Racial disparity in stroke risk factors: the Berlin-Ibadan experience; a retrospective study

Ischemic Brain Injury: Involvement of Lipids in the Pathophysiology of Stroke and Therapeutic Strategies

Stroke is a devastating neurological disorder that is characterized by the sudden disruption of blood flow to the brain. Lipids are essential components of brain structure and function and play pivotal roles in stroke pathophysiology. Dysregulation of lipid signaling pathways modulates key cellular processes such as apoptosis, inflammation, and oxidative stress, exacerbating ischemic brain injury. In the present review, we summarize the roles of lipids in stroke pathology in different models (cell cultures, animal, and human studies). Additionally, the potential of lipids, especially polyunsaturated fatty acids, to promote neuroprotection and their use as biomarkers in stroke are discussed.

Epidemiology, clinical features and outcome of stroke in rural versus urban hospitals in Cameroon

OBJECTIVES

Stroke is a major public health problem worldwide with disparities between urban and rural areas. The aim of this study was to compare the epidemiological, clinical features and outcomes of stroke between rural and urban hospitals in Cameroon.

MATERIALS AND METHODS

We conducted a retrospective cohort study at the Douala General Hospital (urban) and Ad Lucem Hospital of Banka (rural) from January 1st, 2014, to December 31st, 2019. The medical records of all patients admitted for stroke, and meeting the inclusion criteria were reviewed. Diagnosis of stroke was based on brain imaging and/or the World Health Organization definition. Data were analyzed using SPSS version 20.0.

RESULTS

Among the 15277 files reviewed, 752 were included with 623 cases (82.80%) in urban areas. The percentage of patients hospitalized for stroke were 9.06% and 2.85% in urban and rural hospitals respectively. The frequency of patients admitted for severe stroke (Glasgow coma scale ≤ 8) was higher in the rural hospital (p = 0.004). In-hospital mortality (p = 0.010), cumulative mortality at one-month (p = 0.018), poor functional recovery (p = 0.002), one-year stroke recurrence (p = 0.020) were significantly higher in rural setting. Undefined stroke was predictor of mortality in the rural hospital, while hemorrhagic stroke was predictor of mortality at one-month in the urban hospital.

CONCLUSIONS

Stroke cases were significantly more severe with poor outcomes in the rural hospital. Efforts are needed to improve prevention, and access to stroke care for communities, especially in rural setting.

Hypertension Related Co-Morbidities and Complications in Women of Sub-Saharan Africa: A Brief Review

Hypertension is the leading cause of cardiovascular disease in women, and sub-Saharan African (SSA) countries have some of the highest rates of hypertension in the world. Expanding knowledge of causes, management, and awareness of hypertension and its co-morbidities worldwide is an effective strategy to mitigate its harms, decrease morbidities and mortality, and improve individual quality of life. Hypertensive disorders of pregnancy (HDPs) are a particularly important subset of hypertension, as pregnancy is a major stress test of the cardiovascular system and can be the first instance in which cardiovascular disease is clinically apparent. In SSA, women experience a higher incidence of HDP compared with other African regions. However, the region has yet to adopt treatment and preventative strategies for HDP. This delay stems from insufficient awareness, lack of clinical screening for hypertension, and lack of prevention programs. In this brief literature review, we will address the long-term consequences of hypertension and HDP in women. We evaluate the effects of uncontrolled hypertension in SSA by including research on heart disease, stroke, kidney disease, peripheral arterial disease, and HDP. Limitations exist in the number of studies from SSA; therefore, we will use data from countries across the globe, comparing and contrasting approaches in similar and dissimilar populations. Our review highlights an urgent need to prioritize public health, clinical, and bench research to discover cost-effective preventative and treatment strategies that will improve the lives of women living with hypertension in SSA.

Effectiveness of a Health Education Program for Patients Who Had a Stroke and Their Caregivers by Controlling Modifiable Risk Factors to Reduce Stroke Recurrence in a Tertiary Hospital in Bangladesh: Protocol for a Randomized Controlled Trial

BACKGROUND

Stroke is a significant public health concern that causes severe and long-lasting disability. The recurrence of stroke is increasing due to lack of patients' knowledge and compliance with treatment to control modifiable risk factors and lifestyle changes. Health education can be an effective way to increase knowledge about behavioral changes in patients who had a stroke.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of a health education program in Bangladesh for patients who had their first stroke and their family caregivers in order to reduce the recurrence of stroke by controlling modifiable risk factors.

METHODS

This is a parallel, open-label, prospective randomized controlled trial conducted at the National Institute of Neurosciences & Hospital in Dhaka, Bangladesh. We enrolled ≥18-year-old patients of both sexes who had a history of first stroke attack (transient ischemic attack, hemorrhagic stroke, lacunar stroke, atherothrombotic stroke, or cardioembolic stroke). We stratified patients into those aged <65 years and those aged ≥65 years and according to types of strokes for randomization. Our estimated sample size was 432. The intervention group receives face-to-face counseling on lifestyle modifications, blood pressure monitoring, and medication compliance-related health education during enrollment and monthly follow-ups. However, the control group receives only usual care from the hospital. The primary end point of this study is the reduction in the stroke recurrence rates at the end of the 12-month follow-up period. The secondary end points are to (1) assess the occurrence of all adverse events such as other cardiac events and all-cause mortality, (2) evaluate the status of the controlling modifiable risk factors such as blood pressure, glycated hemoglobin, and non-high-density lipoprotein cholesterol, (3) assess the knowledge related to stroke by using the investigator-developed questionnaire, (4) evaluate the lifestyle behavior related to stroke by using the investigator-developed questionnaire, (5) assess medication adherence, and (6) evaluate the quality of life of patients who had a stroke and their family caregivers. The evaluation points will be at baseline, 6 months, and 12 months for both groups.

RESULTS

Patients' enrollment started on October 2022, and follow-up will be completed in March 2024. A total of 432 participants were included in both the intervention (n=216) and control groups (n=216). This study was approved by the institutional review board and the ethics review board of the National Institute of Neurosciences & Hospital (IRB/NINSH/2022/151) on August 30, 2022.

CONCLUSIONS

Our health education program is expected to reduce the recurrence of stroke and improve the quality of life of patients who have had the first stroke. The results of this study will provide insights into the importance of health education for (self)-management and prevention of stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05520034; https://clinicaltrials.gov/ct2/show/NCT05520034.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51178.

