Epidemiology of nonfatal stroke and transient ischemic attack in Al-Kharga District, New Valley, Egypt

Mediatory role of the serum mineral level and discharge disability of stroke survivors

Background

Possible association between minerals contributing and mortality related to stroke were seen, but prospective data on the relation of vitamin D, magnesium and calcium serum levels with stroke were inconsistent. Consideration about the potential health effects of minerals and nutrients, the current study was conducted.

Methods

This analytical cross-sectional study was conducted on 216 stroke survivors who were referred to the Ayatollah Rouhani Hospital of Babol, Iran. Demographic characteristics, clinical variables, and serum mineral levels were completed in the checklist. Admit score and discharge scale of these patients were determined according to the National Institute of Health Stroke Scale. A path model was constructed to explore the interrelationship between variables and to verify the relationship between variables and disability discharges.

Results

Of 216 stroke patients, 185 (85.6%) cases were ischemic. The discharge status of 29 (12.9%) cases were severe or expired. The patients with moderate and severe admit scores, hemorrhagic stroke type, diabetes mellitus, hypertension and live in the village significantly had a poor discharge disability scale (all of p<0.05). Of all direct paths, Mg (β=-2.85), and among indirect paths, calcium(β=-3.59) had the highest effect on the discharge scale. Only mg had affected the discharge scale through direct and indirect (β=-2.45) paths and had the greatest reverse effect on the discharge scale (β=-5.30; totally).

Conclusion

Hypomagnesemia and hypocalcemia play a mediatory role in poor outcomes. Especially, hypomagnesemia was the direct parameter for poor outcomes. The independent role of each mineral in this issue is difficult to define and suggested for future study.

Pre- and in-hospital delays in the use of thrombolytic therapy for patients with acute ischemic stroke in rural and urban Egypt

Background

Reducing pre- and in-hospital delays plays an important role in increasing the rate of intravenous thrombolysis (IVT) in patients with acute ischemic stroke. In Egypt, the IVT rate has increased steadily but is still far away from an ideal rate.

Aim

The study aimed to investigate the factors associated with pre- and in-hospital delays of IVT among patients with acute ischemic stroke coming from urban and rural communities.

Methods

This prospective, multicenter, observational cohort study was conducted from January 2018 to January 2019. Patients with acute ischemic stroke, who did not receive IVT, were included in the study. Patients were recruited from three large university stroke centers in Egypt, Assiut (south of Egypt), Tanta (north of Egypt), both serving urban and rural patients, and the University Hospital in Cairo (capital city), only serving an urban community. All participants underwent the National Institutes of Health Stroke Scale and full neurological assessment, urgent laboratory investigations, and computed tomography or magnetic resonance imaging to confirm the stroke diagnosis. The patients were subjected to a structured questionnaire that was designed to determine the parameters and time metrics for the pre- and in-hospital delays among patients from rural and urban regions.

Results

A total of 618 patients were included in the study, of which 364 patients (58.9%) lived in rural regions and 254 (41.1%) in urban regions. General demographic characteristics were similar between both groups. Approximately 73.3% of patients who arrived within the therapeutic time window were urban patients. The time from symptom onset till hospital arrival (onset to door time, ODT) was significantly longer among rural patients (738 ± 690 min) than urban patients (360 ± 342 min). Delayed onset to alarm time (OAT), initial misdiagnosis, and presentation to non-stroke-ready hospitals were the most common causes of pre-hospital delay and were significantly higher in rural patients. For patients arriving within the time window, the most common causes of in-hospital delays were prolonged laboratory investigations and imaging duration.

Conclusion

The limited availability of stroke-ready hospitals in rural Egypt leads to delays in stroke management, with subsequent treatment inequality of rural patients with acute stroke.

Modeling Survival in Patients With Brain Stroke in the Presence of Competing Risks

Objectives

After heart disease, brain stroke (BS) is the second most common cause of death worldwide, underscoring the importance of understanding preventable and treatable risk factors for the outcomes of BS. This study aimed to model the survival of patients with BS in the presence of competing risks.

