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LEADING ARTICLE
Year : 1996  |  Volume : 3  |  Issue : 1  |  Page : 48-52  

Survival after stroke in Saudis : A hospital based study


King Fahd Specialist Hospital, Qasim, P. O. Box 2290, Saudi Arabia

Date of Web Publication31-Jul-2012

Correspondence Address:
EI Gamri E Mohammed
King Fahd Specialist Hospital, Qasim, P. O. Box 2290
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 23008548

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   Abstract 

Background : Prognosis of stroke has been studied in various population. Factors adversely affecting short term survival include impaired consciousness, leg weakness and increasing age.
Aim of the Study: In this study, the prognostic effects of age, sex, hypertension, diabetes mellitus and presentation in coma on the survival pattern of stroke patients presenting to a referral hospital, are reviewed.
Methodology: The medical records of all patients hospitalized with definite stroke at King Fahd Specialist Hospital, Buraidah, for the period between June 1986 and June 1991, were reviewed. The Cranial CT Scans were also reviewed.
Results : One hundred and seventy four patients, 106 males and 68 females, with a mean age of 64 years who had definite stroke were studied to estimate overall survival and the various risk factors influencing it. The case records and cranial CT scans were reviewed.
At the time of analysis, just over 72% of the patients were, alive, with an overall mean survival after stroke of 120 weeks. Approximately 11% of patients died within two weeks of the stroke diagnosis.
Conclusion : The factors adversely affecting survival in this study, were age above 60 (P<0.04), presentation in coma (P<0.003) and pre-existing heart disease (P<0.0009). There was no significant effect on survival due to sex, hypertension and/or diabetes mellitus.

Keywords: Stroke, Saudis, hospital.


How to cite this article:
Mohammed EE, Nur MA, Kurashi NY, Ibrahim E, Ammar K. Survival after stroke in Saudis : A hospital based study. J Fam Community Med 1996;3:48-52

How to cite this URL:
Mohammed EE, Nur MA, Kurashi NY, Ibrahim E, Ammar K. Survival after stroke in Saudis : A hospital based study. J Fam Community Med [serial online] 1996 [cited 2021 Dec 2];3:48-52. Available from: https://www.jfcmonline.com/text.asp?1996/3/1/48/98599


   Introduction Top


Prognosis of stroke has been studied in various populations [1],[2] . Factors adversely affecting short term survival include impaired consciousness, leg weakness and increasing age. On the other hand, long term survival is adversely affected by advanced age, hypertension and heart disease [1] . The pattern of survival is changing with time in many populations with gradual improvement of survival and decrease in mortality. [3]

Review of the literature suggests that immediate mortality after stroke approaches 30% in the first month. [4] Five year survival rates range between 35-45%. Furlan reported a 5 year survival rate in stroke patients of 77% compared to 85% in matched normal controls. [4] Al Rajah, in a study from Saudi Arabia showed that ischemic strokes accounted for 76.2% of all strokes. Strokes caused by intro-cerebral and sub-arachnoid hemorrhage constituted 21.4% and 2.4% respectively. [5]

Radiological changes in brain computed tomography (CT) correlates with survival. Hankey reported that lesions greater than 50 mm in diameter have a higher mortality than lesions less than 50 mm [8] . Poor prognosis is also noted in CT findings of intracerebral hemorrhage, mass effect and deep intracerebral lesions. [6]

In this study, the prognostic effects of age, sex, hypertension, diabetes mellitus and presentation in coma on the survival pattern of stroke patients presenting to a referral hospital, are reviewed.


   Patient Population Top


All patients hospitalized with definite stroke at King Fahd Specialist Hospital (KFSH), Buraidah, Saudi Arabia for the period between June 1986 and June 1991 were reviewed to determine the effect of age, sex, hypertension, diabetes mellitus, heart disease, atrial fibrillation, transient ischemic attacks, and the pathological type of the stroke on survival.

The medical records of patients were reviewed retrospectively according to pre-established diagnostic and inclusion criteria. Stroke is defined as acute focal or global loss of cerebral functions with symptoms lasting more than 24 hours, without an apparent cause other than the vascular origin. Patients were included if they were Saudi adults of 18 years of age or more, with a definite first stroke. All patients had a CI' brain scan within one month of onset. The clinical diagnosis was made by the admitting physician and reviewed independently by two members of the study group (EM and MN).

The CT brain scans were reviewed by two observers, a Radiologist (KA) and a physician (MN) to determine the pathological type of the stroke. The reliability of the method was confirmed by assessing a random 10% sample of the radiographs without knowledge of prior reports.


   Statistical Method Top


Survival duration was estimated from the date of onset of stroke to the date of death or last contact. Kaplan-Meier analysis was used with log-rank procedure to compare unadjusted survival. Cox proportional hazard analysis was used to investigate the effect of each prognostic factor on survival. In all data analysis, the BMDP statistical software package was used (University of California Press, Berkeley, 1991).


   Results Top


There were 106 males and 68 females with a male to female ratio of 1.56:1. The overall mean age was 64 years. Hypertension, diabetes mellitus and heart disease were found in 54 (31%), 49 (33%) and 57 (28%) of patients respectively.

At the time of analysis, 126 patients, 72.4% of all patients, were alive. Over the follow up period, 19 patients (10.9%) died within 2 weeks, 32 patients (18.4%) died within 4 weeks and 38 patients (21.8%) died within 24 weeks. The overall mean survival was 119.7 weeks. While the median survival has not been reached, the lower 95% confidence limit for the median survival was estimated at 103.14 weeks.

