Cerebrovascular disease in the People's Republic of China: epidemiologic and clinical features

Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met.

In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health

On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases.

Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

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Increasing burden of stroke in China: A systematic review and meta-analysis of prevalence, incidence, mortality, and case fatality

BACKGROUND

The epidemiology of stroke is evolving in China as the population undergoes demographic, lifestyle, and economic transitions. An updated review is pertinent to providing feedback on current, and in planning future, prevention and management strategies.

AIMS

To identify high-quality epidemiological studies for quantifying the prevalence, incidence, mortality, and case fatality for stroke in China.

METHODS

A search was undertaken across a range of bibliographic databases on 30 November 2021 without time limitation. Assessments were made of the risk of bias of the included studies. The outcomes were synthesized using a random-effects model. Subgroup analysis and meta-regression models were used to define the source of heterogeneity.

RESULTS

Of 9407 identified records, 26 population-based studies were included. Due to significant heterogeneity across the studies, the original range for crude rates of indices was wide. The pooled annual prevalence was 1329.5/100,000 (95% confidence interval (CI) 713.6-2131.9, p < 0.001), incidence 442.1/100,000 (327.6-573.8, p < 0.001), mortality 154.1/100,000 (52.6-308.8, I² = 100%, p < 0.001), and case fatality 35.8% (26.1% to 46.1%, I² = 97%, p < 0.001). The prevalence and incidence of stroke have increased, but stroke-related case fatality has declined in China over recent decades. There are significant regional and rural-urban differences in incidence rates.

CONCLUSION

Despite improved public health policies and healthcare delivery, the burden of stroke remains high in China. Further coordinated efforts are required in prevention and community care to offset the likelihood of further expansion in the absolute number of stroke cases in this large population.

Prevalence and risk factors of stroke in a rural area of northern China: a 10-year comparative study

BACKGROUND AND AIMS

Stroke is currently the leading cause of death in China; however, the past decade has produced no new epidemiological studies of stroke. Therefore, the current study aimed to compare the prevalence and risk factors of stroke between 2010 and 2019.

METHODS

A comparative study was used to analyze the prevalence of risk factors for stroke in a population aged 65 years or older between 2010 and 2019. Demographic characteristics, risk factors, medical history, and other clinical characteristics were collected for all participants via door-to-door interviews and inpatient hospital records.

RESULTS

The standardized prevalence of stroke was 7.9% in 2010 and 14.2% in 2019 (p < 0.001). The prevalence of stroke was significantly higher in men than in women (p < 0.05) for all age groups. The risk factors of stroke were being male, hypertension, and diabetes mellitus in both 2010 and 2019. When comparing the risk factors between 2010 and 2019, these risk factors were statistically significantly more strongly associated with stroke in 2019 than in 2010.

CONCLUSION

The current study suggests that the prevalence of stroke increased nearly by twofold in a population aged 65 years or older within the past 10 years. Hypertension, diabetes mellitus, and being male were the primary risk factors. In addition, these factors were more significantly associated with stroke in 2019 compared to 2010.

Geographical Disparities in Pooled Stroke Incidence and Case Fatality in Mainland China, Hong Kong, and Macao: Protocol for a Systematic Review and Meta-analysis

Background

Geographical variations in stroke incidence and case fatality in China have been reported. Nonetheless, pooled estimates in major Chinese regions are unknown.

Objective

This systematic review and meta-analysis aims to investigate pooled estimates of incidence and short-term case fatality of stroke in Mainland China, Hong Kong, and Macao.

Methods

Longitudinal studies published in English and indexed in PubMed/MEDLINE, Embase, CINAHL, and Web of Science, or in Chinese and indexed in SinoMed and CQVIP will be targeted. Articles reporting on adults living in China who experience first-ever stroke or die within 1 year from newly onset stroke will be included. The 95% confidence intervals of the event will be estimated using the exact method based on the Poisson distribution. The log incidence rates together with their corresponding log standard errors will be meta-analyzed using DerSimonian and Laird random effects models. Pooled case fatality rates will also be estimated using a random effect model. Time trends in pooled age-standardized stroke incidence and case fatality will be estimated. The heterogeneity of the included studies will be measured using the I² statistic and meta-regressions will be run to analyze the effect of reported covariates on found heterogeneity. Risk of bias will be examined using the Newcastle-Ottawa Scale. Publication bias will be tested using funnel plots and Egger tests. Sensitivity analysis will be run by risk of bias.

Results

This study was funded and registered in 2020. The systematic searches, study selections, and quality assessments were completed in July 2021. Data extraction and analysis and manuscript writing are scheduled to be completed by December 2021.

Conclusions

This will be the first study to provide regional differences in pooled estimates of stroke incidence with case fatality in Mainland China, Hong Kong, and Macao. This study will assist in addressing inequalities in stroke care across China.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020170724; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170724

International Registered Report Identifier (IRRID)

PRR1-10.2196/32566

Acute Ischemic Stroke at High Altitudes in China: Early Onset and Severe Manifestations

The detailed characteristics of strokes at high altitudes in diverse nations have not been extensively studied. We retrospectively enrolled 892 cases of first-ever acute ischemic strokes at altitudes of 20, 2550, and 4200 m in China (697 cases from Penglai, 122 cases from Huzhu, and 73 cases from Yushu). Clinical data and brain images were analyzed. Ischemic strokes at high altitudes were characterized by younger ages (69.14 ± 11.10 vs. 64.44 ± 11.50 vs. 64.45 ± 14.03, p < 0.001) and larger infract volumes (8436.37 ± 29,615.07 mm³ vs. 17,213.16 ± 47,044.74 mm³ vs. 42,459 ± 84,529.83 mm³, p < 0.001). The atherosclerotic factors at high altitude, including diabetes mellitus (28.8% vs. 17.2% vs. 9.6%, p < 0.001), coronary heart disease (14.3% vs. 1.6% vs. 4.1%, p < 0.001), and hyperlipidemia (20.2% vs. 17.2% vs. 8.2%, p = 0.031), were significantly fewer than those in plain areas. Polycythemia and hemoglobin levels (138.22 ± 18.04 g/L vs. 172.87 ± 31.57 g/L vs. 171.81 ± 29.55 g/L, p < 0.001), diastolic pressure (89.98 ± 12.99 mmHg vs. 93.07 ± 17.79 mmHg vs. 95.44 ± 17.86 mmHg, p = 0.016), the percentage of hyperhomocysteinemia (13.6% in Penglai vs. 41.8% in Huzhu, p < 0.001), and the percentage of smoking (33.1% in Penglai vs. 50.0% in Huzhu, p = 0.023) were significantly elevated at high altitudes. We concluded that ischemic stroke occurred earlier and more severely in the Chinese plateau. While the atherosclerotic factors were not prominent, the primary prevention of strokes at high altitudes should emphasize anticoagulation, reducing diastolic pressure, adopting a healthy diet, and smoking cessation.

Epidemiology of stroke in urban northeast China: A population-based study 2018-2019

BACKGROUND

Stroke has been emerging as the major public health challenge in China. In the present study, we sought to comprehensively estimate of stroke burden in urban northeast China.

METHODS

We conducted the cross-sectional study in 5424 adults aged ≥ 40 years (response rate was 85.3%) living in urban northeast China. A multi-stage cluster sampling method was employed to ensure the population was representative. The prevalent stroke patients were defined as survivors on 31 March 2018. Stroke was defined based on the WHO criteria and was classified into ischemic stroke (IS) and hemorrhage stroke (HS) according to the imaging results.

RESULTS

A total of 292 stroke cases were confirmed (IS-260, 35-HS, and IS concomitant HS-3). Crude prevalence of overall stroke, IS and HS were 5.4%, 4.8% and 0.6%, respectively, and the age-standardized prevalence was 3.8%, 3.4% and 0.5%, respectively. The prevalence of stroke was significantly higher in men compared to women. Among stroke population, 4.5% had disabilities and lived with consequences of stroke. Hypertension, dyslipidemia and diabetes were highly prevalent, accounting for 80.5%, 59.7% and 39.3%, respectively, in stroke population. However, the control rates of those comorbidities were unacceptably low (13.2%, 8.1% and 40.4%, respectively).

