Stroke incidence rates were unchanged, while fatality rates declined, during 1971-1987 in Göteborg, Sweden

Trends in Mortality from Hemorrhagic Stroke in Korea from 2012 to 2020

Purpose

To analyze trends in mortality rates from hemorrhagic stroke (HS) according to HS subtypes, using nationwide data from January 2012 to December 2020.

Materials and Methods

We used data from the National Health Claims Database provided by the National Health Insurance Service for 2012–2020 using the International Classification of Disease. The age-adjusted mortality rates of HS, which included subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH), were calculated, and additional analyses were conducted according to age and sex.

Results

The age-adjusted mortality rates for HS, SAH, and ICH decreased substantially in both sexes between 2012 and 2020. During the study period, mortality rates for HS decreased from 8.87 deaths per 100,000 inhabitants to 6.27 deaths per 100,000 inhabitants. Regarding SAH, mortality rates decreased from 3.72 deaths per 100,000 inhabitants to 2.57 deaths per 100,000 inhabitants. Concerning ICH, mortality rates decreased from 6.91 deaths per 100,000 inhabitants to 4.75 deaths per 100,000 inhabitants. The average annual percentage change for HS, SAH, and ICH was –0.04, –0.04, and –0.05, respectively. Mortality rates from HS, SAH, and ICH in both sexes decreased from 2012 to 2020 in all age groups.

Conclusion

In Korea, the age-adjusted mortality rate of HS, SAH, and ICH demonstrated a declining trend in both sexes and across all age groups. These results may aid in the design and improvement of preventive strategies.

Sudden unexpected death caused by stroke: A nationwide study among children and young adults in Denmark

Background

Stroke is the fifth leading cause of death in young individuals globally. Data on the burden of sudden death by stroke are sparse in the young.

Aims

The aim of this study was to report mortality rates, cause of death, stroke subtype, and symptoms in children and young adults who suffered sudden death by stroke.

Methods

We conducted a retrospective, nationwide study including all deaths within Danish borders between 2000–2009 and 2007–2009 in persons aged 1–35 years and 36–49 years, respectively. Two physicians identified all sudden death cases through review of all death certificates. All available autopsy reports and records from hospitals and general practitioners were retrieved and a neurologist identified all sudden death by stroke cases.

Results

Of the 14,567 deaths in the 10-year period, there were 1,698 sudden death cases, of which 52 (3%) were sudden death by stroke. There was a male predominance (56%) and the median age was 33 years. The incidence of sudden death by stroke in individuals aged 1–49 years was 0.19 deaths per 100,000 person-years. Stroke was hemorrhagic in 94% of cases, whereof subarachnoid hemorrhage was the cause of death in 63% of cases. Seventeen (33%) cases contacted the healthcare system because of neurological symptoms, whereof one was suspected of having a stroke (6%).

Conclusions

Sudden death by stroke in children and young adults occurs primarily due to hemorrhagic stroke. We report a high frequency of neurological symptoms prior to sudden death by stroke. Increased awareness among healthcare professionals towards stroke symptoms in children and young adults may lead to earlier detection of stroke, and thereby potentially lowering the incidence of sudden death by stroke.

Thirty-Year Trends in Mortality from Cerebrovascular Diseases in Korea

Background and Objectives

Cerebrovascular disease is a leading cause of mortality and morbidity in Korea. Understanding of cerebrovascular disease mortality trends is important to reduce the health burden from cerebrovascular diseases. We examined the changing pattern of mortality related to cerebrovascular disease in Korea over 30 years from 1983 to 2012.

Subjects and Methods

Numbers of deaths from cerebrovascular disease, hemorrhagic stroke, and cerebral infarction were obtained from the national Cause of Death Statistics. Crude and age-adjusted mortality rates were calculated for men and women for each year. Penalized B-spline methods, which reduce bias and variability in curve fitting, were used to identify the trends of 30-year mortality and identify the year of highest mortality.

Results

During the 30 years, cerebrovascular disease mortality has markedly declined. The age-adjusted cerebrovascular disease mortality rate has decreased by 78% in men and by 68% in women. In the case of hemorrhagic stroke, crude mortality peaked in 2001 but age-adjusted mortality peaked in 1994. Between 1994 and 2012, age-adjusted mortality from hemorrhagic stroke has decreased by 68% in men and 59% in women. In the case of cerebral infarction, crude and age-adjusted mortality rates steeply increased until 2004 and 2003, respectively, and both rates decreased rapidly thereafter.

Conclusion

Cerebrovascular disease mortality rate has significantly decreased over the last 30 years in Korea, but remains a health burden. The prevalence of major cardiovascular risk factors are still highly prevalent in Korea.

Headache in subarachnoid hemorrhage and headache attributed to intracranial endovascular procedures

Headache is a critical problem in the emergency setting. In this paper we briefly review the epidemiological data regarding headache in Subarachnoid Hemorrhage (SAH), considering the role of headache as a warning symptom and the other clinical manifestation of SAH. We have also introduced a recent clinical entity, represented by headache associated to intracranial endovascular procedures (IEPs).

Molecular basis and genetic predisposition to intracranial aneurysm

Intracranial aneurysms, also called cerebral aneurysms, are dilatations in the arteries that supply blood to the brain. Rupture of an intracranial aneurysm leads to a subarachnoid hemorrhage, which is fatal in about 50% of the cases. Intracranial aneurysms can be repaired surgically or endovascularly, or by combining these two treatment modalities. They are relatively common with an estimated prevalence of unruptured aneurysms of 2%-6% in the adult population, and are considered a complex disease with both genetic and environmental risk factors. Known risk factors include smoking, hypertension, increasing age, and positive family history for intracranial aneurysms. Identifying the molecular mechanisms underlying the pathogenesis of intracranial aneurysms is complex. Genome-wide approaches such as DNA linkage and genetic association studies, as well as microarray-based mRNA expression studies, provide unbiased approaches to identify genetic risk factors and dissecting the molecular pathobiology of intracranial aneurysms. The ultimate goal of these studies is to use the information in clinical practice to predict an individual's risk for developing an aneurysm or monitor its growth or rupture risk. Another important goal is to design new therapies based on the information on mechanisms of disease processes to prevent the development or halt the progression of intracranial aneurysms.

Trends in stroke survival incidence rates in older Australians in the new millennium and forecasts into the future

AIMS

The objective of this study is (i) to evaluate trends in the incidence rates of stroke survivors aged 60 years and older over a 11-year period in the Australian Capital Territory (ACT) and (ii) to forecast future trends in Australia until 2051.

METHODS

Analysis of age- and sex-specific standardized incidence rates of older first-ever stroke survivors in ACT from 1999-2000 to 2009-2010 and projections of number of stroke survivors (NSS) in 2021 and 2051 using 2 models based only on (i) demographic changes and (ii) assuming changing of both incidence rates and demography.

