Mortality among patients diagnosed with stroke presenting to remote Emergency Department in Bhutan – a retrospective study

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BACKGROUND: Stroke is a leading cause of disability and mortality globally, particularly in low- and middle-income countries (LMICs). Outcomes remain poor in remote, resource limited settings due to delayed presentation, limited health literacy, and constrained emergency care systems. Evidence on stroke outcomes from such settings is limited. This study aimed to determine stroke-related mortality and identify factors associated with mortality among patients presenting to a remote Emergency Department (ED) in Bhutan. METHODS: A retrospective cross-sectional study was conducted from August 1, 2018 to July 31, 2021 at the ED of the Eastern Regional Referral Hospital (ERRH), in Bhutan. All newly diagnosed stroke patients were included. Demographic, clinical, and outcome data were collected using a standardized data collection form. Data were analyzed using SPSS version 23. RESULTS: Among 104 stroke patients, 50% (n = 52) were male, and the mean ± SD age was 65.2 ± 16.1 years. Ischemic stroke accounted for 57.7% (n = 60) of cases, while 42.3% (n = 44) had hemorrhagic stroke. Overall, in-hospital mortality was 16.3% (n = 17). Most patients were illiterate (92.3%, n = 96) and farmers (91.3%, n = 95). Hypertension was the most common comorbidity, present in 76.9% (n = 80), followed by diabetes mellitus (16.3%, n = 17). Nearly half of hypertensive patients were untreated, and only 64.7% (n = 11) of diabetic patients were receiving treatment. Among modifiable risk factors, alcohol use was recorded in 35.6% (n = 37), followed by tobacco use in 3.8% (n = 4). Although 84.6% (n = 88) of patients arrived by ambulance, no patients presented within the 4.5-hour thrombolytic window. Delayed presentation was noted in all stroke types, with the median time from symptom onset to hospital presentation of 24 h (IQR 17-76). None of the studied factor reach statistical significance for predicting mortality, likely due to small sample size. CONCLUSION: Stroke-related mortality in our setting was high at 16.3%. Despite ischemic stroke being predominant subtype, no patients presented within the thrombolytic window. These findings highlight the need for public health initiatives to improve stroke recognition, timely hospital presentation, and access to acute care interventions in resource-limited settings.

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