Introduction

A stroke occurs when blood supply to the brain is cut off or reduced, preventing the brain tissue from receiving oxygen and nutrients (Walls, 2018). This causes the brain cells to die in just a few minutes, resulting in the loss of functionality of the part of the body that the injured brain controls (Ferri, 2022). Interruption to the brain’s blood supply can either be due to blockage or bleeding of the blood vessels that supply blood to the brain. There are 2 types of stroke, namely Ischemic and Hemorrhagic stroke. Stroke is a medical emergency and should be treated as such in order to prevent permanent brain damage, other complications, and death (Rink, 2011).

Statistics and Socio-Economic burden of stroke

Figure 1: Global Stroke burden (Source: Benjamin, 2018)

Globally

An average of 1 in 4 adults will have a stroke in their lifetime (Global Burden of Disease, 2018). Meanwhile, 1 in 4 stroke survivors will have another stroke within 5 years (American Heart Association, 2010).  

The risk of stroke within 90 days of a Transient Ischemic Attack may be as high as 17%, with the greatest risk during the first week (Lambert, 2011).

Stroke is the leading cause of disability and dementia. It is also the second leading cause of death worldwide, with an annual mortality rate of about 5.5 million deaths. About 87% of stroke-related disabilities and 70% of stroke deaths arise from low-medium income countries (Kim, 2019). A higher global incidence of ischaemic but not haemorrhagic stroke is reported in men than in women. The incidence rate of stroke in women has significantly decreased between 1990 and 2013, but in men, the decrease was not significant (Barker-Collo, 2015). The estimated cost of care per patient with stroke ranges from US$145 to US$ 4,860, depending on the care setting (Birabi, 2012)

Africa

In the 20th century, infectious diseases made up a huge portion of common diseases in Africa (Owolabi, 2015). However, current evidence indicates that Non-communicable diseases (like stroke) now make up a much bigger portion of common diseases (Owolabi. 2015). 

From published data in Africa, the annual incidence rate of stroke is about 316 cases per 100,000 person-years, while the prevalence rate is about 1,460 cases per 100,000 person-years (Akinyemi, 2021). Akinyemi also noted that stroke in Africa has a 3-year fatality rate greater than 80%, with stroke-related deaths being about 5.5% to 11% of mortality. Additionally, Africans tend to have strokes within the 4th and 6th decade (40-60 years) of their lives.

The increase in stroke burden in Africa is being driven by multiple factors acting across the lifespan, such as utero and early-life undernutrition, increased cardiometabolic risk factors in mid-life, increasing exposure to indoor and outdoor particulate air pollution (Azarpazhooh, 2018), changes in dietary habits and population ageing (Keates, 2017).

Figure 2: Model-derived percentage change in ischaemic and haemorrhagic stroke incidence in African countries between 1990 and 2020 (Source: Akinyemi et al, 2021).

From figure 2, it can be concluded that the Demographic Republic of Congo (DRC) has the highest percentage change in combined stroke incidence (65%), while The Gambia has the lowest (22%). Burundi, Libya and Zambia have the highest percentage change in hemorrhagic stroke incidence (45%). The DRC also has the highest percentage change in ischemic stroke incidence of 29%.

Figure 3: Model-derived percentage change in ischaemic and haemorrhagic stroke mortality rate in African countries between 1990 and 2020 (Source: Akinyemi et al, 2021).

From the figure above, Burkina Faso has the highest percentage increase in stroke mortality rates (over 150 deaths), while Mauritius has the highest percentage decrease in mortality rates (about -90 deaths).

Types and causes of stroke

The various causes of stroke also form the various types of stroke. They can be classified into 3 major types:

1. Ischemic stroke: This makes up about 87% of all the stroke cases worldwide, making it the most common type of stroke (Virani, 2021). It usually occurs due to the narrowing or total blockage of the blood vessels by either fatty deposits, blood clots, or debris in the bloodstream. This can lead to reduced blood flow to the brain starving it of the oxygen and nutrients that it requires to function properly (National Heart, Lung, and Blood Institute, 2021).

