Khan, Hamzullah

Zarif, Muhammad

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Pakistan Journal ofNeurological Sciences (PJNS)Volume 2 | Issue 4 Article 312-2007Etiology and Disturbance of ConsciousnessinStroke: A Hospital-Based StudyHamzullah KhanKhyber Medical CollegeMuhammad ZarifKhyber Medical CollegeFollow this and additional works at: https://ecommons.aku.edu/pjnsPart of the Neurology CommonsRecommended CitationKhan, Hamzullah and Zarif, Muhammad (2007) "Etiology and Disturbance of Consciousnessin Stroke: A Hospital-Based Study,"Pakistan Journal of Neurological Sciences (PJNS): Vol. 2 : Iss. 4 , Article 3.Available at: https://ecommons.aku.edu/pjns/vol2/iss4/3Stroke is a clinical syndrome characterized by rapidlydeveloping symptoms and signs of focal, and at timesglobal, loss of cerebral functions, with symptoms lastingmore than 24 hours or leading to death with no apparentcause other than that of vascular origin.1 According to aWorld Health Organization report from 2002, totalmortality due to stroke in Pakistan was 78,512.2In India, China, the Philippines, Thailand, Sri Lanka, Iran,Pakistan, and Nepal there has been a rapid increase instroke mortali t y concurrent  wi th prevalence ofhypertension. The prevalence of hypertension variesbetween 15-35% in urban adult populations of Asia. Inrural populations, the prevalence is 2-3 times lower thanin urban subjects.3 In a study from Abbotabad, Pakistan,hypertension was found to be the most common riskfactor for stroke, with peak stroke prevalence seen duringthe seventh decade of life in males and the sixth decadein females.4The National Action Plan for Non-Communicable DiseasePrevention, Control and Health Promotion in Pakistan(NAP-NCD) incorporates prevention and control ofcardiovascular diseases as part of a comprehensive andintegrated non-communicable diseases prevention effort.It promotes population-based blood pressure screening,along with screening for dyslipidemia and diabetesmellitus in high-risk groups. This program underscores theneed to conduct clinical end-point trials in the nativePakistani setting to define cost-effective therapeuticstrategies for primary and secondary prevention ofvascular diseases and their complications, includingstroke.5 The present study was therefore designed in orderto further these aims.METHODSThis was a prospective observational study conducted atKhyber Teaching Hospital (Peshawar) from June 2005through August 2006.Stroke was defined as a focal neurological deficit due tovascular lesions (either cerebral infarction or hemorrhage),V O L .  2 ( 4 )   O C T - D E C  2 0 0 7P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  210O R I G I N A L  A R T I C L EETIOLOGY AND DISTURBANCE OF CONSCIOUSNESSIN STROKE: A HOSPITAL-BASED STUDY Hamzullah Khan and Muhammad ZarifKhyber Medical College, Peshawar, PakistanCorrespondence to: Dr. Khan, Department of Neurology, Khyber Medical College, Post office: campus branch, University of Peshawar, Postal code: 25120, Peshawar, Pakistan. Tel: +92-301-591-2063 , Email: hamza_kmc@yahoo.comPak J Neurol Sci 2007; 2(4): 210-12ABSTRACTObjective: To determine the prevalence of stroke risk factors and decreased consciousness level in patients with stroke.L o c a t i o n : Medical wards of Khyber Teaching Hospital, Peshawar, from June 2005 through August 2006. M e t h o d s :Patients with stroke (cerebral infarction or hemorrhage) admitted to our facility were evaluated for clinical strokecharacteristics and the presence of stroke risk factors through a structured questionnaire. Results: One hundred and eighty-three patients were included. Forty-seven (25.68%) had more than one risk factor. Age range was 31-92 years (mean 57years). There were 111 (60.65%) males and 72 (39.34%) females. The distribution of risk factors was: hypertension 95(51.91%), diabetes mellitus 56 (30.60%), hyperlipidemia 21 (11.47%), smoking 23 (12.56%), ischemic heart disease 21(11.47%), atrial fibrillation 5 (2.73%), obesity 5 (2.73%), physical inactivity 2 (1.09%), history of heparin or warfarin use2(1.09%) and history of oral contraceptives 1 (0.54%). Severity of unconsciousness was assessed by the Glasgow comascale in 122 (66.67%) patients; 42.62% had a score >10, 35.24% scored between 6-10, and 22.13% had a score <6.Conclusion: Hypertension, diabetes, hyperlipidemia and smoking are the major modifiable risk factors for stroke in ourpatient population. Over half of our patients had an unsatisfactory Glasgow coma scale score, indicating a worse prognosis.V O L .  