Assessment of Atherosclerosis in Ischemic Stroke by means of Ultrasound of Extracranial/Intracranial Circulation and Serum, Urine, and Tissue Biomarkers

It is a common practice to take into consideration age, diabetes, smoking, treated and untreated systolic blood pressure, total cholesterol, and high-density lipoprotein cholesterol for the prediction of atherosclerosis and stroke. There are, however, ultrasound markers in use for the assessment of atherosclerosis and the evaluation of stroke risk. Two areas of investigation are of interest: the carotid artery and the intracranial arterial circulation. Again, within the domain of the carotid artery, two ultrasonic markers have attracted our attention: intima media thickness of the carotid artery and the presence of carotid plaque with its various focal characteristics. In the domain of intracranial circulation, the presence of arterial stenosis and the recruitment of collaterals are considered significant ultrasonic markers for the above-mentioned purpose. On the other hand, a series of serum, urine, and tissue biomarkers are found to be related to atherosclerotic disease. Future studies might address the issue of whether the addition of proven ultrasonic carotid indices to the aforementioned serum, urine, and tissue biomarkers could provide the vascular specialist with a better assessment of the atherosclerotic load and solidify their position as surrogate markers for the evaluation of atherosclerosis and stroke risk.

Pandemics and Burden of Stroke and Epilepsy in Sub-Saharan Africa: Experience from a Longstanding Health Programme

Eighty percent of people with stroke live in low- to middle-income nations, particularly in sub-Saharan Africa (SSA) where stroke has increased by more than 100% in the last decades. More than one-third of all epilepsy−related deaths occur in SSA. HIV infection is a risk factor for neurological disorders, including stroke and epilepsy. The vast majority of the 38 million people living with HIV/AIDS are in SSA, and the burden of neurological disorders in SSA parallels that of HIV/AIDS. Local healthcare systems are weak. Many standalone HIV health centres have become a platform with combined treatment for both HIV and noncommunicable diseases (NCDs), as advised by the United Nations. The COVID-19 pandemic is overwhelming the fragile health systems in SSA, and it is feared it will provoke an upsurge of excess deaths due to the disruption of care for chronic diseases such as HIV, TB, hypertension, diabetes, and cerebrovascular disorders. Disease Relief through Excellent and Advanced Means (DREAM) is a health programme active since 2002 to prevent and treat HIV/AIDS and related disorders in 10 SSA countries. DREAM is scaling up management of NCDs, including neurologic disorders such as stroke and epilepsy. We described challenges and solutions to address disruption and excess deaths from these diseases during the ongoing COVID-19 pandemic.

Incidence rate and age of onset of first stroke from CT scan examinations in Cape Coast metropolis

Introduction

The trends in the incidence and age of onset of first stroke is lacking in Ghana and with an increasing elderly population, such trends are projected to increase in developing countries. Through the review of Computed Tomography (CT) scan examinations and patients’ records; we assessed the incidence rate and age of onset of first stroke in Cape Coast Metropolis.

Methods

This study retrospectively reviewed all imaging records and clinical data of all stroke patients referred for CT scans in the radiology department of the Cape Coast Teaching Hospital (CCTH) between January 2017 and December 2019. All CT confirmed cases of stroke were classified as either hemorrhagic stroke or ischemic stroke. Age adjusted annual incidence rate with 95% Confidence Intervals (CIs) were calculated assuming a Poisson distribution. Mean difference were tested using one way Analysis of Variance (ANOVA).

Results

840 patients with first onset of stroke were identified, comprising 417 (49.6%) males and 423 (50.4%) females. There was a statistically significant difference in the mean age of onset of first stroke in males (61.47 ± 13.36 years) and in females (63.41 ± 15.41 years), p = 0.049. The incidence of first stroke for the entire age categories were higher in males compared to the same age categories in females, except for patients aged 35–44 years in 2017, 25–34 years in 2018, 15–24 years and 75 years or older age groups in 2019. Males had hemorrhagic stroke at an older age (64.41 ± 15.31 years) compared to ischemic stroke (60.40 ± 12.42 years) in this study. This difference was statistically significant (p = 0.014). There was no significant difference in the mean age of onset of first stroke for the respective years under study: F (3, 836) = 0.693, P = 0.500.

Conclusion

The findings of this study imply that the incidence rate of stroke is higher in males than in females and increases with age. The majority of the strokes were ischemic.

Stroke in Africa: profile, progress, prospects and priorities

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.

The burden of acute coronary syndrome, heart failure, and stroke among emergency department admissions in Tanzania: A retrospective observational study

Introduction

The prevalence of cardiovascular disease in sub-Saharan Africa is substantial and growing. Much remains to be learned about the relative burden of acute coronary syndrome (ACS), heart failure, and stroke on emergency departments and hospital admissions.

Methods

A retrospective chart review of admissions from September 2017 through March 2018 was conducted at the emergency department of a tertiary care center in northern Tanzania. Stroke admission volume was compared to previously published data from the same hospital and adjusted for population growth.

Results

Of 2418 adult admissions, heart failure and stroke were the two most common admission diagnoses, accounting for 294 (12.2%) and 204 (8.4%) admissions, respectively. ACS was uncommon, accounting for 9 (0.3%) admissions. Of patients admitted for heart failure, uncontrolled hypertension was the most commonly identified etiology of heart failure, cited in 124 (42.2%) cases. Ischemic heart disease was cited as the etiology in only 1 (0.3%) case. Adjusting for population growth, the annual volume of stroke admissions increased 70-fold in 43 years, from 2.9 admissions per 100,000 population in 1974 to 202.2 admissions per 100,000 in 2017.

Conclusions

The burden of heart failure and stroke on hospital admissions in Tanzania is substantial, and the volume of stroke admissions is rising precipitously. ACS is a rare diagnosis, and the distribution of cardiovascular disease phenotypes in Tanzania differs from what has been observed outside of Africa. Further research is needed to ascertain the reasons for these differences.

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In northern Tanzania, acute coronary syndrome is a rare admission diagnosis

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Heart failure and stroke are the most common admission diagnoses

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The burden of stroke admissions in this community is rising rapidly

Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life

Stroke is ranked as the second leading cause of death worldwide with an annual mortality rate of about 5.5 million. Not only does the burden of stroke lie in the high mortality but the high morbidity also results in up to 50% of survivors being chronically disabled. Thus stroke is a disease of immense public health importance with serious economic and social consequences. The public health burden of stroke is set to rise over future decades because of demographic transitions of populations, particularly in developing countries. This paper provides an overview of stroke in the 21^st century from a public health perspective.

Prevalence of Balance Impairment Among Stroke Survivors Undergoing Neurorehabilitation in Nigeria

BACKGROUND

Poststroke balance impairment adversely affects stroke outcomes and addressing the impairment is expected to constitute an important focus of neurorehabilitation.

AIMS

To examine the prevalence and factors associated with balance impairment after stroke.

METHODS

Ninety-five stroke survivors undergoing neurorehabilitation at 2 government hospitals in Northern Nigeria participated in this cross-sectional study. Berg Balance Scale (BBS) was used to assess the presence of balance impairment (BBS score of 0-20). Prevalence of balance impairment was presented as frequency and percentage while demographic and stroke-related determinants of balance impairments were identified using logistic regression analysis.

