Heart rate variability and cold-induced vascular dilation after stimulation of two different areas of the ear: a prospective, single-blinded, randomized crossover study

BACKGROUND

Both noninvasive transauricular vagus nerve stimulation (taVNS) and traditional medical practice (TMP), such as auriculotherapy, use the auricle as a starting point for stimulation, but with two different conceptual frameworks: taVNS depends on vagal afferences to account for its effects, whereas TMP requires stimulation of the ear with high topographical accuracy regardless of the afferent nerves. The aim of this study was to measure heart rate variability (HRV) and cold water-induced vasodilation (CIVD) after puncturing two different ear points with the same afference but that should have opposite effects according to TMP.

METHODS

Ten healthy subjects were investigated in this single-blinded crossover study over three sessions. In the first session, sympathetic activation was performed via cold water immersion of the right hand, with recordings taken from multiple fingers. HRV was assessed in the time domain (square root of the mean squared differences of NN intervals (RMSSD)) and frequency domain (low (LF) and high frequencies (HF)). In the second and third sessions, the same skin immersion test was performed, and mechanical stimulation was applied to the ear at two different points on the internal surface of the antitragus, one with alleged parasympathetic activity and the other with alleged sympathetic activity. The stimulation was done with semipermanent needles.

RESULTS

Stimulation of the point with alleged parasympathetic activity immediately resulted in a significant decrease in RMSSD in 75% of the subjects and in LF in 50% of the subjects, while stimulation of the point with alleged sympathetic activity resulted in an increase in HF and RMSSD in 50% of the subjects. Stimulation of these points did not affect the CIVD reflex. The 20 min cold water immersion induced an immediate decrease in LF and the LF/HF ratio and an increase in HF. The skin temperature of the nonimmersed medius significantly decreased when the contralateral hand was immersed, from 34.4 °C to 31.8 °C.

CONCLUSIONS

Stimulation of two different ear points innervated by the same afferent nerves elicited different HRV responses, suggesting somatotopy and a vagal effect beyond vagal afferences. These results are not in accordance with the claims of TMP.

TRIAL REGISTRATION

NCT04130893 (18/10/2019) clinicaltrials.com.

Aurimatrix: Software-as-a-Service Solution for Clinical Work and Research in Auriculotherapy

Objective: Auriculotherapy practitioners need a digital record-keeping method to track their cases that provides different ear maps and methodologies from different schools of auriculotherapy in one place. Materials and Methods: Main requirement were as followed: to be run whatever the platform; to manage different representations of the ear and to allow data analysis from multiple users. Results: Aurimatrix^® is a software-as-a-service solution developed to help the practitioner enter all data pertaining to an auriculotherapy session. Although the software was originally designed for the two schools of French auriculotherapy, this software is highly configurable and can support the use of any ear chart in any language. Moreover, the ear charts are divided in several layers, allowing use of a representation of the ear of one school with the set of auricular points in use in another school. Because the list of medical conditions is limited and the modalities of variables used to evaluate the effectiveness of auriculotherapy are unchangeable, Aurimatrix enables comparison between different sessions, different patients, and different practitioners. Conclusions: Doing so, the software helps pave the way to improve auriculotherapy protocols.

Variations in the TRPV1 gene are associated to exertional heat stroke

OBJECTIVES

Exertional Heat Stroke (EHS) is one of the top three causes of sudden death in athletes. Extrinsic and intrinsic risk factors have been identified but the genetic causes still remain unclear. Our aim was to identify genes responsible for EHS, which is a necessary step to identify patients at risk and prevent crises.

DESIGN

Genetic and functional laboratory studies METHODS: Whole Exome Sequencing (WES) was performed to search for candidate genes in a cohort of 15 soldiers who had a documented EHS episode. In silico and in vitro functional studies were performed to evaluate the effect of mutations identified in the candidate gene TRPV1.

RESULTS

WES led to the identification of two missense variations in the TRPV1 gene. These variations were very rare or unreported in control databases and located in critical domains of the protein. In vitro functional studies revealed that both variations induce a strong modification of the channel response to one of its natural agonist, the capsaicin.

CONCLUSIONS

We evidenced mutations altering channel properties of the TRPV1 gene and demonstrated that TRPV1, which is involved in thermoregulation and nociception, is a new candidate gene for EHS. Our data provide the bases to explore genetic causes and molecular mechanisms governing the pathophysiology of EHS.

