Global Stroke Statistics 2019 Kim, Joosup; Thayabaranathan, Tharshanah; Donnan, Geoffrey A ...
International Journal of Stroke,
10/2020, Letnik:
15, Številka:
8
Book Review, Journal Article
Recenzirano
Odprti dostop
Background
Data on stroke epidemiology and availability of hospital-based stroke services around the world are important for guiding policy decisions and healthcare planning.
Aims
To provide the most ...current incidence, mortality and case–fatality data on stroke and describe current availability of stroke units around the world by country.
Methods
We searched multiple databases (based on our existing search strategy) to identify new original manuscripts and review articles published between 1 June 2016 and 31 October 2018 that met the ideal criteria for data on stroke incidence and case–fatality. For data on the availability of hospital-based stroke services, we searched PubMed for all literature published up until 31 June 2018. We further screened reference lists, citation history of manuscripts and gray literature for this information. Mortality codes for International Classification of Diseases-9 and International Classification of Diseases-10 were extracted from the World Health Organization mortality database for each country providing these data. Population denominators were obtained from the World Health Organization, and when these were unavailable within a two-year period of mortality data, population denominators within a two-year period were obtained from the United Nations. Using country-specific population denominators and the most recent years of mortality data available for each country, we calculated both the crude mortality from stroke and mortality adjusted to the World Health Organization world population.
Results
Since our last report in 2017, there were two countries with new incidence studies, China (n = 1) and India (n = 2) that met the ideal criteria. New data on case–fatality were found for Estonia and India. The most current mortality data were available for the year 2015 (39 countries), 2016 (43 countries), and 2017 (7 countries). No new data on mortality were available for six countries. Availability of stroke units was noted for 63 countries, and the proportion of patients treated in stroke units was reported for 35/63 countries.
Conclusion
Up-to-date data on stroke incidence, case–fatality, and mortality statistics provide evidence of variation among countries and changing magnitudes of burden among high and low–middle income countries. Reporting of hospital-based stroke units remains limited and should be encouraged.
Global stroke statistics Thrift, Amanda G; Thayabaranathan, Tharshanah; Howard, George ...
International Journal of Stroke,
01/2017, Letnik:
12, Številka:
1
Book Review, Journal Article
Recenzirano
Odprti dostop
Background
Up to date data on incidence, mortality, and case-fatality for stroke are important for setting the agenda for prevention and healthcare.
Aims and/or hypothesis
We aim to update the most ...current incidence and mortality data on stroke available by country, and to expand the scope to case-fatality and explore how registry data might be complementary.
Methods
Data were compiled using two approaches: (1) an updated literature review building from our previous review and (2) direct acquisition and analysis of stroke events in the World Health Organization (WHO) mortality database for each country providing these data. To assess new and/or updated data on incidence, we searched multiple databases to identify new original papers and review articles that met ideal criteria for stroke incidence studies and were published between 15 May 2013 and 31 May 2016. For data on case-fatality, we searched between 1980 and 31 May 2016. We further screened reference lists and citation history of papers to identify other studies not obtained from these sources. Mortality codes for ICD-8, ICD-9, and ICD-10 were extracted. Using population denominators provided for each country, we calculated both the crude mortality from stroke and mortality adjusted to the WHO world population. We used only the most recent year reported to the WHO for which both population and mortality data were available.
Results
Fifty-one countries had data on stroke incidence, some with data over many time periods, and some with data in more than one region. Since our last review, there were new incidence studies from 12 countries, with four meeting pre-determined quality criteria. In these four studies, the incidence of stroke, adjusted to the WHO World standard population, ranged from 76 per 100,000 population per year in Australia (2009–10) up to 119 per 100,000 population per year in New Zealand (2011–12), with the latter being in those aged at least 15 years. Only in Martinique (2011–12) was the incidence of stroke greater in women than men. In countries either lacking or with old data on stroke incidence, eight had national clinical registries of hospital based data. Of the 128 countries reporting mortality data to the WHO, crude mortality was greatest in Kazhakstan (in 2003), Bulgaria, and Greece. Crude mortality and crude incidence of stroke were both positively correlated with the proportion of the population aged ≥ 65 years, but not with time. Data on case-fatality were available in 42 studies in 22 countries, with large variations between regions.
Conclusions
In this updated review, we describe the current data on stroke incidence, case-fatality and mortality in different countries, and highlight the growing trend for national clinical registries to provide estimates in lieu of community-based incidence studies.
OBJECTIVE:To quantify the patient lifetime benefits gained from reduced delays in endovascular therapy for acute ischemic stroke.
METHODS:We used observational prospective data of consecutive stroke ...patients treated with IV thrombolysis in Helsinki (1998–2014; n = 2,474) to describe distributions of age, sex, stroke severity, onset-to-treatment times, and 3-month modified Rankin Scale (mRS) in routine clinical practice. We used treatment effects by time of endovascular therapy in large vessel occlusion over and above thrombolysis as reported by the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) study to model the shift in 3-month mRS distributions with reducing treatment delays. From the 3-month outcomes we derived patient-expected lifetimes and cumulative long-term disability with incremental treatment delay reductions.
