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ORIGINAL ARTICLE
Year : 2014  |  Volume : 13  |  Issue : 4  |  Page : 217-220  

Pattern of computerized tomography of the brain findings in stroke patients in Sokoto, northwestern Nigeria


Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication7-Oct-2014

Correspondence Address:
Garba H Yunusa
Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-3519.142294

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   Abstract 

Background: Stroke is a common cause of morbidity and mortality worldwide. Therapeutic decision regarding its management requires prompt and accurate diagnosis as well as exclusion of other conditions mimicking this condition. Computerized tomography (CT) scan has been found to be the gold standard in distinguishing primary intracerebral hemorrhage (ICH) from cerebral infarction (CI).
Methods: A retrospective review of CT findings in 128 patients who presented in the Radiology Department of Usmanu Danfodiyo University Teaching Hospital with clinical diagnosis of stroke was undertaken over a period of 1 year (from December 2008 to November 2009). The following data were recorded; age, sex, clinical diagnosis, and CT findings. All the CT examinations were performed on a Neusoft C3000 multidetector spiral CT. Evaluation was done by consultant radiologists in the department.
Results: Of the 128 patients seen within the period under review, 84 (65.6%) were males while 44 (34.4%) were females. Age range was 4-85 years (mean 49.52, standard deviation (SD) 15.11), while 61 (47.7%) of the patients were in the age group of 41-60 years. Eighty-six patients (67.1%) had cerebral infarction, 38 (29.7%) had intracerebral hemorrhage, while one (0.01%) had subarachnoid hemorrhage. Three patients (0.02%) had normal brain CT findings.
Conclusion: Cerebral infarction is the most common form of stroke in this study. CT is essential in establishing the type of stroke, which subsequently determines the type of intervention as well as follow-up evaluation the patient may require.

   Abstract in French 

Résumé
Contexte: Stroke est une cause frιquente de morbiditι et de mortalitι dans le monde. Dιcision thιrapeutique concernant sa gestion nιcessite invite et un diagnostic prιcis ainsi que l'exclusion d'autres conditions imitant cette condition. Tomodensitomιtrie (CT) s'est avιrι pour κtre l'ιtalon-or en distinguant une hιmorragie intracιrιbrale primaire (ICH) des infarctus cιrιbral (CI).
Mιthodes: Ιtude rιtrospective de A des rιsultats CT dans 128 patients ayant prιsentι dans la radiologie Dιpartement d'Usmanu Danfodiyo University Teaching Hospital avec le diagnostic clinique d'accident vasculaire cιrιbral a ιtι entreprise sur une pιriode de 1 an (ΰ partir de dιcembre 2008 ΰ novembre 2009). Les donnιes suivantes ont ιtι enregistrιes; βge, le sexe, le diagnostic clinique et rιsultats de CT. Tous les examens de CT ont ιtι rιalisιes sur une spirale de Neusoft C3000 multidetector CT. ιvaluation a ιtι faite par les radiologues de consultant dans le dιpartement.
Rιsultats: De la 128 patients vus au sein de la pιriode sous examen, 84 (65,6 %) ιtaient des hommes, alors que 44 (34,4 %) ιtaient des femmes. Tranche d'βge ιtait de 4 ΰ 85 ans (moyenne 49,52, ιcart-type (SD) 15.11), tandis que 61 (47,7 %) des patients ιtaient dans le groupe d'βge de 41 ΰ 60 ans. Eighty-six patients (67,1 %) avaient l'infarctus cιrιbral, 38 (29,7 %) avaient une hιmorragie intracιrιbrale, tandis qu'un (0,01 %) avait une hιmorragie sous-arachnoοdienne. Trois patients (0,02 %) avaient le cerveau normal CT.
Conclusion: L'infarctus cιrιbral est la forme la plus courante d'AVC dans cette ιtude. CT est essentiel pour ιtablir le type d'accident vasculaire cιrιbral, qui dιtermine le type d'intervention ainsi que l'ιvaluation de suivi, le patient peut exiger.
Mots-clιs : La tomographie par ordinateur, hιmorragie, infarctus du myocarde, Sokoto, AVC

