Journal of Radiation Medicine in the Tropics

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 2  |  Issue : 1  |  Page : 12--17

Brain computed tomographic pattern and clinical presentation of patients with hypertensive haemorrhagic stroke at aminu Kano teaching hospital, Kano, Nigeria


Umar Jibo1, Mohammed Kabir Saleh2, Abdulkadir Musa Tabari3, Anas Ismail2, Mansur Adamu Yahuza2, Abubakar Mohammed Jibo4, Usman Muhammad Ibrahim4, Mohammed Sidi5, Idris Sule Kazaure6,  
1 Department of Radiology, General Hospital Dutse, Dutse, Jigawa State, Nigeria
2 Department of Radiology, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
3 Department of Radiology, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria
4 Department of Community Medicine, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
5 Department of Medical Radiography, Faculty of Health Sciences, Bayero University, Kano, Nigeria
6 Department of Radiology, Rasheed Shekoni Teaching Hospital, Dutse, Jigawa State, Nigeria

Correspondence Address:
Mohammed Kabir Saleh
Department of Radiology, Aminu Kano Teaching Hospital, Bayero University, Kano
Nigeria

Abstract

Background: Stroke or cerebrovascular disease is a clinical syndrome consisting of rapidly developing clinical signs of focal or global neurological deficits lasting more than 24 h or leading to death with no apparent cause other than a vascular origin. Study Aims: This study was aimed at evaluating pattern and clinical presentation of hemorrhagic stroke on brain Computed Tomography (CT) scan in Aminu Kano Teaching Hospital, Kano, Nigeria. Materials and Methods: This was a prospective study carried out between March 2018 and August 2018 on brain computed tomographic findings of 100 patients diagnosed with hemorrhagic stroke. Ethical approval to conduct the study was obtained from the Human Research and Ethics Committee of the Aminu Kano Teaching Hospital. Images were acquired using Prime Aquilion Toshiba Japan 2012 160 slice CT machine in the Department of Radiology. The patients' information and CT findings were recorded on the data capture sheet. Results: Headache was the most common clinical presentation seen in 72% of the patients, followed by dysphasia seen in 58%, followed by vomiting seen in 42%, and the least was convulsion seen in 28% of the patients. The most common site of hematoma was putamen with 54%, followed by thalamus 14%, and the least regions affected were parietal lobe, pons, and frontal lobes with 4% each. Conclusion: Headache was the most common clinical presentation of the patients with hemorrhagic stroke and the most common site of the hematoma was putamen.



How to cite this article:
Jibo U, Saleh MK, Tabari AM, Ismail A, Yahuza MA, Jibo AM, Ibrahim UM, Sidi M, Kazaure IS. Brain computed tomographic pattern and clinical presentation of patients with hypertensive haemorrhagic stroke at aminu Kano teaching hospital, Kano, Nigeria.J Radiat Med Trop 2021;2:12-17


How to cite this URL:
Jibo U, Saleh MK, Tabari AM, Ismail A, Yahuza MA, Jibo AM, Ibrahim UM, Sidi M, Kazaure IS. Brain computed tomographic pattern and clinical presentation of patients with hypertensive haemorrhagic stroke at aminu Kano teaching hospital, Kano, Nigeria. J Radiat Med Trop [serial online] 2021 [cited 2022 May 28 ];2:12-17
Available from: http://www.jrmt.org/text.asp?2021/2/1/12/319113


Full Text



 Introduction



Intracerebral hemorrhage (ICH) is an acute neurological state in which there is hemorrhage within the brain parenchyma or in the ventricular system.[1] Stroke can be classified into ischemic and hemorrhagic with ischemic stroke accounting for majority of cases (80%–87%) while hemorrhagic stroke accounts for only 13%–20% of stroke cases.[2],[3] The prevalence of hypertensive stroke in Nigeria is around 1.14 per 1000 while 30-day case fatality is as high as 40%.[4] There are different manifestations of hemorrhagic stroke including ICH, subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), and subdural hemorrhage (SDH). Hypertensive hemorrhagic strokes present more in the form of ICH.[1] The most common sites of hypertensive ICH are the putamen, thalamus, subcortical white matter, pons, and cerebellum.[5],[6] Spontaneous ICH is usually a severe form of stroke with a high mortality rate of approximately 50% by the end of the 1st year.[5] A simple categorization is based on location, namely intra-axial hemorrhage, ICH, basal ganglia hemorrhage, lobar hemorrhage, pontine hemorrhage, cerebellar hemorrhage, or IVH.[6]

