Epidemiology of Cerebrovascular Stroke and TIA in Upper Egypt (Sohag) Relative Frequency of Stroke in Assiut University Hospital

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1 M.R. Kandil et al. Epidemiology of Cerebrovascular Stroke and TIA in Upper Egypt (Sohag) Relative Frequency of Stroke in Assiut University Hospital M.R. Kandil 1, H.N El-Tallawy 1, H.M Farawez 1, G. Khalifa 2, M. A. Ahmed 1, S.A. Hamed 1 and A.M. Ali 1 Department of Neurology and Psychiatry, Assiut University 1, South Valley University 2 ABSTRACT Records of prevalence and incidence of cerebrovascular stroke (CVS) and TIA in our country were insufficient. This study was planned to evaluate the incidence and prevalence of non-fatal CVS in Upper Egypt (Sohag) as a first stage, together with relative frequency and mortality rates of stroke patient admitted to neurology department of Assiut University Hospital during one year (2003) as a second stage. A representative sample was chosen and a door to door study was carried out on 25,000 persons 32.4% from urban, 21.2% from suburban and 44.9% from rural areas. (A lot of investigations were carried out for all patients in Assiut University Hospital to fulfill criteria of stroke and TIA). Prevalence rate of CVS in Upper Egypt was estimated to be 5.08/1000 and TIA was 0.36/1000, while the incidence of CVS in 1992 was 1.8/1000 and TIA was 0.2/1000. Both prevalence and incidence were more frequent in suburban and rural than urban communities. Male to female ratio of the prevalence of stroke was 1.05:1 while the incidence male to female ratio was 1:0.85. Age specific prevalence and incidence rates showed that thrombotic and hemorrhagic stroke as well as TIAs were rapidly increasing after the age of 40 years, while the age period from 20 to 40 years was the peak period for embolic stroke. Regarding relative frequency of CVS among other neurological disorders, cerebrovascular stroke rank, the first (58.5%) disorder of those admitted to neurology department Assiut university hospital during one year (2003). Mortality rate (at discharge) of stroke patients admitted to neurology department, Assiut University Hospital during 2003 was 26.8%, where mortality rate for ischamic stroke was 25.4% and that for hemorrhagic stroke was 30.0%. (Egypt J. Neurol. Psychiat. Neurosurg., 2006, 43(1): ) INTRODUCTION Cerebrovascular stroke (CVS) has been shown to be a major cause of death and disability in all societies in which it has been studied. This is true irrespective of communities (industrial, agricultural, urban or rural). Stroke, the major consequence of cerebrovascular diseases affects all ages but certainly is more common in the sixth, seventh and eighth decade of life 1,2,3. In many epidemiological studies concerning the prevalence of strokes, the rates are expressed as referred to the whole population although it is extremely low in the younger age groups 4. The incidence of cerebrovascular disease has recently been studied in many countries by means of stroke registers on large population. Such studies provide good basis for the description of variation of the incidence of stroke by various demographic and social factors 5. Hospital based studies might provides standards of medical and rehabilitative care and discharge destination should be developed to promote quality of case while containing utilization and costs 6. Although routine morality statistics are useful for making national and international comparison of trends in the epidemiology of stroke 7, it is important that stroke is also studied in a population-wide control because many patients survive the acute phase with residual disability and a large proportion of the burden of care occurs outside of the hospital sector 8,9. 593

