Continental Survey of Access to Diagnostic Tools and Endovascular Management of Aneurysmal Subarachnoid Hemorrhage in Africa

Abstract

Rationale: Interventional neurovascular procedures are effective in lowering the burden of mortality and complications resulting from aneurysmal subarachnoid hemorrhage (aSAH). Despite the wide uptake of interventional neurovascular procedures in high-income countries, access to care in low- and middle-income countries remains limited, and little is known about accessibility in Africa. In this survey, we decided to assess access to diagnostic tools and treatment of aSAH in Africa.Methodology: A Google form e-survey was distributed to African neurosurgery centers accepting responses from January 4th to March 21st 2021. Data on accessibility to diagnostic tools, treatment methodologies, and interventional neuroradiology personnel in African centers were collected. Ninety five percent confidence intervals were computed for each variable.Results: Data was received from 36 neurosurgical centers in 16 African countries (16/54, 30%). Most centers were public institutions. Ninety four percent of the centers had the necessary resources for a lumbar puncture (LP) and a laboratory for the diagnosis of aSAH. Most centers had at least one computed tomography (CT) scanner, 81% of the centers had access to CT angiography and some had access to conventional angiography. Forty seven percent of the centers could obtain a head CT within 2 h of presentation in an emergency. Sixty one percent of centers provided clipping of intracranial aneurysms whilst only 22% of centers could perform the endovascular treatment. Sixty four percent of centers did not have an endovascular specialist.Conclusion: This survey highlights health inequity in access to endovascular treatment for aSAH. Lack of diagnostic tools to identify an aneurysm and a shortfall of qualified endovascular specialists are prime reasons for this. Our findings can inform health system strengthening policies including the acquisition of equipment and capacity building in Africa.

Clinical Outcomes of Primary Subarachnoid Hemorrhage: An Exploratory Cohort Study from Sudan

“…This fact highlights the limitation of diagnostic tools to identify an aneurysm and the lack of access to interventional neurovascular procedures in low and middle-income African countries compared to high-income countries. 104 In this study, 62.5% of patients presented within 24 hours of symptom onset, while the remaining 37.5% of patients had mild symptoms that delayed presentation to the hospital. This finding is consistent with previous study findings to determine the association between presentation time and clinical outcome in SAH, approximately one-quarter of 721 patients presented after 24 hours of symptoms onset.…”

“…This fact highlights the limitation of diagnostic tools to identify an aneurysm and the lack of access to interventional neurovascular procedures in low and middle-income African countries compared to high-income countries. 104…”

Stroke in Sierra Leone: Case fatality rate and functional outcome after stroke in Freetown

“…Subarachnoid hemorrhage CFR of 60% corresponds poorly to global estimates of CFR ranging from 27% to 44%, 32 reported CFR of 40% in Sudan, 33 44.4% in Nigeria, 34 and 45.6% in Kenya 35 and reflects both the severity of strokes included in our cohort and lack of timely access to care, including neurosurgical intervention available in our setting. 36,37…”

“…Subarachnoid hemorrhage CFR of 60% corresponds poorly to global estimates of CFR ranging from 27% to 44%, 32 reported CFR of 40% in Sudan, 33 44.4% in Nigeria, 34 and 45.6% in Kenya 35 and reflects both the severity of strokes included in our cohort and lack of timely access to care, including neurosurgical intervention available in our setting. 36,37 We report strokes occurring in younger people, with a mean age of 59 years. As in other settings, age was significantly associated with increased mortality, and patients alive at 1 year were on average 5 years younger than those dead at 1 year.…”

The Neurology and Neurosurgery Interest Group (NANSIG)—ten years of cultivating interest in clinical neurosciences

“…This programme provides students and junior doctors with the opportunity to design and lead global neurosurgical research projects within a topic of their interest, under the mentorship of experienced academics. Though in its infancy, the collaborative has since contributed to the scholarly output in Africa through identifying areas in need of improvement, such as the lack of availability and accessibility of diagnostic and management tools for aneurysmal subarachnoid haemorrhage in the continent [ 12 , 13 , 35 ].…”