World Journal of Cardiovascular Diseases, 2013, 3, 523-528 WJCD Published Online December 2013 (
Hypertension and intracerebral hemorrhage in Brazzaville*
Thierry Raoul Gombet1,2#, Paul Macaire Ossou-Nguiet1,3, Thibaut Naibe Gankama4,
Bertrand Fikahem Ellenga-Mbolla1,4, Gilbert Fabrice Otiobanda5,
Karen Obondzo-Aloba3, Benjamin Longo-Mbenza6
1Department of Medicine, Faculty of Health Sciences of Brazzaville, Brazzaville, Congo
2Service of Emergency University Hospital of Brazzaville, Brazzaville, Congo
3Service of Neurology University Hospital of Brazzaville, Brazzaville, Congo
4Service of Cardiology University Hospital of Brazzaville, Brazzaville, Congo
5Service of Reanimation University Hospital of Brazzaville, Brazzaville, Congo
6Faculty of Health Sciences, Walter Sisulu University, Mthatha, South Africa
Received 25 October 2013; revised 26 November 2013; accepted 3 December 2013
Copyright © 2013 Thierry Raoul Gombet et al. This is an open access article distributed under the Creative Commons Attribution
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Hypertension is not only an important risk factor, but
also an important cause of spontaneous intracerebral
hemorrhage. Its high prevalence in Africa reflects a
high incidence of cerebral hemorrhage ranging from
30% to 60% against 10% to 20% in industrialized
countries. The aim of our study was to determine the
role of hypertension before the onset of intracerebral
hemorrhage and its variations during the first three
months. This was a longitudinal study conducted at
the University Hospital of Brazzaville from 1st Janu-
ary to 31st August 2012 with all patients admitted for
intracerebral hemorrhage. Patients with subarach-
noid or pure intraventricular hemorrhage were ex-
cluded. The study variables were: history of hyper-
tension, knowledge of its history, treatment, blood
pressure on admission and during the first 3 months
and the relationship between blood pressure and
evolution. Statistical analysis was performed using
the software SPSSS 16.1. The significance level was
set at p < 0.05. During the study 261 patients were
hospitalized for stroke, of which 82 (31.42%) were for
intracerebral hemorrhage. The mean age was 55 ± 11
years and sex ratio of 2 men:1 woman. Hypertension
was found in 80.5% of cases, of which 65.2% had
known hypertension, but 82.6% had discontinued
treatment. The mean systolic blood pressure was 194
± 41 mm Hg and dia stolic 104 ± 20 mm Hg. The loca-
tion was deep in 85.71%. The normalization of blood
pressure was obtained from the second week. After
adjusting for confounders using logistic analysis, only
uncontrolled hypertension was associated significantly
and independently associated with a higher mortality
rate (p = 0.042).
Keywords: Hypertension; Cerebral Hemorrhage;
The hemorrhagic stroke or intra cerebral hematoma (ICH)
is the extravasation of blood into the brain parenchyma.
Its incidence is 9 - 15 cases per 100.000 persons [1].
There are racial variations of hypertension prevalence
which is higher among blacks and Asians than the rest of
the world [2,3]. It represents 10% to 30% of stroke [4,5].
ICH is the most severe and the most deadly subtype.
Chronic hypertension is not only the first risk factor, but
also the primary cause of ICH in 60% of cases [6,7]. Ar-
teriosclerosis and micro-Charcot-Bouchard aneurysms
which may rupture at deep penetrating arterioles explain
the hematoma [8,9]. A high blood pressure is regularly
observed in the acute phase of ICH [10], most often as-
sociated with an increase in the volume of hematoma, or
a poor prognosis [6]. Although studies have been con-
ducted on the management of blood pressure in ICH [11,
12], however, in sub-Saharan Africa, the prevalence of
hypertension is high with a lower prevalence of stroke in
general populations [13].
In Brazzaville (Congo), 32.5% of the population are hy-
pertensive [14]. Furthermore, stroke is a frequent reason
*Conflict of interest: The authors declare no conflict of interest
#Corresponding author.
T. R. Gombet et al. / World Journal of Cardiovascular Diseases 3 (2013) 523-528
for hospitalization, and represents the first hypertensive
emergency in Brazzaville University Hospital [15].
The aim of our study was to assess the role of hyper-
tension before the onset of ICH, and its variations during
the first three months, as well as its impact on prognosis.