Neuroimaging studies are integral to the identification of hemorrhagic stroke, determination of the underlying etiology, prevention of hematoma expansion, treatment of acute complications, and treatment of the underlying etiology, if indicated. Neuroimaging is essential for prognostication and thus directly impacts patient care.[4] The imaging modalities for the evaluation of hemorrhagic stroke include computed tomography (CT), magnetic resonance imaging, and catheter angiography.[7] However, noncontrast head CT is the most common initial in the evaluation of the hemorrhagic stroke.[4] It is commonly used in an emergency room setting for acute stroke because of its convenience and its high sensitivity for detecting ICH, which is a contraindication to thrombolytic therapy. It also allows the quantification of the hematoma volume and monitor hemorrhage evolution in ICH accurately. Perfusion CT and computed tomographic angiography are also used in hyperacute stroke imaging. CT scan can determine the approximate age of hematomas, by evaluating the density of the lesions measured in Hounsfield units, according to the value of X-ray attenuation corrected for the attenuation coefficient of water.[7]

There are documented, published articles on the pattern of hemorrhagic stroke on brain computerized tomography, however, there is a paucity of such data in Aminu Kano Teaching Hospital. The findings of the study are expected to serve as a guide to the radiologists and neurologists in the diagnosis and management of patients with hemorrhagic stroke in our locality. The study was aimed at evaluating the pattern and clinical presentation of hemorrhagic stroke on brain computerized tomography in Aminu Kano Teaching Hospital, Kano, Nigeria.

 Materials and Methods



This was a prospective and cross-sectional study conducted in the Department of Radiology, Aminu Kano Teaching Hospital, from March 2018 to August 2018. Ethical approval to conduct the study was obtained from the Human Research and Ethics Committee of the Aminu Kano Teaching Hospital, and informed consent was obtained from the selected subjects or relatives of the subjects in cases of unconscious subjects. Purposive sampling method was employed in the study, and a sample size of 100 hypertensive stroke patients was used. All cranial CT scans of hypertensive patients presenting with stroke within the study period were included in the study. All patients who had a brain CT scan on account of traumatic brain hemorrhage, nonhypertensive patients who had a brain CT scan with findings of stroke, adult patients who had a brain CT scan based on indications other than stroke, nonhypertensive patients, diabetes mellitus patients, human immunodeficiency virus patients, and hyperlipidemic patients were excluded from the study, based on their clinical history and laboratory investigations. The patients', age and gender, relevant clinical history and findings including the Glasgow coma score were obtained. And for unconscious patients these were obtained from the patient relations or their case folders. The blood pressure at presentation was obtained from the patient case record. Furthermore, before conducting the brain CT scan, blood pressure was measured and documented. All the CT examinations were carried out on Prime Aquilion Toshiba Japan 2012 helical multidetector CT with the patient lying on the table in supine position using brain protocols.

The images acquired from the patients were reviewed by a single observer on the CT monitor to avoid interobserver variation. The various findings such as extent, size, and site of the hemorrhage were documented. Each hematoma was classified in terms of the lobe(s) affected (frontal, parietal, temporal, or occipital), hemisphere affected (left or right), ventricle(s) involved (third, fourth, and lateral ventricles), extra-axial fluid spaces involved (cisterna magna, suprasellar cistern, subarachnoid space, quadrigeminal, and pontine cisterns), and hematoma type (epidural hemorrhage [EDH], SDH, or ICH). Two linear measurements in millimeter (mm) were performed for each hematoma: one in the long axis distance and the second correspond to the transverse distance of the hematoma. Three measurements were taken and their average was used in order to reduce the intraobserver variation. The patient was followed up to the ward on a regular basis to monitor the outcome of the patient of either survival up to the time of discharge or death. Owolabi et al.[8] formula of tomographic hematoma volume measurement was used to determine the volume of hematoma as documented by Chiewvit et al. and Ojaghihaghighi et al.[2],[9] The presence or not of midline shift was also documented.

