CT Scan Pattern of Stroke Patients at Jimma University Medical Center, South West Ethiopia

Background: Stroke is becoming a significant cause of morbidity and mortality in low and middle-income countries. And accurate diagnosis and management of stroke relies on Neuroimaging. Objective: To determine the CT scan pattern, as well as associated risk factors of stroke patients attending Jimma University Medical Center Methods: A hospital-based retrospective study was conducted on all patients with a CT scan of the head with the diagnosis of stroke at JUMC from December 11, 2016, up to October 8, 2019, southwest Ethiopia. Data was analyzed using SPSS V 24 Software. And the results were presented using tables and Figures. Results: A total of 536 patients have undergone head CT for a clinical diagnosis of stroke during the study period and from those 250 people were included in the study, 184(65%) were male and 99(35%) were female. And 180(63.9%) were from rural areas while the rest 103 (36.4%) of came from urban regions. The mean age was (57 ± 14 years. The most common pattern of stroke in the CT findings was hemorrhagic stroke with 126(44.5%) followed by ischemic stroke 122(43.1%). Conclusion: The study shows that stroke is a major public health concern and A prospective community-based study is required to define the true magnitude and socio-de mographic characteristics of stroke and the associated factors in the general population.


Introduction
Cardiovascular disease is the primary global cause of death, responsible for more than 17.3 million deaths annually, and according to data gathered from the Global Burden of Diseases (GBD) the number that is projected to exceed 23.6 million by 2030 [1]. Low and middle-income countries are disproportionately affected by the cardiovascular disease as more than 80% of the death due to cardiovascular disease occurring in low-and middleincome countries (LMICs) according to reports done in 2013 transition with increasing life expectancy and population growth [3]. According to the World Health Organization, there were 39,409 stroke deaths in Ethiopia in 2004, which accounted for 3.6% of all deaths and 15.3% of deaths from non-communicable diseases [4].
Accurate stroke diagnosis and subtype confirmation plays a big role in patient management and prognosis as Current management protocols depend on clearly differentiating between the subtypes of stroke, Although clinical features cannot reliably distinguish Ischemic Stroke (IS) from Intracerebral Hemorrhage (ICH), several clinical signs increase the likelihood of ICH rather than IS: such as coma, neck stiffness, seizures at onset of neurologic deficit, diastolic blood pressure greater than 110 mmHg vomiting and headache are among the few [5].
Although stroke is becoming a major health problem in lowincome and middle-income countries, there are few available data on stroke in Ethiopia. And there are no available data from the Southwestern part of Ethiopia addressing the demography, risk factors, and burden of stroke. The Jimma University medical center started providing CT scan services since 11/11/2016 with the instalment of a 64 slice GE optima 660 Multi detector CT, before the start of the services clinicians mainly relied on clinical signs and symptoms to diagnose as well as speculate on the subtype of stroke the patients had. And this has hampered the quality of care that can be provided to stroke patients as clinical differentiation of stroke subtypes as well as differentiating stroke from differential diagnosis is unreliable and affects the decision making regarding the type of treatment patients should receive [6]. Therefore, Thus, this study aims to assess the CT scan pattern and associated Risk factors seen in stroke patients coming to JUMC Radiology department with the aim of better understanding the local epidemiology of the Disease and to serve as a benchmark for future researches and interventions regarding the care of stoke patients in the region.

CT Scan Patterns of Stroke
The most common pattern of stroke documented in the CT  (Table 4).    Saharan African countries such as Nigeria, Cameron [11,12] and western countries such as the USA and Europe [13][14][15]. The mean age of stroke in the study was (57 ± 14 years) with patients and the age group of above 65 was the most commonly affected. This was in line with studies conducted in other parts the country and other developing countries, which had mean ages ranging from 50-62 [14][15][16]. In the study, both ischemic, as well as hemorrhagic stroke, were more common in patients who came from rural parts of the study area compared to people living in the urban region. These finding were also replicated in other studies done in the country [2,4,14] but differ from other studies that are done in other African countries as well as those done abroad [7,[15][16] and possible reason for these discrepancies are believed to be Regional sociocultural difference as well as differences in the access to health care services.
The most common type of stroke In the study was hemorrhagic stroke which is a comparable to similar studies conducted in the country [2,17,18] as well other countries such as Tanzania, Rwanda, Ghana [16][17][18] while some studies were done in Kenya, Zambia, Senegal, Nigeria showed higher incidences of ischemic stroke this can be due to differences in the Demographic and Risk factors as the studies in which ischemic stroke was more common had an older mean age and increased incidence of certain risk factors such as diabetes, Alcohol & tobacco use as well as higher rates of HIV infections [19][20][21][22]. The most common Risk factors seen in stroke Patients were Hypertension which was seen in around 40% of patients with ischemic stroke and 60% of patients with Hemorrhagic stroke, this finding is reproduced in all studies conducted in the country as well as other African countries this may be because uncomplicated Hypertension is usually symptomless and patents may not be aware of their illness and even after diagnosis long term compliance will be an issues as patients might believe that they have been healed as soon as their symptoms disappear. The other established Risk factors of stroke such as Diabetes, smoking, Dyslipidemia were less common in this study than other studies. [3,15,[20][21][22].
The commonest location for Hemorrhagic stroke was the basal ganglia, thalamus, which accounted for 75% of the cases, these locations are common sites for hemorrhage secondary to Hypertension due to the branching pattern of the lenticulostriate vessels which supply these areas which are susceptible to rupture in cases of elevated blood pressure which was noted in these patients.
Other identified sites of hypertensive bleeds are the cerebellum, internal capsule, and brainstem which accounted for around 9% of the cases [24]. The comments locations of ischemic stroke were the cortical grey matter with 70% followed by the subcortical grey matter which accounted for around 20% of the cases while the rest of the cases were located in the brainstem and the cerebellum. This location is well described to be susceptible to infarcts due to the anatomy of the vessels [25].

Limitations of the Study
Not all patients clinically diagnosed to have stroke did not have CT scans for confirmations and further characterizations due to several reasons. The fact that the study was retrospective medical records were incomplete in most of the study subjects.

Conclusion
The study shows that stroke is a major public health concern and A prospective community-based study is required to define the true magnitude and socio-demographic characteristics of stroke and the associated factors in the general population. Strategies for screening and management of hypertension, structural heart disease, and atrial fibrillation should be given priority as these are the most prevalent risk factors identified. An emergency care setup capable of early patient evaluation with appropriate Neuroimaging and management of early stroke complications is crucial for prevention of early stroke-related mortality.