Stroke Case Fatality Research Articles

Global Stroke Statistics 2019.

Data on stroke epidemiology and availability of hospital-based stroke services around the world are important for guiding policy decisions and healthcare planning. 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. 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. 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. 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.

Abstract TP211: Long-Term Trends in Ischemic Stroke Risk Factors and Outcomes in a Multiethnic Population

Introduction: Stroke medicine has evolved over time, with changing demographics and improving outcomes. We aimed to evaluate trends in incidence, risk factors, treatment and case fatality of acute ischemic stroke (AIS) in a multiethnic population. Methods: Data was obtained from the Singapore Stroke Registry. 60,325 AIS cases that presented to Singapore’s public hospitals from 2005-16 were studied. Trends were analyzed with Poisson regression, logistic regression and Cox regression. Results: The AIS age-standardized incidence rate has decreased by 11.6% (126.5 to 111.8 per 100,000 person-years from 2005-07 to 2014-16, p < 0.001). This was observed in all gender and ethnic groups except in those younger than 65, which saw a 2.5% increase (51.0 to 52.4 per 100,000 person-years, p = 0.017). In terms of risk factors, hypertension, hyperlipidemia, and atrial fibrillation have increased in prevalence, while history of stroke, ischemic heart disease, diabetes, and smoking have decreased (Figure A). Treatment-wise, thrombolysis utilization rates have increased significantly from 0.8% in 2005-2007 to 6.7% in 2014-2016 (p < 0.001). While atrial fibrillation (AF) has become more prevalent (15.8% to 25.2%, p < 0.001), anticoagulant prescription has not increased by the same magnitude (13.2% to 14.4%, p = 0.014). Case fatality has reduced by 25.6% (8.2% to 6.1%, p < 0.001). Conclusion: In a multi-ethnic population, whilst we found that AIS age-standardized incidence rate has been declining, we demonstrate a temporal trend of changing risk factors. Further research is needed to investigate the causes and implications of these trends, so as to better strategize prevention efforts.

Effect of non-vitamin-K oral anticoagulants on stroke severity compared to warfarin: a meta-analysis of randomized controlled trials.

In addition to lowering stroke risk, warfarin use is also associated with reduced stroke severity in patients with atrial fibrillation and acute ischaemic stroke. It was sought to determine whether the effect of non-vitamin-K oral anticoagulants (NOACs), compared to warfarin, differed by stroke severity. Phase III randomized controlled trials with participants who were randomized to receive NOACs or warfarin for stroke prevention in the setting of non-valvular atrial fibrillation were identified. Stroke was classified into two categories, fatal or disabling stroke and non-disabling stroke, and meta-analyses were completed for both outcomes and for comparative case fatality of stroke amongst trials. Five randomized controlled trials met our inclusion criteria. In clinical trials evaluating the NOACs usually prescribed in clinical practice (four trials), acute stroke was reported in 1403 (1.86%) participants, 787 (1.04%) in the NOAC group [386 (0.51%) fatal or disabling, 401 (0.53%) non-disabling] and 616 (0.82%) in the warfarin group [367 (0.49%) fatal or disabling, 249 (0.33%) non-disabling]. On meta-analysis NOACs were significantly superior to warfarin for fatal or disabling stroke (odds ratio [OR] 0.77; 95% confidence interval [CI] 0.66-0.89, I2 =21%) and non-disabling stroke (OR 0.85; 95% CI 0.73-0.98, I2 =2%). The case fatality of stroke was no different between groups (OR 0.90, 95% CI 0.75-1.13, I2 =0%), but the point estimate favoured NOACs. In phase III trials of NOACs, for prevention of stroke in atrial fibrillation, NOACs are associated with a lower risk of both fatal/disabling and non-disabling stroke compared to warfarin.

Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study.

