INTRODUCTION
Stroke now ranks as the second leading cause of death
and the first cause of morbidity allover the world. Among all
the neurological diseases of adult life, stroke clearly ranks
first in frequency and importance, at least 50% of the neurological
disorders in a hospitalized patients are of this type [1-
3].
Despite advances in medical care of stroke and the advent
of treatment of selected patients with acute ischemic
stroke, prevention remains the best approach to reduce the
burden of stroke. High–risk or stroke-prone individuals can
be identified and targeted for specific interventions [4-6].
The prevalence of stroke is heterogeneous and is greater
among the elderly and men and is variable from one region
to another of the world [7]. Few data are available on Middle
East and the developing countries of the African continent.
The aim of this survey was to study the characteristics of
hospitalized stroke patients in upper Egypt, with regard to
the relative prevalence of different stroke-subtypes, the
*Address correspondence to this author at the Unita Neurologica, Istituto di
Neurologia Sperimentale (INSPE), Istituto di Ricovero e Cura a Carattere
Scientifico (IRCCS) San Raffaele, Milano, Italy; Tel: +3902 2643 2813;
Fax: +3902 2643 2951; E mail: corea.francesco@hsr.it
demographic data and the prevalence of risk factors. A specific
pattern of habits and demographic variables between
genders is likely to be present in the study population (for
religious and socio-economical reasons). The study enrolled
all stroke patients admitted to the neurology departement of
Sohag University Hospital during the study period.
DEMOGRAPHY IN EGYPT
Egypt is the most populated country in the Middle East
and the second-most populous on the African continent, with
an estimated 78 million people. Almost all the population is
concentrated along the banks of the Nile (notably Cairo and
Alexandria), in the Delta and near the Suez Canal. Egyptians
can be divided demographically into those who live in the
major urban centers and the fellahin or farmers of rural villages.
The last 40 years have seen a rapid increase in population
due to medical advances and massive increase in agricultural
productivity.
Egyptians are by far the largest ethnic group in Egypt at
94% (about 72.5 million) of the total population. Ethnic minorities
include the Bedouin Arab tribes living in the eastern
deserts and the Sinai Peninsula, the Berber-speaking Siwis
(Amazigh) of the Siwa Oasis, and the ancient Nubian communities
living in cities in Lower Egypt and in villages clus-

42 The Open General and Internal Medicine Journal, 2009, Volume 3 Fawi et al.
number of subjects is referred to rehabilitation facilities/programmes.
The study was designed to be a prospective
hospital based study.
PATIENTS AND METHODS
The study involved 467 stroke-patients consecutively
admitted in the Neurology department of Sohag University
in the study period.
All patients of the study were subjected to the following:
*Detailed medical history interview
*Thorough general and neurological examinations
*Cranial computed tomography (CT) scanning using CT
equipment Siemens, Somatom, HIQS, VB2 with tissue matrix=256x256,one
second scanning time and 10 mm slice
thickness.
Stroke-subtype was diagnosed, and non-stroke patients
were excluded.
*The following investigations were done to define risk factors:

- Electrocardiography & Echocardiography to define relevant
cardiac problems, history of myocardial infarction,
coronary artery disease, congestive heart failure, arrythmia
or valvular heart diseases.
- Blood sugar: Diabetes mellitus (DM), defined as venous
plasma level of glucose > 7.0 mmol/l (>126 mg/dl) or under
hypoglycemic treatment.
- Complete lipogram: Dyslipidemia defined as venous
plasma level of LDL cholesterol > 3.36 mmol/l (> 130
mg/dl) and/or Triglycerides > 1.8 mmol/l (>160 mg/dl).
• The following risk factors were defined:
- Arterial hypertension defined as systolic blood pressure
>140 mmHg, diastolic blood pressure > 80 mmHg or antihypertensive
treatment.
- Smoking: active smoking or not.
- Alcohol abuse active >300 gr/week.
- Over-weight, obesity: body mass index  27kg/m2
- Family history of stroke.
- Previous history of stroke or transient ischemic attacks
(TIA).
- Education: > 6 years education-yes or no.
- Oral contraceptives use.
Follow-up: one month after stroke to define the vital outcome.

