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From THIERRY ADOUKONOU AND PHILIPPE LACROIX, Vascular Disorders. In: PIERRE-MARIE
PREUX AND MICHEL DUMAS, editors, Neuroepidemiology in Tropical Health. Oxford: Academic
Press, 2018, pp. 185-194.
ISBN: 978-0-12-804607-4
Copyright © 2018 Elsevier Inc.
Academic Press.
 Author’s personal copy

C H A P T E R

14
Vascular Disorders
Thierry Adoukonou1 and Philippe Lacroix2
1
University of Parakou, Parakou, Benin 2INSERM UMR 1094 NET, Limoges, France

O U T L I N E

14.1 Introduction 185 14.3 Risk Factors 190

14.2 Burden of Stroke in SSA 185 14.4 The Gaps 191
14.2.1 Overview 185
References 192
14.2.2 Epidemiology 186
14.2.3 Comments 189

14.1 INTRODUCTION The burden of stroke in SSA will be displayed in

In a very near future vascular disorders will be one
of the most important public health issues in the tropi-
cal area. Despite the remaining burden of infectious
and other transmitted diseases in sub-Saharan Africa
(SSA), according to the Global Burden of Diseases
(GBD), the non-transmitted diseases, particularly car-
diovascular disorders, become the first cause of mor-
tality and disability.1 Prevalences of the main types of
vascular disorders such as stroke, coronary artery dis-
ease (CAD), and peripheral artery disease (PAD) are
increasing. Approximately 1.06 million of deaths are
attributable to cardiac and cerebrovascular disease
(CVD). By 2030, non-transmissible conditions in gen-
eral, CAD and CVD in particular, will increase. They
are becoming the first and third causes of mortality in
low- and middle-income countries (LMICs).1 All these
diseases share common risk factors which are more
and more prevalent in this area.
These estimations are supported by (1) the increas-
ing life expectancy from 51 years in 1990 to more than
65 years in 2020 in women and approximately 60 years
in men, (2) the better control of infectious disease and
malnutrition; and (3) the growing burden of vascular
risk factors.2 SSA is undergoing an epidemiological
transition.
the first part of the document, then the related risk
factors will be analyzed.
14.2 BURDEN OF STROKE IN SSA
14.2.1 Overview
Stroke is the major cause of adult disability and the
second cause of mortality in the world.3 Recent studies
stressed the growing burden of stroke in LMICs, par-
ticularly in SSA.4 6
A shortage of stroke specialists and rudimentary
investigations impact negatively on the prognosis of
stroke in SSA.
However, epidemiological data from SAA suffer
from important limits.7,8 First of all, in order to evalu-
ate accurately the burden of stroke in the community,
the source population has to be well defined.9 Very
few high-quality censuses have been conducted in
SAA. For data collection, specific tools adapted and
validated to the population are necessary. Most of
them were established from high-income countries’
surveys. Validations of these tools were rarely con-
ducted in the SAA population. Often modern imaging
technics (computed tomography (CT)-scan or magnetic

Neuroepidemiology in Tropical Health

DOI: http://dx.doi.org/10.1016/B978-0-12-804607-4.00014-9 185 © 2018 Elsevier Inc. All rights reserved.
 Author’s personal copy
186 14. VASCULAR DISORDERS