2 Egypt J. Neurol. Psychiat. Neurosurg. Vol. 43 (2) - July 2006 Changes in diagnostic coding practices and referral patterns can significantly distort trends derived solely from hospital-based data. Yet, there are few population-based studies when compared with the number of studies that use mortality or hospital-based register data and the limited number of stroke incidence studies that fulfill certain ideal criteria further reflects the complexities to such investigations 10,9. Aim of the study: First stage 1- Determination the incidence and prevalence rate of non fatal cerebrovascular stroke and TIA in upper Egypt (Sohag), community based study. 2- Case fatality rate due to CVS during one year (1992). Second stage: Relative frequency of stroke among other neurological disorders and mortality rate (at discharge) of stroke patients, in neurology department Assiut university hospital during one year (2003), hospital based study. PATIENTS AND METHODS First stage: This research work was a prospective study conducted from January 1 st 1992 to April 30, 1993, to study the prevalence and incidence of cerebrovascular stroke and TIAs in Upper Egypt (Sohag). Data collection was performed by a trained team headed by an assistant lecturer of Neurology from Sohag Faculty of Medicine, and supervised by professors of Neurology, Faculty of Medicine, Assiut University. A special short-form sheet was constructed by expert professors of Neurology, Assiut Faculty of Medicine. It was initially applied within a pilot study on several household stroke patients (not included in the study) to test its validity which proved to be valid. All patients who developed CVS, according to Hatano 1, or TIA (Toole) 3 were included in the present study after admission to inpatient Neurology Department of Assiut University Hospital. They were subjected to CT scan, ECG, echocardiogaraphy, laboratory tests as blood urea, creatinine, complete blood picture, serum uric acid, lipogram and vitamin C level in blood, as well as special investigations as carotid Doppler was carried out for some patients. Patients with CVS were classified according to clinical picture and investigations into ischemic stroke (thrombotic and embolic) and hemorrhagic stroke (cerebral and subarachnoid hemorrhage). All embolic strokes included in this study had CT scan and clinical features suggestive for cerebral embolism described by Tool 3 and all were proved to have potential embolic sources by echocardiography and carotid Doppler. Sampling: Study area: The study area is Sohag Governorate, it is one of the governorates of Upper Egypt that lies on both sides of the River Nile, 467 kilometers South to Cairo, its total population is 2, 826, 119 (CAPMAS) 11. Sampling technique: A multistage, systematic random sample was followed to chose the study sample. Seven districts were randomly selected out of which 9 locations were randomly specified for conducting the study. The study sampling unit was the family. The sampling fraction was calculated to be 10%, so, one-tenth of houses in a location were planned to be systematically visited. The assistance of trained female researchers was offered during home visits. This made the interviews much easier and decreased the expected non-responsiveness. The objectives of this study were briefly and clearly described to the members of the family. The consent to participate was asked verbally assuring that this study is mainly for their benefit 594

3 M.R. Kandil et al. and no harm is ever expected and the confidentiality of all data provided is absolutely certain. A total of 52,973 houses were assigned in the 9 studied locations of which 4,872 families (25, 000 persons) were visited in a door to door study. The distribution was as follows 8,464 (33.9%) urban 5,305 (21.2%) suburban and (44.9%) rural. Causes of non-inclusion of families were generally as follows: 1. Some families owned more than one house. 2. Houses were completely vacant, due to travel of all its inhabitant or due to its unsafety, i.e. about to fall. 3. Unwillingness of the inhabitants to participate in this study. In case of families refusing cooperation, the next door was immediately included. Second stage This stage included all patients with different neurological disorders admitted to neurology department in Assiut university hospital during one year (2003). It was carried out through a period of one year retrospectively from January 1st to December 31st, (2003). Assiut university ethical committee approved this study. RESULTS Total prevalence of CVS per 1000 in the population of Sohag, Upper Egypt was 5.08/1000. It was higher among suburban (5.8/1000) than rural (5.4/1000) and urban (4.1/1000). As regard TIA, the prevalence was 0.36/1000 and also it was higher among suburban (0.6/1000) than urban (0.5/1000) and rural areas (0.2/1000). The incidence of CVS was 1.8/1000 population during It was higher among rural (2.1/1000) than suburban (1.8/1000) and urban areas (1.5/1000). The incidence of TIAs during 1992 was 0.2/1000 and it was higher in suburban (0.46/1000) than urban (0.26/1000) and rural areas (0.1/1000). As regards prevalence, the male: female ratio was 1.05:1 while the incidence of male: female ratio was 1:0.85. This distribution was true among suburban populations. However, in rural areas the reverse was observed where females showed higher prevalence as well as incidence rates than males. On the other hand females in urban areas had higher prevalence, but lower incidence rates than males. Regarding prevalence of TIAs, the male: female ratio was 2:1. This was true in all studied areas, while the male to female ratio of the incidence of TIA, was 1.5:1 (Table 1). Prevalence and incidence rates of different subtypes of CVS revealed that the highest rate was observed in thrombotic group (3.1 and 1/1000) followed by cerebral hemorrhage (1.1 and 0.43/1000), then embolic (0.4 and 0.24/1000) and lastly subarachnoid hemorrhage (0.24 and 0.19/1000). Age specific prevalence and incidence rates of CVS showed that thrombotic and cerebral hemorrhage stroke were rapidly increasing after the age of 40 years while in embolic group, the highest prevalence and incidence rates were observed in the age period from 20 to less than 40 years. The highest age for prevalence and incidence of TIA was 40 to less than 60 years, followed by age period 60 years and more (Tables 2 and 3). Study of case fatality rate due to CVS during one year (1992) revealed that the highest fatality rate was recorded in the first month following CVS (35.1%) out of which 14.6% occurred in the first week. As regards different subtypes, about 61.4% of hemorrhagic stroke patients died in the first month versus 18.9% only from thrombotic patients (Table 4). Most deaths were observed within the first week (30.8%) and first month (30.8%) (table 4) of hemorrhagic stroke especially of suburban (50%) and rural areas (35.3%). On the other hand most deaths following ischemic stroke were reported between the third month to 1 year (28.6%). Case fatality rate was significantly higher for patients admitted after 48 hours 595

4 Egypt J. Neurol. Psychiat. Neurosurg. Vol. 43 (2) - July 2006 (47.5%) than those admitted within the first 48 hours after stroke (20.5). Cerebrovascular stroke had the highest percent of admission (58.5%) followed by CNS infection, cord and root lesions, epilepsy and polyradiculopathy (7.7%, 7.7%, 6.5% and 6.4% respectively). Males showed significantly higher percent than females in cerebrovascular stroke, CNS infection, cord and root lesion, polyradiculopathy and children presented by delayed development, while the reverse occurred in benign increased intracranial pressure and brain tumors (Table 5). Ischemic stroke represent 70.4% versus 29.6% for hemorrhagic stroke out of all stroke patients admitted to neurology department, Assiut university hospital during one year (2003). Mortality rate of all cases of cerebrovascular stroke (at discharge) was 26.8% where, it was higher for hemorrhagic stroke (30.0%) than for ischemic stroke (25.4%) (Table 6). Table 1. Incidence* and prevalence per 1000 populations of nonfatal CVS and TIA in different localities according to sex. Total Males Females Incidence Prevalence Incidence Prevalence Incidence Prevalence Total (n = 25000) CVS 39 (1.8) 127(5.08) 21(1.0) 65(5.2) 18(0.85) 62(4.9) TIA 5(0.2) 9(0.36) 3(0.14) 6(0.5) 2(0.09) 3(0.24) Urban (n=8464) CVS 11(1.5) 35(4.1) 7(0.9) 20(4.6) 4(0.53) 15(4.7) TIA 2(0.26) 4(0.5) 1(0.13) 3(0.7) 1(0.13) 1(0.2) Suburban (n=5308) CVS 8(1.8) 31(5.8) 5(1.6) 16(6.4) 3(0.69) 15(5.3) TIA 2(0.46) 3(0.6) 1(0.2) 2(0.7) 1(0.23) 1(0.3) Rural (n=11228) CVS 20(2.1) 61(5.4) 9(0.97) 29(5.1) 11(1.19) 32(5.7) TIA 1(0.1) 2(0.2) 1(0.1) 1(0.2) 0(0.0) 1(0.1 7) P<0.01 *Incidence was calculated among population of 1992 (20.900) Table 2. Prevalence of non-fatal CVS and TIA per 1000 population in various age groups. Item Total <20 years 20<40 years 40<60 years 60+years (n=25000) (n=126666) (n=6629) (n=4017) (n=1688) Total Thrombotic Embolic Cerebral hge Subarachnoid hge Unclassified* TIA P<0.01 hge = Hemorrhage *Chronic cases of stroke were diagnosed on clinical basis only 596

