Epidemiology of Ischemic and Hemorrhagic Stroke: Incidence, Prevalence, Mortality, and Risk Factors

doi:10.1016/j.ncl.2008.07.003

Neurologic Clinics

Volume 26, Issue 4, November 2008, Pages 871-895

https://doi.org/10.1016/j.ncl.2008.07.003 Get rights and content

The epidemiology of ischemic and hemorrhagic stroke is an ongoing exploration to identify risk factors that continue to expand with the advent of technological advancements and preventative medical practices. Identification of risk factors that can or cannot be modified is a crucial step in determining stroke risk. Many of the modifiable risk factors are well established, and specific interventions to reduce stroke risk have been established. Some risk factors are less established, and intervention to reduce risk is yet to be determined by evidence-based medicine. Data from ongoing randomized clinical trials continue to enhance our ability to prevent a first stroke.

Section snippets

Definitions

Stroke is the rapid development of a focal neurologic deficit caused by a disruption of blood supply to the corresponding area of brain. Transient ischemic attack (TIA), by convention, is a focal neurologic deficit lasting less than 24 hours. Recent definitions of TIA describe focal symptoms that last less than 1 hour and do not reveal evidence of infarction [5]. The relevant concept is that TIA is a predictor of stroke [6]. The risk for stroke is greatest in the first 90 days after TIA

Classification of stroke

Strokes can either be ischemic (an occlusion of a blood vessel) or hemorrhagic (a rupture of a blood vessel). Hemorrhagic strokes include intracerebral hemorrhage (ICH, bleeding within the brain) and subarachnoid hemorrhage (SAH, bleeding between the inner and outer layers of tissue covering the brain within the subarachnoid space).

Most strokes in the United States, approximately 87%, are ischemic [4]. Ischemic strokes have been further categorized into subtypes according to the mechanism of

Incidence, prevalence, and recurrence of stroke

Worldwide, stroke incidence ranges from 240 per 100,000 in Dijon, France (standardized to the European population aged 45–84 years), to about 600 per 100,000 in Novosibirsk, Russia [2]. Data from the Framingham Heart Study (FHS) indicate that the age-adjusted incidence of clinical stroke and atherothrombotic brain infarction per 1000 person-years in 1950 to 1977, 1978 to 1989, and 1990 to 2004 was 7.6, 6.2, and 5.3 in men and 6.2, 5.8, and 5.1 in women, respectively. Clinical stroke in FHS

Case fatality and mortality

The overall mortality for stroke in the United States in 2004 was 50 per 100,000. About 70% to 80% of all stroke deaths are ischemic [18]. Hemorrhagic strokes are less prevalent but more likely to be fatal. The proportion of hemorrhagic stroke deaths varies among race/ethnic group. The percentage of hemorrhagic stroke of all stroke deaths among people aged 35 years or older in 1991 to 1998 was 38% for Asian and Pacific Islanders, 32% for Hispanics, 26% for American Indians and Alaskan Natives,

Risk factors for ischemic stroke

Epidemiologic studies have established myriad stroke risk factors. Some of these are not modifiable, such as hereditary factors, but are pivotal in correctly identifying those at high risk (Table 1). Factors relating to lifestyle and environment (Table 2, Table 3) may typically be modified or controlled by proven strategies based on randomized clinical trials.

Risk factors for hemorrhagic strokes

ICH is the most common cause of hemorrhagic stroke in the United States. Age, ethnicity, and hypertension are strongly linked to ICH. Associations have been equivocal with other risk factors. Conditions of nature and environment that contribute to ICH are listed in Table 4, Table 5.

Summary

The epidemiology of ischemic and hemorrhagic stroke is an ongoing exploration to identify risk factors that continue to expand with the advent of technological advancements and preventative medical practices. Identification of risk factors that can or cannot be modified is a crucial step in determining stroke risk. Once risk factors are elucidated, modifiable risk factors can be treated to reduce the risk for stroke. Many of the modifiable risk factors are well established, and specific

