Stroke epidemiology [Neurosurgery Wiki]

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====== Stroke epidemiology ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/10wSXhTwYqcJGzwJ7wudsec0RzzAERYFxsIeJvyBy998ltWkw8/?limit=15&utm_campaign=pubmed-2&fc=20230302154142}}
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===== 🌍 Global Burden =====
  * Leading cause of disability and 2nd cause of death worldwide.
  * >12 million new strokes/year globally.
  * >100 million stroke-related DALYs reported in 2021.

===== 📈 Trends =====
  * ↓ Age-standardized mortality in high-income countries.
  * ↑ Absolute number of strokes globally due to:
    * Aging population
    * Urbanization
    * Rise of metabolic risk factors
  * 10–15% of all strokes occur in adults aged 20–49 (young stroke).
    * Hemorrhagic strokes more common in low-income countries.

===== ⚠️ Key Risk Factors =====
==== Modifiable ====
  * Hypertension (most significant)
  * Diabetes mellitus
  * Dyslipidemia
  * Obesity and physical inactivity
  * Smoking and alcohol
  * Atrial fibrillation

====== Metabolic-Risk Factors in Stroke ======

[[Metabolic-Risk Factors in Stroke]]



==== Non-modifiable ====
  * Age
  * Genetic predisposition
  * Sex (Men <65, Women >75)

===== 🌐 Regional Variation =====
  * High incidence: East Asia, Eastern Europe, Sub-Saharan Africa.
  * High DALY burden in LMICs due to limited acute care access.

===== 👨‍⚕️ Relevance for Neurosurgeons =====
  * ↑ Demand for surgical interventions:
    * Hematoma evacuation
    * Aneurysm clipping
    * Decompressive craniectomy (MCA infarction)
  * Younger patients require tailored neurocritical management.
  * Participation in multidisciplinary stroke teams is essential.

===== 📚 Key Metrics =====
^ Metric ^ Definition ^ Example Use ^
| **ASIR** | Age-standardized incidence rate | Adjusts for aging |
| **DALY** | Disability-adjusted life year | Quantifies total health loss |
| **EAPC** | Estimated annual % change | Measures trend slope |


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Although stroke is more common with advancing age, especially in the [[elderly]], [[women]] of reproductive age may still suffer from stroke, and from its deleterious consequences. Women of reproductive age who suffer a stroke may do so either due to a specific predisposition or due to pregnancy-related hypertensive emergencies.

The age-standardized [[incidence]] of [[stroke]] has decreased globally but, for reasons unknown, conflicting results have been observed regarding the trend in [[incidence]] of major stroke subtypes in young [[adult]]s.

Stroke hospitalizations of young people declined in [[Finland]], except for men 35-44 years of age for whom IS hospitalizations increased. Declining [[length of stay]] (LOS) and in-hospital [[mortality]] of IS patients suggests [[admission]] of less severe cases, improved care or both
((Sipilä JOT, Posti JP, Ruuskanen JO, Rautava P, Kytö V. Stroke hospitalization 
trends of the working-aged in Finland. PLoS One. 2018 Aug 1;13(8):e0201633. doi: 
10.1371/journal.pone.0201633. eCollection 2018. PubMed PMID: 30067825.
)).

[[Spontaneous intracerebral hemorrhage]] (ICH) is a global public health issue and accounts for 10–15% of all [[stroke]] cases
((Qureshi AI, Mendelow AD, Hanley DF. Intracerebral hemorrhage. Lancet. 2009
May 9;373(9675):1632-44. doi: 10.1016/S0140-6736(09)60371-8. Review. PubMed PMID:
19427958; PubMed Central PMCID: PMC3138486.
)).

===== United States =====

Stroke is a leading cause of death and disability in the US. Accurate and updated measures of stroke burden are needed to guide public health policies.

Objective: To present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and describe trends from 1990 to 2019 by age, sex, and geographic location.

Design, setting, and participants: An in-depth cross-sectional analysis of the 2019 Global Burden of Disease study was conducted. The setting included the time period of 1990 to 2019 in the US. The study encompassed estimates for various types of strokes, including all strokes, ischemic strokes, intracerebral hemorrhages (ICHs), and subarachnoid hemorrhages (SAHs). The 2019 Global Burden of Disease results were released on October 20, 2020.

