ischemic stroke is higher than that of hemorrhagic stroke.
What this study adds
An updated data on clinical and neuroimaging Characteristics of Acute Stroke Patients;
A much Higher prevalence of Ischemic Stroke was observed;
Aspiration Pneumonia was the most common complications identified.
Competing interests
The author reports no conflicts of interest in this work
Authors` contributions
Andualem Endrias Yesuf, Yidnekachew Girma Mogessie and Samson Zegeye Endale: Conceptualized the work, drafted the proposal and wrote the manuscript;
Rekik Abebe Degef and Samson Zegeye: improved on work concept, managed data and revised the manuscript;
Rekik Abebe Degef: Supervised data collection and revised the manuscript.
All authors have read and agreed to the final manuscript.
Acknowledgments
First, our gratitude goes to St. Paul’s Hospital Millennium Medical College for providing the chance to conduct this research work and for funding the research project. Last, but not least, we are grateful for those who participated actively and positively from the inception up to the final report of the research project.
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