Stroke, dementia and ischemic heart disease are a triple threat which combined are the leading causes of death and disability globally. Fortunately, the three diseases share similar risk factors ...along the vascular cascade which can be targeted for primordial and primary prevention. In Norway, during 1990–2019, the age‐standardised incidence rates decreased significantly for dementia by −5.4%, ischemic heart disease by −30.0%, and stroke by −35.3%. This was possible because Norway ensured equitable income for her citizens, and committed sufficient funds to universal health coverage while implementing a semi‐decentralized and responsive health system with robust primary health care. This included monitoring the burden of the triple threat and their cardinal risk factors; ensuring primordial, primary and secondary preventive interventions; implementing acute care for ischemic heart disease and stroke; and ensuring interdisciplinary rehabilitation and chronic care for the triple threat. Overall, all countries will need to develop national strategies for combating the triple threat within the context of sustainable development goals with adequate allocation and utilization of resources.
The vascular cascade.
Neurological disorders are the leading cause of disability and the second leading cause of death worldwide. In the past 30 years, the absolute numbers of deaths and people with disabilities owing to ...neurological diseases have risen substantially, particularly in low-income and middle-income countries, and further increases are expected globally as a result of population growth and ageing. This rise in absolute numbers of people affected suggests that advances in prevention and management of major neurological disorders are not sufficiently effective to counter global demographic changes. Urgent measures to reduce this burden are therefore needed. Because resources for health care and research are already overstretched, priorities need to be set to guide policy makers, governments, and funding organisations to develop and implement action plans for prevention, health care, and research to tackle the growing challenge of neurological disorders.
Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At ...the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.
Sub-Saharan Africa has the highest incidence, prevalence, and fatality from stroke globally. Yet, only little information about context-specific risk factors for prioritising interventions to reduce ...the stroke burden in sub-Saharan Africa is available. We aimed to identify and characterise the effect of the top modifiable risk factors for stroke in sub-Saharan Africa.
The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study done at 15 sites in Nigeria and Ghana. Cases were adults (aged ≥18 years) with stroke confirmed by CT or MRI. Controls were age-matched and gender-matched stroke-free adults (aged ≥18 years) recruited from the communities in catchment areas of cases. Comprehensive assessment for vascular, lifestyle, and psychosocial factors was done using standard instruments. We used conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% CIs.
Between Aug 28, 2014, and June 15, 2017, we enrolled 2118 case-control pairs (1192 56% men) with mean ages of 59·0 years (SD 13·8) for cases and 57·8 years (13·7) for controls. 1430 (68%) had ischaemic stoke, 682 (32%) had haemorrhagic stroke, and six (<1%) had discrete ischaemic and haemorrhagic lesions. 98·2% (95% CI 97·2–99·0) of adjusted PAR of stroke was associated with 11 potentially modifiable risk factors with ORs and PARs in descending order of PAR of 19·36 (95% CI 12·11–30·93) and 90·8% (95% CI 87·9–93·7) for hypertension, 1·85 (1·44–2·38) and 35·8% (25·3–46·2) for dyslipidaemia, 1·59 (1·19–2·13) and 31·1% (13·3–48·9) for regular meat consumption, 1·48 (1·13–1·94) and 26·5% (12·9–40·2) for elevated waist-to-hip ratio, 2·58 (1·98–3·37) and 22·1% (17·8–26·4) for diabetes, 2·43 (1·81–3·26) and 18·2% (14·1–22·3) for low green leafy vegetable consumption, 1·89 (1·40–2·54) and 11·6% (6·6–16·7) for stress, 2·14 (1·34–3·43) and 5·3% (3·3–7·3) for added salt at the table, 1·65 (1·09–2·49) and 4·3% (0·6–7·9) for cardiac disease, 2·13 (1·12–4·05) and 2·4% (0·7–4·1) for physical inactivity, and 4·42 (1·75–11·16) and 2·3% (1·5–3·1) for current cigarette smoking. Ten of these factors were associated with ischaemic stroke and six with haemorrhagic stroke occurrence.
Implementation of interventions targeting these leading risk factors at the population level should substantially curtail the burden of stroke among Africans.
National Institutes of Health.
Global Stroke Statistics 2019 Kim, Joosup; Thayabaranathan, Tharshanah; Donnan, Geoffrey A ...
International Journal of Stroke,
10/2020, Volume:
15, Issue:
8
Book Review, Journal Article
Peer reviewed
Open access
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.
