Clinical profile and early outcomes of adult patients with suspected cerebrovascular accident presenting to the emergency medicine department at Muhimbili national hospital in Dar es salaam, Tanzania

Abstract

Background: Cerebrovascular accident (CVA) is among leading causes of death worldwide, and Low income countries (LIC) like Tanzania are disproportionately affected, accounting for approximately 85% of CVA deaths worldwide. Despite the largest burden of CVA in LIC, there is paucity of data on clinical-epidemiological profile and management of patients with CVA presenting to emergency departments or acute intake areas. Objectives: To determine clinical profile and early outcomes of adult patients with suspected cerebrovascular accident presenting to the Emergency Medicine Department at Muhimbili National Hospital (EMD-MNH). Methods: This was a descriptive cohort study of adult patients with a suspected or confirmed CVA presenting to the EMD-MNH between October 2015 to January 2016. CVA patients were identified using the ROSIER scale and structured data sheet recorded the variables of interest. Demographic information, clinical presentation, management plan, the final hospital diagnosis, and in-hospital mortality was obtained from patient chart. Simple descriptive statistics are presented while Confidence interval and Chi-Square is used to demonstrate the statistically significant difference as appropriate. Results: We screened 9582 patients, and 181 [1.9% (95% CI 1.6-2.1%)] patients were enrolled having met the inclusion criteria. The male to female ratio was 1:1.2 and the median age was 61 years (IQR 51-71 years). Most patients (71.3%) had primary level education (59.7%) and the most common risk factors for CVA identified were lack of exercise 166 (91.7%) and hypertension 128 (70.7%). The top most frequent chief complaint was weakness of one side of the body (99.4%) and top physical finding was hemiplegia (100%), while aspiration pneumonia (12.7%) and seizures (11%) were the two top complications. Most patients 144 (79.6%) did not receive CT scan. Among those who received CT scan evaluation, the rate of hemorrhagic CVA 19 (10.5%) and ischemic CVA 18 (9.9%) was almost equal. The EMD, 24-hour and 30-days mortality rate was 2.2% (0.06-4.34%), 3.3% (0.7-5.9%) and 32.6% (25.71-39.49%) respectively. The mRS score at discharge between patients who received CT Scan versus no CT Scan was either 2,4 or 5 versus 3 or 6 respectively (p=0.02). There was no difference of mRS score at 30 days (p=0.23). Conclusions: The proportion of CVA among adult patients presenting to EMD-MNH is less than two percent, with no detectable difference in distribution among patients with hemorrhagic versus ischemic CVA. Most patients had risk factors associated with CVA, and presented with hypertension, respiratory compromise, fever and physical findings of neurological compromise. The 30-days mortality rate was 33%, and there was no clear relationship between availability of results of CT Brain Scan and overall clinical progression of patients.