|Year : 2019 | Volume
| Issue : 1 | Page : 29-33
Comparative study between haemorrhagic and ischaemic strokes in hadramout: A hospital-based study
Rasheed Mohammed Bamekhlah1, Mohammed Rasheed Bamekhlah2, Hussain Saeed Al-Ghazali1, Abdulraheem Abdullah Bahishwan1
1 Department of Medicine, College of Medicine and Health Sciences (HUCOM), Hadramout University, Al Mukalla, Hadramout, Republic of Yemen
2 Department of Medicine, Ibnseena Teaching Hospital, Al Mukalla, Hadramout, Republic of Yemen
|Date of Web Publication||27-Feb-2019|
Rasheed Mohammed Bamekhlah
P.O. Box No. 8892, Al Mukalla Hadramout
Republic of Yemen
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was compare between haemorrhagic stroke (HS) and ischaemic stroke (IS) stroke in relation to risk factors and clinical presentation among stroke patients admitted to a tertiary teaching hospital over a 5-year period. Materials and Methods: This was a retrospective, cross-sectional, hospital-based study. We reviewed the medical files of patients admitted with the diagnosis of stroke at Ibn Sina Teaching Hospital, from January 2011 to December 2015 to compare between HS and IS patients. Results: From a total of 1678 stroke patients, IS constituted 81.2% of them and 18.8% were HS, males were 57.7% and females 42.3%. HS patients were significantly younger than IS patients, (odds ratio [OR] 0.4; 95% confidence interval [CI] 0.31–0.51, P= 0.000), and there was no significant difference in gender (males 61.6% vs. 56.8%, P = 0.12). Hypertension and smoking were significantly higher among HS than IS patients (OR 5.51; 95% CI 3.98–7.62, P < 0.0001) and (OR 1.84; 95% CI, 1.37–2.46, P= 0.003), respectively, whereas diabetes mellitus (OR, 0.75 95% CI, 0.58–0.96, P= 0.024), transient ischaemic attacks (TIA) (OR, 0.23; 95% CI 0.14–0.38, P < 0.0001), hyperlipidaemia (OR, 0.35; 95% CI 0.19–0.66, P = 0.007) and family history of stroke (OR, 0.64; 0.42–0.97, P= 0.033) were significantly higher in IS than HS patients. Sudden onset of stroke attack and impaired consciousness including coma was significantly more frequent in HS than IS patients (98.7% vs. 86.8%, P= 0.000) and (77.5% vs. 34.2%, P = 0.000), respectively. In-hospital fatality was higher among HS than IS victims (46.3% vs. 26.5%, P = 0.000). Conclusion: Younger age, hypertension and smoking were higher in HS than IS patients, and increasing age, diabetes, TIA, hyperlipidaemia and family stroke history were higher in IS patients, sex did not favour any type, HS was more presented with impaired consciousness and had a higher in-hospital fatality than IS.
Keywords: Cerebral haemorrhage, cerebral infarction, cerebrovascular accident, Hadramout, stroke
|How to cite this article:|
Bamekhlah RM, Bamekhlah MR, Al-Ghazali HS, Bahishwan AA. Comparative study between haemorrhagic and ischaemic strokes in hadramout: A hospital-based study. Hamdan Med J 2019;12:29-33
|How to cite this URL:|
Bamekhlah RM, Bamekhlah MR, Al-Ghazali HS, Bahishwan AA. Comparative study between haemorrhagic and ischaemic strokes in hadramout: A hospital-based study. Hamdan Med J [serial online] 2019 [cited 2019 Nov 19];12:29-33. Available from: http://www.hamdanjournal.org/text.asp?2019/12/1/29/241304
| Introduction|| |
Stroke is the second leading cause of death worldwide, and the leading cause of acquired disability in adults in most regions., Countries of low- and middle-income have the largest burden of stroke, accounting for more than 85% of stroke mortality worldwide. Few reliable data are available to identify risk factors for stroke in most of these regions, particularly for haemorrhagic stroke (HS).,,, Stroke has many risk factors such as age, male sex, hypertension, diabetes, cardiac diseases, transient ischaemic attacks (TIA) smoking, hyperlipidaemia and previous attacks of stroke.
