Background: As the second leading cause of death and the leading cause of adult-onset disability, stroke is a major public health concern particularly pertinent in Sub-Saharan Africa (SSA), where nearly 80% of all global stroke mortalities occur, and stroke burden is projected to increase in the coming decades. However, traditional and emerging risk factors for stroke in SSA have not been well characterized, thus limiting efforts at curbing its devastating toll. The Stroke Investigative Research and Education Network (SIREN) project is aimed at comprehensively evaluating the key environmental and genomic risk factors for stroke (and its subtypes) in SSA while simultaneously building capacities in phenomics, biobanking, genomics, biostatistics, and bioinformatics for brain research. Methods: SIREN is a transnational, multicentre, hospital and community-based study involving 3,000 cases and 3,000 controls recruited from 8 sites in Ghana and Nigeria. Cases will be hospital-based patients with first stroke within 10 days of onset in whom neurovascular imaging will be performed. Etiological and topographical stroke subtypes will be documented for all cases. Controls will be hospital- and community-based participants, matched to cases on the basis of gender, ethnicity, and age (±5 years). Information will be collected on known and proposed emerging risk factors for stroke. Study Significance: SIREN is the largest study of stroke in Africa to date. It is anticipated that it will shed light on the phenotypic characteristics and risk factors of stroke and ultimately provide evidence base for strategic interventions to curtail the burgeoning burden of stroke on the sub-continent.

Background and Purpose The Questionnaire for Verifying Stroke-free Status (QVSFS), a method for verifying stroke-free status in participants of clinical, epidemiological and genetic studies, has not been validated in low-income settings where populations have limited knowledge of stroke symptoms. We aimed to validate QVSFS in 3 languages-Yoruba, Hausa and Akan- for ascertainment of stroke-free status of control subjects enrolled in an ongoing stroke epidemiological study in West Africa. Methods Data were collected using a cross-sectional study design where 384 participants were consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in Nigeria and Ghana. Ascertainment of stroke status was by neurologists using structured neurological examination, review of case records and neuro-imaging (Gold standard). Relative performance of QVSFS without and with pictures of stroke symptoms (pictograms) was assessed using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results The overall median age of the study participants was 54 years and 48.4% were males. Of 165 stroke cases identified by Gold standard, 98% were determined to have had stroke while of 219 without stroke 87% were determined to be stroke-free by QVSFS. NPV of the QVSFS across the 3 languages was 0.97 (range, 0.93 – 1.00), sensitivity, specificity and PPV were 0.98, 0.82 and 0.80 respectively. Agreement between the questionnaire with and without the pictogram was excellent/strong with Cohen’s k=0.92. Conclusions QVSFS is a valid tool for verifying stroke-free status across culturally diverse populations in West Africa.

Background Africa has a growing burden of stroke with associated high morbidity and a 3-year fatality rate of 84%. Cardiac disease contributes to stroke occurrence and outcomes, but the precise relationship of abnormalities as noted on a cheap and widely available test, the electrocardiogram (ECG), and acute stroke outcomes has not been previously characterized in Africans. We assessed the prevalence and prognoses of various ECG abnormalities among African acute stroke patients encountered in a multisite, cross-national epidemiologic study. Methods We included 890 patients from Nigeria and Ghana with acute stroke who had 12-lead ECG recording within first 24 hours of admission and stroke classified based on brain CT scan or MRI. Stroke severity at baseline was assessed using the Stroke levity scale (SLS), while one-month outcome was assessed using the modified Rankin scale (mRS). Results Patients mean age was 58.4 (±13.4) years, 490 were male (55%) and 400(45%) females, 65.5% had ischemic stroke, and 85.4% had at least one ECG abnormality. Women were significantly more likely to have atrial fibrillation, or left ventricular hypertrophy (LVH) with or without strain pattern. Compared to ischemic stroke patients, hemorrhagic stroke patients were less likely to have atrial fibrillation (1.0% vs. 6.7%, p=0.002), but more likely to have LVH (64.4% vs. 51.4%, p=0.004). Odds of severe disability or death at one month was higher with severe stroke (AOR: 2.25; 95% CI :1.44–3.50), or atrial enlargement (AOR: 1.45; CI:1.04–2.02). Conclusions About four in five acute stroke patients in this African cohort had evidence of a baseline ECG abnormality, but presence of any atrial enlargement was the only independent ECG predictor of death or disability.