Evolution of hospitalized neurological disorders in Western Madagascar

¹University of Mahajanga, Faculty of Medicine, Neurological Department, Hospital CHU PZAGA, Mahajanga, Madagascar, ²University of Antananarivo, Faculty of Medicine, Resuscitation Department, Hospital CHU JRA, Antananarivo, Madagascar, ³University of Mahajanga, Faculty of Medicine, Psychiatry Department, Hospital CHU PZAGA, Mahajanga, Madagascar, ⁴University of Antananarivo, Faculty of Medicine, Neurology Department, Hospital CHU Befelatanana, Antananarivo, Madagascar

^&Corresponding author
Rahamefy Odilon Randrianasolo, University of Mahajanga, Faculty of Medicine, Neurological Department, Hospital CHU PZAGA, Mahajanga, Madagascar

Introduction    

Deaths and disabilities related to neurological disease increased in the past decade [1]. In Africa, this increase in morbidity and mortality is associated with changing disease patterns, such as increased strokes and HIV-related complications [1-4]. In Madagascar, an increase in stroke mortality was reported and became the first cause of death reported in our population [5]. In western Madagascar in the neurological department, the main causes of neurological disease in order of frequency were epilepsy, stroke, central nervous system infections, and neuropathies in the 1990s [6]. The most recent study on neurological pathologies in the locality was carried out in a primary health center that did not allow the comparison and evaluation of the evolution of neurological disease [7]. Our aim in this research was to characterize the neurological conditions that are observed in the neurological department and to ascertain how these have evolved in comparison to earlier data.

Methods     

Study design and setting: this is a retrospective descriptive study, carried out in the neurology department of Professor Zafisaona Gabriel (PZAGA) University Hospital in Mahajanga in Madagascar for two years from January 1, 2020, to December 31, 2021. This study was carried out in the city of Mahajanga. It is a city located 560km northwest of the capital. It is an urban, coastal district with about 274 720 inhabitants in 2020. It has an area of about 57 km². One neurology department exists in Mahajanga. It is an adult general neurology department. The department's hiring is represented by the subjects living in the city of Mahajanga and the region of Boeny. A descriptive, retrospective study of patients hospitalized in the neurology department of the PZAGA Mahajanga University Hospital in 2020 and 2021 was carried out. Patients with COVID-19, including those with neurological symptoms, were admitted to a different hospital during the study period.

Participant: included in the study were all hospitalized subjects whose discharge diagnosis was a neurological disease. Incomplete records that did not allow the patient's diagnosis to be determined were excluded.

Variables: the diagnosis of neurological disorders of the patients was evaluated and was classified according to the main cause retained at the discharge in stroke, epileptic disorders, headache, neuroinfectious disease, neuromuscular disease, alcohol withdrawal, tumor disease, dementia, and other neurological diseases.

Data source: we collected retrospective data from the patient's medical record.

Bias: this study's etiological analysis and neurological disorder diagnosis were limited since not all patients had access to neuroimaging and neurophysiological testing such as brain CT scans and electromyography. A neurologist examined every medical file to confirm the accurate diagnosis.

Study size: an exhaustive selection was carried out of all patients hospitalized for neurological disorders in the neurology department during the years 2020 and 2021.

Quantitative variable: demographic data was analyzed for each patient: age, gender, occupation, and city of origin. Diagnosis of neurological disorders upon discharge from hospitalization was analyzed.

Statistical methods: the mean and frequency for each variable were calculated. A comparison of the difference in frequency of neurological disorders seen between 2020 and 2021 was carried out using a Chi-square test. Data recording and analysis were done using Microsoft Excel and EPI info software.

Results     

Socio-demographic characteristics of participants: three hundred and thirty four (334) subjects were included as hospitalized for neurological disease. Seven subjects were excluded due to the lack of information. Males represented 52.69% and females 47.31% of all cases. The average age of the subjects was 51.04 years with an extreme of 15 to 94 years. The subjects lived in the city of Mahajanga in 74.85% of cases (Table 1).

Outcome data: stroke represented 46.11% of all cases, epileptic disease 21.26%, headaches 9.58%, neuro-infectious disease 7.49%, alcohol withdrawal 5.39%, neuromuscular disease 4.19%, tumor disease 3.59% and other neurological diseases 2.40% (Figure 1). The mean age of the stroke patients was 59.64 years. The sex ratio was 0.79 men to one woman. 69.48% were undocumented strokes, 17.53% were hemorrhagic strokes, 11.04% were ischemic strokes, and 1.95% were cerebral venous thrombosis. Minor stroke was found in 25.32%, moderate in 47.40%, and severe in 27.27% according to the NIHS score. 83.12% of the subjects with stroke were hypertensive and 94.53% were untreated or irregularly treated. Neuroinfectious diseases were represented by 13 (52%) cases of neurological complications of tuberculosis, 2 of which were associated with co-infection with HIV, 4 cases of cerebral abscesses, 4 cases of bacterial meningitis, 1 case of viral encephalitis, 1 case of neurocysticercosis, 1 case of leprous neuropathy, 1 case of infectious myelitis. No case of neuro malaria was found in the neurological department. For neuromuscular disease, 8 (57.14%) cases of polyneuropathy, 3 cases of myopathy, 2 cases of Guillan barré syndrome, and 1 case of amyotrophic lateral sclerosis were found.