resonance imaging (MRI)) useful for describing the
type of stroke are not available. Neurologists and even
general physicians are lacking. Prospective surveys,
useful in evaluating the exact incidence are limited.
Identification of prevalent or incident cases in the com-
munity as well as stroke mortality cases needs to be
validated. Thus, community-based surveys are scarce
and data are often of intermediate quality. Most data
are hospital based. It is meaningful to keep in mind
that a high number of cases are not admitted to hospi-
tal. Therefore the true prevalence and incidence might
be underestimated. In this context only the combina-
tion of community-based and hospital-based studies
can describe the real burden of stroke in SSA.
The World Health Organization (WHO) defined
stroke as “rapidly developing signs of focal (or global)
disturbance of cerebral function, leading to death or
lasting longer than 24 hours, with no apparent cause
other than vascular”.10 Transient ischemic attack (TIA)
and other ischemic stroke with recovery of the neuro-
logical deficit within 24 hours are excluded in this defi-
nition. However many TIA patients have cerebral
infarction imaged on MRI. Nevertheless, considering
the lack of availability and affordability of CT-scans
elsewhere in Africa, this definition remains useful for
epidemiological studies despite its limitations. Even if
in high-income countries, stroke definition includes
MRI abnormalities, recent data from GBD demonstrate
an increase in the incidence of stroke in LMICs com-
pared to high-income countries where the incidence is
globally stable.11 The mortality rate is extremely high
in SSA. In a recent meta-analysis, the prevalences of
stroke survivors were of 21.2/1000 (95% confidence
interval (CI) 13.7 30.29) in Latin America and the
Caribbean, and 3.5/1000 (95% CI: 1.9 5.7) in SSA.12
14.2.2 Epidemiology
14.2.2.1 Prevalence
The first epidemiological studies on stroke in SSA
were hospital based.13 Several studies were later
conducted in the community often by door-to-door
methods. The WHO definition of stroke was usually
used. General characteristics of the populations were
variable, particularly ages. Sometimes CT-scans were
performed to ensure diagnosis. Prevalence is one of
the best measures of the total burden of stroke in any
population. It provides information about the number
of people who survived a stroke. However, reliable
estimates of stroke prevalence are difficult to obtain.
For the best estimation we need information on
population such as the size, the age distribution and
other demographic data. Considering the increasing
frequency of stroke with age, standardization to age is
useful. This was not realized in most studies.
Prevalences of stroke in various SSA settings are
displayed in Table 14.1. The prevalence ranged from
15/100,000 persons in Ethiopia to 851/100,000 in
Nigeria.13 23 In other parts of the world stroke
prevalence ranged from 500/100,000 to 1000/100,000;
thus the prevalence of stroke in SSA is low.

TABLE 14.1 Prevalence of Stroke in Various Settings in Africa

Year Definition Number Age-
(Reference) Setting Size of stroke Methods of cases Prevalencea standardized

1982 [13] Aiyete (Nigeria) 903 WHO Door-to-door 4 440

1982 [14] Igo-Ora (Nigeria) 18954 WHO Door-to-door 10 53
1987 [15] Udo (Nigeria) 2925 WHO Door-to-door 2 68
1986 [16] Ethiopia 60820 WHO Door-to-door 9 15

2001 [17] Agincourt (South 42378 WHO Demographic 103 243 300b 200c
Africa) surveillance
2007 [18] Lagos (Nigeria) 13127 WHO Door-to-door 15 114

2010 [19] Cotonou (Benin) 15155 WHO 1 CT-scan Door-to-door 70 462 770b
2013 [20] Hai (Tanzania) WHO Demographic 108
surveillance
2014 [21] Anambra (Nigeria) 6150 WHO Door-to-door 10 163
2014 [22] Delta Niger (Nigeria) 1057 WHO Door-to-door 9 851 1230b
2015 [23] Kwara (Nigeria) 12992 WHO Door-to-door 17 131
a
per 100,000.
b
World Health Organization (WHO) world population.
c
Segi world population. [70]