All the obtained information was recorded on a data capture sheet designed for the study. Both descriptive and inferential were employed in data analysis. The mean, standard deviation (SD), and range were obtained using descriptive statistics, while the differences, association, and relationship were obtained using inferential statistics. Pearson Chi-square test was used to determine the relationship between outcome (death and survival) and volume of hematoma, sites of hematoma, and clinical presentations at bivariate level. Furthermore, Chi-square test was used to determine the relationship between clinical presentations and volume of hematoma at bivariate level. Similarly, Chi-square test was used to determine the relationship between site of hematoma and clinical presentation at bivariate level. Pearson's correlation was used to correlate the volume of hematoma and blood pressures (systolic and diastolic). SPSS version 22 (IBM SPSS Statistics for windows, Version 22.0. Armonk, NY, USA: IBM Corp) was used for data analysis, and the preset ρ/Symbol>-value was at 0.05.

 Results



Sociodemographic factors

A total of 100 patients with hypertensive hemorrhagic stroke were recruited for this study. Out of 100 patients, 58 (58%) were male and 42 (42%) were female. The age of the patients ranged from 40 to 78 years with a mean age of 56.7 ± 9.2 SD and a modal age group of 55–59 [Table 1].{Table 1}

The most common symptom at presentation was headache 72 (72%), followed by dysphasia with 58 (58%), followed by vomiting with 42 (42%), and the least of the clinical presentation was convulsion with 28 (28%). However, several patients had various combinations of the above symptoms.

[Table 2] shows the distribution of the diastolic blood pressure (DBP) of the selected subjects; the mean DBP was 116.8 mmHg ± 15.6 mmHg with a range of 80–140 mmHg.{Table 2}

CT findings

[Table 3] shows that the most common site of the hemorrhage was in the putamen having 54 patients (54%) with 34% on the left side and 20% on the right side, followed by thalamus with 14 patients (14%) and occipital lobe with 10 patients (10%). Ten patients (10%) had a hemorrhage in the cerebellar hemisphere. The least frequent sites were pons, parietal, and frontal lobe hemorrhages comprising 4% each.{Table 3}

[Table 4] shows that 90% of the patients had unifocal hematoma, with the remaining 10% having multifocal hematoma, and 14% of the patients had evidence of SAH. Similarly, 28% in addition to the cerebral hemorrhage had ventricular extension of the hemorrhage, 72% had ventricular compression at various levels, and 82% had perilesional edema.{Table 4}

 Discussion



The findings of this study show that the mean age of patients with hypertensive hemorrhagic stroke was 56.76 years ± 9.22 and the age group of 55–59 years was more affected, as shown in [Table 1]. The findings of this study are similar to the findings of the studies by Dastus, et al. and Krishnan, et al.,[5],[6],[7] Yunusa et al.,[10] Sanya et al.,[11] Obajimi et al.,[12] Lompo et al.,[13] Kathyayani et al.,[14] Suthar et al.,[15] and Ok et al.,[16] however, the values reported in this study are slightly lower than the values reported by the studies conducted by Chukwuemeka et al.[17] and Okokhere et al.[18] who reported mean values of 61.59 years and 66.22 years ± 12.67 years, respectively. The differences might be a result of geographical location. The findings of this study show that there was a male preponderance with a male-to-female ratio of 1.4:1. The findings of this study are similar to the findings of the studies conducted by Owolabi et al.,[8],[19] Owolabi and Ibrahim,[20] Yunusa et al.,[10] Ogunseyinde and Atalabi,[21] Chukwuemeka et al.,[17] Obajimi et al.,[12] Lelo and Longo-Mbenza,[22] Chiewvit et al.,[2] Ok et al.,[16] Kathyayani et al.,[14] and Suthar et al.[15] The possible reasons of the male preponderance might be because males are more exposed to risk factors for stroke than females, such as smoking, socioeconomic stress of the family, and workplace.[11]

