Sub-Saharan Africa (SSA) is a vast area with a huge

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1 Mortality ad Recovery After Stroke i The Gambia Richard W. Walker, FRCP; Michael Rolfe, FRCP; Peter J. Kelly, BSc; Melville O. George, FWACS; Oliver F.W. James, FRCP Backgroud ad Purpose There are o previously published studies of the log-term outcome of stroke i sub-sahara Africa. Our goal was to determie the case fatality, time to ad cause of death, ad recovery i a hospital cohort of stroke patiets i The Gambia. Methods For 1 year begiig April 1, 1990, ay patiet presetig to the Royal Victoria Hospital (Bajul) with a diagosis of stroke or havig a stroke as a ipatiet was recruited. After a stadardized assessmet, patiets were followed up at 1 moth, 6 moths, ad 3 to 4 years to assess recovery or, for those who died, record the date ad likely cause of death. Results Mea age of the 106 patiets (70 me) was 58 years (rage, 20 to 93 years). By 1 ad 6 moths, 29 (27%) ad 47 (44%), respectively, had died, with oly 27 (25%) survivig to fial follow-up (4 patiets ot traced). Death occurred i hospital i 43 patiets (57%). Cause of death was the iitial stroke i 46 (61%), further stroke i 5 (7%), ifectio i 9 (12%), miscellaeous i 8 (11%) (oly 1 vascular), ad ukow i 7 (9%). O Cox regressio aalysis, icotiece i the first 24 hours, sesory iattetio, ad impaired gag reflex o admissio were sigificat predictors of mortality. Predictors of recovery were similar to those of developed coutries. Coclusios Despite the youg mea age, there was a high case fatality rate. The mai cause of death was the stroke itself, ad ischemic heart disease was very rare. (Stroke. 2003;34: ) Key Words: Africa south of the Sahara fatal outcome recovery of fuctio stroke Sub-Sahara Africa (SSA) is a vast area with a huge diversity of cultures, ethicity, ad medical resources that eeds to be cosidered whe comparisos betwee regios are made. However, eve for the whole SSA, data relatig to stroke are very limited. Recet verbal autopsy data demostrated that the age-adjusted stroke mortality rates i Tazaia are high. 1 For the age group of 15 to 64 years, ageadjusted stroke mortality rates i all 3 Adult Morbidity ad Mortality Project areas for the years 1992 to 1995 were sigificatly higher tha the age-adjusted rates for Eglad ad Wales for Oe might expect the prevalece of stroke-related disability to be correspodigly high, but whe this was measured i 1 of the Adult Morbidity ad Mortality Project areas, the age-specific rates were lower tha i studies from developed coutries. 2 These fidigs suggest that case fatality i SSA is higher tha i developed coutries, but the published evidece for this is very limited ad based almost etirely o i-hospital mortality figures. I a hospital-based study of 116 patiets i Pretoria, 3 1-moth mortality was 33.6%, but there were o details o follow-up methods, o idicatio of whether deaths outside hospital were recorded, ad o log-term follow-up. There are similar problems with other studies that report case fatality rates. There has bee o detailed published study of the cause of death of stroke patiets i SSA. Most of the few studies examiig recovery after stroke i SSA have bee retrospective ad are therefore hampered by missig ad variable quality of data. I a prospective study of 318 patiets i the Ibada Stroke Register, were alive at 3 weeks, but at 3 moths, oly 76 (24%) were alive, ad at 12 moths, oly 36 (11%) patiets could be traced. The mai coclusio from these data is that it is very hard to follow up patiets after discharge from hospital i Africa. No previously published study has icluded log-term commuity follow-up or classified recovery from stroke i a detailed maer. Therefore, data o recovery after stroke i SSA are very limited. We report here o a prospective hospital-based study i