Journal of the Neurological Sciences 372 (2017) 75–77

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Journal of the Neurological Sciences

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Clinical Short Communication

Therapeutic route of patients at the acute phase of their stroke in

Burkina Faso
Christian Napon a,⁎, Anselme Dabilgou a, Julie Kyelem a, Papougnézambo Bonkoungou b, Jean Kaboré a
a
Neurology Department, Hospital Yalgado OUEDRAOGO, Ouagadougou, Burkina Faso
b
Medical Emergencies Department, Hospital Yalgado OUEDRAOGO, Ouagadougou, Burkina Faso

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The advent of the neurovascular units and thrombolysis has improved support for stroke in devel-
Received 4 November 2016 oped countries. Our objective was to study the therapeutic route of stroke patients in Burkina Faso, a country with
Accepted 9 November 2016 limited resources.
Available online 14 November 2016 Methods: It was a prospective cohort study over a period of 4 months, from February 02, 2014 to June 05, 2014, in
medical emergencies and Neurology department of the teaching hospital Yalgado Ouedraogo. The study focused
Keywords:
on patients diagnosed with stroke through brain imaging when they first entered hospital or during hospitaliza-
Therapeutic route
Stroke
tion. Variables of the study included socio-demographic data of the patients, route of the patients, nature of the
Africa stroke, treatment and clinical course.
Burkina Faso Results: The time between the onset of clinical signs and the first contact with a peripheral public health unit ex-
tended from 30 min to 24 h with an average of 6 h and 56 min. The minimum time between the first contact with
a peripheral public health unit and medical emergencies of the Teaching Hospital Yalgado Ouédraogo was
15 min, and the maximum, two weeks. After their arrival in medical emergencies, patients spent on average
21 h and 18 min to achieve the cerebral CT scan. Concerning the treatment, the thrombolysis, which was not
available yet, had never been prescribed, while 19% of patients were eligible according to the 4h30mn period
criteria.
Conclusion: Our study shows that the long delay in the access of neurological expertise is, in most cases, related to
the therapeutic route of patients. Thus, the setting-up of a stroke sector would improve the management and the
prognosis of cases in Burkina Faso.
© 2016 Elsevier B.V. All rights reserved.

1. Introduction 2. Methods

The advent of stroke units and the development of therapies for
stroke in the acute phase like thrombolysis resulted in an improvement
of the support given to patients having had a stroke in developed coun-
tries. However, this support is non-existent or poorly developed in most
African countries. Burkina Faso is a developing country, in which 43.9%
of the population lives below the poverty threshold [1], without stroke
unit and where thrombolysis has never been performed. As a result,
stroke-related functional sequelae and mortality remain important.
This study was designed to study the diagnosis and therapy route of
stroke patients in a country with limited resources in sub-Saharan Afri-
ca, in order to identify opportunities for the improvement of patients'
care.
⁎ Corresponding author.
E-mail addresses: cnapon@gmail.com, naponc@yahoo.fr (C. Napon).
We conducted a prospective cohort study over a period of 4 months,
from February 02, 2014 to June 05, 2014. The study was carried out in
medical emergencies and Neurology department of Teaching Hospital
Yalgado Ouedraogo, reference hospital of the capital city Ouagadougou,
which hosts the only Neurology department of the country. The study
population consisted of all stroke (227 patients) patients, identified dur-
ing the study period. Were included in the study all patients diagnosed
with stroke by brain imaging (CT scan) at their arrival at hospital or dur-
ing hospitalization. Patients, whose certainty diagnosis was not
established, particularly those without brain imaging, were excluded
from the study. Data was collected using an individual investigation
sheet, including interviews of patients or their attendants, clinical ex-
amination and consultation of the patient's medical record. Variables
of the study included the socio-demographic data of the patients, the
route of patients (the various time limits for admission to first health
training, emergencies, the time of acquisition of the brain scanner, the
length of hospitalization for emergencies, the deadline for transfer of
emergencies at the Neurology Department), the nature of the stroke