Although ischaemic stroke (IS) is more common than HS.,, The latter is the most devastating pathological type of stroke and accounting for 9%–22% of total strokes among Western populations., In some developing countries, HS recorded higher frequencies.,,,
Insufficient data about stroke in Yemen, Sallam et al. was the only published and available study about the clinical profile of stroke in Sanaa, and this made us to start our activity to study stroke from different aspects, and this work was designed to compare between HS and IS.
| Materials and Methods|| |
Study design and data source
A retrospective hospital-based cross-sectional study of all stroke patients stroke admitted at Ibn Sina Teaching Hospital (ISTH), Mukalla, Hadramout, Republic of Yemen during the period between 1st January 2011 and 31st December 2015 without any exclusion. The hospital is a tertiary referral and is the biggest hospital in Hadramout Province in which medical and health institute students get their training and it serves about 4,000,000 inhabitants. Data collected from patients' medical record files, by a trained group of intern graduates and medical students, into a master sheet, based on the World Health Organisation (WHO) stepwise approach to stroke surveillance protocol, involving age, sex, risk factors, clinical presentation and outcome.
Definition of stroke, its subtypes
In this work, data were obtained from patients' medical files. In our hospital, stroke was diagnosed according to the WHO and classified into IS or HS based on CT neuroimaging.
Definitions of hypertension and diabetes
Hypertension was defined as history along with antihypertensive treatment of blood pressure ≥140/90 mmHg, 7 days after stroke; diabetes was defined as history along with antidiabetic treatment or fasting plasma glucose ≥126 mg/dl (≥7 mmol/L).
A written consent from the hospital authority and ethical clearance by the Ethical Research Committee of the College were documented. No consents were obtained from patients or their guardians as the study was retrospective and there was no direct contact with them.
Data were processed by the Statistical Package for the Social Sciences software version 20.0 (IBM Corporation, Armonk, NY, USA). Chi-square test was used to compare age, gender, risk factors, clinical presentations and outcome. We estimated odds ratio (OR) and the resulting 95% confidence interval (CI) for risk factors. All statistical hypothesis tests were two-sided, and P < 0.05 was considered statistically significant.
| Results|| |
This study involved all stroke patients admitted to the medical department of ISTH between January 2011 and December 2015. The hospital is considered as a tertiary-level hospital providing medical care to patients from Hadramout Province (Hadramout, Shabwah, Al-Mahrah and Socotra Governorates).
During this period, 29,644 patients were admitted in the medical department, 1678 (5.7%) of them were stroke patients, with an age range (24–102) years and mean (66.1 ± 14.6) years, 481 (27.5%) were ≤60 years and 1197 (72.5%) >60 years. Males were slightly more than females (968, 57.7% and 710, 42.3% respectively) [Table 1].
From all cases, 1363 (81.2%) was diagnosed as IS and 315 (18.8%) as HS. Patients with HS were significantly younger than IS ones (OR 0.4; 95% CI 0.31–0.51, P = 0.000), while there was no significant difference in gender between groups (OR; 1.22, 95% CI 0.95–1.57, P = 0.12). HS had a significant association with hypertension (OR, 5.51; 95% CI 3.98–7.62, P = 0.0000) and smoking (OR, 1.53; 95% CI 1.15–2.04, P 0.003) more than IS, while the later showed a significant association with diabetes (OR 0.75, 0.58–0.96, P = 0.024), TIA (OR, 0.23; 95% CI 0.14–0.38, P < 0.0001), hyperlipidaemia (OR, 0.35; 95% CI 0.19–0.66, P = 0.007) and family history of stroke (OR, 0.64; 0.42–0.97, P = 0.033) comparing to HS. No significant difference in previous history of strokes, previous history of myocardial infarction, AF and alcohol intake between both stroke types [Table 2].
|Table 2: Characteristics and risk factors distribution in both stroke types|
Click here to view
Sudden onset of stroke attack and impaired consciousness including coma was significantly more frequent in HS than IS patients (98.7% vs. 86.8%, P = 0.000) and (77.5% vs. 34.2%, P = 0.000), respectively. In-hospital fatality among all stroke patients was 30.2% (507 out of 1678) and was higher among HS than IS victims (46.3% vs. 26.5%, P = 0.000). Dysphasia, motor deficit and seizures showed no significant difference, ataxia frequency was very low to be statistically calculated [Table 3].