First Nations people have high rates of diabetes mellitus, which is a risk factor for stroke. We studied the rates of hospital admission, processes of care and outcomes of stroke and transient ischemic attack (TIA) in First Nations people in Ontario. Using linked administrative databases, we identified annual cohorts of people aged 20-105 years in Ontario with prevalent diabetes between Apr. 1, 1995, and Mar. 31, 2015. We identified Status First Nations people in Ontario from the Indian Register. We compared age- and sex-standardized rates of hospital admission for stroke or TIA, processes of care and case fatality among First Nations versus other people in Ontario with diabetes. Overall, 28 874 people with diabetes (of whom 536 were First Nations people) were admitted to hospital with a stroke or TIA between Apr. 1, 2011, and Mar. 31, 2016. Admission rates for stroke or TIA declined over the study period but were higher among First Nations people than other Ontarians in most years after 2005/06. First Nations people admitted with stroke or TIA were as likely as other Ontarians to undergo neuroimaging within 24 hours (94.6% v. 96.0%), be discharged to inpatient rehabilitation (31.8% v. 34.8%) and receive carotid revascularization (1.4% v. 2.7%), but were less likely to receive thrombolysis (6.3% v. 11.0%). Age- and sex-standardized stroke case fatality was similar in First Nations people and other Ontarians at 7 days (12.0% v. 8.5%), 30 days (19.2% v. 16.0%) and 1 year (33.8% v. 28.1%). Rates of hospital admission for stroke or TIA were higher among First Nations people than other people with diabetes in Ontario. Future work should focus on determining Indigenous-specific determinants of health related to this disparity and implementing appropriate interventions to mitigate the risks and sequelae of stroke in First Nations people.

Epidemiology of cardiovascular diseases related admissions in a referral hospital in the South West region of Cameroon: A cross-sectional study in sub-Saharan Africa.

BackgroundSub-Saharan Africa (SSA) is experiencing an epidemic of cardiovascular diseases (CVD) as a result of a rapid epidemiological transition. Little is known about the admission for CVD and outcome in rural and semi-urban settings in Cameroon in this era of epidemiological transition. The aim of this study was to determine the frequency and the pattern of CVD admissions in the South West region of Cameroon.MethodsThis retrospective descriptive study included all adult patients admitted for CVD in the medical unit of the Buea Regional Hospital between Jan 2016 and December 2017.ResultsOut of the 3140 patients admitted, 499(15.9%) had CVD. There were 304(60.9%) females. The mean age was 58.7±16.2 years. There was no age difference between men and women (59.7 years vs 58.1years, p = 0.29). The most commonly affected age group was those aged 50–59 years (22%). Heart failure (38.5%), stroke (33.3%) and uncontrolled hypertension (22.4%) were the most prevalent CVDs. The length of hospital stay ranged from 1 to 37 days with a median length of hospital stay of 7 days. In-hospital case fatality was 78(15.8%). Mortality was higher in women compared to men (9% vs 7%, p = 0.43). The case fatality for stroke was higher compared to case fatality for heart failure (21.7% vs 16.7%, p = 0.23).ConclusionCVDs are a common cause of hospital admission in this semi-urban setting, dominated by heart failure. Women were disproportionately affected and it was associated with high mortality. Prevention, early detection and management of risk factors for cardiovascular disease are imperative given the growing burden of CVD in SSA to reduce CVD morbidity and mortality.

Case Fatality Decline from 2009 to 2013 among Medicare Beneficiaries with Ischemic Stroke

ObjectivesThis study aimed to examine the temporal trend of 30-day and 1-year mortality among U.S. Medicare beneficiaries who were hospitalized for ischemic stroke, with special focus on the mortality among subgroup of patients in relation to acute reperfusion therapies including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). MethodsWe evaluated Medicare fee-for-service beneficiaries age 65 years or older who were hospitalized for ischemic stroke between 2009 and 2013. Multivariable Cox proportional hazards models were generated to analyze the trend of adjusted mortality. ResultsA total of 1,070,574 patients were included in the study. The 30-day mortality did not change among patients who were not treated with IVT or EVT. It decreased by 13% among patients treated with IVT but not EVT (HR = .87, 95% CI .82-.92), 25% among patients treated with EVT but not IVT (HR = .75, 95% CI .59-.95), and 37% among patients treated with both IVT and EVT (HR = .63, 95% CI .52-.77). One-year mortality decreased by 19% among patients who were not treated with IVT nor EVT (HR = .81, 95% CI .80-.83), 22% among those treated with IVT but not EVT (HR = .78, 95% CI .75-.81), 33% among those treated with EVT but not IVT (HR = .67, 95% CI .55-.81), and 38% among those treated with both IVT and EVT (HR = .62, 95% CI .53-.73). ConclusionsFrom 2009 to 2013, the 30-day stroke case fatality decreased only among the patients received reperfusion therapy. The 1-year mortality declined among all the stroke patients, with the greatest decline among those treated with both IVT and EVT.

Stroke burden in Guinea: Results from the Conakry Ignace Deen Hospital stroke registry.

Sub-Saharan Africa has extremely high stroke prevalence and case fatality. Most Sub-Saharan African regions are uncharted in terms of stroke characteristics, epidemiology, and burden. We report here the results from the first stroke registry in Guinea.

Stroke Incidence and Case Fatality According to Rural or Urban Residence: Results From the French Brest Stroke Registry.

