ETHNOBOTANICAL STUDIES OF MEDICINAL PLANTS USED IN THE TREATMENT OF STROKE SEQUELAE IN THE DISTRICT OF ABIDJAN, CÔTE D’IVOIRE

Piba Serge Cherry, Kouakou Donthy Kouakoubah Richard, Kouamé Amoin Gervaise, Koné Mamidou Witabouna, Bakayoko Adama and Tra Bi Fezan Honora. 1. UFR Sciences de la Nature, Université Nangui Abrogoua, 02 BP 801 Abidjan 02 Côte d’Ivoire. 2. Centre Suisse de Recherches Scientifiques en Côte d’Ivoire, 01 BP 1303 Abidjan 01, Côte d’Ivoire. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 01 September 2018 Final Accepted: 03 October 2018 Published: November 2018

Stroke is a public health emergency. This study was carried out in the markets of the District of Abidjan, from April to June 2018, to evaluate the knowledge of Traditional Medicine Practitioners on stroke related to its risk factors, sequelae and phytotherapeutic tools used for treatments. Based on semi-direct interviews, 306 herbalists were interviewed. The results showed that hypertension (Fc = 100%) is the major risk factor known by practitioners. Hemiplegia (95.5%), aphasia (80.1%), slurred speech (66.2%) and vision (48.1%) were the main sequelae. A total number of 101 medicinal plants, distributed in 93 genera and 49 families are sold on markets. Ficus mucuso (0.19%), Ziziphus jujuba (0.13%), Ocimum gratissimum (0.08%), Parkia biglobosa (0.08%), Catharanthus roseus (0.07%) are the most mentioned species. The calculation of the ICF yielded an average consensus at the plant level used to treat hemiplegia, aphasia and slurred speech. This exploratory study should play a role in the management of patients and development traditional medicines.

…………………………………………………………………………………………………….... Introduction:-
Stroke is defined by the World Health Organization (WHO) as the rapid development of localized or global signs of cerebral dysfunction with symptoms lasting more than 24 hours that may lead to death, with no apparent cause other than vascular origin (WHO, 2005;Rusinaru, 2010). Strokes are groups of conditions in which infarction or ischemic stroke is distinguished from cerebral haemorrhage or haemorrhagic stroke. The infarction is caused by an obstruction of intra-cranial blood vessels while and the cerebral haemorrhages are owed to a break of vessel. In all cases, this results in a lack of oxygen and nutrients that jeopardize the functioning of the brain areas concerned. The main risk factors are smoking, high blood pressure, physical inactivity, unhealthy diet, obesity, diabetes, high blood lipids, irrational alcohol consumption, aging, low level of education as well as genetic and psychological factors (WHO, 2006). Sequelae due to stroke represent a vast pathological group, ranging from hemiplegia to slurred speech (aphasia), vision, hearing, or behaviour (Hendricks et al., 2002). Regardless to aetiologies, Stroke, is the leading cause of disability in adults (Rusinaru, 2010) and death in the world, in the category of cardiovascular disease, after coronary heart disease, with 6.2 million deaths (Mendis et al., 2011). These authors estimate that one person has a stroke every 5 seconds worldwide. WHO is talking about pandemic and progressive increase in incidence worldwide from 16 million cases in 2005 to nearly 23 million in 2030 (Maters and Loncar, 2006). In addition, during the last 20 91 years, the stroke mortality rate has increased in low and middle-income countries. In these countries, 80% of death occur are due to stroke (Sagui et al., 2007). In Côte d'Ivoire, 9.3% of death in public hospitals among people aged from 45 to 69 are due to stroke (Cowppli-Bony et al., 2007). The hospital prevalence is estimated at 28% and the prognosis in hospitalization is based on a morbidity of about 24% (Diarra et al., 2016). Stroke mortality remains high during months following the accident, with approximately 25 to 30% of death occurring after one month, and 40 to 50% after six months (Rusinaru, 2010). Motor recuperations are incomplete for 2/3 of people, and human assistance is essential for 25 to 30% of them (Hendricks et al., 2002). The severity of this pathology is probably related to the inadequacies of management. Stroke is therefore a public health emergency. This disease will pose in the incoming decades the problem of the care of a growing number of patients and disabled people, demanding a large amount of human, material and financial resources (Sautereau, 2009). For providing suggestions for a pathology that we still do not really know how to treat clinically (Bouleti et al., 2014), it is necessary to look for other therapeutic arsenals. The aim of this study was to assess Traditional Practitioners' knowledge of stroke, its risk factors and its sequelae, and medicinal plants used in the treatment of brain damage induced sequelae in the District of Abidjan.

