Stroke pattern and outcome of management in type 2 diabetics in a tertiary hospital in North Western Nigeria

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1 Original Article Stroke pattern and outcome of management in type 2 diabetics in a tertiary hospital in North Western Nigeria Lawal Kayode Olatunji, Salisu Abdullahi Balarabe 1, Habibullah Adamu 2, Abdulrahman Bashir Muhammad, Anas Ahmad Sabir 1, Latifatu Bolanle Abdulsalam 3 Departments of Chemical Pathology, 1 Medicine, 2 Community Health and 3 Family Medicine, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria ABSTRACT Background: Diabetes mellitus is a well recognized risk factor for stroke. Clinical features, as well as outcome of stroke, difference between diabetic and nondiabetic patients. The objective of this study is to determine the pattern and outcome of management in diabetes stroke co morbidity. Materials and Methods: This is a retrospective study where case folders of patient admitted from January 1 to December 31, 2009 with the clinical diagnosis of stroke were traced. A questionnaire was used to extract relevant data from case folders. Results: A total of 115 patients with the clinical diagnosis of stroke were admitted during the study period, but only 88 had complete information out of which 12 (13.6%) had type 2 diabetes. The mean age of the diabetic group (69.67 ± 12.7 years) was found to be significantly higher than that of the nondiabetic group (56.93 ± years) (t = 2.615, P = 0.011). Ischemic stroke occurred more frequently in the diabetes stroke the co morbid group. However, the difference was not statistically significant (χ² =0.079, P = 0.540). Outcome in terms of neurological recovery tended to be poor in the diabetes stroke co morbid group as compared to the nondiabetes stroke group (χ² =13.93, P = 0.006). Conclusion: Stroke pattern and outcomes are different in the diabetic patient compared to nondiabetic patient. There is more prevalence of ischemic stroke in the diabetic group of patients often with slow recovery. Keywords: Diabetes mellitus, outcome, stroke pattern INTRODUCTION World health organization defined stroke as rapidly developing clinical signs of focal or global disturbance of cerebral function with symptoms lasting more than 24 h or leading to death with no apparent cause other than vascular origin. [1] Stroke may result from rupture of blood vessel supplying part of brain tissue, that is, hemorrhagic stroke or may result from occlusion of the blood vessel by either thrombus or embolus, that is, the Ischemic stroke. [2] Quick Response Code: Access this article online Website: DOI: / Stroke is a major cause of death in the adult population worldwide and contributes to disability and reduced quality of life. It causes a great burden on the family, friends and society at large due to long stay on bed with subsequent disability and inability to return to work. [3] Stroke is a medical emergency and can cause permanent neurological damage and death. It is the number two cause of death worldwide and may soon become the leading cause of death. [4] Studies carried out in 2005 revealed an estimated sixteen million first stroke patients and 5.7 million stroke deaths, accounting for nearly 10% of all death worldwide. [1] In Africa, stroke accounts for % of all hospital admissions and % of total hospital deaths. [5] The incidence of stroke in Africa is on the increase. [6 8] Diabetes is a major risk factor for cerebrovascular morbidity and mortality. This condition increases the risk of developing cerebrovascular, coronary and Corresponding Author: Dr. Lawal Kayode Olatunji, Department of Chemical Pathology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. drlawalolatunji@gmail.com 161