How to detect and track chronic neurologic sequelae of COVID-19? Use of auditory brainstem responses and neuroimaging for long-term patient follow-up

This review intends to provide an overview of the current knowledge on neurologic sequelae of COVID-19 and their possible etiology, and, based on available data, proposes possible improvements in current medical care procedures. We conducted a thorough review of the scientific literature on neurologic manifestations of COVID-19, the neuroinvasive propensity of known coronaviruses (CoV) and their possible effects on brain structural and functional integrity. It appears that around one third of COVID-19 patients admitted to intensive care units (ICU) for respiratory difficulties exhibit neurologic symptoms. This may be due to progressive brain damage and dysfunction triggered by severe hypoxia and hypoxemia, heightened inflammation and SARS-CoV-2 dissemination into brain parenchyma, as suggested by current reports and analyses of previous CoV outbreaks. Viral invasion of the brain may particularly target and alter brainstem and thalamic functions and, consequently, result in sensorimotor dysfunctions and psychiatric disorders. Moreover, data collected from other structurally homologous CoV suggest that SARS-CoV-2 infection may lead to brain cell degeneration and demyelination similar to multiple sclerosis (MS). Hence, current evidence warrants further evaluation and long-term follow-up of possible neurologic sequelae in COVID-19 patients. It may be particularly relevant to evaluate brainstem integrity in recovered patients, as it is suspected that this cerebral area may particularly be dysfunctional following SARS-CoV-2 infection. Because CoV infection can potentially lead to chronic neuroinflammation and progressive demyelination, neuroimaging features and signs of MS may also be evaluated in the long term in recovered COVID-19 patients.

Anxiety and Psycho-Physiological Stress Response to Competitive Sport Exercise

Introduction: Sport is recognized as beneficial for health. In certain situation of practice, it nevertheless appears likely to induce a stress response. Anxiety is a stress response-modulating factor. Our objective is to characterize the role of anxiety in the stress response induced by a selective physical exercise.

Method: Sixty-three young male military conducted a selective sporting running event (a 8-km commando-walk) and were recorded the day before, the day of the race, and the day after. The variables were psychometric [personality questionnaires, coping and anxious/stress state, and physiological (nocturnal heart rate variability and actigraphy)]. The subjects were classified, using scores on anxiety questionnaires at baseline, into two groups according to their anxious (G ANX) or non-anxious (G N-ANX).

Results: Before the race, the G ANX was characterized by a lower level of self-esteem, higher scores in dysfunctional coping and a greater perceived stress compared to the G N-ANX. Compared to G N-ANX, the stress response to the exercise was higher in G ANX: G ANX exhibited (Selye, 1950) in immediate post-exercise, greater level in activation markers, and mental fatigue associated with a same level of physical fatigue and (Kim et al., 2018) in nocturnal post-exercise, an increase in sympathetic activation associated with a higher sleep fragmentation.

Conclusion: A competition selection sport exercise causes a stress response, particularly for anxious subjects. Anxious status could be involved in the risk of emergence of overtraining in sport practice. These results must be taken into account when sport practice is used for anxiety management.

Thermoregulatory Response to Exercise After Exertional Heat Stroke

BACKGROUND

After one episode of exertional heat stroke (EHS), risk factors must be identified to determine the potential for subsequent episodes. One of these risk factors, core body temperature (T_co) kinetics during strenuous exercise, may be a surrogate marker suggestive of impaired thermoregulation. This study aimed to determine the kinetics of increases in T_co among military subjects who had a history of EHS.

METHODS

Forty subjects (38 males, mean age 28.4 ± 4.9 years, mean body mass index 24.9 ± 2.4) who had a history of EHS ran 8 km in full combat gear with continuous monitoring of T_co and heart rate. The run was a qualifying event for military service. T_co was assessed using an ingestible sensor (Cortemp HQ Inc., Palmetto, Florida). Maximum oxygen uptake (VO_2max) was measured on the day before the run.

FINDINGS

The mean performance time for the run was 44.6 ± 6.6 minutes achieved under mild climatic conditions. No neurological impairment was observed. The mean maximum T_co was 39.9 ± 0.5°C. On the basis of T_co during the last 10 minutes of running, two T_co profiles were identified: increased T_co (T_co increase > 0.5°C) and plateaued T_co. Neither profile depended on initial, mid-run, or maximal T_co, VO_2max, speed running, body surface area or body fat mass.