Exposures: In this study, no particular exposure was specifically targeted.

Main outcomes and measures: The primary focus of this analysis centered on both overall and age-standardized estimates, stroke incidence, prevalence, mortality, and DALYs per 100 000 individuals.

Results: In 2019, the US recorded 7.09 million prevalent strokes (4.07 million women [57.4%]; 3.02 million men [42.6%]), with 5.87 million being ischemic strokes (82.7%). Prevalence also included 0.66 million ICHs and 0.85 million SAHs. Although the absolute numbers of stroke cases, mortality, and DALYs surged from 1990 to 2019, the age-standardized rates either declined or remained steady. Notably, hemorrhagic strokes manifested a substantial increase, especially in mortality, compared with ischemic strokes (incidence of ischemic stroke increased by 13% [95% uncertainty interval (UI), 14.2%-11.9%]; incidence of ICH increased by 39.8% [95% UI, 38.9%-39.7%]; incidence of SAH increased by 50.9% [95% UI, 49.2%-52.6%]). The downturn in stroke mortality plateaued in the recent decade. There was a discernible heterogeneity in stroke burden trends, with older adults (50-74 years) experiencing a decrease in incidence in coastal areas (decreases up to 3.9% in Vermont), in contrast to an uptick observed in younger demographics (15-49 years) in the South and Midwest US (with increases up to 8.4% in Minnesota).

Conclusions and relevance: In this cross-sectional study, the declining age-standardized stroke rates over the past 3 decades suggest progress in managing stroke-related outcomes. However, the increasing absolute burden of stroke, coupled with a notable rise in hemorrhagic stroke, suggests an evolving and substantial public health challenge in the US. Moreover, the significant disparities in stroke burden trends across different age groups and geographic locations underscore the necessity for region- and demography-specific interventions and policies to effectively mitigate the multifaceted and escalating burden of stroke in the country
((Renedo D, Acosta JN, Leasure AC, Sharma R, Krumholz HM, de Havenon A, Alahdab F, Aravkin AY, Aryan Z, Bärnighausen TW, Basu S, Burkart K, Coberly K, Criqui MH, Dai X, Desai R, Dharmaratne SD, Doshi R, Elgendy IY, Feigin VL, Filip I, Gad MM, Ghozy S, Hafezi-Nejad N, Kalani R, Karaye IM, Kisa A, Krishnamoorthy V, Lo W, Mestrovic T, Miller TR, Misganaw A, Mokdad AH, Murray CJL, Natto ZS, Radfar A, Ram P, Roth GA, Seylani A, Shah NS, Sharma P, Sheikh A, Singh JA, Song S, Sotoudeh H, Vervoort D, Wang C, Xiao H, Xu S, Zand R, Falcone GJ, Sheth KN. Burden of Ischemic and Hemorrhagic Stroke Across the US From 1990 to 2019. JAMA Neurol. 2024 Mar 4. doi: 10.1001/jamaneurol.2024.0190. Epub ahead of print. PMID: 38436973.)).
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Stroke is the fourth killer and number one cause of adult disability in the [[United States]]. The estimated direct and indirect costs of stroke care in this country are $68.9 billion for 2009. The prevalence of stroke and its cost will undoubtedly arise as the aging population increases. In addition, stroke incidence and mortality are increasing in less developed countries in which lifestyles and population restructuring are rapidly changing. More population-based research to assess the incidence, risk factors, and outcomes is needed in these countries. Epidemiologic studies can help identify groups of individuals or regions at higher risk for stroke. They can also help us better understand the natural history of certain conditions and therefore push the direction of therapeutic investigations. Furthermore, the study of trends across different time periods and different populations can help investigators evaluate the effects of stroke care programs and treatment options
((Ovbiagele B, Nguyen-Huynh MN. Stroke epidemiology: advancing our understanding
of disease mechanism and therapy. Neurotherapeutics. 2011 Jul;8(3):319-29. doi:
10.1007/s13311-011-0053-1. Review. PubMed PMID: 21691873; PubMed Central PMCID:
PMC3250269.
)).