RESULTS

Thirty-five (36.8%) stroke survivors had balance impairment, and age, gender, and poststroke duration were statistically significant determinants. Stroke survivors aged less than 40 years (odds ratio [OR] = .14 [confidence interval [CI] = .20-.94]) and 40-59 years (OR = .23 [CI = .06-.81]) had a lower likelihood of having balance impairment compared to stroke survivors aged 60 years and above. Similarly, males had a lower likelihood of having balance impairment (OR = 1.60 [CI = .05-.55]) compared to females while those in the acute/subacute phase of stroke had a 7-fold likelihood of having balance impairment (OR = 7.74 [CI = 2.63-22.79]) compared to those with chronic stroke.

CONCLUSIONS

Poststroke balance impairment appears to be significantly influenced by stroke survivors' age, gender, and poststroke duration. Hence, these variables should be considered when planning rehabilitation strategies for improving balance after stroke.

Estimating the uptake of brain imaging and 30-days stroke mortality in Nigeria: A meta-analysis of hospital-based studies

PURPOSE

This study aims to estimate the computed tomography (CT) and Magnetic resonance imaging (MRI) uptake, stroke subtypes and 30-days case-fatality in Nigeria.

METHODS

Stroke diagnosis and mortality data were identified from relevant databases. A random effect meta-analysis was conducted to obtain the pooled percentage uptake of CT/MRI, including 30-days case fatality and a meta-regression-like epidemiological model was applied on all data points.

FINDINGS

A total of 24 studies involving 5874 stroke patients conducted in predominantly tertiary referral hospitals met the inclusion criteria. The pooled CT/MRI uptake in the last seven years was 46.66% (95% CI = 15.35 to 77.98, 8 studies). There were significant variations in the prevalence of stroke subtypes. The pooled prevalence ischemic stroke was highest (55.32%, 95% CI 48.67 to 61.97, 16 studies), followed by intracerebral haemorrhage (ICH) (32.69%, 95% CI 25.54 to 39.83, 16 studies), subarachnoid haemorrhage (SAH) (3.76%, 95% CI 2.30 to 5.22, 14 studies). In addition, the stroke of undetermined aetiology was found to be 16.57% (95% CI, 7.44-25.70, 8 studies). Overall, the 24-h, one-week and 30-days case-fatality from stroke were 10.84% (95% CI, 4.48-17.20), 24.62% (95% CI, 17.20-32.04) and 33.28% (95% CI, 27.80-38.77), respectively. There was a moderate negative correlation between prevalence of brain imaging uptake and ischaemic stroke, albeit not statistically significant (Spearman rho = 0.333, p-value = .412).

CONCLUSION

Uptake of CT/MRI procedure for stroke is poor in Nigeria. Although poverty, inaccessibility and influence of major risk factors remain pronounced, scaling up of effective strategies for stroke prevention and management should be a major public health policy priority in Nigeria.

The epidemiology of stroke in Africa: A systematic review of existing methods and new approaches

Accurate epidemiological surveillance of the burden of stroke is direly needed to facilitate the development and evaluation of effective interventions in Africa. The authors therefore conducted a systematic review of the methodology of stroke epidemiological studies conducted in Africa from 1970 to 2017 using gold standard criteria obtained from landmark epidemiological publications. Of 1330 articles extracted, only 50 articles were eligible for review grouped under incidence, prevalence, case-fatality, health-related quality of life, and disability-adjusted life-years studies. Because of various challenges, no study fulfilled the criteria for an excellent stroke incidence study. The relatively few stroke epidemiology studies in Africa have significant methodological flaws. Innovative approaches leveraging available information and communication technology infrastructure are recommended to facilitate rigorous epidemiological studies for accurate stroke surveillance in Africa.

A cross-sectional population survey on stroke knowledge and attitudes in Greater Kampala, Uganda

Background

Stroke is a neurological condition with rapidly increasing burden in many low- and middle income countries. Africa is particularly hard-hit due to rapid population growth, patterns of industrialization, adoption of harmful western diets, and increased prevalence of risk factors such as hypertension and obesity. Reducing stroke risk factors and teaching people to respond to stroke warning signs can prevent stroke and reduce burden. However, being able to address gaps in knowledge and improving both preventative and early-response care requires a clear understanding of practical and potentially modifiable topics. In this cross sectional study, we assessed the knowledge and attitudes among an urban population residing within the greater Kampala, Uganda.

Methods

A population cross sectional survey was conducted in urban Mukono, district, central Uganda. Through the systematic sampling method, data were gathered from 440 adult participants who were interviewed about selected aspects of stroke knowledge, attitudes and perception using a pretested structured questionnaire.

Results

A total of 440 study participants were enrolled. The leading risk factors for stroke identified by the participants were stress (75.7%) and hypertension (45.2%) respectively. Only two (0.5%) of the study participants identified cigarette smoking as a stroke risk factor. Individuals with hypertension have poor knowledge regarding stroke in spite their high risk for stroke.

Conclusion

Stroke knowledge is poor while, stress and hypertension are the leading perceived risk factors in our settings. While stress is contributing factor, hypertension is likely a more amenable and practical intervention target. Targeting individuals with stroke risk factors to increase stroke knowledge and education is crucial for engagement in healthcare. Implementing a self-management program to support and motivate this high-risk group as well as adopting healthy life-styles may be a way to reduce stroke burden in Uganda.

Stroke in Indigenous Africans, African Americans, and European Americans: Interplay of Racial and Geographic Factors

BACKGROUND AND PURPOSE

The relative contributions of racial and geographic factors to higher risk of stroke in people of African ancestry have not been unraveled. We compared stroke type and contributions of vascular risk factors among indigenous Africans (IA), African Americans (AA), and European Americans (EA).

METHODS

SIREN (Stroke Investigative Research and Educational Network) is a large multinational case-control study in West Africa-the ancestral home of 71% AA-whereas REGARDS (Reasons for Geographic and Racial Differences in Stroke) is a cohort study including AA and EA in the United States. Using harmonized assessments and standard definitions, we compared data on stroke type and established risk factors for stroke in acute stroke cases aged ≥55 years in both studies.

RESULTS

There were 811 IA, 452 AA, and 665 EA stroke subjects, with mean age of 68.0±9.3, 73.0±8.3, and 76.0±8.3 years, respectively (P<0.0001). Hemorrhagic stroke was more frequent among IA (27%) compared with AA (8%) and EA (5.4%; P<0.001). Lacunar strokes were more prevalent in IA (47.1%), followed by AA (35.1%) and then EA (21.0%; P<0.0001). The frequency of hypertension in decreasing order was IA (92.8%), followed by AA (82.5%) and then EA (64.2%; P<0.0001) and similarly for diabetes mellitus IA (38.3%), AA (36.8%), and EA (21.0%; P<0.0001). Premorbid sedentary lifestyle was similar in AA (37.7%) and EA (34.0%) but lower frequency in IA (8.0%).