5 M.R. Kandil et al. Table 3. Incidence of CVS and TIA per 1000 population in various age groups. Item Total <20 years 20<40 years 40<60 years 60+years N=20900 (n=10851) (n=5774) (n=3073) (n=1302) Total Thrombotic Embolic Cerebral hge Subarachnoid hge TIA hge = hemorrhage P< Table 4. Percent of case fatality rate of CVS and its subgroups in relation to time of admission to hospital from the onset of stroke. Total ( n= 34) Thrombotic (n = 21) Hemorrhagic (n=13) 1 st 48 hours 3 rd -7 th day 1 st 48 hours 3 rd -7 th day 1 st 48 hours 3 rd -7 th day 1 st week 3(8.8) 2(5.8) 1(4.7) 0(0.0) 2(15.4) 2(15.4) 1 st week <1 st month 3(8.8) 4(11.7) 1(4.7) 2(9.5) 2(15.4) 2(15.4) 1 st month<3 rd month 0(0.0) 3(8.8) 0(0.0) 2(9.5) 0(0.0) 1(7.7) 3 rd month <6 th month 1(2.9) 3(8.8) 0(0.0) 3(14.3) 1(7.7) 0(0.0) 6 th month < 1 year 0(0.0) 4(11.7) 0(0.0) 3(14.3) 0(0.0) 1(7.7) Total death 7(20.5) 16(47.05) 2(9.5) 10(47.6) 5(38.4) 6(46.2) P<0.017 Table 5. Relative frequencies of different neurological disorders according to the final clinical diagnosis (on discharge) during one year (2003) for patients admitted to neurology department, Assiut University Hospital. Pattern Total Male Female Total No % No % No % Cerebrovascular stroke *** Encephalitis & meningoencephalitis * Cord and root affection *** Epilepsy Polyneuropathy and/or polradicylopathy * Extra pyramidal Syndromes Brain tumors * Muscle diseases Delayed development *** Benign increase ICP ** Ataxias Motor Neuron Disease Multiple sclerosis *p<0.05 **p<0.01 ***p<0.001 N.B.: Most children presented with delayed development were not finally diagnosed. ICP = Increased intracranial pressure 597

6 Egypt J. Neurol. Psychiat. Neurosurg. Vol. 43 (2) - July 2006 Table 6. Immediate outcome (at discharge) of cerebrovascular stroke patients admitted to neurology Department of Assiut University during one year (2003). Outcome Total Improvement Stationary Deterioration Death No. % No % No % No % No % Cerebrovascular stroke Ischemic stroke Hemorrhagic Stroke DISCUSSION It is a fact that epidemiological data about neurological disorders are deficient in Egypt and the recorded data was derived from hospital populations which did not represent the true incidence and prevalence in the community. This community based study was carried out on CVS in Upper Egypt (Sohag) and revealed that the total prevalence rate of CVS was 5.08/1000. The prevalence of CVS was higher among suburban (5.8/1000) than rural (5.4/1000) and urban (4.1/1000). These results were in agreement with Robinson and Toole 12, who reported that the prevalence rate of CVS in USA was 5.6/1000 population and Sorensen 13 in Denmark who reported a prevalence rate of 5.2/1000. However Koul 14 in rural Kashmir (India) recorded a prevalence rate of 1.431/1000 population, while Christlie 15, in Australia reported a prevalence rate of 7.9/1000 population in restricted group aged more than 25 years. The incidence rate of CVS per 1000 population during 1992 in Upper Egypt was 1.8/1000 and it was higher among rural (2.1/1000), than suburban (1.8/1000) and urban (1.5/1000). In agreement with our results, the incidence rate reported by Jerntorp and Berglund 16 in Malmo (Sweden) was 3/1000 while Osuntoken 17 in Nigeria reported an incidence rate of 0.26/1000 population, and Ashock 18 in Libya (Benighazi) reported an incidence rate of 0.63/1000/year. But these last reports could not represent the true as they were hospital based studies with loss of many cases, especially severe cases due to death before admission and mild cases that does not need hospitalization. Sex prevalence showed higher prevalence rate of CVS among males than females (5.2/1000 and 4.9/1000 respectively), while Aho 4 in Finland reported markedly higher (nearly double) prevalence rate in males (10.3/1000) than females (5.8/1000). Incidence rate of CVS was also higher among males (1/1000) than females (0.85/1000) in our study which was in agreement with Wender 19 in Poland who reported an incidence of 2.16/1000 among males and 1.82/1000 among females. Also Komachi 20 in Japan reported a higher incidence of CVS among males (3.94/1000) than females (2.25/1000). Higher prevalence rate of CVS was recorded