DISCUSSION

Subjects who had a history of EHS exhibited different T_co profiles at the end of an 8-km run. Laboratory studies will be necessary to identify the mechanisms underlying these profiles; future longitudinal studies can determine whether a T_co increase >0.5°C during the last 10 minutes is a risk factor for EHS recurrence.

Occupational Exposures to Ebola Virus in Ebola Treatment Center, Conakry, Guinea

We report 77 cases of occupational exposures for 57 healthcare workers at the Ebola Treatment Center in Conakry, Guinea, during the Ebola virus disease outbreak in 2014−2015. Despite the high incidence of 3.5 occupational exposures/healthcare worker/year, only 18% of workers were at high risk for transmission, and no infections occurred.

Round Table on Malignant Hyperthermia in Physically Active Populations: Meeting Proceedings

CONTEXT

  Recent case reports on malignant hyperthermia (MH)-like syndrome in physically active populations indicate potential associations among MH, exertional heat stroke (EHS), and exertional rhabdomyolysis (ER). However, an expert consensus for clinicians working with these populations is lacking.

OBJECTIVE

  To provide current expert consensus on the (1) definition of MH; (2) history, etiology, and pathophysiology of MH; (3) epidemiology of MH; (4) association of MH with EHS and ER; (5) identification of an MH-like syndrome; (6) recommendations for acute management of an MH-like syndrome; (7) special considerations for physically active populations; and (8) future directions for research.

SETTING

  An interassociation task force was formed by experts in athletic training, exercise science, anesthesiology, and emergency medicine. The "Round Table on Malignant Hyperthermia in Physically Active Populations" was convened at the University of Connecticut, Storrs, September 17-18, 2015.

CONCLUSIONS

  Clinicians should consider an MH-like syndrome when a diagnosis of EHS or ER cannot be fully explained by clinical signs and symptoms presented by a patient or when recurrent episodes of EHS or ER (or both) are unexplained. Further research is required to elucidate the genetic and pathophysiological links among MH, EHS, and ER.

Moderate Thermal Strain in Healthcare Workers Wearing Personal Protective Equipment During Treatment and Care Activities in the Context of the 2014 Ebola Virus Disease Outbreak

The extent of thermal strain while wearing personal protective equipment (PPE) during care activities for Ebola virus disease patients has not yet been characterized. From January to March 2015, 25 French healthcare workers (HCWs) in Conakry, Guinea, volunteered to be monitored while wearing PPE using an ingestible thermal sensor. The mean (standard deviation) working ambient temperature and relative humidity were 29.6 °C (2.0 °C) and 65.4% (10.3%), respectively; the mean time wearing PPE was 65.7 (13.5) minutes; and the mean core body temperature increased by 0.46 °C (0.20 °C). Four HCWs reached or exceeded a mean core body temperature of ≥ 38.5 °C. HCWs wearing PPE for approximately 1 hour exhibited moderate but safe thermal strain.

Rhabdomyolysis in Ebola Virus Disease. Results of an Observational Study in a Treatment Center in Guinea

BACKGROUND

The pathogenesis of Ebola virus disease (EVD) remains unclear. The sporadic nature of Ebola outbreaks and their occurrence in resource-limited settings have precluded the acquisition of extensive clinical and laboratory data. Rhabdomyolysis during EVD has been suggested to occur in previous studies showing increased aspartate aminotransferase-alanine aminotransferase ratios, but, to date, has not been confirmed with creatine kinase (CK) assays.

METHODS

We performed an observational study of 38 patients admitted to an Ebola treatment center from January to April 2015. CK values from patients with confirmed EVD were compared with those in patients without confirmed EVD. A panel of other analyses were also performed. In patients with EVD, characteristics were compared between survivors and nonsurvivors.

RESULTS

High levels of CK were more frequent in patients with EVD than in those without (P = .002), and rhabdomyolysis was more frequent (59% vs 19%, respectively; P = .03). CK levels >5000 U/L were observed in 36% of patients with EVD. Also in patients with EVD, fatal outcome was significantly associated with higher creatinine and bilirubin levels, international normalized ratio, and viral load.

CONCLUSIONS

Rhabdomyolysis is a frequent disorder in EVD and seems to be more common than in other viral infections. It may contribute to the renal failure observed in nonsurviving patients. More studies are needed to determine the impact of rhabdomyolysis on EVD outcome.