Keywords: Computerized tomography, hemorrhage, infarction, Sokoto, stroke


How to cite this article:
Yunusa GH, Saidu SA, Ma'aji SM, Danfulani M. Pattern of computerized tomography of the brain findings in stroke patients in Sokoto, northwestern Nigeria. Ann Afr Med 2014;13:217-20

How to cite this URL:
Yunusa GH, Saidu SA, Ma'aji SM, Danfulani M. Pattern of computerized tomography of the brain findings in stroke patients in Sokoto, northwestern Nigeria. Ann Afr Med [serial online] 2014 [cited 2019 Sep 20];13:217-20. Available from: http://www.annalsafrmed.org/text.asp?2014/13/4/217/142294


   Introduction Top


Stroke is defined as a clinical syndrome consisting of rapidly developing clinical signs of focal or global (in the case of coma) disturbance of cerebral function lasting more than 24 h or leading to death with no apparent cause other than a vascular origin. [1] When evaluating a patient with symptoms suggestive of stroke, the clinician must address several issues, notably whether the case represents an instance of acute cerebrovascular disease and, if so, whether the primary lesion is ischemic or hemorrhagic. The goal of early brain imaging in stroke or cerebrovascular disease (CVD) is to exclude intracranial hemorrhage, identify ischemic change, and exclude stroke mimics. Imaging also allows assessment of the intracranial and extracranial vasculature and facilitates delineation of the status of cerebral perfusion, demonstrating the infarct core, as well as the penumbra-the identification of which may aid future management. [1],[2] Computerized tomographic (CT) scanning is currently the gold standard imaging method in the examination of patients presenting to the emergency department with acute focal neurological deficit. This is because CT has certain advantages over other imaging modalities such as its reliability in showing clear difference between cerebral infarction and hemorrhage as well as relative availability. [2] These advantages of CT changed the way CVD is managed globally.

The availability and utilization of this imaging modality has significantly reduced mortality and morbidity from CVDs by way of prompt diagnosis, guiding intervention, and follow-up. Although magnetic resonance (MR) diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) have shown greater sensitivity in the early detection of cerebral ischemic changes; thus, they have now become the primary noninvasive modality for stroke imaging rather than CT scan. [3],[4] Also, these are not readily available in the majority of hospitals in the developing countries. In addition to the current guidelines on the use of intravenous thrombolytic, alteplase, for the treatment of acute thrombotic stroke require the use of CT or magnetic resonance imaging (MRI) to exclude intracranial hemorrhage (ICH) or other pathology. [1],[3],[5] Therefore, increasing availability of CT in the developing countries should be harnessed in the diagnosis and evaluation of patients presenting with signs and symptoms of CVD.


   Methods Top


Brain CT findings of 128 patients referred to the Radiology Department of the Usmanu Danfodiyo University Teaching Hospital, Sokoto from December 2008 to November 2009 with a clinical diagnosis of stroke were reviewed retrospectively. Three patients aged 4, 11, and 13 years are known with sickle cell disease; but presented to the hospital with signs and symptoms of CVD. The CT examinations were carried out on a Neusoft/Philips C3000 helical multidetector CT with the following protocols: Axial sections parallel to the orbitomeatal (OM) line; 2-4 mm thickness sections of the sellar and suprasellar region for better visualization of the circle of Willis and 5 mm sections for the remainder of the brain up to the vertex. No contrast was given to patients that presented in early phase of the ictus. Patients' age, gender, duration of onset of symptoms, and clinical presentation were recorded. The various findings on the CT scan images were retrieved from the archives and reviewed by at least two qualified radiologists in the unit.