Study Area:-
The District of Abidjan is the economic capital of Côte d'Ivoire, located Southern Côte d'Ivoire between at 5°20'27 "N latitude and 4° 01'41" W longitude ( Figure 1). The population of the District that represents 20.8 % of the demographic weight of Côte d'Ivoire is 4,707,404 of the 22,671,331 inhabitants living in the country (RGPH, 2014). The population is heterogeneous and very cosmopolitan. In this city almost all the ethnic groups living in Côte d'Ivoire, are represented. Moreover, various populations coming for West African sub-region are living in Abidjan. Four university health centres are located in Abidjan and these facilities are preferential destination in case of a medical emergency (Konan, 2012). Traditional health Practitioners are also well represented (Manouan et al., 2010) and play an important role in the health care system. The study was conducted in four municipalities of the city of Abidjan (Adjamé, Abobo, Yopougon and Port-Bouët). These municipalities were selected due to their density of populations, the presence within them of great markets of medicinal plants and their location. Abobo, Yopougon and Port-Bouët are gateways to the district, while Adjamé in the centre has the largest wholesale market of medicinal plants.

Ethnobotanical surveys
Ethnobotanical investigations were conducted from April to June 2018, in seven markets of the District: Siaka Koné and Abobo II markets in Abobo; the large medicinal plant market of Adjamé; markets of Sicogi and Wassakara in Yopougon; and the major markets of Treichville and Port-Bouët. The surveys were conducted on the basis of a questionnaire during a semi-directive interview with herbalists. The herbalists surveyed were randomly selected based on their ability to collaborate and share their knowledge. The items in the survey card included information on the respondent's identity, his knowledge of stroke, and the use of medicinal plants to treat the sequelae of brain damage.

Identifications of medicinal species
Numerous plant samples were purchased during the interviews for identification, but also for encouraging the seller to collaboration and to provide more information. The plant samples were identified, named using the flora of Arbonnier (2000) and Aké-Assi (2001 and 2002), then updated with APG IV on the online database of Conservatory and Botanical Garden of the city of Geneva. The list medicinal of species has been cross-checked with that of IUCN (www.iucnredlist.org) for the identification of species with special status.

Data processing
The studied population was characterized from the variables studied  Table 1). The Mandés of North (35.4%), the Gours (24.01%), foreigners (19.7%) and Akans (18.5%) were the most numerous. The other ethnic groups represented only 1.5% of the herbalists. These practitioners were mostly illiterate (61.8% of the population surveyed), against 29% with a primary level and 6% a level of secondary education (Table 1). More than half of the herbalists had more than 10 years of practitioning experience in the field of herbal medicine: 32% between 10 and 20 years, 19% between 20 and 30 years and 4% more than 30 years of experience. The highest percentage of herbalists interviewed was observed in the municipality of Abobo (42%).
93 Stroke Knowledge:-In the markets surveyed, 17.32% of the herbalists did not know stroke. The majority of practitioners (88.68%) recognized stroke, but no herbalist interviewed differentiates ischemic stroke from haemorrhagic stroke. All recognized a single of stroke. They attributed primarily to severe hypertension with 100% relative frequency of citation ( Figure 2). For herbalists, stroke is directly related to hypertension. Malinkés attributed to this disease the name of "tension bana" when others simply call it "tension". There was no local name for this vascular accident.
Other known risk factors are obesity, cited by 22.8% of respondents, diet associated to lifestyle (21.6%), and stress (19.8%). For 14.4%, the origin of this disease could be mystical and caused by witchcraft. Respondents also mentioned diabetes, chronic headache and fatigue. Hemiplegia was the main sequelae cited by 95.5% of the respondents ( Figure 2). Other known sequelae were aphasia of the herbalists (80.1%), speech disorder (66.2%), vision disorders (48.1%) and behavioural disorders (25.9%). Other sequelae such as chronic headache, earache and sinusitis were very weakly cited. 94