http://dx.doi.org/10.1016/j.jns.2016.11.017
0022-510X/© 2016 Elsevier B.V. All rights reserved.
76 C. Napon et al. / Journal of the Neurological Sciences 372 (2017) 75–77
and its etiology, the treatment given to patients, the clinical evolution of
patients and hospital discharge mode. The data were entered using a
microcomputer and analyzed with the SPHINX software version 4.5.
The informed consent of patients was obtained before the collection
and the privacy of patients and the confidentiality of the data collected
have been complied with.
3. Results
During our four months study period, 227 patients entered medical
emergencies (ME) for a stroke, representing an average of 56 patients
per month. Patients were transferred for 6.17% of them from ME to
the intensive care unit, 7.93% and 50.22 respectively, to the cardiology
and neurology departments. We noticed that 11% of patients died at
the ME prior to their transfer, 24.67% went through the ME but could
not reach the Neurology department. The average age of patients was
59.37, with a sex ratio of 1.22. The proportion of patients from the city
of Ouagadougou was 48% and 52% came from surrounding localities.
The time between the onset of clinical signs and the first contact with
a peripheral public health unit ranged from 30 min to 24 h with an av-
erage of 6 h 56 min; 65% of patients arrived within the time of thrombol-
ysis or before 4h30mn. The minimum time between the first contact
with a peripheral public health unit and the hospital Yalgado
Ouédraogo's ME was 15 min, and the maximum time, two weeks. Pa-
tients spent on average 2 days (41 h 48 min) in peripheral health
units, with no CT scans or neurologist there. Some patients (22% of pa-
tients) arrived directly at the ME, within the time of thrombolysis, with-
out passing first through peripheral health units and private care
facilities. After their arrival at ME, patients spent on average 21 h and
18 min to achieve their brain CT scan with extremes of 30 min and
9 days. 65.62% of patients spent more than 24 h at the ME before their
transfer into the Neurology department, and the average time of trans-
fer in neurology was 2.5 days. According to the diagnosis made by the
brain CT scan, ischemic stroke represented 53% of the cases while the
cerebral hemorrhage accounted for 46% with 1% of hemorrhagic infarc-
tion. Therapeutically, thrombolysis was not available and therefore was
never prescribed while 19% of patients were eligible according to the
criteria of 4h30mn period. The average length of hospitalization in neu-
rology was 13 days with extremes of 1 and 74 days. The hospital dis-
charge was normal for 69% of patients. It was also noted that 20% of
cases of death occurred in the course of the hospitalization, and 11% of
patients left the hospital against medical advice.
4. Discussion
We realized a prospective cohort study in which patients and their
attendants were interviewed. However, there are two things that need
to be taken into account. First, our presence during the interviews
may have influenced some of the answers. Secondly, the patients and
their entourage failed sometimes to give details concerning the various
deadlines, so times indicated in the study are not to be considered to the
minute. The Neurology Department, which is supposed to be the spe-
cialized service for the management of stroke, received only half of
the stroke patients entering the Teaching Hospital Yalgado Ouedraogo.
This low rate of transfer to Neurology department could be explained,
on the one hand, by the narrowness of the premises with only 23
beds, and on the other hand, by the lack of an intensive care unit imply-
ing that the service is not authorized to receive unstable patients. It is
also worth noting that 11.01% of stroke patients died in medical emer-
gencies and 24.67% were out of it without transfer to Neurology. Pa-
tients who walked out of medical emergencies without completing
etiologic balance or benefitting from secondary prevention measures,
exposed themselves to recurrences. The average time for admission to
medical emergencies since the appearance of the first symptoms was
48 h 04 min, with extremes of 30 min and 2 weeks. This time is higher
than those found by Siddiqui et al. in Karachi [2] and Sekoranja et al. in
Geneva [3] which were respectively 6 and 3 h 20 min. Twenty-two per-
cent (22%) of the patients arrived at medical emergencies of the Teach-
ing Hospital Yalgado at the time of thrombolysis, while 65% were
arrived at the first peripheral unit within the same timeframe. We lost
43% of patients during the referral from the first peripheral units to
emergencies. This shows that even if the time limit for the request of
care can be improved, the considerable delay is attributed to our referral
system. The minimum period for admission to medical emergencies
from first peripheral health units was 15 min, and the maximum period
two weeks. Patients were on average about 2 days (41 h 48 min) in pe-
ripheral health services, without the human resources (neurologists) or
material resources (CT) required to support them at the acute phase of
stroke. Some patients even left those peripheral health units without
the benefit of a hospitalization or a referral. After their entrance to the
emergency room, it took patients in our cohort an average of 21 h
18 min to perform brain imaging, with extremes of 30 min and
09 days. However, according to the recommendations of the HAS [4],
suspected stroke patients should have priority access to brain imaging
24 h a day, 7 days a week. According to recommendations AHA (Amer-
ican Heart Association) guidelines [5] ‘arrival - beginning of imaging’
time must be less than or equal to 25 min. All of these recommendations
are encapsulated in the strong statement that imaging should be done
promptly. The main cause of this delay in our series was the lack of fi-
nancial means. Brain CT scans costs set at least at 35 Euros for inpatients
and 75 Euros for outpatients, remain financially inaccessible to a large
part of the society, with 43.9% people living below the poverty threshold
[1] and lacking health insurance. In our study, thrombolysis was not
prescribed in any case of stroke whereas after the confirmation of a di-
agnosis by imaging, 18.87% of patients were eligible in accordance with
to the 4 h 30 min period. However, in most developed countries, the rate
of thrombolysis ranged from 2 to 10% in 2009 [5] and was improved ac-
cording to the 69 cases of thrombolysis in 2012 in the teaching hospital
of Angers [6]. The disparity observed in our study can easily be ex-
plained by the fact that the teaching hospital Yalgado Ouedraogo does
not have the necessary infrastructures and molecules to achieve throm-
bolysis, and particularly lacks of stroke unit and thrombolytic medica-
tions. Ossou-Nguiet et al. in Congo in 2013 proved that thrombolysis
was achievable in sub-Saharan Africa despite the lack of stroke unit,
by successfully performing their first thrombolysis with tenecteplase
[7]. This experience should inspire African practitioners. Similarly, tele-
medicine is an interesting alternative to operate in African countries
without stroke unit, like ours. The mortality rate of 20% in our sample
is similar to the data of the literature [8] which estimates between 10
and 30% at 1 month and 40% of death at 1 year, but could also be likened
to the 24.8% found by Touré et al. [9]. However, our results are higher
than those of Leslie and al USA [10] that ranged from 2 to 12% and
those of Woimant et al. in France who were 9% [11]. The lack of
human and material resources adapted (specialists neurologists in
neurovascular, Stroke Unit), the absence of a good organization of the
health system, especially the lack of a stroke care sector, does not
allow for early treatment of patients, thus increasing the mortality
rate in our developing countries.
Conflict of interest
None.
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