•Neuroimaging studies of Self-Referential Processing (SRP) are reviewed.•Verbal (introspective, semantic) SRP is compared with Non-Verbal SRP (interoceptive, somatic)- Active (Task-based) SRP is ...compared with Passive (Off-task) SRP during resting state.•A conceptual and methodological framework for studying SRP occurring during foreground introspective and interoceptive tasks vs. during background resting state is described.•Psychological and Neurological Disorders of SRP are reviewed.
We review neuroimaging research investigating self-referential processing (SRP), that is, how we respond to stimuli that reference ourselves, prefaced by a lexical-thematic analysis of words indicative of “self-feelings”. We consider SRP as occurring verbally (V-SRP) and non-verbally (NV-SRP), both in the controlled, “top-down” form of introspective and interoceptive tasks, respectively, as well as in the “bottom-up” spontaneous or automatic form of “mind wandering” and “body wandering” that occurs during resting state. Our review leads us to outline a conceptual and methodological framework for future SRP research that we briefly apply toward understanding certain psychological and neurological disorders symptomatically associated with abnormal SRP. Our discussion is partly guided by William James’ original writings on the consciousness of self.
...many clinicians and biomedical researchers have balked at the idea of exploring ageing-related disorders in sub-Saharan Africa. The APOE ɛ4 allele, which is robustly associated with Alzheimer's ...disease in most populations, might have more nuanced links to Alzheimer's disease in people with African ancestry.3 The pathology of Alzheimer's disease is also intriguing, as African populations tend not to share risk factors with people living in high-income countries.4 Africa harbours the greatest genetic diversity of any continent (low linkage disequilibrium and short haplotype blocks). ...increasing the representation of indigenous Africans in genomic research could bring novel insights into the biology of brain health and cognition, facilitate translational genomics, and improve understanding of dementia phenotypes and protective and risk factors.2 Furthermore, fine mapping of new loci and variants identified in African populations could help to pinpoint causal genetic variants. The Consortium will focus on several research areas, including epidemiological studies on prevalence, incidence, and risk factors;4 genetic and epigenetic studies; detection of unique biomarkers; clinical trials; capacity building and networking among dementia researchers living or working in Africa; translational research; implementation science for the translation of research evidence to practice and policy; determinants of brain health; and ethical, legal, sociological, and anthropological issues in brain health.
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. Introduction The global burden of stroke is huge: in 2020, stroke was the second leading cause of death (6·6 million deaths) and the third leading cause of disability (responsible for 143 million disability-adjusted life-years DALYs) after neonatal disorders (in children) and ischaemic heart disease (in adults).1,2 Alarmingly, evidence suggests that the incidence of stroke in younger individuals (ie, people younger than 55 years) is increasing worldwide.3 The absolute number of people affected by stroke, which includes those who die or remain disabled, has almost doubled in the past 30 years.1 Most of the contemporary stroke burden—86% of global deaths and 89% of global DALYs lost because of stroke in 2020—is in low-income and middle-income countries (LMICs),1 and the burden of stroke is increasing faster in LMICs than in high-income countries (HICs).1 Stroke is also a leading cause of depression and dementia, which are other common non-communicable diseases (NCDs).4,5 Little progress has been made by most countries towards Sustainable Development Goal (SDG) 3.4—reducing premature mortality from NCDs by a third between 2015 and 2030.6 Achieving SDG 3.4 worldwide, which would in turn facilitate the achievement of nine other SDGs,7 would require an additional US$140 billion of spending on NCD interventions from 2023–30, but could help to avert 39 million deaths and generate $2·7 trillion in net economic benefits (with benefits outweighing costs by a factor of 19:1).6 Given that the incidence of stroke rises with age, the combination of growing populations and ageing demographics is likely to result in large increases in global deaths and disability in the future unless major improvements occur in population prevention programmes that reduce the risk of stroke.8 Thus, pragmatic solutions to reduce the burden of stroke and related NCDs are urgently needed to save lives and improve brain health, quality of life, and socioeconomic productivity globally.8–11 Key messages Multiple factors contribute to the high burden of stroke in low-income and middle-income countries, including undetected and uncontrolled hypertension, lack of easily accessible, high-quality health services, insufficient attention to and investment in prevention, air pollution, population growth, unhealthy lifestyles (eg, poor diet, smoking, sedentary lifestyle, obesity), an earlier age of stroke onset and greater proportion of haemorrhagic strokes than in high-income countries, and the burden of infectious diseases resulting in competition for limited healthcare resources. Major facilitators include professional stroke organisations and networks that could advocate and build capacity for stroke care and research, and universal health coverage that can facilitate population-wide access to evidence-based care (pre-hospital care, acute care, rehabilitation, and prevention).
PDF