CONCLUSIONS

Environmental risk factors such as sedentary lifestyle may contribute to the higher proportion of ischemic stroke in AA compared with IA, whereas racial factors may contribute to the higher proportion of hypertension and diabetes mellitus among stroke subjects of African ancestry.

Early Mortality and Associated Factors among Patients with Stroke Admitted to a Large Teaching Hospital in Tanzania

BACKGROUND

Stroke is a major cause of death worldwide and 85.5% of stroke deaths occur in low- and middle-income countries due to stroke. The aim of this study was to investigate correlates and predictors of 30-day mortality in stroke patients in urban Tanzania.

METHODS

A prospective 30-day follow-up study was conducted at the Muhimbili National Hospital, Dar es Salaam, Tanzania. We recruited all patients with stroke seen at the Emergency Medicine Department and medical wards. Patients underwent medical history and physical examination including full neurological examination. For those who met the criteria for the diagnosis of stroke according to the World Health Organization, further data were collected, including cholesterol, creatinine, fasting blood glucose, full blood picture, human immunodeficiency virus serology, and electrocardiogram. Patients were followed up at 30 days from the date of stroke onset. The date and the cause of death of those participants who died within 30 days of stroke onset were recorded.

RESULTS

A total of 224 patients were recruited into the study, with follow-up data available on 186 (83.0%). At 30 days post stroke, 124 patients (66.7%) were still alive. Mortality was significantly higher among stroke patients who were over 65 years of age. Of the 62 who died, 54% died of aspiration pneumonia and 21% of septicemia. Patients with infection were 4.4 times more likely to die than thosewithout (P = .001).

CONCLUSIONS

Poststroke mortality rates were high. Many deaths were potentially preventable.

Short term stroke outcome is worse among indiv1iduals with sickle cell trait

Background

Most (86%) of the global stroke mortality are from low- and middle-income countries (LMIC) including African countries which have the highest prevalence of the sickle cell trait (Hb AS). The effects of this trait on stroke occurrence and outcome are poorly understood. We aimed to investigate the effects of the sickle cell trait on the 30-day stroke mortality in Nigerian-Africans.

Method

This was a prospective study of 35 stroke patients with sickle cell trait (Haemoglobin AS) and 35 age and sex-matched controls without haemoglobinopathy (Haemoglobin AA). Haemoglobin electrophoresis was performed for all before recruitment and they all had neuroimaging done. Patients with haemoglobin AS were used as cases and those with haemoglobin AA as controls. The National Institute of Health Stroke Scale (NIHSS) was used to assess the severity of stroke at presentation and the Modified Rankin Scale for 30-day stroke outcome.

Result

There was no significant difference in the baseline stroke severity between the two groups (p = 0.21). Univariate analysis of the factors predicting the 30-day stroke outcome revealed that NIHSS score > 20 (p < 0.001), haemorrhagic stroke (p = 0.01) and the presence of Hb AS (p < 0.001) were significantly associated with 30-day mortality. Haemorrhagic stroke type was strongly associated with HbAS (OR = 2.9, 95% CI = 1.10–7.99, p-value = 0.02). With multiple logistic regression model, the presence of Hb AS (p = 0.01) and NIHSS score > 20 (p = 0.05) emerged as independent risk factors for 30-day mortality. The cases had worse stroke outcome at 30 days.

Conclusion

Stroke had1 a worse 30-day mortality and outcome in patients with sickle cell trait (HbAS) than in patients with normal adult haemoglobin (HbAA).

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Thirty- day stroke outcome is worse in sickle cell trait patients.

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Haemorrhagic stroke is commoner among the individuals with sickle cell.

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The prevalence of dyslipidaemia, HDL < 50 mg/dl, was more in sickle cell trait patients (87%) than in patients with normal adult haemoglobin (20.0%).

Carotid IMT is more associated with stroke than risk calculators

BACKGROUND

It is unclear whether a natural marker of atherosclerosis (carotid intima-media thickness: CIMT) or calculated risk score is more associated with stroke. We therefore comparatively examined the relationship between CIMT as well as two cardiovascular risk calculators (Omnibus Risk Score -ORS and Framingham Risk Score- FRS) and the occurrence of stroke among hypertensive African patients.

METHODS

CIMT was measured in 555 consecutive consenting hypertensive adults (377 stroke patients and 178 stroke-free subjects). The 10-year cardiovascular risk was calculated for each participant with the FRS and ORS. The strengths of association between FRS, ORS, CIMT, and stroke occurrence were examined using logistic regression. The discriminative capacity of FRS, ORS, and CIMT for stroke occurrence was assessed with c-statistics.

RESULTS

Higher average CIMT (OR 11.71; 95% CI 1.65-83.07; P = 0.01) was strongly associated with stroke after adjusting for age, sex, blood pressure, serum cholesterol, and blood sugar. Neither the FRS (OR: 1.03; CI: 0.89-1.19, P = 0.68) nor the ORS (OR: 1.08; CI: 0.90-1.30; P = 0.41) was significantly associated with stroke. CIMT had a higher c-statistic for differentiating stroke patients from hypertensive controls (right: c = 0.63, P < 0.001; left: c = 0.67, P < 0.001; average: c = 0.66, P < 0.001) than some conventional risk factors. Neither FRS (P = 0.39) nor ORS (P = 0.55) was able to independently differentiate between stroke and hypertensive patients.

CONCLUSION

CIMT, but neither FRS nor ORS, is independently associated with stroke among Nigerian African hypertensive patients. CIMT may be a better tool for estimating the overall risk of stroke than FRS or ORS in this population.

Post-stroke bacteriuria among stroke patients attending a physiotherapy clinic in Ghana: a cross-sectional study

BACKGROUND

Infections are known to be a major complication of stroke patients. In this study, we evaluated the risk of community-acquired bacteriuria among stroke patients, the associated factors, and the causative organisms.

METHODS

This was a cross-sectional study involving 70 stroke patients and 83 age- and sex-matched, apparently healthy controls. Urine specimens were collected from all the study subjects and were analyzed by standard microbiological methods. Demographic and clinical information was also collected from the study subjects. For stroke patients, the information collected also included stroke parameters, such as stroke duration, frequency, and subtype.

RESULTS

Bacteriuria was significantly higher among stroke patients (24.3%, n=17) than among the control group (7.2%, n=6), with a relative risk of 3.36 (confidence interval [CI], 1.40-8.01, P=0.006). Among the control group, all six bacteriuria cases were asymptomatic, whereas the 17 stroke bacteriuria cases comprised 15 cases of asymptomatic bacteriuria and two cases of symptomatic bacteriuria. Female sex (OR, 3.40; CI, 1.12-10.30; P=0.03) and presence of stroke (OR, 0.24; CI, 0.08-0.70; P=0.009) were significantly associated with bacteriuria. The etiology of bacteriuria was similar in both study groups, and coagulase-negative Staphylococcus spp. were the most predominant organisms isolated from both stroke patients (12.9%) and the control group (2.4%).