2 peripheral arterial diseases up to 4 fold. [9] The disease severity, as measured by chronic glycemia, is associated with increased frequency of the clinical event in each vascular bed. [10] Compared with patients without diabetes, those with diabetes have greater de novo vascular disease progression. [11,12] For example, it was found that the risk of stroke among patients taking oral hypoglycemic drugs due to chronic hyperglycemia was increased 3 folds among nearly 350,000 men in the multiple risk factor intervention trials. [13] The prevalence of diabetes in adult worldwide is projected to be 5.4% by the year 2025 as compared to 4.0% in 1995 (i.e. a rise from 135 to 300 million). The major part of this numerical increase will occur in the developing countries. There will be a 42% increase (i.e., from 51 to 72 million) in the developed countries and a 170% increase (i.e. from 84 to 228 million) in the developing countries. Thus, by the year 2025, more than 75% of people with diabetes will reside in the developing countries as compared with 62% in [14] Diabetes was found to increase the risk of developing of stroke about 2 5 times higher than in a nondiabetic patient. [13] Certain factors have been incriminated in the causation of stroke among diabetic patients, and these factors include hyperglycemic state, chronic hypertension, cigarette smoking, atrial fibrillation, male sex and increase ageing. [15] Preexisting hyperglycemia (diabetes mellitus [DM]) is found commonly among stroke patients, and diabetes increases the risk for all type of strokes. [16] DM is an independent risk factor for stroke. The mechanism is believed to be by accelerated atherosclerosis, which can affect cerebral blood vessels. [17] In a population based study of 1192 men and women examined at a 5 years interval, progression of intima media thickness on ultrasound study of common carotid and internal carotid artery was approximately twice the rate in diabetes compared with nondiabetes. [18] In the Baltimore Washington Cooperative young stroke study, stroke risk increased more than 10 fold in diabetic patients younger than 44 years of age and ranging as high as 23 fold in young white men. [19] The significance of diabetes as a risk factor for hemorrhagic stroke could differ depending on the ethnicity. For example, in the Honolulu Heart Program; diabetes was not associated with increased risk of hemorrhagic stroke in Japanese American men but in the Framingham study, there was a 4 5 fold excess risk of this type of stroke in white men with diabetes. [20] Diabetes may result in dyslipidemia, for example, elevated levels of triglycerides, low density lipoprotein (LDL) and very LDL along with lower than normal level of high density lipoprotein. [21] Combined effect of the hyperglycemia and dyslipidemia result in the promotion of atherosclerosis and thrombosis. [21] Hyperglycemia results in the formation of advanced glycation end products that are toxic to endothelial cells, and production of free radicals from various sources may result in further vascular injury. [17] Diabetes not only significantly increases the risk of stroke, but also is a predictor of reduced survival following stroke. Higher mortality rates from stroke have been reported in diabetics, compared to nondiabetics in most studies [22 25] but not all studies. [26] These studies demonstrate that higher mortality rate is present throughout the entire poststroke period. Mortality rates are higher in diabetics during acute hospitalization for stroke, 1 year, and one decade after stroke. [22 24] Diabetes may affect the rate of recovery of neurologic function following stroke. Lithner et al. [27] reported that 4 days after hospital admission, more stroke patients with diabetes than without diabetes were still confined to bed. In Bayelsa state, Nigeria on incidence and pattern of stroke reveals that about 10.7% of all stroke patients are diabetic. [28] This study aims to find out the pattern and outcome of management of stroke in type 2 diabetes patients compared to nondiabetic patients. MATERIALS AND METHODS This was a retrospective study that was conducted from January 1 to December 31, 2009 in the Usmanu Danfodiyo University Teaching Hospital Sokoto, Sokoto State, Nigeria. Case records of patients with the clinical diagnosis of stroke were traced using International Classification of Diseases 10 codes with fourth sub character, subcategory A questionnaire was designed to extract relevant clinical data from case folders. These data include age, sex, marital status, occupation, date of admission, date of death, stroke risk factors, admission blood sugar, side of the body affected, admission blood 162