RESULTS

In the ACT in the first decade of the 21st century, the absolute numbers and age-adjusted standardized incidence rates of stroke survivors (measured as a function of age and period) increased among both men and women aged 60 years or older. The trend toward increased survival rates in both sexes was driven mainly by population aging, whereas the effect of stroke year was more pronounced in men compared with women. The absolute NSS (and the financial burden to the society) in Australia is predicted to increase by 35.5%-59.3% in 2021 compared with 2011 and by 1.6- to 4.6-fold in 2051 if current only demographic (first number) or both demographic and incidence trends (second number) continue.

CONCLUSIONS

Our study demonstrates favorable trends in stroke survivor rates in Australia in the first decade of the new millennium and projects in the foreseeable future significant increases in the absolute numbers of older stroke survivors, especially among those aged 70 years or older and men.

The neuro-behavioral profile in rats after subarachnoid hemorrhage

Despite significant advancements in the understanding of the pathophysiological mechanisms of subarachnoid hemorrhage (SAH), little is known about the emotional consequences. The primary goal of this study was to describe the locomotor and behavioral patterns in rats following both a single-injection and double-injection model of SAH. In 48 rats, SAH was induced by injecting 0.3 ml of autologous arterial blood into the cisterna magnum (single-hemorrhagic model). In 24 of these rats, post-SAH vasospasm was induced by a repeated injection of blood into the cisterna magnum 24h later (double-hemorrhagic model). In 24 additional rats, 0.3 ml of saline was injected into the cisterna magnum (sham group). Neurological performance was assessed at 24, 48 h, 1, 2 and 3 weeks after SAH. Four behavioral tests were performed for 3 weeks after SAH for the duration of 6 consequent days, in the following order: open field test, sucrose preference test, elevated plus maze test and forced swimming test. Following both, a single and double-hemorrhagic models of SAH, rats were found to have significant behavioral abnormalities on the open field test, sucrose preference test, elevated plus maze test, and forced swimming test. A more prominent disability was found in rats that underwent the double-hemorrhagic model of SAH than rats that underwent the single-hemorrhagic model. Both a single and double injection model of rats SAH are associated with significant behavioral disturbances including locomotor abnormalities, depressive behavior and increased anxiety, even as early as 3 weeks after SAH.

Temporal trends in ischemic and hemorrhagic strokes in Northern Italy: results from the cardiovascular monitoring unit in Northern Italy population-based register, 1998-2004

BACKGROUND

We compared rates and case fatality from a population-based stroke register in Northern Italy between 1998 and 2004 to assess changes over time and to evaluate changes in case diagnosis and management.

METHODS

The WHO Multinational Monitoring of Trends and Determinants in Cardiovascular Disease criteria were used to identify suspected fatal or nonfatal events occurring among residents 35-74 years of age. Data on in-hospital treatments, symptoms and diagnostic tools were extracted. Out-of-hospital deaths were also investigated. The annual average relative change (ARC) in death rate, attack rate and case fatality were derived from Poisson models.

RESULTS

Death rates due to ischemic stroke (IS) decreased [men: ARC -12.7, 95% confidence interval (CI) -21.3 to -3.2; women: ARC -14.0, 95% CI -23.3 to -3.5]. These reductions are attributable to decreases in case fatality; attack rates of nonfatal IS increased (men: ARC 3.6, 95% CI 0.5-6.7; women: ARC 4.1, 95% CI 0.0-8.2). IS patients showed a higher prevalence of dyslipidemia and hypertension and underwent MRI more frequently in 2004. Both findings may explain the increased proportions of less severe cases. Case fatality and attack rates for hemorrhagic strokes (HS) were stable, with an observed increased prevalence of patients under anticoagulant/antiplatelet treatments.

CONCLUSIONS

In this low-IS-incidence population, death rates decreased substantially during the investigated period. More accurate diagnostic tools increase the probability of detecting less severe cases. HS remains a frequently fatal disease with a stable incidence.

The effect of blood glutamate scavengers oxaloacetate and pyruvate on neurological outcome in a rat model of subarachnoid hemorrhage

Blood glutamate scavengers have been shown to effectively reduce blood glutamate concentrations and improve neurological outcome after traumatic brain injury and stroke in rats. This study investigates the efficacy of blood glutamate scavengers oxaloacetate and pyruvate in the treatment of subarachnoid hemorrhage (SAH) in rats. Isotonic saline, 250 mg/kg oxaloacetate, or 125 mg/kg pyruvate was injected intravenously in 60 rats, 60 minutes after induction of SAH at a rate of 0.1 ml/100 g/min for 30 minutes. There were 20 additional rats that were used as a sham-operated group. Blood samples were collected at baseline and 90 minutes after SAH. Neurological performance was assessed at 24 h after SAH. In half of the rats, glutamate concentrations in the cerebrospinal fluid were measured 24 h after SAH. For the remaining half, the blood brain barrier permeability in the frontal and parieto-occipital lobes was measured 48 h after SAH. Blood glutamate levels were reduced in rats treated with oxaloacetate or pyruvate at 90 minutes after SAH (p < 0.001). Cerebrospinal fluid glutamate was reduced in rats treated with pyruvate (p < 0.05). Neurological performance was significantly improved in rats treated with oxaloacetate (p < 0.05) or pyruvate (p < 0.01). The breakdown of the blood brain barrier was reduced in the frontal lobe in rats treated with pyruvate (p < 0.05) and in the parieto-occipital lobes in rats treated with either pyruvate (p < 0.01) or oxaloacetate (p < 0.01). This study demonstrates the effectiveness of blood glutamate scavengers oxaloacetate and pyruvate as a therapeutic neuroprotective strategy in a rat model of SAH.

Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.

CONCLUSIONS

aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

Epidemiology of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a form of hemorrhagic stroke that affects up to 30,000 individuals per year in the United States. The incidence of aSAH has been shown to be associated with numerous nonmodifiable (age, gender, ethnicity, family history, aneurysm location, size) and modifiable (hypertension, body mass index, tobacco and illicit drug use) risk factors. Although early repair of ruptured aneurysms and aggressive postoperative management has improved overall outcomes, it remains a devastating disease, with mortality approaching 50% and less than 60% of survivors returning to functional independence. As treatment modalities change and the percentage of minority and elderly populations increase, it is critical to maintain an up-to-date understanding of the epidemiology of SAH.

Effects of age, period and cohort on stroke mortality among a middle-aged Lithuanian urban population from 1980 to 2004

AIMS

The main purpose of this paper was to assess the effect of age, period, and cohort on stroke mortality rates among a Lithuanian urban population aged 25-64 years (1041 men and 724 women) between 1980 and 2004.

METHODS

Routine stroke mortality data were obtained from official Kaunas region mortality register by codes 430-438 and I60-I69 in the 9th and in the 10th revisions of the International Classifications of Diseases (ICD), respectively. Mortality rates per 100,000 persons for men and women were age-adjusted using the age distribution of the European Standard Population. Age-specific mortality rates were analysed by sex, period, and birth cohort in eight 5-year age groups and five 5-year age groups. Goodness of fit of the Poisson regression models were evaluated using Pearson and Freeman-Tukey residuals. The age-period and age-period-cohort models provided a significantly better fit than a model with the factors "age'' and "cohort''.