Background and Purpose- Recent findings suggest that in the United States, stroke incidence is higher in rural than in urban areas. Similar analyses in other high-income countries are scarce with conflicting results. In 2008, the Brest Stroke Registry was started in western France, an area that includes about 366 000 individuals living in various urban and rural settings. Methods- All new patients with stroke included in the Brest Stroke Registry from 2008 to 2013 were classified as residing in town centers, suburbs, isolated towns, or rural areas. Poisson regression was used to analyze stroke incidence and 30-day case fatality variations in the 4 different residence categories. Models with case fatality as outcome were adjusted for age, stroke type, and stroke severity. Results- In total, 3854 incident stroke cases (n=2039 women, 53%) were identified during the study period. Demographic and socio-economic characteristics and primary healthcare access indicators were significantly different among the 4 residence categories. Patterns of risk factors, stroke type, and severity were comparable among residence categories in both sexes. Age-standardized stroke rates varied from 2.90 per thousand (95% CI, 2.59-3.21) in suburbs to 3.35 (95% CI, 2.98-3.73) in rural areas for men, and from 2.14 (95% CI, 2.00-2.28) in town centers to 2.34 (95% CI, 2.12-2.57) in suburbs for women. Regression models suggested that among men, stroke incidence was significantly lower in suburbs than in town centers (incidence rate ratio =0.87; 95% CI, 0.77-0.99). Case fatality risk was comparable across urban categories but lower in rural patients (relative risk versus town centers: 0.76; 95% CI, 0.60-0.96). Conclusions- Stroke incidence was comparable, and the 30-day case fatality only slightly varied in the 4 residence categories despite widely different socio-demographic features covered by the Brest Stroke Registry.

Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults

ObjectivesTo study trends in stroke mortality rates, event rates, and case fatality, and to explain the extent to which the reduction in stroke mortality rates was influenced by changes in...

Abstract WP213: Age-specific Black-white Differences in 30-day Post-Stroke Fatality in the National Regards Study

Introduction: Previous studies have suggested that post-stroke case fatality in blacks is similar to or lower than that in whites. Black-white (B-W) differences in case fatality have not been examined within age strata. Methods: This study was conducted in REGARDS, a national population-based cohort enrolled in 2003-2007, followed for stroke events through September 30, 2017 and deaths through March 31, 2018. Medical records of suspected stroke events were retrieved and adjudicated by physicians. Case fatality (defined as death within 30-days of stroke event) following ischemic stroke was examined within age strata (45-64, 65-74 and 75+) among REGARDS participants aged 45+ who were stroke-free at baseline. Logistic regression was used to examine B-W differences in case-fatality after adjustment for sex, additional adjustment for the “Framingham risk factors,” and additional adjustment for socio-economic status (income and education). Results: There were 1,104 physician-adjudicated incident ischemic stroke events among 28,253 participants over a median of 9.4 years of follow-up. Case fatality was 9.8% (63/643) in whites and 6.1% (28/461) in blacks (B-W Odds Ratio (OR) = 0.60; 95% CI: 0.39 - 0.95). Case fatality significantly increased across age strata in whites (p trend ≤ 0.0001) but not blacks (p trend = 0.85) (see table.) At ages 45-64, the sex-adjusted B-W case fatality OR was 1.33 (95% CI: 0.56 - 3.11), and decreased to 0.42 (95% CI: 0.19 - 0.93) for ages 75+ (p trend = 0.013). Adjustment for risk factors and SES did not mediate the trend for lower case fatality in blacks at older ages (p trend = 0.012). Conclusions: These data confirm the lower stroke case-fatality in blacks compared to whites across the age-span of our study, and suggest that the benefit among black stroke patients is greatest at older ages.

