Stroke in young Nigerian adults

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Stroke in young Nigerian adults A. C. Onwuchekwa, FMCP, R. C. Onwuchekwa, FWACS, and E. G. Asekomeh, FWACP.

Stroke in adults under the age of 45 results in a greater loss of potential years of life than for other adults. This premature loss of life is associated with a high social and economic burden. Few data are available regarding stroke among young Nigerian adults in the Niger Delta Basin. This study sought to determine the incidence, risk factors, stroke subtypes and case fatality of stroke among young Nigerian adults. The medical records of all 18- to 45-year-old patients admitted with stroke in the medical wards of the University of Port Harcourt Teaching Hospital (UPTH) from January 2003 to December 2008 were retrospectively reviewed. Of the 611 patients admitted with stroke, 54 (8.8%) were aged 18-45 years. There were 26 males and 28 females. Hypertension was responsible for 42 (77.8%) stroke cases. Other important risk factors were excessive alcohol intake (27.8%), heart disease (13%), diabetes mellitus (11.1%), cigarette smoking (11.1%) and HIV infection (7.4%). The total case fatality was 29.6% with intracerebral hemorrhage (ICH) having higher case fatality of 69.2% than cerebral infarction (CI) with a case fatality of 16.7%. Among the young Nigerian adults who presented with stroke, 53.7% survived. The authors conclude from the above information that the incidence of stroke in young patients at UPTH is low. Hypertension is the most important risk factor of stroke; however, other less common but important risk factors in the young adults are cigarette smoking, diabetes mellitus and HIV. Efforts should be made to reduce the impact of stroke in this age group by focusing on these risk factors, which are either preventable or modifiable. (J Vasc Nurs 2009;27:98-102)

Stroke is a rapidly developing clinical sign of focal or global disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death with no apparent cause other than vascular origin.1 It is an increasing public health concern throughout the world. Stroke is the second commonest cause of death and the leading cause of long-term disability.2 Many reports have suggested that the risk of stroke differs between African-Americans and whites in the United States of America (U.S.), with a higher incidence and mortality in African-American individuals.3, 4 In sub-Saharan Africa (SSA), the prevalence and incidence of stroke remain unclear.5 In comparison with industrialized countries, some reports in SSA show a higher mortality rate, and younger age at onset and hypertension as the main risk factors.5, 6 Few data exist regarding stroke in young Nigerian patients, the most quoted having been reported between 2-3 decades ago.7,8 These studies reported stroke as uncommon in the young, with those seen being related to sickle cell disease, cervical trauma and cocaine abuse.7 The current status of the incidence, risk factors, subtypes and case fatality of stroke in the young Nigerian adults is unknown, and this forms the basis of this study.

From the Departments of Medicine and Radiology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria. Corresponding Author: A.C Onwuchekwa, FMCP, Department of Internal Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria. 1062-0303/2009/$36.00 Copyright Ó 2009 by the Society for Vascular Nursing, Inc. doi:10.1016/j.jvn.2009.08.001

METHODS This is a retrospective descriptive study of stroke in young Nigerian adults. All patients between the ages of 18-45 years old with stroke admitted into the medical wards of the UPTH (between January 2003 and December 2008) were identified from the ward records. The folders were retrieved from the medical records department and reviewed by one of the authors (E.G.A.). Information extracted from the records included age, sex, occupation, admission date, presence or absence of risk factors such as hypertension, diabetes mellitus, hypercholesterolemia, history of cigarette smoking, abuse of cocaine and other substances, alcohol intake and history of stroke in first-degree relatives. In women, information regarding the use of oral contraceptives was also sought. Features of heart disease were identified based on clinical manifestation and diagnostic investigation, such as ECG and echocardiography. Such features were categorized as congestive cardiac failure, rheumatic valvular disease, hypertensive heart disease, atrial fibrillation and ischemic heart disease. A neurologist (A.C.O.) classified all strokes into cerebral infarction (CI), intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) subtypes. The definition of CI and ICH were based on the criteria of Siriraj Stroke Score (SSS).9 The SSS was calculated as (2.5 x level of consciousness) + (2 x vomiting) + (2 x Headache) + (0.1 x diastolic blood pressure) (3 x atheroma markers) – 12. This formula was computed for each patient, and based on the individual’s score, each patient was classified as ICH or CI, using the criteria > + 1 for ICH and < 1 for CI. Values between 1 and +1 were regarded as ill-defined or indeterminate stroke (Table I).9 SAH was diagnosed when there was a history of sudden onset of severe headache with or without loss of consciousness, presence of neck stiffness, subhyaloid hemorrhage and uniformly stained or xanthochronic CSF

