Research Article ISSN 2641-4333

Neurology - Research & Surgery

Management of The Acute Serious Strokes in Sub-Saharan Africa: Case of

Togo
Josué Euberma Diatewa1,2,3*, Kossivi Apetse2, Marleine Djobosse2, Komi Assogba2, Michel KF Tassa2
and Agnon Ayélola Koffi Balogou2

Unit of Neurology, Department of Medicine, Makélékélé

1
Correspondence:
*
Hospital, Brazzaville, Congo. Diatewa Josué Euberma, Unit of Neurology, Department of
Medicine, Makélékélé Hospital, Faculty of Health Sciences,
2
Department of Neurology, University Hospital-Campus of Marien NGOUABI University, Brazzaville, Congo, BP 15117,
Lomé, Togo. Tél: 00 242 050951699.
Faculty of Health Sciences, Marien NGOUABI University,
3
Received: 20 April 2019; Accepted: 09 May 2019
Congo.

Citation: Josué Euberma Diatewa, Kossivi Apetse, Marleine Djobosse, et al. Management of The Acute Serious Strokes in Sub-
Saharan Africa: Case of Togo. Neurol Res Surg. 2019; 2(1): 1-7.

ABSTRACT
Introduction: Serious strokes are a particular evolutive form of strokes. They present significant diagnostic and
therapeutic challenges.

Objectives: To describe diagnostic and therapeutic aspects of acute serious strokes.

Methods: A prospective cohort study was carried out from January 1st 2015 to December 31th 2016 (2 years)
at neurology department of University Hospital Campus. It included patients with acute serious strokes. Clinical
features, brain imaging findings, therapeutic measures and outcome were evaluated.

Results: Of the 1964 strokes diagnosed, there were 163 cases of acute serious strokes (8.3%). Among of the latter,
it was noted 100 (61.3%) hemorrhages and 63 (38.7%) arterial infarcts. Supra tentorial damage location was
predominant (77.3%). Main etiologies of hemorrhages and arterial infarcts were, respectively, hypertension
(83.5%) and atherosclerosis of large arteries (84.1%). Rates of patients hospitalized within 4:30 hours (arterial
infarcts) and 8:00 hours (hemorrhages) were, respectively, 20.6% and 40%. In the same time ranges, rates of
CT scan performing were 4.8 and 6% in patients with arterial infarcts and hemorrhages, respectively. Minimum
resuscitation measures and active therapies were implemented in patients. Mortalities in 7 and 15 days were,
respectively, 32.5% and 12.3 %. Overall mortality (44.8%) was correlated with diagnosis and treatment delay, and
active therapy limitations, in addition to the predictive factors of mortality.

Conclusion: Real problems of acute serious strokes management remain in Togo. They have a negative effect on
the vital and functional prognosis. Because of that, it is important to strengthen therapeutic management resources
and preventive measures.