Statistical analysis: data coding and analysis using the
SPSS 11.0 version were done, our resuls, were analysed using
Odds Ratio, Risk limits, and P value.
RESULTS
Mean age at enrollment in the study populationwas 57.7
years, the median age was 60 years, range: 16 – 90 years.
Hemorrhagic stroke prevalence was reported in 37.5% and
infarction in 62.5%. Fifty six % were above 60 years and
8.6% were below 46 years. Sixty two % of stroke occurred
in autumn-winter. Hemorrhagic stroke was higher in springsummer
(53%). Fifty seven % of stroke involved residents in
rural areas. Hypertension reported in 42% of patients, more
in males 59%, more in > 40years (97.4%), smoking in
37.7%, ischemic heart diseases in 32.8%, dyslipidaemia in
29.5%, history of TIA in 23.1%, DM in 21.6%, past medical
history of stroke in 10.5%, obesity in 10.1%, Positive family
history of stroke in 9.6%, atrial fibrillation in 6%, RHD in
5.6% of patients and alcohol abuse in only 1.3% of cases.
At the univariate analysis the prevalence of juvenile
events was found higher in the female gender (11.5% vs
6.2%). A peculiar seasonal trend was found: in springsummer
the prevalence of hemorrhagic events reached the
highest values with a 47.4% of the total. Regarding the educational
level, those below 6 years of school more often suffered
of an hemorrhagic event (Table 1).
Regarding demographics we found how smoking habit
was more diffuse in the male gender (84% of smokers were
males) while alphabetization was lower in female gender.
Males had also more often a positive familiar history for
vascular events (86% vs 13.3). At the 1-month follow-up
contact 130 subjects were dead, with a case fatality rate of
27.8% (Table 2).
The vascular risk factors were analyzed for age groups
showing how DM was more diffused in older adults (21.6%)
like hypertension (42.0%). Twenty-six patients had history
of RHD, the 5.6% of the total. (Table 3).
DISCUSSION
Regarding stroke subtypes, we reported a high prevalence
of hemorrhagic stroke (37.5%). This proportion is one
of the highest rates compared with other national studies,
where in Ain shams (Cairo, Egypt) study [8-12], it was 22%
for hemorrhage and 75% infarction, also our result is still
higher than most of the international results where in many
European studies it was 83% for infarction and 17% for
hemorrhage [13-17]. In non European surveys such as Japan
it was found at 30.5% for hemorrhage and 69.5% for
ischemic [18] also in China it was reported to be 12 up to
48% for cerebral hemorrhage [19]. It is well documented that
the pathological patterns of stroke, stroke subtypes and
stroke risk factors vary widely between racial groups
(blacks, whites, hispanics), also these variations related risks
may be related to environmental related risk factors or inherited
risk factors [19-24]. The possible reasons for the higher
incidence of cerebral hemorrhage in southern Egypt population
in our study include the following, firstly, most of the
populations in southern Egypt belongs to blacks, who usually
carry a higher prevalence of hypertension. High prevalence
of hypertension is reported in other studies [24, 25], in
our study hypertension was found up to 55% in hemorrhagic
stroke patients p<0.001 % O.R.>1.6. Secondly, in southern
Egypt, most of the populations are still following the traditional
traits of marriage of related family members with potential
consequence of inheritance of some of stroke related
risk factors including hypertension, vascular malformations.
Interestingly in our study we reported higher incidence of
positive family history in our stroke patients (9.6%), and
29% of those with positive family history were presented
with cerebral hemorrhage and most of those hemorrhagic
Stroke, Case Fatality, Southern Egypt The Open General and Internal Medicine Journal, 2009, Volume 3 43
strokes, their CT or MRI showed large lobar and/or intraventricular
hemorrhage with great possibility of rupture of underlying
vascular malformations. Previous reports stated that
the site of hemorrhage shown on CT provides some clue to
the cause, where hypertensive hemorrhage tend to occur
slightly more in the basal ganglia, thalamus and pons, while
lobar hemorrhage tend to be more often due to cerebral amyloid
angiopathy, vascular malformations, and hemostatic
failure [26, 27]. Also primary ventricular hemorrhage may
be due more often to vascular malformation [28, 29]. Intracrainial
vascular malformations are properly congenital or
familial [30]. A few strokes are clearly familial in the studied
population with a simple Mendelian pattern of inheritance of
the underlying cause [31, 32].