3 pressure and outcome within the first 3 months. Diabetes was taken positive; if there is the history of diabetes or the use of oral anti diabetes drugs. Hypertension was taken positive if there is the history of hypertension or use of anti hypertensive drugs. Data were analyzed using Statistical Package for Social Sciences (SPSS) Statistics for Windows, version 17.0 (Released 2008), Chicago, USA the level of statistical significance was taken to be P < 0.05, independent t test, Chi square and Fischer s extract were used in data analysis. Ethical permission was sought from the Ethical Committee of the Hospital. RESULTS In the diabetes stroke co morbidity group, males were 58.3% while females were 41.7%, whereas in the nondiabetics stroke patients, males were 55.3%, and females were 44.7%. Males contribute 55.7% of total stroke patients while female constituted 44.3% (P = 0.548, χ² =0.400). The mean of the random blood sugar level of the diabetes stroke comorbid patients was found to be 8.63 ± 3.38 at presentation while in the nondiabetic stroke group of patients it was 7.23 ± 1.68 (t = 1.621, P = 0.115). Ischemic stroke constitute 75% in the diabetes stroke co morbid patients and 71.1% in the nondiabetic stroke patients, while hemorrhagic stroke constitute about 25% in the diabetes stroke co morbid patient and 28.9% in the nondiabetics stroke patients (P = 0.540). Ischemic stroke accounts for 71.6% of the entire stroke while hemorrhagic account for 28.4% of all the stoke cases seen in the institution within the study period. About 83% were hypertensive, 8.3% had previous history of mini stroke, 8.3% had heart diseases and 8.3% smoked cigarette in the diabetes stroke co morbidity group as compared to 78.9% who were hypertensive, 10.5% with previous history of mini stroke, 9.2% who smoke cigarette, 1.3% who consume alcohol, 7.9% heart diseases and 1.3% sickle cell disease patient in the nondiabetes stroke patients. The outcome in the diabetes co morbid patient were 25% died, 25% improved, 41.7% had no improvement and 8.3% signed against medical advice whereas in the nondiabetic patients, about 21.1% died, 48.6% improves out of which 5.3% fully recovered, 6.6% have no improvement and 23.7% sign against medical advice. DISCUSSION It was found that stroke patients constituted 1.1% of total hospital admissions and about 9.9% of total medical admissions; this finding is similar to what was obtained by Abubakar et al. [29] at the same institution, Ojini and Danesi [30] at Lagos University Teaching Hospital, Oni et al. [28] at the Niger Delta University Teaching Hospital, Ammassoma in Bayelsa State. Stroke constituted about 2.8% of the total medically related death within the study period. This is similar to report from other studies. [5,28] The mortality rate of 26.1% in this study is similar to % reported for Africa and developed world. [5,28,31] About 13.6% of the total stroke patients had diabetes (P = 0.645). This is similar with reports from other studies in Africa but lower than studies from the developed world. [5,28] The mean age of the diabetic group (69.67 ± 12.7 years) was found to be significantly higher than that of the nondiabetic group (56.93 ± years) (t = 2.615, P = 0.011). This is similar to what was obtained by Karapanayiotides et al. [32] (P < 0.001) but was higher than what was obtained by Zafar et al. [33] who showed that there is no difference between the diabetic and nondiabetic groups (P = 1.00) and Jørgensen et al. [22] who showed that diabetic stroke patients were 3.2 years younger than the nondiabetic stroke patient (P < 0.001). It was also observed that the incidence of the stroke increased with age and the peak incidence for male and female in the diabetes stroke co morbid patient was in the seventh and eighth decades, respectively, and for the nondiabetes stroke patient, the peak incidence for male and female was in the sixth and seventh decades, respectively, thus peak incidence of stroke tends to be higher among the diabetes stroke co morbid group of patient than the nondiabetic group. The peak incidence of a stroke patient regardless of presence or absence of diabetes was seen in the sixth and seventh decades for males and females, respectively. This finding is similar to what was obtained by Oni et al. [31] However, differ in peak incidence for female. In this study, there is no significant difference between the sexes of both the diabetes stroke co morbidity group and the nondiabetics stroke group (P = 0.548, X² =0.400). This correlate with the findings of Wagenknecht et al. [18] It was found that there is no significant difference in occurrence of stroke risk factors such as hypertension, mini stroke, heart disease, and smoking of cigarette between the diabetes stroke co morbid group and the 163