among males in suburban areas and in females of rural and urban areas. This could be explained by the active participation of females in work in rural and urban areas together with the greater responsibilities and worries about the absent husband or son abroad, in addition to lower socioeconomic state among rural populations than other localities (P<0.002). Prevalence and incidence rate of different types of CVS were increased with increasing age except in the embolic group where the highest age of embolic stroke occurred in the age period 20 to less than 40 years. However, the highest prevalence and incidence rate of TIA was observed in the age period from 40 to less than 60 years. Many researchers reported the same observation Study of the prevalence and incidence rate of Different types of CVS in our community clarified that thrombotic stroke was the most frequent one followed by cerebral hemorrhage then embolic stroke and lastly subarchnoid hemorrhage. In agreement with our results those reported by Dennis 25 and Fogelholm 22 as follows: 598

7 M.R. Kandil et al. Our results Dennis et al. (1989) Fogelholm et al. (1992) Incidence of: Thromboembolic stroke 1.2/ / Cerebral hemorrhage 0.43/ / /1000 Subarachnoid hemorrhage 0.19/ / TIAs 0.25/ / Case fatality rate due to CVS during the first month of stroke (35.2%) in our study was higher than those reported in western countries. Jerntorp and Berglund 16, in Malmo (Sweden) reported that the overall case fatality rate at 30 days was 15%. However, case fatality rate in Oxfordshire community stroke within one month was 19%. Meanwhile, Ricci 23, in Italy reported a rate of 20.3% during the first 30 days of CVS. This higher case fatality rate in our community (Upper Egypt) than western countries could be attributed to delay in transportation and proper management in specialized ICU or stroke center. Case fatality rate of hemorrhagic stroke was higher than thrombotic group during the first month in our results. However, Jerntorp and Berglund 16 and Bamford 26 reported the same observation, although their case fatality rate was lower than our results. Higher case fatality rate among rural and suburban than urban patients especially in the first month could be attributed to same factors mentioned before as well as other associated diseases and co-morbid organ affection which complicates the management and make it more tedious and more costly. However, delayed time of admission of recent stroke after 48 as occurred in our cases added to the risk of death especially in thrombotic stroke. Cerebrovascular stroke represents the major bulk of diseases admitted to our hospital (58.5%) followed by inflammatory diseases of CNS, diseases of spinal cord and root and epilepsy. In agreement with our results Tabbi 27, in Nigeria over 3 years found that, stroke was the most common and accounts for 50.4% of cases admitted in this period, the second rate of admission was CNS infection (14.2%) myelopathies (8.1) followed by epilepsy. Also Ojini 28 in their hospital based study found that cerebrovascular stroke was the most common neurological disease (50%) followed by infection of CNS (25%). Mortality rate of patients with cerebrovascular stroke admitted to Assiut university hospital, neurology department along one year (2003) was 26.8% (n= 221 out of n=825). However mortality rate of ischemic stroke patients during one year (2003) was 25.4% and that of hemorrhagic stroke patients was 30.0%. Our results partially agree with Musolino 29, who reported that the overall 30 day case fatality rate was 24.2%. Also, Hollander 30 reported that the overall 28 days case fatality rate was 32.5% for all stroke, 12.4% for cerebral infarction and 33.3% for cerebral hemorrhages. The high percent of mortality rate of stroke patients in our hospital could be explained firstly by; the fact that Assiut University Hospital is the largest hospital in Upper Egypt and is considered as drainage area and referral center for all complicated cases, secondly by the finding that most families of stroke patients refuse admission of their patients to the hospital except in complicated cases. Case fatality rate during first month of stroke in 1992 (35%) was higher than mortality rate during first month of admitted stroke patients to neurology department of Assiut University hospital in 2003 (26.8%). Meanwhile fatality rate in the first month of hemorrhagic stroke in 1992 (61.6%) markedly decreased among hemorrhagic stroke patients admitted to neurology department of Assiut University hospital in 2003 (30.0%). High facilities and early admission of stroke 599

