Ischemic Stroke at a Tertiary Academic Hospital in Tanzania: A Prospective Cohort Study With a Focus on Presumed Large Vessel Occlusion

Abstract

BackgroundLarge vessel ischemic strokes account for more than one-third of all strokes associated with substantial morbidity and mortality without early intervention. The incidence of large vessel occlusion (LVO) is not known in sub-Saharan Africa (SSA). Definitive vessel imaging is not routinely available in resource-limited settings.AimsWe aimed to investigate the burden and outcomes of presumed LVO among patients with ischemic stroke admitted to a large tertiary academic hospital in Tanzania.MethodsThis cohort study recruited all consenting first-ever ischemic stroke participants admitted at a tertiary hospital in Tanzania. Demographic data were recorded, and participants were followed up to 1 year using the modified Rankin Scale (mRS). A diagnosis of presumed LVO was made by a diagnostic neuroradiologist and interventional neurologist based on contiguous ischemic changes in a pattern consistent with proximal LVO on a non-contrast computed tomography head. We examined factors associated with presumed LVO using logistic regression analysis. Inter-observer Kappa was calculated.ResultsWe enrolled 158 first-ever ischemic strokes over 8 months with a mean age of 59.7 years. Presumed LVO accounted for 39.2% [95% confidence interval (CI) 31.6–47.3%] and an overall meantime from the onset of stroke symptoms to hospital arrival was 1.74 days. Participants with presumed LVO were more likely to involve the middle cerebral artery (MCA) territory (70.9%), p < 0.0001. Independent factors on multivariate analysis associated with presumed LVO were hypertension [adjusted odds ratio (aOR) 5.74 (95% CI: 1.74–18.9)] and increased waist-hip ratio [aOR 7.20 (95% CI: 1.83–28.2)]. One-year mortality in presumed LVO was 80% when compared with 73.1% in participants without presumed LVO. The Cohen's Kappa inter-observer reliability between the diagnostic neuroradiologist and interventional neurologist was 0.847.ConclusionThere is a high burden of presumed LVO associated with high rates of 1-year morbidity and mortality at a tertiary academic hospital in Tanzania. Efforts are needed to confirm these findings with definitive vessel imaging, promoting cost-effective preventive strategies to reduce the burden of non-communicable diseases (NCDs), and a call for adopting endovascular therapies to reduce morbidity and mortality.

Mechanical Thrombectomy Global Access For Stroke (MT-GLASS): A Mission Thrombectomy (MT-2020 Plus) Study

“…It is prudent to understand the reasons for this underuse in LMIC and to identify obstacles that can be solved in the least resource-intensive manner. Underuse could be because of delays in reaching the MT center, 48,49 which could in turn be because of multiple interconnected factors such as lack of public awareness about stroke and stroke centers, 50,51 primary physician knowledge gaps and reluctance to refer, 52,53 nonexistent prehospital ambulance system, and lack of EMS training. To achieve a cohesive system of care, a regional understanding of these factors followed by customized local solutions to enhance and incentivize use of the existing infrastructure needs to be pursued in parallel with careful planning for additional infrastructure.…”

Late Window Imaging Selection for Endovascular Therapy of Large Vessel Occlusion Stroke: An International Survey

“…Adherence to these guidelines may not be practical or necessary in many practice paradigms, especially in lower resource settings 4,10,11 or more generally when additional imaging may incur unnecessary delays to treatment. 12,13 Access to acute MRI or CTP is not readily available 24/7, within acceptable delays, or performed across many stroke centers.…”

“…12,13 Access to acute MRI or CTP is not readily available 24/7, within acceptable delays, or performed across many stroke centers. 11,[14][15][16] In a survey of imaging resources across 17 countries in Africa, CT scan was available in all countries, whereas CTP was available in only 2 countries, and MRI available in 16 countries. Whether or not these imaging modalities were available in an acute emergency was not reported.…”