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TABLE I

TABLE II

DETAILS OF SIRIRAJ STROKE SCORE

REVERSED ORDERED MODIFIED VERSION OF THE GLASGOW OUTCOME SCALE

Siriraj stroke score = (2.5 x consciousness) + (2 x vomiting) + (2 x headache) + (0.1 x diastolic blood pressure) – (3 x atheroma) – 12 Consciousness: alert = 0; drowsy, stupor = 1; semicoma, coma = 2 Vomiting: no = 0; yes = 1 Atheroma markers: none = 0; yes = 1 Siriraj stroke score Below 1: Ischemic stoke Between 1 and 1: Indeterminate stroke Above 1: Hemorrhagic stroke Note: Atheroma markers include history of diabetes, angina or intermittent claudication.

with or without focal neurological abnormality.10 The Computerized Tomography (CT) scan results of the stroke patients who had CT scans were reviewed by a radiologist (R. C. O.). The results of the outcome (clinical evaluation according to the Glasgow Outcome Scale at the last visit) following stroke were extracted from the records of the patients. A good outcome was defined as a Glasgow Outcome Scale (GOS) of 1 or II; a poor outcome was defined as a GOS of III to V (Table II).11 In this study, hypertension was defined as blood pressure > 140/90 mm Hg before admission or at least 1 week after stroke or found to have other evidence of hypertensive disease in the heart, kidneys and retina. Diabetes mellitus was defined as a fasting blood glucose level > 7 mmol/l (126 mg/dl) or plasma glucose of > 11 mmol/l (198 mg/dl) at any time of the day. Patients were defined as current smokers or nonsmokers of cigarettes, cocaine or other substances. Hypercholesterolemia was ascertained by fasting cholesterol concentration of > 5.5 mmol/l (200 mg/dl). History of stroke in the family was recorded based on self or family reporting.

Statistics Data was analyzed using SPSS 11 statistical software.12 The procedures followed were in accordance with UPTH institutional guidelines, and the hospital ethics committee approved the study.

RESULTS A total of 611 stroke patients were admitted during the 6-year period. Of this number, 54 (8.8%) were between 18 and 45 years old. The minimum age was 19 years, and the maximum age was 45 years with a mean of 37.5  6.1 years. There were 26 males and 28 females giving a male: female ratio of 1:1. The age and sex distribution of the patient are shown in Table III. The frequency of risk factors among the patients according to stroke subtype is shown in Table IV. Hypertension was responsible for 42 (77.8%) cases, excessive alcohol intake 15 (27.8%) and

Score 1 2 3 4

5

Clinical/functional state Good recovery: Able to return to normal activities/work. Moderate disability: Able to live independently but unable to return to work. Severe disability: Able to follow command but unable to live independently. Persistent vegetative state: Unable to interact with environment; exhibits no obvious cortical function Death

