Research Article
Ann Depress Anxiety. 2024; 11(1): 1125.
Clinical Profile of Patients with Cerebrovascular Accidents
Afif Al-Nabhi¹*; Mohammed Sallam¹; Ahmed Al-Gharati¹; Amin Abdulrab¹; Ali Ahmed Al-Zaazaai²
1Department of Medicine, Faculty of Medicine and Science - Sana’a University
2Department of Pharmacy, Wenzhou Medical University, Wenzhou
Corresponding author: Afif Al-Nabhi, Department of Medicine, Faculty of Medicine and Science, Sana’a University, PR, China. Email: alzaazaiali@yahoo.com
Received: September 20, 2024 Accepted: October 10, 2024 Published: October 17, 2024
Abstract
Background: Stroke is the leading cause of mortality and disability across the world.
Objectives: The Objectives of the study were, to study the clinical profile of stroke, risk factors, and hospital outcomes among stroke patients attending a tertiary hospital in Sana’a city
Materials and Methods: A cross-sectional study was conducted in Al-Gomhouri Hospital from 2015 to 2018. Every patient enrolled in the study underwent a clinical examination, history of risk factors, and investigation. We followed all cases during their hospital stays.
Results: Of the total 117 stroke cases, the main clinical presentation was hemiplegia or hemiparesis accounting for 53%, While altered sensorium and speech disturbances occurred for 15%. The majority had an ischemic stroke (76.2%). And hemorrhagic stroke in 28.2%. The incidence of stroke was higher in the 51–60 years age group with male preponderance. (30%) of ischemic stroke patients had hypertension, currently cigarette smoking (31.6 %) Qat Showers (47.8%), a small percentage (7.7% and 13.6%) had DM, and had dyslipidemia respectively. The mortality rate was (12%), and complete recovery and partial recovery were found in (40.2% & 30% respectively. However, no recovery was detected in (17.1%).
Conclusion: Ischemic stroke is the most common type of stroke in the age group of the 5th–6th decade with male preponderance. hemiplegia & hemiparesis being the most common presentation. hypertension, smoking, and Qat showing were Preventable risk factors associated with poor prognosis.
Keywords: Cerebral vascular stroke (CVS); Risk factors; Outcome; Yemen
Introduction
Cerebrovascular Accident (CVA) or stroke is defined as the abrupt onset of a neurological deficit that is attributable to a focal vascular cause [1].
It is a leading cause of mortality, and morbidity and is considered to be a leading cause of long-term disability worldwide [2,3].
Cerebrovascular accidents include hemorrhagic stroke, ischemic stroke, and cerebrovascular anomalies such as intracranial aneurysms and Arteriovenous Malformations (AVMs). Ischemic and hemorrhagic stroke accounts for about 85% and 15%, respectively [4].
Stroke and its sequel are important issues for healthcare planners and medical services everywhere. The cost of treatment and long-term care are very high. The incidence of stroke is increasing due to the aging of the population in many countries [4].
Risk factors for CVA include non-modifiable factors such as age, sex, ethnicity, geography, and a family history of stroke [1,4].
Modifiable risk factors are smoking, alcohol consumption, drug abuse, arterial hypertension, diabetes mellitus, dyslipidemia, and heart disease [5,6]. Stork can be prevented by effective risk factor modification. measures that will reduce the incidence of stroke [1].
Data regarding CVA in Yemen are scarce, this study is conducted to identify the risk factors and etiology in patients with CVA. This study has attempted to know the prognosis of CVA with reference to risk factors.
Materials and Methods
This retrospective cross-sectional observational study was carried out in AL-Gomhory Hospital in Sana’a among patients with Cerebrovascular Accident (CVA), who were admitted to the medical department during 20015- 20018
Study Protocol
ALL files of patients admitted to the department with suspected CVA were Reviewed. Every patient who fulfilled the following criteria was included in this study
Inclusion criteria
• Patients of either sex with CVA are admitted to the medical department with symptoms and signs of loss of focal or global cerebral function.
• Age greater than or equal to 30 years.
