Stroke Epidemiology in Douala: Three Years Prospective Study in a Teaching Hospital in Cameroon

Abstract

Background and Objectives: Cerebro-vascular accident or stroke constitutes a major challenge in
sub-Saharan Africa. In Cameroon, basic epidemiologic data are not routinely available. Aims: The aim of this study was to determine the type, the associated risk factors, time to admission, the clinical presentation and the case fatality of stroke at the Douala General Hospital (DGH) in Cameroon. Methods: A cross-sectional study was performed from January 1, 2010 to December 31, 2012 at the neurology and intensive care units of the DGH. All patients above 15 years of age with a diagnosis of established stroke were enrolled. For each patient, socio-demographic, clinical and paraclinical data were recorded as well as the duration of hospitalization and the case fatality. Results: In all, 325 patients were enrolled with males constituting 68.1% and general mean age of 58.66 ± 13.6 years. The mean initial consultation delay was 47.36 ± 18.48 hours. The majors cerebro-vascular risk factors were hypertension (81.15%), chronic alcohol consumption (28.3%), diabetes mellitus (20.61%), obesity (18.15%), cigarette smoking (16%), dyslipidemia (8.9%) and atrial fibrillation (3.07%). Ischemic stroke accounted for 52% of cases while 48% were hemorrhagic. The mean duration of hospitalization was 8.58 ± 6.35 days with a case fatality rate of 26.8%. Septic conditions appeared to be the leading cause of death accounting for 35.6% of cases. Conclusion: Stroke in the DGH is associated with a high case fatality rate and hypertension remains the number one risk factor. There is a clear and urgent need for public health authorities to reinforce measures for the control of modifiable stroke risk factors.

Full text

World Journal of Neuroscience, 2014, 4, 406-414
Published Online November 2014 in SciRes. http://www.scirp.org/journal/wjns
http://dx.doi.org/10.4236/wjns.2014.45044
How to cite this paper: Mapoure, Y.N., Kuate, C., Tchaleu, C.B., Mbatchou Ngahane, H.B., Mounjouopou, G.N., Ba, H.,
Mbahe, S., Fonsah, J.Y., Beyiha, G., Luma, H.N., Mouelle, A.S., Ndouongo, P.K. and Njamnshi, A.K. (2014) Stroke Epidemiol-
ogy in Douala: Three Years Prospective Study in a Teaching Hospital in Cameroon. World Journal of Neuroscience, 4, 406-
414. http://dx.doi.org/10.4236/wjns.2014.45044
Stroke Epidemiology in Douala: Three Years
Prospective Study in a Teaching Hospital
in Cameroon
Yacouba N. Mapoure1,2, C. Kuate3, Clet B. Tchaleu2,4, Hugo B. Mbatchou Ngahane1,
Gérard N. Mounjouopou1, Hamadou Ba3, Salomon Mbahe2, Julius Y. Fonsah5,
Gérard Beyiha6, Henry N. Luma2,3, Albert S. Mouelle2, Philomène K. Ndouongo7,
Alfred K. Njamnshi3
1Department of Clinical Sciences, University of Douala, Douala, Cameroon
2Department of Internal Medicine, Douala General Hospital, Douala, Cameroon
3Department of Internal Medicine, University of Yaoundé I, Douala, Cameroon
4Department of Clinical Sciences, Université des Montagnes, Douala, Cameroon
5Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
6Department of Surgery, University of Douala, Douala, Cameroon
7Department of Neurology, University of Health Sciences, Libreville, Gabon
Email: mapoureyacouba@gmail.com
Received 25 August 2014; revised 26 September 2014; accepted 3 October 2014
Copyright © 2014 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/
Abstract
Background and Objectives: Cerebro-vascular accident or stroke constitutes a major challenge in
sub-Saharan Africa. In Cameroon, basic epidemiologic data are not routinely available. Aims: The
aim of this study was to determine the type, the associated risk factors, time to admission, the
clinical presentation and the case fatality of stroke at the Douala General Hospital (DGH) in Cam-
eroon. Methods: A cross-sectional study was performed from January 1, 2010 to December 31,
2012 at the neurology and intensive care units of the DGH. All patients above 15 years of age with
a diagnosis of established stroke were enrolled. For each patient, socio-demographic, clinical and
paraclinical data were recorded as well as the duration of hospitalization and the case fatality.
Results: In all, 325 patients were enrolled with males constituting 68.1% and general mean age of
58.66 ± 13.6 years. The mean initial consultation delay was 47.36 ± 18.48 hours. The majors cere-
bro-vascular risk factors were hypertension (81.15%), chronic alcohol consumption (28.3%),
diabetes mellitus (20.61%), obesity (18.15%), cigarette smoking (16%), dyslipidemia (8.9%) and
atrial fibrillation (3.07%). Ischemic stroke accounted for 52% of cases while 48% were hemor-
rhagic. The mean duration of hospitalization was 8.58 ± 6.35 days with a case fatality rate of
26.8%. Septic conditions appeared to be the leading cause of death accounting for 35.6% of cases.