The Gambia with rigorous commuity follow-up for up to 4 years to ivestigate the log-term recovery from stroke ad to determie case fatality, time to death, ad likely cause of death. Methods Research Desig The Gambia straddles the Gambia river ad is 322 km log by a average of 35 km wide. I the populatio cesus just before the Received December 13, 2002; fial revisio received Jauary 20, 2003; accepted February 19, From the Departmet of Medicie, North Tyeside Geeral Hospital, Tye ad Wear, UK (R.W.W.); Departmet of Medicie, Withybush Geeral Hospital, Haverfordwest, Pembrokeshire, UK (M.R.); Tees Health Authority, Nuthorpe, UK (P.J.K.); WHO Coutry Office, Accra, Ghaa, Africa (M.O.G.); ad Departmet of Medicie, Medical School, Uiversity of Newcastle Upo Tye, UK (O.F.W.J.). Correspodece to Dr R.W. Walker, Departmet of Medicie, North Tyeside Geeral Hospital, Rake Lae, North Shields, Tye ad Wear, NE29 8NH, UK. Richard.Walker@orthumbria-healthcare.hs.uk 2003 America Heart Associatio, Ic. Stroke is available at DOI: /01.STR

2 Walker et al Mortality ad Recovery After Stroke i The Gambia 1605 study, oly 6% of the populatio was 60 years of age, but oly 5% of older people actually had a birth certificate. Of the 1 millio populatio, 95% were Muslim, ad 54% lived i rural areas. Bajul, the capital, is situated at the mouth of the Gambia river. The Royal Victoria Hospital i Bajul has 300 beds ad is the mai referral hospital for the coutry. The medical uit has 1 male ward ad 1 female ward, each with 30 beds, ad has 2000 admissios per year. The ipatiet fee ca be waived if the family caot afford it. At the time of the study, there was o CT scaer i the coutry. For 1 year begiig April 1, 1990, ay patiet presetig to the Royal Victoria Hospital with a diagosis of stroke or havig a stroke as a ipatiet was recruited to the study. Stroke was defied accordig to the World Health Orgaizatio defiitio, 5 ad both recurret ad first-ever strokes were icluded, but patiets with a history ad cerebrospial fluid fidigs suggestive of subarachoid hemorrhage were excluded. The patiets were see as soo as possible after admissio, usually withi 24 hours, almost all withi 48 hours. Details were collected o demography, medical history, ad potetial risk factors. If the exact age of the patiet was ot kow, it was calculated by estimatig their age at the time of sigificat evets i Gambia history such as Gambia Idepedece i 1965 or World War II. Date, mode of oset, ad progressio, if ay, of the stroke were also detailed. The patiets uderwet a full geeral ad eurological examiatio, ad blood samples were tested with the Veereal Disease Research Laboratory (VDRL) test (all cofirmed by the Trepoema Pallidum Hemagglutiatio test). Blood pressure was recorded i patiets recumbet o admissio, durig the first week, at 7 days after stroke (whe possible), ad at all subsequet follow-up visits. Durig their hospital stay, patiets received stadard care, but resources meat that there was a lack of itesive moitorig ad therapy iput. Patiets were followed up at home (or i hospital if still a ipatiet) at 1 moth, 6 moths, ad betwee 3 ad 4 years to assess eurological recovery ad disability, icludig Barthel Idex score. Without addresses or telephoe umbers for most patiets, a careful descriptio of the geographical locatio of their home ad ames of close relatives were recorded at hospital discharge. Patiets were classified as havig good (Barthel score 15) or poor (Barthel score 15) recovery. Stroke recurrece ad details of atihypertesive treatmet, aspiri, ad other treatmet were recorded. If patiets died, details o timig ad likely cause of death were recorded after questioig of relatives, frieds, ad sigificat others if ecessary. Statistical aalysis was carried out with a SPSS statistical package. Dichotomous variables were cross-tabulated ad