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14.2 BURDEN OF STROKE IN SSA
A door-to-door method was used in all studies. In
two studies, respectively, in Tanzania and in South
Africa a demographic surveillance method with yearly
census was conducted. In the first study the Hai popu-
lation in a rural district of Tanzania was included, and
a demographic surveillance was conducted.18 It was
the largest project on the prevalence of disabling hemi-
plegic stroke. The second survey by the South Africa
Stroke Prevention Initiative (SASPI) was conducted in
Agincourt, a rural district in South Africa.15
14.2.2.2 Incidence
Incidence is considered as one of the most relevant
epidemiological indicators. Incidence studies can
adopt many forms but require a rigorous methodol-
ogy. The best option remains the register of stroke that
combines population data and hospital data. However
this kind of study is very expensive and restrictive to
scale in SSA. Criteria for stroke incidence studies were
defined by Sudlow and Warlow24 and updated in
20049 (see Box 14.1). These criteria ensure not only the
quality of the data but also facilitate comparisons
between studies.
The first study on incidence of stroke in SSA
took place in Nigeria in 1973.25 The incidence was of
15/100,000 persons per year. Later other studies took
BOX 14.1
U P D AT E D C R I T E R I A F O R I D E A L S T U D Y O F S T R O K E I N C I D E N C E
A N D / O R M O R TA L I T Y
Standard definition
WHO definition of stroke.
At least 80% verification by CT or MRI of diagnosis
of ischemic, intracerebral hemorrhage, and
subarachnoid hemorrhage.
Classification of ischemic stroke into subtypes
(e.g., large-artery disease, small-artery disease,
cardioembolic, other) if possible.
First ever in a lifetime and recurrent stroke
(separately and combined).
Standard methods
Complete population-based case ascertainment,
based on multiple overlapping sources of
information: hospitals (including admissions for
acute vascular problems and cerebrovascular
imaging studies and/or interventions), outpatient
clinics (including regular checking or general
practitioners’ databases), death certificates.
IV. FOCUS ON SPECIFIC NEUROLOGICAL SYNDROMES OR DISEASES IN TROPICAL AREAS
187
place in SSA and the reported incidences ranged from
15/100,000 to 149/100,000 persons.25 30 Other studies
used weaker diagnostic criteria and were limited to
hospital-based data. Incidences in various SSA settings
are displayed in Table 14.2.
Worth noting is that in Africa most strokes occur at
ages ,60 years; conversely, the mean age is close to 65
in Western Europe and North America.
14.2.2.3 Mortality
Mortality data are the second important indicator
after the incidence data. In SSA a reliable epidemiolog-
ical study on stroke mortality is difficult to conduct.9,24
We need two sources to register the mortality data: the
death certificate and a verbal autopsy. Those data are
not available everywhere in tropical areas. If available,
the data are often unreliable. The real burden of stroke
cannot be estimated from isolated hospital data. In the
community, many deaths were not notified. Moreover,
data from verbal autopsy are limited if they are col-
lected several weeks or months after the event. The
awareness of stroke symptoms is very poor in SSA.
Then it is difficult retrospectively to attribute the death
to stroke as far as people did not know those symp-
toms. Another issue is the lack of reliable demographic
data. The registries of death in Africa are scarce and
Prospective study design, ideally with “not pursuit”
or cases.
Large, well-defined stable population.
Follow-up or patients vital census for at least
1 month.
Reliable method for estimating denominator (census
data not more than 5 years old).
Standard data presentation
Complete calendar years data or data: not more than
5 years of data averaged together.
Men and women presented separately.
Recommended reporting of age specific estimates
within standard mild decade age bands (e.g., 45 54
years).
95% CIs around rates.
Source: Feigin V, Hoorn SV. How to study stroke incidence? Lancet
2004;363:1920.
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188 14. VASCULAR DISORDERS

TABLE 14.2 Community Incidence Studies in Various Setting in Sub-Saharan Africa

Year Definition Type of Number Age-
(Reference) Setting Size of stroke Methods stroke of cases Incidencea standardizedb

1973 [25] Ibadan 803098 WHO DDSS All 318 15

1997 [26] Harare 887768 WHO Hospital First ever 275 31 68

c
1986 [27] Pretoria 114931 HCSR criteria and Hospital All 116 101
CT-scan (79%)

2007 [28] Maputo WHO, Autopsy Hospitalc All 651 148.7 260.1
CT-scan (92.3%)
2010 [29] Dar es Salam 56517 WHO DDSS All 183 107.9 315.6

2010 [29] Hai 159814 WHO DDSS All 453 94.5 108.6
c
2013 [30] Lagos 750.000 WHO Hospital First ever 189 25.2 54.08
a
Incidence rate per 100,000 person-years.
b
Segi World population.
c
Hospital: hospital-based study.
DDSS, door-to-door survey or demographic system surveillance.