• Evidence of ischemia or hemorrhage on CT scan or MRI of brain.
• Patients with first episode of CVA.
Exclusion criteria
• Patients with a history of epilepsy, migraine, and head injury.
• Ischemia or hemorrhage on CT brain due to infection, connective tissue disorders, and tumors.
• Patients with Cortical venous thrombosis.
• Patients presented with transient ischemic attack.
• Patients with metabolic encephalopathy
Data Collection
The special sheet was designed to collect demographic data, clinical history, clinical examination, and investigations. Risk factors for CVA like hypertension, diabetes, dyslipidemia; family history of CVA was evaluated. All investigations of patients were reviewed and recorded such as CT scan of brain MRI brain, CT Angiography, Magnetic Resonance Angiography.
The other relevant investigations about their clinical status including biochemical and the factors profile of each patient such as; smoking, DM, lipid profile, and blood analysis were reviewed and recorded. The approval for the study was obtained from the hospital Ethics Committee.
Statistical Methods
The data was entered in Microsoft Excel and was analyzed using SPSS Package version (18) In descriptive statistics: results were expressed in percentages and proportions and were represented by using tables, bar diagrams, and pie charts. In analytical statistics: Two sample proportion tests using Z value were applied.
Results
The total number of patients who fulfilled the criteria of CVA in this study was 117 patients, 60 were males and 57 were females, and Male: Female ratio was 1.05:1.
The mean age of the patients was 55 for males and 56 for females’ sex and age distribution of the patients is shown in Table (1). Most patients 38 (32.5%) presented with CVA were in the age group of 51-60 years. The age group 41-50 and age group 61-70 years represented (17% and 16.2%) respectively. No males were below 30 years, while females were 4 below 30 years. Most patients (51.3%) were from Sana'a, followed by Amran governorate which accounted for (15.5%). Thirty-nine patients came from Thamar, the other cases were from Al Mahweet, Ibb, and Taiz governorates which presented in (11.1%, 4.2%, 6.8%, 5.1%, 6.0%,) respectively. 7 cases came from 3 governorates (Al-Hudaidah 3 cases, Lahj 2 cases, and Mareb 2 cases) see table 2.
Age group in years
Female
Total
Percentage %
30 years
None
4
4
3.40%
31-40
3
4
7
6.00%
41-50
7
13
20
17.10%
51-60
23
15
38
32.50%
61-70
10
9
19
16.20%
71-80
12
10
22
18.80%
80 and (+)
5
2
7
6.00%
Total
60
57
117
100%
Table 1: Age and six distributions of the patients presented with CVA.
Residency
No
%
Sana's
60
51.30%
Thamar
13
11.10%
Amran
18
15.50%
Al-Mahwe
5
4.20%
Ibb,
8
6.80%
Taiz
6
5.10%
Others
7
6.00%
Total
117
100%
Table 2: Distribution of the patients according to residency.
Clinical Presentation
The main clinical presentation was Motor weakness presented in 62(53%) patients, followed by headache. accounted for 20 (17%) cases, while altered sensorium and speech disturbances occurred in (15% &7%) respectively. Less common presentations were vomiting and convulsions see Figure 1.
Figure 1: Clinical presentation of CVA Patients.
Aetiology of Cerebrovascular Accident
The high frequency of CVA found in this study was Thrombotic stroke accounted for 62 (53%) patients, males were more affected than females (37 versus 25) patients. The second event was haemorrhagic stroke presented in 33 (28.2%) patients among them 18 were females and 15 were males table 3). The other causes were embolic stroke and carotid stenosis represented in 14.5% & 2.6%) respectively. In 2 cases the etiology was not recognized.
Type of CVS
No
%
Male
Female
Thrombotic strokes
62
53.00%
37
25
Hemorrhagic
33
28.20%
15
18
Embolic
17
14.50%
9
8
Carotid stenosis
3
2.60%
3
0
Non specific
2
1.70%
1
1
Total
117
100%
65
52
Table 3: Causes of cerebrovascular accidents among117 patients admitted into hospital.