2. Haemorrhagic stroke: There are ‌2 types of hemorrhagic stroke:

– Intracerebral haemorrhage: This type of stroke occurs due to the rupturing of a ballooned blood vessel (aneurysms) or the leaking of weakened blood vessels that supply blood to the brain (WebMD, 2021). There are some conditions that lead to the bulging or weakening of blood vessels, some of which are: taking too many blood thinners, uncontrolled high blood pressure, trauma, protein deposits in blood vessel walls and many more (Ferri, 2021). Bleeding in the brain can also be caused by the rupture of the irregular tangling of thin-wall blood vessels (arteriovenous malformation), although this is usually less common (Ferri, 2021). Blood build-up usually results in the damage of surrounding blood tissues (CDC, 2021).

-Subarachnoid haemorrhage: This is the less common type of hemorrhagic stroke and it usually occurs when there is bleeding in the area between the brain and the thin tissues that cover it (CDC, 2021).

Hemorrhagic strokes can be very serious and are responsible for about 40% of stroke-related deaths (Pietrangelo, 2019)

3. Transient Ischemic Attack (TIA) stroke: This is commonly known as a ministroke. It is usually caused by a temporary decrease in blood supply to the brain, which might last for as little as five minutes. The temporary decrease in blood supply is caused by clots or debris blocking blood flow to the part of the nervous system (AskMayoExpert, 2021). It usually doesn’t cause any permanent damage because blood flow resumes after a short time, resolving the symptoms without treatment needed (McIntosh, 2020).

Risks factors

Figure 4: Risk factors for stroke in Africa according to INTERSTROKE Africa (Source: O’Donnell (INTERSTROKE), 2016)

A 2016 global study involving 5 African countries (Mozambique, Nigeria, South Africa, Sudan and Uganda), identified the 10 top risk factors accounting for 82% of stroke among Africans and 92% of stroke in the rest of the world (O’Donnell, 2016). The risks factors identified in this study are:

High blood pressure: This is a leading cause of stroke (CDC, 2020). It can cause the arteries that supply blood and oxygen to the brain to burst or be blocked, causing a stroke (Whelton, 2018).

Dyslipidemia: Also known as high levels of cholesterol, has been linked to stroke and related heart conditions (CDC, 2020).

Central obesity: This can lead to high blood pressure and diabetes, which are known to increase the risks of stroke (CDC, 2020).

Psychosocial factors: Stressors, depression, and the other psychosocial feelings of negativity are associated with stroke incidence (Araki, 2013)

Current smoking: This can increase the risk of stroke by damaging the heart and blood vessels. Carbon monoxide from cigarette smoke reduces the amount of oxygen the blood carries. Nicotine in cigarettes also raises blood pressure (CDC, 2020).

Cardiovascular disease: Heart disease increases the risk of getting a stroke. An example of this is coronary artery disease, where plaque builds up in the arteries and blocks the flow of oxygen-rich blood to the brain (CDC, 2020).

High alcohol intake: This raises blood pressure, and blood pressure as earlier stated is one of the leading causes of stroke. Excessive drinking is also known to increase the levels of triglycerides (a form of fat) which hardens the arteries (CDC, 2020).

Diabetes mellitus: Glucose sugar is needed by the body for energy. Diabetes causes the build-up of sugar in the blood, which prevents oxygen and nutrients from getting to the various parts of the body including the brain (National Institute of Neurological Disorders and Stroke, 2009).

Unhealthy diet: Diets high in saturated fats, trans fat, and cholesterol have been linked to stroke and related conditions, such as heart disease. Also, getting too much salt (sodium) in the diet can raise blood pressure levels, which increases the risk of stroke (CDC, 2020)

Physical inactivity: Being physically inactive can lead to conditions that increase the risk of stroke. Some of those conditions include obesity, diabetes and high cholesterol (CDC, 2020).

From figure 4, hypertension is the highest risk factor of stroke with population attributed risk of about 50%, while diabetes has the lowest. This simply means that hypertension is the most common factor that increases the risk of stroke in Africa. A healthy diet and regular exercise, on the other hand, reduce the risk of developing a stroke amongst Africans.

