In this study stroke accounted 16.5 % of total medical admissions, and 23.6 % of the
total medical cases of in hospital mortality. This admission rate was higher than
findings from Gambia in which the stroke patients made up 5% [
23] and in southwestern Nigeria made up of 4.5% medical admission[
24]. But the finding was in agreement with previous study conducted in Hawasa Ethiopia
in which stroke accounted for 13.7% of all medical admissions [
14]. The elevated number of stroke admission in Ethiopia may be due to lack of awareness,
poor risk factor control and being hospital based study with referral bias.
A total of (78.4%) patients were discharged being alive from the hospital with in
hospital mortality rate of (21.6%). From those discharged being alive more than half
(57.8%) were discharged with improvement which was lower as compared to study by Masood
et al in Pakistan (91%) [
25], Jowi et al in kenya (93.8%) [
26] and Tirschwell etal in Vietnam (65.8%) [
16], but higher than study done by Gebremariam etal in Ethiopia (47.9%) [
27]. But there was correspondence similarity with study done in Ethiopia by Greffie
etal in which 59.18% of the patients were discharged with improvement [
9]. These difference in outcome/vital status of the patient during discharge may vary
with the severity of stroke, set up of the hospital, complications, co morbidities
associated with the patients and experts available in caring of the patient.
The median length of hospital stay of patients was 9.21days which was shorter than
study by Walker etal 19 days [
23], Jowi et al 12.5 days [
26], Greffie etal 13 days [
9], Gebremariam etal 11 days [
27], and De Carvalho etal 15.4 days [
28]. For the shorter length of hospital stay in our set up, multiple reasons could be
explained. Some patients were rapidly improved and discharged due to the stroke unit
had proper possible care as compared to other wards in the hospital. Secondly some
patients were died rapidly, some discharged LAMA and others discharged with medical
advice without improvement due to small bed occupy of the stroke unit of the hospital.
In this regard if the patient stayed longer than other patients and any improvement
to the condition was seen, the bed would be left for new stroke patients.
In some patients there was shorter length of stay because of stroke unit provides
better quality of care during the early phase. Additionally in some patient’s delays
in complimentary evaluations is one of the most feasible explanations for the prolonged
admission time, which not only significantly increases the costs for stroke care,
but also increases the risks for infection, other complications, and recurrence in
patients with suboptimal treatment and evaluation.
The in-hospital stroke mortality (21.6%) was comparable with the study by De Carvalho
et al in Brazil 20.9% [
28] and Desalu et al in Nigeria 23.8% [
24]. But this was higher as compared study by Deresse et al in Ethiopia 14.7% [
14], Tirschwell etal in Vietnam 6.5% [
16], Masood etal in Pakistan 9 % [
25], Gebremariam etal in Ethiopia 12.0% [
27], Greffie et al in Ethiopia 13.3% [
9] and Jowi et al in kenya (5%) [
26]. In addition, this in hospital mortality was lower as compared to study by Damasceno
et al in Mozambique which was 33.3% [
29], Atadzhanov etal in Zambia 40 % [
15] and Walker et al in Gambia 57% [
23]. The difference in hospital mortality rate could be due to different ways of stroke
diagnosis, type of stroke, treatment approaches, risk factors, comorbidities, complications
and in hospital patient care.
The prominent immediate causes suspected and forwarded by clinicians was increased
intracranial pressure and respiratory failure secondary aspiration pneumonia, which
complies with other studies particularly in Ethiopia [
9,
14]. Additionally, study done in Arabian Gulf countries reported that both neurologic
and systemic complications accounted 63% of in hospital mortality[
30]. But it was unlike to study by Walker etal in Gambia as the most immediate cause
of death was the initial stroke in 61% patients[
23]. The difference could be due to difference in physician’s duty note and prediction
based on comorbidities as well as complications that were developed in the patient
at the end of patient’s life. Prevention, early identification and management of complications
like increased intracranial pressure and aspiration pneumonia factors would at least
have salvage life of the some patients.
In general the in hospital case fatality rate of stroke in our study was higher than
reports from western studies, but was quite similar to SSA studies. This difference
could reflect the limited access to hospital care, limited staffing, including availability
of physiotherapy and occupational therapy similar to other developing countries as
well as insufficient number of hospital beds for longer period care. In addition to
this some caregivers/patients belief that people should die at home, where they spent
most of their lives, with family members around and caring for them. Absence of treatment
with thrombolytic, the low frequency of treatment with antiplatelets for patients
with ischemic stroke and lack of evaluation with neuroimaging suggest that suboptimal
care be the most likely explanation.
The hospital median survival time for patients who died in hospital was 4.38days which was earlier as compared to study by Walker etal 7.5 days [
23], Greffie etal 6 days [
9] and Damasceno et al 6 days [
29]. However it was relatively similar with the study done by Deresse et al Ethiopia
reporting that median survival time of the patients was 4.5 days after admission [
14]. It has been stated that the high mortality rate in this study during the first
one-week (17.2%) may be due to raised intracranial pressure and aspiration pneumonia.
Brain edema, urine incontinence, NIHSS>13 during hospital arrival and diagnosis of stroke clinically alone were the independent predictors of in hospital mortality up on multivariable cox regression. Except stroke severity other factors were not
reported study by Atadzhanov et al in Zambia [
15]. In this study increased NIHSS was associated with stroke severity constituting
decreased level of consciousness. High NIHSS score as a predictor of mortality, was
consistent with previous study done by Deresse et al [
14].
In this study brain edema as complication was one predictor of in hospital mortality
unlike study by Mamushet et al in Ethiopia in which mortality was not significantly
associated with the complication of increased intracranial pressure [
31
</a>]. The overall difference in independent predictors of in hospital mortality could
be due to sample size, study design, significance value considered and inclusion criteria
of the patient.</p>
The in hospital mortality was higher for hemorrhagic stroke (more than triple) compared
to ischemic stroke patients that complies with other studies [
14,
15,
19]. In contrary to this, study by Mamushet etal in Ethiopia showed that mortality was
higher for ischemic stroke cases (22%) than hemorrhagic stroke (17%) which was significant
(P=0.049) [
31]. This contrary finding by Mamushet et al might be due to the study design, study
population and comorbidity of the cases. Similar to our finding, study by Deresse
etal showed that the rate of stroke mortality was not different by age and sex [
14].