Y. N. Mapoure et al.
407
Conclusion: Stroke in the DGH is associated with a high case fatality rate and hypertension re-
mains the number one risk factor. There is a clear and urgent need for public health authorities to
reinforce measures for the control of modifiable stroke risk factors.
Keywords
Stroke, Epidemiology, Risk Factors, Case Fatality, Douala, Cameroon
1. Introduction
Stroke is the second leading cause of death worldwide [1]. Over the last 20 years, modifications of the disease
epidemiology have been observed in Sub-Saharan Africa with emergence of non-communicable chronic dis-
eases like hypertension, diabetes mellitus, dyslipidemia and the obesity [2] [3]. On the other hand, substantial
modifications of lifestyle are also observed with increasing sedentary tendencies, alcohol consumption and to-
bacco smoking. All these conditions are prone to increase the incidence of stroke in this part of the world. Data
on stroke in Cameroon are scarce and are generally related to specific conditions [4]-[10].
2. Objective
The objective of this study was to determine the type, the associated risk factors, time to admission, the clinical
presentation and the case fatality of stroke at a reference hospital in Cameroon: the Douala General Hospital
(DGH).
3. Materials and Methods
3.1. Study Setting
Douala, the economic capital of Cameroon has a population of 3 million inhabitants, an equatorial climate and is
situated in the Gulf of Guinea. The DGH is a state-owned teaching hospital with 320 beds for the following de-
partments: paediatrics, surgery, gynaecology and obstetrics, cobaltotherapy, nephrology and haemodialysis, in-
tensive care, emergency, and internal medicine. The imaging department operates an 8-barettes CT scan allow-
ing for 24 hours daily service. Magnetic resonance imaging is available in Douala only in the private sector (the
cost of a brain MRI was 381.38 € at time of study). Stroke patients were hospitalized in the neurology unit (NU)
of the internal medicine department and those with severe conditions at admission were hospitalized in the in-
tensive care unit (ICU).
3.2. Study Design and Patient Management
A prospective cross-sectional study was performed from January 1st 2010 to December 31st 2012. All consenting
patients more than 15 years of age with clinical diagnosis of stroke and CT scan confirmation were enrolled. Pa-
tients with severe clinical state (Glasgow Coma Scale < 8/15 or septic shock) were admitted directly into ICU
while other cases were hospitalized in the NU. For each patient, socio-demographic, past medical history and
clinical data were recorded. Initial consultation delay for initial consultation was also accessed as difference in
time of onset of symptoms to time of consultation. The definitions of vascular risk factors are found in Table 1.
Upon admission, vital signs included blood pressure, pulse, respiratory rate, oxygen saturation, temperature,
capillary glycaemia and dipstick urine analysis were recorded. Neurological assessment was done by a neurolo-
gist or intensive care specialist or both. Interpretation of CT scans was done by both radiologists and neurolo-
gists. Electro-cardiography was systematically done for patient with ischemic strokes and for hypertensive pa-
tients with hemorrhagic strokes. For patients with ischemic stroke, transthoracic and supra-aortic Doppler ultra-
sound studies were done; except for critically ill patients. Blood samples were collected for standard assess-
ments including: a full blood count with platelet counts, urea and creatinine, electrolytes, fasting glucose, lipid
profile, prothrombin time, cephaline-kaoline time, uric acid, C-reactive protein, erythrocyte sedimentation rate
and HIV serology. Other tests were prescribed if required by the patients’ conditions: chest X-ray, urine culture,
haemoculture, thick blood film to check for Plasmodium falciparum. Patient follow-up was done daily for clini-