statistically assessed for associatio with the 2 test. Fisher s 2-tailed exact test was used whe ay of the expected values i the table fell to 5. Results for progostic idicators are show for those admitted to hospital withi 1 week of stroke. Kapla-Meier survival curves were calculated with the STATA statistical package, ad curves were compared by use of the log-rak test. Data were aalyzed with a backward stepwise Cox regressio with a sigificace level of 0.1 for removig cadidate variables. Results Of the 109 patiets origially admitted to the study, 3 were subsequetly excluded. Two of these showed progressive deterioratio ad had other sigs ad symptoms suggestive of cerebral maligacy; the other had a recurrig Todd s paresis after seizures. For the remaiig 106 patiets (70 me; 66%), the mea SD age at stroke was years, ad the media age was 60 years (rage, 20 to 93 years) for the group as a whole. For me, the mea age was years, ad the media was 59.5 years (rage, 20 to 93 years). For wome, the mea SD age was 58 16, ad the media was 62.5 years (rage, 21 to 80 years). Sevety were from rural ad 36 were from urba areas; 95 were Muslims ad 11 were Christias. History was obtaied solely from the 14 patiets, from the patiet ad caregiver or other iformat i 59 cases, ad solely from relatives ad/or frieds i 33 cases. Te were ipatiets at the time of stroke, whereas 80 (56 me) were admitted withi 1 week, with a mea time to admissio for this group of 29 hours (media, 8 hours). Sixtee patiets (8 me) took 1 week ad 8 (6 me) took 1 moth to be admitted. At the time of stroke, 24 (23%) lost cosciousess, 40 (38%) complaied of a headache, ad 9 (8%) had vomitig. Te patiets (9%) gave a history of previous stroke (8 o the same side), 0 idicated previous trasiet ischemic attack, 3 had kow diabetes, 1 was takig regular aspiri, ad 3 were pregat (12, 23, ad 32 weeks gestatio); oly 10 had ever cosumed alcohol. There was o history of hypertesio i 78 patiets (74%), of whom 62 (58%) had ever had their blood pressure measured. Of the 15 receivig atihypertesive treatmet, 6 had had treatmet for 1 year. Fifty-three patiets had a stroke ivolvig the right carotid territory; 53 had a stroke ivolvig the left carotid territory. O the Bamford classificatio, there were 54 total aterior circulatio strokes, 33 partial aterior circulatio strokes, ad 19 lacuar strokes. The stroke patiets made up 5% of adult hospital medical admissios ad, with a mea duratio of stay of 19 days (media, 14 days; rage, 1 to 142 days), accouted for 10% of medical bed days occupied. Follow-Up By 6 moths ad the fial follow-up, 3 ad 4 patiets (all me), respectively, had bee lost to follow-up. By 1 ad 6 moths, 29 (27%) ad 47 (44%), respectively, had died. At the fial follow-up (at least 3 years), 27 patiets (16 me) were alive, ad 75 were kow to have died. The mea age at stroke for those who died was 61 years (media, 60 years; rage, 24 to 90 years). Of these, 37 (26 me) died i hospital durig their origial admissio. A 77-year-old ma with a i-hospital stroke after a fractured eck of femur died after 142 days. Excludig this ma, mea time from stroke to death for this group was 18 days (media, 7.5 days; rage, 1 to 81 days), ad mea duratio of admissio was 9 days (media, 5 days; rage, 1 to 66 days). For the 38 who died after iitial discharge from hospital, 6 (2 me) died i hospital o a subsequet admissio, ad 32 (22 me) died at home. Mea time to death was 538 days (media, 504 days; rage, 35 to 1300). Table 1 shows causes of death i relatio to place of death for all patiets. The other causes of death icluded hypertesive ecephalopathy, septicemia, ad cogestive heart failure. The 7 with ukow cause were all me with limited recovery (1-moth Barthel scores 10) who died at home after 3 moths, so it is likely that they died from causes related to their origial stroke. Of the 10 patiets (7 me) who had previously had a stroke, 1 was lost to follow-up, ad 4 were alive at 6 moths, but oly 1 was still alive at fial follow-up. Iterestigly, oly 1 died of aother stroke. Tables 2 ad 3 show the progostic idicators for case fatality at 1 moth ad 3 to 4 years, respectively, ad Table 4 gives the progostic idicators for stroke recovery at 1 moth (missig data o 4) for those patiets admitted to

