Background: Stroke is a leading cause of death and disability worldwide, accounting for 11.13% of total deaths, and the main cause of disability worldwide. The aim of this study is to know the pattern of stroke admissions at Benghazi Medical Center (BMC) and the possible risk factors. Materials and Methods: This was a cross-sectional study of 110 patients admitted to BMC who were diagnosed with stroke based on the International Classification of Diseases, Revision 10 (ICD-10), from January to June 2019. Data about age, gender, comorbidities, and medical history were collected. Results: In the study period, the medical records of 110 patients were surveyed for stroke diagnostic code based on ICD-10. Our research protocol identified 110 stroke records, out of which 10 cases were unspecified stroke. Of 100 specified stroke cases, 70 cases described an ischemic incidence and 30 cases reported a hemorrhagic incidence. Analysis of demographic attributes over this dataset showed that 65 men and 35 women with mean ages of 66.4 ± 14.2 and 64.6 ± 12.4, respectively, were admitted with stroke diagnosis, irrespective of stroke type. Further analysis indicated that both ischemic and hemorrhagic stroke subtypes had a high incidence in age ≥70 years (P = 0.003). The relationship between age group and stroke subtype was significant (P < 0.05). The mortality rate in this population based on the stroke subtype indicated that the mortality rate in patients diagnosed by hemorrhagic stroke is higher than those with ischemic attack (P = 0.004). Furthermore, there was no significant statistical difference between stroke subtypes and gender (P = 0.768). Analysis of possible relations between comorbid risk factors and stroke subtypes using the Chi-square test showed that, compared to other comorbid risk factors, diabetes mellitus (P = 0.003) and dyslipidemia (P = 0.001) were significantly prevalent among ischemic and hemorrhagic stroke patients. While hypertension (HTN) was strongly associated with hemorrhagic strokes (P = 0.001). There was no significant difference between ischemic and hemorrhagic strokes with regard to other risk factors. Conclusion: Ischemic stroke was more common than hemorrhagic stroke; overall, HTN, diabetes mellitus, and dyslipidemia were the major risk factors of stroke in our studied population.
Keywords: Admission, stroke, risk factor
| Introduction|| |
Stroke is the second leading cause of death, accounting for 11.13% of total deaths, and the main cause of disability worldwide. According to the latest WHO data published in 2017, stroke deaths in Libya reached 3417 or 11.53% of total deaths. The age-adjusted death rate is 88.80/100,000 of population, which ranks Libya #87 in the world. The major type of stroke is ischemic, which occurs in about 87% of all stroke cases. According to the Global Burden of Disease (GBD) study in 2010, more than 11 million ischemic strokes occurred, whereas 63% of them were in low- and middle-income countries. Furthermore, near 3 million deaths occurred due to ischemic stroke. About 13% of stroke is of a hemorrhagic type. According to the GBD study in 2010, there were about 5.3 million hemorrhagic stroke cases, out of which about 80% occurred in low- and middle-income countries. Over 3 million deaths occurred from hemorrhagic stroke. Stroke has different risk factors, which can be grouped into modifiable and nonmodifiable risk factors. Major risk factors for stroke include age, history of cerebrovascular event, smoking, alcohol consumption, physical inactivity, hypertension (HTN), dyslipidemia, diabetes mellitus, cardiovascular diseases, obesity, metabolic syndrome, diet, nutrition, and genetic risk factors.,
The aim of this study is to know the pattern of stroke admissions at Benghazi Medical Center (BMC) and to identify major risk factors among those patients.
| Materials and Methods|| |
This was a cross-sectional study of 110 patients admitted to BMC who were diagnosed with stroke from January to June 2019. Cases were included in the study if a confirmed discharge diagnosis of stroke based on International Classification of Diseases, Revision 10 [ICD.10] codes in the categories of I60, I61, I62, I63, and I64). Diagnosis was mainly based on a physician's opinion, clinical features, and magnetic resonance imaging (MRI) or computed tomography (CT scan) reports. Medical records with a diagnosis of unspecified stroke (code I64 of ICD-10) were rechecked with a specialist coder to assign a correct code based on MRI or CT scan reports or after consulting with the attending physician or a neurologist.
A valid and reliable data collection form was used to capture data contained in the medical records. In this form, the following criteria and clinical parameters were considered: patient demographic data (age, gender, ethnicity, and residence area), diagnostic data, type of stroke (hemorrhagic or ischemic), history of diseases (such as HTN, ischemic heart disease, nonischemic heart disease, diabetes, hyperlipidemia, previous stroke, or transient ischemic attack), and lifestyle data (such as cigarette smoking and opium addiction).