heart disease 7 (13%), of which 4 (7.4%) were in congestive cardiac failure. Diabetes mellitus, cigarette smoking and HIV were responsible for stroke in 6 (11.1%), 6 (11.1%) and 4 (7.4%) patients, respectively. In addition, 2 patients (3.7%) had sickle cell disease, and 2 patients (3.7%) had hypercholesterolemia. Only 1 patient (1.9%) smoked marijuana. Among the females, 1 patient (1.9%) was on contraceptive pill, and 1 patient (1.9%) had ovarian malignancy. None of the patients had a record of atrial fibrillation, rheumatic heart disease or cocaine abuse. Family history of stroke was recorded in 8 (14.8%) patients, 6 (11.1%) in the mother and 2 (3.7%) in the father. No history of migraine headache was reported. With clinical criteria using the SSS of < 1, 35 patients (64.8%) were classified as CI, and 13 (24.12%) with SSS of > + 1 were classified as ICH. Three patients (5.6%) were classified as indeterminate, with an SSS between +1 and 1. Another 3 patients (5.6%) had SAH by clinical definition (Table V). Only 19 patients (35.2%, comprising 14 males and 5 females) could afford a CT scan evaluation. Of this number, 14 (73.7%) had CI, 4 (21%) had ICH and 1 (5.3%) was normal and this result was regarded as CI. Of the 14 patients with a CT diagnosis of CI, 11 (78.6%) were clinically diagnosed as having CI using SSS criteria. Similarly, of the 4 patients with a CT diagnosis of ICH, 3 (75%) were clinically diagnosed as having ICH using SSS criteria. Echocardiography was carried out in 21 young adult stroke patients. Of this number, 14 (66.6%) had evidence of hypertensive heart disease, 3 (14.3%) having dilated cardiomyopathy, 2 (9.5%) with atrial septal defects, 1 (4.8%) with diabetic cardiomyopathy and 1 (4.8%) with HIV cardiomyopathy. Of the 54 patients, 16 (29.6%, comprising 8 males and 8 females) died, 6 patients (11.1%) absconded, 3 (5.6%) discharged themselves against medical advice, and 29 (53.7%) were discharged home to continue with outpatient rehabilitation. At discharge, 20 patients (69%) were functionally independent (GOS1). Eighteen of the 20 patients (90%) who were discharged with GOS1 had CI by SSS criteria, but only 2 (10%) had ICH by

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TABLE III

TABLE IV

AGE AND SEX DISTRIBUTION OF YOUNG NIGERIAN ADULT STROKE PATIENTS

RISK FACTORS IN YOUNG NIGERIAN ADULT STROKE PATIENTS

Age Group 18 - 25 26 - 35 36 - 45 Total

Male

Female

2 5 19 26

1 9 18 28

Total (%) 3 14 37 54

(5.6) (25.9) (68.5) (100)

SSS criteria. Among the other 9 patients discharged home, 7 (24.1%) had a GOS of stage 2, and 2 patients (6.9%) had a GOS stage 3. The case fatality for CI was 16.7% and case fatality for ICH was 69.2%. In addition, SAH had a case fatality of 50%. Post mortem study of the dead was not done due to cultural disapproval.

DISCUSSION This study found that the occurrence of stroke in Nigerian adults under the age of 45 years is uncommon. This finding is similar to that reported by Osuntokun et al13 in a community survey 3 decades ago in southwest Nigeria. That study found a prevalence of stroke under the age of 40 years of 12.3%. In Benghazi, Libya, a stroke prevalence of 6% in the age group 15 to 45 years was reported in the study series.14 Nwosu et al 7 in a later study at the University of Nigeria Teaching Hospital in Enugu, in southeast Nigeria, had a higher incidence of 27.9% among hospital inpatients, although the study conceded that the relatively high figure recorded could have been due to selection bias. This general finding supports the observation that increasing age is the most powerful independent predictor of cardiovascular morbidity and mortality (stroke inclusive).15 There was no significant gender difference in the presentation of young stroke patients in this UPTH study. The Framingham studies have shown that hypertension is a clear risk factor for stroke in both sexes and in all ages and races.16 This UPTH study confirms that this risk is also true for young adult Nigerians, with hypertension being responsible for 77.8% of stroke cases. Excessive alcohol intake, cigarette smoking, diabetes mellitus and heart diseases are other risk factors predisposing Nigerians to stroke at a young age as found in other studies.17-19 However, cocaine abuse, which has been implicated in the pathogenesis of stroke in young AfricanAmericans,19 was not encountered in this study. Similarly, cervical spine hyperflexion, atrial fibrillation, systemic lupus erythematosus, and rheumatic heart disease, which have been reported in a small number of patients to constitute ‘‘strong’’ risk factors for stroke in the young in some studies,7, 20, 21 were not found in this study. Human immunodeficiency virus (HIV) and sickle cell disease were found to constitute small but important risk factors for stroke in the young Nigerians in this study. The occurrence of stroke in