RESULTS:Each minute saved in onset-to-treatment time granted on average 4.2 days of extra healthy life, with a 95% prediction interval 2.3–5.4. Women gained slightly more than men due to their longer life expectancies. Patients younger than 55 years with severe strokes of NIH Stroke Scale score above 10 gained more than a week per each minute saved. In the whole cohort, every 20 minutes decrease in treatment delays led to a gain of average equivalent of 3 months of disability-free life.
CONCLUSIONS:Small reductions in endovascular delays lead to marked health benefits over patientsʼ lifetimes. Services need to be optimized to reduce delays to endovascular therapy.
Summary Background Results of initial randomised trials of endovascular treatment for ischaemic stroke, published in 2013, were neutral but limited by the selection criteria used, early-generation ...devices with modest efficacy, non-consecutive enrolment, and treatment delays. Recent developments In the past year, six positive trials of endovascular thrombectomy for ischaemic stroke have provided level 1 evidence for improved patient outcome compared with standard care. In most patients, thrombectomy was performed in addition to thrombolysis with intravenous alteplase, but benefits were also reported in patients ineligible for alteplase treatment. Despite differences in the details of eligibility requirements, all these trials required proof of major vessel occlusion on non-invasive imaging and most used some imaging technique to exclude patients with a large area of irreversibly injured brain tissue. The results indicate that modern thrombectomy devices achieve faster and more complete reperfusion than do older devices, leading to improved clinical outcomes compared with intravenous alteplase alone. The number needed to treat to achieve one additional patient with independent functional outcome was in the range of 3·2–7·1 and, in most patients, was in addition to the substantial efficacy of intravenous alteplase. No major safety concerns were noted, with low rates of procedural complications and no increase in symptomatic intracerebral haemorrhage. Where next? Thrombectomy benefits patients across a range of ages and levels of clinical severity. A planned meta-analysis of individual patient data might clarify effects in under-represented subgroups, such as those with mild initial stroke severity or elderly patients. Imaging-based selection, used in some of the recent trials to exclude patients with large areas of irreversible brain injury, probably contributed to the proportion of patients with favourable outcomes. The challenge is how best to implement imaging in clinical practice to maximise benefit for the entire population and to avoid exclusion of patients with smaller yet clinically important potential to benefit. Although favourable imaging identifies patients who might benefit despite long delays from symptom onset to treatment, the proportion of patients with favourable imaging decreases with time. Health systems therefore need to be reorganised to deliver treatment as quickly as possible to maximise benefits. On the basis of available trial data, intravenous alteplase remains the initial treatment for all eligible patients within 4·5 h of stroke symptom onset. Those patients with major vessel occlusion should, in parallel, proceed to endovascular thrombectomy immediately rather than waiting for an assessment of response to alteplase, because minimising time to reperfusion is the ultimate aim of treatment.
Every two seconds, someone across the globe suffers a symptomatic stroke. ‘Silent’
cerebrovascular disease insidiously contributes to worldwide disability by causing
cognitive impairment in the ...elderly. The risk of cerebrovascular disease is
disproportionately higher in low to middle income countries where there may be barriers to
stroke care. The last two decades have seen a major transformation in the stroke field
with the emergence of evidence-based approaches to stroke prevention, acute stroke
management, and stroke recovery. The current challenge lies in implementing these
interventions, particularly in regions with high incidences of stroke and limited
healthcare resources. The Global Stroke Services Action Plan was conceived as a tool to
identifying key elements in stroke care across a continuum of health models.
At the minimal level of resource availability, stroke care delivery is
based at a local clinic staffed predominantly by non-physicians. In this environment,
laboratory tests and diagnostic studies are scarce, and much of the emphasis is placed on
bedside clinical skills, teaching, and prevention. The essential services
level offers access to a CT scan, physicians, and the potential for acute thrombolytic
therapy, however stroke expertise may still be difficult to access. At the
advanced stroke services level, multidisciplinary stroke expertise,
multimodal imaging, and comprehensive therapies are available. A national plan for stroke
care should incorporate local and regional strengths and build upon them.
This clinical practice guideline is a synopsis of the core recommendations and quality
indicators adapted from ten high quality multinational stroke guidelines. It can be used
to establish the current level of stroke services, target goals for expanding stroke
resources, and ensuring that all stages of stroke care are being adequately addressed,
even at the advanced stroke services level. This document is a start, but
there is more to be done, particularly in the realm of primary prevention.
Despite differences in resource availability, the message we wish to convey is that
stroke awareness, education, prevention, and treatment should always be feasible.
Communities and institutions should set goals to continuously expand their stroke service
capabilities. This document is intended to augment stroke advocacy efforts throughout the
world, providing a strategic plan for optimizing stroke outcomes.