Is there a link between exertional heat stroke and susceptibility to malignant hyperthermia?

Objective

The identification of a predisposition toward malignant hyperthermia (MH) as a risk factor for exertional heat stroke (EHS) remains a matter of debate. Such a predisposition indicates a causal role for MH susceptibility (MHS) after EHS in certain national recommendations and has led to the use of an in vitro contracture test (IVCT) to identify the MHS trait in selected or unselected EHS patients. The aim of this study was to determine whether the MHS trait is associated with EHS.

Methods

EHS subjects in the French Armed Forces were routinely examined for MHS after experiencing an EHS episode. This retrospective study compared the features of IVCT-diagnosed MHS (iMHS) EHS subjects with those of MH-normal EHS patients and MH patients during the 2004–2010 period. MHS status was assessed using the European protocol.

Results

During the study period, 466 subjects (median age 25 years; 31 women) underwent MHS status investigation following an EHS episode. None of the subjects reported previous MH events. An IVCT was performed in 454 cases and was diagnostic of MHS in 45.6% of the study population, of MH susceptibility to halothane in 18.5%, of MH susceptibility to caffeine in 9.9%, and of MH susceptibility to halothane and caffeine in 17.2%. There were no differences in the clinical features, biological features or outcomes of iMHS EHS subjects compared with those of MH-normal or caffeine or halothane MHS subjects without known prior EHS episode. The recurrence rate was 12.7% and was not associated with MH status or any clinical or biological features. iMHS EHS patients exhibited a significantly less informative IVCT response than MH patients.

Conclusions

The unexpected high prevalence of the MHS trait after EHS suggested a latent disturbance of calcium homeostasis that accounted for the positive IVCT results. This study did not determine whether EHS patients have an increased risk of MH, and it could not determine whether MH susceptibility is a risk factor for EHS.

[Unexplicated neuropsychiatric disorders: Do not ignore dysimmune encephalitis. A case report of a dysimmune encephalitis with anti-leucine rich glioma inactivated 1 (LGI-1) antibodies]

INTRODUCTION

Anti-leucine rich glioma inactivated 1 encephalitis is a common and a treatable etiology of autoimmune encephalitis. Its diagnosis is a challenge because the initial diagnostic work-up is often normal.

CASE REPORT

A 48-year-old man experienced cognitive and behavioral troubles, facio-brachial dystonic seizures and a syndrome of inappropriate antidiuretic hormone secretion. First line tests excluded infectious, neoplastic, systemic inflammatory, endrocrine or toxic etiologies. Cerebral (18)Fluoro-desoxy-glucose (FDG) position emission tomography and research of specific antibodies in cerebro-spinal fluid and serum led to diagnose an anti-leucine rich glioma inactivated 1 encephalitis. Intravenous immunoglobulins and corticosteroids were partially effective. Cyclophosphamid permitted a good recovery.

CONCLUSION

In the presence of acute neuropsychiatric disorders with a negative etiologic research, physician should think about dysimmune encephalitis. Facio-brachial dystonic seizures and syndrome of inappropriate antidiuretic hormone secretion are highly evocative of anti-leucine rich glioma inactivated 1 encephalitis. The diagnosis needs specific diagnostic tests (cerebral (18)FDG position emission tomography and antibodies research in cerebro-spinal fluid and in serum), after the exclusion of alternative diagnoses. Extensive and repeated diagnostic work-up for neoplasia is required. Immunosupressive therapies are effective in most cases.

Is muscle energy production disturbed in exertional heat stroke?

BACKGROUND

Exertional heat stroke (EHS) is a life-threatening disease that shares some clinical similarities with malignant hyperthermia (MH). By use of (31)Phosphorus magnetic resonance spectroscopy (MRS), EHS patients with MH susceptibility and MH patients shared common metabolic abnormalities. The aim of this study was to determine whether subjects who suffered from an EHS episode had disturbed muscle energetics.

METHOD

This retrospective study was performed within the French database of military subjects that were explored from 2004 to 2010 after they suffered an EHS. All subjects had both in vitro contracture test to determine their MH susceptibility and (31)Phosphorus MRS at 4.7 Tesla to assess muscle energetics by means of MRS score, a composite score corresponding to the sum of metabolic abnormalities recorded during a standardized rest-exercise-recovery protocol.