RESULTS

During the study period, mortality rates decreased from 46.8 to 33.0 per 100,000 for men, and from 20.2 to 18.1 per 100,000 for women (average annual decrease of -1.3%, p<0.1 for men, and -1.6%, p<0.03 for women). An age effect was present in both sexes. The definite upward period effect was observed from 1990 to 1994 both among men and women, and was followed by a sharp fall during 2000-4. Cohort and period effects have contained relevant information which partially explained trends in stroke mortality among a 25-64 year-old Lithuanian urban population.

CONCLUSIONS

During the period of 1980-2004, the mortality trend declined among women only. The period effect contains relevant information for the explanation of increasing mortality rates during 2000-4 among men and women. The Poisson regression models could be applied for the examination and explanation of the different causes of the population mortality.

Effects of age, period, and cohort on stroke mortality among the Lithuanian urban population during the 24-year follow-up period

The main purpose of this paper was to assess the effects of age, period, and cohort on stroke mortality among the urban Lithuanian population. Routine stroke mortality data among the Lithuanian urban population aged 25–64 years (1041 men and 724 women) between 1980 and 2004 were obtained from the official Kaunas region mortality register and classified by codes 430–438 and 160–169 in the 9th and 10th revisions of the International Classifications of Diseases (ICD), respectively. Mortality rates per 100,000 persons for men and women were age-adjusted using the age distribution of the European Standard Population. Goodness of fit of the Poisson regression models was evaluated using the Pearson and Freeman-Tukey residuals. During the study period, mortality rates decreased from 46.8 to 33.0 per 100,000 for men, and from 20.2 to 18.1 per 100,000 for women (average annual decrease of −1.3%, p<0.1 for men, and −1.6%, p<0.03 for women). An age effect was present in both sexes. The definite upward period effect was observed from 1990 to 1994 both among men and women, and was followed by a sharp fall during 2000–2004. Cohort and period effects have contained relevant information that partially explained trends in stroke mortality among 25–64 year-olds in the Lithuanian urban population. The Poisson regression models could be applied for the examination and explanation of the different causes of the population mortality.

Trends in blood pressure, hypertension control, and stroke mortality: the Minnesota Heart Survey

OBJECTIVE

The study's objective was to determine population trends in blood pressure, hypertension prevalence, hypertension control, and stroke mortality.

METHODS

We performed population-based surveys of 2906 to 5630 adults from 1980 to 1982, 1985 to 1987, 1990 to 1992, 1995 to 1997, and 2000 to 2002, and stroke mortality from 1980 to 2002, in the Minneapolis/St Paul, Minn metropolitan area (2.63 million population according to the 2000 census). Randomly selected resident adults aged 25 to 74 years (n = 21773) were each screened once. The main outcome measures were standardized measures of blood pressure, treatment and control of hypertension, and stroke mortality rates.

RESULTS

The mean systolic blood pressure adjusted for age decreased in men (-1.5 mm Hg [95% confidence interval -0.3 to -2.7], P <.01) and women (-1.8 mm Hg [95% confidence interval -0.5 to -3.0], P <.001) from 1980 to 1982 and 2000 to 2002. The mean diastolic blood pressure was unchanged for men (0 mm Hg) and women (-0.4 mm Hg, not significant). The proportion of the population taking antihypertensive medications decreased in the 1990s but returned to 1980s levels from 2000 to 2002. The use of other methods to decrease blood pressure (diet, exercise, and weight loss) peaked in the 1990 to 1992 survey and then decreased. Proportions of hypertensive patients in the aware, treated, and/or controlled categories leveled in the 1980s and 1990s, but improved substantially from 1995 to 1997 and 2000 to 2002 with blood pressure controlled at the less than 140 and/or 90 mm Hg criteria in 44% of the men and 55% of the women. Population mortality trends for stroke paralleled those for hypertension control.

CONCLUSIONS

Population data beginning in 1980 to 1982 from the Minnesota Heart Survey indicate a leveling in the detection and control of hypertension in the 1990s followed by improvement from 2000 to 2002.

Trends in Five-Year Survival and Risk of Recurrent Stroke after First-Ever Stroke in the Perth Community Stroke Study

BACKGROUND

Few studies provide information on trends in the long-term outcome of stroke. We aimed to determine trends in survival and recurrent stroke, over 5 years after first-ever stroke, for 2 cohorts of patients enrolled in the Perth Community Stroke Study in 1989-90 and 1995-96.

METHODS

For 12-month periods beginning February 1989 and February 1995, all individuals with an acute stroke who were resident in a geographically-defined and representative region of Perth, Western Australia, were registered and followed-up prospectively 5 years after the index event.

RESULTS

The 5-year cumulative risk of death was 59% (95% confidence interval (CI) 53%, 65%) and 58% (95% CI 52%, 65%) for the 1989-90 and 1995-96 cohorts, respectively (p = 0.94). The 5-year cumulative risk of first recurrent stroke was 32% (95% CI 25%, 40%) and 23% (95% CI 16%, 30%) for the 1989-90 and 1995-96 cohorts, respectively (p = 0.07).

CONCLUSIONS

Although no statistically significant improvement occurred in 5-year survival after first-ever stroke in Perth between 1989-90 and 1995-96, there was a statistically nonsignificant trend towards a smaller cumulative risk of recurrent stroke over 5 years after a first-ever stroke. Serial community-based studies of the incidence and outcome of stroke are an important means of monitoring the translation of proven preventive interventions to improvements in population health.

Trends in Surgical and Management Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage in Izumo City, Japan, between 1980–1989 and 1990–1998

BACKGROUND AND PURPOSE

The purpose of this community-based study was to evaluate temporal changes in surgical and management outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

The subjects were 358 patients with aneurysmal SAH who were treated during the 19-year period from 1980 to 1998 in Izumo City, Japan. We compared data during the 9-year period 1990-1998 (period B; 188 patients) with those during the 10-year period 1980-1989 (period A; 170 patients).

RESULTS

The proportion of patients 80 years of age or older or those with World Federation of Neurosurgical Societies grade V increased significantly (period A, 5 and 25%; period B, 18 and 35%, respectively). The operability rate did not change for patients 69 years of age or younger, whereas it increased significantly for those 70-79 years of age (period A, 48%; period B, 72%). The 6-month and 2-year case fatality rates in surgically treated patients decreased significantly (period A, 12 and 20%; period B, 2 and 8%, respectively), whereas they were virtually unchanged for overall management (period A, 41 and 46%; period B, 38 and 42%, respectively). In patients who underwent surgery, the incidence of permanent symptomatic vasospasm decreased from 21% during period A to 11% during period B, and there was no death from vasospasm in the later period. However, no significant difference was found in the functional outcome between the two periods, regardless of whether surgery was performed. The most important determinants of 6-month and 2-year survival rates were grade on admission, rebleeding and the site of the ruptured aneurysms. Age was also a significant predictor of the 6-month case fatality rate.

CONCLUSIONS

For patients with SAH who underwent surgery, there were trends towards decreases in the case fatality rate and in the incidence of permanent symptomatic vasospasm. Nevertheless, the overall management outcome was still unsatisfactory, mainly because of increasing numbers of very elderly and/or high-risk patients. .

Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study)

BACKGROUND

The incidence of stroke is predicted to rise because of the rapidly ageing population. However, over the past two decades, findings of randomised trials have identified several interventions that are effective in prevention of stroke. Reliable data on time-trends in stroke incidence, major risk factors, and use of preventive treatments in an ageing population are required to ascertain whether implementation of preventive strategies can offset the predicted rise in stroke incidence. We aimed to obtain these data.

METHODS

We ascertained changes in incidence of transient ischaemic attack and stroke, risk factors, and premorbid use of preventive treatments from 1981-84 (Oxford Community Stroke Project; OCSP) to 2002-04 (Oxford Vascular Study; OXVASC).

FINDINGS

Of 476 patients with transient ischaemic attacks or strokes in OXVASC, 262 strokes and 93 transient ischaemic attacks were incident events. Despite more complete case-ascertainment than in OCSP, age-adjusted and sex-adjusted incidence of first-ever stroke fell by 29% (relative incidence 0.71, 95% CI 0.61-0.83, p=0.0002). Incidence declined by more than 50% for primary intracerebral haemorrhage (0.47, 0.27-0.83, p=0.01) but was unchanged for subarachnoid haemorrhage (0.83, 0.44-1.57, p=0.57). Thus, although 28% more incident strokes (366 vs 286) were expected in OXVASC due to demographic change alone (33% increase in those aged 75 or older), the observed number fell (262 vs 286). Major reductions were recorded in mortality rates for incident stroke (0.63, 0.44-0.90, p=0.02) and in incidence of disabling or fatal stroke (0.60, 0.50-0.73, p<0.0001), but no change was seen in case-fatality due to incident stroke (17.2% vs 17.8%; age and sex adjusted relative risk 0.85, 95% CI 0.57-1.28, p=0.45). Comparison of premorbid risk factors revealed substantial reductions in the proportion of smokers, mean total cholesterol, and mean systolic and diastolic blood pressures and major increases in premorbid treatment with antiplatelet, lipid-lowering, and blood pressure lowering drugs (all p<0.0001).

INTERPRETATION

The age-specific incidence of major stroke in Oxfordshire has fallen by 40% over the past 20 years in association with increased use of preventive treatments and major reductions in premorbid risk factors.

Primary intracerebral hemorrhage in Izumo City, Japan: incidence rates and outcome in relation to the site of hemorrhage

OBJECTIVE

The aim of this community-based study was to investigate the incidence rates and outcome of primary intracerebral hemorrhage (ICH) in relation to the site of hemorrhage.

METHODS

The subjects were 350 patients with primary first-ever ICH who were treated during the 8-year period 1991 to 1998 in Izumo City, Japan.

RESULTS

The crude and age- and sex-adjusted incidence rates for all types of ICH were 52 and 47 per 100,000 population, respectively, for all ages. The most common site of ICH was the putamen (120 patients, 34%), followed by the thalamus (115, 33%), lobar areas (53, 15%), brainstem (30, 9%), cerebellum (25, 7%), and caudate nucleus (7, 2%). The crude and age- and sex-adjusted annual incidence rates per 100,000 population were 18 and 16 for putaminal, 17 and 15 for thalamic, 8 and 7 for lobar, 4 and 3 for cerebellar, 4 and 4 for brainstem, and 1 and 1 for caudate hemorrhages, respectively. The Glasgow Coma Scale scores on admission were best in patients with cerebellar hemorrhage and worst in those with brainstem hemorrhage. Surgery was performed for 34% of putaminal, 9% of thalamic, 14% of caudate, 21% of lobar, and 32% of cerebellar hemorrhages but not for brainstem hemorrhages. The 30-day case fatality rate was 11% for putaminal, 9% for thalamic, 14% for caudate, 11% for lobar, 0% for cerebellar, and 53% for brainstem hemorrhages. When patients with ICH were analyzed as a whole, the overall survival rates at 30 days, 3 months, and 3 years were 87, 83, and 73%, respectively. Both the short-term and long-term outcomes after ICH were directly related to the site of hemorrhage and the severity of bleeding, which was assessed by the hematoma volume and Glasgow Coma Scale score. Overall, 190 (54%) of 350 patients had a favorable outcome, and 55 (16%) had died at discharge.

CONCLUSION

Marked differences were observed in the incidence rates and outcome of primary ICH in relation to the site of hemorrhage. The differences in outcome were primarily a result of differences in the severity of bleeding for each ICH subtype.

Waist circumference, body mass index, and risk for stroke in older people: a 15 year longitudinal population study of 70- year-olds

OBJECTIVES

To investigate waist circumference (WC) and body mass index (BMI) at age 70 as risk factors for stroke.

DESIGN

Cohort study of 70-year-olds with 15-year follow-up.

SETTING

Geriatric Medicine Department, Göteborg University, Sweden.

PARTICIPANTS

Two thousand two hundred eighty-seven (1,045 men; 1,242 women) 70-year-olds examined between 1971 and 1981 in Göteborg, Sweden.

MEASUREMENTS

Cox regression model was used to calculate relative risk (RR) and 95% confidence interval (CI) for first-ever stroke (fatal and nonfatal) in reference to the lowest quartiles of WC and BMI. Tests for trend were performed fitting WC and BMI in their original continuous form.

RESULTS

In men and women, RRs for stroke, in the highest WC quartile were 1.65 (95% CI = 1.08-2.51) and 1.31 (95% CI = 0.88-1.92), respectively, after adjustment for cohorts, smoking habit, coronary heart disease (CHD), diabetes mellitus, total cholesterol (TC), systolic blood pressure (SBP), and height at age 70. In men, RR for stroke in the highest BMI quartile (> or=28 kg/m2) was 1.68 (95% CI = 1.12-2.53) after adjustment for cohorts, smoking habits, CHD, diabetes mellitus, TC, and SBP at age 70. In women, adjusted RRs for stroke across the BMI quartiles were not significantly different. In men, population attributable fractions of stroke were 24.8% and 25.2% for the highest quartiles of WC and BMI, respectively.

CONCLUSIONS

High WC (> or =99 cm) and BMI (> or =28 kg/m2) are risks for stroke in older men but not in older women.

The Mureş-Uzhgorod-Debrecen study: a comparison of hospital stroke services in Central-Eastern Europe

Stroke mortality is extremely high in Central-Eastern European countries. The high rate of risk factors and differences in health care services might be among the factors resulting in high stroke morbidity and mortality in this region. As only few prospectively collected information are available from this region, we decided to evaluate some characteristics of stroke services in neurological departments of a Romanian, a Ukrainian and a Hungarian city in the framework of the Mureş-Uzhgorod-Debrecen comparative epidemiological study. We registered demographic data, the absence or presence of the most important risk factors, and clinical signs on admission and at discharge. We recorded the application of various diagnostic methods, stroke treatment and recommendations for secondary prevention. Follow-up is planned after 30 days and after 1 year. The paper summarizes the methodology of this prospective epidemiological study of stroke patients hospitalized in neurological departments in Târgu Mureş, Uzhgorod and Debrecen, three Central-Eastern European cities in Romania, Ukraine and Hungary, respectively.