Thirdly, the effect of the characteristic higher environmental
temperature of southern Egypt, in this high temperature
climates, central nervous system dysfunction may occur
including intracereberal hemorrhage, this dysfunction can be
explained by a number of potential pathogenetic mechanisms
including disidratation and rehydratation syndromes leading
to tissue swelling and brain edema. In many critical weeks of
the year the temperature rise over 40°C. Temperature elevation
its itself a threat for the central nervous system and to
the body in general The excessive amounts of the released
exitotoxic glutamets [33] may cause an encephalopathy, including
seizures. Hemorrhages may occur in various organs
including the brain. This are small lesions related to endothelial
damage and disseminated intravascular coagulation. Areas
showing maximal damage are cortex, thalamus and striatum.

Mortality rate in our study after one month was 27.8%,
this rate is higher than that reported by many other western
Table 1. Distribution of Stroke Subtypes and Demographic Differentials
Infarction
N = 292 (62.5%)
Hemorrhage
N = 175 (37.5%)
Total
Item No. N = 467 (100%)
Column %
No. % No. % No. %
P*
Gender:
---Male
-- < 40 y.
-- > 40 y.
161
11
150
55.1
6.8
93.2
98
5
93
56.0
5.1
94.9
259
16
243
55.5
6.2
93.8
NS
---Female
-- < 40 y.
-- > 40 y.
131
15
116
44.9
11.5
88.5
77
9
68
44.0
11.7
88.3
208
24
184
44.5
11.5
88.5
NS
P** value NS
Age at enrollment*:
---< 40 years
--- 40 – 60
---> 60 years
26
106
160
8.9
36.3
54.8
14
58
103
8.0
33.1
58.9
40
164
263
8.6
35.1
56.3
P value NS
Residence:
---Rural
---Urban
164
128
56.2
43.8
107
68
61.1
38.9
271
196
56.9
43.1
P value NS
Education:
---Educated
---Non-educated
124
168
42.5
57.5
28
147
16.0
84.0
152
315
32.5
67.5
P value <0.001
Seasonal variation:
---Aut.-winter
---Spr.-summer
197
95
67.5
32.5
92
83
52.6
47.4
289
178
61.9
38.1
P value 0.001
*NS = insignificant statistical difference. P*= statistical difference between sub-items, P** = statistical difference between items.
Mean age at enrollment = [57.7 + 12.9] years, the median = 60 years, the infarction started at 16 years old while the hemorrhage started at 21 years of age.
44 The Open General and Internal Medicine Journal, 2009, Volume 3 Fawi et al.
studies, where in Malmo, Sweden it was 15% [9] in the Oxford
shire Community Stroke Project it was 19% [15] and in
Umbria Italy, it was 20.3 % [34], however some other studies
reported similar results as in the U.K. it was 31% [16]
and in Australian study it was 24 % [35].
These variations may be due to and explained by the followings,
our study is a hospital based study which usually
includes most of the severe stroke patients not the mild ones.
The low awareness in the community, regarding stroke
warning signs, and the poor scholarization accounts for big
Table 2. Demographic Data and Risk Factors Distribution According to Gender in the Study Population
Male (n = 259) Female (n = 208)
Item
Total No. of
Cases (%) No. of Cases Row % No. of Cases Row %
P
Sociodemographic Data
Education
--Educated
--Non- educated
152 (32.5%)
315 (67.5%)
138
264
90.8
83.8
14
51
9.2
16.2
0.04
+ve family history 45 (9.6%) 39 86.7 6 13.3 0.000
Previous attack 49 (10.5%) 32 65.3 17 34.7 NS
Obesity+ 47 (10.1%) 16 34.1 31 65.9 .001
Smoking 171 (36.7%) 110 84.3 61 15.7 0.002
Alcohol cons. 6 (1.3%) 6 100 0 0 0.02
Associated Risk Factor
Hypertension 196 (41.9%) 115 58.7 81 41.3 NS
Ischemic H.D. 153 (32.7%) 84 54.9 68 45.1 NS
Atrial fibril. 28 (5.9%) 11 39.3 17 60.7 NS
Diabetes M. 101 (21.6%) 50 49.5 51 50.5 NS
Rheumatic H. 26 (5.6%) 8 30.8 18 69.2 NS
Outcome of the Cases at Discharge from the Hospital
Improvement 337 (72.2%) 180 53.4 157 46.6 NS
Death 130 (27.8%) 79 60.8 51 39.2 NS
*P = NS, there were no statistically significant difference between strokers males and females as regard the the specified factor. Mean age of M (59.4 + 12.2) was > that of F (55.6 +
13.6) years. + Obesity = body mass index ( weight, kg / height, m2) > 30.