The data were summarized using Microsoft Excel 2010 and then coded and processed on IBM compatible computers, using the Statistical Package for the Social Sciences (SPSS) 17.0 (SPSS; SPSS Inc. Chicago, IL, USA). Descriptive statistics of the different variables were presented either as frequencies and percentages or as means ± standard deviation. For statistical comparisons, independent samples Chi-square test was employed for testing the statistical significance of association between two discrete variables. Significant value is set up at P < 0.05.
| Results|| |
In the study period, the medical records of 110 patients were surveyed for stroke diagnostic code based on ICD-10. Our research protocol identified 110 stroke records, out of which 10 cases were unspecified stroke. Of 100 specified stroke cases, 70 cases described an ischemic incidence and 30 cases reported a hemorrhagic incidence. Analysis of demographic attributes over this dataset showed that 65 men and 35 women with mean ages of 66.4 ± 14.2 and 64.6 ± 12.4, respectively, were admitted with stroke diagnosis, irrespective of stroke type [Graph 1]. Further analysis indicated that both ischemic and hemorrhagic stroke subtypes had a high incidence in age ≥70 years (P = 0.003) [Graph 2]. The relationship between age group and stroke subtype was significant (P < 0.05). The mortality rate in this population based on the stroke subtype indicated that the mortality rate in patients diagnosed by hemorrhagic stroke is higher than those with ischemic attack (P = 0.004). Furthermore, there was no significant statistical difference between stroke subtypes and gender (P = 0.768). Analysis of possible relations between comorbid risk factors and stroke subtypes using the Chi-square test showed that, compared to other comorbid risk factors, diabetes mellitus (P = 0.003) and dyslipidemia (P = 0.001) were significantly prevalent among ischemic and hemorrhagic and ischemic stroke patients, whereas HTN was strongly associated with both hemorrhagic strokes (P = 0.001 and 0.003, respectively). There was no significant difference between ischemic and hemorrhagic strokes with regard to other risk factors [Table 1].
| Discussion|| |
In our study, ischemic stroke was the most common subtype accounting for 70% of cases, while hemorrhagic stroke was reported in 30% of cases, these results are similar to previous studies conducted in Libya, a review of stroke incidence and pattern in Benghazi by El Zunni et al. on 1995 found that ischemic stroke was reported in 76.9%, while hemorrhagic stroke was reported in 23.1%, the same results was reported in southern parts of Libya by Ahmed et al. where 78.4% of strokes were ischemic. These results are consistent with results of studies from other countries.,, The observed higher rates of ischemic stroke incidence suggests that ischemic stroke patients have a great exposure to modifiable risk factors whose control through lifestyle modifications can prevent a large proportion of such incidences.As expected, comparable to most studies,,, age played a major role. Stroke has its highest incidence in the sixth to eighth decades of life. In our study, the mean age was 65.3 ± 10.2 years. Further analysis indicated that both ischemic and hemorrhagic stroke subtypes had a high incidence in age ≥70 years (P = 0.003). the age of our patients was slightly older compared with previous studies in Libya, and other developing countries where stroke in which the mean age was between 50 and 60.,,,,
Both hemorrhagic and ischemic strokes were more prevalent among males; the same results were reported in other studies.,,, Another finding in our patient sample was the higher mortality rate among patients admitted with hemorrhagic stroke, which indicates that those patients are exposed to fatal aneurysmal ruptures in the brain and such incidences might be prevented by early diagnosis and screening for unruptured aneurysms.
HTN is a major risk factor for stroke, both ischemic and hemorrhagic. In our study, HTN was the third most common risk factor of stroke after diabetes and dyslipidemia; in other studies, HTN was the first most common risk factor.,, A prospective study of 50,000 adults in the Golestan Cohort by Sepanlou et al. showed a positive association between HTN and stroke mortality: they found that the stroke mortality rate was 147.1 (95% confidence interval: 133.9–160.1)/100,000 person-years, although they did not consider stroke subtypes. With regard to the stroke subtype, our study shows that the prevalence of HTN was higher among hemorrhagic stroke patients.
Another important finding in our study was a positive and significant association between diabetes mellitus and dyslipidemia with an increased risk of stroke, particularly the ischemic subtype. This finding is in line with other studies that show a strong association between diabetes and stroke.,,
| Conclusion|| |
Ischemic stroke was more common than hemorrhagic stroke. Overall, HTN, diabetes mellitus, and dyslipidemia were the major risk factors of stroke in our studied population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. (2018). Assessing national capacity for the prevention and control of noncommunicable diseases: Report of the 2017 global survey. World Health Organization. License: CC BY-NC-SA 3.0 IGO. Available from: https://apps.who.int/iris/handle/10665/276609
. [Last accessed 2020 Feb 10].
Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al
. Heart disease and stroke statistics-2015 update: A report from the American Heart Association. Circulation 2015;131:e29-322.
Bennett DA, Krishnamurthi RV, Barker-Collo S, Forouzanfar MH, Naghavi M, Connor M, et al
. The global burden of ischemic stroke: Findings of the GBD 2010 study. Glob Heart 2014;9:107-12.
Krishnamurthi RV, Moran AE, Forouzanfar MH, Bennett DA, Mensah GA, Lawes CM, et al
. The global burden of hemorrhagic stroke: A summary of findings from the GBD 2010 study. Glob Heart 2014;9:101-6.
Bang OY, Ovbiagele B, Kim JS. Nontraditional Risk Factors for Ischemic Stroke: An Update. Stroke 2015;46:3571-8.
von Sarnowski B, Putaala J, Grittner U, Gaertner B, Schminke U, Curtze S, et al
. Lifestyle risk factors for ischemic stroke and transient ischemic attack in young adults in the Stroke in Young Fabry Patients study. Stroke 2013;44:119-25
El Zunni S, Ahmed M, Prakash PS, Hassan KM. Stroke: Incidence and pattein Benghazi, Libya. Ann Saudi Med 1995;15:367-9.
Ahmed M, Ali M, Sufrani A, Shenib F, Musbah A. Stroke in South Libya. Sebha Univ J Med Sci 2002;3:104-8.
Al Rajeb S, Awada A, Niazi G, Larbi E. Stroke in a Saudi Arabian national guard community. Stroke 1993;24:1365-637.
Greffie ES, Mitiku T, Getahun S. Risk factors, clinical pattern and outcome of stroke in a referral hospital, Northwest Ethiopia. Clin Med Res 2015;4:182-8.
Habibi-Koolaee M, Shahmoradi L, Niakan Kalhori SR, Ghannadan H, Younesi E. Prevalence of stroke risk factors and their distribution based on stroke subtypes in Gorgan: A retrospective hospital-based study-2015-2016. Neurol Res Int 2018;2018:2709654.
Allen CL, Bayraktutan U. Risk factors for ischemic stroke. Int J Stroke 2008;3:105-16.
Tirschwell DL, Ton TG, Ly KA, Van Ngo Q, Vo TT, Pham CH, et al
. A prospective cohort study of stroke characteristics, care, and mortality in a hospital stroke registry in Vietnam. BMC Neurol 2012;12:150.
Sagui E, M'Baye PS, Dubecq C, Ba Fall K, Niang A, Gning S, et al
. Ischemic and hemorrhagic strokes in Dakar, Senegal: A hospital-based study. Stroke 2005;36:1844-7.
Ahangar AA, Ashraf Vaghefi SB, Ramaezani M. Epidemiological evaluation of stroke in Babol, northern Iran (2001-2003). Eur Neurol 2005;54:93-7.
Fekadu G, Wakassa H, Tekle F. Stroke Event Factors among Adult Patients Admitted to Stroke Unit of Jimma University Medical Center: Prospective Observational Study. Stroke Res Treat 2019;2019:4650104. Published 2019 Feb 3. doi:10.1155/2019/4650104.
Sarkar D, Halder S, Saha B, Biswas P. A study of stroke patients with respect to their clinical and demographic profile and outcome. Int J Res Med Sci 2016;4:4061-6.
Watila MM, Nyandaiti YW, Ibrahim A, Balarabe SA, Gezawa ID, Bakki B, et al
. Risk factor profile among black stroke patients in Northeastern Nigeria. J Neurosci Behav Health 2012;4:50-8.
Walker RW, Rolfe M, Kelly PJ, George MO, James OF. Mortality and recovery after stroke in the Gambia. Stroke 2003;34:1604-9.
Masood CT, Hussain M, Anis-ur-Rehman, Abbasi S. Clinical presentation, risk factors and outcome of stroke at a district level teaching hospital. J Ayub Med Coll Abbottabad 2013;25:49-51.
Williams LN, Brown RD. Management of unruptured intracranial aneurysms. Neurology 2013;3:99-108.
Aronow WS. Hypertension-related stroke prevention in the elderly. Curr Hypertens Rep 2013;15:582-9.
Sepanlou SG, Sharafkhah M, Poustchi H, Malekzadeh MM, Etemadi A, Khademi H, et al
. Hypertension and mortality in the Golestan Cohort Study: A prospective study of 50 000 adults in Iran. Journal of human hypertension. 2016;30:260-7.
Khaled D Alsaeiti,
Department of Internal Medicine, Aljamhorya Hospital, Benghazi
Source of Support: None, Conflict of Interest: None