TABLE 14.3 Stroke Mortality in Various Settings in Africa

Years (Reference) Setting Size Stroke mortalitya Part of mortality (%)

1975 1980 [31] Accra (Ghana) 4075 8

1992 1995 [32] Agincourt (South Africa) 63000 127 6

1992 1995 [33] Dar Es Salam (Tanzania) 65826 158 6.1
1992 1995 [33] Hai (Tanzania) 142414 165 8.8
1992 1995 [33] Morogoro (Tanzania) 99672 82 2.5
a
per 100,000 inhabitants.

the reliability is fragmentary. Then it is very difficult
to estimate the real mortality of stroke in Africa.
Nevertheless by combining verbal autopsy, hospital
data and other sources of notification, stroke mortality
can be evaluated. Mortality rates varied from 82 to
more than 200 per 100,000 inhabitants.31 33 The avail-
able data are summarized in Table 14.3.
14.2.2.4 Stroke Case-Fatality
In SSA among stroke patients, many died at home
or before hospital admission. In these countries, acute
management is lacking. The case fatality is very high
in LMICs compared to those reported in the high-
income countries. One-month case-fatality rates ranged
from 20% to more than 50% in the tropics.34 36 After
7 years of follow-up in Tanzania, 82.3% of the stroke
subjects were dead.37 Many factors influenced the mor-
tality in the acute phase of stroke. Good management
can prevent most of them. Early detection and man-
agement of these complications such as pneumonia,
venous thrombo-embolism, urinary tract infection,
cerebral edema, and early recurrence of stroke is of
major importance. Nevertheless, information about the
trend and the temporal census of the case-fatality are
useful.
14.2.2.5 Stroke Subtypes
The CVD events are strokes, cerebral venous throm-
bosis and subarachnoid hemorrhage. Stroke are com-
monly ischemic or hemorrhagic. Mechanisms and
management of both are different. Many scales or
scores were developed in order to distinguish hemor-
rhagic from thrombotic strokes (Siriraj Stroke Scale,
Guy’s Hospital) but their accuracy is limited.
According to a recent meta-analysis, they cannot help
clinicians in practice.38 Imaging techniques such as
CT-scan and MRI allow an accurate diagnosis. MRI is
the best imaging strategy. It cannot be routinely used
in tropical areas because of its availability and afford-
ability. Nevertheless the available data indicates that
the ischemic stroke accounted for 40% 70% and hem-
orrhage for 21% 60% in SSA.39 Some recent surveys
illustrate a switch from a hemorrhagic predominance
to an ischemic one.
According to the Trial of ORG 10172 in Acute
Stroke Treatment (TOAST)40 classification of stroke

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14.2 BURDEN OF STROKE IN SSA
and on the basis of available data41,42 the etiologies of
stroke in the black population may be:
1. small vessel disease due to hypertension and
diabetes mellitus;
2. undefined cause (lack of investigation);
3. cardio embolic;
4. atherosclerosis;
5. other causes (vasculitis, sickle cell disease, etc.).
Vasculitis due to HIV infection may be an important
part of ischemic stroke where the HIV infection is
prevalent particularly among young patients. In fact,
due to the growing prevalence of vascular risk factors
in SSA, the role of atherosclerosis will be important in
the coming years. Current large comprehensive studies
will contribute to a better understanding of stroke eti-
ologies in this setting.43 Regarding the hemorrhagic
strokes, about 70% 80% can be explained by
189
hypertension with small-vessel disease involvement
causing small lipohyalinotic aneurysms and their rup-
ture. The location of the hematoma (deep location) and
the past history of hypertension or the other damage
of this disease (cardiac, eye, kidney, etc.) can help to
ascertain diagnosis.
14.2.3 Comments
Considering the strict application of the incidence or
mortality criteria difficulties, especially in some tropi-
cal areas, the WHO proposed a new approach in three
steps in order to obtain reliable epidemiological data
in developing countries.44 This approach may be gen-
eralized. The first step is the identification of hospital
cases. The second is the identification of the fatality
cases outside the hospital, and the third is the

