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Incidence and pattern of stroke among patients admitted to medical ward at Yirgalem General Hospital, Sidama Regional State, Southern-Ethiopia

Introduction: In the current days, stroke has become one of the common reasons for admission in many health care setups and becoming an alarming public health problem in Ethiopia. Hence, this study aimed to assess the incidence and associated factors of stroke among patients admitted to the medical wards in Yirgalem hospital. Methods: An institution-based retrospective cross-sectional study design was carried out from 01 January 2017, to 30 December 2019. Admitted adult patients’ medical charts were used to collect all required information using structured checklists. Data were analyzed using statistical package for social sciences (SPSS) version 20 software, and a p value < 0.05 was accepted as statistically significant. Result: From a total of 3016 admitted patients, the incidence of stroke was 3.15% (n = 95). Of the 95 stroke cases, 58.9% were males and 69.5% of them were urban dwellers. 62.1% (59/95) of the stroke patients had an ischemic stroke, whereas 37.9% (36/95) had a hemorrhagic stroke. Patients with age ⩾ 65 years, smokers, hypertension, and type-II diabetes had significantly higher ischemic stroke when compared to patients with hemorrhagic stroke (62.7% vs 30.5%, p = 0.008), (49.1% vs 11.1%, p ⩽ 0.0001), and (71.2%vs 13.9%, p < 0.0001), respectively. While patients with hypertension had a significantly higher rate of hemorrhagic stroke when compared to patients with ischemic stroke (88.9% vs 61%, p = 0.003). Conclusion: The majority of stroke patients had cardiovascular problems and hypertension. More than 44% and 34.7% of them had a history of alcoholism and smoking. Therefore, proper management of hypertension, lifestyle modification, early screening and management of strok risks and avoiding risk-full personal behaviors like smoking and alcoholism are important tools to limit or prevent stroke-related morbidity and mortality.


Introduction
Stroke ranks as the third leading cause of death in the world, with 5.8 million deaths annually. It is now being documented as a significant reason for deaths in Sub-Saharan Africa (SSA). 1 The global incidence of stroke is estimated to be approximately 15 million new stroke cases per year, of these, two-thirds of which happen in low-to middle-income countries, 2,3 and it is highly fatal in SSA countries which indicated that 85% of death due to stroke occurred in SSA. 3,4 It causes mortality, morbidity, and disability, and the situation is currently increasing in the world. 5,6 According to the classification of the American Heart Association report, stroke can be subtype into ischemic and hemorrhagic and their occurrence rate is about 87% and 13%, respectively. The ischemic type of stroke fatality rate was less than the hemorrhagic type of stroke. 7 The trend of stroke incidence showed a 40% reduction especially in developed countries; however, it increased abruptly in areas of developing countries. 8,9 According to the 2014 World Health Organization (WHO) report, 28,320 peoples died in Ethiopia due to stroke, which accounts for 4.71% of the total deaths. 10 Currently almost 24% of all neurological related admissions in the hospitals of Ethiopia are due to the problem of stroke. 11,12 The risk factors of stroke are classified as either modifiable or non-modifiable. Age, sex, family history, and race/ethnicity are categorized under the group of non-modifiable risk factors; while hypertension, smoking, diet, and sedentary lifestyle are some of the recognized modifiable risk factors. 13,14 In addition, the knowledge gap leads to low compliance in making use of preventive programs. 15,16 Moreover, stroke has nowadays become one of the commonest reasons for admission in many health care setups and an alarming serious public health problem in Ethiopia. 17,18 Ischemic stroke has been identified as the sixth leading cause of death in Ethiopia. 19 Assessment of epidemiology, pattern, risk factors, and the clinical presentation of stroke is still compulsory to get more information about stroke occurring in Ethiopia, but they are not known well yet, especially stroke in south Ethiopia. Therefore, this study aimed to assess the incidence and pattern of stroke among patients admitted to the medical ward at Yirgalem General Hospital.