Factor Hypertension Diabetes Mellitus Hypercholesterolaemia More than occasional alcohol consumption Cigarette smoking Ovarian malignancy Heart Disease HIV Sickle Cell Disease Family History of stroke Marijuana Oral Contraceptives

Male

Female

22 3 10

20 3 2 5

5 3 2 2 4 1 -

1 1 4 2 4 1

the young patient who is HIV positive may be incidental, especially in SSA where there is a high seropositive prevalence. In addition to unscreened blood transfusion, HIV is commonly a disease of the young adult who engages in high- risk behaviors, such as unprotected heterosexual contact and intravenous drug abuse. In Nigeria, current HIV prevalence is 5.8%, which is close to the 7.4% HIV incidence recorded in this study.22 Some studies have shown, however, a strong association between HIV infection and stroke.23, 24 Potential etiologies for vascular disease among HIV infected patients include an underlying viral myocarditis, congestive cardiomyopathy, infective endocarditis, atheroma and thromboembolism from arterial plaques.25 Other possible etiological factors are hematological disorders, such as an antiphospholipid antibody syndrome, vasculitis secondary to opportunistic infections and vasculitis secondary to substance abuse, such as cocaine or heroin use.22 In addition to the lipodystrophy syndrome in patients on antiretroviral therapy, metabolic changes that may be proatherogenic also exist in HIV-positive patients.26, 27 These lipid abnormalities could add to accelerated atherosclerosis. This study demonstrates that 64.8% of all young stroke patients had CI, and ICH was the subtype in 24.1% of patients. This finding is similar to the observation of stroke in the general population, where 71% of stroke patients had CI in a multicenter study in southwest Nigeria28 and 63% at Maiduguri, in northeast Nigeria.29 The mortality of 29.6% recorded in this study among young stroke patients is higher than the 23% of mortality recorded in young African-American stroke patients in the U.S,19 and the 9.9% found among young stroke patients in Israel.30 Similarly, the case fatality of 69.2% for ICH in this study is much higher than the 40% recorded in U.S. 19 The poor outcome

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TABLE V DISTRIBUTION OF STROKE SUBTYPE AMONG 54 YOUNG NIGERIAN ADULT PATIENTS Stroke Subtype

Male

Female

Total

Cerebral Infarction Intracerebral Hemorrhage Subarachnoid Hemorrhage Unclassified