RESULTS

437 subjects were investigated and 32.5% of them exhibited abnormal MRS score. MRS score did not segregate subjects on demographic, clinical, or biological grounds. No clear correlation could be done between MH status and MRS score.

DISCUSSION

These results did not confirm the potential relationship between calcium homeostasis and muscle energetics previously reported. However, muscle energy production was disturbed in a significant number of EHS subjects.

Is critical illness polyneuropathy associated with decreased heart rate variability?

INTRODUCTION

This pilot study assessed the association between critical illness polyneuropathy (CIP) and decreased heart rate variability (HRV) in intensive care patients.

METHODS

All patients admitted to the intensive care unit and expected to be ventilated for at least 72 hours were included and underwent weekly electromyograms and HRV analyses for three weeks. HRV was assessed by time domain analysis of 24h recording electrocardiograms, and alterations in HRV were assessed as the square root of the mean squared differences of successive RR intervals (RMSSD) ≤ 15.

RESULTS

We evaluated 26 patients, 12 men and 14 women, median age 64 years. During follow-up, 12 patients died and 9 developed CIP. CIP was not associated with age, sex, simplified acute physiology score II and treatment agents. Altered RMSSD tended to be associated with onset of CIP (P=0.06). Altered RMSSD occurred earlier or at the same time as electromyogram abnormalities in all CIP patients, but the difference was not significant.

CONCLUSION

Altered HRV, may be associated with the onset of CIP in ICU patients. Although not statistically significant (P=0.06), altered RMSSD may be a surrogate marker of CIP in ICU patients undergoing mechanical ventilation. The physiological pathway linking HRV and CIP remains uncertain.

A 78-year-old woman with an acute eosinophilic gastroenteritis

Eosinophil accumulation in the gastrointestinal tract is a common feature of numerous disorders including mainly parasitic infection, drug-induced allergic reactions, inflammatory bowel disease, and various connective tissue disorders. Digestive tissue eosinophilia requires thorough searching for secondary causes that may be specifically treated with antibiotics, dietary and drug elimination or immunosuppressive therapy. Frequency, prognosis and therapeutic implications must guide the diagnostic course. An acute eosinophilic gastroenteritis in a 78-year-old asthmatic woman receiving celecoxib is reported. She presented later with neurologic and cutaneous features and was finally treated by methylprednisolone and cyclophosphamide. The diagnostic approach leading to a Churg-Strauss syndrome (CSS) assertion is described. We discuss the pathogenesis, the management and the potential enhancing role of celecoxib in CSS gastrointestinal involvement.

Determinants of compliance with anti-vectorial protective measures among non-immune travellers during missions to tropical Africa

BACKGROUND

The effectiveness of anti-vectorial malaria protective measures in travellers and expatriates is hampered by incorrect compliance. The objective of the present study was to identify the determinants of compliance with anti-vectorial protective measures (AVPMs) in this population that is particularly at risk because of their lack of immunity.

METHODS

Compliance with wearing long clothing, sleeping under insecticide-impregnated bed nets (IIBNs) and using insect repellent was estimated and analysed by questionnaires administered to 2,205 French military travellers from 20 groups before and after short-term missions (approximately four months) in six tropical African countries (Senegal, Ivory Coast, Chad, Central African Republic, Gabon and Djibouti). For each AVPM, the association of "correct compliance" with individual and collective variables was investigated using random-effect mixed logistic regression models to take into account the clustered design of the study.

RESULTS

The correct compliance rates were 48.6%, 50.6% and 18.5% for wearing long clothing, sleeping under bed nets and using repellents, respectively. Depending on the AVPM, correct compliance was significantly associated with the following factors: country, older than 24 years of age, management responsibilities, the perception of a personal malaria risk greater than that of other travellers, the occurrence of life events, early bedtime (i.e., before midnight), the type of stay (field operation compared to training), the absence of medical history of malaria, the absence of previous travel in malaria-endemic areas and the absence of tobacco consumption.There was no competition between compliance with the different AVPMs or between compliance with any AVPM and malaria chemoprophylaxis.

CONCLUSION

Interventions aimed at improving compliance with AVPMs should target young people without management responsibilities who are scheduled for non-operational activities in countries with high risk of clinical malaria. Weak associations between compliance and history of clinical malaria or variables that pertain to threat perception suggest that cognition-based interventions referencing a "bad experience" with clinical malaria could have only a slight impact on the improvement of compliance. Further studies should focus on the cognitive and behavioural predictors of compliance with AVPMs.