3 1606 Stroke July 2003 TABLE 1. Cause of Death i Relatio to Place of Death Aother Stroke, Other Causes, Place of Death Iitial Stroke, Ifectios, Ukow, All 50 (40) 32 (26) 3 (3) 5 (4) 3 (2) 7 (5) Hospital readmissio 3 (3) 0 2 (2) 1 (1) 0 0 Home 22 (18) 7 (7) 1 (1) 4 (3) 3 (2) 7 (5) Origial hospital admissio 25 (19) 25 (19) Values i paretheses are for those admitted withi 1 wk of stroke. hospital withi 1 week of stroke. Data are missig for receptive ad expressive dysphasia, dysarthria, visual field defect, ad facial palsy for 1 patiet who died shortly after admissio. Age; sex; area of abode; marital status; history of previous stroke, agia, hypertesio, smokig, alcohol use, or sorig; time of day of stroke; atrial fibrillatio o examiatio; ad positive VDRL all had o sigificat effect o mortality or recovery. For the backward stepwise Cox regressio, iitial cadidate variables icluded that were excluded with regressio modelig were sex; area of abode; history of hypertesio, sorig, ad cigarette or pipe smokig; whether the stroke occurred durig the day or ight or durig sleep; impaired cosciousess after stroke; atrial fibrillatio; carotid territory distributio; dysarthria; expressive dysphasia; swallowig problems; facial palsy; or visual field deficit. Table 5 shows the fial model. I relatio to Kapla-Meier survival curves, impaired cosciousess level o admissio, uriary icotiece i the first 24 hours, ay swallowig problems durig admissio, expressive dysphasia, ay visual field deficit, ad sesory iattetio all had a major impact o mortality, particularly early. Those 65 of age teded to do worse from the outset (see the Figure). At 1 moth, there was full recovery i 9 patiets (8.5% of total), whereas 9 had o recovery of movemet at all. Of the 51 (29 me) assessed (5 [4 me] could ot be followed up) at 6 moths, 17 (33%) were o atihypertesive medicatio, 9 (18%) had made a full recovery, ad 17 (33%) were left with a severe impairmet (uable to lift affected limbs agaist gravity). Of the 27 (25%) still alive at fial follow-up, 3 had had aother stroke, 4 were regularly takig aspiri, ad 12 were uder regular follow-up for hypertesio, of whom oly 4 were satisfactorily cotrolled ad 3 had completely defaulted from treatmet. Sevetee (65%) patiets had a maximum Barthel score of 20, of whom 8 (31%) had made a complete recovery. Discussio This is the first published stroke study for SSA that provides comprehesive data o log-term commuity follow-up ad provides the most comprehesive assessmet of recovery to date. Cosiderig the difficulties (most dwelligs had o street ame or umber, post [ZIP] codes were oexistet, TABLE 2. Progostic Idicators for Mortality at 1 Moth i Patiets Admitted to Hospital Withi 1 Week of Stroke Dead ( 28), Alive ( 62), Statistical Sigificace* Epileptic seizure at time of stroke 6 (21) 2 (3) Loss of cosciousess at stroke 15 (54) 7 (11) Impaired cosciousess at admissio 19 (68) 16 (26) Impaired gag reflex o admissio 22 (79) 10 (16) Swallowig problems o admissio 24 (86) 12 (19) Receptive dysphasia 22 (81) 16 (26) Expressive dysphasia 23 (85) 31 (50) Dysarthria 25 (93) 44 (71) Visual field deficit 22 (81) 26 (42) Facial palsy 15 (55) 24 (39) 0.14 Sesory iattetio 23 (82) 19 (31) Right carotid territory 14 (50) 31 (50) 1.00 Icotiece i first 24 h 28 (100) 34 (55) Uriary catheter 9 (32) 12 (19) 0.18 Chest ifectio 11 (39) 6 (10) * 2 test. Fisher s 2-tailed exact test.