|Table 3: Clinical presentation and in-hospital fatality of both stroke types (n=1678)|
Click here to view
| Discussion|| |
There were many studies for stroke carried out in Arab Countries, but limited studies which compared between HS and IS. From hospital-based studies in the Asian Arab countries, HS frequencies were 14.5%–25% of all strokes and IS represented 75%–85.5%.,,, At Sanaa, North Yemen, a hospital-based and 4-year study by Sallam et al. showed that IS was 72%, HS 25.5% and 2.5% of cases were undetermined. Moreover, at Hadramout, East Yemen, our work was within the range of Asian Arab Countries (81.5 for IS and 18.8% for HS). In African Arab Countries, some studies showed that HS was higher, 41.3% in Sudan and 29.6% in Egypt, but it was similar to other African studies., The INTERSTROKE study, which involved 84 centres in 22 countries, reported that in some developed countries (Australia, Canada, Croatia, Denmark and Germany), HS constituted 9% only of all stroke cases. Other studies supported this low HS frequency,,, and this may be attributable to the effective measures for primary and secondary prevention of HS, comparing with IS whose main risk factors cannot be prevented efficiently alike aging, atherosclerosis and even chronic diabetic complications.
The incidence of stroke tended to increase with age, with a mean age within the sixth and the seventh decade.,, We reported that HS was higher among younger patients than IS, with no gender differences. A recent hospital-based Chinese study showed similar findings. Whereas, in a meta-analysis review, by the same author, compared between HS and IS in Chinese and European populations, they summarised results from many Chinese and Western studies; Chinese HS patients were younger and more often male than IS patients, while age and sex distribution were similar between Western HS and IS patients. A Saudi study by Bashir and Al-Kawi restricted to young stroke patients reported that HS was more frequent among them than IS.
In-hospital mortality is ranged between 9.3% and 43%,,,,,, this wide range may be due to many factors such as health service availability, awareness, stroke prevention programs, urban versus rural locations, this study found a figure within this range (30.2%) and was higher among HS than IS patients (46.3% versus 26.5%, respectively), and this was supported with many studies worldwide.,,,
HS tends to be more severe clinically than IS, and this may explain that in-hospital was higher in the first. Andersen et al. reported that the relative frequency of HS increased with increasing stroke severity from 2% in patients with mildest strokes to 30% to the most severe strokes. We reported that 77.5% of HS and only 34.2% of IS patients were presented with impaired consciousness including coma. A study in Egypt, 56.2% of HS patients and 23.9% of IS ones, were presented with impaired consciousness. sssAnother study in Qatar noted that coma was presented in 45.3% of HS and only 9.2% of IS patients. In France, a study restricted to HS revealed that 60.5% of patients presented with coma.
Hypertension was the most frequent risk factor for stroke patients. This study showed that it more frequents among HS than in IS patients; many studies supported this finding,,,, although in the last century, hospital-based and large population-based studies,, it was associated with IS more than HS.
Diabetes mellitus in this study was associated with IS more than HS, this may be explained by its close relation to atherosclerosis, many studies worldwide supported these findings,,, although, there were studies recorded that diabetes did not favour either stroke types.,
Smoking is a risk factor for stoke, many studies reported that it was higher in IS than HS patients,, or with no difference between both stroke types., Recently, a hospital-based study by Ahangar et al., in Iran, was the first one who reported a significant association between HS and smoking, comparing with IS; our work was consistent with it.
| Conclusion|| |
We reported that younger age, hypertension and smoking were more frequent among HS than IS patients, while older age, diabetes, TIA, hyperlipidaemia and family stroke history were more related to IS than HS. Sex did not favour either stroke type. Impaired consciousness including coma and in-hospital fatality was more among HS than in IS victims.
As the study is a retrospective, and there was no direct contact with patients, data sometimes were not sufficient, namely, in collecting some risk factors' data, especially, about hyperlipidaemia and history of previous myocardial infarction. Alcohol intake frequency seemed to be low too; our culture makes people deny it.
We wish to thank the group of intern doctors and medical students as well as the Manager of the Medical Archive of Ibn Sina Teaching Hospital, for their great assistance in collecting data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Feigin VL. Stroke in developing countries: Can the epidemic be stopped and outcomes improved? Lancet Neurol 2007;6:94-7.
Strong K, Mathers C, Bonita R. Preventing stroke: Saving lives around the world. Lancet Neurol 2007;6:182-7.