Study setting, design, and study population
The study was conducted in Yirgalem General Hospital, Sidama Regional State, which is about 315 km from Addis Ababa, the capital city of Ethiopia. The hospital serving more than 4.3 million population in the catchment area and nearby zones of the Oromia region and Gedeo zone population. The hospital has the following departments: Medical, Surgical, Pediatrics, and Gynecology/Obstetric wards. Besides, the hospital has special care units like the Medical Intensive Care Unit, Neonatal Intensive Care Unit, and surgical recovery Room and clinics like Eye, Antiretroviral Therapy, Dental, TB, and MDR-TB clinics. Currently, it has 251 functional beds, and 180 health care workers (specialists, dentists, general practitioners, health officers, laboratory technicians and technologists, nurses, and other discipline staff). It provides health services at both inpatient and out-patient levels. An institution-based retrospective cross-sectional study design was carried out among 3016 adult patients who were admitted to medical wards in the hospital from 01 January 2017 to 30 December 2019. Concerning the provision of healthcare service: patients get the healthcare service with a charge of pocket money, while the hospital provides payment-free healthcare service only for patients who obtain an official confirmation letter from their residence administrative office to be free of health care service charge due to low economic status and or other issues. The imaging diagnostics like X-ray, ultrasonography, echocardiography, and electrocardiogram (ECG) are available in the hospital, while there are no computed tomography (CT) scan and magnetic resonance imaging (MRI) diagnostic services. If patients requested diagnostic imaging like CT scan and MRI, they travel about 35 km (to Hawassa city) to get the diagnostic service in the private and or government institution. All adult patients who were admitted to the medical ward were the source of the study population. Moreover, populations from nearby zones of Oromia and Gedeo zone also receive healthcare service from this hospital in addition to Sidama populations ( Figure 1).

Data collection and assessments
Data on socio-demographic variables such as age, sex, clinical data like stroke, diabetes mellitus (DM), hypertension, cardiovascular diseases, dyslipidemia, and lifestyle and behavioral information such as alcohol intake and smoking were collected from medical records/charts of the admitted patients using structured checklists.

Operational terms
Stroke: an episode of acute neurological dysfunction presumed to be caused by ischemia or hemorrhage, persisting ⩾24 h or until death, but without sufficient evidence to be classified as one of the above. 20 Ischemic stroke: An episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction. 20 Hemorrhagic stroke: A stroke that happens when an artery in the brain leaks blood or ruptures (breaks open). The leaked blood puts too much pressure on brain cells, which damages them.
Hypertension: Patients were previously diagnosed and receiving antihypertensive medication or diagnosed with hypertension that indicated blood pressure of ⩾140/90 mm/Hg. Dyslipidemia: Patients using lipid-lowering medication or previously diagnosed and had hyperlipidemia (total cholesterol ⩾200 mg/dL, low-density lipopolysaccharide (LDL) cholesterol ⩾1030 mg/dL, and high-density lipopolysaccharide (HDL) cholesterol <40 mg/dL for men or <50 mg/dL for women, and or serum triglyceride ⩾150 mg/dL).
Diabetes mellitus (DM): If the patient was previously on oral hypoglycemic agents/insulin treatment or diagnosed and had DM (fasting blood sugar (FBS) level ⩾ 126 mg/dL or had documented random blood sugar (RBS) level ⩾200 mg/ dL, or glycosylated hemoglobin of ⩾6.5%).

Inclusion and exclusion criteria
All newly registered and admitted patients in the medical wards from 01 January 2017 to 30 December 2019 with age greater than or equal to 18 years old were included in the study. However, those admitted patients whose record was incomplete for the evaluation of stroke pattern and those patients whose medical records absent in the archives room when tracing were not included in this study.

Data analysis
Data were coded and entered into a statistical package for social science (SPSS) version 20 for statistical analysis. Descriptive statistics were used to summarize the features of study participants. In addition, the chi-square test was used to compare categorical variables and a p value <0.05 was accepted as statistically significant. Finally, the results were presented by frequency and percentage using tables.

Results
Out of the total 3016 medical wards admitted patients, 6 records were incomplete for the assessment of stroke pattern and 95 (3.15%) of patients had a stroke, which was diagnosed by physical as well as diagnostic imaging (Echo, ECG, CT scan, and MRI). Of 95 patients with stroke, 56 (58.9%) were males, 39 (41.1%) were females, and 69.5% were urban dwellers ( Table 1).

The pattern of stroke in relation to the study variables
Hemorrhagic stroke was found to have highly prevalent among patients aged between 50 and 56 years (58.3%) and the rate was higher in males when compared to females (61.1% vs 38.9%, respectively). However, 62.7% of the patients with ischemic stroke were aged greater than or equal to 65 years and the rate also was higher in males when compared to females (57.6% vs 42.4%, respectively). The prevalence of HTN was significantly lower among patients with ischemic stroke when compared to patients with hemorrhagic stroke (61% vs 88.9%, p = 0.003), respectively. In addition, patients with ischemic stroke had a higher rate of type-II DM compared to patients with hemorrhagic stroke (71.2% vs 13.9%, p < 0.0001), respectively. HHD was significantly higher among patients with hemorrhagic stroke when compared to patients with ischemic stroke (75% vs 27.1%, p < 0.0001), respectively. Moreover, more than 49% of patients with ischemic stroke, and 11% patients with of hemorrhagic stroke had a history of smoking (Table 3).