CONCLUSION

The considerable stroke burden was observed in urban northeast China with high proportion of stroke and related risk factors. Poorly controlled comorbidities are likely to contribute to the substantial burden in the future. Long-term primary and secondary prevention should be highlighted in urban northeast China.

Prevalence of stroke and stroke related risk factors: a population based cross sectional survey in southwestern China

Background

Stroke and its risk factors epidemiological survey can help identify individuals at higher risk and therefore promote stroke prevention strategies. The aim of this study was to estimate the current prevalence of stroke and high risk stroke population, and evaluate stroke associated risk factors in southwestern China.

Methods

This was a multi-center, cross sectional survey in southwestern China from May 2015 to September 2015. The eight communities were selected at random, and 17,413 residents aged ≥40 years volunteered to participate in this survey. Data were collected through face-to-face survey using a structured questionnaire. Five hundred twenty-one participants with incomplete questionnaires on stroke history or risk factors records were excluded.

Results

A total of 16,892 people included in analysis. The overall prevalence of stroke was 3.1% (95% CI 2.6–3.9%), 17.1% of participants were the high risk stroke population. After full adjustments, hypertension, diabetes, dyslipidemia, overweight, lack of exercise and family history of stroke were significantly associated with overall stroke and ischemic stroke. The largest contributor was hypertension (population-attributable risk 23.6%), followed by dyslipidemia, physical inactivity, family history of stroke, diabetes, and overweight. However, only hypertension (OR = 3.66, 95% CI 1.82–8.23) was significantly associated with hemorrhagic stroke.

Conclusions

The prevalence of stroke and high risk stroke population was high among adults aged ≥40 years in southwestern China. Hypertension, dyslipidemia and lack of exercise were stronger contributors for stroke, these findings suggest that individual-level and population-level interventions for these leading risk factors are necessary to prevent stroke.

High prevalence of stroke and uncontrolled associated risk factors are major public health challenges in rural northeast China: A population-based study

BACKGROUND

Stroke has become a major burden and public health problem in rural China. We aimed to comprehensively assess the current status of stroke burden as well as the associated risk factors in rural northeast China.

METHODS

This population-based, cross-sectional study was conducted in 10,926 adults (response rate 85.3%) aged ≥40 years residing in rural northeast China. A multistage cluster sampling method was used to select the representative sample. The prevalent stroke cases were considered as stroke survivors on 31 August 2017. Stroke was diagnosed according to the World Health Organization's recommendations and was classified as ischemic stroke and hemorrhagic stroke based on the results of computed tomography or magnetic resonance imaging. The status of related risk factors was also evaluated.

RESULTS

Of the 10,926 participants, 731 were diagnosed with stroke (602 patients with ischemic stroke, 151 with hemorrhage stroke, and 22 with both ischemic stroke and hemorrhage stroke). The crude prevalence of overall stroke, ischemic stroke, and hemorrhage stroke was 6690.5, 5509.8, and 1382.0 per 100,000 people, respectively, and the age-standardized rate was 4903.8, 4041.7, and 990.9 per 100,000 people. Among the overall stroke population, 13.4% were living with consequences of stroke. Hypertension (86.7%), dyslipidemia (37.2%), and diabetes (24.5%) were highly prevalent in stroke participants. However, most of those comorbidities remained uncontrolled (93.7, 44.7, and 88.9%, respectively).

CONCLUSION

The burden of stroke in rural northeast China was substantial, with a high prevalence of stroke, recurrence, and disabilities. Uncontrolled comorbidities will likely contribute to recurrence and worsening disabilities in the coming decades. Strategies of long-term management of stroke and related risk factors are urgently required in rural northeast China.

The effects of cardiovascular risk factor combined anti-platelet therapy and the risk of cerebrovascular events in patients with T2DM in an urban community over 96-months follow-up: The Beijing communities diabetes study 19

OBJECTIVE

We investigated the prognostic significance of metabolic risk scores and aspirin with respect to cerebrovascular events.

METHODS

A total of 25 communities of diabetic patients were enrolled in Beijing Community Diabetes Study (BCDS) from 2008. 3413 patients with T2DM in BCDS have complete screening data, including blood glucose, blood pressure, lipid profiles and anti-platelet therapy, which were assigned metabolic score (MS) and add up to the total metabolic score (TMS). According to the total metabolic score (TMS), the patients were divided into four equal groups: Group 1 (24 < TMS < 40), Group 2 (40 < TMS < 47), Group 3 (47 < TMS < 55) and Group 4 (55 < TMS < 87). After 96 months, patients were followed-up to assess the long-term effects of the multifactorial interventions.

RESULTS

During 96-months follow-up, a total of 91 cerebrovascular events occurred, including acute cerebral infarction, acute cerebral hemorrhage and transient ischemic attack (TIA). The incidence of cerebrovascular events was higher in the Group 4 than in the Group 1. In Cox multivariate analyses, there are significant differences in incidences of cerebral infarction events among the four groups during the 96-months follow-up. Cox proportional hazards analysis revealed that, HbA1c (p ≤ 0.001), systolic pressure (p ≤ 0.001), aspirin free treatment (P = 0.0023) are independent predictor for cerebrovascular events in diabetic patients.

CONCLUSIONS

This study indicates that total metabolic score (TMS) influences the incidence of cerebrovascular events in diabetic patients. In addition to good control of blood glucose, blood pressure and lipid profiles, anti-platelet therapy is important for the prevention of cerebrovascular events in T2DM.

TRIAL REGISTRATION

ChiCTR-TRC-13003978, ChiCTR-OOC-15006090.

Prevalence of stroke and associated risk factors: a population based cross sectional study from northeast China

OBJECTIVES

Epidemiological studies aimed at stroke and its risk factors can help identify persons at higher risk and therefore promote stroke prevention strategies. We aimed to explore the current prevalence of stroke and its associated risk factors in northeast China.

DESIGN

Population based cross sectional study.

SETTING

Data were collected using a structured precoded questionnaire designed by the Stroke Screening and Prevention Programme of the National Health and Family Planning Commission of China, between January and March 2016.

PARTICIPANTS

4100 permanent residents, aged 40 years or older, who had lived in Dehui City of Jilin Province for more than 6 months volunteered to participate in the survey, with a response rate of 92.2%. For the purpose of the present analysis, 48 subjects were excluded due to missing values, giving a total of 4052 people included in this analysis.

MAIN OUTCOME MEASURE

The questionnaire included demographic characteristics, stroke related behavioural factors, personal and family medical history of stroke, physical examination and laboratory testing.

RESULTS

The overall prevalence of stroke in Jilin Province was 7.2% (95% CI 6.3% to 8.2%). Of all stroke cases, 91.7% (95% CI 87.4% to 94.6%) were ischaemic stroke and 8.3% (95% CI 5.4% to 12.6%) were haemorrhagic stroke. The prevalence rates of dyslipidaemia, smoking and hypertension were ranked as the top three cerebrovascular risk factors and were 62.1%, 61.8% and 57.3%, respectively. We found that hypertension, dyslipidaemia and lack of exercise were associated with ischaemic stroke. However, only hypertension (OR=4.064, 95% CI 1.358 to 12.160) was significantly associated with haemorrhagic stroke.

CONCLUSIONS

The prevalence of stroke, especially ischaemic stroke, and associated cerebrovascular risk factors among adults aged 40 years or older in northeast China were high. A higher regional prevalence of hypertension, dyslipidaemia and lack of exercise may be responsible.