O'Donnell M, Yusuf S. Tackling the global burden of stroke: The need for large-scale international studies. Lancet Neurol 2009;8:306-7.
Donnan GA, Hankey GJ, Davis SM. Intracerebral haemorrhage: A need for more data and new research directions. Lancet Neurol 2010;9:133-4.
Ahangar AA, Saadat P, Heidari B, Taheri ST, Alijanpour S. Sex difference in types and distribution of risk factors in ischemic and hemorrhagic stroke. Int J Stroke 2018;13:83-6.
Lavados PM, Sacks C, Prina L, Escobar A, Tossi C, Araya F, et al.
Incidence, 30-day case-fatality rate, and prognosis of stroke in Iquique, Chile: A 2-year community-based prospective study (PISCIS project). Lancet 2005;365:2206-15.
Cabral NL, Gonçalves AR, Longo AL, Moro CH, Costa G, Amaral CH, et al.
Incidence of stroke subtypes, prognosis and prevalence of risk factors in Joinville, Brazil: A 2 year community based study. J Neurol Neurosurg Psychiatry 2009;80:755-61.
Delbari A, Salman Roghani R, Tabatabaei SS, Rahgozar M, Lokk J. Stroke epidemiology and one-month fatality among an urban population in Iran. Int J Stroke 2011;6:195-200.
Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: A systematic review. Lancet Neurol 2009;8:355-69.
O'Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P, et al.
Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): A case-control study. Lancet 2010;376:112-23.
Tsai CF, Thomas B, Sudlow CL. Epidemiology of stroke and its subtypes in Chinese vs. white populations: A systematic review. Neurology 2013;81:264-72.
Ogun SA, Ojini FI, Ogungbo B, Kolapo KO, Danesi MA. Stroke in South West Nigeria: A 10-year review. Stroke 2005;36:1120-2.
Njoku CH, Aduloju AB. Stroke in Sokoto, Nigeria: A five year retrospective study. Ann Afr Med 2004;3:73-6.
Memon TF, Lakhair MA, Shaikh M, Rafique A, Rind MS. Socio-dermographic risk factors for hemorrhagic and ischemic stroke: A study in tertiary care hospital of Hydarabad. Pak J Neurol Sci 2017;11:24-9.
Sallam A, Al-Aghbari K, Awn H. The clinical profile of stroke: A Yemeni experience. Jordan Med J 2009;43:115-121.
Truelsen T, Heuschmann PU, Bonita R, Arjundas G, Dalal P, Damasceno A. Standard method for developing stroke registers in low-income and middle-income countries: Experiences from a feasibility study of a stepwise approach to stroke surveillance (STEPS stroke). Lancet Neurol 2007;6:134-9.
The World Health Organization MONICA project (monitoring trends and determinants in cardiovascular disease): A major international collaboration. WHO MONICA project principal investigators. J Clin Epidemiol 1988;41:105-14.
Qari FA. Profile of stroke in a teaching university hospital in the western region. Saudi Med J 2000;21:1030-3.
Hamad A, Hamad A, Sokrab TE, Momeni S, Mesraoua B, Lingren A. Stroke in Qatar: A one-year, hospital-based study. J Stroke Cerebrovasc Dis 2001;10:236-41.
Awad SM, Al-Jumaily HF, Al-Dulaimi KM, Abdulghafoor RH. Assessment of major risk factors among stroke patients. Saudi Med J 2010;31:1028-31.
Lahoud N, Abbas MH, Salameh P, Saleh N, Abes S, Hosseini H, et al.
Aretrospective analysis of 254 acute stroke cases admitted to two university hospitals in Beirut: Classification and associated factors. Funct Neurol 2017;32:41-8.
type, Sokrab TE, Sid-Ahmed FM, Idris MN. Acute stroke risk factors, and early outcome in a developing country: A view from Sudan using a hospital-based sample. J Stroke Cerebrovasc Dis 2002;11:63-5.
Kndil MR, El-Tallawy HN, Farawez HM, Khalifa G, Ahmed MA, Hamed SA, et al
. Epidemiology of cerebrovascular stroke and TIA in Upper Egypt (Sohag) – Relative frequency of stroke in Assiut University hospital. Egypt Neurol Psychiat Neurosurg 2006;43:593-602.