Discussion
In this study, the overall incidence of stroke was 3.15% and the rate was lower than the report of different studies conducted in Ethiopia like 19.3%, 21 7.7%, 22 7.5%, 23 and 7.2%. 24 Lack of the diagnostic technology such as MRI or CT scan and manual registration and management system of records in the study hospital might have an association with lower rates of stroke patients. In addition, lack of stroke awareness might lead to a lower consultation rate. Even though patients notice the stroke symptom, they might not go to the hospital or reject admission because of their financial problems. Moreover, majority (58.9%) of the stroke patients were males, and it was similar with the report of different studies. 18,21,23,25 In this study, 71.6% of the stroke patients were comorbid with hypertension. In similar, the study conducted in Southwest Ethiopia indicated that 75.9% of the stroke patients had hypertension. 26 In addition to this, different studies indicated the association between hypertension and stroke. 27 This might reflects the economic burden especially in proper medical follow-up and treatment, and inadequate awareness of hypertension might consequence poor controlling status of the disease. The second comorbid disease with stroke was type-2 diabetes (49.5%). Likewise the pooled prevalence report from  SSA indicated that diabetes and HIV were at a suggestively greater risk of suffering from all stroke types. 28 In this study, the incidence of ischemic stroke was 62.1 % (95% CI: 51.3-71.6), and it was a frequently encountered subtype of stroke. Likewise, several studies reported that ischemic stroke was the dominant subtype of stroke. [21][22][23][24]26,27,[29][30][31][32][33] However, some studies reported that hemorrhagic stroke is the dominant subtype of the stroke in other parts of Ethiopia. 12,25,12 Patients in this study were more likely to have risk factors associated with ischemic stroke and this might be a reason for the variation. In addition, a higher rate of ischemic stroke might relatively affect the lower rate of hemorrhagic stroke.
In this study, patients with ischemic stroke had a significantly high rate of type-II diabetes (71.2%) and the finding was in line with the report of other studies. 24,29,[34][35][36] This might be due to the higher rate of microvascular disease complication and the co-existence of hypertension seen more in diabetes patients.
In this study, 37.9% of the stroke patients had a hemorrhagic stroke. Comparatively, the study conducted in Zambia indicated that 35% of stroke patients had hemorrhagic strokes. 37 However, the higher rate of hemorrhagic stroke was reported in different studies that conducted in Ethiopia like 49.7% at Hawassa, 38 59.2%, 39 and 56% 20 at Tikur Anbessa Teaching Hospital. This variance might be related to patients' hypertension management conditions between the studies. Better hypertension management might be associated with a lower rate of hemorrhagic stroke than other studies.
This study revealed a significantly high rate of HHD (75%) among patients with hemorrhagic stroke, and the majority (88.9%) of patients with hemorrhagic stroke had hypertension. The studies revealed that the most common causes of hemorrhagic stroke are hypertension, bleeding diatheses, amyloid angiopathy, drug misuse, and vascular malformations. 40 Besides, hypertension can damage the arteries and form weak places that rupture easily (aneurysm) which leads to hemorrhagic stroke. 41

Limitations
This study was retrospective by its approach, used secondary data, and focused on documented information from patients' records. This study conducted on institution-based records review, some important information could not be found, and others were incomplete. In addition, a power calculation was not performed to determine sample size instead, all records that contain full information were reviewed based on the study period (from 01 January 2017 to 30 December 2019).

Conclusion
The incidence of stroke among patients who attended Yirgalem general Hospital was lower when compared with the prior studies conducted elsewhere. More than half of stroke patients were males and more than 69% were urban dwellers. In addition, majorities of the stroke patients had cardiovascular problems and hypertension; more than 44% and 34.7% of the patients had a history of alcoholism and smoking. Therefore, proper management of hypertension, lifestyle modification, early screening and management of stroke risks, and avoiding riskful personal behaviors like smoking and alcoholism are important to prevent stroke-related morbidity and mortality.