Prevalence of Stroke and Vascular Risk Factors in China: a Nationwide Community-based Study

We aimed to investigate the prevalence of stroke and related vascular risk factors in adult population aged 40 years and older in China. We conducted a prospective cross-sectional survey in nationally representative sample of 207323 individuals from all 31 Chinese provinces in 2013. Data were used to analyze the prevalence of stroke by age, sex, geographical regions and educational level. The age-standardized prevalence of stroke was significantly higher in men than in women in all age groups (P < 0.001). The age-standardized prevalence of stroke was significantly higher in rural than in urban residents among both men and women (P < 0.001). The prevalence of stroke was inversely associated with educational level. There were striking geographical variations in stroke prevalence in China with a higher prevalence of stroke in northern provinces as compared with southern provinces of the country. The age-standardized prevalence of hypertension, diabetes, dyslipidemia, atrial fibrillation and obesity in the Chinese population aged 40 years and older were 35.24%, 9.55%, 58.72%, 1.57% and 4.09%, respectively. Stroke and related vascular risk factors remains a major public threat in China and effective primary preventive strategies that aimed at reducing the burden of stroke and its risk factors are urgently needed.

Prevalence, Incidence, Prognosis, Early Stroke Risk, and Stroke-Related Prognostic Factors of Definite or Probable Transient Ischemic Attacks in China, 2013

The epidemiological characteristics of transient ischemic attacks (TIAs) in China are unclear. In 2013, we conducted a nationally representative, door-to-door epidemiological survey on TIA in China using a complex, multistage, probability sampling design. Results showed that the weighted prevalence of TIA in China was 103.3 [95% confidence interval (CI): 83.9–127.2] per 100,000 in the population, 92.4 (75.0–113.8) per 100,000 among men, and 114.7 (87.2–151.0) per 100,000 among women. The weighted incidence of TIA was 23.9 (17.8–32.0) per 100,000 in the population, 21.3 (14.3–31.5) per 100,000 among men, and 26.6 (17.0–41.7) per 100,000 among women. No difference in average prognosis was found between TIA and stroke in the population. Weighted risk of stroke among TIA patients was 9.7% (6.5–14.3%), 11.1% (7.5–16.1%), and 12.3% (8.4–17.7%) at 2, 30, and 90 days, respectively. The risk of stroke was higher among male patients with a history of TIA than among female patients with a history of TIA (OR: 2.469; 95% CI: 1.172–5.201; P = 0.018), and higher among TIA patients with hypertension than among TIA patients without hypertension (OR: 2.671; 1.547–4.613; P < 0.001). It can be concluded that there are an estimated 1.35 million TIA patients nationwide, with 0.31 million new cases of TIA annually in China. TIA patients were not better managed prior to a stroke event. Early risk of stroke among TIA patients is high. Sex and hypertension may be stroke-associated prognostic factors among TIA patients. TIA clinics and surveillance should be integrated into the national health-care system.

Trend of declining stroke mortality in China: reasons and analysis

Introduction

There is a downward trend of stroke-related mortality in the USA. By reviewing all published articles on stroke mortality in China, we analysed its trend and possible factors that have influenced the trend.

Methods

Both English and Chinese literatures were searched on the mortality of stroke or cerebrovascular diseases in China. Potential papers related to this topic were identified from PubMed, Medline, Embase, Cochrane Library, Wanfang Database, SINOMED and China National Knowledge Infrastructure databases.

Results

Comparing the results from the most recent population-based epidemiological survey and databank from the national Center for Disease Control and Prevention, the age-adjusted stroke mortality rate has shown a downward trend among both urban and rural population in the past 30 years in China. Comparing with 30 years ago, the rate of stroke mortality has decreased by more than 31% in urban/suburban population and 11% in rural population. In men, the age-adjusted stroke mortality rate decreased by 18.9% and in women by 24.9% between 1994 and 2013. Factors that may have contributed to the trend of decreased stroke mortality rate include (1) improved healthcare coverage and healthcare environment; (2) improved treatment options and medical technology; (3) support by government to educate the public on stroke and stroke prevention; and (4) improved public knowledge on stroke.

Conclusions

The age-adjusted stroke mortality rate in China has shown a downward trend among both urban and rural population in the past 30 years. The major influencing factors that helped in reducing stroke mortality in China included improved healthcare coverage, healthcare environment, the updated treatment options and modern medical technology.

Mortality of Stroke and Its Subtypes in China: Results from a Nationwide Population-Based Survey

Background: In China, stroke is the leading cause of death and contributes to a heavy disease burden. However, a nationwide population-based survey of the mortality of stroke and its subtypes is lacking for this country. Methods: Data derived from the National Epidemiological Survey of Stroke in China, which was a multistage, stratified clustering sampling-designed, cross-sectional survey, were analyzed. Mortality rate analyses were performed for 476,156 participants ≥20 years old from September 1, 2012 to August 31, 2013. Results: Of the 476,156 participants in the investigated population, 364 died of ischemic stroke, 373 of hemorrhagic stroke, and 21 of stroke of undetermined pathological type. The age-standardized mortality rates per 100,000 person-years among those aged ≥20 years were 114.8 for total stroke, 56.5 for ischemic stroke, and 55.8 for hemorrhagic stroke. The age-standardized mortality rates of total stroke, ischemic stroke, and hemorrhagic stroke were all higher in rural areas than those in urban areas. The stroke mortality rate was higher in the northern regions than in the south. An estimated 1.12 million people aged ≥20 years in China died of stroke during the period from September 1, 2012 to August 31, 2013. Conclusions: The burden of stroke in China is still heavy. Greater attention should be paid to improve strategies for preventing stroke.

Prevalence, Incidence, and Mortality of Stroke in China

Background:

China bears the biggest stroke burden in the world. However, little is known about the current prevalence, incidence, and mortality of stroke at the national level, and the trend in the past 30 years.

Methods:

In 2013, a nationally representative door-to-door survey was conducted in 155 urban and rural centers in 31 provinces in China, totaling 480 687 adults aged ≥20 years. All stroke survivors were considered as prevalent stroke cases at the prevalent time (August 31, 2013). First-ever strokes that occurred during 1 year preceding the survey point-prevalent time were considered as incident cases. According to computed tomography/MRI/autopsy findings, strokes were categorized into ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and stroke of undetermined type.

Results:

Of 480 687 participants, 7672 were diagnosed with a prevalent stroke (1596.0/100 000 people) and 1643 with incident strokes (345.1/100 000 person-years). The age-standardized prevalence, incidence, and mortality rates were 1114.8/100 000 people, 246.8 and 114.8/100 000 person-years, respectively. Pathological type of stroke was documented by computed tomography/MRI brain scanning in 90% of prevalent and 83% of incident stroke cases. Among incident and prevalent strokes, ischemic stroke constituted 69.6% and 77.8%, intracerebral hemorrhage 23.8% and 15.8%, subarachnoid hemorrhage 4.4% and 4.4%, and undetermined type 2.1% and 2.0%, respectively. Age-specific stroke prevalence in men aged ≥40 years was significantly greater than the prevalence in women ( P <0.001). The most prevalent risk factors among stroke survivors were hypertension (88%), smoking (48%), and alcohol use (44%). Stroke prevalence estimates in 2013 were statistically greater than those reported in China 3 decades ago, especially among rural residents ( P =0.017). The highest annual incidence and mortality of stroke was in Northeast (365 and 159/100 000 person-years), then Central areas (326 and 154/100 000 person-years), and the lowest incidence was in Southwest China (154/100 000 person-years), and the lowest mortality was in South China (65/100 000 person-years) ( P <0.002).

Conclusions:

Stroke burden in China has increased over the past 30 years, and remains particularly high in rural areas. There is a north-to-south gradient in stroke in China, with the greatest stroke burden observed in the northern and central regions.