BOX 14.2

ROSIER SCALE PROFORMA

Assessment Date: |__|__|/|__|__|/|__|__|__|__| Time: |__|__|/|__|__|

Symptom onset Date: |__|__|/|__|__|/|__|__|__|__| Time: |__|__|/|__|__|

GCS: E |__| V |__| M |__| BP: |__|__| __|/|__|__|__| mmHg BG: |__|__|,|__|mmol/l

If BG<3.5mmol/l treat urgently and reassess once blood glucose normal

Has there been loss of consciousness or syncope? |__| (Yes= -1, No=0)

Has there been seizure activity? |__| (Yes=-1, No=0)

Is there a NEW ACUTE onset (or on awakening from sleep)

Asymmetric facial weakness |__| (Yes=+1, No=0)

Asymmetric arm weakness |__| (Yes=+1, No=0)

Asymmetric leg weakness |__| (Yes=+1, No=0)

Speech disturbance |__| (Yes=+1, No=0)

Visual field deficit |__| (Yes=+1, No=0)

TOTAL SCORE |__| ( -2 to +5)

Provisional diagnosis (Score>0 predicts Stroke, Score<0 Non-stroke)

|__| Stroke |__| Non-stroke (specify)………………………………………………………

BG, blood glucose; BP, blood pressure; E, eye; GCS, Glasgow Coma Scale; M, motor; V, voice.

Source: Nor AM, Davis J, Sen B, et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke
recognition instrument. Lancet Neurol. 2005;4(11):727 734.

