1. Najat BOUKHRISSI (1-4) Moulay Rachid EL HASSANI(1), Mohammed JIDDANE(1) KelthoumTLILI-GRAIESS(2), Boujemaa MANSOURI (3), Mohammed BEDDI (4) (1)Specialities Hospital, Rabat, MOROCCO; (2)Hospital University, Sousse, TUNISIA; (3)Hospital University Bab El Oued, ALGERIA; (4) National Hospital Center, Nouakchott, MAURITANIA. 6th October 2010

2. INTRODUCTION  Cerebrovascular pathologies in their stroke pattern are part of the most important public healthcare priorities in the world  The knowledge of validated epidemiological datas in USA, Europe has taken aware of the great scale of this medical problem at the same level of cancers and cardiovascular pathologies.  Management of stroke gives a key role to medical imaging for diagnosis, prognosis and therapeutic approach

3. GEO - HEALTH ECONOMY BACKGROUND (WHO data, 2006) COUNTRY Population Gross National Income /cap Expenditure on Health /cap Total Expenditure on Health as % of GDP Physicians Density Nurses & Midwives Density ALGERIA 32 854 00062801883.6%11.322.3 LIBYA 6 294 00011.6302704.1%12.548 MAURITANIA 3 069 0002750452%1.16.4 MOROCCO 31 514 00038602735.1%6.28.9 TUNISIA 10 215 00064904885.3%11.932.9

4.  Population & Gross National Income

5. CARDIO VASCULAR DISEASES in NORTH AFRICA (WHO data, 2004) Estimated Mortality COUNTRY Cerebro Vasc. DiseaseHTAIsch. HeartRhumat. Heart ALGERIA 7.8%1.2%8.7%0.1% LIBYA 6.7%4.6%23.5%0.5% MAURITANIA 7.1%1.6%4.4%0.1% MOROCCO 6.8%5.4%19.9%0.4% TUNISIA 6.5%4.0%19.2%0.3%

6. EQUIPMENTS & HEALTH CARE SYSTEMS COUNTRYPopulation (million) CT plantsCT plants/ million inhab. MRI plants MRI plants/ million inhab. ALGERIA 33 1745.3110.3 LIBYA 5 NA MAURITANIA 3 82.720.6 MOROCCO 31 1504.9250.8 TUNISIA 10 11611121.2 Their healthcare systems are varied, but in general are either government- subsidized or free healthcare system

7. TASK FORCE COUNTRYPopulation (million) RadiologistsRadiologists Density ALGERIA3378824 LIBYA5255 MAURITANIA3114 MOROCCO3145015 TUNISIA1025025 International radiologists density standard : 70

8. PATHOLOGIES PROFILE  1986 - Libya : in Benghazi, 2nd biggest city stroke incidence :0.63%, sex ratio :1.19 ; infarcts:80.9%.  1990 -Tunisia : ** in urban Tunis population, CVD incidence: 5,4%; prevalence 0.6-1% ; global risky population in Tunisia, CVD incidence 19,2%; ** Hemorragic stroke: 28%.

9. PATHOLOGIES PROFILE  1991 - Morocco, Maghrebine medical sciences meeting report: neurology series (Rabat) 735 cases with -> 75.6% ischemic stroke -> 23.17% hemorragic stroke, age range : 70% >45y. 30%<45y. sex ratio :1.44, risk factors : * HTA 44.8% * cardio embolic 24% * diabetus,obesity 23% * dislipidemy 4.19% * tobacco 11.61% * oral contraception 5.33% ** hemorragic stroke due to - aneurysm 34.6% peak 40-60y. - AVM 15.7% peak 20-40y.

10. PATHOLOGIES PROFILE  1991 – Morocco, Maghrebine medical sciences meeting report: neuroradiology series (Rabat) 1103 cases’ ischemic stroke series, - 26.3% juvenile - etiology * embolic cardiopathy 29% * neurobehcet disease 13% * infection ( tuberculosis, syphilis, hydatic) 10% * arteriopathy (Moya, Takayashu, lupus etc.) 11% * unknown 35%

12. NEUROBEHCET MEDICAL IMAGING RESULTS  Brain stem & diencephalon location : 46%

13. NEUROBEHCET MEDICAL IMAGING RESULTS  Ponto-bulbar & cerebellar location : 40%

14. NEUROBEHCET MEDICAL IMAGING RESULTS  Thrombophlebitis : 30% thrombophlebosis alone 21%

15. PATHOLOGIES PROFILE next decade (1)  2002- Mauritania, in Nouakchott - public sector neurology dept. CVD 35.1% admissions 52% ischemic stroke, 48% hemorragic stroke risk factor : HTA 78% mean age for ischemia 60y., hemorrage 56y. mortality 29.3%