MIS Score: Prediction Model for Minimally Invasive Surgery

BACKGROUND

Reports suggest that patients with spontaneous intracerebral hemorrhage (ICH) can benefit from minimally invasive surgery, but the inclusion criterion for operation is controversial. This article analyzes factors affecting the 30-day prognoses of patients who have received minimally invasive surgery and proposes a simple grading scale that represents clinical operation effectiveness.

METHODS

The records of 101 patients with spontaneous ICH presenting to Qianfoshan Hospital were reviewed. Factors affecting their 30-day prognosis were identified by logistic regression. A clinical grading scale, the MIS score, was developed by weighting the independent predictors based on these factors.

RESULTS

Univariate analysis revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.01), age ≥80 years (P < 0.05), blood glucose (P < 0.01), ICH volume (P < 0.01), operation time (P < 0.05), and presence of intraventricular hemorrhage (P < 0.001). Logistic regression revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.05), age (P < 0.05), ICH volume (P < 0.01), and presence of intraventricular hemorrhage (P < 0.05). The MIS score was developed accordingly; 39 patients with 0-1 MIS scores had favorable prognoses, whereas only 9 patients with 2-5 MIS scores had poor prognoses.

CONCLUSIONS

The MIS score is a simple grading scale that can be used to select patients who are suited for minimal invasive drainage surgery. When MIS score is 0-1, minimal invasive surgery is strongly recommended for patients with spontaneous cerebral hemorrhage. The scale merits further prospective studies to fully determine its efficacy.

Clinical study to assess the outcome in surgically managed patients of spontaneous intracerebral hemorrhage

Introduction

Spontaneous intracerebral hemorrhage (SICH) subtype of stroke is characterized by bleeding into brain parenchyma which is not accompanied by trauma. Emergency surgical evacuation of large size SICH increases the chances of survival but does not help in functional recovery of the patients. The present study was conducted to assess the outcome of surgical management in patients with SICH.

Materials and Methods

All patients who were diagnosed with SICH and underwent surgical evacuation of the hematoma included in the study. The outcome at 1 month was obtained through follow-up visits/telephonic interview when the former is not available. The primary outcome measure was in hospital mortality/condition at the time of discharge/neurological deficit/modified Rankin Scale (mRS) at 1 month follow-up.

Results

Out of 87 patients, 49 patients (63%) were male and 38 patients (37%) were females, male to female ratio was 1.2:0.8. Nearly 42% patient had systolic blood pressure with in normal range; however, in almost 50% of the cases, the systolic blood pressure at the time of admission was more than 140 mmHg. mRS was assessed for the patients at the time of admission, 39% patients had slight disability, 15% patients had moderate disability, 11% patients had moderately severe disability, and 33% patients had severe disability. Mortality was relatively higher in patients who had admission systolic blood pressure more than 140 mmHg (51% vs. 43%). mRS was assessed for the patients at the time of discharge after completion surgery and the severity of scale.

Conclusions

Hypertension was found to be most common comorbid illness followed by smoking, alcohol intake, and diabetes mellitus. Hematoma was evacuated in 58% of the cases; it was supplement with decompressive craniectomy in 12% of the cases. Morality was relatively higher in patients who had admission systolic blood pressure more than 140 mmHg. Mortality was highest in <40 years age group in age group of 40-65 years, the mortality was 30.6%, and in >65 years age group, mortality was 15.4%; however, this was not statistically significant. Only 10% of patients can recover and live independently at 1 month, and only 20% of the survivors were independent at 6 months.

Prevalence and incidence of neurological disorders among adult Ugandans in rural and urban Mukono district; a cross-sectional study

Background

The burden of neurological diseases is increasing in developing countries. However, there is a prominent scarcity of literature on the incidence of neurological diseases in sub-Saharan Africa. This study was therefore undertaken to determine the prevalence and incidence of neurological diseases in this setting to serve as a baseline for planning and care for neurological disorders in Uganda.

Methods

The study was conducted within rural and urban Mukono district, east of Kampala city of Uganda, central region. Over a period of six months, a cross sectional survey was conducted and screening was performed using a standardized questionnaire. All subjects with neurological symptoms and signs were reviewed by a team of neurologists and neurological diagnoses made.

Results

Of the 3000 study subjects, 50.3% (1510/3000) were from the rural setting. Out of the participants screened, 67.4% were female, with a median age of 33 years. Among the 98 subjects with confirmed neurological disorders, the frequency of diseases was as follows; peripheral neuropathy (46.2%), chronic headaches (26.4%), and epilepsy (8.5%), followed by pain syndromes (7.5%), stroke (6.6%) and tremors/Parkinson disease (3.8%). The crude prevalence rates of these disorders (95% CI) were 14.3% (8.5–24.1); 13.3% (7.7–22.8); 33.7% (23.9–47.4) for stroke, epilepsy and peripheral neuropathy respectively. Peripheral neuropathy followed by chronic headaches had the highest estimated incidence/1000 years. Stroke had an estimated incidence of 3.6 new cases with 95% CI of (2.1–6.1)/1000 years.

Conclusion

Peripheral neuropathy, chronic headaches and epilepsy disorders are major causes of morbidity in Sub-Saharan settings. There is an urgent need of more robust and powered studies to determine the incidence of these diseases.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0732-y) contains supplementary material, which is available to authorized users.

The Epidemiology of Stroke in the East Asian Region: A Literature-Based Review

Stroke is a leading cause of morbidity and mortality in the developed world. Our objective was to review comparable studies of stroke incidence, prevalence, and subtypes in the East Asian region. English language epidemiologic studies of stroke published from 1984 through 2004 were identified for the East Asian region (China, Hong Kong, Taiwan, Japan, North and South Korea and the ASEAN countries). The Sudlow–Warlow criteria were modified to identify comparable studies. Stroke epidemiology is relatively well characterized in China, Taiwan, and Japan; however, little information is available for other countries. Four studies of stroke incidence, from China, Taiwan, and Japan, were identified, which reported a total of 4995 first-ever stroke events. There was an over twofold difference in the age-adjusted incidence of stroke between the Chinese Seven Cities and Okinawa study (483 vs 201 per 100 000). The 1-month case fatality rate ranged from 12·7% to 17·3%. Only one population-based study on stroke prevalence, from Taiwan, was identified: Studies show the relatively high proportion of hemorrhagic stroke (30%). Stroke epidemiology is relatively well characterized in China, Japan, and Taiwan but not in other countries in the region. More recent data are needed to monitor stroke prevention efforts and guide planning of health care resources in the region.

Stroke survivors in low- and middle-income countries: A meta-analysis of prevalence and secular trends

PURPOSE

To provide an up-to-date estimate on the changing prevalence of stroke survivors, and examines the geographic and socioeconomic variations in low and middle-income countries (LMICs).

METHODS

We searched MEDLINE, EMBASE, SCOPUS and Web of Science databases and systematically reviewed articles reporting stroke prevalence and risk factors from inception to July 2015. Pooled prevalence estimates and secular trends based on random-effects models were conducted across LMICs, World Bank regions and income groups.

RESULTS

Overall, 101 eligible community-based studies were included in the meta-analysis. The pooled crude prevalence of stroke survivors was highest in Latin America and Caribbean (21.2 per 1000, 95% CI 13.7 to 30.29) but lowest in sub-Saharan Africa (3.5 per 1000, 95% CI 1.9 to 5.7). Steepest increase in stroke prevalence occurred in low-income countries, increasing by 14.3% annually while the lowest increase occurred in lower-middle income countries (6% annually), and for every 10years increase in participants' mean age, the prevalence of stroke survivors increases by 62% (95% CI 6% to 147%).

CONCLUSION

The prevalence estimates of stroke survivors are significantly different across LMICs in both magnitude and secular trend. Improved stroke surveillance and care, as well as better management of the underlying risk factors, primarily undetected or uncontrolled high blood pressure (HBP) are needed.