Methods

This longitudinal study was conducted on 332 patients with a definitive diagnosis of BS. Demographic characteristics and risk factors were collected by a validated checklist. Patients’ mortality status was investigated by telephone follow-up to identify deaths that may be have been caused by stroke or other factors (heart disease, diabetes, high cholesterol, etc.). Data were analyzed by the Lunn-McNeil approach at alpha=0.1.

Results

Older age at diagnosis (59–68 years: adjusted hazard ratio [aHR], 2.19; 90% confidence interval [CI], 1.38 to 3.48; 69–75 years: aHR, 5.04; 90% CI, 3.25 to 7.80; ≥76 years: aHR, 5.30; 90% CI, 3.40 to 8.44), having heart disease (aHR, 1.65; 90% CI, 1.23 to 2.23), oral contraceptive pill use (women only) (aHR, 0.44; 90% CI, 0.24 to 0.78) and ischemic stroke (aHR, 0.52; 90% CI, 0.36 to 0.74) were directly related to death from BS. Older age at diagnosis (59–68 years: aHR, 21.42; 90% CI, 3.52 to 130.39; 75–69 years: aHR, 16.48; 90% CI, 2.75 to 98.69; ≥76 years: aHR, 26.03; 90% CI, 4.06 to 166.93) and rural residence (aHR, 2.30; 90% CI, 1.15 to 4.60) were directly related to death from other causes. Significant risk factors were found for both causes of death.

Conclusions

BS-specific and non-BS-specific mortality had different risk factors. These findings could be utilized to prescribe optimal and specific treatment.

Stroke in Africa: profile, progress, prospects and priorities

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.

The epidemiology of stroke in Africa: A systematic review of existing methods and new approaches

Accurate epidemiological surveillance of the burden of stroke is direly needed to facilitate the development and evaluation of effective interventions in Africa. The authors therefore conducted a systematic review of the methodology of stroke epidemiological studies conducted in Africa from 1970 to 2017 using gold standard criteria obtained from landmark epidemiological publications. Of 1330 articles extracted, only 50 articles were eligible for review grouped under incidence, prevalence, case-fatality, health-related quality of life, and disability-adjusted life-years studies. Because of various challenges, no study fulfilled the criteria for an excellent stroke incidence study. The relatively few stroke epidemiology studies in Africa have significant methodological flaws. Innovative approaches leveraging available information and communication technology infrastructure are recommended to facilitate rigorous epidemiological studies for accurate stroke surveillance in Africa.

Intra-arterial Infusion of Autologous Bone Marrow Mononuclear Stem Cells in Subacute Ischemic Stroke Patients

Introduction

Based on many preclinical and small clinical trials, stem cells can help stroke patient with the possibility of replacing the cells and supporting the remaining cells. The aim of this study was to evaluate the safety and feasibility of bone marrow mononuclear (BMMN) stem cell transplantation in subacute ischemic stroke patients.

Materials and methods

Thirty-nine (n = 39) patients with subacute ischemic cerebral infarct due to large artery occlusion in the middle cerebral artery (MCA) territory were recruited. They were distributed into two groups: first group (n = 21) served as an experimental group, which received intra-arterial (IA) mononuclear stem cells (bone marrow-derived mononuclear cell), while the other group (n = 18) served as a control group. All the patients were evaluated clinically by National Institutes of Health Stroke Scale, modified Rankin Scale, Barthel Index, modified and standardized Arabic version of the Comprehensive Aphasia Test, and radiological for 12 months.

Results

The stem cell-treated group showed better improvement, but it was not significant when compared with the non-treated group. The volume of infarction changes at the end of the study was non-significant between both the groups. There was no, or minimal, adverse reactions in stem cell-treated group.

Conclusion

The study results suggest that autologous BMMN stem cell IA transplantation in subacute MCA ischemic stroke patients is safe with very minimal hazards, but no significant improvement of motor, language disturbance, or infarction volume was detected in stem cell-treated group compared with the non-treated group.

