Elsevier

The Lancet Neurology

Volume 8, Issue 4, April 2009, Pages 355-369
The Lancet Neurology

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

https://doi.org/10.1016/S1474-4422(09)70025-0Get rights and content

Summary

This systematic review of population-based studies of the incidence and early (21 days to 1 month) case fatality of stroke is based on studies published from 1970 to 2008. Stroke incidence (incident strokes only) and case fatality from 21 days to 1 month post-stroke were analysed by four decades of study, two country income groups (high-income countries and low to middle income countries, in accordance with the World Bank's country classification) and, when possible, by stroke pathological type: ischaemic stroke, primary intracerebral haemorrhage, and subarachnoid haemorrhage. This Review shows a divergent, statistically significant trend in stroke incidence rates over the past four decades, with a 42% decrease in stroke incidence in high-income countries and a greater than 100% increase in stroke incidence in low to middle income countries. In 2000–08, the overall stroke incidence rates in low to middle income countries have, for the first time, exceeded the level of stroke incidence seen in high-income countries, by 20%. The time to decide whether or not stroke is an issue that should be on the governmental agenda in low to middle income countries has now passed. Now is the time for action.

Introduction

WHO estimates for 2001 indicate that death from stroke in low-income and middle-income countries accounted for 85·5% of stroke deaths worldwide, and the disability-adjusted life years (DALYs) lost in these countries was almost seven times those lost in high-income countries.1 Evidence from developed countries suggests that one in 20 adults (aged >14 years) is affected by stroke, including clinically covert strokes,2, 3 and the incidence of acute cerebrovascular events (stroke and transient ischaemic attack combined) currently exceeds the incidence of acute coronary heart disease.4 Although rates of stroke mortality and burden vary greatly among countries, low-income countries are the most affected. Current measures of the prevalence of cardiovascular risk factors at the population level poorly predict overall stroke mortality and burden and do not explain the greater burden in low-income countries.5 This worldwide stroke epidemic and the well recognised medicosocial consequences of stroke (including post-stroke dementia) justify the need for periodic reviews of the best available evidence of worldwide stroke epidemiology. This will advance our understanding of stroke frequency and determinants in various populations, enabling better health-care planning.

The most reliable data on stroke incidence and case fatality come from population-based incidence studies. Our last systematic review of population-based stroke incidence and case fatality studies was published in 2003.6 Several new population-based stroke incidence studies have been published since, which suggests there is a need for more in-depth systematic analysis. In addition, this and other reviews6, 7 of population-based stroke incidence studies were limited: they did not include all previously published studies, they did not provide pooled estimates, and they did not systematically analyse stroke morbidity and early mortality in various populations. The aims of this systematic review are to update current knowledge of stroke morbidity and early case fatality with all available population-based stroke incidence studies and to review secular trends in stroke incidence and case fatality.

Section snippets

Search strategy and selection criteria

We searched Medline, Scopus, PubMed, and ScienceDirect, from 1950 to May, 2008, with the words “stroke”, “isch(a)emic stroke”, “intracerebral”, “intraparenchymal”, “subarachnoid”, “h(a)emorrhage”, “population-based”, “community-based”, “community”, “epidemiology”, “epidemiological”, “incidence”, “attack rates”, “survey”, “surveillance”, “mortality”, “morbidity”, “fatality”, “case fatality”, or “trends”.

Eligibility criteria were as follows: complete, population-based case ascertainment based on

Results

We initially retrieved 3051 potentially relevant studies (figure 1). The titles of these were scanned for appropriateness for our review, and those that did not meet the inclusion criteria (eg, those for only specific age ranges or those for only hospitalisations) were removed (2190). The abstracts of the remaining 861 studies were retrieved and reviewed to eliminate any that were obviously inappropriate (757 removed). The remaining 104 manuscripts were appraised independently by three

Discussion

To the best of our knowledge, this study reviews all the available data from population-based stroke incidence studies and documents stroke incidence rates over the past four decades: there has been a 42% decrease in stroke incidence in high-income countries and more than 100% increase in low to middle income countries. A summary of key findings is shown in the panel. From 1970 to 2008, the yearly percentage change in pooled age-standardised stroke incidence rates was reduced by 1·1% in

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