Relation of Paraoxonase1, Arylesterase and Lipid Profile in Ischemic Stroke Patients

BACKGROUND

Paraoxonase 1 (PON1) is an enzyme associated with High density lipoprotein (HDL) in blood and it is considered to have antioxidant and antiatherogenic properties. PON1 plays an important role in protecting HDL and especially low density lipoprotein (LDL) from oxidative modification by hydrolyzing lipid peroxides which are known to be associated with many vascular diseases including atherosclerosis and ischemic stroke.

AIM

The aim of the study was to evaluate and correlate serum paraoxonase (PON1) and arylesterase (ARE) activities as well as lipid profile levels in patients with ischemic stroke.

MATERIALS AND METHODS

The study population was comprised of 50 ischemic stroke patients and 50 healthy controls. The serum PON1 and ARE activities were measured spectrophotometrically by using paraoxon and phenylacetate as substrate respectively by Eckerson method. Serum lipid was measured using routine biochemical method.

RESULTS

The normality of the distribution of the parameters are assessed by Shapiro-Wilk test. Two sample t-test is applied for hypothesis testing. The serum PONI and arylesterase ARE decreased significantly in ischemic stroke patients (p<0.001). The PON1 was positively correlated with HDL.

CONCLUSION

This study strongly suggests that the estimation of HDL-C associated PON1 enzyme gives valuable information for prediction of risk of ischemic stroke due to cerebrovascular thromboembolism. The result shows that PON1 and ARE could be considered as a risk factors for ischemic stroke.

Infarction of the corpus callosum: a retrospective clinical investigation

Objectives

The aim of this study was to investigate patients with ischemic infarctions in the territory of the corpus callosum to advance our understanding of this rare stroke subtype by providing comprehensive descriptive and epidemiological data.

Methods

From January 1, 2010 to June 30, 2014, all cases of acute ischemic stroke diagnosed by clinical manifestation and diffusion weighted imaging in Dalian Municipal Central Hospital were investigated. The patients presenting with corpus callosum infarctions were selected and further allocated into genu and/or body and splenium infarction groups. Proportion, lesion patterns, clinical features, risk factors and etiology of corpus callosum infarction were analyzed.

Results

Out of 1,629 cases, 59 patients (3.6%) with corpus callosum infarctions were identified by diffusion weighted imaging, including 7 patients who had ischemic lesions restricted to the corpus callosum territory. Thirty six patients had lesions in the splenium (61.0%). Corpus callosum infarction patients suffered from a broad spectrum of symptoms including weakness and/or numbness of the limbs, clumsy speech, and vertigo, which could not be explained by lesions in corpus callosum. A classical callosal disconnection syndrome was found in 2 out of all patients with corpus callosum infarctions. Statistical differences in the risk factor and infarct pattern between the genu and/or body group and splenium group were revealed.

Conclusion

Corpus callosum infarction and the callosal disconnection syndrome were generally rare. The most susceptible location of ischemic corpus callosum lesion was the splenium. Splenium infarctions were often associated with bilateral cerebral hemisphere involvement (46.2%). The genu and/or body infarctions were associated with atherosclerosis. The most common cause of corpus callosum infarction probably was embolism.

Prevalence of stroke in three semi-urban communities in middle-belt region of Nigeria: a door to door survey

Introduction

The burden of stroke has been projected to increase for developing countries, but data are limited, especially in sub-Saharan Africa. This necessitated this study to determine the stroke prevalence in a semi urban community in middle-belt region of Nigeria.

Methods

A two-phase door-to-door study was performed in three semi-urban communities of Kwara state; in the first phase 12,992 residents were screened and probable stroke cases were identified by trained health care workers. In the second phase individuals adjudged to be positive for stroke were screened with a stroke-specific questionnaire and made to undergo a complete neurological examination by a neurologist. Stroke diagnosis was based on clinical evaluation using WHO criteria.

Results

Out of the numbers that were screened, 18 probable stroke cases were identified in the first stage, and of these, 17 fulfilled WHO criteria for stroke, giving a crude prevalence rate of 1.31/1000 population. The prevalence of stroke was higher among the males than the females (1.54/1000 vs. 1.08/1000) with a ratio 1.4: 1. Sixteen subjects (94.1%) had one or more risk factors for stroke. Uncontrolled systemic hypertension (82.4%) was the commonest risk factors for stroke followed by transient ischaemic attack (TIA) (41.2%).

Conclusion

Stroke is a condition that is prevalent in our environment; especially in older adults and men. Uncontrolled systemic hypertension and previous transient ischaemic attacks were the commonest risk factors for stroke in our community.

Predictors of Restenosis After Carotid Endarterectomy

Introduction:

Carotid endarterectomy (CEA) is a well-established surgical technique in stroke prophylaxis. Long-term follow-up data on restenosis or recurrent neurological symptoms in Oriental patients are unclear.

Methods:

Patients’ notes from 1994 to 2011 were retrospectively reviewed and analyzed. A total of 301 cases of CEA were identified.

Results:

A lower restenosis rate was associated with the use of patch and never smokers in both univariate and multivariate analysis. Use of patch and never smokers were also found to be significantly associated with longer restenosis-free survival. Use of patch and postoperative use of statin were associated with better overall survival in both univariate and multivariate analysis.

Conclusion:

Use of patch and lack of smoking history are associated with less restenosis and longer restenosis-free survival. Use of patch and use of postoperative statin improves overall survival. Although restenosis after CEA is relatively common, reintervention was rarely necessary.

Association of Kallikrein gene polymorphisms with sporadic intracranial aneurysms in the Chinese population

OBJECT

Variants of Kallikreins have been shown to be risk factors for intracranial aneurysm (IA) in a Finnish population. In the present study, the authors investigated the correlation between polymorphisms in the Kallikrein gene cluster and IAs in the Chinese population.

METHODS

The association of Kallikrein variants (rs1722561 and rs1701946) with sporadic IAs was tested in 308 cases and 443 controls. The differences in allelic frequencies between patients and the control group were evaluated with the chi-square test.

RESULTS

The C allele of rs1722561 showed a significant reduction in the risk of sporadic IA (OR 0.71, 95% CI 0.53-0.95; p = 0.023). However, no association of the variant rs1701946 with sporadic IA was found (OR 0.78, 95% CI 0.57-1.06; p = 0.115).

CONCLUSIONS

The variant rs1722561 of Kallikreins might reduce the risk of sporadic IAs among individuals of Chinese Han ethnicity. This study confirms the association between Kallikreins and IAs.

Is There a Stroke Belt in China and Why?

Background and Purpose—

In 1960s, a stroke belt with high stroke mortality was discovered in the southeast United States. In China, where stroke is the leading cause of death, we aimed to determine whether a focal region of high stroke incidence (stroke belt) exits and, if so, the possible causal and modifiable factors.

Methods—

We systematically reviewed all studies of stroke incidence in China between 1980 and 2010, and included those which met our criteria for a high-quality study. Criteria for a provincial region of high stroke incidence were ranking in the top one third of all provinces for stroke incidence and ranking of more than one third of prefectural regions within the province in the top two sevenths of all prefectural regions for stroke incidence. We also reviewed regional distribution of major vascular risk factors, socioeconomic status, and demographic profiles in China.

Results—

Nine eligible studies provided data on the incidence of stroke in 32 of 34 provincial regions of China (with Hong Kong and Macao as exceptions) and 52% of the 347 prefectural regions. Nine provincial regions (Heilongjiang, Tibet, Jilin, Liaoning, Xinjiang, Hebei, Inner Mongolia, Beijing, and Ningxia) met our criteria for a region of high stroke incidence and constitute a stroke belt in north and west China. The incidence of stroke in the stroke belt was 236.2 per 100 000 population compared with 109.7 in regions outside the belt (rate ratio, 2.16; 95% confidence interval, 2.10–2.22). The mean population prevalence of hypertension and overweight (body mass index, >25) was greater in the stroke belt than that in other regions (15.3% versus 10.3%, P <0.001; 21.1% versus 12.3%, P =0.013, respectively). The prevalence of hypertension and overweight also correlated significantly with regional stroke incidence ( R =0.642, P <0.001; R =0.438, P =0.014, respectively, by Spearman rank correlation).

