A systematic review of the incidence and outcomes of ICD-11 defined stroke

Abstract

The World Health Organisation has expanded the definition of stroke to include people with symptoms less than 24 hours if they have evidence of stroke on neuroimaging. The impact is that people previously diagnosed as having a transient ischaemic attack (TIA) would now be considered to have had a stroke. This change will impact incidence and outcomes of stroke and increase eligibility for secondary prevention. We aimed to evaluate the new ICD-11 criteria retrospectively to previous TIA studies to understand the change in incidence and outcomes of this type of stroke. We conducted a systematic review of observational studies of the incidence and outcomes of clinically defined TIA. We searched PubMed, EMBASE, and Google Scholar from inception to 23rd May 2023. Study quality was assessed using a risk of bias tool for prevalence studies. Our review included 25 studies. The rate of scan positivity for stroke among those with clinically defined TIA was 24%, (95% CI, 16% - 33%) but with high heterogeneity (I2=100%, p = 0). Sensitivity analyses provided evidence that heterogeneity could be explained by methodology and recruitment method. The scan positive rate when examining only studies at low risk of bias was substantially lower, at 13% (95% CI, 11 - 15%, I2=0, p = 0.77). We estimate from population-based incidence studies that ICD-11 would result in an increase stroke incidence between 4.8 and 10.5 per 100,000 persons/year. Of those with DWI-MRI evidence of stroke, 6% (95% CI, 3 - 11%) developed a recurrent stroke in the subsequent 90 days, but with substantial heterogeneity (I2=67%, p = 0.02). The impact of the ICD-11 change in stroke definition on incidence and outcomes may have been overestimated by individual studies. Community-based stroke services with access to DWI MRI are likely to accurately diagnose greater numbers of people with mild ICD-11 stroke, increasing access to effective prevention.