Y. N. Mapoure et al.
408
Table 1. Definition of vascular risk factors.
Vascular Risk Factors Definition
Hypertension -Patient with medical history of hypertension, treated or not. Or
-Patient with persistent high blood pressure > 140/90 mmHg after stroke
Diabetes Mellitus -Patient with medical history of diabetes, treated or not. Or
-Random serum glucose > or = 2 g/l. Or venous fasting glucose test > 1.26 g/l
Dyslipidemia
One of these conditions
-Patient with medical history of dyslipidemia or
-Total cholesterol > 2 g/l or
-Low density lipoprotein > 1 g/l or
-High density lipoprotein < 0.40 g/l or
Sleep Apnoea Disease
Suspected in patient with 3 of these conditions:
-Snoring when sleeping
-Apnea during sleeping
-Excessive diurnal sleepiness
-Can be associated with obesity
Alcohol Consumption Daily alcohol intake > 40 g/l
Obesity
2 methods were used
-the body mass index > 30: obesity
-and when it’s impossible to have the BMI, we used the abdominal circumference:
>102 cm in male and >88 cm in female
cal evaluation and any complications were recorded. In case of death, a staff meeting was held to ascertain the
cause of death. Oxygen was administrated if ambient oxygen saturation was less than 94%. Paracetamol was
administered to patients who developed a fever (body temperature superior to 37.5˚C) at a dose of 1g six-hourly.
Prevention of deep venous thrombosis and stress ulcers was done using prophylactic dose of enoxaparine (40
mg) and omeprazole (20 mg) respectively. An insulin protocol was set up when capillary glycaemia was above
1.4 g/l. Concerning blood pressure management, nicardipine was given intraveniously with an electric syringe in
case of high blood pressure with a target of 140 to 160 mmHg for systolic blood pressure in hemorrhagic stroke.
In ischemic stroke, early elevated blood pressure was not tempered with excepted when it was above 220 mmHg.
Aspirin (100 - 250 mg per day) was given in ischemic stroke while a curative dose of low molecular weight
heparin was used in case of atrial fibrillation with CHADS > 3, presence of intraluminal thrombus in a cerebral
artery or presence of blood clot in the heart. Antibiotics and arthemeter were administered in case of bacterial
infection and malaria respectively. Thrombolysis treatment is not yet practiced in Cameroon.
3.3. Statistical Analysis
We used the SPSS software version 20 to analyse data. Khi-square and Fisher tests were used to compare quali-
tative variables while the Student’s T test was performed for quantitative variables. P values < 0.05 were con-
sidered statistically significant.
3.4. Ethical Issues
We obtained clearance from the National Ethic Committee. The objective of the study and other relevant infor-
mation was explained to each patient or their relative and their (oral or written) consent was obtained.
4. Results
A total of 325 patients were enrolled with 258 (79.39%) from the NU and 67 (20.61%) from the ICU. There
were 201 males representing 68.1% of cases with a M/F sex ratio of 1.62. Figure 1 shows the distribution of pa-
tients according to age and sex while Table 2 presents the characteristics of the study population. The mean age
of male was 58.66 ± 13.06 years and the mean age of female at 61.56 years (P = 0.002). Some 127 patients
(39.1%) were admitted directly from their homes while 198 (61.1%) were referred from public health care cen-
tres (109 cases) and private clinic (89 cases).
Table 3 gives the known cerebro-vascular risk factors (CVRF) before stroke considering the nature of stroke.

