|Year : 2021 | Volume
| Issue : 1 | Page : 24-30
Computed tomographic pattern of stroke among hypertensive and diabetic patients in Kano, Nigeria
Mansur Yahuza Adamu1, Naimatu A T Abdullahi2, Kabiru Isyaku1, SK Idris1, Yusuf Lawal1
1 Department of Radiology, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Radiology, Federal Medical Center, Katsina, Nigeria
|Date of Submission||18-Jan-2021|
|Date of Decision||11-Apr-2021|
|Date of Acceptance||11-Apr-2020|
|Date of Web Publication||22-Jun-2021|
Mansur Yahuza Adamu
Department of Radiology, Bayero University/Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Background: Stroke accounts for a significant proportion of neurological disorders and carries a high morbidity and mortality. Hypertension and diabetes mellitus are the major risk factors for stroke in Nigeria. Aims and Objectives: The need to determine the pattern of radiologic changes of stroke in patients with hypertension or diabetes mellitus on computed tomography scan (CT) of the brain. Materials and Methods: A prospective study using CT of the brain of 104 adult patients with stoke per group was carried out. Results were analyzed using (SPSS) version 16.0 software. Proportion of pattern of stroke in each group was analyzed and possible association between the socio-demographic factors was determined. Results: 104 diabetic patients (67 males and 37 females) and 104 hypertensive patients (68 males and 36 females) were studied. Their ages ranged from 30-90 years. Most of the patients had thrombotic stroke with the diabetic having a higher proportion (92.3%) than their hypertensive counterparts (66.3%). The parietal lobe is most affected part with (58.7%) in hypertensive's and 44.2% of the diabetics. The left side of the brain was most affected in more than 50% of both the hypertensive and diabetic stroke patients. Conclusion: Ischaemic stroke was equally prevalent in both diabetic and hypertensive patients while haemorrhagic stroke was more common among hypertensive patients. The parietal lobe and the left side of the brain were the more frequent area of predilection in both groups.
Keywords: Computed tomography, diabetes, hypertension, stroke
|How to cite this article:|
Adamu MY, T Abdullahi NA, Isyaku K, Idris S K, Lawal Y. Computed tomographic pattern of stroke among hypertensive and diabetic patients in Kano, Nigeria. J Radiat Med Trop 2021;2:24-30
|How to cite this URL:|
Adamu MY, T Abdullahi NA, Isyaku K, Idris S K, Lawal Y. Computed tomographic pattern of stroke among hypertensive and diabetic patients in Kano, Nigeria. J Radiat Med Trop [serial online] 2021 [cited 2022 Jan 24];2:24-30. Available from: http://www.jrmt.org/text.asp?2021/2/1/24/319108
| Introduction|| |
A stroke is a rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain. This can be due to ischemia caused by thrombosis or embolism or due to hemorrhage. In the past stroke was referred to as cerebrovascular accident but the term “stroke” is now preferred. The 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.
A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. It is the leading cause of neurological disability in adults and cause of death worldwide second only to ischemic heart disease.,, Studies carried out in 2005 revealed an estimated 16 million first time stroke patients and 5.7 million stroke deaths, accounting for nearly 10% of all deaths worldwide.,, In Africa, stroke accounts for 0.9% to 4% of all hospital admissions and 2.8% to 4.5% of total deaths. The incidence of stroke in Africa is on the increase.,,, In Africa, access to safe and effective blood pressure control medication is limited; consequently, mortality, case fatality, and morbidity remain high., In Nigeria, stroke is a major cause of neurological admission and its incidence may be on the increase., The extended hospitalization required in survivors with subsequent inability of many to return to work is a great burden on their family and the community.
Risk factors for stroke include advanced age, hypertension (high blood pressure), previous stroke or transient ischemic attack, diabetes, hypercholesterolemia, cigarette smoking, atrial fibrillation, excess alcohol consumption, polycythemia, and oral contraceptives.,,, Hypertension is the most common important modifiable risk factor. The major risk factors in Nigerians are hypertension, diabetes, and hyperlipidemia. Compared with nondiabetic patients, diabetic patients have at least twice the risk for stroke, earlier onset of symptoms, and worse functional outcomes. Approximately 20% of diabetic patients will die from stroke, making it one of the leading causes of death.