2 ( 4 )   O C T - D E C  2 0 0 7P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  211confirmed on CT scanning.3 Patients with focal deficitsfrom causes other than stroke (such as trauma orintracranial mass lesions) were excluded from this study.Hypertension was defined as a history of systolic bloodpressure > 140 mmHg and/or diastolic BP > 90 mmHg onmore than one occasion. Diabetes was diagnosed asfasting blood glucose > 126 mg/dl on more than oneoccasion and random blood glucose > 200 mg/dl on morethan one occasion. Patients were labeled as hyperlipidemicif total serum cholesterol was > 240 mg/dl, and/or serumtriglyceride level was > 200 IU/dl. Patients with a history ofcoronary artery disease, diagnosed and confirmed by acardiologist, were also recorded.6Prevalence of risk factors was recorded on a structuredquestionnaire. Level of consciousness was assessed withthe help of the Glasgow coma scale system. We dividedour patients into three groups: Group A with score > 10,Group B with score between 6-10, and Group C with score<6.7 RESULTSA total of 183 patients met the inclusion criteria and wereselected for the study. Age range was from 31-92 years(mean age 57 years). There were 111 (60.65%) malesand 72 (39.34%) females.The distribution of risk factors was as follows: hypertension95 (51.91%), diabetes mell itus 56 (30.60%),hyperlipidemia 21 (11.47%), smoking 23 (12.56%),ischemic heart disease 21 (11.47%), atrial fibrillation 5(2.73%), obesity 5 (2.73%), physical inactivity 2 (1.09%),history of heparin or warfarin use 2 (1.09%), and historyof using oral contraceptives 1 (0.54%). These data aresummarized in Table 1.In 122 (66.67%) patients, we were able to asses the levelof consciousness using the Glasgow coma scale. Of these,42.62% had a score > 10, 35.24% scored between 6-10, and 22.13% had a score < 6. DISCUSSIONStroke is a major cause of mortality and morbidity,associated with disability and social dependence. In theWestern world, stroke is the third commonest cause ofdeath after heart disease and all cancers.8 According to aWHO report from 2003, disability-adjusted life years(DALYs) lost due to stroke per 1000 population is 5-9years in Pakistan, 10-14 in India, 15-19 in Russia, and20 or greater in Mongolia.Hypertension was identified as the major modifiable riskfactor for stroke in our study, noted in 51.91% of patients.Our findings correlate with findings from elsewhere inPakistan, including Karachi (50%)9 , 1 0 and Abbotabad( 5 2 % ) .6 Diabetes mell i tus was the second majormodifiable risk factor for stroke in our patients, with aprevalence of 30.60%. Our findings correlate with otherstudies, including reports by Basharat (21%)10 and Liaqat(27%).11 Hyperlipidemia was recorded in 11.47% patientspresenting with stroke, which matches with published data(16%).12Smoking was recorded as a modifiable risk factor in12.56% cases. The respective population-attributablefraction for current smoking has been reported to be22.0% for lacunar and 11.4% for non-lacunar stroke. ThePAF for elevated von Willebrand factor was greater thanthat for current smoking for cardioembolic stroke.13In 122 patients, we also assessed level of consciousnessusing the Glasgow coma scale. Our findings correlate withthe findings of a study conducted in Dublin, in which areduced Glasgow coma scale and larger strokes wereassociated with shorter delays to presentation. Longerdelays occurred in patients living alone. There weresignificant delays in referral to, and assessment by, certainrehabilitation disciplines. Delayed