Research Article: Mortality and functional outcomes after a spontaneous subarachnoid haemorrhage: A retrospective multicentre cross-sectional study in Kenya

Date Published: June 12, 2019

Publisher: Public Library of Science

Author(s): Peter Waweru, Samwel Maina Gatimu, Stephan Meckel.


Despite a reduction in poor outcomes in recent decades, spontaneous subarachnoid haemorrhage (SAH) remains associated with severe disability and high mortality rates. The exact extent of these outcomes is however unknown in Africa. This study aimed to determine the mortality and functional outcomes of patients with SAH in Kenya.

We conducted a retrospective multicentre cross-sectional study involving patients admitted with SAH to three referral hospitals in Nairobi. All patients with a confirmed (primary) discharge diagnosis of first-time SAH between January 2009 and November 2017 were included (n = 158). Patients who had prior head trauma or cerebrovascular disease (n = 53) were excluded. Telephone interviews were conducted with surviving patients or their next of kin to assess out-of-hospital outcomes (including functional outcomes) based on modified Rankin Scale (mRS) scores. Chi-square and Fisher’s exact tests were used to assess associations between mortality and functional outcomes and sample characteristics.

Of the 158 patients sampled, 38 (24.1%) died in hospital and 42 (26.6%) died within 1 month. In total, 87 patients were discharged home and followed-up in this study, of which 72 reported favourable functional outcomes (mRS ≤2). This represented 45.6% of all patients who presented alive, pointing to high numbers of unfavourable outcomes post SAH in Kenya.

Mortality following SAH remains high in Kenya. Patients who survive the initial ictus tend to do well after treatment, despite resource constraints.

The study findings should be interpreted with caution because of unavoidable limitations in the primary data. These include its retrospective nature, the high number of patients lost to follow up, missing records and diagnoses, and/or possible miscoding of cases.

Partial Text

Spontaneous subarachnoid haemorrhage (SAH) is associated with severe disability and high mortality rates; despite a reduction in case fatality rates over the last four decades [1]. Recent studies have reported mortality rates from 25% at pre-hospital [2] to 18% in hospital [3]. Mortality also remains high after discharge from hospital, with rates of 40% within 30 days [4], 50% within 1 year [5] and an elevated long-term mortality [6]. Only half of patients with SAH who get to the hospital return to their previous level of functioning. The remainder are plagued by numerous complications, from gross neurological deficits to subtle cognitive and neurobehavioural difficulties that hinder normal functioning and lower quality of life [7,8].

This study aimed to determine the mortality and functional outcomes of patients with spontaneous subarachnoid haemorrhage (SAH) in Kenya. We recorded 158 SAH cases over the nine-year study period. This low number of SAH cases could be explained by the retrospective nature of the study and possibly a large number of undiagnosed hence unreported SAH cases resulting from a lack of neuroimaging and angiographic diagnostic tools for SAH as seen in this study. This is also evidenced by the high proportion of autopsy identified SAH cases in unexplained deaths in Kenya [11]. Moreover, for SAH patients who eventually get diagnosed, record keeping in our region is deficient [18].

In-hospital and 1-month mortality rates for SAH are high in Kenya, and functional outcomes are generally low. For patients who reach neurosurgical centres and are actively managed however, favourable functional outcomes are comparable to other centres; although given the limitations of this study including treatment bias, this needs to be further studied.