Neurological, Psychiatric, and Developmental Disorders Meeting the Challenge in the Developing World (2001) / Chapter Skim
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10 Stroke
10 Stroke
Pages 339-376
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From page 339... ...
. A hemorrhagic stroke may be caused by a ruptured cerebral blood vessel, a ruptured intracranial aneurysm, or an arterio-venous malformation leading to an intracerebral hemorrhage in or near the brain.
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From page 340... ...
Table 10-l lists several additional reports describing stroke mortality in diverse populations. While the wide range of mortality rates shown may to some extent reflect population differences in exposure to risk factors for stroke (as discussed further below)
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From page 341... ...
The stu y determined ~age-spechc stroke mortality rates~for mere arid women in the three::areas, : compared with ~ 993 rate3~;for~ Eagland~ and Walies.:~Stroke mortalitg;rates~ For -each: of ~-the~:Tanzan:tan: -commun~ties~: were higher than-rates Win England and Wales-for all ~-age; bands ~Q~p~to 65 years. The ; ~;~ umbef o ; ~ I s Ski: from stroke In Tanzania is low In compansDn with similar figures horn other developtr~g countries, however", sirs e only about 6~ percen of he Tanzanian popu~labon is old~er~than~65.~ It appears likely~th~at~as~-increasing~numbers of people~:ln:~:~sub-Saharan::Afr~ca~surv~ve:to old ag~e,~:there: will be a significant- : :.2 : - :.
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From page 342... ...
death registries, 59 (age 197~1 994 standardized) South Africa [22]
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From page 343... ...
. The growing adoption of behaviors and lifestyles known to elevate stroke risk, such as tobacco use and high saturated fat intake, that can lead to hypertension, obesity, and diabetes (see the discussion of risk factors below)
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From page 344... ...
For example, researchers have documented relatively high rates of obesity, hypertension, glucose intolerance, and ischemic heart disease—all risk factors for stroke—among adults whose growth was stunted during childhood. Among populations where food has been historically scarce, "thrifty genes" appear to predispose bearers to obesity and diabetes when food is plentiful.~30]
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From page 345... ...
As the transition progresses, thrombotic strokes account for an increasing fraction of mortality, and ultimately become the most prevalent stroke type.~2] During the 1980s, WHO undertook a major international effort to monitor stroke prevalence and incidence in 10 countries of Asia and Europe: the Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA)
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From page 346... ...
Researchers have offered a variety of explanations for low stroke incidence, including young populations, lack of influence of Western diets, low diastolic blood pressure, and low cholesterol levels.~49,50] A substantial decrease in stroke mortality noted over recent years in the United States remains unexplained, but appears to be due to individual lifestyle modifications, as well as improvements in the general environment and in medical care.~51 ~ Severa]
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From page 347... ...
Door-to-door survey 647 Saudi Arabia Hospital-based (500) Review of records; diagn o- 186 [68]
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From page 348... ...
50 and over all participants Tunisia [76] Tunis Stroke registry 192 (age-adjusted, 45 years and older)
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From page 349... ...
This represents fertile ground for future epidemiological studies, as does the possibility that new stroke risk factors of particular significance in developing countries might be identified (for example, infectious agents, nutritional factors, or developmental syndromes that rarely occur in developed countries)
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From page 350... ...
A 10 percent higher prevalence of hypertension was associated with a 2.8-fold higher incidence of stroke, even after adjustment for differences in prevalence of cigarette smoking and alcohol consumption.~6,46] Hypertension is a major public health problem in African countries, where it may affect up to 10 percent of the population and contributes to coronary heart disease, as well as to hemorrhagic and thrombotic stroke.
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From page 351... ...
Most participants in the Framingham study who suffered stroke were found to have such comorbid conditions as congestive heart failure, coronary artery disease, or atrial fibrillation; the last condition appeared most significant among elderly populations, where it was found to account for approximately 30 percent of all strokes.~951 In developing countries, cardiac diseases are also recognized risk factors for stroke; however, there are variations in the type of cardiac disease and the affected age groups.
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From page 352... ...
is associated with a fourfold increase in stroke risk among men.~l11] Several recent studies indicate that elevated serum homocysteine is a risk factor for stroke in both adults and children.[ll2-115]
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From page 353... ...
.tl 29,130] Risk Factors for Stroke in Children dw ~ ., As noted earlier, stroke in children is uncommon worldwide, but may occur at higher levels in some developing communities as a result of the presence of several known and suspected risk factors, including sickle cell disease, congenital heart disease, intracranial infections, ran rem ~ or ~ ^~ ~~ 1 .~ · ~ ~ .~ .
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From page 354... ...
The remarkable reduction in stroke mortality achieved in several Western countries since 1970 suggests that population-wide efforts to educate people about causes and risk factors for stroke and other cardio- and cerebrovascular diseases are effective in reducing the impact of these disorders.~51] The concept of stroke as a serious condition may be highlighted at the public level using terms such as "brain attack," applied in the same context as heart attack.
