Summary Background Sub-Saharan Africa has the highest incidence, prevalence, and fatality from stroke globally. Yet, only little information about context-specific risk factors for prioritising interventions to reduce the stroke burden in sub-Saharan Africa is available. We aimed to identify and characterise the effect of the top modifiable risk factors for stroke in sub-Saharan Africa. Methods The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study done at 15 sites in Nigeria and Ghana. Cases were adults (aged ≥18 years) with stroke confirmed by CT or MRI. Controls were age-matched and gender-matched stroke-free adults (aged ≥18 years) recruited from the communities in catchment areas of cases. Comprehensive assessment for vascular, lifestyle, and psychosocial factors was done using standard instruments. We used conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% CIs. Findings Between Aug 28, 2014, and June 15, 2017, we enrolled 2118 case-control pairs (1192 [56%] men) with mean ages of 59.0 years (SD 13.8) for cases and 57.8 years (13.7) for controls. 1430 (68%) had ischaemic stoke, 682 (32%) had haemorrhagic stroke, and six (<1%) had discrete ischaemic and haemorrhagic lesions. 98.2% (95% CI 97.2–99.0) of adjusted PAR of stroke was associated with 11 potentially modifiable risk factors with ORs and PARs in descending order of PAR of 19.36 (95% CI 12.11–30.93) and 90.8% (95% CI 87.9–93.7) for hypertension, 1.85 (1.44–2.38) and 35.8% (25.3–46.2) for dyslipidaemia, 1.59 (1.19–2.13) and 31.1% (13.3–48.9) for regular meat consumption, 1.48 (1.13–1.94) and 26.5% (12.9–40.2) for elevated waist-to-hip ratio, 2.58 (1.98–3.37) and 22.1% (17.8–26.4) for diabetes, 2.43 (1.81–3.26) and 18.2% (14.1–22.3) for low green leafy vegetable consumption, 1.89 (1.40–2.54) and 11.6% (6.6–16.7) for stress, 2.14 (1.34–3.43) and 5.3% (3.3–7.3) for added salt at the table, 1.65 (1.09–2.49) and 4.3% (0.6–7.9) for cardiac disease, 2.13 (1.12–4.05) and 2.4% (0.7–4.1) for physical inactivity, and 4.42 (1.75–11.16) and 2.3% (1.5–3.1) for current cigarette smoking. Ten of these factors were associated with ischaemic stroke and six with haemorrhagic stroke occurrence. Interpretation Implementation of interventions targeting these leading risk factors at the population level should substantially curtail the burden of stroke among Africans. Funding National Institutes of Health.
A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.
ObjectiveTo characterize risk factors for spontaneous intracerebral hemorrhage (sICH) occurrence and severity among West Africans.MethodsThe Stroke Investigative Research and Educational Network (SIREN) study is a multicenter case-control study involving 15 sites in Ghana and Nigeria. Patients were adults ≥18 years old with CT-confirmed sICH with age-, sex-, and ethnicity-matched stroke-free community controls. Standard instruments were used to assess vascular, lifestyle, and psychosocial factors. Factors associated with sICH and its severity were assessed using conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% confidence intervals (CIs) for factors.ResultsOf 2,944 adjudicated stroke cases, 854 were intracerebral hemorrhage (ICH). Mean age of patients with ICH was 54.7 ± 13.9 years, with a male preponderance (63.1%), and 77.3% were nonlobar. Etiologic subtypes of sICH included hypertension (80.9%), structural vascular anomalies (4.0%), cerebral amyloid angiopathy (0.7%), systemic illnesses (0.5%), medication-related (0.4%), and undetermined (13.7%). Eight factors independently associated with sICH occurrence by decreasing order of PAR with their adjusted OR (95% CI) were hypertension, 66.63 (20.78–213.72); dyslipidemia, 2.95 (1.84–4.74); meat consumption, 1.55 (1.01–2.38); family history of CVD, 2.22 (1.41–3.50); nonconsumption of green vegetables, 3.61 (2.07–6.31); diabetes mellitus, 2.11 (1.29–3.46); stress, 1.68 (1.03–2.77); and current tobacco use, 14.27 (2.09–97.47). Factors associated with severe sICH using an NIH Stroke Scale score >15 with adjusted OR (95% CI) were nonconsumption of leafy green vegetables, 2.03 (1.43–2.88); systolic blood pressure for each mm Hg rise, 1.01 (1.00–1.01); presence of midline shift, 1.54 (1.11–2.13); lobar ICH, 1.72 (1.16–2.55); and supratentorial bleeds, 2.17 (1.06–4.46).ConclusionsPopulation-level control of the dominant factors will substantially mitigate the burden of sICH in West Africa.
Background AIM on ClearCanvas Enriched Stroke- phenotyping Software (ACCESS) is a novel standalone computer software application that allows creation of simple standardized annotations for reporting brain images of all stroke types. We developed the ACCESS application and determined its inter-rater and intra-rater reliability in the Stroke Investigative Research and Educational Network (SIREN) study to assess its suitability for multicenter studies. Methods One hundred randomly selected stroke imaging reports from five SIREN sites were reevaluated by four trained independent raters to determine inter-rater reliability of ACCESS (version 12.0) software for stroke phenotyping. To determine intra-rater reliability, six raters reviewed the same cases previously reported by them after a month interval. Ischemic stroke was classified using the Oxfordshire Community Stroke Project (OCSP), TOAST and ASCO protocols, while hemorrhagic stroke was classified using the SMASH-U protocol in ACCESS. Agreement among raters was measured with Cohen’s kappa statistics. Results For primary stroke type, inter-rater agreement was 0.98 (95%CI: 0.94–1.00) while intra-rater agreement was 1.00 (95%CI: 1.00). For OCSP subtypes, inter-rater agreement was 0.97 (95%CI: 0.92–1.00) for the Partial Anterior Circulation Infarcts (PACI), 0.92 (95%CI: 0.76–1.00) for the Total Anterior Circulation Infarcts(TACI) and excellent for both Lacunar Infarct (LACI) and Posterior Circulation Infarcts (POCI). Intra-rater agreement was 0.97 (0.90–1.00) while inter-rater agreement was 0.93 (95%CI: 0.84–1.00) for TOAST subtypes. Inter-rater agreement ranged between 0.78 (cardioembolic) to 0.91 (large artery atherosclerotic) for ASCO subtypes and was 0.80 (95%CI: 0.56–1.00) for SMASH-U subtypes. Conclusion The ACCESS application facilitates concordant and reproducible classification of stroke subtypes by multiple investigators, making it suitable for clinical and multicenter research.
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