16.  2000 – Tunisia, in Sfax ( 2 nd biggest city)  Juvenile population (44 cases stroke during 7y.) 5-10% of stroke and 6.2% of ischemia for whole age range risk factors: tobacco 27.3%, diabetus13.6%, dyslipidemy11.4%, HTA 6.8% etiology: non atherosclerotic arteriopathy 29.6%, cardiopathy 25% (45.4% valvular), atherosclerosis 13.6%, unknown 31.8% > same literature restitutio ad integrum 30%.  Pediatric population (31 cases during 10y.) follow up : restitutio ad integrum 13%, recurrency 11%, onset epilepsia 25.8%, intellectual handicap 40.7%. PATHOLOGIES PROFILE next decade (2)

17. PATHOLOGY PROFILE next decade (3)  Geriatric series (68 cases during 1y.; 2004_05) 85% ischemic stroke, 15% hemorragic stroke; only 4.4% managed within 3hours after onset; Risk factors :88% cases, » HTA 66.7%, » diabetus 35%, » embolic cardiopathy 30% » » dyslipidemy 15.8% Etiology > ischemia: 70% atheroma, 21%embolic cardiopathy, 21% 9% unknown; > hemorrage: 63.7% HTA, 9%, AVM, unknown:27.3%

18. PATHOLOGY PROFILE next decade (4)  2006, in Sfax prospective study about risk factors (100 cases during 4 months_1month follow up) - 72% ischemia -> sex ratio : 1.48; - 28% hemorrage -> sex ratio : 2.5; - mean age : 66 (+/- 14.5y.); - 1/3 patients admitted within 3 hours after onset ; - 24% no risk factors; - mortality : 27%, same in African countries, higher than literature->15% because of 28% hemorrage;  POPULATION NOT EDUCATED FOR HTA THREAD DANGER

19. PATHOLOGY PROFILE nowaday  2008 in Algeria : CVD 5th cause of mortality cause 50 000 deaths/y. 5x more than road traffic 60 000 new cases/ y.  2010 in Tunisia : 3rd mortality cause; 1% patients managed within 6 hours after onset.  2010 in Morocco : A national epidemiologic survey is on the way, final report on september 2011 ; A sample of 60 031 people from the 2 biggest regional agglomerations (Rabat & Casablanca)-> sex ratio:0.96; 61% urban - 39% rural 0.18% stroke with 25% ischemia, 15% hemorrage, 60% unknown stroke category, ->sex ratio:0.95, 58%urban-42% rural; cardio embolic etiology 16.8%; These preliminary results emphasize the necessity of regional surveys in order to determine the impact of housing conditions.

20. MEDICAL IMAGING CONTRIBUTION  CT already the 1990’s epidemiologic survey in Tunisia brought up the key role of medical imaging for this pathology : It straigthen out diagnosis between ischemic and hemorrage stroke in 10%; CT shown 28% hemorrage.  1990’s neuroradiology series in Morocco : CT helped for category stroke (ischemia / hemorrage); Confirmed * arterial disease 96%,* thrombo phlebitis 4%; Location : 97% supratentorial with 79% in MCA territory; Type : territorial or watershed 97%, lacunar 3%.

21. MEDICAL IMAGING CONTRIBUTION  1990’s neurology & neuroradiology series in Morocco Angiography performed in 29.65% patients for etiologic inquiry : - 100% juvenile cases, 4.5% atheroclerosis; - hemorragic stroke * 34.6% aneurism; * 15.7% AVM; - ischemic stroke * 2.7% AVM;  2000’s series in Tunisia  Echocardiography (TT or TO) done in 26% patients, was abnormal in 23.9%;  Echodoppler -> velocity and morphological quantification of arterial stenosis, -> plaque characterisation with its structure & surface appearance ; - these critarias play a key role in the individual risk of stroke thus it allows a comprehensive evaluation of a carotid lesion 1. Geriatric series > done in 36.3% cases with 21.6%plaques with/ without stenosis 2. Juvenile series, > done in 47.7%, abnormal in 23.9%

22. MEDICAL IMAGING CONTRIBUTION  2000’s series in Tunisia  CT done 1. Geriatric series : 91.2% isch. stroke and 100% hemorragic stroke; 2. Juvenile series : confirm 93.3%, supratentorial location 87%; 3. Pediatric series : 74%.  MRI more widely introduced since 1995 1. Geriatric series : done in 19.3% cases (angioMR->18.2%); 2. Pediatric series : done in 58% (angioMR->26%).  Angiography performed for etiologic query 1. Pediatric series : done in 22.5%, shown Moya (5 cases), basilar obstruction (1 case) 2. Juvenile series : done in 36.5% series, pathologic in 50%