===== China =====

In a large, nationally representative [[sample]] of adults aged 40 years or older, the estimated prevalence, incidence, and mortality rate of stroke in China in 2020 were 2.6%, 505.2 per 100 000 person-years, and 343.4 per 100 000 person-years, respectively, indicating the need for an improved [[stroke prevention]] strategy in the general Chinese population
((Tu WJ, Zhao Z, Yin P, Cao L, Zeng J, Chen H, Fan D, Fang Q, Gao P, Gu Y, Tan G, Han J, He L, Hu B, Hua Y, Kang D, Li H, Liu J, Liu Y, Lou M, Luo B, Pan S, Peng B, Ren L, Wang L, Wu J, Xu Y, Xu Y, Yang Y, Zhang M, Zhang S, Zhu L, Zhu Y, Li Z, Chu L, An X, Wang L, Yin M, Li M, Yin L, Yan W, Li C, Tang J, Zhou M, Wang L. Estimated Burden of Stroke in China in 2020. JAMA Netw Open. 2023 Mar 1;6(3):e231455. doi: 10.1001/jamanetworkopen.2023.1455. PMID: 36862407.)).
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A community-based cross-sectional study with 8,018 Chinese adults aged ≥40 years was used to determine the prevalence of stroke and associated risk factors. Within the screened population, the prevalence of stroke was 2.21% for both sexes, 1.60% for females, and 3.18% for males. Prevalence increased with age in both sexes (P < 0.0001). In a multivariable model, factors significantly associated with stroke were increasing age (odds ratio [OR] = 1.87, 95% CI: 1.58-2.24), male gender (OR = 2.03, 95% CI: 1.42-2.90), family history of stroke (OR = 4.33, 95% CI: 2.89-6.49), history of hyperlipidemia (OR = 1.87, 95% CI 1.31-2.68), history of hypertension (OR = 1.47, 95% CI 1.02-2.12), and physical inactivity (OR = 1.74, 95% CI: 1.16-2.59). The findings indicate that stroke prevalence in middle-aged and older Chinese adults is higher in males than in females, and increases with age in both sexes. Population-based public health intervention programs and policies targeting hyperlipidemia and hypertension control and encouragement of physical activity should be highly prioritized for middle-aged and older adults in Shenzhen, China
((Gan Y, Wu J, Zhang S, Li L, Yin X, Gong Y, Herath C, Mkandawire N, Zhou Y,
Song X, Zeng X, Li W, Liu Q, Shu C, Wang Z, Lu Z. Prevalence and risk factors
associated with stroke in middle-aged and older Chinese: A community-based
cross-sectional study. Sci Rep. 2017 Aug 25;7(1):9501. doi:
10.1038/s41598-017-09849-z. PubMed PMID: 28842623.
)).

===== South Korea =====

The [[stroke]] [[incidence]] has increased rapidly in [[South Korea]], calling for a national-wide system for long-term stroke management. Park et al. investigated the effects of [[socioeconomic status]] (SES) and geographic factors on chronic phase [[survival]] after [[stroke]]. They retrospectively enrolled 6994 patients who experienced a stroke event in 2009 from the Korean National Health Insurance database. They followed them up from 24 to 120 months after stroke onset. The endpoint was all-cause mortality. They defined SES using a medical-aid group and four groups divided by health insurance premium quartiles. Geographic factors were defined using Model 1 (capital, metropolitan, city, and county) and Model 2 (with or without university hospitals). The higher the insurance premium, the higher the survival rate tended to be (P < 0.001). The patient survival rate was highest in the capital city and lowest at the county level (P < 0.001). Regions with a [[university hospital]](s) showed a higher survival rate (P = 0.006). [[Cox regression]] revealed that the medical-aid group was identified as an independent risk factor for chronic phase mortality. Further, NHIP level had a more significant effect than geographic factors on chronic stroke mortality. From these results, long-term nationwide efforts to reduce inter-regional as well as SES discrepancies affecting stroke management are needed
((Park D, Lee SY, Jeong E, Hong D, Kim MC, Choi JH, Shin EK, Son KJ, Kim HS. The effects of socioeconomic and geographic factors on chronic phase long-term survival after stroke in South Korea. Sci Rep. 2022 Mar 14;12(1):4327. doi: 10.1038/s41598-022-08025-2. PMID: 35289331.)).


===== References =====