This is a longitudinal study conducted at the University
Hospital of Brazzaville, services of Neurology, Emer-
gency and Intensive Care Unit from 1st January to 31st
August 2012 for a period of 8 months. The study popula-
tion consisted of patients admitted for ICH in these ser-
vices. We included all patients hospitalized for hemor-
rhagic stroke confirmed by CT scan without contrast
injection, regardless of age and sex. Informed consent
was obtained either from the patient when he was not
conscious and aphasic, either from a close family mem-
ber when the patient was unconscious or in case of se-
vere aphasia. We excluded all patients hospitalized for
suspicion of stroke not confirmed by brain CT-scan, pa-
tients with normal scan or signs of ischemic stroke, iso-
late subarachnoid hemorrhage, intraventricular hemor-
rhage, hemorrhagic infarction, head trauma, brain tumor-
induced hemorrhage, or patients in whom informed con-
sent was not obtained. The diagnosis of hemorrhagic
stroke was confirmed by the presence of an intraparen-
chymal hyperdensity with or without spontaneous ven-
tricular break. The study variables were: age, sex, vascu-
lar risk factors such as the history of hypertension de-
fined as systolic blood pressure(SBP or PAS in french)
140 mmHg and/or diastolic blood pressure (DBP or PAD
in French) 90 mmHg or the existence of antihyperten-
sive treatment in. Knowledge of hypertension, its dura-
tion, the time between ICH onset and the time of hospi-
talization, adherence, control, daily monitoring, the loca-
tion and the site of the hematoma, the severity of hyper-
tension at admission, the initial severity stroke by the
NIHSS score, the progression of the disease and out-
comes(death or survivorship) of patient. The evolution
was evaluated on the third day (D3 or J3 in French) on
the seventh day (D7 or J7 in French), the fourteenth day
(D14 or J14 in French), one month (M1), two months
(M2) and three months (M3 or J90 in French).
The data collected were entered in Excel, and then ana-
lyzed using the SPSSS version 16.1 on Windows. The
qualitative variables were expressed as frequency (n) or
proportions (%) and quantitative variables as mean ±
standard deviation(SD). The chi-square test was used to
compare proportions, while Student-t test was used to
compare means. Statistical significance was set for the
probability p 0.05.
Of 689 patients in these services, 261(37.88%) were ad-
mitted for stroke, among them 86 (32.95%) cases of ICH
with 82 cases of intra-parenchymal hemorrhage (31.42%)
and 4 cases (1.53%) of subarachnoid hemorrhage.
A total of 82 cases of ICH, there were 51 (63.4%) men
and 31 (36.6%) women with a sex ratio of 2 men: 1
woman. The mean age of patients was 55 ± 11 years
(range 26 to 83 years).
Table 1 shows the frequency of various risk factors.
In terms of frequency of risk factors, hypertension was
the first with 80.5 % of patients. Twenty-three hyperten-
sive patients were adherent to hyp 19 (82.6%) had dis-
continued treatment before hospitalization. Hypertension
was found in 80.5% of cases whose 65.2% had known
hypertension but 82.6% had discontinued treatment.
Only 4 (17.4%) had not interrupted the assessment of the
longitudinal follow-up. On admission, the mean systolic
blood pressure (SBP) was 194.51 ± 41.31 mmHg, with a
range from 100 to 270mmHg. Diastolic blood pressure
(DBP) averaged 104.51 ± 20.44 mmHg, with a range
from 70 to 170 mmHg. Figure 1 shows the levels of
blood pressure on admission.
In terms of initial severity, the NIHSS score at admis-
sion average was 14.9 ± 7.3, with a range from 2 to 30.
The electrocardiogram had revealed left ventricular
hypertrophy (LVH) in 42 (63.6%) on 66 hypertensive.
The average time for completion of the CT scan was
2.4 ± 2 days, with ranging from 1 to 14 days.
Ventricular break of hemorrhage was noted in 24
(29.4%) patients. The hematoma was supratentoriel in
92.7% and 6.1% in infratentorial. The average volume of
the hematoma was 24 ± 17 ml.
The deep site was the most frequent (55%) followed
by lobar site in 29% (Figure 2).
The management of blood pressure involved the ad-
ministration of intravenous nicardipin for all patients
with blood pressure 160/110 mmHg, and all known
hypertensive patient were treated by combination of
Enalapril and Hydrochlorothiazide.