Y. N. Mapoure et al.
409
Table 2. Sociodemographic characteristics of patients.
Number (n) Percentage
Instruction Level
Illiterate 35 7.7
Primary 73 16.3
Secondary 99 23.7
University 118 28.6
Total 325 100.0
Profession
No 156 48.0
Yes 169 52.0
Total 325 100.0
Care’s Payment
Insurance 53 16.3
Individual 11 3.4
Individual and Family 29 8.9
Family Alone 232 71.4
Total 325 100.0
Patient’s Residence
Douala 207 63.7
Littoral 42 12.9
Other Region 71 21.8
Abroad 5 1.5
Total 325 100.0
Table 3. Known cerebro-vascular risk factors in patients.
Stroke Risk Factors Ischaemic N (%)* Haemorrhagic N (%)** Total N (%)*** P
High Blood Pressure
Alcohol
Diabetes
Overweigh/Obesity
127 (74.71%)
50 (29.42%)
49 (28.83%)
42 (24.705)
100 (64.52%)
42 (27.10%)
18 (11.62%)
17 (10.96%)
227 (69.84%) 0.46
92 (28.30%) 0.64
67 (20.61%) 0.00
59 (18.15%) 0.02
Tobacco
Past History of Stroke 28 (16.47%)
24 (14.12%) 24 (15.49%)
14 (9.04%) 52 (16%) 0.80
38 (11.69%) 0.15
Dyslipidemia
Other Emboligenic Cardiopathy 21 (12.36%)
21 (12.36%) 08 (5.17%)
05 (3.23%) 29 (8.9%) 0.02
26 (8%) 0.02
Sleep Apnoea Syndrome 06 (3.53%) 05 (3.23%) 11 (3.38%) 0.88
Atrial Fibrillation 09 (5.30%) 01 (0.65%) 10 (3.07%) 0.01
HIV Seropositivity 05 (2.95%) 05 (3.23%) 10 (3.07%) 0.56
* = Percentage relative to ischemic stroke (N = 170); ** = Percentage relative to hemorrhagic stroke (N = 155); *** = Percentage relative
to the total study population (N = 325); P = 0.05: Level of significance comparing ischaemic and haemorrhagic strokes.

Y. N. Mapoure et al.
410
Figure 1. Distribution of patients according to age group and sex.
The prevalence of hypertension was 81.53% (265 cases out of which 38 cases were de novo new cases of high
blood pressure). The situation was similar for diabetes mellitus and dyslipidemia where 10 and 16 new cases
were diagnosed giving a prevalence of 23.69% and 14.15% respectively. Fourteen new cases of atrial fibrillation
were diagnosed giving a prevalence of 13.53% during ischemic stroke.
The mean delay from the onset of symptoms suggestive of stroke and the initial consultation was 47.36 ±
18.48 hours (1 to 441.75 hours). The mean delay for consultation at the DGH was 96.37 ± 64.99 hours (range: 1
to 720 hours). Only 84 patients (25.84%) consulted in the DGH before 4.5 hours from the beginning of symp-
toms.
Table 4 shows the clinical characteristics on admission. Up to 167 patients (51.3%) had a capillary glycaemia
above to 1.4 g/l and the temperature was above or equal to 38.5˚C for 29 (8.9%) patients. The Glasgow coma
score was inferior or equal to 8/15 for 58 (17.8%) patients. Urine analysis showed a suspicion of urinary tract
infection based on the presence of both nitrite and leucocytes in 31 patients (9.53%). Glucosuria, proteinuria and
cetonuria were positive in respectively 85 (26.25%), 34 (10.46%) and 31 (9.53%). Figure 2 shows the different
types and subtypes of stroke. Ischemic and haemorrhagic strokes represented respectively 52% and 48% of
cases. Strokes were associated with one or more comorbid conditions as shown on Table 5. The global (NU and
ICU) mean duration of hospitalization was 8.56 ± 6.35 days. The case fatality rate was 26.8%. Septic conditions
appeared to be the leading cause of death in 35.6%.
5. Discussion
Although stroke is the second cause of death and the first cause of acquired handicap worldwide, its incidence in
the general population remains poorly studied in sub-Saharan Africa [11]. In Cameroon, some studies have been
carried on patients in the intensive care units [7] [8], sickle cell children [4] [6] and on risk factors of stroke [5]
[10]. The only study that employed modern imaging technique (CT or MRI) is that of Chiasseu and Mbahe [9]
although it looked mainly at less severe stroke in a small sample and very little information was reported on
stroke subtypes. The study we report in this paper included cases in the intensive care and neurology units al-
lowing a better sample size to study epidemiological features of stroke.
The mean age of the patients was 58.66 ± 13.06 years and was higher in women than in men. Sagui et al. in
Dakar, Senegal found a mean age of 61.9 ± 12.4 in 2008 in Dakar [12], a result similar to that of other develop-
ing countries [13] [14]. The mean age in the current study is 8 to 15 years lower than that observed in developed
countries [15] [16]. Situation is same with life expectancy between developing and developed countries. But we
0
10
20
30
40
50
60
70
80
<25
25-34
35-44
45-54
55-64
65-74
75-84
85-94
>95
Women
Men