4 Walker et al Mortality ad Recovery After Stroke i The Gambia 1607 TABLE 3. Progostic Idicators for Mortality at Fial Follow-Up i Patiets Admitted to Hospital Withi 1 Week of Stroke Dead ( 61), Alive ( 25), Statistical Sigificace* Epileptic seizure at time of stroke 7 (11) 1 (4) 0.43 Loss of cosciousess at stroke 20 (33) 2 (8) Impaired cosciousess at admissio 29 (48) 5 (20) Impaired gag reflex o admissio 18 (30) 4 (16) Swallowig problems o admissio 30 (49) 5 (20) Receptive dysphasia 32 (53) 4 (16) Expressive dysphasia 41 (68) 10 (40) Dysarthria 50 (83) 16 (64) Visual field deficit 41 (68) 6 (24) Facial palsy 28 (47) 10 (40) 0.57 Sesory iattetio 38 (62) 4 (16) Right carotid territory 31 (51) 13 (52) 0.92 Icotiece i first 24 h 51 (84) 9 (36) Uriary catheter 16 (26) 4 (16) 0.31 Chest ifectio 15 (25) 2 (8) * 2 test. Fisher s 2-tailed exact test. ad oly 2 patiets had a telephoe), the successful follow-up rate (96%) is very high. Oly 1 other study (retrospective) has reported progostic idicators for mortality, ad o study has reported progostic idicators for recovery. This is also the first study to ascribe cause of death i stroke patiets i SSA. The high case fatality rate supports our origial cotetio that the lower prevalece of stroke-related disability i SSA is likely to be due i part to higher case fatality. At the 3- or 4-year follow-up, oly 19 patiets (18% of total) were alive ad livig with stroke-related disability i the commuity. This cohort is ot likely to be etirely represetative of all strokes occurrig i the commuity. Those makig a early good recovery ad those with severe stroke such as primary itracraial hemorrhage causig early death are less likely to have reached the hospital. We have also icluded recurret (geerally a worse progosis) ad first-ever strokes, although TABLE 4. Progostic Idicators at 1 Moth for Stroke Recovery Poor (Barthel <15) Versus Good (Barthel >15) i Patiets Admitted Withi 1 Week of Stroke Poor ( 34), Good ( 24), Statistical Sigificace* Epileptic seizure at time of stroke 0 (0) 2 (8) 0.17 Loss of cosciousess at stroke 4 (12) 3 (12) 1.00 Impaired cosciousess at stroke 12 (35) 2 (8) Impaired gag reflex o admissio 8 (24) 1 (4) Swallowig problems o admissio 10 (29) 1 (4) Receptive dysphasia 12 (35) 3 (12) Expressive dysphasia 22 (65) 8 (33) Dysarthria 28 (82) 15 (63) Visual field deficit 21 (62) 3 (12) Facial palsy 19 (56) 3 (12) Sesory iattetio 14 (41) 3 (12) Right carotid territory 17 (50) 11 (46) 0.75 Icotiece i first 24 h 27 (79) 5 (21) Uriary catheter 11 (32) 1 (4) Chest ifectio 4 (12) 2 (8) * 2 test. Fisher s 2-tailed exact test.

5 1608 Stroke July 2003 TABLE 5. Fial Model of Cox Regressio Aalysis for Risk Factors for Mortality by 3 to 4 Years i Patiets Admitted Withi 1 Week of Stroke Relative Risk Cofidece Iterval P Age 65 y Impaired gag reflex o admissio Ay sesory iattetio Icotiece withi first 24 h separate aalyses showed o importat differeces. Iterestigly, i a study from Copehage, although mortality for recurret strokes was almost double that for first-ever strokes, eurological ad fuctioal outcomes ad the speed of recovery i survivors were, i geeral, similar i the 2 groups. 6 Without CT sca results, we caot reliably commet o the cause of the strokes. May of the progostic idicator aalyses are hampered by the small sample size, which is further restricted by the iclusio of oly those patiets admitted to hospital withi a week of stroke. This was felt to be ecessary i view of the cosiderable legth of time some patiets took to reach hospital. Most recovery after stroke occurs withi the first few weeks, whe case fatality is also high. Recovery was graded i terms of Barthel score. Because stairs are rare i The Gambia, we assessed the ability to walk up a iclie as a alterative for stair climbig. The Barthel does ot iclude aalysis of speech problems; therefore, a patiet ca score a maximum of 20 while remaiig totally aphasic. We have show the progostic data for recovery at 1 moth oly, but the 6-moth data showed similar results, ad at fial follow-up, the umbers are small. Icotiece withi the first 24 hours, facial palsy, visual field deficit, sesory iattetio, swallowig problems, expressive dysphasia, ad use of uriary