Keywords intensive care unit. Their management requires the use of targeted
Serious strokes, Diagnosis, Treatment, Sub-Saharan Africa, Togo. active therapies, such as thrombolysis/thrombectomy and
endovascular treatment, in addition to resuscitation measures [3,4].
Introduction
Severity of strokes is variable. Serious stroke is defined as a stroke Only a small ratio of patients with serious strokes is hospitalized
that is life-threatening and/or will cause disabling sequelae [1,2]. at intensive care unit and neurovascular intensive care unit [3].
Management of targeted active therapies is limited and carried out
Serious strokes have some peculiarities that can justify the at neurology departments. This management is often encouraged
admission of patients at the intensive care unit and neurovascular by parents who take into account unfavourable vital and functional
Neurol Res Surg, 2019 Volume 2 | Issue 1 | 1 of 7
prognosis. Palliative approach observed in nearly 53% of cases is Stroke Score; arterial pressure and temperature at hospital
decided within 24 hours [5]. admission; information from brain imaging. In the case of the
variable "information from brain imaging", it was noted:
In sub-Saharan Africa, palliative approach is almost systematic and - in the case of hemorrhages: the anatomical localization
global, because neuro-diagnostic (CT scan, MRI and angiography) (meningeal or parenchymal); the extension in height (cortico-
and therapeutic (neurovascular intensive care unit, thrombolysis subcortical or to the brainstem if sus tentorial location; bulbar,
and/or thrombectomy) resources are limited [6,7]. Because of protuberant or peduncular if localization at the brainstem); the
that, challenges related to acute serious stroke management are possible presence of complications (ventricular contamination or
numerous. flood, axial involvement, hydrocephalus). Extent of parenchymal
lesions was determined using volume and maximum transverse
In sub-Saharan Africa, serious stroke data reported in literature diameter;
result from search released at intensive care units [6,8]. Those - in the case of arterial infarcts, the topography according to the
which come from neurology departments without neurovascular affected arterial territory. Carotid artery infarct was defined as
intensive care unit are missing. a homolateral occlusion simultaneously present in the middle
cerebral artery and anterior cerebral artery.
In this paper, we focus on acute serious stroke management at
neurology department of University Hospital Campus of Lomé. Inclusion criteria were: age over 18 years old; diagnosis delay
Our department has not a neurovascular intensive care unit. The lower 8 days; patient’s parents who agreed to take part in the study
purpose of this study is to describe diagnostic and therapeutic after informed consent.
aspects.
Not included in the study: patients whose serious stroke diagnosis
Methods was not confirmed by brain imaging; patients whose biological
This prospective cohort study focused on patients with acute serious examination (blood count; erythrocyte sedimentation rate;
stroke. It was conducted, from January 1st 2015 to December 31st plasma activity levels of aspartate aminotransferase and alanine
2016, at neurology department of University Hospital Campus of aminotransferase; plasma concentrations of glucose, urea and
Lomé. creatinine, serum creatinine; serological evaluation of human
immunodeficiency virus) and first-line check-up were incomplete;
Serious stroke was defined as a stroke in which: subdural hematomas; cerebral venous thromboses; post-traumatic
• National Institute of Health Stroke Score and Glasgow Score hemorrhages.
were, respectively, higher 17 and lower 9;
• neuroimaging revealed: Etiological research was performed using MRI and/or cerebral
- for the case of hemorrhages, the meningeal hemorrhage classified angioscan, cardiac echo-Doppler and supra aortic trunks,
as stages 3 and 4 according to the Fisher classification, posterior coagulation assessment, standard electrocardiogram (ECG) and
fossa hemorrhage, cerebral hemorrhage with ventricular flood and ECG Holter of 24 hours for patients whose strong suspicion of
mass effect/axial involvement; cardio embolic origin was retained despite the normal standard
- for the case of arterial infarcts, the damage of posterior fossa ECG. Arterial infarct etiologies were grouped according to the
structures and/or extensive cerebral damage related to the occlusion Toast classification [11].
of large arterial trunks with cardio embolic or atheromatous origin
[1,2,9-11]. For the therapies offered for patients, there were the targeted active
therapies, minimum measures of resuscitation (conventional
In addition, serious strokes were grouped into two classes: oxygenation, cardiopulmonary resuscitation, anti-edematous,
- very serious strokes in which ranges of National Institute of sedatives, hemodynamic balance), decision-making process
Health Stroke Score and Glasgow Score were, respectively, 17–20 (transfer to intensive care unit and palliative approach).
and 7–9;
- extremely serious strokes in which National Institute of Health In the case of arterial infarcts, active therapies were used according
Stroke Score and Glasgow Score were, respectively, higher 20 and to the protocols established in our department. On account of
lower 7. thrombolysis that is not available in Togo, following therapies were
offered for patients: intravenous aspirin at 1 g/day for 5 days, then
Diagnoses of serious strokes were based on neuroimaging and platelet antiaggregant relay at 250 mg/day if emboligenic heart
clinical features [1,2]. CT scan was released in all patients in the disease excluded, hospital admission before 5:00 hours, motor
first position. MRI without axial diffusion sequence owing to low deficit and moderate lesion extent, absence of prior arterial infarct,
magnetic field (0.5 tesla) was performed in delayed time. National Institute of Health Stroke Score range of 17–20 and age
under 80 years old; heparin with curative dose if emboligenic heart
Clinical variables were: clinical history; modifiable cardiovascular disease and HAS-BLED Score lower 3 for the case of extended
risk factors; inaugural symptomatology; depth of loss arterial infarct; decompressive hemi-craniotomy in the case of
consciousness; Glasgow Score and National Institute of Health extended middle cerebral artery infarct and carotid artery infarct
Neurol Res Surg, 2019 Volume 2 | Issue 1 | 2 of 7
for patients under 60 years old, hospitalized within 48 hours and Median hospital admission time determined from symptom onset
having no associated comorbidity. was 82 hours at least, with limits of: 1 and 720 hours. Of the 63
patients with arterial infarct, 13 (20.6%) were hospitalized within
In the case of hemorrhages, external ventricular drainage or 4:30 hours. Among the 100 patients with hemorrhages, 40 (40%)
sub-occipital craniotomy was indicated as an active therapy for (40/100) were hospitalized within 8:0 hours.
infra tentorial hematomas and stereotaxis for deep compressive
hematomas with or without hydrocephalus and if patients Hospitalization was mainly caused by motor deficit (76.1%),
hospitalized within 8:0 hours [4]. impairment of consciousness (62.6%) and headache (20.9%).