Figure 3 depicts the changes of SBP and DBP across
the time of the monitoring which showed a constant nor-
malization of blood pressure from the second week to the
end of the follow-up (3 months).
The incident mortality rate was 37.8% (n = 31/82 pa-
tients). After adjusting for age, sex, history of hyperten-
sion, and initial severity, multivariate analysis identified
only uncontrolled hypertension was associated signifi-
cantly and independently associatedwith higher mortality
rate (p = 0.042) (Table 2).
We conducted a prospective study, including all patients
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T. R. Gombet et al. / World Journal of Cardiovascular Diseases 3 (2013) 523-528 525
Table 1. Frequency of risk factors.
Risk Factors Number %
Hypertension 66 80.5
Sedentarity 49 59.8
Smoking 13 15.9
Diabetes 2 2.4
Figure 1. Different levels of blood pressure at admission.
Figure 2. Distribution of bleeding anatomical sites of the brain.
admitted to University Hospital of Brazzaville for ICH.
Likewise, this study involved a small number of patients.
But it allowed us to estimate the impact of uncontrolled
hypertension in cerebral hemorrhage in Central Africa.
The ICH rate was estimated at 32.95% during the
study period. Our results were different from those of the
most Western literature where the incidence of cerebral
hemorrhage is between 10% and 20% [16,17]. This differ-
ence can be explained in two ways, first, the fact that our
study was purely performed in hospital, so that our find-
ings cannot be generalized to the Congolese population.
It may not reflect the true incidence. Second, the higher
frequency ofICH is well known among black individuals
[5,18]. In INTERSTROKE multicenter study conducted
in 22 countries, O’Donnell et al. [19] reported a frequency
of 9% in the industrialized countries, 22% in South East
Asia, 26% in South America and 34% in Africa. Belo et
al. [20] in a study of the characteristics of stroke in Black
Africans from Togo, found incidences of ICH between
Figure 3. Changes in blood pressure during the first three
months, SBP (a) and DBP (b). Legend: PAD = DBP, PAS =
SBP, J = D (day).
28% and 60%. Our hospital frequency of ICH (32.95%)
was consistent with that interval. from Sagi et al. in dif-
ferent African countries[21] Adoukonou et al. [13]
showed 12 African studies report a frequency ICH rang-
ing from 21% to 60.1% which is consistent with our
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T. R. Gombet et al. / World Journal of Cardiovascular Diseases 3 (2013) 523-528
Copyright © 2013 SciRes.
Table 2. Associations between variables and outcomes.
Parameters Population n(%) or
mean ± SD
Death n(%)
mean ± SD
Survivor n(%)
mean ± SD P-Value
Hypertension 66(80.5) 25(37.9) 41(62.1) 0.607
Alcohol 56(69.1) 22(39.3) 34(60.1) 0.490
Sedentarity 49(59.8%) 20(40.8%) 29(59.2) 0.327
Smoking 13(15.9) 6(46.2) 7(53.8) 0.352
Diabetes 2(2.4) 2(100) 0(0) 0.140
SBP 194.5 ± 41,3 190.3 ± 34,1 197 ± 45.2 0.042
DBP 104.5 ± 20.4 104.5 ± 19.2 104.5 ± 21.4 0.847
Supra + infra
Lobar and deep
results. The high frequency and observed is related to the
prevalence of hypertension in Brazzaville which varies
between 32.6% and 43% [14,22], hypertension is not
only a risk factor, but the main cause of ICH. Its fre-
quency in stroke patients ranges from 40% to over 80%
[21]. Also this increase in frequency reflects the system-
atic implementation of a brain scan for suspected stroke
as also reported by Ossou-Nguiet [23].
The mean age of our patients was 55 ± 11 years and
very similar to those of Ossou-Nguiet et al. [24], Rave-
loson et al. in Madagascar [25], Benedict et al in Dji-
bouti [26], and Sagi et al. across several sub-Saharan
African countries [21].
Regarding hypertension, 80.5% of our patients had a
previous hypertension. Our results were similar with
most African and Western studies as reported by Manno
et al. [17], Ossou-Nguiet et al. [24], Raveloson et al. [25],
Shoemaker et al. [27], Chuang et al. [28], and Li et al.