Distinguishing between stroke subtypes and knowing the time of stroke onset are critical in clinical practice. Thrombolysis and thrombectomy are very effective treatments in selected patients with ...acute ischemic stroke. Neuroimaging helps decide who should be treated and how they should be treated but is expensive, not always available and can have contraindications. These limitations contribute to the under use of these reperfusion therapies.
An alternative approach in acute stroke diagnosis is to identify blood biomarkers which reflect the body's response to the damage caused by the different types of stroke. Specific blood biomarkers capable of differentiating ischemic from hemorrhagic stroke and mimics, identifying large vessel occlusion and capable of predicting stroke onset time would expedite diagnosis and increase eligibility for reperfusion therapies.
To date, measurements of candidate biomarkers have usually occurred beyond the time window for thrombolysis. Nevertheless, some candidate markers of brain tissue damage, particularly the highly abundant glial structural proteins like GFAP and S100β and the matrix protein MMP-9 offer promising results. Grouping of biomarkers in panels can offer additional specificity and sensitivity for ischemic stroke diagnosis. Unbiased "omics" approaches have great potential for biomarker identification because of greater gene, protein, and metabolite coverage but seem unlikely to be the detection methodology of choice because of their inherent cost.
To date, despite the evolution of the techniques used in their evaluation, no individual candidate or multimarker panel has proven to have adequate performance for use in an acute clinical setting where decisions about an individual patient are being made. Timing of biomarker measurement, particularly early when decision making is most important, requires urgent and systematic study.
Spasticity is defined clinically by increased muscle tone and tendon jerk hyperreflexia in patients who are at rest. However, the excitability of spinal circuits changes during movement, and this ...definition provides no insight into the extent to which spasticity and associated motor disturbances cause disability. Only a few spinal circuits have been shown to underlie the abnormalities of patients at rest. Movement can be restrained by pathologically enhanced muscle tone, and there is defective control of the feedback to active motoneurons through virtually all spinal reflex pathways. Spasticity does not necessarily require treatment: in fact, some patients rely on the increased muscle tone to help support otherwise weak muscle contractions for stance and locomotion. In addition, much of the increase in muscle tone arises from changes in muscle and motor units, independent of reflex mechanisms. Managing a patient with impairment after a stroke requires therapy tailored to that particular patient because the mechanisms contributing to the disability experienced by one patient may differ from those affecting another.
Interest in dementia has increased over the past few decades. Stroke is an important cause of cognitive problems. The term vascular cognitive impairment is now used to describe dementia attributed to ...stroke or deep white matter lesions detected on imaging. Although vascular cognitive impairment is increasingly diagnosed, Alzheimer's disease remains the most common dementia worldwide. The relationship between Alzheimer's disease and vascular cognitive impairment is unclear, although there exists significant overlap, which prompts physicians to consider them opposite ends of a disease spectrum, rather than separate entities. There is also substantial evidence that stroke risk factors such as hypertension, diabetes; lipid disorders, etc. are independently associated with an increased risk of Alzheimer's disease and vascular cognitive impairment. Evidence suggests that these risk factors have a cumulative effect on Alzheimer's disease development but not on vascular cognitive impairment. This is more marked in Alzheimer's disease patients in the presence of the ε4 allelic variant of apolipoprotein E. How these risk factors increase the risk of dementia is largely unknown. Physicians must be aware that stroke causes dementia; that vascular risk factors appear to be independent risk factors in developing dementia, and that poststroke care must include cognitive assessment.
CT perfusion (CTP) is widely and rapidly accessible for imaging acute ischemic stroke but has limited validation. Cerebral blood volume (CBV) has been proposed as the best predictor of infarct core. ...We tested CBV against other common CTP parameters using contemporaneous diffusion MRI.
Patients with acute ischemic stroke<6 hours after onset had CTP and diffusion MRI<1 hour apart, before any reperfusion therapies. CTP maps of time to peak (TTP), absolute and relative CBV, cerebral blood flow (CBF), mean transit time (MTT), and time to peak of the deconvolved tissue residue function (Tmax) were generated. The diffusion lesion was manually outlined to its maximal visual extent. Receiver operating characteristic (ROC) analysis area under the curve (AUC) was used to quantify the correspondence of each perfusion parameter to the coregistered diffusion-weighted imaging lesion. Optimal thresholds were determined (Youden index).
In analysis of 98 CTP slabs (54 patients, median onset to CT 190 minutes, median CT to MR 30 minutes), relative CBF performed best (AUC, 0.79; 95% CI, 0.77-81), significantly better than absolute CBV (AUC, 0.74; 95% CI, 0.73-0.76). The optimal threshold was <31% of mean contralateral CBF. Specificity was reduced by low CBF/CBV in noninfarcted white matter in cases with reduced contrast bolus intensity and leukoaraiosis.
In contrast to previous reports, CBF corresponded with the acute diffusion-weighted imaging lesion better than CBV, although no single threshold avoids detection of false-positive regions in unaffected white matter. This relates to low signal-to-noise ratio in CTP maps and emphasizes the need for optimized acquisition and postprocessing.
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