presentation in stroke isa barrier to thrombolysis. Increasing public awareness mayreduce this delay.14According to a study from the United States, intracerebralhemorrhage has a wide range of severity at presentation.TABLE 1Risk factors for stroke (n=183)Risk factors Number of patients (%)Hypertension 60 (32.78)Diabetes 20 (10.92)Hyperlipidemia 9 (4.91)Smoking 11 (6.01)Ischemic heart disease 21 (11.47)Hypertension and diabetes 23 (12.56)Hypertension and hyperlipidemia 3 (1.63)Hypertension and smoking 8 (4.37)Diabetes and hyperlipidemia 8 (4.37)Diabetes and smoking 4 (2.18)Diabetes, hyperlipidemia and hypertension 1 (0.54)Atrial fibrillation 5 (2.73)Use of heparin or warfarin 2 (1.09)Obesity 5 (2.73)Physical inactivity 2 (1.09)Use of oral contraceptives 1 (0.54)Hydrocephalus is a potentially reversible cause of a lowerGCS score. Since early withdrawal-of-care decisions areoften based on the initial GCS score, recognition of theimportant influence of hydrocephalus on GCS is warrantedbefore such decisions are made.15CONCLUSIONHypertension, diabetes mellitus, hyperlipidemia andsmoking are major modifiable risk factors for stroke in ourpopulation. A reduced Glasgow coma scale and largerstrokes were associated with high morbidity. Our findingsunderscore the needs for awareness, education, elevationof poverty, proper use of medication, and adoption ofhealthy life style, for stroke prevention. REFERENCES1. Davenport R, Dennis M. Neurological emergencies: acute stroke. J Neurol Neurosurg Psychiatry2000;68(3):277-88.2. Singh RB, Suh IL, Singh VP, et al. Hypertension andstroke in Asia: prevalence, control and strategies in developing countries for prevention. J Hum Hypertens 2000;14(10-11):749-63.3. Mackay J, Mensah GA. The Atlas of Heart Disease and Stroke: World Health Organization; 2004.4. Khan J, Attique ur R, Ali Shah A, Jielani A. Frequency of hypertension in stroke patients presenting at Ayub Teaching Hospital. J Ayub Med Coll 2006;18(1):59-61.5. Nishtar S, Faruqui AM, Mattu MA, Mohamud KB, Ahmed A. The National Action Plan for the Prevention and Control of Non-communicable Diseases and Health Promotion in Pakistan--Cardiovascular diseases. J Pak Med Assoc2004;54(12 Suppl 3):S14-25.6. Khan H, Afridi AK, Ashraf S. A Hospital based study on stratification of risk factors of stroke in Peshawar.Pak J Med Sci 2006;22(3):304-7.7. Working Party of the Royal College of Physicians; The vegetative state: guidance on diagnosis and management. Clin Med 2003:249-54(6).8. Michael JA. Nervous system. In: Lawrence M, Tierney JR, Stephen JM, Maxine AP, eds. Current Medical Diagnosis & Treatment 2004. 43 ed: McGraw-Hill/Appleton & Lange; 2004.9. Vohra EA, Ahmed WU, Ali M. Aetiology and prognostic factors of patients admitted for stroke. JPak Med Assoc 2000;50(7):234-6.10. Basharat RA, Elahi A, Tariq M, Saeed A. One-month audit of Stroke at PIMS. Pak J Neurol1999;5(1):12-5.11. Liaquat A, Jamil H, Alam MS. Risk factors in stroke. J Coll Physician Surg Pak; 1996:7-10.12. Tanveer A. Localization and management in Cerebrovascular accident: A comparison of clinical assessment versus CT Scan (Dissertation). J Coll Physician Surg Pak 1996:5-6.13. Ohira T, Shahar E, Chambless LE, Rosamond WD, Mosley TH, Jr., Folsom AR. Risk factors for ischemicstroke subtypes: the Atherosclerosis Risk in Communities study. Stroke 2006;37(10):2493-8.14. Pittock SJ, Meldrum D, Hardiman O, et al. Patient and hospital delays in acute ischaemic stroke in a Dublin teaching hospital. Ir Med J 2003;96(6):167-8, 70-1.15. Zahuranec DB, Gonzales NR, Brown DL, et al. Presentation of intracerebral haemorrhage in a community. J Neurol Neurosurg Psychiatry2006;77(3):340-4.V O L .  2 ( 4 )   O C T - D E C  2 0 0 7P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  212

Etiology and Disturbance of Consciousnessin Stroke: A Hospital-Based Study

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Etiology and Disturbance of Consciousnessin Stroke: A Hospital-Based Study

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