Epidemiology and the Global Burden of Stroke

doi:10.1016/j.wneu.2011.07.023

World Neurosurgery

Volume 76, Issue 6, Supplement, December 2011, Pages S85-S90

https://doi.org/10.1016/j.wneu.2011.07.023 Get rights and content

Objective

Stroke remains one of the most devastating of all neurological diseases, often causing death or gross physical impairment or disability. As numerous countries throughout the world undergo the epidemiological transition of diseases, trends in the prevalence of stroke have dramatically changed.

Methods

All major international epidemiological articles published during the past 20 years addressing the global burden of stroke were reviewed. A focus was placed upon better defining current and future trends in surveillance, incidence, burden of disease, mortality, and costs associated with stroke internationally.

Results

Despite the fact that various surveillance systems are used to identify stroke and its sequela around the world, it is clear that stroke remains one of the top causes of mortality and disability-adjusted life-years (DALYs) lost globally. Concerning trends include the increase of stroke mortality and lost DALYs in low- and middle-income countries. The global economic impact of stroke may be dire if effective preventive measures are not implemented to help decrease the burden of this disease.

Conclusion

The global burden of stroke is high, inclusive of increasing incidence, mortality, DALYs, and economic impact, particularly in low- and middle-income countries. The implementation of better surveillance systems and prevention programs are needed to help track current trends as well as to curb the projected exponential increase in stroke worldwide.

Introduction

Stroke remains one of the most devastating of all neurological conditions. Worldwide it accounts for approximately 5.5 million deaths annually, with 44 million disability-adjusted life-years lost. As a disease of aging, the prevalence of stroke is expected to increase significantly around the world in the years ahead as the global population older than 65 years of age continues to increase by approximately 9 million people per year (30). By 2025, the global population of people older than the age of 65 years is estimated to be approximately 800 million people, of whom two-thirds are expected to live in still-developing countries, particularly in Latin America and Asia (25). With such drastic changes projected in the years ahead, we explore the surveillance challenges, burden of disease, risk factors, economic impact, and future trends associated with stroke globally.

Section snippets

Methodology of Assessing the Global Burden of Stroke

To fully assess the global burden of stroke, important basic epidemiological data are required from all regions. Unfortunately, even relatively simple measures, such as mortality, are reported by less than one-third of all countries, with most available data coming from already-developed countries (30). With the projected increase in the aging population, it is becoming increasingly important to develop and maintain reliable methods of surveillance to accurately measure the incidence, burden,

Incidence and Stroke Deaths

Globally, an estimated 16 million people suffered from a first-ever stroke in the year 2005, with an estimated prevalence of 62 million stroke survivors (21). In the absence of any meaningful clinical or public health interventions, it is expected that this number will increase to an estimated 23 million first-ever strokes, with an associated 7.8 million deaths, by 2030 (21). Approximately 56 million deaths occur annually worldwide, with approximately one-quarter of these deaths attributable to

Risk Factors for Stroke Worldwide

There has to date been only one large study cataloging the impact of varying risk factors upon the global incidence of stroke. Via a standardized case-control study design that took place in 22 countries over 3 years, a total of 3000 cases, with an equal number of age- and sex-matched controls, took part in the INTERSTROKE study (18). Cases were identified as patients presenting within five days of an acute, first-time stroke; control subjects had no history of stroke. The 22 countries included

Global Access to Stroke Care

Access to stroke care and inpatient stroke units vary widely across the world, with a large proportion of such services centered in already-developed or high-income countries. However, efforts are increasingly being made in low- and middle-income countries to increase rates of intravenous tissue plasminogen activator (tPA) administration, endovascular services, and basic emergency or rehabilitation care.

Traditionally, there have been some concerns regarding the safety and efficacy of

Economic Impact of Stroke

Stroke incidence and mortality have been highly correlated with national per capita income. For instance, a recent study of 56 population-based registries worldwide demonstrated that, from 1970 to 2008, there was a 42% decrease in stroke incidence in high-income countries, whereas low- and middle-income countries experienced a 100% increase in stroke incidence (7). In addition, another recent report analyzing more than 30 years worth of data demonstrated stroke mortality significantly increased

Conclusions

Chronic diseases have increased to approximately 50% of total disease burden in low- and middle-income countries undergoing the epidemiological transition (21). As a result, the global burden of stroke has increased, with an exponential expansion of this burden projected worldwide in the decades to come, particularly within low- and middle-income countries. Without effective preventive measures to curb this trend, the economic impact of such a stark increase in stroke burden could prove to be

References (30)

D.O. Abegunde et al.
The burden and costs of chronic diseases in low-income and middle-income countries
Lancet
(2007)
K. Asplund et al.
Multinational comparisons of stroke epidemiologyEvaluation of case ascertainment in the WHO MONICA Stroke Study. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease
Stroke
(1995)
B.T. Bateman et al.
Factors associated with in-hospital mortality after administration of thrombolysis in acute ischemic stroke patients: an analysis of the nationwide inpatient sample 1999 to 2002
Stroke
(2006)
M.S. Clark et al.
A randomized controlled trial of an education and counselling intervention for families after stroke
Clin Rehabil
(2003)
J. Durai Pandian et al.
Stroke and thrombolysis in developing countries
Int J Stroke
(2007)
L.L. Edwards
Using tPA for acute stroke in a rural setting
Neurology
(2007)
V.L. Feigin et al.
Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review
Lancet Neurol
(2009)
A.J. Furlan
IV tissue plasminogen activator for stroke in the community: what we know and don't know 10 years after FDA approval
Stroke
(2006)
Hachinski V, Donnan GA, Gorelick PB, Hacke W, Cramer SC, Kaste M, Fisher M, Brainin M, Buchan AM, Lo EH, Skolnick BE,...
S. Hatano
Experience from a multi centre stroke register: a preliminary report
Bull World Health Organ
(1976)

P.U. Heuschmann et al.