CT examinations of 128 patients were reviewed for presence or absence of hemorrhage; presence or absence of infarction; site and size of hemorrhage or infarction; evidence of arterial thrombus; effacement of cerebral gyri and/or fissures; and prominence of the cerebral ventricles, gyri, fissures as well as the effacement of the gray-white matter interface. Patients with features suggesting mimics of CVD were given intravenous contrast and diagnosis confirmed, hence were excluded from this review. Variable window settings (width = 40-80 Hounsfield units (HU), center = 20-35) were used during image evaluation to improve sensitivity and specificity as shown by Lev et al., [6] Data analysis was performed using Statistical Packages for Social Sciences (SPSS) version 17.0 (Chicago: SPSS Inc. Released 2008).


   Results Top


Of the 128 patients seen within the period under review, 84 (65.6%) were males while 44 (34.4%) were females, with a male to female ratio of 1.9:1. Age range was 4-85 years (mean 52.5; standard deviation (SD) 15.1), wherein 61 (47.7%) patients were in the 41-60 age group. Eighty-six patients (67.1%) had cerebral infarction, 38 (29.7%) had ICH, while one (0.01%) had subarachnoid hemorrhage. Three patients (0.02%) had normal brain CT findings. [Table 1] shows age distribution, while [Figure 1] is a pie chart showing distribution of the CT findings. [Figure 2] and [Figure 3] show patients with ICH, [Figure 4] shows acute subdural hematoma, while [Figure 5] shows cerebral infarction.
Figure 1: A pie chart showing the distribution of CT brain findings

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Figure 2: CT of the brain showing intracerebral hemorrhage in the left thalamus and internal capsule. There is surrounding perilesional edema (arrow) and effacement of the body of left lateral ventricle

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Figure 3: Intracerebral hemorrhage in the region of the right caudate nucleus and right internal capsule as well as intraventricular hemorrhage in the anterior horn of the left lateral ventricle (arrow)

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Figure 4: Uncontrasted CT of the brain showing a hyperdense concavo-convex area in the right frontoparietal region with associated effacement of the ipsilateral cerebral sulci, fissures, and lateral ventricle. Findings are consistent with an acute subdural hematoma (arrow)

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Figure 5: Axial CT of the brain showing a large irregular hypodense area in the left parietal lobe. A second irregular area of hypodnesity is also seen in the left frontal lobe. There is associated compression of the ipsilateral lateral ventricle and shift of the falx cerebri to the contralateral side

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Table 1: Patient distribution by age group

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   Discussion Top


This review showed that cerebral infarction constituted 67.1% of all cases examined with a CT scan, while primary ICH constituted 29.7% [Figure 1]. This finding is in agreement with previous studies that reported a higher prevalence of ischemic than hemorrhagic stroke in southwestern Nigeria. [7] However, our finding in this study differs with the finding by Obajimi et al., [8],[9] who reported a higher incidence of intracranial hemorrhage of up to 52.9% among Ghanaians.

There is male preponderance with a male to female ratio of 1.9:1, while the mean age was 52.5 years. This corresponds to the middle age group with higher prevalence of risk factors for cerebrovascular accidents. [7],[8],[10] Three patients in the less than 20 year age group had sickle cell disease as a predisposing factor, one of which had intracerebral hemorrhage; while two had cerebral infarction. This is in agreement with the findings by Ogunseyinde et al., and further reiterates the need to promptly utilize CT in the evaluation of this group of patient as soon as clinical diagnosis of CVD is entertained. [11]

Three patients were considered to have a normal CT scan after a follow-up scan that agreed with the initial examination and showed no abnormalities. Unenhanced CT was used in the initial evaluation of the patients with utilization of variable window width and window center in order to accentuate the image contrast between normal and edematous tissues. This improves sensitivity and specificity of the scan as shown by Lev et al. [6] Unenhanced CT has the advantage that it can be performed quickly, does not require the administration of intravenous contrast material, and apart from detecting early-stage acute ischemia can easily identify hemorrhage, which is a contraindication to thrombolytic therapy. [2],[3],[12],[13]

Timing between onset of symptoms and the conduct of a CT scan examination for patients with a suspected CVD is very important as patients that were diagnosed with ischemia early (within 6 h of onset of symptoms) tend to have better response to thrombolytic therapy. [12],[13] Therefore, a clinical audit of the timing between onset of symptoms and imaging of patients presenting with sign and symptoms of CVD in our environment is worth undertaking with a view of identifying possible causes of delays and ways of avoiding them.