Conclusions—

A stroke belt of high stroke incidence exists in 9 provincial regions of north and west China. The stroke belt may be caused, at least in part, by a higher population prevalence of hypertension and excess body weight. Lowering blood pressure and body weight in the stroke belt may reduce the geographic disparity in stroke risk and incidence in China.

Stroke Rehabilitation in China: A Systematic Review and Meta-Analysis

Background

Stroke rehabilitation is regarded as an essential component of organized care, therefore withholding treatment is considered unethical in Western trials. Poststroke rehabilitation is not standard in China, and trials with no treatment controls have been possible. We believed aggregation of these data represented a unique opportunity to examine the ‘effect size’ of this intervention.

Aim

The aim of this study was to systematically review randomized controlled trials that compare rehabilitation to standard care after stroke in China.

Methods

We searched 24 databases including Wanfangdata (China), MEDLINE, EMBASE, CENTRAL, Cochrane Stroke Group Register, and Cochrane Central Register of Controlled trials. The primary outcome of interest was activities of daily living (Barthel Index), and the secondary outcome was disability (Fugl-Meyer Score). Random-effect meta-analysis was performed. Results Thirty-seven randomized controlled trials consisting of 5916 patients met inclusion criteria. Mean age reported in each study range from 47·2 to 72·5 years, 52·6% were male and 23·8% had a haemorrhagic stroke. Rehabilitation interventions varied between studies, but all included additional exercise therapy. Control patients had no formal rehabilitation. Patients who received rehabilitation showed marked improvements in Barthel Index (standardized mean difference: 1·04, 95% confidence interval: 0·88–1·21, P < 0·001, I2 = 85·9%) and Fugl-Meyer Score (standardized mean difference: 1·10, 95% confidence interval: 0·82–1·38, P < 0·001, I2 = 94·3%) compared with controls. However, reporting quality was low, and time to start of rehabilitation was often unclear.

Conclusion

These data provide some evidence that rehabilitation poststroke is more effective than no rehabilitation, improving activities of daily living and reducing disability. Although results are limited by low reporting quality and study heterogeneity, conducting research in countries in which rehabilitation is not standard care provides an opportunity to advance our understanding and should be encouraged.

Prevalence of cardiovascular disease and risk factors in a rural district of Beijing, China: a population-based survey of 58,308 residents

Background

Cardiovascular disease (CVD) is the leading cause of global disease burden. Although stroke was thought to be more prevalent than coronary heart disease (CHD) in Chinese, the epidemic pattern might have been changed in some rural areas nowadays. This study was to estimate up-to-date prevalence of CVD and its risk factors in rural communities of Fangshan District, Beijing, China.

Methods

A cross-sectional population survey was carried out by stratified cluster sampling. A total of 58,308 rural residents aged over 40 years were surveyed by face-to-face interview and physical examination during 2008 and 2010. The standardized prevalence was calculated according to adult sample data of China's 5th Population Census in 2000, and the adjusted prevalence odds ratio (POR) was calculated for the association of CHD/stroke with its cardiovascular risk factors in multivariate logistic regression models.

Results

Age- and sex-standardized prevalence was 5.6% for CHD (5.2% in males and 5.9% in females), higher than the counterpart of 3.7% (4.7% in males and 2.6% in females) for stroke. Compared with previous studies, higher prevalence of 7.7%, 47.2%, 53.3% in males and 8.2%, 44.8%, 60.7% in females for diabetes, hypertension and overweight/obesity were presented accordingly. Moreover, adjusted POR (95% confidence interval) of diabetes, obesity, stage 1 and stage 2 hypertension for CHD as 2.51 (2.29 to 2.75), 1.53 (1.38 to 1.70), 1.13 (1.02 to 1.26) and 1.35 (1.20 to 1.52), and for stroke as 2.24 (1.98 to 2.52), 1.25 (1.09 to 1.44), 1.44 (1.25 to 1.66) and 1.70 (1.46 to 1.98) were shown respectively in the multivariate logistic regression models.

Conclusions

High prevalence of CVD and probably changed epidemic pattern in rural communities of Beijing, together with the prevalent cardiovascular risk factors and population aging, might cause public health challenges in rural Chinese population.

Dietary patterns are associated with stroke in Chinese adults

We recently featured Chinese dietary patterns that were associated with obesity, hyperglycemia, hypertension, and metabolic syndrome. In this study, we examined the association of those dietary patterns and risk of stroke among 26,276 Chinese adults aged ≥45 y by using data from the 2002 China National Nutrition and Health Survey and explored whether those associations were mediated by obesity, hypertension, hyperglycemia, and other cardiovascular risk factors. The traditional southern Chinese dietary pattern, characterized by high intakes of rice and vegetables and moderate intakes in animal foods, was related to the lowest prevalence of stroke. Compared to the traditional southern dietary pattern, the traditional northern Chinese dietary pattern, characterized by high intakes of refined cereal products, potatoes, and salted vegetables, was associated with an elevated risk of stroke [OR = 1.96 (95% CI = 1.48-2.60); P < 0.0001]. Adjustment for conventional cardiovascular risk factors did not appreciably change the association [multivariate adjusted OR = 1.59 (95%CI = 1.16-2.17); P = 0.004]. The Western dietary pattern characterized by high consumption of beef, fruit, eggs, poultry, and seafood is also associated with an elevated risk of stroke [OR = 2.36 (95%CI = 1.82-3.06); P < 0.0001], but the associations became nonsignificant after adjustment for obesity, hypertension, hyperglycemia, and dyslipidemia. In conclusion, we found that the traditional southern dietary pattern was related to low prevalence of stroke and the traditional northern dietary pattern was associated with an increased stroke risk. The Western dietary patterns also association with high risk of stroke, which was largely mediated by obesity, hypertension, hyperglycemia, and dyslipidemia.

Prevalence of stroke and related burden among older people living in Latin America, India and China

OBJECTIVES

Despite the growing importance of stroke in developing countries, little is known of stroke burden in survivors. The authors investigated the prevalence of self-reported stroke, stroke-related disability, dependence and care-giver strain in Latin America (LA), China and India.

METHODS

Cross-sectional surveys were conducted on individuals aged 65+ (n=15 022) living in specified catchment areas. Self-reported stroke diagnosis, disability, care needs and care giver burden were assessed using a standardised protocol. For those reporting stroke, the correlates of disability, dependence and care-giver burden were estimated at each site using Poisson or linear regression, and combined meta-analytically.

RESULTS

The prevalence of self-reported stroke ranged between 6% and 9% across most LA sites and urban China, but was much lower in urban India (1.9%), and in rural sites in India (1.1%), China (1.6%) and Peru (2.7%). The proportion of stroke survivors needing care varied between 20% and 39% in LA sites but was higher in rural China (44%), urban China (54%) and rural India (73%). Comorbid dementia and depression were the main correlates of disability and dependence.

CONCLUSION

The prevalence of stroke in urban LA and Chinese sites is nearly as high as in industrialised countries. High levels of disability and dependence in the other mainly rural and less-developed sites suggest underascertainment of less severe cases as one likely explanation for the lower prevalence in those settings. As the health transition proceeds, a further increase in numbers of older stroke survivors is to be anticipated. In addition to prevention, stroke rehabilitation and long-term care needs should be addressed.

Vital and functional outcomes of the first-ever hemispheric stroke, epidemiological comparative study between Kunming (China) and Limoges (France)

BACKGROUND

Clinical outcomes and socioeconomic consequences after a stroke may differ between regions.