Incidence of stroke in Europe at the beginning of the 21st century

Stroke

(2009)

S.C. Johnston et al.

Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modeling

Lancet Neurol

(2009)

C.M. Lawes et al.

Global burden of blood-pressure-related disease, 2001

Lancet

(2008)

Liu X, Xu G: Endovascular treatments of atherosclerotic carotid diseases in China. Int J Stroke...

Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A,...

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Brain endothelial CD200 signaling protects brain against ischemic damage
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Ischemic stroke induced inflammatory responses contribute significantly to neuronal damage and stroke outcomes. CD200 ligand and its receptor, CD200R, constitute an endogenous inhibitory signaling that is being increasingly recognized in studies of neuroinflammation in various central nervous system disorders. CD200 is a type 1 membrane glycoprotein that is broadly expressed by endothelia and neurons in the brain. In the present study, we have examined the role of endothelial CD200 signaling in acute ischemic stroke. Endothelial CD200 conditional knock out (CKO) mice were generated by breeding CD200 gene floxed mice with Cdh5^Cre mice. The mice were subjected to a 60-min transient middle cerebral artery occlusion (MCAO). Flow cytometry, Immunohistochemical staining, and Western blotting were performed to assess the post-stroke inflammation; stroke outcomes (infarct volume and neurobehavioral deficits) were evaluated at 72 h after MCAO. We found CD200R was near-null expressed on microglia at 24 h after stoke. Endothelial CKO of CD200 had no impact on peripheral immune cell development. Immunohistochemical staining confirmed CD200 was expressed on CD200 floxed but not on CD200 CKO endothelia. CD200 CKO mice exhibited larger infarct size, worse neurological deficit scores (NDS), and more deficits in the adhesive removal when compared with control mice, 72 h after MCAO. Western blot results showed that endothelial CKO of CD200 did not change BBB protein expression. Together it suggests that endothelial CD200 signaling protects brains against ischemic injury through a mechanism not directly related to microglial activation.
Responsiveness of Section GG Scores in Tracking Post-Stroke Functional Recovery From Inpatient Rehabilitation Admission to 90-Day Follow-Up
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To evaluate the responsiveness and scale-to-sample targeting of Section GG of the Inpatient Rehabilitation Facility-Patient Assessment Instrument in measuring the trajectory of functional recovery in patients with stroke from inpatient rehabilitation admission to 90 days after discharge.
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Not applicable.
Admission and discharge self-care and mobility scores from Section GG were analyzed for the Inpatient Only group (n= 817). Admission, discharge and 90-day post-discharge Section GG scores from telephone interviews with patients or caregivers were analyzed for the Follow-Up group (n=270). Standardized response means (SRM) determined responsiveness of the tool for each group and time interval. Score means, standard deviations, and floor/ceiling effects illustrated scale-to-sample targeting of the tool.
Self-care and mobility scores improved significantly from admission to discharge (P<.001) for both groups and from discharge to 90 days (P<.001) for the Follow-Up group. Large SRM existed from admission to discharge for self-care and mobility scores in both groups. A small-to-moderate SRM was seen from discharge to 90 days for self-care (0.46) and a moderate SRM was observed for mobility (0.68). Overall floor effects were minor at admission for self-care (9.8%) and mobility (7.2.%). Overall ceiling effects were minor at discharge for self-care (11.2%) and mobility (4.6%) and significant at follow-up for both self-care (45.2%) and mobility (32.2%).
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The Korean Stroke Cohort for functioning and rehabilitation data was used, and patients with mild stroke with a National Institute of Health Stroke Scale score of < 5 were included. Quality of life after 6 months was analyzed using EuroQol-5 dimensions. Demographic and clinical characteristics were evaluated, and factors affecting the quality of life at 6 months were analyzed.
Age, current drinking, marital status, length of stay, and modified Rankin Scale, Fugl–Meyer assessment, Functional Independence Measure, and Geriatric Depression Scale scores affected the quality of life at 6 months in patients with mild stroke. Fugl–Meyer assessment score was a predictor for those aged < 65 years, while the functional ambulatory category was a predictor for those aged ≥ 65 years. Predictors of quality of life, excluding alcohol consumption, were comparable between male and female.
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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Stroke and the NeurosurgeonPeer-Review ReportEpidemiology and the Global Burden of Stroke

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methodology of Assessing the Global Burden of Stroke

Incidence and Stroke Deaths

Risk Factors for Stroke Worldwide

Global Access to Stroke Care

Economic Impact of Stroke

Conclusions

The burden and costs of chronic diseases in low-income and middle-income countries

Lancet

Multinational comparisons of stroke epidemiologyEvaluation of case ascertainment in the WHO MONICA Stroke Study. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease

Stroke

Factors associated with in-hospital mortality after administration of thrombolysis in acute ischemic stroke patients: an analysis of the nationwide inpatient sample 1999 to 2002

Stroke

A randomized controlled trial of an education and counselling intervention for families after stroke

Clin Rehabil

Stroke and thrombolysis in developing countries

Int J Stroke

Using tPA for acute stroke in a rural setting

Neurology

Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review

Lancet Neurol

IV tissue plasminogen activator for stroke in the community: what we know and don't know 10 years after FDA approval

Stroke

Experience from a multi centre stroke register: a preliminary report

Bull World Health Organ

Incidence of stroke in Europe at the beginning of the 21st century

Stroke

Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modeling

Lancet Neurol

Global burden of blood-pressure-related disease, 2001

Lancet

Stroke and the Neurosurgeon
Peer-Review Report
Epidemiology and the Global Burden of Stroke