The findings of this study show that the entire subjects were diagnosed with hypertension between 1 and 15 years prior to presentations, with about 60% being diagnosed <6 years ago. Eighty percent of the subjects presented to the hospital within 24 hours after the onset of the stroke, out of which 44% presented within the first 6 hours of the onset of the stroke [Figure 1]. The findings of this study are similar to the findings of the studies conducted by Chiewivit et al.[2] and Okokhere et al.[18] who reported that 79.8% and 69% of their cases presented to the hospital <24 h. However, the findings of this study are contrary to the findings of the studies conducted by Owolabi et al.,[20] Yunusa et al.,[10] and Ogunseyinde and Atalabi[21] who reported that 41% of their patients presented after 24 h of onset of stroke. The findings of the studies conducted by Chukwuemeka et al.,[17] Obajimi et al.,[12] and Lelo and Longo-Mbenza[22] also reported late presentation of the patients after the onset of the stroke. The early presentation of the patients to the hospital after stroke may be as a result of knowledge of hypertension and the awareness of stroke as its complication.{Figure 1}

In this study, the main clinical presentation was hemiplegia/hemiparesis seen in 100%, with hemiparesis having 54%, and dense hemiplegia was seen in 46% of the patients, as shown in [Figure 2]. Chukwuemeka et al.[17] in Southeastern Nigeria found that the main clinical presentation was hemiparesis/hemiplegia in 70% of the patients. These findings are comparable to the findings of Lal et al.[23] in North Shore University Hospital, USA. They reported that 46% of their patients had hemiplegia. Acharya and Chaturvedi[24] in Nepal reported that 77% of their patients presented with hemiplegia/hemiparesis. It is also close to 49.5% of the hemiplegic cases reported by Masood et al.[25] in Kashmir. The second most common clinical presentation was headache seen in 72 patients (72%), followed by dysphasia seen in 58 patients (58%), followed by vomiting seen in 42 patients (42%), and the least of the clinical presentation was convulsion seen 28 (28%), as shown in [Table 5]. However, several patients had various combinations of the above clinical presentations. This is relatively higher than the findings of Chiewivit et al.[2] as they reported that 21.4% of their patients presented with headache and 11.7% with vomiting and 4.5% with seizure, which also is slightly more than that of Masood et al.,[25] whereby 31% of their patients presented with headache, 23% with vomiting, and only 10% with convulsion. Our findings conform to what was reported by Ojaghihaghighi et al.[9] in Imam Reza Hospital, Tehran, that 51.6% of their patients had headache, 41% presented with vomiting, and 24% presented with seizures. Our findings are also consistent with the findings of Suthar et al.[15] in India, whereby they reported the occurrence of headache as 41%, vomiting as 39%, and seizures as 17%. Lal et al.[23] in the USA also reported that 48% of their patients presented with headache and also 48% presented with vomiting and 10.7% presented with convulsion.{Figure 2}{Table 5}

It is an important indicator of the outcome of the patients. In this study, 46.46% of the patients were unconscious at presentation as seen in [Figure 3]. This conforms to the findings of Masood et al.[25] in Kashmir, as they reported that 47% of their patients were unconscious at presentation and Okokhere et al.[18] in South-South Nigeria, whereby 75% of their unconscious patients died. While Owolabi and Nagoda reported 56% mortality among the unconscious patients with GCS of <8 in their study and was found to be an independent predictor of mortality in stroke patients. In addition, it is directly related to the severity of the neurological damage. Fiesch et al.[26] in Rome, Italy, reported that two-thirds of the comatose patients died within the 30-day period. Similarly, Lal et al.[23] in the USA showed that 61.5% of their patients were unconscious at presentation which is above our findings likely that was the explanation behind their reported high mortality of 55%. Chiewivit et al.[2] in Bangkok reported that 33% of their patients were unconscious at presentation.{Figure 3}