Other analysis: there was no significant difference between the neurological disorders seen in 2020 and 2021 (p=0.26).

Ethical approval: prior authorization from Hospital staff and the head of the department was requested beforehand.

Discussion     

In Mahajanga, stroke was the most frequent neurological pathology in hospitalization in a neurology department, followed by epilepsy, headaches, and infectious pathologies. Compared to the study which was carried out in the same department in 1995 [6], the most change was the increase in cases of hospitalization for stroke, which represented 21.80% of the causes of hospitalization in 1995 to 46.11% in 2020 and 2021. The number of stroke cases was multiplied by 3 over the 2 years of our study, compared to the number of cases seen over 3 years from 1993 to 1995. Cases of epilepsy did not change and represented 22.22% in 1995 and 21.26% in 2021. A decrease in cases of neurological infectious disease and neuropathies was noted. The clinical and epidemiological context limits the comparison between these two studies. In the previous studies, it was noted the unavailability of certain means of exploration such as computed tomography (CT) scans, magnetic resonance imaging (MRI), and electroencephalogram (EEG) which were available now in our country even if all the patients did not have access to these explorations. This strong increase in stroke cases in Madagascar has been reported by studies of causes of death in our population, where stroke was the 4^th cause reported in 1990 and became the leading cause in 2016 [5]. This increase follows the trend in Africa where morbidity and mortality from stroke are increasing [3,4,8].

This strong increase can be linked to several factors, including the urbanization of lifestyle, the high prevalence of arterial hypertension, and the increase in smoking [3]. In our study, 83.12% of subjects with stroke were hypertensive and 94.53% were untreated or irregularly treated, excluding this being the most frequently encountered risk factor for stroke [9,10]. For epilepsy, the hospital prevalence has not changed in 25 years with a high prevalence of more than 20% compared to studies in other African countries which could range from 3 to 10% of the causes of hospitalization in neurology [11-14]. Indeed, Madagascar is a country with a high prevalence of epilepsy [15] and this finding contrasts with estimates where the prevalence and mortality of epilepsy have decreased in recent decades [16]. One of the major changes in the profile of the diseases seen in neurology in our practice was the reduction and change in the neurological infectious pathologies encountered. In the study carried out in 1995, the infectious pathologies of the central nervous system (CNS) represented 19.24% of hospitalizations and were only 7.49% in our study.

The pathologies found were neurocysticercosis first, followed by meningitis and encephalitis, by neuro malaria, then leprosy and neurosyphilis. In our study, the infections found were dominated by complications of tuberculosis with two co-infections with HIV, followed by meningitis, abscesses, and encephalitis, a case of neurocysticercosis and leprosy. The difference between these results can be explained by the diagnosis of neurocysticercosis which was evoked by the clinic and the biological explorations in the 1995 study and by the scanner in our study [6]. The fact that not all of our patients could benefit from a brain CT scan could reduce the cases of neurocysticercosis in our results. These results with an increase in tuberculosis could be explained by the fact that in Madagascar, tuberculosis is constantly increasing, which is associated with the increase in HIV infection [17,18]. It was also observed the absence of cases of neuro malaria and these can be linked to our recruitment, but also a decrease in cases of malaria in the city of Mahajanga. In our hospital, malaria cases could be hospitalized in the emergency room or the infectious disease department. The cause of the decrease in cases of neuropathy is difficult to identify because the cause of these pathologies was not determined, but was later reported to be a high prevalence of mononeuropathy [6]. It was also to observe the persistence of cases of leprosy, which remains frequent, especially in rural areas in the region [6,7].

Limitations: access to paraclinical analyses could limit etiological research for neurological disorders in our context.

Conclusion     

This study allows us to see the evolution of neurological disorders seen in a neurology department in Mahajanga over 3 decades and forecasts the evolution of neurological pathologies in developing countries. The epidemic context of 2020 and 2021 with COVID-19 could modify our recruitment, even if no significant variation of neurological disease encountered was noted during 2020 and 2021. A similar situation could be observed in other regions of Madagascar, but over studies would be necessary. Improved preventive measures and care, in particular for stroke, epilepsy, tuberculosis, and HIV, should be improved given the evolution of these pathologies.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the individuals listed as co-authors in this manuscript have participated in the research work and manuscript write-up.

Acknowledgments     

We thank the staff of the CHU PZAGA Mahajanga Hospital.

Table and figure     

Table 1: demographic characteristics of the study population

Figure 1: distribution of neurological disorders in the Mahajanga Neurology Department

References