Acute care in neurosurgery: quantity, quality, and challenges

OBJECTIVE

Part of the daily routine in neurosurgery is the treatment of emergency room admissions, and acute cases from other departments or from outside hospitals. This acute care is not normally included in performance figures or budget management, nor analysed scientifically in respect of quantity and quality of care provided by neurosurgeons.

METHOD

Over a 1 year period, all acute care cases managed by two neurosurgical on call teams in a large northern German city, were recorded prospectively on a day by day basis. A large database of 1819 entries was created and analysed using descriptive statistics.

RESULTS

The minimum incidence of patients requiring neurosurgical acute care was estimated to be 75-115/100 000 inhabitants/year. This corresponds to a mean of about 6/day. Only 30% of patients came directly via the emergency room. The fate of 70% of patients depended initially on the "neurosurgical qualification" of primary care doctors and here deficits existed. Although most intracerebral and subarachnoid haemorrhages were managed with the participation of neurosurgeons, they were not involved in the management of most mild and moderate traumatic brain injuries. Within 1 year the additional workload from acute care amounted to 1000 unplanned admissions, 900 acute imaging procedures, and almost 400 emergency operations.

CONCLUSION

The current policy in public health, which includes cuts in resources, transport facilities, and manpower, is not compatible with the demonstrated extent of acute neurosurgical care. In addition to routine elective work, many extra admissions, evening or night time surgery, and imaging procedures have to be accomplished. An education programme for generalists is required to improve overall patient outcome. These conclusions hold special importance if health authorities wish to not only maintain present standards but aim to improve existing deficits.

Incidence and outcome of subarachnoid haemorrhage: a retrospective population based study

OBJECTIVES

The purpose was to define the incidence and case fatality rates of subarachnoid haemorrhage in the population of Devon and Cornwall.

METHODS

A retrospective population based design was employed with multiple overlapping methods of case ascertainment. A strict definition of subarachnoid haemorrhage was used. Age and sex specific incidence rates and relative risks for death at different time intervals are calculated.

RESULTS

Eight hundred cases of first ever subarachnoid haemorrhage were identified; 77% of cases were verified by CT, 22% by necropsy, and 1% by lumbar puncture. The incidence rates are higher than those previously reported in the United Kingdom. The age standardised incidence rate (/100 000 person-years) for females was 11.9 (95% confidence interval (95% CI) 9.5-15.0), for males 7.4 (5.4-10.0), and the total rate was 9.7 (7.5-12.6). The case fatality rates at 24 hours, 1 week, and 30 days were 21 (18-24)%, 37 (33-41)%, and 44 (40-49)% respectively. The relative risk for death at 30 days for those over 60 years:under 60 years was 2.95 (2.18-3.97).

CONCLUSION

The incidence of subarachnoid haemorrhage in the United Kingdom is higher than previously reported. Three quarters of the mortality occurs within 3 days.

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part I: incidence and seasonal and diurnal variations

OBJECT

The purpose of this community-based study was first to estimate the incidence rates of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) in Izumo City, Japan, and second to investigate whether there were seasonal and diurnal periodicities in their onset.

METHODS

During 1991 through 1996, 267 patients with primary ICH and 123 with aneurysmal SAH were treated in Izumo City. The crude and the age- and sex-adjusted annual incidence rates per 100,000 population for all ages were 52 and 48 for ICH and 24 and 23 for SAH, respectively. These incidence rates were higher than those previously published for any other geographical region. The incidence rates of both ICH and SAH increased almost linearly with age. For ICH, a significant seasonal pattern was observed in men and in patients younger than 65 years, with a peak in winter and a trough in summer. However, no significant seasonal fluctuation was found in women or in individuals aged 65 years or older. There was no significant seasonal periodicity for SAH, even when patients were analyzed according to sex and age. Diurnal variations in the onset of both ICH and SAH were significant (except in men with SAH), with a nadir between midnight and 6:00 a.m.

CONCLUSIONS

The actual incidence rates of both primary ICH and aneurysmal SAH seem to be much higher than have been reported so far. In addition, the data indicate the existence of seasonal periodicity for men and younger patients with ICH, and that the risk of both ICH and SAH is lower during nighttime.

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II: management and surgical outcome

OBJECT

The purpose of this study was to assess the overall management and surgical outcome of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) among the 85,000 residents of Izumo City, Japan.

METHODS

During 1991 through 1996, 267 patients with ICH and 123 with SAH were treated in Izumo. Of the 267 patients with ICH, 25 underwent hematoma removal by open craniotomy or suboccipital craniectomy and 34 underwent stereotactic evacuation of the hematoma, whereas aneurysm clipping was performed in 71 of the 123 patients with SAH; operability rates were thus 22% for ICH and 58% for SAH (p < 0.0001). The overall 30-day survival rates were 86% for ICH and 66% for SAH (p < 0.0001) and the 2-year survival rates were 73% and 62% (p = 0.0207), respectively. In patients who underwent surgery, 30-day and 2-year survival rates were 93% for ICH and 100% for SAH (p = 0.0262), and 75% for ICH and 97% for SAH (p = 0.0002), respectively. In patients with ICH, the most important predictors of 30-day case-fatality rates were the volume of the hematoma, the Glasgow Coma Scale (GCS) score, rebleeding, and midline shifting, whereas those for 2-year survival were the GCS score, age, rebleeding, and hematoma volume. In patients with SAH, the most important determinants of 30-day case-fatality rates were the GCS score and age, whereas only the GCS score had a significant impact on 2-year survival.

CONCLUSIONS

The overall survival rates for patients with ICH or SAH in Izumo were more favorable than those in previously published epidemiological studies. However, despite improved surgical results, the overall management of ICH and SAH still produced an unsatisfactory outcome, mainly because of primary brain damage.

Subarachnoid haemorrhage: epidemiology, risk factors, and treatment options

The present review focuses on subarachnoid haemorrhage (SAH) secondary to the rupture of an intracranial aneurysm, a condition with a high case fatality rate. Additionally, many of the surviving patients are left with significant disabilities. Risk factors for aneurysmal SAH include both genetic and acquired conditions. The most common presenting symptom is sudden onset of severe headache. Since headache is very common in the general population, it is not unusual that SAH is misdiagnosed at its onset with often catastrophic consequences. Unlike other acute neurological disorders such as brain injury, in which patient outcome is closely related to the extent of the injury occurring at the time of the trauma, patients with aneurysmal SAH are at risk of subsequent deterioration from 'avoidable' complications such as rebleed, vasospasm, hydrocephalus, and several other non-neurological general medical complications. Thus, the critical care management of the patient with SAH is of utmost importance in order to maximise the chances of satisfactory recovery. Although surgical clipping of the ruptured aneurysm remains the gold standard therapy, with the continuing refinement of endovascular techniques, a new, 'less invasive' option is now available, especially for patients considered poor surgical candidates.