Stroke manifests with hemiparesis, headache, dysphasia or aphasia, and cranial nerve dysfunction (the most common nerve affected is facial nerve). Point for special attention on examination includes blood pressure, heart rhythm, murmurs, peripheral pulses and bruits, jugular venous pressure, respiratory and urinary tract infections, bedsores, urinary retention, and retinal changes. If arterial blood flow is obstructed or impaired at any point within the vascular route, portions of the brain relying on the occluded vessel for oxygenated blood become deprived of oxygen thus initiating a cascade of mechanisms that result in brain tissue ischemia and eventually infarction.
Hypertension causes increase in vascular rigidity and increase pressure causing vascular rupture thus leading to hemorrhagic stroke. Diabetes mellitus is associated with atheromatous changes and microaneurysms in the vessel walls thus predisposing to both dislodgement of plaque and rupture of vessel wall leading to either thrombotic or hemorrhagic. Previous reports have shown that patients with diabetes are more prone to ischemic than hemorrhagic stroke, while hemorrhagic stroke is seen more common in hypertensive than diabetic patients.
Noncontrast computed tomography (CT) remains the first-line investigation for patients alleged to have a stroke. This is because of its ability to differentiate between ischemic and hemorrhagic stroke as well as its easy accessibility. Functional imaging like CT-perfusion and CT-angiography can also be performed in some settings. Magnetic resonance imaging (MRI) is currently not widely available for the imaging of acute stroke in the developing countries. Cerebral infarction is the most common type of stroke seen occurring in 48% of patients while intracerebral hemorrhage occurs in 15.7% and subarachnoid hemorrhage in 11.3% of patients.,
The mortality and severity of stroke are on the decline in developed countries because of lifestyle modification, use of increased preventive measures such as adequate blood pressure control, increase use of antilipid drugs, and aspirin.
This study, therefore, is aimed at evaluating the CT features and pattern of stroke in hypertensive and diabetic patients in Kano, Nigeria, which will help in the management and reduction of its complications.
| Materials and Methods|| |
This prospective study was carried out from January, 2012 to June, 2013 at the Department of Radiology, Aminu Kano Teaching Hospital (AKTH) Kano, Nigeria. The hospital serves the population of about nineteen (19) million people mainly from Kano, Jigawa, and Katsina States from the 2006 population census. The study population was adult stroke patients with either hypertension or diabetes referred for CT scan during the period of study (see sample size determination below).
The patients included are adults 18 years and above that are hypertensives or diabetic. Those excluded were patients with both hypertension and diabetes, those with no history of hypertension or diabetes, patients with features of intracranial space-occupying lesion, and patients with previous history of neurologic disease.
SSample size was determined using formula for sample size determination for comparative studies: n = 2 (zα+zβ) 2 π(1-π)/△2
Where, n = minimum sample size for each of the comparison group; zα = standard normal deviate set at 95% confidence level = 1.96; zβ = standard normal deviate for power of test to detect difference between hypertensives and diabetics set as 80% corresponding to 0.84; π = arithmetic average of the two proportions = (p2-p1/2); and △= arithmetic difference between the two proportions = (/p2-p1/), P1 = proportion of hypertension and P2 = proportion of diabetics
Based on the study of Fawi et al., the prevalence of hypertension is 42% and diabetes mellitus is 21.6%. Substituting the figures into the formula above, the minimum sample size was 94 per group. To correct for nonresponse rate, the sample size was increased by 10% in the respective groups. Thus, a sample size of 104 was used in this study for each of the groups.
Approval and permission to conduct this study were obtained from the ethics and research committee of AKTH.
Using a structured data collection checklist, the age and gender of the patients for the study were documented as well as the pattern of stroke. The clinical history and risk factor of either hypertension or diabetes were also included.