CONCLUSION

Stroke patients in the study region have a significantly higher risk of community-acquired bacteriuria, which in most cases is asymptomatic. Community-acquired bacteriuria in stroke patients appears to have little or no relationship with clinical parameters of stroke such as stroke subtype, duration and frequency.

Recent patterns and predictors of neurological mortality among hospitalized patients in Central Ghana

BACKGROUND

Although neurological disorders are projected to escalate globally in the coming decades, there is a paucity of enumerated data on the burden, spectrum and determinants of outcomes of adult neurological admissions in resource-limited settings, especially within sub-Saharan Africa.

OBJECTIVE

To evaluate the diversity, demography, and determinants of mortality among adult patients presenting with neurological disorders over a 6-year period in a tertiary medical referral institution in the Central belt of Ghana.

METHODS

A retrospective analysis of data on neurological admissions and in-patient outcomes between 2008 and 2013 was undertaken. Data collected for analyses included age, gender, neurological diagnosis, documented comorbidities, duration of admission and vital status at discharge. Predictors of in-patient mortality were evaluated using Kaplan-Meier survival curves and Cox Proportional Hazards regression models.

RESULTS

The 6494 admissions with neurological disorders represented 15.0% of all adult medical admissions over the study period. Male-to-female ratio of admissions was 1.6:1.0 with a mean±SD age of 52.9±20 years. The commonest neurological disorders were Cerebrovascular, Infectious, Seizures/epilepsy, Alcohol-use and Spinal cord disorders representing 54.0%, 26.7%, 10.3%, 4.0% and 2.3% of admissions respectively. Despite the low national HIV prevalence of 2.0%, the frequency of HIV infection among patients with infectious disorders of the nervous system was 40.9%. Overall crude mortality rate for neurologic admissions was 30.6% being 39.1% and 33.9% for Infectious affectations of the nervous system and stroke respectively and 7.4% for seizure disorders. Probability of death was higher for females than males aHR (95% CI) of 1.53 (1.40-1.68) and increasing age aHR (95% CI) of 1.11 (1.06-1.17) for each 20-year increase in age.

CONCLUSION

Almost one in three patients admitted with neurological disease to a tertiary care center in Ghana died in the hospital, and the majority of these deaths were due to non-communicable conditions. Enhanced multi-dimensional public health disease prevention strategies and neurological inpatient care processes are warranted.

The burden of stroke in Africa: a glance at the present and a glimpse into the future

Objective

Information on the current burden of stroke in Africa is limited. The aim of this review was to comprehensively examine the current and projected burden of stroke in Africa.

Methods

We systematically reviewed the available literature (PubMed and AJOL) from January 1960 and June 2014 on stroke in Africa. Percentage change in age-adjusted stroke incidence, mortality and disability-adjusted life years (DALYs) for African countries between 1990 and 2010 were calculated from the Global Burden of Diseases (GBD) model-derived figures.

Results

Community-based studies revealed an age-standardised annual stroke incidence rate of up to 316 per 100 000 population, and age-standardised prevalence rates of up to 981 per 100 000. Model-based estimates showed significant mean increases in age-standardised stroke incidence. The peculiar factors responsible for the substantial disparities in incidence velocity, ischaemic stroke proportion, mean age and case fatality compared to high-income countries remain unknown.

Conclusions

While the available study data and evidence are limited, the burden of stroke in Africa appears to be increasing.

Poor drug adherence and lack of awareness of hypertension among hypertensive stroke patients in Kampala, Uganda: a cross sectional study

Background

Raised blood pressure (BP) remains an important risk factor for cardiovascular diseases such as stroke. Adherence to therapeutic recommendations especially antihypertensive drugs is important in BP control. The aim of the study was to assess the stroke risk factors and levels of adherence among hypertensive patients with stroke in Kampala Uganda.

Methods

In a cross-sectional study we describe 112 hypertensive subjects with stroke from two Kampala city hospitals. A standardized pre-tested questionnaire was used to collect medical history, clinical details, radiological findings and laboratory data.

Results

A total of 112 hypertensive subjects with stroke were enrolled between May 2013 and April 2014. The median ages were 63.5 years (52.5–75.0) for the cases. Seventy percent (78/112) of the study participants had ischemic strokes. Only 17 % were adherent to anti-hypertensive medications. The main cause of non-adherence appears to be lack of knowledge.

Conclusions

Poor adherence of anti-hypertensive medications among hypertensive patients remains a big challenge in our setting. This has been attributed to lack of adequate knowledge and cost of the prescribed drugs. There is therefore an urgent need to promptly diagnose and educate hypertensive patients with emphasis on adherence to anti hypertensive drugs.

Quality of life and associated factors among poststroke clinic attendees at a University Teaching Hospital in Nigeria

BACKGROUND

Quality of life (QOL) measures are effective in quantifying disease burden after stroke, more so than levels of debility. The objective of this study is to determine QOL and associated factors of stroke survivors in Lagos, Nigeria.

MATERIALS AND METHODS

Seventy stroke survivors (study sample) and seventy stable hypertensive patients (control sample) attending clinics at a Nigerian hospital were recruited for the study. Respondents were assessed using sociodemographic/clinical questionnaires, modified mini-mental state examination, modified Rankin Scale, schedule for clinical assessment in neuropsychiatry, and World Health Organization-QOL-BREF.

RESULTS

Mean ages of the study and control respondents were 57.43 (±9.67) years and 57.33 (±9.33) years, respectively. Each sample comprised 38 male and 32 female respondents. Stroke survivors were significantly more likely to: be unemployed (P = 0.001), pay more for healthcare (P = 0.001), consume alcohol (P = 0.02), and have physical impairments (P = 0.001) compared with control. The mean QOL scores of stroke survivors were significantly lower than controls across all spheres. Stroke survivors who were unemployed, younger, female, paying more for healthcare, more disabled, with right stroke lateralization, having comorbidities, and sexual dysfunction had significantly poorer QOL specific grades. Depression or anxiety poststroke was also associated with reduced QOL means scores.

CONCLUSION

Besides, clinical variables such as levels of disability and stroke lesion lateralization, other factors such as unemployment, health costs, age, gender, and emotional problems influenced QOL after stroke.

Stroke risk factors in an incident population in urban and rural Tanzania: a prospective, community-based, case-control study

BACKGROUND

The burden of stroke on health systems in low-income and middle-income countries is increasing. However, high-quality data for modifiable stroke risk factors in sub-Saharan Africa are scarce, with no community based, case-control studies previously published. We aimed to identify risk factors for stroke in an incident population from rural and urban Tanzania.