The epidemiology of stroke in the Middle East

Purpose

The purpose of this paper is to review and synthesize data from different countries in the Middle East on stroke and its potential risk factors.

Method

A systematic review of all published stroke articles in the Middle East between 1980 and May 2015 was conducted.

Findings

Sixty-four papers were included in the review. The incidence rate for all strokes ranged between 22.7 and 250 per 100,000 population per year. The prevalence rate for stroke ranged between 508 and 777 per 100,000 population. Among studies reporting gender differences, 75% reported a high male-to-female ratio among stroke patients. The mean age of stroke was within the sixth and the seventh decade. Ischemic stroke was the most reported type followed by intracerebral hemorrhage and subarachnoid hemorrhage. Hypertension was the most reported risk factor followed by diabetes. The overall case-fatality rate within one month was 12-32%.

Discussion

During the last decades, there was an increase in stroke incidence and mortality rates in the Middle East. The Middle East faces low rates of self-awareness and control of noncommunicable diseases and also lacks knowledge for stroke risk factors, awareness, causes, and symptoms.

Conclusion

There is an urgent need to develop more efficient and accurate methods to measure stroke in the Middle East. There is also a significant call to increase public awareness and implement interventions on stroke and its risk factors and symptoms to help people understand the negative impact of stroke on quality of life and potentially prevent this disease.

The burden of stroke in Africa: a glance at the present and a glimpse into the future

Objective

Information on the current burden of stroke in Africa is limited. The aim of this review was to comprehensively examine the current and projected burden of stroke in Africa.

Methods

We systematically reviewed the available literature (PubMed and AJOL) from January 1960 and June 2014 on stroke in Africa. Percentage change in age-adjusted stroke incidence, mortality and disability-adjusted life years (DALYs) for African countries between 1990 and 2010 were calculated from the Global Burden of Diseases (GBD) model-derived figures.

Results

Community-based studies revealed an age-standardised annual stroke incidence rate of up to 316 per 100 000 population, and age-standardised prevalence rates of up to 981 per 100 000. Model-based estimates showed significant mean increases in age-standardised stroke incidence. The peculiar factors responsible for the substantial disparities in incidence velocity, ischaemic stroke proportion, mean age and case fatality compared to high-income countries remain unknown.

Conclusions

While the available study data and evidence are limited, the burden of stroke in Africa appears to be increasing.

An estimate of the incidence and prevalence of stroke in Africa: a systematic review and meta-analysis

BACKGROUND

Stroke is increasingly becoming a challenging public health issue in Africa, and the non-availability of data has limited research output and consequently the response to this burden. This study aimed to estimate the incidence and prevalence of stroke in Africa in 2009 towards improved policy response and management of the disease in the region.

METHODS

A systematic search of Medline, EMBASE and Global Health for original population-based or hospital-based studies on stroke was conducted. A random effect meta-analysis was conducted on crude stroke incidence and prevalence rates, and a meta-regression-like epidemiological model was applied on all data points. The fitted curve generated from the model was used to estimate incident cases of stroke and number of stroke survivors in Africa at midpoints of the United Nation population 5-year age groups for the year 2009.

RESULTS

The literature search yielded a total of 1227 studies. 19 studies from 10 African countries were selected. 483 thousand new stroke cases among people aged 15 years or more were estimated in Africa in 2009, equivalent to 81.2 (13.2-94.9)/100,000 person years. A total of 1.89 million stroke survivors among people aged 15 years or more were estimated in Africa in 2009, with a prevalence of 317.3 (314.0-748.2)/100,000 population. Comparable figures for the year 2013 based on the same rates would amount to 535 thousand (87.0-625.3) new stroke cases and 2.09 million (2.06-4.93) stroke survivors, suggesting an increase of 10.8% and 9.6% of incident stroke cases and stroke survivors respectively, attributable to population growth and ageing between 2009 and 2013.

CONCLUSION

The findings of this review suggest the burden of stroke in Africa is high and still increasing. There is need for more research on stroke and other vascular risk factors towards instituting appropriate policy, and effective preventive and management measures.