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      Stroke Outcomes in Malawi, a Country with High Prevalence of HIV: A Prospective Follow-Up Study

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          Abstract

          Background

          Stroke contributes significantly to disability and mortality in developing countries yet little is known about the determinants of stroke outcomes in such countries. 12% of Malawian adults have HIV/AIDS. It is not known whether having HIV-infection alters the outcome of stroke. The aim of this study was to document the functional outcome and mortality at 1 year of first-ever acute stroke in Malawi. Also to find out if the baseline variables, including HIV-infection, affect the outcome of stroke.

          Methods and Findings

          147 adult patients with first-ever acute stroke were prospectively followed up for 12 months. Conventional risk factors and HIV-infection were assessed at baseline. Stroke severity was evaluated with modified National Institute of Health Stroke Scale (mNIHSS) and functional outcome with modified Rankin scale (mRS). Fifty (34%) of patients were HIV-seropositive. 53.4% of patients had a poor outcome (severe disability or death, mRS 4–6) at 1 year. Poor outcome was related to stroke severity and female gender but not to presence of HIV-infection. HIV-seropositive patients were younger and had less often common risk factors for stroke. They suffer more often ischemic stroke than HIV-seronegative patients.

          Conclusions

          Mild stroke and male gender were associated with favourable outcome. HIV-infection is common in stroke patients in Malawi but does not worsen the outcome of stroke. However, it may be a risk factor for ischemic stroke for young people, who do not have the common stroke risk factors. Our results are significant, because stroke outcome in HIV-seropositive patients has not been studied before in a setting such as ours, with very limited resources and a high prevalence of HIV.

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          Classification and natural history of clinically identifiable subtypes of cerebral infarction.

          J. Bamford, P Sandercock, M. Dennis … (1991)
          We describe the incidence and natural history of four clinically identifiable subgroups of cerebral infarction in a community-based study of 675 patients with first-ever stroke. Of 543 patients with a cerebral infarct, 92 (17%) had large anterior circulation infarcts with both cortical and subcortical involvement (total anterior circulation infarcts, TACI); 185 (34%) had more restricted and predominantly cortical infarcts (partial anterior circulation infarcts, PACI); 129 (24%) had infarcts clearly associated with the vertebrobasilar arterial territory (posterior circulation infarcts, POCI); and 137 (25%) had infarcts confined to the territory of the deep perforating arteries (lacunar infarcts, LACI). There were striking differences in natural history between the groups. The TACI group had a negligible chance of good functional outcome and mortality was high. More than twice as many deaths were due to the complications of immobility than to direct neurological sequelae of the infarct. Patients in the PACI group were much more likely to have an early recurrent stroke than were patients in other groups. Those in the POCI group were at greater risk of a recurrent stroke later in the first year after the index event but had the best chance of a good functional outcome. Despite the small anatomical size of the infarcts in the LACI group, many patients remained substantially handicapped. The findings have important implications for the planning of stroke treatment trials and suggest that various therapies could be directed specifically at the subgroups.
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            Recovery of motor function after stroke.

            R Bonita, R Beaglehole (1988)
            The natural history of recovery of motor function after stroke is described using data from a 1-year community-based study in Auckland, New Zealand. Of 680 patients, 88% presented with a hemiparesis; the proportion of survivors with a persisting deficit declined to 71% at 1 month and 62% at 6 months after the onset of the stroke. At onset, there were equal proportions of people with mild, moderate, and severe motor deficits, but the majority (76%) of those who survived 6 months had either no or only a mild deficit. Recovery of motor function was associated with the stroke severity but not with age or sex; patients with a mild motor deficit at onset were 10 times more likely to recover their motor function than those with a severe stroke. Our results confirm the reasonably optimistic outcome for survivors of stroke and further suggest that recovery of motor function is confined to patients whose motor deficit at onset is either mild or moderate.
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              Increasing incidence of ischemic stroke in patients with HIV infection.

              Bruce Ovbiagele, Avindra Nath (2011)
              Large-scale epidemiologic data on stroke in HIV-infected persons are scarce, especially in an era of combination antiretroviral therapies, which have prolonged patient survival, but may boost stroke risk. We assessed trends in the proportion of HIV infection among patients with stroke in the United States. Data were obtained from all states within the United States that contributed to the Nationwide Inpatient Sample. All patients admitted to hospitals between 1997 and 2006 with a primary discharge diagnosis of stroke (identified by the International Classification of Diseases, Ninth Revision procedure codes) were included. Time trends in the proportion of these patients with HIV diagnosis were computed, and independent predictors of comorbid HIV diagnosis evaluated using multivariable logistic regression. Of all (ischemic and hemorrhagic) stroke hospitalizations, patients with comorbid HIV infection constituted 0.09% in 1997 vs 0.15% in 2006 (p < 0.0001). Actual numbers of overall US stroke hospitalizations lessened 7% (998,739 to 926,997), while actual numbers of stroke hospitalizations with coexisting HIV infection rose 60% (888 to 1,425). Patients with comorbid HIV infection comprised 0.08% of ischemic strokes in 1997 vs 0.18% in 2006 (p < 0.0001), but their proportion of hemorrhagic strokes did not significantly change. Factors independently associated with higher odds of comorbid HIV diagnosis were Medicaid insurance, urban hospital type, dementia, liver disease, renal disease, and cancer. Over the last decade in the United States, there has been a substantial and significant rise in patients hospitalized for stroke with coexisting HIV infection. This has important public health and socioeconomic consequences.
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2012
                Publication date (Electronic): 29 March 2012
                Volume: 7
                Issue: 3
                Electronic Location Identifier: e33765
                Affiliations
                [1 ]Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
                [2 ]Department of Medicine, College of Medicine, Blantyre, Malawi
                [3 ]Department of Radiology, College of Medicine, Blantyre, Malawi
                Innsbruck Medical University, Austria
                Author notes

                Conceived and designed the experiments: TH JK TA. Performed the experiments: TH DC. Analyzed the data: TH SK TA. Wrote the paper: TH JK SK TA.

                Article
                Publisher ID: PONE-D-11-25305
                DOI: 10.1371/journal.pone.0033765
                PMC ID: 3315584
                PubMed ID: 22479439
                SO-VID: 0a026c2e-cb88-46de-8b05-5f6cc2da05a7
                Copyright © Heikinheimo et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Date received : 9 December 2011
                Date accepted : 21 February 2012
                Page count
                Pages: 6
                Categories
                Subject: Research Article
                Subject: Medicine
                Subject: Diagnostic Medicine
                Subject: Pathology
                Subject: General Pathology
                Subject: Infectious Diseases
                Subject: Viral Diseases
                Subject: HIV
                Subject: Neurology
                Subject: Cerebrovascular Diseases

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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