Risk Factors Associated with CVA Patients
The most frequent risk factors associated with CVA patients in descending order were Qat chewing, smoking and hypertension accounted for (47.8%, 31.6% & 30%) respectively. The Second group of risk factors was Shama users, dyslipidemia, and heart diseases represented (13.7%, 13.7, &13.6% &12%) respectively. The other less frequent risk factors are illustrated in Table 3.
Risk Factors
%
No. of Patients
Male
Female
Qat showing
47.80%
36
20
Yes 56
No
Hypertension
30.00%
20
15
Yes 35
No
Diabetes Mellitus
7.70%
6
3
Yes 9
No
Smoking
31.60%
27
10
Yes 37
No
Shama user
13.70%
16
0
Yes 16
No
Dyslipidemia
13.60%
11
5
Yes 16
No
Heart Disease
12.00%
10
4
Yes 14
No
Carotid Stenosis
2.60%
3
0
Yes 3
No
Family History of Stroke
1.70%
0
2
Yes 2
No
Table 4: Risk factors associated with CVA patients.
Hospital Outcome
Complete recovery was observed in 47 patients (40.2%) and 36 (30.7%) patients whose conditions were partially improved while 20 (17.15%) patients did not improve and 14 patients were expired (12.0%). there are no significant differences between males and females, regarding outcome with Chi-square 3.1 and P value 0.3193. Regarding the Correlation between risk factors and outcome We found that smoking was the risk factor that correlated significantly with the outcome of CVA correlation with a P value (0.007) followed by Qat Chewing and HTN With p values (0.014 & 0.033) respectively, we did not find significant effect of Diabetes mellitus and dyslipidemia on CVA outcome the other risk factors are shown in table [6].
Patients
Total
Males
Females
No (%)
Complete recovery
25 (38.5%)
22 (42.3%)
47 (40.2%)
Partial recovery
23 (35.3%)
13 (25.0%)
36 (30.7%)
Same Condition
12 (18.5%)
8 (15.4%)
20 (17.1%)
Death
5 (7.7%)
9 (17.3%)
14 (12.0 %)
Total
65 (100%)
52 (100%)
117 (100%)
Table 5: Hospital outcome of the patients with CVA.
Risk factors
Patients
Chi2 P Value
Complete recovery
Partial recovery
Same condition
Death
No (%) 47
No (%) 36
No (%) 20
No (%) 14
Qat showing
29 (51.8%)
15 (26.8%)
10 (17.9%)
2 (3.6%)
10.52
0.014Yes 56
No 61
Hypertension
20 (57.1%
8 (22.9%)
2 (5.7%)
5 (14.3%)
8.6
0.033Yes 35
No 82
Diabetes Mellitus
3 (33.3%)
2 (22.2%)
2 (22.2%)
2 (22.2%)
1.35
0.716Yes 9
No 108
Smoking
15 (40.5%)
18 (48.7%)
3 (8.1%)
1 (2.7%)
12.06
0.0071Yes 37
No 80
Shama user
8 (50.0%)
6 (37.5%)
2 (12.5%)
0 (0.0%)
3.17
0.366Yes 16
No 101
Dyslipidemia
5 (31.25%)
4 (25.0%)
5 (31.25%)
2 (12.5%)
2.74
0.432Yes 16
No 101
Heart Disease
8 (57.1%)
2 (12.3%)
2 (12.3%)
2 (12.3%)
2.69
0.442Yes 14
No 103
Carotid Stenosis
0 (0.0%)
1 (33.3%)
2 (66.7%)
0 (0.0%)
6.04
0.109Yes 3
No 114
Family History of Stroke
1 (50.0%)
1 (50.0%)
0 (0.0%)
0 (0.0%)
0.88
0.829Yes 2
No 115
Table 6: Correlation between risk factors and outcome of CVA patients.
Discussion
In this study majority of patients presented with CVA were males. Males' preponderance than females was noted in the previous studies of stroke [5-8]. Most patients 70 (59.8%) in this study presented with CVA were in the age group of 51-60 years. While the minority of CVA was found in younger age (below 41 years). This finding points out that the occurrence of stroke is increasing with increased age [5-9].