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From page 355... ...
focused on the early detection and treatment of hypertension, diabetes, and other known risk factors for stroke. Although the available scientific evidence suggests that most of the risk factors for stroke identified for industrialized countries are also applicable to developing countries, the special genetic and environmental conditions prevalent in Africa, Asia, and Latin America call for specific case-control studies on risk factors for stroke among these populations.
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From page 356... ...
Additional predictors of recurrence include elevated blood glucose, hypertension, age, coronary artery disease, atrial fibrillation, congestive heart failure, prior transient ischemic attacks, a low albumin/globulin ratio, and heavy alcohol consumption. Congestive heart failure also appears to be a strong predictor of stroke recurrence, and has been associated with about a 26 percent risk of recurrence at 3 years.
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From page 357... ...
At this level, stroke prevention is best undertaken through a broad preventive health program for vascular disease that promotes a healthy lifestyle encompassing diet, exercise, and the avoidance of smoking and excess alcohol consumption.~8] Targeted campaigns may be directed at general, modifiable risk factors for cardioand cerebrovascular disease, most notably smoking.
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From page 358... ...
Primary care providers in developing countries should be provided with the training and equipment necessary to conduct preventive monitoring of conditions that are known risk factors for stroke, including hypertension, diabetes, and coronary artery disease. Secondary strategies for stroke prevention include treatment for conditions that are known risk factors for stroke, such as hypertension, diabetes, coronary artery disease, and TIAs, as well as measures to prevent stroke recurrence.
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From page 359... ...
However, aspirin appears to be the more cost-effective option in many cases.[l75] Aspirin has been shown in clinical studies to reduce the relative risk of stroke or death by approximately 20 percent per year after a TIA or minor ischemic stroke.tl68,176]
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From page 360... ...
Recom mendation 10-6. Treatment, including essential medications, should be made available through primary care to all individuals with conditions such as hypertension, diabetes, and postpartum cerebral venous thrombosis that represent risk factors for stroke, as well as for those who have experienced TIAs.
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From page 361... ...
Because of these limitations, the best option for managing stroke in developing countries is prevention, both of first stroke and of recurrence. A particularly thorny issue in the treatment of acute stroke is the need to diagnose stroke subtype, because existing treatments for ischemic stroke.
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From page 362... ...
Research on rehabilitation approaches in developing countries should examine home-based strategies and other potentially cost-effective means of supporting stroke patients and their families. Cost Analysis Determination of the monetary costs of mortality, morbidity, disability, and handicap due to stroke is difficult, if not impossible, and many such studies performed to date have serious inadequacies.
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From page 363... ...
At the community level, health care workers and other paramedical personnel should provide basic education regarding stroke risk factors and promote a healthy diet, smoking cessation, and other lifestyle modif~cations, as well as regular checkups to test for hypertension and diabetes. Guidelines for accomplishing these tasks have been developed by WHO and PAHO ~ 188~; training programs should be established to distribute such
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From page 364... ...
Primary health care workers, nurses, and physicians play an important role in detecting, diagnosing, and treating hypertension, hypercholesterolemia, and atrial fibrillation, and in ensuring compliance with treatment. Their training, too, should emphasize the importance of stroke prevention through both patient education and the management of conditions known to be risk factors for stroke.
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From page 365... ...
Stroke therapy clinical guidelines. South African Medical Journal 90:292-306.
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From page 366... ...
Mortality from cardiovascular diseases in the various population groups in the Republic of South Africa. South African Medical Journal 56:10231030, 1979.
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From page 367... ...
Stroke incidence, case fatality, and mortality in the WHO MONICA project. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease.
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From page 368... ...
Cardiovascular risk factors in a Melanesian population apparently free from stroke and isehemic heart disease: The Kitava study. Journal of Internal Medicine 236:331-340, 1994.
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From page 369... ...
Stroke incidence rates among black residents of Harare A prospective community-based study. South Africa Medical Journal 87:606 609, 1997.
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From page 370... ...
Ischemic heart disease in black South African stroke patients. Stroke 31:1294-1298, 2000.
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From page 371... ...
Soman. High risk for coronary heart disease in Thiruvananthapuram city: A study of serum lipids and other risk factors.
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From page 372... ...
Cerebrovascular disease in young, HlV-infected black Africans in the KwaZulu Natal Province of South Africa. Journal of Neurovirology 6~3~:229~236, 2000.
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From page 373... ...
Hennekens. A prospective study of moderate alcohol consumptions and the risk of coronary heart disease and stroke in women.
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From page 374... ...
Supari, et al. A study of baseline risk factors for coronary heart disease: results of population screening in a developing country.
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From page 375... ...
Guidelines for the management of hypertension at primary care level. South African Medical Journal 85:1321-1325, 1995.
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