Epidemiological Aspects of Cerebrovascular Accidents in the Diabetic : Experience of the Medical Clinic II of the Hospital Center Abass Ndao of Dakar

Introduction: The objective of our study was to describe the socio-demographic characteristics and cardiovascular risk factors (RVFs) of diabetic patients admitted for stroke in a department other than neurology. Methods: Retrospective cross-sectional study over a period of six (6) years (January 2010 and December 2016), performed at the Internal Medicine Department of the Abass Ndao Hospital Center in Dakar. Results: 79 adults with a mean age of 64.67 years, a female predominance (51.89%). The major risk factors found were arterial hypertension in 74.68% of cases, dyslipidemia in 32.35% of cases, smoking in 6.32% of cases. The reasons for consultation were a disorder of consciousness in 27.4% of cases, hemiplegia in 43.3% of cases, headache in 18.98% of cases, vertigo in 8.86% and dysarthria in 10.12% of the cases. Mean systolic blood pressure was 150 mmHg, mean diastolic blood pressure was 86 mmHg. The average blood glucose was 3 g/l. Strokes were associated with left ventricular hypertrophy in 30.55% of cases. Ischemic stroke accounted for 74.68%. The evolution was marked by a death in 20.25% (16) cases. Conclusion: Stroke is a major public health problem. Despite its predominance of women, they (stroke) affected 48.10% of men in our study when we know that in Africa the social activity is based on men. They remain a serious pathology in the diabetic by the high lethality.


Introduction
Diabetes is a public health problem because of the medical, social, and financial implications [1].The International Diabetes Federation (IDF) 2015 estimates report a prevalence of 8.8%.Prevalence in sub-Saharan Africa will increase from 4.8% to 5.7% [2].In Senegal, prevalence data remain approximate.According to 2015 IDF estimates, 3.4% of the Senegalese population is diabetic [2].Diabetes is a leading cause of blindness, kidney failure, heart attack, stroke and lower limb amputation [3].Stroke (all-cause) is the second leading cause of death in the world [4] [5], and recent studies show that mortality rates for ischemic stroke or cerebral hemorrhage are much higher in developing countries than in the industrialized countries [6] [7].Nevertheless prospective data in diabetics are rare on the management and the short and medium term evolution of these pathologies in sub-Saharan Africa [8] [9].The objective of our study was to describe the socio-demographic characteristics and Cardiovascular Risk Factors for diabetic patients admitted to stroke in an internal medicine unit to help better identify prevention targets.

Material and Methods
This was a descriptive retrospective study from January 2010 to December 31 st of 2016, performed in the internal medicine department of the Abass Ndao hospital center.It concerned diabetic patients of all ages admitted during the period of study for neurovascular accident documented by a systematic brain scan.Stroke was excluded from the study and not documented by cerebral computed tomography (CT) scans.The diagnosis of the stroke was clinical and paraclinical: Clinic: any patient presenting with neurological clinical abnormality lasting more than 24 hours; paraclinical: based on scan criteria.Non-hospitalized diabetic subjects, patients transferred or abused or with undocumented stroke were excluded.For this survey, we selected the following variables: -Sociodemographic characteristics: sex, age grouped by slice and occupation, provenance; -Study of diabetes mellitus: seniority, type of diabetes, nature of treatment, associated cardiovascular risk factors, level of glycemic equilibrium using fasting glucose and treatment of patients; -A review of cardiovascular risk factors.
Those considered in this study, since all patients are diabetic, were: age (>55 years in men and 60 years in women), active smoking, sedentary lifestyle, blood pressure over 130 mmHg, obesity, dyslipidemia, micro albuminuria greater than 30 mg/24h, hypercholesterolemia > 2 g/l, hypoHDLemia < 0.35 g/l, hypertriglyceridemia.The lipid balance was performed during a checkup.
-The treatment: low sodium diet, drug treatment of diabetes and treatment of high blood pressure, platelet and antiplatelet therapy statins; -Reasons for hospitalization: reasons mentioned in the medical file or in the reference bulletin for hospitalization; -The study of pathologies associated with diabetes.
-The hospital outcome: we examined patient records to assess three possible outcomes: discharge from hospital, transfer to another department and finally death during hospitalization.
For the collection of data, we used the patient's medical record as well as the data that existed in the patient's hospital registry.
The capture and exploitation were carried out by SPSS STATISTICS 18.0 software.