Comparing our study to the studies from other countries CVA occurred one decade younger than CVA reported in other countries where the most common age of presentation of stroke was above 60 years [5-7]. However, a study from India found that the maximum number of cases was seen in 7th decade [9].
Regarding the main clinical presentation, we found that more than half of cases (53%) of CVA presented with motor weakness, while a minority (15%) presented with altered sensorium. Similar results were reported hemiplegia was the most common presenting feature [5-10]. indicated that the pyramidal tract was the most commonly involved area in CVA.
In this study, two-thirds (67.5%) of the stroke patients had ischemic stroke (thrombosis and emboli) and one-quarter of the patients had hemorrhagic stroke. Nearly similar results have been reported by other studies, but the percentages of hemorrhage in their studies were high compared to our study [5,7,10-15].
Regarding smoking, about one-third of the stroke patients in our study were associated with smoking. A similar finding was observed in studies from India [16,17]. Smoking is well-known as a risk factor for CVA [18].
In this study, patients with smoking as a risk factor had poor outcomes, similar findings were reported by several previous studies study [19,20].
Similarly, in this study, hypertension was associated with CVA in 31.2% of the patients and it was considered a prime risk factor for stroke which was reported in several studies [15-20], However, the much higher figure of association between hypertension and CVA was reported by Swetha and Singh [21]. In this study, we observed CAV, patients with hypertension as a risk factor had poor outcomes. A study by Tikrit reported that hypertension was the most common risk factor for in-hospital mortality rate [20].
Diabetes millets was associated with CVA only in 7% in our patients which was lower than studies done before from different countries [10,22,23]. This may be related to the low prevalence of diabetes mellitus in the general population in Yemen 24] However similar results were reported by Behera et al who reported that 6.96% of the stroke patients were diabetic [25.]
Dyslipidemia as a risk factor in CVA was noted in 13% of our cases of CVA which was lower than reported in other, studies [5,8,10].
Outcome and Mortality
In this study, Complete recovery was observed in 47 patients (40.2%) while 20 (17.15%) patients did not improve and 36 (30.7%) patients whose conditions were partially improved, and 14 patients were expired (12.0%). comparing these results with other results similar results were reported by Marwat et al.; [26] where he found 34% of patients had partial recovery however, the mortality rate was high in our cases (12% versus 9%). These differences may be related to the time of study in our cases the prognosis was studied after 3 weeks of admission while in Marwat et al.; the prognosis was studied one week after admission
Conclusion
Ischemic stroke is the most common type of stroke and occurs more frequently in the age group of the 5th–6th decade with male preponderance. Infarction or hemorrhage was the most common finding. Hemiplegia & hemiparesis are the most common presentations. Hypertension, smoking, and Qat which are Preventable risk factors were associated with poor prognosis in cases of CVA.
References
- Sorganvi V, Kulkarni MS, Kadeli D, Atharga S. Risk Factors for Stroke: A Case-Control Study. IJCRR, 2014; 6: 46-52.
- World Health Organization. Global Health Estimates. G;heneva: World Health Organization. 2012.
- Johnson W, Onuma O, Owolabi M, Sachdev S. Stroke: A global response is needed. Bull World Health Organ. 2016; 94: 634A.
- Fauci AS, Dennis L, Kasper L, Longo DL, Hauser SL, Jameson JL, et al. Eds Harrison’s Principles of Internal Med. 20th ed. United States of Am, NY: McGraw-Hill. 2018: 3068-3079.
- Adams HP, Norris JW. Ischemic cerebrovascular disease. CNS Series. 2003: 1-46.
- Shafi HM, Hakeem AA. Clinical profile of stroke in Kashmir. Int Arch Integr Med. 2019; 6: 137-43.
- Smith WS, English JD, Johnston SC; Cerebrovascular diseases. In Harrison’s Principles of Internal Medicine. 18th Edition, Longo DL et al editors, McGraw Hill, New York. 2012: 3270-3299.