The relationship between cholesterol and stroke: implications for antihyperlipidaemic therapy in older patients

Various studies on the relationship between serum cholesterol level and the risk of stroke have been published recently. Subsequent reviews have extrapolated information on stroke from the clinical trials originally aimed at lowering cholesterol for the primary and secondary prevention of myocardial infarction (MI) in middle-aged patients. We have reviewed the epidemiological knowledge on the relationship between serum cholesterol levels and stroke, and also focused on possible reduction of the risk of stroke with hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitor treatment. Possible benefits from such therapy are particularly relevant for the elderly population which is at particularly high risk for stroke. The effects of serum cholesterol levels on the risk for haemorrhagic and ischaemic stroke have been evaluated. Indirect epidemiological evidence indicates that serum levels of total cholesterol and its subfractions are determinants of stroke, but their associations are relatively weak. When exploring the possible association of serum cholesterol levels with the increased risk of stroke with aging, we concluded that, as in younger adults, elevated total cholesterol and decreased high density lipoprotein-cholesterol levels predispose to ischaemic stroke in the elderly. The mechanism through which serum cholesterol levels increase stroke risk is based on its actions on the artery walls. Indirect evidence suggests that the reduction in the stroke risk with HMG-CoA reductase inhibitors is larger than would be expected with reduction of elevated serum cholesterol level alone. Therefore, antioxidant and endothelium-stabilising properties of HMG-CoA reductase inhibitors may contribute in reducing the risk of stroke in recipients. Lowering high serum cholesterol with HMG-CoA reductase inhibitors has been beneficial in the primary and secondary prevention of MI. No trials have specifically tested the effect of cholesterol lowering with HMG-CoA reductase inhibitors on stroke occurrence. High serum cholesterol levels are a risk factor for ischaemic stroke, although the risk imparted is lower than that for MI. Although the relative risk of stroke associated with elevated serum cholesterol levels is only moderate, its population attributable risk is high given the increase in the elderly population worldwide. The effect of cholesterol reduction with HMG-CoA reductase inhibitors on prevention of ischaemic stroke should be evaluated in prospective, randomised, placebo-controlled trials in the elderly. The tolerability of lipid-lowering drugs in the elderly and the cost effectiveness of primary prevention of stroke using lipid-lowering drugs also needs to be assessed in the elderly.

Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral

OBJECTIVE

Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report.

METHODS

An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed).

RESULTS

There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis.

CONCLUSIONS

Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed.

Improved survival after aneurysmal subarachnoid hemorrhage: review of case management during a 12-year period

OBJECT

Based on the concept that unfavorable clinical outcome after aneurysmal subarachnoid hemorrhage (SAH), to a large extent, is a consequence of all ischemic insults sustained by the brain during the acute phase of the disease, management of patients with SAH changed at the authors' institution in the mid-1980s. The new management principles affected referral guidelines, diagnostic and monitoring methods, and pharmacological and surgical treatment in a neurointensive care setting. The impact of such changes on the outcome of aneurysmal SAH over a longer period of time has not previously been studied in detail. This was the present undertaking.

METHODS

The authors analyzed all patients with SAH admitted to the neurosurgery department between 1981 and 1992. This period was divided in two parts, Period A (1981-1986) and Period B (1987-1992), and different aspects of management and outcome were recorded for each period. In total, 1206 patients with SAH (mean age 52 years, 59% females) were admitted; an aneurysm presumably causing the SAH was found in 874 (72%). The 30-day mortality rate decreased from 29% during the first 2 years (1981-1982) to 9% during the last 2 years (1991-1992) (Period A 22%; Period B 10%; p<0.0001) and the 6-month mortality rate decreased from 34 to 15% (Period A 26%; Period B 16%; p<0.001). At follow-up review conducted 2 to 9 years (mean 5.2 years) after SAH occurred, patients were evaluated according to the Glasgow Outcome Scale. Subarachnoid hemorrhage-related poor outcome (vegetative or dead) was reduced (Period A 30%; Period B 18%; p<0.001). There was an increase both in patients with favorable outcome (good recovery and moderate disability) (Period A 61 %; Period B 66%) and in those with severe disability (Period A 9%; Period B 16%; p<0.01).

CONCLUSIONS

This study provides evidence that the prognosis for patients with aneurysmal SAH has improved during the last decades. The most striking results were a gradual reduction in mortality rates and improved clinical outcomes in patients with Hunt and Hess Grade I or II SAH and in those with intraventricular hemorrhage. The changes in mortality rates and the clinical outcomes of patients with Hunt and Hess Grades III to V SAH were less conspicuous, although reduced incidences of mortality were seen in some subgroups; however, few survivors subsequently appeared to attain a favorable outcome.

Decreasing incidence of stroke in central Finland, 1985-1993

INTRODUCTION

During the last decades the age-standardized stroke mortality has declined in Finland as in many other industrialized countries. Epidemiological studies have, however, not been consistent in explaining this fall in mortality. Our aim was to shed light on this question by using two consecutive, population-based surveys.

PATIENTS & METHODS

The target of the two one-year surveys was the population living in the Jyväskylä Region of central Finland, and the surveys were performed in 1985-86 (population 114,669) and 1993 (population 123,547). The case finding methods and the diagnostic criteria were identical in both studies. All hospital records and autopsy reports of patients with ICD (8th and 9th revision) codes 430-438 were collected and perused. Patients with first-ever stroke were included in the study.

RESULTS

The number of patients with first-ever stroke in the 1985-86 and 1993 surveys were 219 and 189, respectively, and 92% of them were treated at the Department of Neurology. The age-standardized (European standard population > or = 25 years) annual total stroke incidence showed a statistically significant decline over these 8 years from 317 (95% confidence interval 274-360) to 227 (95% confidence interval 194-260) per 100,000. In both studies the survival was similar with 79% of the patients surviving at 28 days after stroke onset, and 65-69% at 1 year. Recurrent strokes, 52 in 1985-86 and 50 in 1993 also showed a declining trend and no changes in survival were observed.

CONCLUSIONS

The decline in stroke mortality in Finland is best explained by the declining incidence of stroke. In the present study we did not find changes in the 1st year survival after stroke onset.

Is hypertension changing? Blood pressure development in cohorts of 50-year-old men between 1963 and 1993

OBJECTIVE

To study secular trends in the prevalence and treatment of hypertension in the general population, and the disease course.

DESIGN

Health examinations of cohorts of 50-year-old men in 1963, 1973, 1983 and 1993.

SETTING

The city of Göteborg, Sweden (about 400,000 inhabitants).

PARTICIPANTS

Random population samples of 50-year-old men.

MAIN OUTCOME MEASURE

Mean blood pressure (BP) levels in the populations and among treated hypertensives, proportions of hypertensives, and frequency of high BP values (> or = 160/and or 95, and > or = 175/115 mmHg, respectively).

RESULTS

The mean population BP decreased from 138.4/89.0 mm to 128.7/84.4 mmHg during the 30-year period (p < 0.0001). Mean BP levels among treated hypertensives decreased from 170/113 to 142/94 mmHg (p < 0.0001), and the proportion of men with high BP values diminished from 3.9 to 0.1%. Also BP levels among normotensives decreased significantly (p < 0.0001).