METHODS

Stroke cases from urban Dar-es-Salaam and the rural Hai district were recruited in a wider study of stroke incidence between June 15, 2003, and June 15, 2006. We included cases with fi rst-ever and recurrent stroke. Community-acquired controls recruited from the background census populations of the two study regions were matched with cases for age and sex and were interviewed and assessed. Data relating to medical and social history were recorded and blood samples taken.

FINDINGS

We included 200 stroke cases (69 from Dar-es-Salaam and 131 from Hai) and 398 controls (138 from Dar-es-Salaam and 260 from Hai). Risk factors were similar at both sites, with previous cardiac event (odds ratio [OR] 7.39, 95% CI 2.42-22.53; p<0.0001), HIV infection (5.61, 2.41-13.09; p<0.0001), a high ratio of total cholesterol to HDL cholesterol (4.54, 2.49-8.28; p<0.0001), smoking (2.72, 1.49-4.96; p=0.001), and hypertension (2.14, 1.09-4.17; p=0.026) identified as significant independent risk factors for stroke. In Hai, additional risk factors of diabetes (4.04, 1.29-12.64) and low HDL cholesterol (9.84, 4.06-23.84) were also significant.

INTERPRETATION

We have identified many of the risk factors for stroke already reported for other world regions. HIV status was an independent risk factor for stroke within an antiretroviral-naive population. Clinicians should be aware of the increased risk of stroke in people with HIV, even in the absence of antiretroviral treatment.

Phenotyping Stroke in Sub-Saharan Africa: Stroke Investigative Research and Education Network (SIREN) Phenomics Protocol

BACKGROUND

As the second leading cause of death and the leading cause of adult-onset disability, stroke is a major public health concern particularly pertinent in Sub-Saharan Africa (SSA), where nearly 80% of all global stroke mortalities occur, and stroke burden is projected to increase in the coming decades. However, traditional and emerging risk factors for stroke in SSA have not been well characterized, thus limiting efforts at curbing its devastating toll. The Stroke Investigative Research and Education Network (SIREN) project is aimed at comprehensively evaluating the key environmental and genomic risk factors for stroke (and its subtypes) in SSA while simultaneously building capacities in phenomics, biobanking, genomics, biostatistics, and bioinformatics for brain research.

METHODS

SIREN is a transnational, multicentre, hospital and community-based study involving 3,000 cases and 3,000 controls recruited from 8 sites in Ghana and Nigeria. Cases will be hospital-based patients with first stroke within 10 days of onset in whom neurovascular imaging will be performed. Etiological and topographical stroke subtypes will be documented for all cases. Controls will be hospital- and community-based participants, matched to cases on the basis of gender, ethnicity, and age (±5 years). Information will be collected on known and proposed emerging risk factors for stroke. STUDY SIGNIFICANCE: SIREN is the largest study of stroke in Africa to date. It is anticipated that it will shed light on the phenotypic characteristics and risk factors of stroke and ultimately provide evidence base for strategic interventions to curtail the burgeoning burden of stroke on the sub-continent.

Tailored Hospital-based Risk Reduction to Impede Vascular Events After Stroke (THRIVES) study: qualitative phase protocol

BACKGROUND

There is an urgent need to develop effective strategies to improve stroke outcomes in Sub-Saharan Africa (SSA), where use of evidence-based therapies among patients receiving conventional care is poor. Designs of behavioral interventions to improve stroke care in SSA need to be sensitive to both individual and community factors (including local perceptions and public policies) contributing to the likelihood of compliance with recommended therapeutic goals. This article presents a community-based participatory research protocol that will evaluate systems and processes affecting the continuum of stroke-preventive care in an SSA country.

METHODS

Phase 1 of the Tailored Hospital-based Risk Reduction to Impede Vascular Events study will be implemented from 2013 to 2014 at 4 different types of hospital settings in Nigeria. Six adult stroke survivor focus group discussions and six caregiver focus group discussions, each lasting about 120 minutes will be conducted. Each group will comprise 6 to 8 participants. We will also conduct 22 semi-structured key informant interviews (informed by the Theoretical Domains Framework) with several types of providers and hospital administrators. Purposive and maximum variation sampling will be used to identify and recruit participants from participating hospitals. Transcript data will be analyzed by reviewers in an iterative process to identify recurrent and unifying themes using a constructivist variant of the grounded theory methodology, and will involve participatory co-analysis with key stakeholders to enhance authenticity and veracity of findings.

DISCUSSION

On the basis of the results of Tailored Hospital-based Risk Reduction to Impede Vascular Events phase 1, we intend to develop a culturally sensitive, system-appropriate, multipronged intervention whose efficacy to boost adherence to evidence-based stroke-preventive care will be tested in a future randomized trial (phase 2).

Profile and health-related quality of life of Ghanaian stroke survivors

BACKGROUND

Stroke is a leading cause of mortality with a major effect on health-related quality of life (HRQoL). There are no previous studies exploring HRQoL among stroke survivors in Ghana, despite the increasing public health significance of the disease in this country. Here we describe the profile of and factors associated with HRQoL among stroke survivors in Ghana.

METHODS

This was a cross-sectional study involving 156 stroke survivors and 156 age- and sex-matched, apparently healthy controls. A robust HRQoL questionnaire involving seven domains was used to collect data from the study participants. Clinical epidemiology data were also collected from stroke survivors on parameters such as stroke severity and risk factors. Statistical analyses were performed on the interrelationships among the study variables.

RESULTS

The mean ages of the stroke survivors and healthy controls were 58.0 (standard deviation, 11.4) and 57.6 (standard deviation, 12.0) years, respectively. Fifty-three percent (86) of the stroke survivors had mild stroke and 35.3% (55) had moderate stroke, whereas 12.2% (19) had severe stroke. Ischemic infarction was the prevalent stroke subtype (78.1%). Hypertension was the most common risk factor (89%) among the stroke survivors, followed by diabetes (29%). HRQoL scores ranged from 57.7% (cognitive domain) to 80.0% (spirit domain) for stroke survivors, whereas HRQoL scores of the control group ranged from 65.6% (cognitive domain) to 85.2% (soul domain). For each HRQoL domain, significantly higher scores were observed for the control group compared with the stroke survivors, at P<0.05. Determinants of HRQoL of stroke survivors in multivariate analysis included age, stroke severity, poststroke duration, stroke recurrence, frequency of laughter, and negative emotions.

CONCLUSION

The most affected HRQoL domains are of the physical, psychoemotional, and cognitive domains. Rehabilitation of stroke patients in this region should include interventions targeted at these domains and modifying the statistical determinants of HRQoL where possible.

Can common carotid intima media thickness serve as an indicator of both cardiovascular phenotype and risk among black Africans?