   Conclusion Top


Cerebral infarction is the commonest finding in patient presenting with cerebrovascular accident in this study. CT is of utmost importance in establishing the diagnosis, differentiating between hemorrhage and infarction, and also helps in optimizing the therapy for patients with CVD.

 
   References Top

1.Beauchamp NJ Jr, Barker PB, Wang PY, vanZijl PC. Imaging of acute cerebral ischemia. Radiology 1999;212:307-24.  Back to cited text no. 1
    
2.Srinivasan A, Goyal M, Al Azri F, Lum C. State-of-the-art imaging of acute stroke. Radiographics 2006;26:S75-95.  Back to cited text no. 2
    
3.Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, et al. American Heart Association Council on Cardiovascular Radiology and Intervention, Stroke Council, and the Interdisciplinary Council on Peripheral Vascular Disease. Recommendations for imaging of acute ischemic stroke: A scientific statement from the American Heart Association. Stroke 2009;40:3646-78.  Back to cited text no. 3
[PUBMED]    
4.Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: A prospective comparison. Lancet 2007;369:293-8.  Back to cited text no. 4
    
5.Ringleb, PA, Bousser MG, Ford G, Bath P, Brainin M, Caso V, et al. Guidelines for management of ischaemic stroke and transient ischaemic attack. 2008. Retrieved from: http://www.eso-stroke.org/pdf/ESO08_Guidelines_English [Last accessed on 24 May 2013].  Back to cited text no. 5
    
6.Lev MH, Farkas J, Gemmete JJ, Hossain ST, Hunter GJ, Koroshetz WJ, et al. Acute stroke: Improved nonenhanced CT detection--benefits of soft-copy interpretation by using variable window width and centre level settings. Radiology 1999;213:150-5.  Back to cited text no. 6
    
7.Ogun SA, Ojini FI, Ogungbo B, Kolapo KO, Danesi MA. Stroke in south west Nigeria: A 10-year review. Stroke 2005;36:1120-2.  Back to cited text no. 7
    
8.Obajimi MO, Nyame PK, Jumah KB, Wiredu EK. Spontaneous intracranial haemorhage: Computed tomographic patterns in Accra. West Afr J Med 2002;21:60-2.  Back to cited text no. 8
    
9.Obajimi MO, Nyame PK, Jumah KB, Wiredu EK. Computed tomographic patterns of intracranial infarcts in Ghanaians. West Afr J Med 2002;21:121-3.  Back to cited text no. 9
    
10.Njoku CH, Aduloju AB. Stroke in Sokoto, Nigeria: Five year retrospective study. Ann Afr Med 2004;3:73-6.  Back to cited text no. 10
    
11.Ogunseyinde AO, Obajimi MO, Fatunde OJ. Computed tomographic pattern of stroke in children with sickle cell anaemia in Ibadan. Afr J Med Med Sci 2005;34:115-8.  Back to cited text no. 11
    
12.Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 1995;274:1017-25.  Back to cited text no. 12
    
13.von Kummer R, Bourquain H, Bastianello S, Bozzao L, Manelfe C, Meier D, et al. Early prediction of irreversible brain damage after ischemic stroke at CT. Radiology 2001;219:95-100.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]


This article has been cited by
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Amos Olufemi Adeleye,Uyiosa A. Osazuwa,Godwin I. Ogbole
Frontiers in Neurology. 2015; 6
[Pubmed] | [DOI]



 

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