Results
Clinic: 79 patients met the criteria for inclusion.The sample consisted of 41 women (51.89%) and 38 men (48.10%) with a sex ratio of 0.92.The average age was 64.67 years with extremes [36 -95 years].Diabetes evolved for less than 5 years in 23.28% of patients and inaugural in 14.28%.All our patients had type 2 diabetes.The treatment was essentially insulin in 27.50% and oral anti-diabetics in 52.50%.Mean fasting blood glucose was 3.5mg/dl with extremes of 0.25 and HI.62.67 patients had blood glucose (>2 mg/dl).The Table 1 shows the partition of patients according to socio demographic characteristics.
Major risk factors were dominated by high blood pressure followed by dyslipidemia and tobacco 74.68% respectively; 32.35% and 6.32%.The reasons for consultation were mainly loss of consciousness in 27.84% of cases, hemiplegia in 43.03% of cases, headache in 18.98% of cases, vertigo in 8.86% and dysarthria in 10.12% of the cases.On clinical examination they all had motor deficits, average systolic blood pressure was 147 mmHg (60 -240), average diastolic blood pressure was 86 mmHg (40 -140).The Table 2 shows the partition of patients according to clinical characteristic.
Para clinical: the electrocardiogram revealed a disturbance of the heart rhythm in 27.7% of cases, left atrial hypertrophy in 22.2% of cases and left ventricular hypertrophy in 30.55% of cases.Ischemic stroke was the dominant lesion type with 74.68% ischemic brain scan lesion and 12.65% normal CT scan and bleeding stroke 12.65% of cases.Immediate evolution: patients who had hemorrhagic stroke were all transferred to an intensive care unit and some ischemic stroke (15.18%).The evolution was marked by a death in 20.25% ( 16) cases.The Table 3 shows the distribution of patients according to paraclinical characteristics.

Discussion
This retrospective study carried out at the internal medicine department of the Abass Ndao Dakar hospital, showed us an average age of patients admitted for stroke at 62.14 years.This average age is close to that of a predominantly black American population [8] with 62 years old.Other Africans [10] [11] [12] describe an average age ranging from 44.5 years to 61 years.In the African literature, there is a variability in prevalence by sex, either female or male: the majority of studies favored a male preponderance with a ratio between 1.3 and 1.5 [13] [14] [15].Ratios to 2 have been described [10], as well as a female preponderance with ratios between 0.82 and 0.97 [16] [17].The predominance was female in our study with a sex ratio of 0.92.In Ivory Coast a Masculine predominance has already been described [18].The major risk factors were dominated by arterial hypertension followed by diabetes and tobacco respectively 74.68%; 32.35% and 6.32%.Hypertension as the   main risk factor is described everywhere, both in Africa [10] [11] and in developed countries [19].The frequency of risk factors would be different in black subjects with successively hypertension, smoking, diabetes, heart disease while in Caucasian subjects it would be smoking, hypertension, heart disease, alcoholism, diabetes [19].For dyslipidemia, several major epidemiological studies have highlighted the link between lipid abnormalities and cardiovascular risk in type 2 diabetics.Thus, in the UKPDS [20] and the Strong Heart Study [21], cardiovascular risk is multivariate analysis, positively associated with LDL-cholesterol and negatively with HDL-cholesterol levels.
The reasons for consultation found (loss of consciousness, hemiplegia, headaches) in our study have already been written in the literature [22] [23].In one large European cohort study has shown that diabetic subjects had more motor deficit and dysarthria, while aphasia and swallowing disorders were more common in non-diabetics [24].
In our study diabetes was unbalanced in 58% of patients.The elevation of glycated hemoglobin (Hb A1C) would also be correlated with a pejorative prognosis.In the UKPDS study, A1C elevation of 1% was associated with a 37% increase in stroke lethality [25].Hyperglycemia is frequently observed in the acute phase of stroke and is life-threatening, exacerbating the risk of early death.
The deleterious mechanisms of hyperglycemia would include pro-coagulant action and decreased fibrinolysis, reduced reperfusion of ischemic tissue, and increased size of necrosis.Hyperglycemia increases reperfusion-related lesions, accounting for the greater frequency of hemorrhagic changes [26] [27].In the search for emboligenic heart disease we found a heart rhythm disorder in 27.7% of cases.Coulibally et al. [11] in Mali and Bendriss et al. [28] in Morocco reported proportions of 19.7% and 17.3% respectively, while for Lazzaro et al. [29] it was slightly lower (6%).These differences are related to the mode of selection of the patients, the type, and especially the duration of recording.Thus a recording over a longer period (48 or 72 hours) makes it possible to significantly increase the probability of detection of atrial fibrillation [30].Our lethality (25%) is concordant with that observed (10% to 60%) in the African literature [31].This is due to the late management of patients in hospital structures.This rate is higher than in the West where rapid admission to the neurovascular unit reduces stroke mortality [32].The limits of the study are constituted by the fact that it is about a study on file of patients.The collection of data was not exhaustive clinically and paraclinically.Microalbuminuria, arterial echo doppler in search of arterial disease and effective diabetic nephropathy and fundus were not performed in all patients because of the high cost of these central examinations.

Conclusion
Diabetes is a major risk factor for stroke.Hence, hyperglycemia should be treated early and effectively in the acute phase of stroke and all vascular risk factors associated with diabetes, including hypertension.

Table 1 .
Partition of patients according to socio demographic characteristics.

Table 2 .
Partition of patients according to clinical characteristic.

Table 3 .
Distribution of patients according to paraclinical characteristics.