BACKGROUND

It is not known whether common carotid intima media thickness (CIMT) can serve as a surrogate marker of cardiovascular risk among black Africans. Therefore, we examined whether CIMT differed significantly among individuals with distinct cardiovascular phenotype and correlated significantly with traditional cardiovascular risk factors in a black African population.

METHODS

CIMT was measured in 456 subjects with three distinct cardiovascular phenotypes - 175 consecutive Nigerian African stroke patients, 161 hypertensive patients without stroke and 120 normotensive non-smoking adults. For each pair of cardiovascular phenotypes, c-statistics were obtained for CIMT and traditional vascular risk factors (including age, gender, weight, waist circumference, smoking, alcohol, systolic and diastolic blood pressures, fasting plasma glucose, fasting total cholesterol). Pearson's correlation coefficients were calculated to quantify bivariate relationships.

FINDINGS

Bilaterally, CIMT was significantly different among the three cardiovascular phenotypes (right: p < 0.001, F = 33.8; left: p < 0.001, F = 48.6). CIMT had a higher c-statistic for differentiating stroke versus normotension (c = 0.78 right; 0.82 left, p < 0.001) and hypertension versus normotension (c = 0.65 right; 0.71 left, p < 0.001) than several traditional vascular risk factors. Bilaterally, combining all subjects, CIMT was the only factor that correlated significantly (right: 0.12 ≤ r ≤ 0.41, 0.018 ≤ p < 0.0001; left: 0.18 ≤ r ≤ 0.41, 0.005 ≤ p < 0.0001) to all the traditional cardiovascular risk factors assessed.

CONCLUSION

Our findings support CIMT as a significant indicator of both cardiovascular risk and phenotype among adult black Africans. However, specific thresholds need to be defined based on prospective studies.

Randomized controlled trial of a multipronged intervention to improve blood pressure control among stroke survivors in Nigeria

RATIONALE

Stroke is the second-leading cause of death in low- and middle-income countries, but use of evidence-based therapies for stroke prevention in such countries, especially those in Africa, is extremely poor. This study is designed to enhance the implementation and sustainability of secondary stroke-preventive services following hospital discharge.

AIM/HYPOTHESIS

The primary study aim is to test whether a Chronic Care Model-based initiative entitled the Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke (THRIVES) significantly improves blood pressure control after stroke.

DESIGN

This prospective triple-blind randomized controlled trial will include a cohort of 400 patients with a recent stroke discharged from four medical care facilities in Nigeria. The culturally sensitive, system-appropriate intervention comprises patient report cards, phone text messaging, an educational video, and coordination of posthospitalization care.

STUDY OUTCOMES

The primary outcome is improvement of blood pressure control. Secondary endpoints include control of other stroke risk factors, medication adherence, functional status, and quality of life. We will also perform a cost analysis of THRIVES from the viewpoint of government policy-makers.

DISCUSSION

We anticipate that a successful intervention will serve as a scalable model of effective postdischarge chronic blood pressure management for stroke in sub-Saharan Africa and possibly for other symptomatic cardiovascular disease entities in the region.

Epidemiology of stroke in a rural community in Southeastern Nigeria

Background

The prevalence and incidence of stroke vary from community to community worldwide. Nonetheless, not much is known about the current epidemiology of stroke in rural Nigeria and indeed Africa.

Methods

We carried out a two-phase door-to-door survey in a rural, predominantly low-income, community in Anambra, Southeastern Nigeria. We used a modified World Health Organization (WHO) protocol for detecting neurological diseases in the first phase, and a stroke-specific questionnaire and neurological examination in the second phase. An equal number of sex- and age-matched stroke-negative subjects were examined.

Results

We identified ten stroke subjects in the study. The crude prevalence of stroke in rural Nigeria was 1.63 (95% confidence interval [CI] 0.78–3.00) per 1,000 population. The crude prevalence of stroke in males was 1.99 (95% CI 0.73–4.33) per 1,000, while that for females was 1.28 (95% CI 0.35–3.28) per 1,000 population. The peak age-specific prevalence of stroke was 12.08 (95% CI 3.92–28.19) per 1,000, while after adjustment to WHO world population, the peak was 1.0 (95% CI 0.33–2.33) per 1,000.

Conclusion

The prevalence of stroke was found to be higher than previously documented in rural Nigeria, with a slightly higher prevalence in males than females. This is, however, comparable to data from rural Africa.

Exploring carotid sonographic parameters associated with stroke risk among hypertensive stroke patients compared to hypertensive controls

OBJECTIVES

Globally, and particularly in low- and middle-income countries, the prevalence of hypertension is increasing with a consequent rise in the burden of stroke. There is a need to identify biomarkers of stroke, which can be used to design stroke prevention programs in these populations. Sonography is an affordable and widely available imaging modality that is ideal for resource-poor countries. We conducted a case-control study to identify carotid sonographic parameters that may be associated with stroke risk among hypertensive patients.

METHODS

Selected demographic, clinical, and laboratory characteristics were collected from 135 consecutive African hypertensive stroke patients and compared with 117 age and sex-matched hypertensive patients with no clinical evidence of stroke, transient ischemic attacks, or ischemic heart disease (controls). The luminal diameter, intima-media thickness, peak systolic velocity (PSV), and end-diastolic velocity (EDV) of the common and internal carotid arteries were measured in all participants, and other carotid parameters, including pulsatility and resistive indices, were derived. Univariate, bivariate, and multivariate analyses were performed

RESULTS

Among hypertensive patients, carotid parameters significantly (P < .05) associated with stroke included a higher diameter and intima-media thickness as well as a lower PSV and EDV in the common carotid and proximal internal carotid arteries. However, the diameter (>6.3 mm; adjusted odds ratio [OR], 8.91; 95% confidence interval [CI], 2.18-36.34; P = .002) and EDV (>21 cm/s; adjusted OR, 0.15; 95% CI, 0.03-0.71; P = .017) of the common carotid artery were the only parameters associated with stroke in multivariate analysis.

CONCLUSIONS

Among hypertensive patients, the common carotid artery diameter and EDV are significantly associated with stroke risk. These findings have implications for development and evaluation of stroke prevention programs.

The relationship of flow velocities to vessel diameters differs between extracranial carotid and vertebral arteries of stroke patients

BACKGROUND

Chronic changes in flow rate through arteries produce adjustment of arterial diameters. We compared the relationship between flow velocity and diameter in the carotid and in the vertebral arteries of stroke patients.

METHODS

Using triplex ultrasonography, the internal diameter and flow velocities of the common carotid, internal carotid, and vertebral arteries of 176 consecutive stroke patients were measured. Correlations were examined with Pearson's statistics at an alpha level of 0.05.