17 9 -

18 4 3 3

35 13 3 3

of stroke in young adult Nigerians may be attributed to several factors. These factors include late presentation of patients to hospital, poverty (many patients cannot afford to pay for medications), absence of structured hospital-based methods for stroke management and the absence of dedicated stroke centers in Nigeria.31 In the Niger Delta Basin of Nigeria, postmortem studies of the dead is usually resisted by the family members of the deceased because, culturally, mutilated bodies are not accorded customary burial rites.32 This study has certain limitations. The results are hospital based and as such are prone to bias. Because this is a retrospective study, the frequency of variables such as alcohol use, cigarette smoking, drug abuse and contraceptive use in women may be underrepresented. In addition, the hospital acquired CT scan machines only 2 years ago, and even when available, CT scans could not be performed in many patients because of cost. Although CT scan remains the gold standard and cornerstone in the diagnosis of stroke subtype, the use of SSS in our environment and other developing countries is encouraged in most centers and rural settings lacking CT scan equipment.28 Even where available, cost is a limiting factor to its use.28 The SSS has accuracy similar to the Allen score, but it is easier to use at bedside with fewer variables.28 There was also as in most medical centers in Nigeria a lack of Doppler–ultrasound scan. Hence, cases of carotid stenosis as a cause of cerebral emboli could have been missed. Similarly, transthoracic echocardiography (TTE) was not done on all patients because of cost. The absence of trans-esophageal echocardiography (TEE) would have made for absence of thrombus in the left atrial appendage, which could not be assessed well with TTE when it became available. These limitations notwithstanding, it is concluded from this study that stroke incidence in the young Nigerian adults is low, arteriolar hypertension constitutes the main risk factors, and diabetes mellitus, cigarette smoking, excessive alcohol intake, congestive cardiac failure, HIV, sickle cell disease and hypercholesterolemia were among other less frequent but important factors. We recommend that hypertension screening and control programs be emphasized, beginning in childhood. Community health education, with emphasis on control of predisposing factors such as diabetes mellitus, as well as avoidance of smoking, excess alcohol intake and fatty foods, should be embarked upon during school years. Emphasis on genetic counseling for prematrimonial couples should be continued as is done in churches, mosques and court registries to raise awareness as to the cause

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and prevention of sickle cell disorders. This enhanced education will enable such couples to make informed choices. The current campaign against HIV infection that places emphasis on faithfulness for married couples and condom use or abstinence for unmarried couples should be continued. Structured stroke management protocols should be drawn in tertiary academic centers, and the government should establish dedicated stroke units even at regional levels. These practices, in addition to reducing stroke mortality, will enhance early recovery from stroke, improve functional outcome and reduce the need for prolonged institutional care.

Acknowledgments The contribution of Professor Ndu Eke is highly appreciated. He read and made valuable comments on the manuscript. We are also grateful to Drs. Wobe and Emem-Chioma, who assisted with data collection and analysis. REFERENCES 1. World Health Organization Monica Project, Principal Investigators. The World Health Organization Monica Project (Monitoring trends and determinants in cardiovascular disease) a major international collaboration. J Clin Epid 1988;41:105-14. 2. Kwan J. Clinical epidemiology of stroke. CME J Ger Med 2001;3:94-8. 3. Gillum RF. Stroke mortality in blacks disturbing trends. Stroke 1999;30:1711-5. 4. Kissela B, Schneider A, Kleindorfer D, et al. Stroke in a biracial population. Stroke 2004;35:426-31. 5. Sagui E. Stroke in sub-Saharan Africa. Med Trop 2007;67: 596-600. 6. Lemogoum D, Degaute JP, Bovet P. Stroke prevention, treatment, and rehabilitation in sub-Saharan Africa. Am J Prev Med 2005;29:95-101. 7. Nwosu CM, Nwabueze AC, Ikeh VO. Stroke at the prime of life: A study of Nigerian Africans between the ages of 16 and 45 years. East Afr Med J 1992;69:384-90. 8. Osuntokun BO. Stroke in Africans. Afr J Med Med Sci 1977; 6:39-53. 9. Poungvarin N, Viriyavejakul A, Komontri C. Siriraj stroke score and validation study to distinguish supratentorial intracerebral haemorrhage from infarction. BMJ 1991;302: 1565-7. 10. Schievink WI. Intracranial aneurysms. N Eng J Med 1997; 335:28-40. 11. Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1(7905):480-4. 12. Stats Direct Statistical Software, version 2.6.5.2007 Cheshire: Stats Direct Ltd. 13. Osuntokun BO, Bademosi O, Akinkugbe OO, Oyedrran AB, Carlise R. Incidence of stroke in an African city: results from the stroke registry at Ibadan, Nigeria, 1973-1975. Stroke 1979;10:205-7. 14. Zunni EI, Ahmed M, Prakash PS, Hassan KM. Stroke: incidence and pattern in Benghazi Libya. Ann Saudi 1995;15: 367-9.

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