Figure 5: Risk factors for stroke in Africa according to SIREN (Source: Owolabi (SIREN), 2018)

The Stroke Investigative Research and Educational Network Study (SIREN) is the largest multi-site case-control stroke risk factor study to be performed in Africa to date. It occurred 2 years after the INTERSTROKE study. This study included 2,118 case-control pairs of Indigenous Africans from 15 sites in Nigeria and Ghana. It used rigorous case ascertainment methodology and a similar case mix as the INTERSTROKE study. 

The SIREN study found that 98.2% of strokes were associated with 11 potentially modifiable risk factors. 8 out of these 11 risk factors (hypertension, dyslipidemia, central obesity, psychosocial, current smoking, cardiac disease, diabetes mellitus and physical inactivity) were also included in the INTERSTROKE study. 

From the 2 studies carried out 2 years apart, hypertension was the highest risk factor for stroke in Africans, followed by dyslipidemia and central obesity, but in the SIREN study, there was a noticeable increase in population attributable risk of these 3 factors. There was also a significant increase in diabetes mellitus’s population attributable risk. Psychosocial, current smoking, cardiac disease and physical inactivity on the other hand experienced a decrease in their population attributable risks in the SIREN study.

Other risks factors from the SIREN study but not included in the INTERSTROKE study are:

-High salt intake

-High meat intake

-Low vegetable intake

Although high salt intake, meat intake, and low vegetable intake can also be grouped as unhealthy diet, and unhealthy diet was included in the INTERSTROKE study.

From figure 5, the factor with the lowest population attributable is current smoking at 5% or less. High vegetable intake and regular exercise according to SIREN help to reduce the risk of stroke in Africans.

Other factors not included in the INTERSTROKE and SIREN study that can increase the risk of getting a stroke include‌s:

Age: Older people at the age of 55 and older are more likely to get stroke than people below (MayoClinic, 2022).

Race and ethnicity: Africans, African Americans, American Indians, Alaska Natives and Hispanics have a higher risk of stroke than people from other races or ethnicities (MayoClinic, 2022).

Sex/Gender: Men have a higher risk of developing stroke than women, although older women are more likely to die of strokes than men (MayoClinic, 2022)

Hormones: The use of estrogens and birth controls have been discovered to increase the risk of stroke (MayoClinic, 2022). Pregnancy and the use of birth control pills also increase the risk of stroke (Bushnell, 2014).

The use of illegal and hard drugs: Repeated use of hard drugs like cocaine can raise blood pressure, increasing the risk of stroke (Esse, 2011).

Obstructive sleep apnea: As these apneic/hypoxemic episodes cause oxygen desaturation in Obstructive sleep apnea (OSA) patients without any compensatory mechanism of anti-oxygenation, it leads to overproduction of reactive oxygen species, further oxygen desaturation and hypoxia causing ischemia in the brain and leading to TIA and stroke (Pialoux, 2009)

Family/personal history of stroke and genetics: Genetic factors usually play a role in blood pressure, obesity, and stroke. Several genetic conditions that can cause stroke include sickle cell disease. Also, people with a family history of stroke tend to share common environments and other factors which can increase their risk for stroke (CDC, 2021).

Previous stroke or transient ischemic attack: A history of stroke or transient ischemic attack (TIA) greatly increases the chances of getting another stroke (CDC, 2021).

Figure 6: Effect of race and geography on risk factors for stroke (Source: Owolabi (SIREN), 2017)

According to figure 6, Indigenous Africans had a significantly higher prevalence of hypertension and diabetes, similar frequency of dyslipidemia and lower prevalence of cardiac disorders than Americans of European descent. However, obesity and lifestyle factors, including smoking, alcohol consumption and physical inactivity, were more prevalent among African Americans and Americans of European descent than Indigenous Africans.

Figure 7: A life course approach to factors driving stroke burden in Africa (Source: Akinyemi, 2021).