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190 14. VASCULAR DISORDERS
identification of non-fatality cases in community. This
step-wise approach documents the initial outcomes of
stroke patients: events in hospital, fatal events in com-
munity, and non-fatal events in community. The stroke
surveillance system begins with cases admitted to hos-
pital: this group is easily identified, and patients are
followed until discharge or death. The second level
consists of identifying and validating the diagnoses of
fatal stroke events for patients not admitted to hospi-
tal, i.e., the fatal events in the community. The third
step represents non-fatal, non-hospitalized events. The
optimal stroke surveillance system requires collection
of data from all three steps.
However, in resource-limited countries due to the
unavailability and inaccessibility of modern imaging
techniques, it is difficult to identify hospital cases.
Furthermore it is necessary to ensure that stroke cases
are properly confirmed at least clinically. The WHO
definition of stroke is very useful for epidemiological
studies but non-applicable for hospital cases requiring
treatment which depends on the subtype. Appropriate
identification is sometimes difficult and differential
diagnoses have to be excluded especially in case of
neurological disorders of sudden onset. Seizure, hypo-
glycemia, confusion and other differential diagnoses
might be confusing. Then a good emergency clinical
diagnosis by non-neurologist health workers coupled
with the CT-scan could optimize the management.
Lack of neurologists in those areas should encourage
the development of simple diagnostic tools. Several
tools have been developed for this purpose.45 47 The
Rosier scale48 (see Box 14.2) seems easier and is useful
in the emergency room, and has a good accuracy. This
tool evaluates several items with a total score from 22
to 15. A score .0 predicts stroke with a sensitivity of
92%, a specificity of 86%, a negative predictive value
of 88% and a negative predictive value of 91%.
Importantly, in SSA the poor awareness of stroke
signs and definition amongst health workers49 and in
the community50 is a strong limitation for diagnosis
and management. The analysis of the epidemiological
studies conducted in SSA ought to integrate these
limitations.
14.3 RISK FACTORS
Africa is facing an epidemiological transition,
characterized by an increasing burden of non-
communicable disorders (NCD) including hyperten-
sion, diabetes mellitus and dyslipidemia. The rapid
urbanization results in lifestyle changes, particularly in
tobacco smoking, overweight and obesity driven by
changes in food supply, alcohol consumption and
decreased physical activity. The influence of all these
IV. FOCUS ON SPECIFIC NEUROLOGICAL SYNDROMES OR DISEASES IN TROPICAL AREAS
risk factors was extensively documented in high-
income countries’ populations. Most of them are con-
sidered as stroke risk factors. Longitudinal surveys
conducted in high-income countries’ communities
illustrated this relationship. Large prospective epide-
miological studies are very scarce in SSA.51 Most data
come from cross-sectional surveys particularly in hos-
pital setting. The finding in high-income countries can-
not always be generalized to the SSA population. Even
in high-income countries, data from epidemiological
studies demonstrate a wide variation in the prevalence
of exposure to risk factors and events outcome.52
Regarding SSA, the prevalence of the stroke risk fac-
tors was documented but often the level of the rela-
tionship was not weighed. In addition to modifiable
risk factors, NCD might influence the stroke outcome,
particularly cardiac abnormalities (atrial fibrillation,
valvular diseases, heart failure). These diseases share
most of the risk factors for stroke. Few risk factors
seem to be more specific to SSA population. HIV status
was independently associated with stroke risk in
SSA.53 Stroke is also a recognized complication of
sickle cell disease, a most prevalent condition in the
African population. Genetic risk factors more prevalent
in African people may contribute to stroke incidence.
Very few are monogenic such as sickle cell disease. In
many cases, strokes result from complex multifactorial
genetic factors. Few genetic variants related to hyper-
tension were described in the African population.54
Thus, the underlying factors for stroke in SSA are
complex. The epidemiological characteristics of these
factors in this setting will be discussed.
Hypertension is highly prevalent in the SSA com-
munity. In the STEPS (STEPwise approach to noncom-
municable disease risk factor surveillance) surveys,
more than 25% of the subjects describe this con-
dition.55 57 In Benin, similar prevalences were
reported in urban and in rural areas.55 Differences
were minimal between male and female indivi-
duals.51,58 The prevalence of hypertension was steadily
increasing with age up to 16%, 26%, 35%, and 44% at
mean ages of 30, 40, 50, and 60 years, respectively.59
Only 27% out of those with hypertension were aware
of the condition, less rarely treated and very few were
controlled. In SSA the available evidence is that hyper-
tension remains the dominant causal risk factor
regardless of the stroke type. The relationship was
documented in community studies; data from Nigeria
and Tanzania showed that .80% of the stroke index
cases had hypertension.23,29 In the hospital setting,
the prevalence of hypertension was up to 68% in the
Johannesburg hospital stroke register.42 In the
Interstroke study60 O’Donnell analyzed the risk of
stroke associated with hypertension according the
region. Compared with other countries, the risk was
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14.4 THE GAPS
the highest in Africa: 4.96 (3.11 7.91). Maredza
reported similar data in the Agincourt health and
demographic surveillance system (HDSS), 38% of the