CONCLUSION

The findings could partly be seen as a result of successful case-finding and treatment of hypertension in the region, but alteration of the natural course of hypertension cannot be excluded.

A 3-year follow-up of stroke patients: relationships between activities of daily living and personality characteristics

The importance of some personality characteristics for improvement of activities of daily life (ADL) was studied in sixty-six stroke patients, initially admitted to geriatric rehabilitation (n=37) or the department of medicine (n=29), 3 years after stroke. Outcome measurements were activities of daily life and motor and mental functions assessed using the Activity Index (AI) by Hamrin and Wohlin (1982). Neuroticism and extroversion were measured with the Eysenck Personality Inventory Scale. Preferred coping strategies were assessed from interviews on how the patients handle difficult events. Major improvements of ADL and motor functions were seen the first year after stroke. There was no major differences between patients admitted, either to geriatric rehabilitation or traditional medical wards regarding the outcome measurements except for better eating ability in the former group 3 years later. Subjects living alone showed deteriorated ADL functions after 3 years. Extrovert personality and active coping strategy predicted improved ADL functions. Multiple regression analyses with AI as the dependent variable proved active coping to predict functional outcome. In conclusion; increased knowledge about personality characteristics can improve possibilities for a more individual rehabilitation program.

Costs of stroke in Sweden. A national perspective

BACKGROUND AND PURPOSE

Cost-effectiveness analyses of stroke management are hampered by paucity of economic data. We made an update of the direct and indirect costs of stroke in Sweden (population, 8.5 million).

METHODS

Direct costs (ie, the costs for hospital and outpatient care and social services) were estimated on the basis of two prospective population-based studies of stroke and of two nationwide cross-sectional inventories of bed-days and diagnoses. Indirect costs (ie, the costs for loss of productivity and early retirement) were based on official statistics.

RESULTS

The direct annual costs of care for stroke patients in 1991 equaled 7836 million Swedish krona (SKr) ($1306 million in US dollars), and the indirect costs, 2430 million SKr ($405 million). The cost of stroke care was 1208 SKr ($201) per inhabitant in Sweden. The expected direct costs per patient from first stroke to death were 440,000 SKr ($73,333). When prestroke costs for other diseases and advanced age were subtracted, the sum was reduced to 180,000 SKr ($30,000).

CONCLUSIONS

Costs for hospital and outpatient care and social services accounted for 76% of Swedish stroke costs and for 24% of costs for loss of production and early retirement. Only 41% of direct costs were stroke-related.

Declining trends in incidence, case-fatality and mortality of stroke in three geographic areas of Finland during 1983-1989. Results from the FINMONICA stroke register

Stroke mortality has decreased during the last decade in many industrialized countries, but there has been no clear evidence for a decline in the incidence of stroke. The present study analyzes the trends in the incidence, mortality and case-fatality of stroke in Finland from 1983 to 1989. We used data from the FINMONICA stroke register, a community based register collecting information on all suspected stroke cases aged 25-74 in three geographical areas of Finland. Annual attack rate, incidence, mortality and case-fatality rates were calculated for all strokes and for different subcategories of stroke. A linear regression model was applied to calculate the yearly trends of these rates. In men, the attack rate of stroke was 336/100,000 in 1983 and 310/100,000 in 1989 (-8% during the observation period); incidence declined from 269/100,000 in 1983 to 236/100,000 in 1989 (-12%); mortality declined from 82/100,000 to 64/100,000 (-22%), and case-fatality declined from 25% to 21% (-18%). Also among women similar declining trends were observed (-11%, -13%, -16%, and -10% respectively), but they were not statistically significant. In both incidence and mortality of stroke, the decline was seen in all age groups. Incidence and mortality of cerebral infarction declined similarly to all strokes. A large fall in the incidence (-24% in both men and women) and mortality (-38% in men and -27% in women) of subarachnoid haemorrhage was also observed. An increasing trend, although not significant, was instead observed for cerebral haemorrhage. First stroke and especially first cerebral infarction contributed most to the decline in case-fatality. The availability of computerized brain tomography improved from 18% in 1983 to 60% in 1989. We observed a fall in the incidence, mortality, and case-fatality of stroke during 1983-1989. Among the subtypes of stroke, cerebral infarction contributed most to the decline, but the data suggested also a declining trend in the incidence and mortality of subarachnoid haemorrhage, observed now for the first time in Finland since the 1960s. The fall in the incidence of stroke was not as steep during the 1980s as it was during the 1970s; Finland is anyhow the only European country which has reported a decreasing trend in stroke incidence during the 1980s. We need now to investigate how much the decline in the classical risk factors for stroke observed in Finland during the last two decades predicts the observed trends.

Trends in incidence, case-fatality rate, and severity of stroke in northern Sweden, 1985-1991

BACKGROUND AND PURPOSE--Incidence, case-fatality rate at 28 days, and severity of acute stroke were recorded for 7 years in a large population-based stroke register to understand the reasons for the decline in stroke mortality in northern Sweden.

METHODS

Within the framework of the World Health Organization MONICA Project, acute stroke was monitored in people aged 35 to 74 years in northern Sweden from 1985 through 1991 (target population in 1985, 238,948).

RESULTS

The annual incidence of stroke decreased by an average of 2.3%/y in men aged 35 to 64 years (P = .074) and increased significantly by 1.1%/y in men aged 65 to 74 years (P = .041). No significant changes in incidence occurred in either age group in women. The 28-day case-fatality rate in first-ever strokes (both sexes together) declined from 21.9% to 15.4% in patients aged 65 to 74 years (P = .02). Among survivors, the proportion with extensive motor deficits (at any time during the first 28 days) declined in patients younger than 65 years as well as in those older than 65 years (P = .007 and P = .019, respectively). In patients aged 35 to 64 years, the proportion with aphasia/dysphasia also decreased significantly (P = .032), but no such trend was seen in those aged 65 to 74 years.

CONCLUSIONS

A shift toward higher ages has been noted in the occurrence of first-ever strokes in men, while incidence has remained unchanged in women. During the 7 years of observation, stroke has become a less severe disease.

Trends in survival after stroke among Medicare beneficiaries

BACKGROUND AND PURPOSE

Most strokes occur among people aged 65 years and older. The increasing proportion of persons who are in this age group underlines the importance for health-care providers to be aware of trends in poststroke survival. We investigated poststroke survival trends from 1985 to 1989 among Medicare beneficiaries.

METHODS

Medicare hospital claim records and enrollment data were obtained on 1 901 439 Medicare patients with a principal diagnosis of stroke occurring during the years 1985 through 1989. Cox proportional hazard techniques were used to compare the 2-year poststroke survival for strokes occurring in 1986, 1987, 1988, and 1989 relative to strokes occurring in 1985. Poststroke survival trends were examined among groups defined by age, race, region, type of stroke, and, for a 20% subset, history of stroke.

RESULTS

We observed a modest improvement in poststroke survival from 1985 to 1989 (1989:1985 hazard ratio, 0.96; P < .05). Trends for persons with hemorrhagic stroke showed more improvement (hazard ratio, 0.88; P < .05) than those for persons with ischemic stroke (hazard ratio, 0.98; P < .05). Improvement was also greater among persons without known prior hospitalization for stroke (hazard ratio, 0.94; P < .05) and during periods of follow-up shorter than 2 years.