4 nondiabetics stroke group (83.3% vs. 78.9% P = for hypertension, 8.3% vs. 10.5% P = for mini stroke, 8.3% vs. 7.9% P = for heart disease, 8.3% vs. 9.2% P = for smoking of cigarette) this is similar to what was obtained by Zafar et al. [33] but contrast other studies. [32,34] difference observe may be probably due to relative high prevalence of such risk factors in the study environment. The mean of the random blood sugar level of the diabetes stroke comorbid patients (mean = 8.63 ± 3.38) at presentation tends to be higher than in the nondiabetic stroke group of patients (mean = 7.23 ± 1.68) though the difference was not statistically significant (t = 1.621, P = 0.115). This contrast what was obtained by Hamidon and Raymond [35] who show that there is strong positive association between admission blood glucose and DM. Ischemic stroke tends to occur more frequent in the diabetes stroke co morbid group than in the nondiabetic group (75% vs. 71.1%). Similarly, hemorrhagic stroke tends to less in the stroke co morbid group than in the nondiabetic group (25% vs. 28.9%) However the differences observe were not statistically significant (X² =0.079, P = 0.540) this contrast many studies. [22,33,36] this may be due to small sample size used in the study. Ischemic stroke accounts for 71.6% of the entire stroke while hemorrhagic account for 28.4% of all the stoke cases seen in the institution within the study period. This correlates with other studies. [5,28] There is no difference in mortality observe between the groups (27.2% vs. 27.1%) this is similar to what was obtained by Stöllberger et al. [36] and Hamidon and Raymond [35] but differ from other studies. [22 24] The outcome in terms of neurological recovery was significantly lower in the diabetes co morbid group as compared to the nondiabetic group of patients (27% vs. 66% who improves compare to45% versus 8% without clinical improvement, P = 0.006, χ 2 = ) this correlate with most studies. [22 25,36] CONCLUSIONS In this study, there is a significant age difference between the diabetes stroke co morbid patient and nondiabetic stroke patient. The random blood sugar level of the diabetes stroke co morbid patient tends to Table 1: Stroke risk factors distribution DM (%) Non DM (%) Total (%) Gender Male 7 (14.3) 42 (85.7) 49 Female 5 (12.8) 34 (87.2) 39 P=0.548, χ 2 =0.40 Hypertensive Present 10 (14.3) 60 (85.7) 18 Absent 2 (11.1) 16 (88.9) 70 P=0.537 (Fischer s exact), χ 2 =0.123 Cigarette smoking No Yes 1 (8.3) 7 (9.2) 8 P=0.701 (Fischer s exact), χ 2 =0.01 Alcohol consumption No Yes 0 (0) 1 (1.3) 1 P=0.864 (Fischer s exact), χ 2 =0.16 Previous history of mini stroke No Yes 1 (8.3) 8 (10.5) 9 P=0.645 (Fischer s exact),χ 2 =0.054 Heart disease No Yes 1 (8.3) 6 (7.9) 7 P=0.656 (Fischer s exact), χ 2 =0.003 Stroke type Hemorrhagic 3 (25) 22 (28.9) 25 Ischemic 9 (75) 54 (71.1) 63 P=0.540 (Fischer s exact), χ 2 =0.079 Outcome Dead 3 (27.2) 16 (27.1) 19 Improves 3 (27) 38 (63) 41 No improvement 5 (45) 5 (8) 10 Total P=0.006 (Fischer s exact), χ 2 = DM: Diabetes mellitus be higher than in the nondiabetic stroke group of patient at presentation. Majority of both victims were male. The outcome in terms of neurological recovery was found to be poor in the diabetes co morbid patients, and about 8.3% signed against medical advice to seek for alternative treatment elsewhere. In conclusion, the following recommendations have been proposed. Health education on preventive measures for type 2 DM, adequate regulation of blood pressure and blood sugar level through compliance to medical advice and medication, regular clinic attendance and periodic measurement of blood pressure and blood sugar level. 164

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