The findings of this study show that the classic textbook pattern of 80/20 ischemic/hemorrhagic stroke is no longer valid in MCH, and there is a more equal proportion between ischemic/hemorrhagic stroke events. This study also shows that hemorrhagic strokes are occurring at more early ages than ischemic, the fatality-rate is relatively high, and significant proportion of hospitalized patients in MCH do not receive a CT Scan for stroke confirmation and classification.
This ischemic/hemorrhagic non-classic pattern of stroke was also observed in 2005/2006 although with higher incidence for ischemic (42.0% vs 36.1%) when Damasceno et al. studied the incidence, characteristics, and short-term consequences of hospitalizations for stroke in Maputo, Mozambique [2]. High proportion of hemorrhagic stroke is observed in African countries, differing from the patterns in developed countries. In the INTERSTROKE study, hemorrhagic stroke was 34% in Africa and 9% in high-income countries [4]. The proportion of hemorrhagic stroke in Africa ranges from 29 to 57%, in comparison with 16 to 20% in North America [5].
Hemorrhagic stroke is correlated with the prevalence and severity of uncontrolled hypertension [5 - 9]. Extremely high levels of uncontrolled hypertension are observed in Mozambique. Treatment and control among the hypertensive are only 7.3% and 3.2%, respectively [3]. The increased prevalence of hypertension in Mozambicans (from 33.1% in 2005 to 38.9% in 2014/15) [3] associated with low treatment levels and poor control might well be the determinant factors for the ischemic/hemorrhagic shifting patterns of stroke observed in this study. In fact, this study found that hypertension (87.1%) was the most frequent associated risk factor, followed by the combination of hypertension and diabetes (9.2%). Among CT scan confirmed hemorrhagic stroke, hypertension was a significant associated risk factor in 96% of the cases compared with 79% of the confirmed ischemic stroke cases.
In this study, hemorrhagic stroke was found to occur in younger ages than ischemic, which is also in line with the literature. Ischemic stroke is more associated with diabetes mellitus, cardiac disease, age above 61 years and previous transient ischemic attacks. This study found a significant difference of mean age of 63 years for ischemic stroke and 56 for hemorrhagic stroke—Table 3. Damasceno et al. also reported first-ever episode of hemorrhagic strokes occurring at younger ages in Maputo (60.5 years for ischemic and 54.7 years for hemorrhagic) [2]. This younger age for hemorrhagic stroke might also be related with uncontrolled hypertension. The study aimed to assess the current prevalence, awareness, treatment and control of arterial hypertension in Mozambican population reported high prevalence of hypertension in participants aged 15–24 years (13.1%) [3], which also corroborates the younger age for hemorrhagic stroke.
Another important finding of this study is the high case-fatality rate of stroke. In 2005/06, the intrahospital mortality was 33.3%, being higher in hemorrhagic (47.9%) than in ischemic (17.4%) for the first-ever stroke event [2]. This study showed an overall case-fatality rate of 22.9% (20.3% among CT scanned stroke confirmed cases), which is not much different from the 2005/06 study. Hospital-based studies have demonstrated a one-month case fatality rate between 27 and 46% in Africans [6, 7, 9]. In the hospital-based INTERSTROKE study, the one-month case fatality rate for stroke was 22% in the African region compared to 4% in high-income countries [4].
This relatively high case-fatality rate can be explained by the scarcity of human, technical, and pharmacological resources. Patients are cared for in a medical ward and not in stroke units, and thrombolytic therapeutic is not available for acute management of stroke in Maputo [2]. A third of stroke patients was not confirmed by CT scan and received only a clinical diagnosis, with negative implication for a properly clinical and pharmacological quality of care. Despite this relatively high case-fatality, favorable outcome improved over the years, and was associated with younger ages and female patients.
The reduced mean LOS (5.76) is the lowest one when compared with 12 days in a rural south-western hospital in Nigeria [10], 18.2 days in National hospital in Abuja [11], but similar to Ghana where the mean LOS of 6.2 days have been reported [12]. The median LOS for Maputo was 6 days for the year 2005/06 [2]. This relatively low mean LOS can be explained by the inexistence of a Stroke Unit and the high occupancy bed rates in MCH.
This study has limitations. Only one public hospitalization data were analyzed, so it excludes stroke patients admitted in other differentiated and private hospitals in Maputo. Another limitation is the high proportion of unspecified strokes (30.1%), which could lead to different patterns than observed in this analysis. In the future, the authors aim to conduct a one-year prospective study on admitted stroke patients in MCH in order to obtain a clearer picture of the ischemic/hemorrhagic pattern.
Although this limitations, this study brings an update on stroke in MCH, and provides a useful knowledge for preventive actions and raise the importance of stroke epidemic in the major public hospital of Mozambique.