In our study, 34.80% of patients did not know their
hypertension status. This high rate of ignorance of hy-
pertension reflects the weaknesses of management
awareness and screening of hypertension which are es-
sential way to fight against hypertension. Our results
confirmed those of Raveloson et al. with 70.59% igno-
rant of hypertension [25]. The history of hypertension
did not influence the prognosis. Our results were very
similar to those of Ossou-Nguiet et al. in Brazzaville
[24], and Cheung and Zouin China [30]. However,
Chuang et al. in Taiwan showed that hypertension was
associated with earlier death with only 29.4% hyperten-
sives among all participants [28]. This difference could
be explained by the magnitude (over 80%) of hyperten-
sion in the study populations from Ossou-Nguiet et al
[24], Cheung et al. [30], and the present study.
The response rate to the steps of the monitoring was
low and estimated only 34.90% in the present study and
similar with that of 29.1% reported by Ravelosonin
Madagascar [25]. Of 39 hypertensive patients, more than
half (59%) received treatment against hypertension. How-
ever, the number of untreated hypertension is relatively
large (41%), highlighting the lack of communication, the
denial or offers of health care, but also low economic
level. The present percentage of treated hypertensive
obtained in our study exceeded that of 29.4% observed
by Raveloson [25].
With a mean SBP of 194.5 mmHg and a mean DBP
104.5 mmHg fromour study was consistent with that of
Cheung and Zouin China [30] in China and Matsoukawa
et al. in Japan [31]. The later pressures were higher than
those found by Chuang et al. in Taiwan [28]. Both ethnic
and environmental factors may explain severity of hy-
pertension in black Africans and Indians [32].
The increase in SBP was significantly associated with
death as evidenced by Ossou Nguiet et al. [24], Hu et al.
[32] and Béjot et al. [33]. The mean NIHSS score at ad-
mission was 14.9 ± 7.3. Our results corroborate those of
Dowlatshahi [34] who obtained an average of 13. A high
NIHSS score (over 20) was a predictor of mortality at 30
days and poor recovery at 3 months as reported by some
authors [24,30]
The ventricular hypertrophy found in our hypertensive
patients was the main complication and well established
as one of coronary heart disease and should be recog-
nized in the management of hypertension [35].
The supratentorial location represented 92.7% against
T. R. Gombet et al. / World Journal of Cardiovascular Diseases 3 (2013) 523-528 527
6.1% infratentorial location. These results were consis-
tent with most studies [36]. Indeed the main causes of
cerebral hemorrhage including hypertension, arterioven-
ous malformations and amyloid angiopathy induce more
supratentorial hematoma than infratentorial hematoma.
The deep site was most frequent (55%) and followed
by lobar site representing 29% and cerebellar site for 6.1
%. This distribution was consistent with data from the
literature [29,36]. The deep location is the predilection of
the hematoma related to hypertension at determining
micro-aneurysms of perforating arteries. The location of
the hematoma did not influence the prognosis as also
reported by Cheung and Zou [30] and by Godoy [36].
Ventricular break frequently encountered was observed
in 29.4%. These data are congruent with those of
Raveloson et al [25], Dowlatshahi et al. [34] who found
36.4% and 33%. It was associated with death (p = 0.044)
as described in the literature [30,36], respectively.
The mortality rate at 30 days (1 month) was 35.4%.
This result is in the range of mortality rates described in
Black Africansin Togo [20] and France [27,36]. However,
the mortality rate reported in this work was lower than
that found by Raveloson et al. in Madagascar [25]. The
difference in these mortality rates is due to the fact that
these authors have worked on too small samples of 34
patients. The mortality rate at 48 hours was 15.9 %. He
corresponded almost to half of the 30-day mortality. The
mortality rate at 7 and 14 days was double the rate of 48
precisely for 25.7% and 34.2%, respectively. Our results
differed from those of Ossou-Nguiet et al. in Congo and
who found a mortality rate at 14 days for 13% in the
Neurology Department [24]. This difference is explained
by the fact that his work had an inclusion bias. We have
included not only patients from Neurology but also in
Intensive Care and Emergency, and the hospital system
in our context is organized so that patients a severe
stroke are often directly oriented to intensive care not in
neurology service.
Hypertension remains a major risk factor of mortality
and most frequently found in the intracerebral hemor-
rhage. In sub-Saharan Africa, as in the Congo, its high
prevalence contrasts with the weakness of management
awareness, support and especially patient education.
Better control of blood pressure would not only reduce
the incidence of cerebral hemorrhage, but also reduce
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