Figure 7 shows the various factors at every stage of the life cycle that contribute to the burden of stroke in Africa.

Symptoms

-Numbness and paralysis of the face, arm and leg.

-Difficulty speaking and understanding what others are saying, which leads to confusion.

-Severe headache which might be accompanied by dizziness, vomiting and altered consciousness.

-Difficulty walking, which may include stumbling and problems with balance

-Problem with vision either in one or both eyes (MayoClinic, 2022).

-Complete paralysis of one side of the body 

-Difficulty with swallowing (NHS, 2019)

One should seek immediate medical attention if any signs or symptoms of a stroke are noticed, even if they seem to come and go or they disappear completely. Think “FAST” and do the following:

Face: Ask the person to smile. Does one side of the face droop?

Arms: Ask the person to raise both arms. Does one arm drift downward? Or is one arm unable to rise?

Speech: Ask the person to repeat a simple phrase. Is his or her speech slurred or strange?

Time: If you observe any of these signs, call 911 or emergency medical help immediately.

Prevention

According to the CDC, the following are ways in which strokes can be prevented:

1. Eating a healthful and nutritious diet. This diet should include vegetables, nuts, seeds, fruits, legumes and whole grains.

2. Avoiding smoking cigarettes or/and tobacco.

3. Being more active and engaging in regular exercise.

4. Drinking moderately or avoiding alcohol altogether.

5. Maintaining a moderately healthy weight.

6. Controlling blood pressure levels

7. Getting heart diseases treated or managed

8. Managing diabetes.

9. Reducing the use of certain medications that might increase the risk of stroke, or better still explore other alternatives in replacement of such medication.

10. Always check cholesterol levels

11. Always take prescribed medications on time 

Diagnosis

When a patient displays stroke-like symptoms, a doctor must not only confirm the symptoms but also identify the type of stroke, its location, and the extent of brain damage. There are a variety of ways to do this. They include:

Physical exams: First of all, a couple of physical exams are performed by checking blood pressure or listening to the heart. This will be followed up with neurological exams to see how much of an impact the stroke had on the nervous system (Hasan, 2018).

Blood tests: A couple of blood tests might be performed by a doctor to determine how high the risk of bleeding or blood clotting is, how high or low the blood glucose level is and also if an infection is present (CDC, 2020).

Magnetic Resonance Scan (MRI) scan: The doctor uses this scan to locate the damaged brain tissue by creating an image of the brain from radio waves and magnets (CDC, 2020).

Computerised tomography (CT) scan: The CT scan is used to locate bleeding in the brain using a series of X-rays (CDC, 2020).

Cerebral angiogram: The doctor might insert a dye into the brain’s blood vessels to make them visible under X-ray and MRI scan, providing a detailed view of the blood vessels in the brain and neck (Mclntosh, 2020).

Echocardiogram: Sound waves are used to create detailed images of the heart. They can be used to find the source of a blood clot in the heart that might have travelled to the brain (Hasan, 2018).

Carotid ultrasound: This test shows buildup of fatty deposits and the blood flow in the arteries that supplies blood (carotid artery) to the brain. This is done by using sound waves to create detailed images of the carotid arteries located in the neck (CDC, 2020).

Treatment

The treatment plan depends on the type of stroke one is having, either ischemic or hemorrhagic stroke.

Ischemic stroke treatment: The first thing that doctors do to treat this type of stroke is the rapid restoration of blood flow to the brain. This can be done with:

a. Emergency intravenous (IV) medication: Using drugs (Tissue Plasminogen Activator) that can break up blood clots. The drug restores blood flow to the brain by dissolving the blood clots responsible for the stroke (CDC, 2020).

b. Emergency endovascular procedures: This can be done by directly delivering medications to the brain or by removing the clot with a stent retriever. The latter is more beneficial for people with larger clots that can’t be dissolved with TPA. (Silva, 2020).

c. Angioplasty and stents: Using an inflated balloon to expand narrowed blood vessels. This is done by threading a catheter into the carotid arteries (CDC, 2020).

d. Carotid endarterectomy: This is a surgical procedure that is done to remove plaque from carotid arteries. This procedure is especially risky for people with heart disease. (National Heart, Lung, and Blood Institute, 2020).

e. Mechanical thrombectomy: This procedure involves pulling out a clot from a large blood vessel in the brain by inserting a catheter into said blood vessel (Sorte, 2012).