CONCLUSIONS

The variations in poststroke survival among subgroups of the population have important implications for the quality of life of stroke survivors and for the future medical and nursing needs of these populations.

Trends in stroke incidence and mortality in Hawaiian Japanese men

BACKGROUND AND PURPOSE

Vital statistics show a sharp decline in stroke mortality since the late 1960s. It is not clear whether this has been associated with a decline in stroke incidence.

METHODS

Since 1966 the Honolulu Heart Program has monitored the incidence and mortality of coronary heart disease and stroke in a target population of 11,136 men of Japanese ancestry living on Oahu. Trends were analyzed from January 1, 1969, through December 31, 1988.

RESULTS

Of 7893 men aged 45 to 68 years and free of stroke at entry examination, 530 developed first episodes of stroke in the period 1969 to 1988 (389 cases of thromboembolic stroke, 124 cases of hemorrhagic stroke, and 17 cases of stroke of unknown type). Age-adjusted annual stroke incidence declined from 5.1 per 1000 person-years in 1969 to 1972 to 2.4 in 1985 to 1988. The incidences of thromboembolic stroke, hemorrhagic stroke, and total stroke decreased 3.5%, 4.2%, and 4.4% per year, respectively. The 1-month case-fatality rates for thromboembolic stroke decreased moderately; those for hemorrhagic stroke fell dramatically.

CONCLUSIONS

These findings suggest that the decline in stroke mortality in the past two or three decades results from a decline in both incidence rates and early case-fatality rates in thromboembolic and hemorrhagic stroke and stroke of unknown type. The decreases may be related to changes in risk factors, such as the decline in blood pressure and the decrease in cigarette smoking, as well as improvements in diagnosis and treatment.

Stroke incidence and mortality in rural and urban Shanghai from 1984 through 1991. Findings from a community-based registry

BACKGROUND

Mortality from stroke has declined in many countries. This decline may result from a fall in incidence of stroke or a decrease in case fatality from stroke. The present study was conducted to investigate the temporal trends of incidence rate, mortality rate, and case fatality of stroke in an urban and rural Chinese population.

METHODS

A community-based registry study was established in 1983 in defined rural and urban areas of Shanghai with a population aged 35 to 74 years of approximately 86,000 subjects, adhering to the methods and definitions of the World Health Organization MONICA protocol. All stroke events occurring in the population aged 35 to 74 years in these areas were registered by a special three-level case-registration system.

RESULTS

From 1984 through 1991, 1391 stroke cases were identified. No significant change in the incidence rate of stroke was observed from 1984 through 1991 in men and women living in rural and urban areas. Age-standardized mortality rates (per 100,000 person years) of stroke declined significantly during this period, except for rural women. The annual changes and 95% confidence intervals of age-standardized mortality rates were: for rural men -4.6% (-5.4, -3.9), for rural women -0.6% (-1.6, 0.5), for urban men -2.5% (-3.5, -1.6), and for urban women -4.7% (-5.2, -4.2). A significant decrease in case fatality from stroke from 1984 through 1991 was found among men living in rural areas (from 62.4% to 46.0%) and among women living in urban areas (from 48.4% to 33.3%). Overall case fatality, however, showed a nonsignificant decline over time.

CONCLUSIONS

We observed a decline in stroke mortality rate in a rural and urban Chinese population. No significant changes in stroke incidence were found in this study, whereas case fatality appeared to have decreased, in particular among men living in rural areas and women living in urban areas.

Are cerebral aneurysms atherosclerotic?

BACKGROUND AND PURPOSE

The aim of our study was to investigate plasma and genetic risk factors for rupture of cerebral aneurysms.

METHODS

In London, a case-control study was made of 56 consecutive patients admitted to a regional neurosurgical service for treatment of ruptured cerebral aneurysm and of 93 control subjects. A further 40 consecutive patients admitted in Arhus with ruptured cerebral aneurysm also were studied.

RESULTS

The British case-control study showed that smoking was associated with an increased risk of ruptured cerebral aneurysm (odds ratio, 9.1; 95% confidence interval [CI], 3.4 to 23.8; P < .001 for a history of > 10 pack years). After age and sex adjustment, factors associated with ruptured cerebral aneurysm included a cholesterol concentration in the highest tertile (> or = 6.3 mmol/L; odds ratio, 10.2; 95% CI, 3.9 to 26.7; P < .001), an apolipoprotein B concentration in the highest tertile (> or = 0.84 g/L; odds ratio, 6.4; 95% CI, 2.5 to 16.3; P < .001), and concentrations of HDL cholesterol in the lowest tertile (< 1.1 mmol/L; odds ratio, 3.6; 95% CI, 1.4 to 8.2; P < .01). History of hypertension was of less importance (odds ratio, 4.0; 95% CI, 1.41 to 11.7; P < .01). Smoking history (P < .001) and increased concentrations of cholesterol (P < .0001) were the most important independent risk factors associated with ruptured cerebral aneurysm on multivariate analysis. The histories of hypertension and smoking, together with apolipoprotein B levels, in the Danish patients were similar to those in the British patients. In the entire patient group, the frequencies of two polymorphic variations in the type III collagen gene and polymorphisms at the apolipoprotein B, apolipoprotein C-III, and haptoglobin gene loci were not different from control subjects or the normal population; allele frequencies in British and Danish patients were similar.

CONCLUSIONS

An atherosclerotic profile including increased total cholesterol concentration and a long smoking history may contribute to the rupture of cerebral aneurysms. This study provides no support for the hypothesis that inherited abnormalities of type III collagen are a common cause of cerebral aneurysms.

Changes in stroke incidence and case-fatality in Auckland, New Zealand, 1981-91

The explanation for the substantial decline in stroke death rates can be investigated only by measuring trends in stroke incidence and case-fatality. Two community-based studies carried out in Auckland, New Zealand, in 1981 and 1991 used comparable methods and definitions, met criteria for well-designed studies, and had the power to detect small changes in incidence and case-fatality rates. 703 events (representing 50% of all strokes) were registered in 1981 and 1735 events in 1991. 521 (74.1%) and 1255 (72.3%) events in 1981 and 1991, respectively, were first-ever (in a lifetime) strokes. Although there was no change in overall stroke incidence between 1981 and 1991, there were changes in age and sex groups. The incidence rate among women younger than 75 years rose by a fifth (rate ratio 1.23 [95% CI 1.04-1.47]), whereas that in men of 75 years and older fell by a third (rate ratio 0.67 [0.54-0.82]). The 28-day case-fatality declined from 27.1 (21.7-32.6)% to 21.9 (18.1-25.7)% in men and from 37.6 (31.8-43.5)% to 25.8 (22.3-29.4)% in women from 1981 to 1991, but the decline was not statistically significant in any age or sex group. These findings suggest that we need to reappraise strategies for the prevention of stroke and assess the implications of improved survival in elderly stroke patients.