The mean systolic blood pressure (SBP) was 193.7 mmHg ± 32.78 mmHg and the mean DBP was 116.80 mmHg ± 15.56 mmHg at presentation. This conforms to the findings of Okokhere et al.[18] in South-South Nigeria among stroke patients which showed that mean SBP and DBP at presentation were 171.41 ± 39.10 mmHg and 100.44 ± 21.13 mmHg, respectively, as shown in [Figure 4]. High blood pressure is an important risk factor for the development of stroke. A 10-mmHg rise in DBP has been found to increase stroke risk by 86% in Negroes and very high SBP has also been shown to increase stroke risk in Blacks as well as may predispose to greater mortality.[11] This study showed a linear correlation between rise in blood pressure (systolic or diastolic blood) and volume of hematoma. This is in agreement with the study conducted by Chukwuemeke et al.[17] in Southeastern Nigeria. They documented that a rise of 10 mmHg in the mean arterial pressure leads to about 20%–30% increase stroke risk and further rise in mortality. Owolabi et al.[4] reported mean SBP of 147.8 mmHg among the survivors and mean SBP of 189.1 mmHg among the deceased patients with odd ratio (OR) at 95% confidence interval (CI) of (−41.84–−35.55). The mean DBP was 91.6 mmHg among survivors and the mean DBP of 116.8 mmHg among the deceased with OR at 95% CI of −29.15–−21.38, as shown in [Table 2]. Our findings conform to the findings of Kumar[5] in India whereby they reported that 5 (15%) out of 34 patients who presented with SBP of <180 mmHg and DBP of <110 mmHg died on admission. Also, 24 (42%) out 57 patients with a SBP of 180 – 230mmHg and a DBP of 110mmHg died. Furthermore, 18 (95%) out of 19 patients who presented with SBP of >230 and DBP of >140 mmHg died.{Figure 4}

The most common site of hemorrhage was putamen (54%), followed by occipital lobe and Cerebellum (with 10% each). Hematoma has the highest predilection for the left side with 62%; this further confirms the left hemispheric dominance, as shown in [Table 3]. This is in consonance with the findings of Ogunseyinde and Atalabi[21] in Ibadan, Southwestern Nigeria; Bassey et al.[27] in Calabar, South-South Nigeria; and Obajimi et al.[12] in Korle Bu Teaching Hospital, Ghana. This is also consistent with the findings of Chiewvit et al.[2] in Bangkok, Thailand, as they documented that gangliothalamic hemorrhage was the most common site of hemorrhage with 63.1% followed by lobar hemorrhage with 14%, brain stem, and cerebellum. This conforms to the report of Xavier et al.[28] and Panchal et al.[29] all in India. It is also comparable with the finding of Acharya et al.[22] in Nepal as they found 61% of the hemorrhage was in the gangliothalamic region, followed by lobar with 25%. Similar findings were reported by Nilsson et al.[30] in Sweden with proportion of hematomas in the brainstem as 4% and cerebellum as 8%. It also conforms to the findings of Suthar et al.[15] in India, where they reported that the most common site of ICH was basal ganglia 49%, followed by lobar with 21%, followed by thalamus with 14%, brain stem 9%, and cerebellum 7%. Agarwal et al.[31] in India reported that 70% of their patients had gangliothalamic hemorrhage with putamen having 57% and thalamus having 18%.

 Conclusion



Headache was the most common clinical presentation of the patients with hemorrhagic stroke and the most common site of the hematoma was putamen while convulsion was the least. The most common site of hematoma was putamen while the least regions affected were parietal lobe, pons, and frontal lobes.

Acknowledgment

We wish to acknowledge the contribution and support of Mr. Nafi'u Ahmad Muhammad and Mr. Mubaraq Abdulsalam Yakub being the radiographers involved in the acquisition of the brain CT images of the patients. We also acknowledge the support of Sister Maryam Hassan, the nurse in the CT Suite where the investigation was performed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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