Table 3. Age Groups, Risk Factors Distribution and Outcome in the Study Population
Risk Factors
DM Hypertension IHD AF RHD Outcome
Item No.
(column %)
- ve + ve - ve + ve - ve + ve - ve + ve - ve + ve Death Improvement
< 40 years 39 1 31 9 33 7 35 5 26 14 7 33
> 40 years 327 100 240 187 281 146 404 23 415 12 123 304
Total
% from total
366
78.4
101
21.6
271
58.0
196
42.0
314
67.2
153
32.8
439
94.0
28
6.0
441
94.4
26
5.6
130
27.8
337
72.2
Odds Ratio*
Risk limits
11.9
1.7-236.5
2.7
1.2-6.2
2.45
1.0-6.2
0.4
0.1-1.3
0.05
0.02-0.14
0.52
0.21-1.28
P value 0.002 0.009 0.03 0.06 0.00000 0.52
Stroke, Case Fatality, Southern Egypt The Open General and Internal Medicine Journal, 2009, Volume 3 45
delays in the arrival of patients in the hospital, when the
natural history of the disease may be hardly modifiable.
Moreover most of stroke risk factor e.g. DM, hypertension,
TIAs, were usually unchecked, untreated, and so were more
prevalent and intense in most of our non-scholarized stroke
patients.
Stroke mortality, as expected, was higher in hemorrhagic
strokes 42.3% vs 19.2% in ischemic strokes. Stroke patients
with DM carried mortality rate of 34.7%, followed by those
with AF 32.1%, then hypertension 31.1%, IHD 28.8% while
in those with RHD carried mortality rate of 15.4%, in stroke
patients with two or more of the previous risk factors, the
mortality rate reached more than 40%. Mortality rate in our
stroke patients above 46 years of age was 29%, much higher
than that in the juvenile stroke group (17.5%) [36, 37]. Mortality
of males was 30.5%, while in females was 24.5% in all
age groups also these results agree with literature data [38,
39].
Hyperlipidemia reported more in ischemic strokes but
with no definite relationship with stroke subtypes. TIAs were
reported more in ischemic strokes, more in older subjects.
Alcohol consumption was reported in only the 1.3% of subjects,
as expected. Obesity was reported more in females and
more in ischemic strokes.
This study was limited to some extent in that it was not
undertaken among the general population. However, as more
than 80% of patients with acute stroke are hospitalised in this
urban area of Sohag, major sampling bias was considered to
be unlikely. Other limitations were due to the difficulties
faced in a developing country, such as, likely selection bias
due to care/deaths at home, referral patterns, case selection,
missing data, and information bias due to errors in diagnosis
or risk factor information.
The accuracy of diagnosis of stroke type (ischaemic or
haemorrhagic) was satisfactory in the present study, since
brain CT scan was performed in all individuals. Our hospital-based
data probably well represent the situation in the
Upper Egypt population in general because all acute medical
cases are admitted to tertiary hospitals.
In general, age and hypertension are the most important
risk factors for incidence of stroke in the developing world.
In the study population, the prevalence of both ischaemic
and hemorrhagic stroke rises within the age groups. Other
factors such a diabetes mellitus and high lipid levels, was
less relevant in this study.
Despite the availability of cost-effective intervention
there are significant gaps, in primary prevention of cerebrovascular
diseases, in low- and middle- income areas such
as southern Egypt. Mostly there is a need to facilitate the
access to preventive drug therapy and to promote healthy
life-styles. Tailored policies are also required to promote
clinical prevention, strengthen infrastructures of health-care
facilities and providing continuing medical education for the
personnel.