METHODS

One cohort was established prospectively in Kunming (China) to compare with a cohort of 156 stroke patients included in Limoges (France). During 1 year, patients hospitalized within 48 hours for a first-ever hemispheric stroke were included. Demographic data and neurocardiovascular risk factors were registered. Hemiplegia was evaluated. Functional outcome was assessed using the Barthel Index (BI) after 3 months.

RESULTS

One hundred and eighteen patients were included in Kunming. Patients of Kunming were younger (61.4 ± 13.4 vs 72.3 ± 14.6 years in Limoges, P<0.0001), more involved in professional activity (36.4% vs 12.8%, P<0.0001). Survival analysis indicated that mortality did not differ between cohorts, but independently predicted by coma at the 2nd day (HR=9.33, 95% CI [4.39, 19.78]) and age>70 years (HR=6.29, 95% CI [2.36, 16.59]). Despite a better baseline BI for patients of Kunming (50.0 ± 34.9 vs 37.4 ± 34.2, P=0.0031), after adjustment for confusing, patients in Limoges had a 2.11 OR 95% CI [1.03, 4.31]) to reach a BI>80 at 3 months.

CONCLUSIONS

Functional recovery for patients of Kunming was not as good as expected. The socioeconomic consequences of stroke in Kunming are significant as they involved younger subjects who were still in work.

Nontraumatic hemorrhagic stroke in young adults in taiwan

We reviewed the medical records and imaging studies on the in-hospital patients to investigate the clinical and etiological patterns in hemorrhagic stroke in young patients. We evaluated 210 patients (131 males and 79 females) aged 15-45 years who had traumatic hemorrhagic stroke between April 1, 1986, and November 30, 1992. Nontraumatic intracerebral hemorrhage was diagnosed in 170 patients (80.9%). The main causes of nontraumatic intracerebral hemorrhage were hypertension, ruptured arteriovenous malformation, and blood dyscrasia. A cause was not found in 42 patients (24.7%). Subarachnoid hemorrhage was found in 40 patients (19.1%). The main causes were ruptured aneurysms and arteriovenous malformations. The overall in-hospital survival of young patients with hemorrhagic stroke was 64.7%. Young adults with nontraumatic intracerebral and subarachnoid hemorrhage are a heterogeneous group. Hypertension accounts for about one-third of intracerebral hemorrhage and is an important preventable cause of hemorrhagic stroke in young adults in Taiwan.

Chapter 50: history of tropical neurology

Tropical neurology began less than two centuries ago. Consumption of dietary toxins predominated at the beginning and gave birth to the geographic entity. The story moved from lathyrism through Jamaican neuropathy to cassava-induced epidemic neuropathy, which was contrasted with Konzo, also associated with cassava. Other tropical diseases enumerated with chronological details include: Chaga's diseases, kwashiorkor, Madras type of motor neuron disease, atlanto-axial dislocation, Burkitt's lymphoma and Kuru, associated with cannibalism among the Fore linguistic group in New Guinea. More recent documentation includes the Cuban neuropathy in 1991 with an epidemic of visual loss and neuropathy, Anaphe venata entomophagy in Nigeria presenting as seasonal ataxia, and neurological aspects of the human immunodeficiency virus infection complete the picture. With time, professional associations were formed and the pioneers were given prominence. The World Federation of Neurology featured Geographic Neurology as a theme in 1977 and Tropical Neurology was given prominence at its 1989 meeting in New Delhi, India. The situation remains unchanged with regards to rare diseases like Meniere's, multiple sclerosis, hereditary disorders. However, with westernization and continued urbanization, changing disease patterns are being observed and tropical neurology may depart from dietary toxins to more western world-type disorders.

Stroke and active life expectancy among older adults in Beijing, China

PURPOSE

Increasing stroke prevalence, population ageing and economic change in China necessitate a better understanding of the impact of stroke. This study examines the impact of stroke on disability and trends over time.

METHOD

Data are from longitudinal surveys conducted in the Beijing municipality from 1992 to 1997 and 2000 to 2004. Multi-state life tables constructed from hazard models are used to estimate life expectancy (LE) and active life expectancy (ALE). The active state is defined using six functional tasks and mortality is determined using interviewer follow-ups.

RESULTS

LE and ALE are higher among those without stroke. Population-based estimates for the cohort observed beginning in 1992 indicate LE at age 55 of about 17 for those who have had a stroke and about 21 for others, whereas years of active life are about 14 and 19, respectively. Disability status at baseline is important for determining ALE. For those active, LE and ALE patterns are similar regardless of stroke status. For those inactive, the stroke group lives almost their entire lives inactive. Stroke reduces years of life by 20-40%, but active life by up to 90%.

CONCLUSION

Trends in ALE among those with stroke suggest possible influences of rapid development, concomitant improvement in health care and an increased focus on disease management.

Surveillance of Trend and Distribution of Stroke Mortality by Subtype, Age, Gender, and Geographic Areas in Tianjin, China, 1999–2006

Background

The purpose of this study was to analyze the epidemiological trend and distribution of stroke mortality in the city of Tianjin, China, in order to provide evidence for the prevention and control of stroke.

Methods

The study was based on 102 718 cases of stroke mortality in Tianjin between 1999 and 2006. The cause of death was coded according to the International Classification of Diseases into stroke subtypes. Standardized mortality rates were calculated for stroke and its subtypes, adjusted for age and gender using the year 2000 world standard population. The age, gender, and geographic distribution of stroke and subtype mortality were analyzed. χ2-tests were used to determine the statistical significance of differences in mortality trends.

Results

The stroke mortality rate in Tianjin declined from 133·52/100000/year in 1999 to 102·52/100000/year in 2006. The stroke mortality rate for males was higher than that for females. Stroke mortality rates increased with increasing age. The subtypes of stroke have changed considerably in Tianjin. Hemorrhagic was major in 1999–2001, while cerebral infarction attained the first rank and accounted for more than 50% of stroke mortality in 2002–2006. The most pronounced finding was that the proportion of ischemic stroke was 66·65% in the urban population and over 20% higher than that in the rural area. Stroke in the suburban area was mainly hemorrhagic stroke, up to 62·67%.

Conclusions

There are significant differences in the distribution of stroke mortality by subtype, age, gender, and geographic areas in Tianjin, China. Various subtypes of stroke are associated with different risk factors and therefore require different public health prevention and control measures. This study provides pertinent information for formulation of measures for the prevention and control of stroke.

Minimally invasive craniopuncture therapy vs. conservative treatment for spontaneous intracerebral hemorrhage: results from a randomized clinical trial in China

BACKGROUND AND PURPOSES

To evaluate the effects of minimally invasive craniopuncture therapy compared with conservative treatment in treating intracerebral hemorrhage (25-40 ml) in the basal ganglion.

METHODS

A multicenter, randomized control clinical trial comprised 465 cases of hemorrhage in the basal ganglion from 42 hospitals in China. Three hundred and seventy-seven patients with hemorrhage were randomly assigned to receive minimally invasive craniopuncture therapy (n=195) or conservative control treatment (n=182). The main indices of evaluation were the degree of neurological impairment at the 14th day after treatment, activities of daily living at the end of the 3rd month and the case fatality within 3 months.

RESULTS

Improvement of neurological function in the minimally invasive craniopuncture group was significantly better than that in the control group at the 14th day (chi(2)=7.93, P=0.02). At the end of the 3rd month, there was a significant difference between the two groups in activities of daily living score (chi(2)=23.13, P<0.001). The proportion of dependent survival patients (modified Rankin scale >2) in the craniopuncture group (40.9%) was significantly lower than that in the conservative group (63.0%) at the end of the 3rd month (chi(2)=16.95, P<0.01). There was no significant difference in the cumulative fatality rates within three months between the two groups [6.7% (13/195) in the craniopuncture group and 8.8% (16/182) in the conservative group].

CONCLUSIONS

This minimally invasive craniopuncture technique can improve the independent survival of patients with small basal ganglion hemorrhage. It is a safe and practical technique in treating cerebral hemorrhage.