Study patients had cranial CT scan using fifth-generation spiral (helical) bright speed GE (4 slices) CT machine with the following specifications: maximum kilovoltage – 140 kV, minimum kilovoltage – 40 kV, maximum milliamperage – 500, minimum milliamperage – 50, and a maximum tilting angle – 60°. Patients were placed in the supine position on the CT table, and scanning was done in axial planes from base of the skull to the vertex after proper selection of the field of view. Slice thickness of 2.5 mm was used from the base of the skull to the sella turcica and then 5 mm for the rest of the cranium. Images were reformatted into sagittal and coronal views for better analysis. 50 ml of water-soluble low-osmolar contrast was given to the patients in the absence of an hemorrhage. Images were then acquired and analyzed.
The Statistical package for the social sciences (SPSS) version 16.0 software (Released 2010. SPSS Inc. Chicago USA) was used for data analysis. In addition to the descriptive statistics, proportion of pattern of stroke in each group was analyzed and possible association between the sociodemographic factors such as age, gender, and risk factors using Chi square; at 95% confidence interval. Findings were represented with graphs and tables.
| Results|| |
A total of 208 consecutive adults were studied, comprising of 104 (50%) diabetes Mellitus (DM) and 104 (50%) hypertensive (HTN) patients. There were more males than females in the combined groups [Figure 1], male: female 2:1. Among the diabetics, 67 (64.4%) were males and 37 (35.6%) were females while among the hypertensives, 68 (65.4%) were males and 36 (34.6%) were females.
The respondents' ages ranged from 30 to 90 years with mean age of 61.6 ± 12.7 years and 62.5 ± 13.4 years in the diabetic and hypertensive patients, respectively, as shown in [Table 1]. Majority (75.9% in diabetic group and 77.9% in hypertensive group) were within the age range of 50–79 years. In both groups, <10% were below 40 years.
The prevalence of stroke among diabetic and hypertensive patients by type of stroke is shown in [Figure 2] where majority of the diabetic patients (92.3%) presented with ischemic stroke while on the other hand, only eight (7.7%) were hemorrhagic. In the same vein, 66.3% of the hypertensive patients presented with ischemic stroke while 35 (33.7%) had hemorrhagic stroke [Table 2]. A statistically significant association was observed between the type of stroke and the risk factor (hypertension and diabetes) (χ2 = 21.4, P ≤ 0.0001). The Hypertensive patients had a higher proportion of hemorrhagic stroke (33.7%) than their diabetic counterparts (7.7%).
zThe different parts of brain affected by stroke are shown in [Table 3] where more than half (58.7%) of the hypertensive patients showed affectation of the parietal lobe whereas less than half (44.2%) of the diabetic patients had involvement of the parietal lobe. On the other hand, more than one-third of the diabetic patients (37.5%) had mixed pattern with more than one part of the brain involved, while less than a quarter of the hypertensive patients (22.1%) had the mixed pattern. This study observed a statistically significant difference in the parts of the brain affected by stroke in the diabetic and hypertensive patients (χ2 = 11.1, P = 0.025).
|Table 3: Distribution of stroke by part of the brain affected in hypertensive and diabetic patients|
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The side of brain affected by stroke among the patients is shown in [Table 4] where both the hypertensive and diabetic patients showed affectation of the left side in more than 50% of the patients while <5% had both sides involved.
|Table 4: Distribution of stroke by side of brain affected in hypertensive and diabetic patients|
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The relationship between sex and type of stroke among diabetic and hypertensive patients is as depicted in [Table 5] and [Table 6]. Most of the male (91.0%) and female (94.6%) diabetic patients had ischemic stroke. This study observed no statistically significant difference between the type of stroke and gender of the diabetic patients (P > 0.05) [Table 5]. Similarly, majority of both the male (67.6%) and female (63.9%) patients had ischemic stroke. The study observed no statistically significant difference between the gender and stroke pattern (P > 0.05) [Table 6].