stroke burden was due to hypertension.61 These rela-
tionships illustrate the potentially dramatic impact of
hypertension detection and treatment. It is estimated
that up to one-half of the strokes might be prevented
through risk factors detection and prevention.
Overall prevalence rate of diabetes mellitus in
Africa is up to 2% 3%.55,62 A survey conducted in
Tanzania53 showed that, in the community, 11% of the
stroke index cases were diabetics. In the Johannesburg
hospital registry diabetes prevalence was up to 15%.42
The urbanization and the aging of the SSA populations
would result in changes in dietary patterns that may
explain the increasing prevalences.
In the INTERSTROKE study60 the risk of stroke
associated with smoking was lowest in Africa, at 2.18
(1.07 4.43). The burden of stroke due to smoking
seems to be limited in SSA, particularly in the black
population. In the Johannesburg stroke register42 only
22% of the white patients were in the never smoking
group; conversely, 65% of the black patients were in
the same group. Residency might influence the smok-
ing habits; in Malawi and Benin the prevalence of
daily tobacco smoking was higher in rural than in
urban areas.55,57
Few studies highlighted the substantial burden of
stroke attributable to elevated body mass index (BMI)
and abdominal obesity in SSA. The overall risk of
stroke related to waist to hip ratio in the
INTERSTROKE study60 was at 1.73 (0.99 3.02) in
Africa but at 2.70 (1.95 3.74) in the female group; con-
versely the risk was lower in the male group at 1.25
(0.99 1.59). In the Agincourt HDSS,61 excess BMI was
considered to be responsible for 20% of the stroke bur-
den (3.5% males; 16% females). This risk was concen-
trated amongst the females and the youngest age
groups. Overweight and obesity were more prevalent
in urban than in rural populations.55,56 Elevated cho-
lesterol level appeared more prevalent among high
educational and urban populations.63
Stroke has been reported to be associated with HIV
infection in European cohorts. Ischemic stroke is the
predominant type. Prospective studies assessing the
role of HIV infection in stroke risk in ASS are lacking.
In a retrospective case control study conducted in
South Africa,64 the infection was associated with a
trend toward an increased risk of stroke. However,
later a relationship between acquired immunodefi-
ciency syndrome and stroke risk was shown in the
Baltimore-Washington Cooperative Young Stroke
Study.65 The adjusted relative risk was 9.1 for cerebral
infarction (95% CI, 3.4 24.6) and 12.7 for intracerebral
hemorrhage (95% CI, 4.0 40.0). In 2013 a study
IV. FOCUS ON SPECIFIC NEUROLOGICAL SYNDROMES OR DISEASES IN TROPICAL AREAS
191
conducted in Tanzania53 showed that the HIV infection
was an independent risk factor of stroke (odds ratio
(OR): 4.20, 95% CI: 1.56 11.30). The other factors were
the hypertension, smoking status, previous stroke, TIA
or myocardial infarction and a high ratio of total to
high-density lipoprotein cholesterol ratio. None or low
alcohol consumption was protective.
Stroke is a well-known complication of sickle cell dis-
ease. This monogenic disorder is highly prevalent in
SSA; the gene carrier rate was estimated to be up to 40%
in Nigeria.66 Amongst 5721 Nigerian sickle cell patients
registered in clinics, prevalence of stroke was
12.4/1000.67 Other mono- or multigenic disorders may
influence the stroke epidemiology in SSA, through their
impact on usual risk factors such as hypertension,
diabetes, and dyslipidemia.
Other known stroke risk factors include heart dis-
eases. The shift from hemorrhagic toward ischemic
stroke reflects the growing burden of these disorders.
In Tanzania53 14% 20% of the stroke cases versus
3% 4% in the control group presented a history of
previous cardiac events. In high-income countries,
atrial fibrillation (AF) is the most common cardiac
arrhythmia associated with stroke. The prevalence of
AF in the SSA community was poorly documented. In
older Tanzanian subjects ($60 years old)68 the preva-
lence was 0.67% but the related 1-year mortality rate
was extremely high (50% 66%). AF might be related
to hypertension and heart failure. Additionally in ASS,
rheumatic heart disease due to undertreated strepto-
coccal infection may contribute to the burden of AF.
Stroke risk may be increased by sociocultural fac-
tors. Poverty and lack of infrastructure for healthcare
have been documented as risk factors for stroke and
were common in SSA.
14.4 THE GAPS
The burden of stroke is growing in SSA, this rise is
driven substantially by the influence of common risk
factors. Without further investments in identification
of subjects at risk and prevention, the stroke incidence
will increase. In order to identify the subjects at risk of
cardiovascular events, particularly stroke, tools dedi-
cated to this population have to be developed and vali-
dated. Cardiovascular risk scales have been developed
from high-income country cohorts such as the
Framingham study or the SCORE project. The trans-
portability of such models in SSA was not studied and
most of them included biological data not available in
low- or middle-income countries. The main risk factors
for stroke, particularly hypertension, are not only
undetected but even if detected the effective manage-
ment is suboptimal. Alternative approaches are
 Author’s personal copy
192 14. VASCULAR DISORDERS
required to control these treatable risk factors. The
interventions have to be sustainable, cost effective, and
acceptable to the local population. In low-resource set-
tings, telemedicine and mHealth interventions69 might
be relevant for the clinical approaches for hypertension
and diabetes. Community health workers can be inte-
grated in such interventions and have to be included
in educational program delivery on tobacco use,
unhealthy diet and low activity.
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