General characteristics of medicinal plants used:-Parts used, methods of preparation and administration
The common plant parts were leaves (55.9%), barks (22.3%) and stems (11.2%), followed by Roots (6%) and fruits (4%). For Ziziphus jujuba, Ocimum gratissimum, Catharanthus roseus, Phyllanthus amarus, Ageratum conyzoides and Paullinia pinnata, the whole plant was also used in preparations. The pharmacological preparation was mostly decoction with 85.9% of frequency of citations, compared to 14.1% for all other methods of preparation (Trituration, kneading, calcination and maceration) ( Figure 5). The decocted and all preparations are generally absorbed by oral route in 86.1%, skin absorption by body massage (66.33%) and skin absorption by bath (55.44%). The massage was done with a piece of cloth, a towel or a floor cloth. Other modes of absorption, mouthwash, enema, facial rinsing, etc. were less common ( Figure 6). Plants counted in 223 medicinal recipes, of which 18.9% were composed of monospecific recipes and 81.1% of multispecies recipes. The multispecies recipes containing three species were the most numerous, 40.2% of the preparations, against 30.1% of the bi-specific preparations and 14.5% of the tetraspecific preparations. Few multi-species preparations containing more than four species were prescribed (0.9%).

Characteristics of the treatments for the different known sequelae of stroke
The various sequelae of stroke were treated by many plant drugs from several plant species. The most commonly treated sequel was Hemiplegia with 92 medicinal species, 37 species for Aphasia, 25 for vision disorders and 15 for speech disorders. Only four species were mentioned for fatigue and three for behavioural disorders. Hypertension was treated by 31 species as sequelae of stroke. For herbalists, the increase in blood pressure was directly associated with stroke as a direct cause and then as disorders to treatment. Regulating the blood pressure would greatly help to heal the stroke to which it was very often assimilated. The most cited species for regulating blood pressure were Catharanthus roseus and Annona muricata. In the case of hemiplegia, disorders of vision and aphasia, Ficus mucuso, Ziziphus jujube and Ocimum gratissimum were frequently cited. Most of the time, the remedy was used until the complete disappearance of the sequelae or during at least a month. The calculation of the degree of consensus showed that the ICF varies from 0.25 to 0.63. An average consensus was observed at the plant level used for hemiplegia (0.63), aphasia and slurred speech (0.51). Treatment of other sequelae (vision disorder, behavioural disorder and hypertension) was not a consensus among herbalists. The ICFs (0.42, 0.38 and 0.25) were less than the average value of 0.5.  . Hemiplegia is also very debilitating and represents a negative handicap for the socio-occupational future of this active segment of the population given the difficulties of rehabilitation in our countries (Diarra et al., 2016). It is therefore the best-known sequelae, the most treated by traditional medicine and presents a greater number of medicinal remedy sold on the markets. The calculation of the ICF showed an average consensus for the species mentioned for hemiplegia, aphasia and slurred speech. This is less the case for behavioural vision disorders and high blood pressure. However, 11 species used to treat hypertension, including Catharanthus roseus, Phyllanthus amarus and Parkia biglobosa, are also cited by Tra Bi et al. (2008). The multiplicity of species, recipes and therapeutic practices would be at the origin of the differences. In the case of the most frequently treated sequelae, the practical experience of the traditional healers and the comments of the customers would favour the consensus around the most effective species.
Three species listed in this study, Khaya senegalensis, Vitellaria paradoxa and Isoberlinia doka, have a special status and should be given attention when harvested as plant drugs. The exploitation and sustainable management of these medicinal plants are imperative to protect highly vulnerable species and biological diversity in general.

Conclusion:-
The present work was carried out for the first time, in Côte d'Ivoire, to evaluate the knowledge of practitioners of traditional medicine on cerebrovascular accident, its risk factors, sequelae and the phytotherapeutic means used for treatment. It reveals the knowledge of herbalists and shows that Ivorian flora is rich in medicinal plants used to treat after-effects of stroke. According to herbalist, high blood pressure is defined as the main risk factor while hemiplegia is the main known sequel. Among the variety of commercialized plants, Ficus mucuso, Ziziphus jujuba, Ocimum gratissimum, Parkia biglobosa, Catharanthus roseus, Tamarindus indica, Annona muricata and Boscia senegalensis are the commonly mentioned plants in medicinal preparations. Some species with special status based 101 on UICN list has been identified and should be protected. This work is an exploratory study conducted to provide data for future research in the perspective of improving the use as traditional plant-based medicines against the aftereffects of stroke.