Outcome was evaluated by means of mortality in 7 days and Disease onset was abrupt and in successive shocks sequential during
mortality in 15 days. SPSS software version 21 was used for 24 to 48 hours in 156 (96%) and 7 (4%) patients, respectively.
statistical analysis. Qualitative and quantitative variables were There was no particular schedule for symptom onset in all patients.
assessed, respectively, by the frequencies and averages associated
with standard deviation. To demonstrate a significant difference At hospital admission, patients had a mean temperature of 37 ±
between two quantitative variables, Fisher’s test was used. 3°C, average arterial pressure of 170.6/170.6 ± 36/20.6 mm Hg,
Comparison of two groups was released by Pearson correlation average Glasgow Score of 10.03 ± 7.5 and average National
test. P value of < 0.05 was considered as statistically significant. Institute of Health Stroke Score of 22.8 ± 8.9.

Results Disease onset was correlated with elevated arterial pressure (p =

Epidemiological data 0.04), excessive alcohol consumption (p = 0.02), stroke history
Of the 1964 diagnosed strokes, 216 cases of serious strokes were (p = 0.004), obesity (p = 0.003) and hypercholesterolemia (p =
identified. On account of the lack of brain imaging, 53 patients 0.008).
(24.5%) were excluded. Thus, prevalence of serious strokes was
8.3% (95% CI: 7.1 - 9.5%). Impairment degree of consciousness was correlated with elevated
arterial pressure (p = 0.01).
Among the 163 serious strokes, there were 63 arterial infarcts Neuroimaging data.
(38.7%) and 100 hemorrhages (61.3%). It was also noted 82 men
(50.3%) and 81 women (49.7%). Mean age of patients was 55.8 ± Median performing time of CT scan determined from symptom
12.9 years old, with limits of 20 and 86 years old. onset was 60.21 ± 71.51 hours, with limits of 1 and 720 hours. CT
scan was performed within 4:30 and 8:00 hours, respectively, in 3
A history of stroke was noted in 26 patients (16%). Of the latter, (4.8%) and 6 (6%) patients with arterial infarct and hemorrhage.
23 patients had initially presented arterial infarct. Among the 23
patients, 18 had sequela with a modified Rankin score ≥ 2. Mean MRI was released in delayed time in 27 patients (16.6%) whose
age of stroke history was 5.15 ± 4.25 years. CT scan was not very efficient. It was also performed to search
The Figure 1 presents medical history and modifiable cardiovascular vascular malformation or bleeding tumor in 24 patients and
risk factors. follow-up 2 patients with vertebrobasilar artery infarct (n = 2) and
1 patient with extended middle cerebral artery infarct.