|Table 5: Relationship between sex of respondents and type of stroke among Diabetes Mellitus patients|
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|Table 6: Relationship between sex of respondents and type of stoke among Hypertensive patients|
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The relationship between age and type of stroke among the diabetic and hypertensive patients is shown in [Table 7] and [Table 8]. They show no statistically significant difference between the age and type of stroke among diabetics (P > 0.05) and hypertensive patients (P > 0.05), respectively.
|Table 7: Relationship between age and type of stroke among diabetic patents|
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|Table 8: Relationship between age and type of stroke among Hypertensive patients|
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| Discussion|| |
The major risk factors for stroke in Nigerians are hypertension, diabetes, and hyperlipidemia. Cerebral infarction is the most common type of stroke seen occurring in 48% of patients while intracerebral hemorrhage occurs in 15.7% and subarachnoid hemorrhage in 11.3% of patients., In a recent study in Kano, stroke was found to be the most common neurological disorder seen accounting for about 78% of all neurologic diagnoses. Hypertension and diabetes mellitus accounted for 81.5% and 17.2%, respectively, as the most common risk factors., This is similar to the study conducted by Ogunseyinde in Ibadan.
In a developing country like Nigeria, CT is relied upon in case of stroke to provide maximum information in the shortest possible time, although clinical appraisal might be faster and cost-effective. MRI, which is much more sensitive and very expensive, is not readily available in the country, so CT is the main stay of investigating a patient with stroke.
Diabetic patients comprised of 67 (64.4%) males and 37 (35.6%) females while hypertensive patients were 68 (65.4) males and females 36 (34.6%), respectively [Figure 1], equivalent to 2:1 male-to-female ratio in each group. This study is in conformity with the study conducted by Owolabi et al., here in Kano which found that male-to-female ratio is about 2:1 and contrasted with that conducted by Eze et al. in Enugu who found the ratio of male-to-female incidence to be about 3:1 (P < 0.05). The higher incidence in male is not surprising as they bear the brunt of the socioeconomic stress from the family and workplace. Likewise, the fact that more men get affected than women may also be attributed to the fact that risk factors such as smoking which is more prevalent in men and to a lesser extent hormonal factor, play an important role.
The age range is 30–90 years with a mean age of 61.6 (±12.7) years in the diabetic patients and 62.5 (±13.4) years in their hypertensive counterparts. The age range of 50–79 years had the highest frequency among both groups with the diabetic patients having 75.9% and hypertensive patients 77.9% while < 10% were under the age of 40 years [Table 1]. This is similar to the study of Owolabi et al. in Kano with the peak age found to be around the seventh decade and mean age of 55 years (52 and 60 years in males and females, respectively). Komolafe et al. also found the mean age to be 62 (±12) years in their study conducted in Osun state, South-West Nigeria, which is similar to the index study. In the Caucasians, the mean age is found to be slightly higher as documented by Karapanayiotides et al. where they found the mean age to be 67 years and this may be attributed to low socioeconomic status, racial factors, and literacy level.
The prevalence of the type of stroke in this study showed that majority of the diabetic patients had ischemic type (92.3%) and hemorrhagic type was least common (7.7%) while two-third of the hypertensive patients had ischemic type (66.3%) and about one-third (33.7%) suffered from hemorrhagic stroke. This study noticed significant association between type of stroke and risk factors (χ2 = 21.4, P ≤ 0.0001), hypertensive patients having much greater incidence of hemorrhagic type of stroke than the diabetic patients [Figure 2] and [Table 2]. Karapanayiotides et al. in his study found that diabetic patients have a higher relative prevalence of ischemic stroke and much lower prevalence of hemorrhagic type of stroke which is similar to the index study. Both groups in majority of the literature reviewed showed the much higher prevalence of ischemic stroke compared to the much lower hemorrhagic type of stroke.
Rajah et al. in Saudi Arabia found that about 76.2% stroke patients suffered from ischemic type and only about 23.8% had hemorrhagic type with hypertension (56%) and diabetics (42%) been the most common risk factors, and this is in conformity with the result found in this study.
Ogunseyinde et al. also confirm the above finding with 55% infarctive and 43.7% hemorrhagic types among the patients and risk factors being hypertension and diabetics.