Andersen KK, Olsen TS, Dehlendorff C, Kammersgaard LP. Hemorrhagic and ischemic strokes compared: Stroke severity, mortality, and risk factors. Stroke 2009;40:2068-72.
Bhalla A, Wang Y, Rudd A, Wolfe CD. Differences in outcome and predictors between ischemic and intracerebral hemorrhage: The South London stroke register. Stroke 2013;44:2174-81.
Kelly PJ, Crispino G, Sheehan O, Kelly L, Marnane M, Merwick A, et al.
Incidence, event rates, and early outcome of stroke in Dublin, Ireland: The North Dublin population stroke study. Stroke 2012;43:2042-7.
Abdul-Ghaffar NU, el-Sonbaty MR, el-Din Abdul-Baky MS, Marafie AA, al-Said AM. Stroke in Kuwait: A three-year prospective study. Neuroepidemiology 1997;16:40-7.
Ashok PP, Radhakrishnan K, Sridharan R, el-Mangoush MA. Incidence and pattern of cerebrovascular diseases in Benghazi, Libya. J Neurol Neurosurg Psychiatry 1986;49:519-23.
Tsai CF, Jeng JS, Anderson N, Sudlow CL. Comparisons of risk factors for intracerebral hemorrhage versus ischemic stroke in Chinese patients. Neuroepidemiology 2017;48:72-8.
Tsai CF, Anderson N, Thomas B, Sudlow CL. Comparing risk factor profiles between intracerebral hemorrhage and ischemic stroke in Chinese and white populations: Systematic review and meta-analysis. PLoS One 2016;11:e0151743.
Bashir R, Al-Kawi. Stroke in the young: experience at King Faisal Specialist Hospital. Ann Saudi Med 1983;3:149-153.
Khan FY, Yasin M, Abu-Khattab M, El Hiday AH, Errayes M, Lotf AK, et al.
Stroke in Qatar: A first prospective hospital-based study of acute stroke. J Stroke Cerebrovasc Dis 2008;17:69-78.
Bornstein NM, Aronovich BD, Karepov VG, Gur AY, Treves TA, Oved M. The Tel Aviv Stroke Registry 3600 consecutive patients. Stroke 1996;27:1770-3.
Ahangar AA, Ashraf Vaghefi SB, Ramaezani M. Epidemiological evaluation of stroke in Babol, Northern Iran (2001-2003). Eur Neurol 2005;54:93-7.
El Tallawy HN, Farghaly WM, Badry R, Hamdy NA, Shehata GA, Rageh TA, et al.
Epidemiology and clinical presentation of stroke in Upper Egypt (Desert area). Neuropsychiatr Dis Treat 2015;11:2177-83.
Tatu L, Moulin T, El Mohamad R, Vuillier F, Rumbach L, Czorny A. Primary intracerebral hemorrhages in the Besançon stroke registry. Initial clinical and CT findings, early course and 30-day outcome in 350 patients. Eur Neurol 2000;43:209-14.
Benamer HT, Grosset D. Stroke in Arab countries: A systematic literature review. J Neurol Sci 2009;284:18-23.
Aziz ZA, Lee YY, Ngah BA, Sidek NN, Looi I, Hanip MR, et al.
Acute stroke registry Malaysia, 2010-2014: Results from the National Neurology Registry. J Stroke Cerebrovasc Dis 2015;24:2701-9.
Liu XF, van Melle G, Bogousslavsky J. Analysis of risk factors in 3901 patients with stroke. Chin Med Sci J 2005;20:35-9.
Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS. Intracerebral hemorrhage versus infarction: Stroke severity, risk factors, and prognosis. Ann Neurol 1995;38:45-50.
Jamrozik K, Broadhurst RJ, Anderson CS, Stewart-Wynne EG. The role of lifestyle factors in the etiology of stroke. A population-based case-control study in Perth, Western Australia. Stroke 1994;25:51-9.
Shravani K, Parmar MY, Macharla R, Mateti UV, Martha S. Risk factor assessment of stroke and its awareness among stroke survivors: A prospective study. Adv Biomed Res 2015;4:187.
] [Full text]
Siddique A, Nur Z, Mahbub S Alam B, Miah T. Clinical presentation and epidemiology of stroke: A study of 100 cases. J Med 2009;10:86-9.
[Table 1], [Table 2], [Table 3]