Starting point of hemorrhages was meningeal (Figure 2) and

parenchymal in 8 and 92 patients, respectively. Mean maximum
transverse diameter of hematomas was 43.8 ± 19.6 mm, with
hematoma volume of 15–25 ml in 55% of cases, > 25 ml in 37% of
cases and < 15 ml in 8% of cases. Diencephalon was starting point
for bleeding in 75 (75%) patients with midbrain extension among
7 of them. Brainstem and cerebellum were affected, respectively,
in 20 (20%) and 5 (5%) patients. Of the 20 brainstem hematomas,
7 were protuberant, 4 mesencephalic, and 9 extended. The latter
were initially protuberant before being extended to the bulb (n = 2)
or mesencephalon (n = 7).
Figure 1: Medical history and modifiable cardiovascular risk factors of
serious strokes.
Among the patients with extended hematomas, 76 had encephalic
complications: ventricular flood (n = 38, 50%), axial involvement
Diagnostic data (n = 24, 31.6%), and hydrocephalus. associated with ventricular
Clinical data flooding (n = 14, 18.4%) (Figure 3). The presence of encephalic
Strokes were very serious and extremely serious in 89 (54.6%) and complications was correlated with hematoma volume (> 15 ml) (p
74 (45.4%) patients, respectively. = 0.0003), maximum transverse diameter (p = 0.04) and elevated

Neurol Res Surg, 2019 Volume 2 | Issue 1 | 3 of 7

arterial pressure (p = 0.005). Table 1 presents arterial territories (alcoholic cirrhosis) (1%); unknown origin (9%). Arterial infarcts
affected among patients with arterial infarct. were grouped into 2 classes, according to the Toast classification:
atherosclerosis of large arteries (84.1%) (Figure 4) and embolism
(15.9%) (Figure 5). Cardiac sources of cerebral embolism were
at high risk in 25 (39.7%) patients (atrial fibrillation with left
ventricular thrombus) and moderate risk in 38 (60.3%) patients
(segmental hypokinesia of the left ventricle with sinusal cardiac
rhythm).

Figure 2: Meningeal hemorrhage classified as stages 4 according to the

Fisher classification.

Figure 4: CT-Scan showing large left pontic infarct by basilar trunk

occlusion of atheromatous origin.

Figure 3: Extended hematomas complicated by ventricular flood, axial

involvement and hydrocephalus.

Artery Number Percentage

Middle cerebral 48 76,2
Posterior inferior cerebellar 5 7,9 Figure 5: CT-scan showing a left Carotid artery infarct du to a embollism
Carotid 3 4,8 origin.
Anteroinferior cerebellar 2 3,2 Therapeutic and outcome measures
Superior cerebellar 2 3,2 Table 2 Indicates minimum resuscitation measures implemented
Basilar trunk 1 1,6 in patients.
Vertebral 1 1,6 Resuscitation measure Number Percentage
Anterior spinal 1 1,6 Conventional oxygenation 148 90.8
Total 63 100 Hemodynamic balance 39 23.9
Table 1: Arterial territories affected in patients with arterial infarct. Sedative 25 15.3
Glycemic control 14 8.6
Etiologies of hemorrhages were: presumed hypertensive (81%); Table 2: Minimum resuscitation measures implanted in patients with
aneurysm rupture (9%); acquired disorder of coagulation serious stroke.

Neurol Res Surg, 2019 Volume 2 | Issue 1 | 4 of 7

Neurosedation with benzodiazepines or anxiolytics was used to literature (64-65 years old) [6,12]. These results could be explained
reduce anxiety and treat the patients with agitation. Its effectiveness by the residence in urban areas, work-related or low income-
was noted in 58.2 % of cases. related stress and lifestyle changes that increase the prevalence of
modifiable cardiovascular risk factors [7,14-16].
Following active therapy limitations were decided by the parents:
oxygenation stopping (n = 17; 10.4%), no cardiopulmonary Literature reports that patients who present a serious arterial infarct,
resuscitation (n = 2; 1.2%), reduction of complementary notably, an extended middle cerebral artery infarct, have already
examinations (n = 49; 30.1%;) and refusal to transfer the patient developed a first ischemic episode [14]. Our results corroborate
from neurology department to intensive care unit (n = 48; 29.5%). this epidemiologic finding. Because of that, it is important to
The latter was decided by the parents with practitioner advice for strengthen secondary preventive measures in order to prevent
47(28.8%) patients. serious stroke onset.