Kaplan-Meier survival curve for all patients in the study is shown in [Figure 1]. [Figure 2]a, b and c show the survival curves of the patients who presented with or without coma, heart disease and age below and above 60 years consecutively. Unadjusted analysis of survival as a function of various variables is shown in [Table 1]. A logistic regression analysis to examine the adjusted effect of these variables to estimate their independent influence on survival is shown in [Table 2].
Figure 1: Overall survival of patients with stroke

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Figure 2a: Survival of patients with heart disease compared to patients with no heart disease (bold line).
Figure 2b: Survival of patients presenting in coma compared to patients who were conscious on presentation (bold line).
Figure 2c: Survival of patients below age 60 years (bold line ) compared to patients of age above 60 years .


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Table 1: Survival Estimates (Unadjusted Analysis)

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Table 2: Logistic Regression Analysis of Factors Influencing Survival Adversely (Cox proportional hazards)

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Mortality risk was statistically significant for patients above age 60 (P< 0.04), patients presenting in coma (P<0.003) and patients with heart disease (P<0.0009). There was no significant statistical difference in mortality risk due to gender, hypertension or diabetes mellitus.

Cerebral infarction was the most frequently observed pathological type of stroke seen in 142 patients (82%). This was associated with 76% of deaths and a mean survival of 124 weeks. There were 17 patients with intracerebral hemorrhage with a mean survival of 105 weeks. There were 17 patients with intracerebral hemorrhage with a mean survival of 105 weeks, and 6 patients with sub-arachnoid hemorrhage with a mean survival of 29 weeks. These differences however, were not statistically significant.


   Discussion Top


In common with other reports, the single most important determinant of overall survival in the Saudi stroke patients, was the state of consciousness on presentation, with the presence or absence of coma [1],[2],[3],[7] . Age over 60 years and the presence of heart disease also adversely affected survival.

Ischemic, valvular and hypertensive disease were the most frequent cardiac culprits. Atrial fibrillation was less frequent and noted in 18 patients only. The poor survival may be the result of the added mortality risk from heart disease or the associated high risk of cerebral vascular disease in patients with coronary artery disease. It was not possible to study other factors such as body mass index, previous stroke, hemianopia, and blood glucose due to the limitations of the retrospective study.

Several multi-variate models have been designed to predict the effects of different variables on the outcome of stroke. The accuracy in prediction of death has varied between different models. The prediction value for the Belfast model is 75%, [8] Guy's Hospital 65% [9] and for Uppsala 50%. [10] The state of consciousness and urinary incontinence predicted good and poor outcome with accuracy comparable to that of multi-variate models. These multi-variate methods may have possible values in defining prognostic factors for designing clinical studies. Yet in prospective studies, these models did not show advantage over simple clinical variables.

In this study, data from a regional referral hospital was analyzed to define the prognostic factors useful in predicting the outcome and mortality of stroke in the Saudi population. These factors can be used to evaluate the effectiveness of interventions in the treatment of stroke. Factors affecting survival after stroke in Saudi patients, has been found to be more or less similar to those commonly observed in other populations.[11]

 
   References Top

1.Chambers BR, Norris JW, Shurvell BL, Hackinski VC. Prognosis of Acute Stroke. Neurology 1987 February ; 37 (2): 221-5.  Back to cited text no. 1
    
2.Kelly-Hays M, Wolf PA, Kannel WB, Sytkowski PD'Agostino RB, Gresham GE. Factors Influencing Survival and the Need for Institutionalization Following Stroke in the Framinghan Study. Arch Phys Med Rehabilitation 1988 January ; 69 (6):415-8.  Back to cited text no. 2
    
3.Garraway WM, Whisnant JP, Drury I. The Changing Pattern of Survival Following Stroke. Stroke 1983 ; 14(5): 699-703.  Back to cited text no. 3
    
4.Furian AJ, Whisnant JP, Baker HL, Jr. Long term prognosis after carotid artery occlusion. Neurology, Minneapolis 30; 1980: 986.  Back to cited text no. 4
    
5.Al Rajeh S, Awada A, Niazi G, Larbi E. Stroke in a Saudi Arabian National Guard Community. Analysis of 500 consecutive cases from a pop­ulation-based hospital. Stroke 1993; 24 (11): 1635-9.  Back to cited text no. 5
    
6.Hankey GJ, Davis SJ, Stewart-Wynne EG, Chakera TM. Cranial CT Scan Appearances that Correlate with Patient Outcome in Acute Stroke. Clin Exp Neurology 1987; 32: 71-4.  Back to cited text no. 6
    
7.Nakano KK. An Overview of Stroke. Epidemiology Classification Risk Factor, Clinical Aspects. Postgraduate Med 1986 ; 80 (4) 82-8.  Back to cited text no. 7
    
8.Fullerton KJ, Mac Kenzi G, Stout RW. Prognostic indices in stroke. Q J Med 1988;66: 147-62.  Back to cited text no. 8
    
9.Allen CMC. Predicting the outcome of acute stroke, a prognostic score. J Neurol Neurosurg Psychiatry 1984;47: 475-80.  Back to cited text no. 9
    
10.Frithz G, Werner I. Studies on cerebrovascular strokes II. Clinical findings and short term prognosis in a stroke material. Acta Med Scand 1976; 199: 133-40.  Back to cited text no. 10
    
11.Gladman JR, Harwood DM, Barer DH, Predicting the outcome of Acute Stroke : Prospective eval­uation of five multivariate models and compari­son with simple methods. J Neurology Neuro­surgery Psychiatry; 1992; 55 (5): 347-51.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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