In this study, we found that it is feasible to collect essential clinical data on stroke patients in a resource-constrained hospital. However, the limited access to brain imaging and supporting investigations provided an inadequate basis for decision making on treatment and secondary prevention.
The WHO definition of stroke was well known and used routinely at the hospital prior to the study period. The ward facilities were quite favorable for bedside assessment. Thus, the clinical scales were easily implemented. Few data on socio-demographics and medical history were missing after the interviews of the patients and next of kin. The medical records were mostly complete with some exceptions for medical history.
The study cohort consisted of mostly serious cases. Nearly three in four patients had severe or very severe stroke symptoms as measured by the NIHSS. Similar findings were reported in the Gambian and Malawian studies [10, 11]. Furthermore, more than half of the patients in our study had a depressed level of consciousness, and one-third were classified with total anterior circulation syndrome. We suggest that severe stroke events led to hospitalization more frequently than mild and moderate events. The widespread poverty might be a major cause why patients with mild and moderate stroke symptoms did not present to the hospital.
Among the risk factors available for recording, hypertension was the most frequent. This is entirely consistent with other studies in low-income SSA [9,10,11,12,13]. The INTERSTROKE study suggested that hypertension is the dominating risk factor for stroke, particularly in low-income regions [30]. A study conducted in Moramanga district, Madagascar, showed that hypertension is highly prevalent and insufficiently treated [31]. Besides hypertension, tobacco smoking was a common risk factor in our study. Both hypertension and tobacco smoking were easily detected. Therefore, antihypertensive treatment and strategies for smoking cessation could be implemented. The shortage of laboratory tests and absence of ECGs led to an incomplete mapping of risk factors, such as diabetes, HIV, and atrial fibrillation, and few measures were taken to modify these.
The limited access to brain imaging meant that the pathological stroke type remained unknown for the great majority of patients. By using the SSS, approximately half of the patients were classified as having a hemorrhagic stroke. However, the SSS has not proven to be reliable enough to distinguish between ischemic and hemorrhagic stroke [32]. Nevertheless, clinical assessment could be used to determine which pathological stroke type that is most likely [33]. The presence of headache, vomiting, severe hypertension, neck stiffness, and coma are suggestive of hemorrhagic stroke. When these symptoms and findings are absent, it should be beneficial to initiate acetylsalicylic acid for secondary prevention after stroke with unknown etiology [34]. However, antithrombotic treatments such as thrombolysis and anticoagulation cannot be administrated without brain imaging.
Chest infection was the most frequent complication of immobility in our study. Complications of immobility are potentially preventable [27]. A few basic measures to prevent infections and bedsores should be feasible in resource-constrained settings: testing of swallowing function before giving the patient oral feedings, avoiding indwelling urinary catheter whenever possible, repositioning the patient in bed every 2 h, and using cushions to protect bony areas. Early mobilization is a key component of acute stroke care [35]. We experienced considerable uncertainty about how to mobilize the patient, both among the staff and family members. Therefore, we suggest that guidelines for mobilization should be handed out to all caregivers.
The in-hospital stroke mortality of 30% was within the expected range in light of the results from the Gambian, Malawian, and Mozambican studies [10,11,12].
At discharge, most of the survivors had a severe disability (mRS 4–5) and severe or total dependency (BI ≤ 60). Similar findings for disability have been reported in Ethiopia and for dependency in the Gambia [9, 10].
A few previous studies have also reported on stroke treatment in hospitals of SSA without full access to technical facilities. The Gambian study was conducted in the absence of CT scans [10]. Some limitations in access to ECGs and CT scans were described in Malawi [11]. However, the shortage of laboratory tests and absence of ECGs seemed unique to our study.
The limitations of our study are the small sample size, the wide variation in prehospital time lapse, and no long-term follow-up information. We cannot generalize on the basis of this small-scale study conducted at a single hospital. However, the general conditions at the Andranomadio Lutheran Hospital are quite similar to those at many other hospitals in Madagascar.
In our study, there was probably a bias towards serious cases. Nevertheless, we are concerned about the high in-hospital mortality and the low functional status for the survivors at discharge. We suppose that both the lack of a systematic approach to stroke care and the limited access to technical facilities contributed to the severe outcomes. The clinical examinations at admission provided a basis for supportive treatment, such as intravenous fluids, paracetamol for pyrexia, and reduction of very elevated blood pressure [14]. However, there was no structured protocol for the management of physiological abnormalities in the acute phase. Moreover, several risk factors and complications were detected, but few measures were taken to modify or treat them. Finally, socioeconomic status had a major impact on the possibility of conducting a CT brain scan. This examination was unaffordable to most of the patients, and this circumstance appears unlikely to change in the next few years. These conditions illustrate the enormous gap between high-income and low-income countries and emphasize the urgent need for guidelines for the management of acute stroke of unknown etiology in resource-limited settings [36].
Based on our experiences, there is a long way to go to establish modern stroke services in resource-constrained hospitals in Madagascar. Nevertheless, we think it is possible to take small steps towards a better in-hospital stroke care. When access to brain imaging and supporting investigations are limited, the care for stroke patients will largely rely on non-drug treatments and rehabilitation interventions [16]. Involvement of the carers, particularly family caregivers, will be a central component of the service. We suggest introducing a practical protocol for stroke assessment and management. This will ensure a systematic approach to patients hospitalized for stroke. The protocol should include stabilization at admission, diagnostic assessment, assessment of stroke severity, management of risk factors, prevention and management of complications, mobilization, assessment of disability, mapping of home circumstances, strategies for secondary prevention, and education programs for family caregivers. The measures must be adapted to the resources available to the patient. It is also crucial that a stroke assessment and management protocol does not lead to increasing out-of-pocket costs for the patient.
Our study suggests that it is possible to collect data required for establishing a basic stroke assessment and management protocol in a resource-constrained hospital in Madagascar. Such a protocol could be the first step towards improving the in-hospital stroke care [16]. The study also suggests that further research on stroke services in resource-constrained settings is feasible.