Patients with arterial infarct (n = 30) and hemorrhage (n = 60), Diagnostic aspects
who presented edema, were treated with hypertonic solutes. CT scan used as a first-line examination for the positive diagnosis
of serious strokes in our study is very efficient. MRI is difficult
Heparin and platelet aggregation inhibitor were administered in to access in emergency state because of the limited financial
patients whose the origin of arterial infarct was not cardio-embolic resources of patients or their parents. Thus, it was performed in
(n = 53). Anticoagulation with heparin at curative dose followed delayed time in patients with CT scan not efficient. It also used
by vitamin K antagonists was used to treat the patients whose to search vascular malformation or bleeding tumor and follow-
the origin of arterial infarct was cardio-embolic (n = 5). Patients up patients with vertebrobasilar artery infarct or extended middle
with occlusion of large vertebrobasilar arterial trunks (n = 5) were cerebral artery infarct [7,17].
treated with aspirin.
In our study, rate of serious hemorrhages related to aneurysms
Surgical therapies (decompressive hemi-craniotomy, external and unspecified origin could result from the inadequate technical
ventricular derivation, sub-occipital craniotomy and stereotaxis) resources. Insufficiency of the latter does not allow carrying out a
did not implement in patients. complete and appropriate etiological search.

Mortality during the first 7 days was 32.5% (n = 53). Of the 53 Origin of serious arterial infarcts is most often cardioembolic [18].
deaths, there are 37 hemorrhages and 16 arterial infarcts. In 15 In our study, origin is poorly represented. This result could be
days, we noted a stabilization of the clinical state in 90 (81.8%) explained by:
patients and an aggravation with death in 20 (18.2%) patients. - the difficulty in confirming origin owing the coexistence of
Thus, overall mortality was 44.8%. atherosclerosis [11];
- the performing of 24-hour ECG only in patients strongly suspected
Overall Mortality was correlated with hematoma volume (p = of having a cardio-embolic arterial infarct, despite the variable
0.001), presence of encephalic complications (p = 0.003), high embolic risk of some patients. For this purpose, a long-term ECG
arterial pressure (p = 0.004), deep decrease of consciousness (average time: 3 days) and transesophageal echocardiography
level at hospital admission (p = 0.0001), treatment (minimum must be carried out in all patients with serious arterial infarcts. The
resuscitation measures) delay (p = 0.0003) and limitations of optimization of diagnosis of paroxystic atrial fibrillation, as well
therapeutic measures (p = 0). as the visualization of various cardiac abnormalities in absence of
cardiac history (thrombus of left atrium, foramen oval and/or atrial
Discussion septal aneurysm, aortic plaques) in a patient with sinus rhythm,
Epidemiology would be guaranteed [7].
Prevalence of serious strokes in the present study is lower than
those reported in literature (27%) [5]. This low prevalence could be Therapeutic aspects
explained by the exclusion of 53 patients who had not confirmation Elevated median times of hospital admission and radiological
brain imaging, choice of study department, early deaths before examination implicate a treatment delay, as well as a great
admission of patients at neurology department. However, our variability in the therapeutic management. This delay could be
prevalences of hemorrhages and arterial infarcts are situated in explained by the absence of mobile emergency units [17], serious
the ranges reported in literature: 46.6-78.7% for hemorrhages and state of patients which requires a stabilization, distance between
21.3-44.6% for arterial infarcts [8,12]. the department of medical imaging and that of neurology in
University Hospital Campus of Lomé, limited financial resources
Literature data reveal that annual incidence of hemorrhages is of patients.
higher than that of arterial infarcts [13]. This epidemiological
finding is also noted in our study. Use of minimum resuscitation measures in patients with serious
strokes is open to discussion. Artificial ventilation with intubation
The average age of our patients is lower than those reported in is more effective than conventional oxygenation [3]. Because of
Neurol Res Surg, 2019 Volume 2 | Issue 1 | 5 of 7
that, conventional oxygenation would be only performed in 5-8 therapeutic resources and limited financial resources of patients
% of cases [19]. In our study, conventional oxygenation is greatly or their parents. These problems have a negative effect on the
used (Table 2) because of the lack of neurovascular intensive care vital and functional prognosis. Because of that, it is important to
unit and/or decision of parents to limit active therapies that is strengthen therapeutic and preventive measures.
caused by the low yield of intensive resuscitation [3,6].
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