RESULTS

Mean age of the patients was 59.3 ± 12 years, and 66% had cerebral infarcts. Diameter and blood flow velocities showed significant negative correlations (-0.115 ≥ r ≥ -0.382) in the carotid arteries on both sides, but positive correlations (0.211 ≤ r ≤ 0.320) in the vertebral arteries, even after controlling for age, gender, and blood pressure.

CONCLUSIONS

Our study demonstrated different diameter/flow relationships in the carotid and the vertebral arteries of stroke patients, which may suggest pathologic changes in the adaptive processes governing vessel diameter and growth, especially in the carotid arteries.

Which risk factors are more associated with ischemic rather than hemorrhagic stroke in black Africans?

OBJECTIVE

To comprehensively examine the relationship of vascular risk factors to stroke type in native black Africans.

METHODS

We explored 34 candidate demographic, clinical, and laboratory variables in 282 consecutive adult stroke patients with brain imaging.

RESULTS

Ischemic stroke (IS) was found in 61.7% (174). Gender, alcohol, cigarette, homocysteine, C-reactive peptide, anthropometry, and carotid parameters were not significantly associated with stroke type (p>0.05). Patients with IS had relatively lower BP, were significantly older, and more frequently had diabetes mellitus, cardiac disease, or previous transient ischemic attack than patients with hemorrhagic stroke (HS). However, in multivariate regression model predicting 69% of stroke type correctly, age≥62 years (OR: 4.0, 95% CI: 2.0-7.9), previous TIA (OR: 4.3, 95% CI: 1.2-15.7) and systolic BP≥140 mmHg (OR: 0.4, 95% CI: 0.2-0.9) were the only independent significant predictors of IS.

CONCLUSIONS

With increasing proportion of the population over 61 years and better BP control, the proportion of IS is expected to rise in black African countries currently undergoing epidemiological transition (changing lifestyle/disease pattern). Therefore, relevant components of the stroke intervention quadrangle (stroke surveillance, acute care, preventive and rehabilitation services) should be tailored toward this need.

White matter changes on magnetic resonance imaging: a risk factor for stroke in an African population?

BACKGROUND

White matter changes are frequently observed incidental findings in elderly individuals. Many studies in Europe and the United States have assessed the association of white matter changes with stroke and other diseases. No similar study has been conducted in sub-Saharan Africa, where risk factors for stroke differ. Our objective was to explore the association between severity of white matter changes (based on visual rating scales) and stroke in a Nigerian population.

METHODS

Magnetic resonance imaging (MRI) scans of 50 patients were retrospectively assessed and scored using 3 different visual rating scales (by Fazekas et al, Scheltens et al, and Manolio et al). The scores were classified as either mild or severe. Clinical indications and MRI scan results were classified into vascular (stroke) and nonvascular groups. The association between severity of white matter changes and stroke on MRI was explored using the Student t test, the Chi-square test, and multiple regression analysis at an alpha level of .05.

RESULTS

White matter changes were consistently and significantly more severe in patients with stroke than in patients without stroke (.01 ≤ P < .001; odds ratios 4.58 and 13.3, respectively) using the 3 visual rating scales. This finding was independent of age and gender as confirmed by regression analysis (adjusted odds ratios 4.8 and 9.2; .015 ≤ P ≤ .003).

CONCLUSIONS

Our findings suggest that severity of white matter changes in Nigerians may be a significant risk factor for stroke independent of age and gender. Prospective larger studies will be required to confirm its role in predicting stroke and stroke recurrence independent of other vascular risk factors, such as hypertension, diabetes, and cardiac diseases.

Dyslipidaemia in patients with established cardiovascular disease in Sub-Saharan Africa: a systematic review and meta-analysis

Dyslipidaemia has been recognized as a major risk factor for cardiovascular diseases. Our objectives were to conduct a systematic review and meta-analysis of published studies to determine the prevalence of dyslipidaemia among hospitalized adult patients with cardiovascular disease in sub-Saharan Africa and to compare between the various cardiovascular disease types. We searched Internet-based search tools and other sources for studies on dyslipidaemia or hypercholesterolaemia among hospitalized adult patients with established cardiovascular disease in sub-Saharan Africa, from 1985 to May 2011. Established cardiovascular disease was defined as ischaemic heart disease, heart failure, stroke or chronic kidney disease. We then assessed for between-study heterogeneity and carried out sensitivity analyses. Study quality was assessed using Downs and Black Checklist and publication bias was considered present when positive in both Egger's and Begg's tests. Restricted analyses were then performed on data from studies on ischaemic heart disease, heart failure and stroke separately. A total of 451 studies were screened and eventually 16 studies were included with a total of 2584 persons. The overall estimate of dyslipidaemia was 38.38% (95% confidence intervals = 26.75-50.0; I(2 )= 96.878; p < 0.001). The prevalence was highest among those with ischaemic heart disease (49.64%) than among those with stroke (26.53%) or heart failure (15.4%; p-values for all comparisons<0.001). Prevalence of dyslipidaemia in subjects with cardiovascular disease including ischaemic heart disease, stroke and heart failure in sub-Saharan Africa was high and similar to what was obtained in Western Europe and North America; highest in subjects with ischaemic heart disease, followed by those with stroke and heart failure.

Stroke incidence in rural and urban Tanzania: a prospective, community-based study

BACKGROUND

There are no methodologically rigorous studies of the incidence of stroke in sub-Saharan Africa. We aimed to provide reliable data on the incidence of stroke in rural and urban Tanzania.

METHODS

The Tanzania Stroke Incidence Project (TSIP) recorded stroke incidence in two well defined demographic surveillance sites (DSS) over a 3-year period from June, 2003. The Hai DSS (population 159,814) is rural and the Dar-es-Salaam DSS (population 56,517) is urban. Patients with stroke were identified by use of a system of community-based investigators and liaison with local hospital and medical centre staff. Patients who died from stroke before recruitment into the TSIP were identified via verbal autopsy, which was done on all those who died within the study areas.

FINDINGS

There were 636 strokes during the 3-year period (453 in Hai and 183 in Dar-es-Salaam). Overall crude yearly stroke incidence rates were 94.5 per 100,000 (95% CI 76.0-115.0) in Hai and 107.9 per 100,000 (88.1-129.8) in Dar-es-Salaam. When age-standardised to the WHO world population, yearly stroke incidence rates were 108.6 per 100 000 (95% CI 89.0-130.9) in Hai and 315.9 per 100,000 (281.6-352.3) in Dar-es-Salaam.

INTERPRETATION

Age-standardised stroke incidence rates in Hai were similar to those seen in developed countries. However, age-standardised incidence rates in Dar-es-Salaam were higher than seen in most studies in developed countries; this could be because of a difference in the prevalence of risk factors and emphasises the importance of health screening at a community level. Health policy makers must continue to monitor the incidence of stroke in sub-Saharan Africa and should base future funding decisions on such data.

FUNDING

The Wellcome Trust.