Hemorrhagic stroke treatment: The treatment for this type of stroke focuses on controlling the bleeding and reducing pressure in the brain that is usually caused by excessive fluids. According to a 2021 study done by Attig, the following are treatments that can be used for treating Hemorrhagic stroke: 

a. Coiling: This procedure involves blocking blood flow into the aneurysm. It does this by filling the aneurysm with detachable coils using a catheter inserted into an artery.

b. Stereotactic radiosurgery: Beams of highly focused radiation are used to repair blood vessels malformations.

c. Surgical clipping: This procedure keeps an aneurysm from bursting or haemorrhaging again by placing a tiny clamp at the base of that aneurysm.

d. General surgery: This is done to remove blood and relieve the pressure on the brain if the area of the bleeding is large. Surgery can also be done to repair blood vessels associated with hemorrhagic stroke.

e. Surgical Arteriovenous Malformation removal: Arteriovenous Malformation (AVM) is an abnormal tangle of blood vessels connecting arteries and veins which disrupts normal blood flow. If the AVM is small and in an accessible area of the brain, surgeons do this procedure to remove it. This procedure eliminates the risk of it rupturing.

f. Emergency measures: This includes taking blood-thinning medications to prevent blood clots. Drugs to lower the pressure on the brain, lower blood pressure and prevent spasms of the blood vessels might also be given.

Stroke Medication: According to a 2021 study by Kimberly, there are several medications that can ‌treat strokes, some of them includes:

a. Direct-acting Oral Anticoagulants (DOACs): This reduces the blood’s ability to clot and can also reduce the risk of brain bleed

b. Tissue plasminogen activator (tPA): Given during a stroke to break up the blood clot causing the stroke.

c. Antiplatelet drugs: Prevents blood clots by making it more difficult for the platelets to stick together.

d. Statins: This lowers high blood cholesterol levels.

e. Blood pressure drugs: This helps to manage high blood pressure.

Complications of Stroke

According to Kimberly 2020, the following complications might arise because of stroke:

1. Difficulty swallowing

2. Changes in behaviour and self-care ability

3. Paralysis or loss of muscle movement

4. Depression

5. Bedsores

6. Pain

7. Cognitive impairment, e.g Dementia

8. Loss of bladder and bowel control

9. Seizures

10. Sensory or sensation changes 

11. Emotional or mood changes

Stroke recovery and rehabilitation

It is crucial that recovery and rehabilitation from a stroke begin as soon as possible. In the hospital after a stroke is stabilised and its effects are assessed, therapy targeting the affected skills of the individual can begin. According to a 2019 study carried out by Powers, stroke recovery focuses on four main areas:

Cognitive therapy: An occupational therapist works with the stroke patient to regain former thinking and behaviour. This also targets the management of emotional responses.

Physical therapy: Stroke may weaken muscle tone and strength, a physical therapist usually helps to regain the strength in those weakened muscles.

Speech therapy: Stroke sometimes causes language and speech impairment. A speech therapist works with the affected individual to relearn how to speak.

Relearning sensory skills: Senses are dulled or stop working completely if the part of the brain that relays sensory signals are affected during a stroke. An occupational therapist helps affected individuals to learn how to adjust to this lack of sensation.

Figure 8: Diagram showing Best foods for stroke recovery (Source: iStock, 2017)

Recommendations and Conclusion

Stroke care in Africa faces numerous challenges related to epidemiological surveillance, health promotion and disease prevention, acute care and rehabilitation and although there has been an improvement in stroke medications, as well the understanding of both traditional and emerging risk factors, there is still substantial gaps in our understanding of stroke in Africa as well as in stroke care, practice and policy on the continent.

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