Owolabi et al. also found similar result with infarctive stroke having about 63.7% and about 36.3% being hemorrhagic type with hypertension as the highest risk factor (81.3%) and diabetics (17.2%). In contrast to the index study and reviews above, Njoku et al. in their study of 93 patients with stroke in Sokoto, North-Western Nigeria found that about 45.2% had a hemorrhagic type and 37.6% had thromboembolic type with hypertension being the major risk factor (83.9%). The reason for this contrast may be due to the higher number of hypertensive patients in their study than the diabetic patients. Hypertension causes increase in vascular rigidity and increase pressure causing vascular rupture thus leading to hemorrhagic stroke. Diabetes mellitus is associated with atheromatous changes and microaneurysms in the vessel walls thus predisposing to both dislodgment of plaque and rupture of vessel wall leading to either thrombotic or hemorrhagic stroke. Previous reports have shown that patients with diabetes are more prone to ischemic than hemorrhagic stroke, while hemorrhagic stroke is seen more common in hypertensive than diabetic patients. This conforms to the findings of the index study.
The part of brain affected and the vascular territory involved in this study was mainly the parietal lobe and the middle cerebral artery (MCA), where more than half of the hypertensive patients (58.7%) and slightly less than half of the diabetic (44.2%) showed affectation of the parietal lobe and MCA territory. More than one-third of the diabetic patients had involvement of greater than one part of the brain and less than one-quarter of the hypertensive patients showed affectation of more than one part. The study observed a statistically significant difference in the part of brain affected by stroke in diabetic and hypertensive patients (χ2 = 11.1, P = 0.025) [Table 3]. This is in conformity with the study of Ogunseyinde et al. conducted in Ibadan, though the parietal and frontal lobes are said to be more involved when lesion occurs in single site while others such as caudate, putamen, and ventricles are commonly affected when lesion is involved in more than two sites. Yoo et al. in their study of MCA occlusive disease in the US found that infarcts in patients with MCA embolic occlusion (75%) and carotid artery (CA) disease (43%) most often involved the parietal lobe. Similar finding was reported by previous authors documenting the cerebral mantle as the most common part of the brain affected with the MCA territory having 50%, posterior cerebral artery 10%, the watershed MCA + ACA territory 7%, and ACA only 4%. The reason for the MCA vascular territory being the most common area affected may be explained by the fact that MCA is the largest and most direct of the terminal branches of the internal carotid and is, therefore, the vessel most prone to embolism.
In this study, the side of the brain affected was predominantly the left side (>50%) and <5% showed affectation of both sides [Table 4] in both hemorrhagic and infarctive stroke. This contrasts the findings of Ogunseyinde et al. where, hemorrhagic stroke involves mainly the left side while infarctive stroke was seen to occur equally on both sides (61.7%:38.3%). Previous studies in normal and hypertensives, on intima-media thickness difference between the left and right common carotid arteries on ultrasound found that there is a significant difference between both sides (left 0.75 ± 0.11 mm; right 0.71 ± 0.11 mm; P ≤ 0.001).
The reasons for such differences may be connected with the anatomy of the origins of the great vessels from the arch of the aorta, where the left common CA arises directly from the arch while the right is a branch of innominate artery (brachiocephalic trunk). Therefore, it is possible that dissimilarity existed in arterial growth between both arteries and/or that flow-mediated mechanical forces applied to the carotid wall also differ between the two sides.
This study observed that there was no statistically significant difference between the type of stroke and gender of the patients involved (P > 0.05). Similarly, this study observed that there is no statistically significant difference between age of the patients and type of stroke among both hypertensive and diabetic patients (P > 0.05) [Table 7] and [Table 8]. This is in conformity to the study conducted by Peter et al. in the US, where they found that the incidence rates of brain infarction and intracerebral hemorrhage were higher among men, whereas the rate of subarachnoid hemorrhage was higher among women, although this difference was not statistically significant. Similarly, no statistically significant difference was noticed between age of the patients and stroke subtypes.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]