Stroke in China: epidemiology, prevention, and management strategies

In this review, we examine the current status of stroke epidemiology, prevention, and management strategies in mainland China. The main findings suggested that total age-adjusted incidence of first-ever stroke in China is not very different from that in developed countries. Stroke incidence, mortality, and prevalence varied widely among different regions within China, with a noticeable north-south gradient. The proportion of intracerebral haemorrhage was high and reached 55% in one city. Hypertension is the most important risk factor for stroke. The mass approach combined with a high-risk approach for stroke prevention showed encouraging effects, and various unconventional local therapeutic traditions are commonly used to treat stroke in China. Several national guidelines on stroke prevention and treatment have been developed. Because of methodological limitations in the epidemiology studies, data are unreliable in terms of making any firm conclusions. Up-to-date, well-designed, and well-done epidemiological studies and therapeutic trials in China are urgently needed.

Spontaneous intracerebral hemorrhage in young adults

Few studies have addressed intracerebral hemorrhage (ICH) in younger adults. We studied spontaneous ICH in adults <or=45 years of age. We retrospectively reviewed patients hospitalized with ICH between 2000 and 2001 to investigate incidence, etiology, risk factors, bleeding sites, management, and prognosis. Patients (224 men, 72 women; 37.0 +/- 7.7 years) had a mortality rate of 24%. The most common risk factor for mortality was hypertension (HTN) (48.7%). Bleeding was most common in the ganglion (49.0%). Multiple hemorrhages (83.3%) caused the highest mortality, with the most common cause of mortality being HTN (46.6%). Coagulopathy (62.5%) caused the highest mortality based on etiologic classification. Recurrent HTN-induced hemorrhage rate was 3.6%. In Taiwanese adults <or=45 years of age, ICHs mainly involve the ganglion and result from HTN. Rates of HTN-induced hemorrhage are higher in Taiwan (46.6%) than elsewhere. Differences between races or countries should be investigated further.

Stroke in Asia

The epidemic of cardiovascular disease across most of Asia is at a different stage from that in the West; the incidence and prevalence of stroke are increasing steadily, associated with nutritional changes and aging of the population. Epidemiologic data, crucial in combating stroke, have been relatively sparse in Asian populations, but a few international collaborative studies on stroke have been in progress for several years. Through these, we now know that ischemic stroke is actually the most frequent type of cerebrovascular accident in Asia, although hemorrhagic stroke remains more common in Asia than in the West. Also, the percentage of ischemic stroke attributable to intracranial vascular disease is much higher than in the West. In Japan and a few other countries, stroke rates are declining; however, increasing rates in most other countries make primary prevention of critical importance in minimizing the severe impact of this epidemic in Asia.

Prevalence of Stroke Among Chinese, Malay, and Indian Singaporeans

Background and Purpose— Stroke prevalence data among mixed Asian populations are lacking. Prevalence rates of stroke were studied among Singaporeans aged ≥50 years of Chinese, Malay, and Indian origin.

Methods— Study participants were selected by disproportionate stratified random sampling by race. Trained interviewers performed face-to-face interviews with subjects using the World Health Organization screening protocol for neurological diseases. Data were also collected on a self-report of stroke. Subjects suspected to have had a stroke underwent a clinical evaluation to diagnose or exclude stroke. Case notes review was performed for those who were unable to come for clinical evaluation.

Results— The study involved 14 906 participants: 6734 men, 8172 women, age range 52 to 106 years, Chinese:Malay:Indian ratio 3:1:1. Participation rate was 66.9%. Six hundred and six were diagnosed to have a stroke, yielding a crude prevalence rate of 4.05% (95% CI, 3.75 to 4.38) and a World Health Organization world population age-gender-standardized rate of 3.65% (95% CI, 3.36 to 3.96). Prevalence rates rose with age ( P <0.001 for trend) and were higher among men compared with women, 4.53% (95% CI, 4.05 to 5.07) versus 2.91% (95% CI, 2.57 to 3.29), P <0.01. Age and gender-standardized rates among Chinese, Malays, and Indians were 3.76% (95% CI, 3.38 to 4.17), 3.32 (95% CI, 2.72 to 4.07), and 3.62% (95% CI, 2.95 to 4.44), respectively, P >0.2. Prevalence was highest among Chinese men at 4.78% (95% CI, 4.14 to 5.50) and lowest among Malay women at 2.81% (95% CI, 2.08 to 3.81), P =0.01.

Conclusions— There is no difference in stroke prevalence among Chinese, Malay, and Indian Singaporeans. Prevalence is highest among Chinese men and lowest among Malay women. The reasons for these differences warrant further investigation.

Does Danshen improve disability after acute ischaemic stroke?

OBJECTIVES

Danshen, a Chinese herb, has been used as a standard treatment for acute ischaemic stroke in China. This study assesses the quality of all randomized control trials (RCTs) comparing Danshen of any preparation to without Danshen (placebo or other western or herbal medicines), and to evaluate its effectiveness in improving disability.

MATERIALS AND METHODS

Systematic review through literature search in MEDLINE, Cochrane Library, China Biological Medicine Database and others. The main outcome measure is disability improvement on the Chinese National Disability Scale (CNDS) at 2 weeks after intervention.

RESULTS

Of 33 Danshen control trials for acute ischaemic stroke identified in the literature, none were placebo-controlled. Eleven RCTs comparing Danshen with one of seven Western and two herbal medicines met the inclusion criteria for review, however, these studies were of poor quality. Compared with the nine medicines, the effect of Danshen was inferior in five trials and not significantly different in another six trials. For the two trials comparing Danshen with Buflomedil, the combined odds ratio (OR) was 0.27 (95% CI: 0.12-0.61) favouring Buflomedil, but the test of homogeneity revealed heterogeneity (P = 0.083). For the two trials comparing Danshen with Naloxone, the combined OR was 0.16 (95% CI: 0.07-0.40) favouring Naloxone. However, none of the nine medicines per se has been proven effective in post-stroke disability improvement.

CONCLUSIONS

The existing Danshen RCTs are not placebo-controlled and are of poor quality, therefore, there is no substantial evidence that Danshen is effective. Systematic review on RCTs comparing Danshen with other medicines does not support the notion that Danshen may be beneficial to disability improvement after acute ischaemic stroke.

Proportion of different subtypes of stroke in China

BACKGROUND AND PURPOSE

The goal of this article is to clarify the proportion of stroke subtypes in China, where stoke is the most common cause of death.

METHODS

A total of 16,031 first-ever strokes in subjects >or=25 years of age were identified in 1991 to 2000 from 17 Chinese populations through a community-based cardiovascular disease surveillance program in the China Multicenter Collaborative Study of Cardiovascular Epidemiology. World Health Organization diagnosis criteria were used for classification of stroke subtypes.

RESULTS

CT scan rate of stroke cases reached a satisfactorily high level only after 1996 in the study populations. In 8268 first-ever stroke events from 10 populations with CT scan rate >75% in 1996 to 2000, 1.8% were subarachnoid hemorrhage, 27.5% were intracerebral hemorrhage, 62.4% were cerebral infarction, and 8.3% were undetermined stroke. The proportion of intracerebral hemorrhage varied from 17.1% to 39.4% and that for cerebral infarction varied from 45.5% to 75.9% from population to population. The ratio of ischemic to hemorrhagic stroke ranged from 1.1 to 3.9 and averaged 2.0). The 28-day fatality rate was 33.3% for subarachnoid hemorrhage, 49.4% for intracerebral hemorrhage, 16.9% for cerebral infarction, and 64.6% for undetermined stroke.

CONCLUSIONS

In our study, ischemic stroke was more frequent and its proportion was higher than hemorrhagic stroke in Chinese populations. Although hemorrhagic stroke was more frequent in Chinese than in Western populations, the variation in the proportion of stroke subtypes among Chinese populations could be as large as or larger than that between Chinese and Western populations.