- Md Shahid Iqbal, Shachindra Kumar Astik. study on clinical profile and risk factors of cerebrovascular accident with special reference to ct scan findings of brain. Indian journal of research. 2020: 9.
- Chitralekha Vora, Krunal Talsaniya, Bhavikkumar Prajapati. Clinical profile of cerebrovascular accident patients with special reference to serum homocysteine level. IAIM. 2019; 6: 76-82.
- Madhura Talkad Lakshmikumar, Shruthi Bettegowda, Spandana Vuyyuru. Clinical Profile of Patients with Cerebrovascular Accident: A Study from Rural Hospital. Scholars Journal of Applied Medical Sciences. Sch J App Med Sci. 2015.
- Jebasingh YK, Sivanesan P. Clinical profile of stroke patients in South Tamil Nadu tertiary care hospital-a cross-sectional study. Int J Sci Study. 2019; 7: 83-6.
- Vaidya CV, Majmudar DK. A retrospective study of clinical profile of stroke patients from GMERS medical college and hospital, Gandhinagar, Gujarat. Int J Clin Trials. 2014; 1: 62-6.
- Patne SV, Chintale KN. Study of clinical profile of stroke patients in rural tertiary health care center. Int J Adv Med. 2016; 3: 666-70.
- Behera BP, Maharana DN, Mohanty PS. An observational study of clinicopathological profile of stroke patients in a new tertiary care hospital in North Odisha, India. Int J Res Med Sci. 2019; 7: 3095.
- Sridharan SE, Unnikrishnan JP, Sukumaran S, Sylaja PN, Nayak SD, Sarma PS, et al. Incidence, types, risk factors, and outcome of stroke in a developing country: the Trivandrum Stroke Registry. Stroke. 2009; 40: 1212–8.
- Dalal PM, Malik S, Bhattacharjee M, Trivedi ND, Vairale J, Bhat P, et al. Population-based stroke survey in Mumbai, India: incidence and 28-day case fatality. Neuroepidemiology. 2008; 31: 254–61.
- Lakshmikumar MT, Bettegowda S, Vuyyuru S. Clinical Profile of Patients with Cerebrovascular Accident: A Study from Rural Hospital. Sch J App Med Sci. 2015; 3: 3253-3264.
- Sorganvi V, Kulkarni MS, Kadeli D, Atharga S. Risk Factors for Stroke: A Case Control Study. IJCRR. 2014; 6: 46-52.
- Robbins AS, Manson JE, Lee IM, Satterfield S, Hennekens CH. Cigarette smoking and stroke in a cohort of U.S. male physicians. Ann Intern Med. 1994; 120: 458-462.
- Pandiyan U, Arjundas G, Arjundas D. Risk Factors and Stroke Outcome-An Indian Study. IJPMR. 2005; 16: 29-33.
- Turkey AM. Case fatality rate in one-month duration for first-ever stroke in Tikrit teaching hospital. Tikrit Medical Journal. 2012; 18: 29-37.
- Swetha K, Singh S. A retrospective study of the prescription pattern of drugs in the management of stroke, at BRIMS teaching hospital, Bidar, India. Int J Basic Clin Pharmacol. 2018; 7: 1929-33.
- Behera BP, Maharana DN, Mohanty PS. An observational study of clinicopathological profile of stroke patients in a new tertiary care hospital in North Odisha, India. Int J Res Med Sci. 2019; 7: 3095.
- Dhamija RK. Long-term outcome of stroke in rural communities. J Assoc Physicians India. 1999; 47: 39.
- Al-Habori M, Al-Mamari M, Al-Meeri A. Type II Diabetes Mellitus and impaired glucose tolerance in Yemen: prevalence, associated metabolic changes and risk factors Diabetes Res Clin Pract. 2004; 65: 275-81
- Behera BP, Maharana DN, Mohanty PS. An observational study of clinicopathological profile of stroke patients in a new tertiary care hospital in North Odisha, India. Int J Res Med Sci. 2019; 7: 3095.
- Marwat MA, Usman M, Hussain M. Stroke and Its Relationship to Risk Factors. Gomal Journal of Medical Sciences. 2009; 7: 17-21.
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