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Cerebrovascular accidents, also known as strokes, are the leading cause of permanent disability in society, presenting significant socioeconomic and healthcare costs. They can be caused by ischemic factors or hemorrhages, with ischemic strokes being the most common among the population. Therapies for patients suffering from this condition are limited and primarily focus on acute-phase treatment. In recent years, there has been an increase in cellular therapies, employing Stem Cells to mitigate or eliminate the consequences arising from this disease. Mesenchymal Stem Cells (MSCs) hold substantial therapeutic potential in Nervous System pathologies due to their low antigenicity and capacity to differentiate into various human tissues, such as adipogenic, chondrogenic, and osteogenic tissues. This study conducts a literature review using the “clinical trials” and “Pubmed” database, summarizing all ongoing clinical trials for ischemic strokes that utilize MSCs as treatment.
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Ischemic stroke is the second leading cause of death and disability worldwide, and efforts to prevent stroke, mitigate secondary neurological damage, and promote neurological recovery remain paramount. Recent findings highlight the critical importance of microbiome-related metabolites, including vitamin B12 (VB12), in alleviating toxic stroke-associated neuroinflammation. Here, we showed that VB12 tonically programmed genes supporting microglial cell division and activation and critically controlled cellular fatty acid metabolism in homeostasis. Intriguingly, VB12 promoted mitochondrial transcriptional and metabolic activities and significantly restricted stroke-associated gene alterations in microglia. Furthermore, VB12 differentially altered the functions of microglial subsets during the acute phase of ischemic stroke, resulting in reduced brain damage and improved neurological function. Pharmacological depletion of microglia before ischemic stroke abolished VB12-mediated neurological improvement. Thus, our preclinical studies highlight the relevance of VB12 in the functional programming of microglia to alleviate neuroinflammation, minimize ischemic injury, and improve host neurological recovery after ischemic stroke.
Optimal blood pressure for stroke prevention in healthy adults below 65 years: A nationwide 10-year observational study
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There have been few reports on the preventative value of intensive blood pressure (BP) management for stroke since the American College of Cardiology/American Heart Association (ACC/AHA) announced the new criteria for hypertension (HTN) in 2017. This study aimed to identify optimal BP for prevention of stroke in healthy adults under 65 years.
We conducted a 10-year observational study on the risk of stroke, subclassified as hemorrhagic stroke (HS) or ischemic stroke (IS), according to BP categories (low-normal BP, high-normal BP, elevated BP, stage 1 HTN, and stage 2 HTN) using the National Health Insurance Service Database.
In 2008, a health checkup was conducted for a total of 8,327,751 participants, and 949,551 of them enrolled in this study. The risk of HS increased from stage 2 HTN (adjusted hazard ratio [AHR], 3.036 [95 % confidence interval [CI], 2.159–4.252]) in men to stage 1 HTN (AHR, 2.972; 95 % CI, 2.256–3.897) in women. The risk of IS increased in both men (AHR, 1.404 [95 % CI, 1.164–1.693]) and women (AHR, 2.012 [95 % CI, 1.603–2.526]) with stage 1 HTN. The overall risk of stroke increased in men (AHR, 1.386; [95 % CI, 1.180–1.629]) and women (AHR, 2.363 [95 % CI, 1.973–2.830]) with stage 1 HTN.
This study underscores the importance of maintaining BP below Stage 1 HTN to prevent stroke in healthy adults aged below 65 years. These findings highlight the significance of the new HTN guidelines established by the ACC/AHA in 2017.
Modulation of thioredoxin by chlorogenic acid in an ischemic stroke model and glutamate-exposed neurons
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Ischemic stroke increases the production of reactive oxygen species (ROS), which can eventually lead to neuronal death. Thioredoxin is a small reductase protein that acts as an eliminator of ROS and protects neurons from brain damage. Chlorogenic acid is known as a phenolic compound that has a neuroprotective effect. We investigated the change of thioredoxin expression by chlorogenic acid in a middle cerebral artery occlusion (MCAO) animal model. Adult rats were injected intraperitoneally with phosphate buffered saline or chlorogenic acid (30 mg/kg) 2 h after MCAO. MCAO damage induced neurological defects and increased ROS and lipid peroxidation levels, however, chlorogenic acid mitigated these changes. MCAO damage reduced thioredoxin expression, which was mitigated by chlorogenic acid treatment. The interaction between thioredoxin and apoptosis signal-regulating kinase 1 (ASK1) was decreased in MCAO animals, chlorogenic acid treatment prevented this decrease. In cultured neurons, chlorogenic acid dose-dependently attenuated glutamate-induced decreases in cell viability and thioredoxin expression. Glutamate toxicity downregulated bcl-2 and upregulated bax, cytochrome c, and caspase-3, however, chlorogenic acid attenuated these changes. The mitigating effect of chlorogenic acid was lower in thioredoxin siRNA-transfected cells than in non-transfected cells. These results provide evidence that chlorogenic acid exerts potent antioxidant and neuroprotective effects through regulation of thioredoxin and modulation of ASK1 and thioredoxin binding in ischemic brain injury. These findings indicate that chlorogenic acid exerts a neuroprotective effect by regulating thioredoxin expression in cerebral ischemia and glutamate exposure conditions.
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Stroke is the leading cause of disability worldwide, yet there is currently no effective treatment available to mitigate its negative consequences. Pro-inflammatory cytokines, such as interleukin-1 (IL-1), are known to play a crucial role in exacerbating the aftermath of stroke. Thus, it is hypothesized that blocking inflammation and administering anti-inflammatory drugs at an optimal time and dosage may improve the long-term quality of life for stroke patients.
This systematic review examines the effectiveness and safety of IL-1 receptor antagonist (IL-1Ra), commercially known as “anakinra,” in clinical studies involving the treatment of stroke patients. A comprehensive literature search was conducted until October 2023 to identify relevant studies. The search yielded 1403 articles, out of which 598 were removed due to duplication. After a thorough review of 805 titles and abstracts, 797 articles were further excluded, resulting in 8 studies being included in this systematic review.
The findings from all the included studies demonstrate that IL-1Ra is safe for use in acute ischemic and hemorrhagic stroke patients, with no significant adverse events reported. Additionally, biomarkers, clinical assessments, serious adverse events (AEs), and non-serious AEs consistently showed more favorable outcomes in IL-1Ra receiving patients. Stroke elevates the levels of several inflammatory cytokines, however, administration of IL-1RA directly or indirectly modulates these markers and improves some clinical outcomes, suggesting a potential therapeutic benefit of this intervention.
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The influence of antiplatelet drugs on the risk of hemorrhagic stroke and the reduction of ischemic stroke in patients with intracerebral hemorrhage (ICH) remains unclear. This study aimed to elucidate the impact of antiplatelet therapy on the risk of recurrent stroke in ICH patients.
The study encompassed ICH survivors discharged from a central Taiwanese teaching hospital between January 1, 2013, and December 31, 2019. Patient hospitalization and treatment data were retrieved from electronic medical records. The primary endpoint was re-hospitalization due to ischemic or hemorrhagic stroke. Patients who continued antiplatelet drug use for over a month prior to stroke recurrence constituted the antiplatelet drug use group. Risk factors for recurrent hemorrhagic and ischemic strokes were evaluated using binary logistic regression.
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Epidemiology of Ischemic and Hemorrhagic Stroke: Incidence, Prevalence, Mortality, and Risk Factors