23. MEDICAL IMAGING CONTRIBUTION  Mauritania, in the 2 nd part 2000 decade  MRI *during 1.5 y., done in private sector for cerebrovascular pathology 2x less than for cerebral tumor ; *during 0.5 year in public sector - 32 cases  5.3% of MRI studies; - 25% cerebrovascular malformations; - 37.5% juvenile stroke; - 21.9% hemorragic stroke; reproduces the 1990’s Moroccan pathology profile

24. MEDICAL IMAGING CONTRIBUTION  In North Africa medical imaging contributes for risk factors evaluation of stroke.  The Tunisian prospective study revealed that : Hemorrage stroke, Presence of mass effect, Brain engagement, Intraventricular bleeding were poor vital prognosis factors Leucoareosis, Brain atrophy were poor functional prognosis factors

25. COMMENTS (1)  Unknown etiology :- 29% in juvenile Moroccan series, - 31.8% in juvenile Tunisian series, is the same in literature.  High % of juvenile patients is related to neurobehcet & infections in 1990’s Moroccan series; Etiology trend for these series is moving to developed countries profile with tobacco, obesity & dyslipidemy.  High % of hemorragic stroke in North Africa is linked almost to « a population not educated for HTA thread danger »

26. COMMENTS (2)  That’s why the prospective epidemiological survey in Morocco will come up specific recommendations about I ary or II ary prevention.The rising risk factors will lead out into a communication strategy concerning the knowledge, habits and aptitudes of the Moroccan population to be targeted.  These rising risk factors are very important to predict the outcome and to undertake the most adequate therapeutic strategy. It is clearly demonstrated that in one hand stroke units are beneficial in terms of mortality & morbidity. The poor prognosis observed in North African studies must be a good incitement for policy maker to create stroke units. Particularly for groups like juvenile & pediatric patients.

27. COMMENTS (3)  Before the1980’s angiography was the only tool, then CT became the rule while MRI has been sparsely introduced. Echo doppler is currently used in general clinics and departments while interventional diagnostic and therapeutic are pushed in institutes dedicated to head & neck and nervous system.

28. Neurosurgery & Interventional Neuroradiology  A national survey of aneurysms conducted in Morocco for the International Congress of Neurosurgery- 2005 is a reference of the historical background and trends in matter of cerebrovascular malformations in North Africa.

29. Neurosurgery & Interventional Neuroradiology  Common belief of low incidence of these vascular malformations is wrong :  250 brains’ autopsy series (1980-1982) > 1% cerebral aneurisms : same incidence/ literature > no specific morphology of the arterial circle of Willis;  Ruptured cerebral aneurisms are not rare in Morocco;  The increase of cases admitted in the country : frequency doubles every 5 years.

30. Incidence of cerebral aneurysms in Morocco Autopsy study- 250 brains --> 1% cerebral aneurysms

31. Interventional Neuroradiology & Neurosurgery  Develop awareness of the practitioners and population in North Africa  Make available the diagnosis and treatment tools : * NR technology : CT Scan and Angiography; *Microsurgical techniques ; *Endovascular techniques.  1984-2004, 306 patients series - ANEURYSM:  75% underwent surgical treatment;  8% benefited from endovascular treatment (2.5% by coils, 5.5% balloon ).

32. Endovascular Treatment (27 cases) Embolisation by coils: 2 cases Embolisation for geant aneurysm : 3 cases

33. Interventional Neuroradiology & Neurosurgery  Cerebral ArterioVeinous Malformation 1. 24 patients underwent surgery =32% 2. 29 patients endovascular embolisation = 39% 3. 22 patients – abstention = 29%

34. Interventional Neuroradiology & Neurosurgery  Cooperation between Neurosurgery, Interventional neuroradiology, Neuroradiosurgery and Neurorehabilitation thank to a non profit foundation  Make available the diagnosis and treatment tools : * NR technology : CT Scan and Angiography; * Microsurgical techniques ; * Endovascular techniques.

35. CONCLUSION : FUTURE  The public sector through university hospitals are engines for progress, training and research in neurosciences.  Nevertheless their limited budgets should be successfully helped and supported by nonprofit foundations.  These prospects are the positive interaction of academic institutions and nonprofit organisms in term of cerebrovascular diseases management in North Africa.