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VOLUME 15 NUMBER 1 • JULY 2018
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
more prevalent than haemorrhagic stroke, as stated by two
studies; 66.4% for ischaemic stroke and 33.6% for haemorrhagic
stroke,
7
with the highest mortality rates (57%) occurring in the
haemorrhagic stroke type.
4,8
There is a significant absence of any
reference to sub-arachnoid haemorrhage in the information that
has been reported in the Sudanese studies on CVAs.
4,8
Risk factors of cerebrovascular diseases in Sudan
Hypertension is the most frequently cited risk factor, with
a prevalence of 61%, and found in 46% of the cases in two
different studies.
8
Interestingly, 26% of the stroke patients in
one study were newly diagnosed cases of hypertension, detected
after the occurrence of stroke.
4,7
Other reported risk factors were
heart diseases in 16% of the cases, diabetes mellitus in 14%,
syphilis in 4.2% and previous transient ischaemic attacks in
2.1%.
4,8
Smoking and hypercholesterolaemia were also reported
as risk factors, but without specific figures.
Females are more affected than males when it comes to
this type (thrombotic type) of stroke and the most prevalent
risk factor is the use of combined oral contraceptive pills.
Haematological profiles of the study subjects were indicative of
natural anticoagulant (protein C, protein S and antithrombin III)
levels at the lower range of normal in all patients (
p
= 0.04), but
significantly lower in those of the age- (
p
= 0.04) and gender-
matched controls (
p
= 0.02).
9
Neurological services and cerebrovascular diseases
in Sudan
Modern medicine was introduced to Sudan in the early nineteen-
hundreds by the British government, which colonised Sudan from
1898 until 1956. Since then, health services and systems in Sudan
have been quantitatively and qualitatively evolving, but not as fast
as required. Proof of this is the high mortality and morbidity rates
in the country and the poor development of certain components
of the health system, including neurological services.
10
Despite the high numbers of hypertension cases reported,
very little research in the literature has addressed the situation of
neurological services in Sudan and none has approached it with
regard to the problem of healthcare for cerebrovascular disease in
Sudan. There are no recent and accurate published figures on the
actual size of the services devoted to the problem.
11
A recent study estimated the number of neurologists per
million populating to be 0.530, which means 18 neurologists for
the whole Sudanese population.
11
Also, the ratio of neurologists
in academic institutions to neurologists in training is 3:21.
11
The national centre for specialised neurological care in Sudan is
located in Khartoum, and it has to meet the needs of the entire
population.
5,10
However, it lacks key equipment and facilities that
are crucial for the adequate provision of services, for example,
intensive care needs, with serious deficiencies in the number of
beds in intensive care and ventilation support for patients.
5
The
centre provides both neuromedical and neurosurgical services but
no neurophysiology or neuro-rehabilitation activities.
5,10
Neuro-imaging techniques, such as computed tomography
(CT) scanning and magnetic resonance imaging (MRI) are the key
diagnostic measures for CVA. However, the centres are located
in the capital city only, and are mainly operated by the private
sector, which reflects a deficiency in the services devoted to such
needs.
10
This increases the difficulty of service utilisation by the
patients due to financial, geographical or social barriers. There is
also a complete lack of diagnostic modalities, even in the national
governmental centre for neurology in Khartoum.
5
Interventional radiological procedures for CVA are carried out in
only one centre, Khartoum.
5,10
However, such procedures are rarely
done as they are too expensive for the majority of the population,
with an estimated average cost of $5 000 per procedure.
5,6
Such an
intensive medical care centre was expensive to set up, however, and
employment of the required number of specialists is also costly.
6
Neuro-rehabilitation is neglected in Sudan, with no governmental
bodies assigned to providing such services for needy patients. The
few available centres offering such services are privately operated
with high average costs, and the working personnel are limited to
trained nurses and physiotherapists.
5,10
Recommendations
• National, systematic and wide-based epidemiological research
on the incidence of, and morbidity and mortality caused by CVA
is desperately needed to guide decision making and service
improvement.
• Research on clinical profiling, presentation and outcomes of
cerebrovascular diseases are of great importance in instituting
the neglected aspects of neurological services in Sudan, such as
neuro-rehabilitation, neuropsychology and neurophysiology.
• Primary care neurological services in Sudan need to be
identified, established and organised, with appropriate clinical
identification and interventional protocols for CVA, and
guidelines directed through national programmes that cover
both rural and urban areas. There is also a need for systematic
research efforts.
• Neurological service centres for CVAs in Sudan need to be
adjusted to population needs and characteristics, quantitatively
by increasing the number of services and imaging facilities
both in urban and rural cities, and qualitatively through free
or affordable and accessible provision of crucial diagnostic and
treatment measures.
• Statistics are deficient for the utilisation of health services, as
well as on the quality of services and patient satisfaction with
regard to cerebrovascular diseases in Sudan. This needs to be
improved by broad research action.
Conclusion
Cerebrovascular diseases account for the majority of the morbidity
and disability experienced in Sudan, with hypertension being the
number one risk factor. Insufficient research action has resulted in
lack of knowledge about the epidemiological, clinical and socio-
demographic characteristics of cerebrovascular diseases.
The absence of nationally organised, wide-based, quantitative
research using valid and reliable indicators for measuring disability,
morbidity and mortality burdens caused by cerebrovascular
diseases, as well as the lack of qualitative research has left a gap
in the knowledge on the state of affairs regarding cerebrovascular
disease in Sudan. This explains the deficit in neurological services for
cerebrovascular diseases, which are not able to meet the needs of
the population in terms of quality or quantity of neurological health
services. The lack of political will and dedication of resources, as
well as the socio-cultural characteristics of the Sudanese population
have exacerbated the problem.