A woman with forearm amyotrophy

We present the case of a 33-year-old woman with benign sporadic monomelic amyotrophy of the distal part of the arm, called Hirayama disease. Clinical features included forearm amyotrophy sparing the brachioradialis muscle, cold paresis and causalgia. Neck magnetic resonance imaging was normal in neutral and flexion position. Electromyography showed denervated patterns in the extensor digitorum communis, and conduction studies ruled out multifocal motor neuropathy. Motor evoked potentials were normal. Serum IgG anti-GM1 antibodies were moderately raised but were negative 8 months later. Outcome was favourable within 15 months, with partial motor recovery. Pathogenesis remains controversial: neck flexion induced myelopathy via chronic anterior horn ischaemia due to forward displacement of the posterior wall of the dura mater, or benign variant of lower motor neuron disease? Whatever the pathomechanism is, the clinical features and outcome are the same.

[Hemiparesia with cutaneous and mucosal ulcerations in a black-skinned man]

The purpose of this report is to describe the case of a 46-year-old Comorian man in whom presentation with right hemiparesia with buccal and genital ulcerations lead to diagnosis of Behçet's disease. The most remarkable aspect of this case is the patient's ethnic group since Behçet's disease is less frequent in Africans than Caucasians. The most likely explanation for this difference is the absence of genetic susceptibility linked to HLAB51 that is rare in Africans. However lack of awareness of Behçet's disease and changes in environmental triggers in Africa cannot be ruled out.

[Wernicke encephalopathy after subtotal gastrectomy for morbid obesity]

Wernicke's encephalopathy (WE) is one of the potential complications of obesity surgery. It is an acute neuropsychiatric syndrome resulting from thiamine deficiency often associated with repeated vomiting. The classic triad is frequently reported in these patients (optic neuropathy, ataxia and confusion), associated with uncommon features. Cerebral impairment affects the dorsal medial nucleus of the thalamus and the periaqueductal grey area, appearing on MRI, as hyperintense signals on T2, Flair and Diffusion weighted imaging. Early diagnosis and parenteral thiamine are required to decrease morbidity and mortality. We report a case of WE and Korsakoff's syndrome in a young obese patient after subtotal gastrectomy, who still has substantial sequelae. The contribution of MRI with diffusion-weighted imaging is illustrated. The interest of nutritional supervision in the first weeks and preventive thiamine supplementation in case of repeated vomiting are of particular importance in these risky situations.

[Stroke in sub-Saharan Africa]

Stroke is the second cause of mortality worldwide and 87% of deaths are recorded in developing countries. Due to biases in most studies, the prevalence and incidence of stroke in sub-Saharan Africa remains unclear. In comparison with industrialized countries, sub-Saharan countries present several differences, i.e., higher mortality rate, younger age at onset, and hypertension as the main risk factor for stroke. Conversely the distribution of ischemic and hemorrhagic stroke in developing countries appears to be the same as in industrialized countries. Without appropriate public health policies, the coming years are likely to witness an epidemic of non-communicable diseases in sub-Saharan Africa and stroke will probably become the second most common cause of morbidity and mortality.

Ischemic and Hemorrhagic Strokes in Dakar, Senegal

Background and Purpose— Basic stroke features are hardly known in sub-Saharan countries, and no data are available in Senegal.

Methods— We performed a retrospective hospital-based study in Dakar, Senegal, to assess risk factors and etiology of stroke. Patients were recruited from January 1, 2003, to July 31, 2004, at the Hôpital Principal, Dakar. Strokes had to be ascertained by computed tomography.

Results— A total of 107 patients were studied. Seventy percent of strokes were of ischemic nature. For ischemic strokes, mean age was 64.2 years. Hypertension was the main risk factor, occurring in 68%, and diabetes was encountered in 37.3%. Lacunar strokes and cardioembolism accounted for 20% and 13.3%, respectively. Because of the lack of systematic investigations, two thirds of strokes were of undetermined origin. Mortality within 1 month was 38%. For hemorrhagic strokes, mean age was 51 years and 1 month mortality was 56%.

Conclusion— Hypertension is the main risk factor for both ischemic and hemorrhagic strokes in this hospital-based study.