8 Egypt J. Neurol. Psychiat. Neurosurg. Vol. 43 (2) - July 2006 patients to neurology department of Assiut University hospital in 2003 significantly decreased mortality rate. Thus we agree with many others 7,10 that although morality rate of stroke has fallen substantially in many countries over recent decades, stroke incidence has not declined to the same extent. Also Bae 31 in his study on 579 patients with acute ischemic stroke (within 7 days after onset) admitted to department of neurology at Eulji general hospital from November 1998 to February 2001 suggests that the appropriate prevention and management of inhospital complications could improve short term and long term prognosis after stroke. CONCLUSION Prevalence of CVS in Upper Egypt (Sohag) was 5.08/1000 and it was higher among suburban than rural and urban. Also, prevalence rate was higher among males than females in suburban areas, while the reverse was found in rural and urban areas. Prevalence of TIAs was 0.36/1000. Incidence rate of CVS in Upper Egypt during 1992 was 1.8/1000 and it was higher among rural and suburban than urban population. Also, incidence of stroke was higher among males than females in all studied areas except rural areas where the reverse was observed. Incidence of TIAs was 0.2/1000. Cerebrovascular stroke was the most frequent one (58.5%) among all neurological disorders admitted to neurology Department, Assiut University Hospital during one year (2003). Case fatality rate of stroke patients admitted to neurology department, Assiut University Hospital during one year (2003) was 26.8% (25.4% for ischemic stroke patients and 30.0% for hemorrhagic stroke patients). REEFRENCES 1. Hatano, S (1976): Experience from a multicenter stroke register: Apreliminary report. Bull WHO 54: Goldstein, M.; Sartorius N.; Vereschchagin, N. (1989): Special report from the World Health Organization. Recommendations on Stroke Prevention, Diagnosis and Therapy. Stroke 20 (10): Toole, J.F. (1990): Cerebrovascular disorders. Raven Press, New Yourk. 4. Aho, K.; Reunanen, A.; Aruma, A.; Knekt, P. and Maatela, J. (1986): Prevalence of stroke in Finlane. Stroke 17 (4): Reunanen, A.; Aho, K.; Aromaa, A. and Knekt, P. (1986): Incidence of stroke in a Finnish prospective population study. Stroke 17 (4): Bertus N., Resnizky S. (2003). Care of acute stroke patients in general hospitals in Israel. Isr Med. Assoc. May; 5(5): Sarti C., Rastenyte D., Cepaitis Z., Tuomilehto J. (2000): International trends in mortality from stroke, 1968 to Stroke. 31: Sudlow CLM., Warlow CP. (1996): Comparing stroke incidence worldwide. What makes studies comparable? Stroke, 27: Bonita R., Broad JB., Anderson NE., Beaglehole R., (1995):Approaches to the problems of measuring the incidence of stroke: The Auckland stroke study, Int. J. Epidemial, 24: Feigin VL., Lawes CM., Bennett DA., Anderson CS. (2003): Stroke epidemiology: a review of population-based studies of incidence, prevalence and case-fatality in the late 20 th century. Lancet Neurol.; 2: CAPMAS (1992): Central Agency of Mobilization of Population and Statistics. 12. Robinson, M.K. and Toole, J.F. (1992): Ischemic cerebrovascular disease. Ch. 15, V2, Clinical Neurology, Joynt, R.J., Revised ed., J.P. Lippincott Company, Philadelphia. 13. Sorensen, P.E.; Boysen, G. and Schnohr, P. (1982): Prevalence of stroke in a district of Copenhagen. The Copenhagen City Heart Study. Acta Neurol. Scand. 66: Koul, R.; Motta, A.; Razdan, S. (1990): Epidemiology of young stroke in Kashmir, India. Acta Neurol. Scand 82 (1): Chrislie, D. (1981): Prevalence of stroke and its sequelae. Med. J ust. 2: Jerntorp, P.; Berglund, G. (1992): Stroke registry in Malmo, Sweden. Stroke 23 (3):

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10 Egypt J. Neurol. Psychiat. Neurosurg. Vol. 43 (2) - July 2006 وبائيات انسكتة انمخية فى مصر انعهيا )سوهاج( نمط انسكتة اندماغية ومعدل انوفيات فى مرضى انقسم انداخهى بمستشفى أسيوط انجامعى :1 0.85: