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International Journal of Stroke 18(6)
Figure 4. Forest plots on the pooled crude annual incidence rates of stroke per 100,000 persons stratified by study setting
(community-based, hospital-based, community-based, and hospital-based).
modeling-based GBD estimates, are multifaceted41 and
might be related to the vast difference in age structure in
Europe (with a more aging population) versus Africa.
Furthermore, we found country-level differences in
stroke burden in Africa. For example, reports from East and
North African countries presented higher estimates compared
to those from West Africa. The GBD estimates for
East and West Africa were comparable, but reports from
North Africa presented higher estimates for stroke burden.
Methodological differences in design arising from multifaceted
limitations detailed in an earlier report42 might
account for these differences. Apart from methodological
differences, the differential rates between North and SubSaharan
Africa are likely attributable to the substructural
population and demographic differences between North
Africa (which has a higher proportion of older persons-60
years and above) versus sub-Saharan Africa and
regional differences in the profile of stroke risk factors.3,5,9
Also, the sparse contribution of African data to the GBD
study, poor stroke literacy, diverse socio-cultural barriers
and ethnic differences across African countries, and the
lack of rigorous community-based and institutional surveillance
infrastructure, including neuroimaging for stroke care
to promote detection, prognosis, and timely interventions,
are additional reasons for these differences.
Pooled CFR revealed that one in every four strokes in
Africa is likely to be fatal within the first month. This is similar
to a 24% estimate reported in an earlier review.35 Also,
our observation is comparable to the 36% global CFR
reported in the GBD study3 and India.15 The point estimate of
International Journal of Stroke, 18(6)
the pooled CFR was comparatively lower among males than
females, contrary to observations in other reports.3,15 Several
factors account for these differences; the paucity of data and
lack of stroke surveillance sites in Africa limit the generalizability
of these estimates. Also, timely emergency care (critical
to mortality reduction) is grossly deficient in Africa and
reduced women's access to hospital care.43 In addition, there
is a significant deficit of well-coordinated and holistic stroke
care program(s), including the lack of public awareness, primary
prevention, acute management, and post-stroke management,
in many African countries.44-46
Some notable studies on stroke epidemiology among
Africans47-49 were omitted in this systematic review primarily
due to missing details, uncertainties in reporting and
other methodological issues previously identified in stroke
incidence studies in Africa.42 We intentionally and prospectively
limited our review to studies whose design is close to
an ideal stroke incidence study in design and rigor.50 While
such stringent criteria are necessary for comparing similar
studies, they can be problematic in regions like Africa,
where limited funding, infrastructure, capacity, and access
to diagnostic and time-dependent resources to execute
comprehensive stroke epidemiological and surveillance
studies effectively make conducting any studies almost
impossible. The stroke community must not equate resource
constraints with " lesser quality " research. However, this
means that understanding is limited regarding the epidemiological
dynamics of stroke among Africans.
In the light of the current understanding of stroke presentation
in clinical settings among Africans, our findings on
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