Section snippets

Definitions

Classification of stroke

Incidence, prevalence, and recurrence of stroke

Case fatality and mortality

Risk factors for ischemic stroke

Risk factors for hemorrhagic strokes

Summary

Lancet

Lancet Neurol

Neurosurg Clin N Am

J Am Coll Cardiol

Blood

Blood

Am J Clin Nutr

Blood

Am Heart J

Am Heart J

J Am Coll Cardiol

Global burden of stroke

Stroke: time for a global campaign?

Cerebrovasc Dis

Heart disease and stroke statistics—2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Circulation

Transient ischemic attack—proposal for a new definition

N Engl J Med

Short-term prognosis after emergency department diagnosis of TIA

JAMA

Timing of TIAs preceding stroke: time window for prevention is very short

Neurology

Secular trends in stroke incidence and mortality. The Framingham Study

Stroke

Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment

Stroke

Ischemic stroke subtypes: a population-based study of incidence and risk factors

Stroke

Racial variations in location and risk of intracerebral hemorrhage

Stroke

Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years

JAMA

Intracerebral hemorrhage associated with oral anticoagulant therapy: current practices and unresolved questions

Stroke

Subarachnoid hemorrhage incidence among whites, blacks and Caribbean Hispanics: the Northern Manhattan Study

Neuroepidemiology

Survival and recurrence after first cerebral infarction: a population-based study in Rochester, Minnesota, 1975 through 1989

Neurology

Ischemic stroke subtypes: a population-based study of functional outcome, survival, and recurrence

Stroke

The risk of recurrent stroke after intracerebral haemorrhage

J Neurol Neurosurg Psychiatry

Stroke incidence and survival among middle-aged adults: 9-year follow-up of the atherosclerosis risk in communities (ARIC) cohort

Stroke

Atlas of stroke mortality: racial, ethnic, and geographic disparity in the United States

Long-term survival after first-ever stroke: the Oxfordshire Community Stroke Project

Stroke

The unchanging incidence and case-fatality of stroke in the 1990s: a population-based study

Stroke

Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study

Circulation

2006 chartbook on cardiovascular and lung diseases

Stroke incidence, prevalence, and survival: secular trends in Rochester, Minnesota, through 1989

Stroke

Circulation

Pregnancy and the risk of stroke

N Engl J Med

Familial aggregation of stroke. The Framingham study

Stroke

A study of twins and stroke

Stroke

CADASIL: hereditary disease of arteries causing brain infarcts and dementia

Neuropathol Appl Neurobiol

The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report

JAMA

Stroke

Impact of high-normal blood pressure on the risk of cardiovascular disease

N Engl J Med

Glucose intolerance and 22-year stroke incidence. The Honolulu heart program

Stroke

Epidemiology of ischemic stroke in patients with diabetes: the greater Cincinnati/Northern Kentucky stroke study