catheter were all predictive of a poorer outcome. The duratio of admissio is ot dissimilar to that of developed coutries, eve though there is o istitutioal care available i The Gambia to which patiets with sigificat residual disability ca be discharged. At follow-up, few of those with hypertesio had adequate blood pressure cotrol, ad very few were takig aspiri despite havig o obvious cotraidicatios. Three patiets had a recurret Kapla-Meier survival curves for those admitted withi 1 week of stroke for those 65 vs those 65 years of age. stroke, whereas 3 (12%) of the survivors at fial follow-up had had aother stroke. There were a equal umber of left ad right carotid distributio strokes, a fidig similar to previous Africa studies. O the Bamford Classificatio (ot previously reported i published Africa studies), there is a relative overrepresetatio of total aterior circulatio strokes ad uderrepresetatio of partial aterior circulatio strokes. This could be due to higher rates of hemorrhagic stroke. The lack of posterior circulatio territory strokes may relate to case ascertaimet, although these strokes do ot appear to be commo. Impaired cosciousess after stroke was foud i 36 patiets, which is similar to the oe third quoted by the Ibada Stroke Registry i the 1970s. 4 This is ot reported i detail i other Africa studies. There are o reliable data for SSA with which to compare the case fatality progostic idicators. Loss of cosciousess at the time of the stroke ad icotiece withi the first 24 hours after stroke were sigificatly associated with icreased mortality, a established fidig from studies i developed coutries. 7 Fidigs at the time of admissio of impaired gag reflex, swallowig problems, impaired cosciousess, sesory iattetio, visual field defect, expressive ad receptive dysphasia, ad chest ifectio were all sigificatly associated with icreased mortality. Most of these variables are sigs of a severe stroke. Optios for feedig patiets with impaired swallow were very limited. O Cox regressio aalysis, sesory iattetio ad icotiece withi the first 24 hours were both very sigificatly associated with icreased mortality. Previous Africa Studies I all the previously published stroke studies from SSA except the prevalece study from Tazaia, 2 the average age of the stroke patiets was 60 years, usually betwee 55 ad 60 years. Geerally, up to twice as may me as wome are represeted i hospital studies, as i this preset study. This may reflect the fact that wome are less likely tha me to go to hospital for cultural ad fiacial reasos 8 rather tha a differece i icidece. The most commo cause of death i cohorts of stroke patiets i Wester coutries is ischemic heart disease, but i earlier Africa stroke studies, as i this study, this was rare or oexistet. Very few prospective studies examiig outcome have had the beefit of a CT scaer because there are few CT scaers i SSA. The figures from Pretoria 3 reflect the poorer progosis i patiets with cerebral hemorrhage, as has bee foud i studies i developed coutries, but this is somewhat self-fulfillig because those who died before CT were predomiatly classified as hemorrhagic. A 1-moth mortality of 33% for 304 stroke patiets was reported from Medusa, South Africa, 9 but o breakdow ito hemorrhage ad ifarctio or follow-up details were give. I relatio to studies without CT scaig, i a Harare icidece study, 96 (35%; 44 me) of the 273 patiets (142 me) died withi the first week, with a higher case fatality rate for wome (40%) tha me (31%). 10 A study from Accra 11 that examied stroke admissios over 3 time periods from the early 1960s to the early 1990s foud a dramatic icrease i both admissios ad