Y. N. Mapoure et al.
411
Figure 2. Types and subtypes of stroke.
Table 4. Clinical characteristics of patients at entrance.
Mean Standard Deviation Minimum Maximum
Systolic BP (mmHg) 168.38 33.60 88 255
Diastolique BP (mmHg) 100.88 20.50 50 171
Pulse Rate (/min) 84.41 19.32 26 169
Respiratory Rate (/min) 23.75 9.24 12 99
Temperature (˚C) 37.29 0.76 35.8 40.30
Capillary Glycaemia (g/l) 1.47 0.77 0.23 5.99
Glasgow Coma Score 12.25 3.35 3 15
BP = Blood pressure.
cannot give an exact explanation relative to this difference of age at stroke onset in the two situations, may be
easily access to healthcare for CVRF screening. In Cameroon, patients generally seek medical care only when
they have symptoms.

Y. N. Mapoure et al.
412
Table 5. Associated cerebrovascular risk factors in stroke patient.
Associated Condition Number Percentage (%)
HBP 166 51.1
HBP/Diabetes 56 17.2
Atrial Fibrillation 18 5.5
HBP/Dyslipidaemia 19 5.3
HBP/Diabetes/Renal Failure 8 2.5
HBP/Dyslipidaemia/Diabetes 6 1.8
HBP/Atrial Fibrillation 6 1.8
Diabetes 4 1.2
HBP/Diabetes/Dyslipidaemia/Renal Failure 2 0.6
HBP/Dyslipidaemia/Renal Failure 2 0.6
Dyslipidaemia 16 4.7
Diabetes/Dyslipidaemia 1 0.3
HBP = High blood pressure.
There were more men in this study making up 68.1% of the cases. Apart from the study by Kouna et al. in
Gabon [17], the masculin predominance of stroke is reported in other studies carried out in sub-Saharan Africa
and elsewhere [12]-[14] [18]. This masculine predominance may be partly explained by the hormonal differenc-
es and lifestyle of men who tend to consume alcohol and tobacco more than women in our setting.
The majority of enrolled patients were living in Douala and its environs, while 21.8% were referred from oth-
er regions of Cameroon. The absence of basic stroke infrastructure, inadequacy and specialized personnel in
other regions of the country apart Yaoundé and Douala can explain the referral of patients to the Douala General
hospital which is better equipped to handle cerebrovascular diseases. There is need for population studies to
access the incidence and risk factors of stroke in the country as this information will constitute the basis of a na-
tion-wide stroke management and risk factors control programme.
Concerning the stroke risk factors known before the occurrence of stroke, 69.84% of the patients were hyper-
tensive, and with newly diagnosed patients, this prevalence rose to 81.53%. The prevalence hypertension in
stroke victims appears to be lower in developed countries [15] [16] and is situated around 55%. The review of
Sagui [19] on stroke in sub Saharan Africa estimated the prevalence of hypertension between 32.3% and 68%
among stroke victims. In Cameroon, there has been significant progression of the prevalence of hypertension
both in rural and urban area [20]. At discharge from hospitalization, 23.69% of the patients were confirmed with
diabetes mellitus whereas only 20.61% of them were known to be diabetic before the onset of stroke. Amu et al.
[21] screened 26.25% of diabetics among stroke victims in 2002 in Nigeria. Apetse et al. found 30.7 % of di-
abetic patients in a sample of 307 patients in Togo in 2007 [22]. These results however differ from those of
Touré et al. [23] who report a 9.2% prevalence of diabetes in stroke patients in Senegal. Nigerian and Cameroo-
nian population share several similarities in terms of biological and cultural characteristics. On the other hand,
the low rate of diabetes in Senegalese may be due to their Sahelien style of life and the possible existence of en-
vironmental factors which may influence the risk of diabetes cannot be totally excluded. The prevalence rate of
diabetes in stroke patients is similar to ours in Europe [15] but lower than 45% reported in Saudi Arabia [14].
We found regular consumption of alcohol to be an important vascular risk factor in this study, present in 28.30%
of cases. Kouna et al. had a similar result with 27.1% of cases in Gabon, a country located along the southern
border of Cameroon. There is no strict control of alcohol consumption in Cameroon and there is a significant
among of an indigenous production of alcohol that is consumed mainly by poor people. Many studies do not re-
port this risk factor may be for religious reasons [12]-[14]. Tobacco consumption was present in 16% of the pa-
tients and especially in men, in our study. Napon et al. in Burkina Faso found similar results: 17.1% in a sample
of 70 cases of stroke [24] while Kouna et al. [17] reported 9.5% tobacco consumption in a sample of 105 pa-

