Background: Hemorrhagic strokes are highly prevalent among Africans and contribute to significant morbidity and mortality from stroke in Lower and Middle Income Countries. Although hypertension is the most dominant risk factor for intracerebral hemorrhage (ICH), other risk factors may contribute to its occurrence.
Objective: To identify and quantify the contributions of concomitant risk factors for hypertension-related ICH among patients in the SIREN study.
Methods: The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Nigeria and Ghana. Cases included adults aged >18 years with CT/MRI confirmed stroke and hemorrhagic strokes were etiologically subtyped using the SMASH-U protocol. Controls were age-and-gender matched stroke-free adults recruited from the communities in catchment areas of cases. Comprehensive evaluation for vascular, lifestyle and psychosocial factors was performed using standard instruments. We used conditional logistic regression to estimate odds ratios (OR) with 95% CIs.
Results: Among a cohort of 2,118 stroke subjects, 682 (32.2%) had ICH. The mean age of ICH cases and controls were 53.7 ± 12.5 and 52.6 ± 12.5 years respectively. Using the SMASH-U etiologic classification of hemorrhagic strokes, 93.9% were hypertensive, 7.2% were related to structural lesions such as aneurysms, 2.2% cerebral amyloid angiopathy, 1.8% systemic diseases, 1.1% medication-related and 1.8% undetermined. Hypertension-related hemorrhagic strokes were associated with the following risk factors (aOR, 95% CI): diabetes mellitus 2.33 (1.33-4.09), stress 2.22 (1.20-4.11), dyslipidemia 1.69 (1.01-2.83), tobacco use 10.01 (1.06-94.41) while green leafy vegetable consumption 0.36 (0.20-0.66) was strongly protective.
Interpretation: ICH affects a predominantly young and productive population in Africa. In this population, stress and green leafy vegetable consumption are novel factors with potential opposing modulating effects on occurrence of hypertensive hemorrhagic stroke.