6 Walker et al Mortality ad Recovery After Stroke i The Gambia 1609 case fatality i the early 1990s ad a chage i the sex ratio. I the 2 earlier periods, studied me geerally outumbered wome by 2:1, but for 1990 to 1992, wome outumbered me. I the early 1990s, stroke was the leadig cause of death i hospital i adults, accoutig for 17.2% of deaths o the medical wards, with case fatality ragig from 41.9% to 50.3% over the time period. Although the most commo age decade for admissio with stroke was 50 to 59 years, the highest death rate was see i the 60- to 69-year age group. Noe of the above studies examied mortality i relatio to time to admissio to hospital. For various reasos, icludig distace from hospital, access to trasport, ability to afford hospital fees, ad local beliefs, it is likely that there is greater delay i patiets reachig hospital i Africa (particularly from rural areas) tha i developed coutries. May patiets try local treatmet before hospital admissio, ad some may ot be admitted at all. Worldwide Data Worldwide, comparisos are geerally based o first-i-alifetime stroke. Depedig o the age structure ad health status of the populatio studied, 1-moth case fatality varies betwee 17% ad 34%, with a average of 24%, 12 while 1-year case fatality is 42%. 13 I this study, mortality was 27% at 1 moth ad 44% at 6 moths. Iterestigly, i the Uited States i 1996, age-adjusted death rates for stroke per were 39.2 for black wome, 22.9 for white wome, 50.9 for black me, ad 26.3 for white me, with the higher rates for blacks particularly evidet i the lower age groups. 14 Util the preset study, there have bee o reliable data related to cause of death i stroke patiets i SSA. I this study, the cause of death was the iitial or subsequet stroke i two thirds, while other comorbidity was rare, so measures aimed at maximizig recovery from the stroke itself could have a sigificat impact o case fatality. I the Oxfordshire Commuity Stroke Project, half of all deaths withi 30 days of stroke were due to the direct eurological sequelae of the stroke. 15 I the cerebral ifarctio group, half of all deaths were due to complicatios of immobility (eg, peumoia, pulmoary embolism), ad these were more likely to occur after the first week. Cardiovascular disease was the most commo cause of death after the first year. 16 The care of patiets after stroke withi the limited health budgets of most coutries i SSA offers a major ad icreasig challege. The higher case fatality rate i this study is likely to relate to a variety of factors such as limited facilities ad staffig, icludig availability of physiotherapy ad occupatioal therapy. With the evidece that is ow available from developed coutries o the beefit of stroke uits i terms of both mortality ad morbidity, suitable compoets that are locally available ad feasible eed to be itroduced i SSA. For example, although it is ulikely that the therapy iput that ca be afforded i the West could be afforded i Africa, a few traied therapists could work with ad trai other staff, relatives, ad caregivers to carry out therapy tasks. This would take advatage of oe of the great stregths i may SSA commuities, amely exteded family support. I additio, measures for secodary prevetio were limited, particularly poor follow-up ad treatmet (icludig drug compliace) for hypertesio. Compliace could be improved educatig both patiets ad caregivers ad improvig the availability of locally affordable moitorig ad treatmet. The cost-effectiveess of hypertesio treatmet for primary prevetio of stroke i Africa is much debated, 17 but there ca be less doubt about the cost-effectiveess of secodary prevetio. Similarly, other measures such as aspiri that are cheap ad affordable should be maximized. Ackowledgmets For subsequet follow-up visits, fudig support was received from the Uiversity of Newcastle Upo Tye ad the Research Travel Fud at South Clevelad Hospital, Middlesbrough, UK. Durig the period of erollmet of patiets i this study, Dr Walker was employed by the Overseas Developmet Admiistratio as a seior registrar i medicie attached to the Royal Victoria Hospital, Bajul. We thak Haddy Kha for assistace with iterpretig ad Gillia Tough for secretarial assistace. Refereces 1. Walker RW, McLarty DG, Kitage HM, Whitig D, Masuki G, Mtasiwa DM, Machibya H, Uwi N, Alberti KGMM. Stroke mortality i urba ad rural Tazaia. Lacet. 2000;355: Walker RW, McLarty DG, Masuki G, Kitage HM, Whitig D, Moshi AF, Massawe JG, Amaro R, Mhia A, Alberti KGMM. Age specific prevalece of impairmet ad disability relatig to hemiplegic stroke i the Hai District of orther Tazaia. J Neurol Neurosurg Psychiatry. 2000;68: Rosma KD. The epidemiology of stroke i a urba black populatio. 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