Y. N. Mapoure et al.
413
tients. These findings suggest the high level of tobacco consumption as a modifiable risk factor on which the
sensitization of the population should be focused. Before stroke, 8.9% of the patients were known for dyslipi-
daemia and in the course of stroke, this prevalence rose to 13.83% in our sample. Apetse et al. in Togo in 2007
(22) reported a prevalence of 32.12% cases of dyslipidemia in a sample of 301 patients with stroke. Before the
onset of ischemic stroke 5.3% of the patients had a past medical history of atrial fibrillation. Among the 24 cases
of patients we received in atrial fibrillation, 23 (13.53%) were recognised as being the cause of the ischaemic
stroke. Amu et al. in Nigéria [21] screened 6.25% cases of atrial fibrillation. Other studies did not mention their
ECG results [9] [12] [17] [18]. In developed countries, the prevalence of atrial fibrillation in the course of con-
stituted ischaemic stroke is estimated between 15% and 20% [15] [16].
In the current study, ischaemic stroke is slightly more frequent (52%) than for haemorrhagic stroke (48%).
Similar results have been found by Komolafe et al. in Nigeria [18] with 51.1% ischaemic stroke. Kouna et al. in
2005 in Gabon [17] reported 61.9% cases of ischaemic stroke in a population of patients hospitalized the neu-
rology department. In Europe, 80% of strokes are ischemic in nature [15]; similar to what obtains in Middle East
[13] [14] [16]. Are there any existences of genetic or environmental factors which may explain this high preva-
lence of ischaemic stroke? Are there any biaises for example: are the haemorrhagic strokes so severe that the pa-
tients die in the communities (given the high prevalence of HBP) and are therefore not seen in the health facili-
ties? Verbal autopsies could be helpful to attempt an answer to this question.
In-hospital mortality in this study was 26.8% for a mean duration of hospitalisation of 8.56 ± 6.35 days. Touré
et al. [23] reported a similar mortality in a sample of 314 patients including patients admitted in intensive neu-
rology care. Komolafe et al. [18] and Kouna et al. [17] estimated the mortality rate at 15.6% and 9.5% respec-
tively. The difference between these mortality rates compared to that in the current study as well as that in Touré
report is probably due to the fact that these studies did not include severe cases of patients hospitalized in inten-
sive care unit. This hospital mortality rate is significantly lower in developed countries and is estimated to be
around 13% to 14% [15] [16], and is relatively lower in developing countries around 19% [13].
6. Conclusion
The epidemiologic study of stroke in the Douala General Hospital suggests that cerebral haemorrhage and
ischaemia have similar prevalence rates. The risk factors are similar to those described in the global literature.
Hospital mortality is high and justifies that more action should be geared towards primary prevention in order to
reduce the impact of stroke in our environment.
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