Study of Outcome of Ischemic Stroke Patient With Atrial Fibrillation

Atrial fibrillation (AF) is a common arrhythmia and a major risk factor for ischemic stroke, especially in the elderly. Patients with nonvalvular AF have a 5-fold excess risk of stroke. However, population-based data are scarce in patients who have experienced a first-ever ischemic stroke in the presence of AF regarding long-term risk of stroke recurrence and case-fatality rate. Aim of the study is to find out the outcome of ischemic stroke patients with Atrial Fibrillation. It was a descriptive type cross sectional study where 125 diagnosed cases of ischemic stroke were included. Presence of atrial fibrillation was detected by electrocardiogram. They were divided into two groups – those with atrial fibrillation and those without. Comparison was done between the two group in term of recurrence, mortality and clinical improvement. Atrial fibrillation was present in 22 (17.6%) of 125 patients with ischemic stroke. Those with AF were more frequently male, aged 45 years and older. The presence of AF was associated with high 3 months (Χ2 =4.562, df = 1, p<0.05) and 6 months mortality (Χ2 =7.868, df = 1, p<0.05), with a higher stroke recurrence rate within the first 6 months follow-up (22.7% versus 7.8% (<0.05)). At 3 months follow up clinical deterioration was noted in 9.1% patient with atrial fibrillation compared to 2.9% patients who had no arrhythmia(p<0.01) and at 6 months follow up clinical deterioration was noted in 18.2% patient with atrial fibrillation compared to 4.9% patients who had no arrhythmia(p<0.01). Ischemic stroke patients with atrial fibrillation had significant mortality within the study period compared to those without atrial fibrillation. Significant deterioration in clinical outcome was noted in atrial fibrillation group after six months. Recurrence was more in ischemic stroke patients with atrial fibrillation. Multivariate linear regression analysis shows atrial fibrillation as well as CKD, Diabetes mellitus and smoking as independent risk factor for recurrence. In conclusion, patients who had an ischemic stroke with accompanying atrial fibrillation had higher mortality, grave stroke severity, more recurrences and poorer functional status than those without atrial fibrillation.TAJ 2015; 28(2): 1-6

Racial differences in recurrent ischemic stroke risk and recurrent stroke case fatality.

To determine black-white differences in 1-year recurrent stroke and 30-day case fatality after a recurrent stroke in older US adults. We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries with fee-for-service health insurance coverage who were hospitalized for ischemic stroke between 1999 and 2013. Hazard ratios for recurrent ischemic stroke and risk ratios for 30-day case fatality comparing blacks to whites were calculated with adjustment for demographics, risk factors, and competing risk of death when appropriate. Among 128,789 Medicare beneficiaries having an ischemic stroke (mean age 80 years [SD 8 years], 60.4% male), 11.1% were black. The incidence rate of recurrent ischemic stroke per 1,000 person-years for whites and blacks was 108 (95% confidence interval [CI], 106-111) and 154 (95% CI 147-162) , respectively. The multivariable-adjusted hazard ratio for recurrent stroke among blacks compared with whites was 1.36 (95% CI 1.29-1.44). The case fatality after recurrent stroke for blacks and whites was 21% (95% CI 21%-22%) and 16% (95% CI 15%-18%), respectively. The multivariable-adjusted relative risk for mortality within 30 days of a recurrent stroke among blacks compared with whites was 0.82 (95% CI 0.73-0.93). The risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks compared to whites, while 30-day case fatality after recurrent stroke remains lower for blacks.

Sex Differences in Stroke Incidence in a Portuguese Community-Based Study

Background and AimStroke is a major health problem. Several studies reported sex differences regarding stroke. We aim to study this issue in an incidence stroke study. MethodsData were retrieved from a community-based prospective register of patients that had a first ever stroke in a life time between October 2009 and September 2011. We studied sex differences regarding demographic data, vascular risk factors, stroke type, stroke severity (NIHSS), disability at 28days (modified Rankin scale (mRS)), and case fatality at 30 and 90days. ResultsFrom 720 stroke patients, 45.3% were men. Women were older (75.0 ± 13.6 versus 67.2 ± 14.9 years), had a worse premorbid mRS (39.3% versus 25.5%, P < .001), and a higher prevalence of hypertension (P = .004) and atrial fibrillation (P < .001). Previous myocardial infarction was more frequent in men (P = .001), as well as smoking habits (P < .001). Ischemic stroke was more common in women than men (87.6% versus 81.3%, P = .038). The 28 days’ outcome was worse in women (mRS ≥ 2, 77.2% versus 70.6%, P = .044). No differences were found in initial stroke severity (median NIHSS = 4) and case fatality at 30 and 90days, after adjusting for age and premorbid mRS. ConclusionNo differences were found in stroke initial severity and mortality at 30 and 90days between men and women, despite the sex differences pertaining to the stroke profile—age, vascular risk factors, stroke type, and outcome. Our results are somewhat discrepant from those described in the literature; more research is needed to understand if this may be due to changes in stroke standard of care.

Association between blood pressure and acute phase stroke case fatality rate: a prospective cohort study

ed to investigate the association between blood pressure and acute phase stroke lethality in a Brazilian intensive care unit. This was an observational, prospective cohort study of hemorrhagic and ischemic stroke intensive care patients. The primary outcome was all-cause mortality during the first seven days. There were 146 patients, aged 66 ± 13.4 years, 56% men, 89% Caucasian, 69% had ischemic stroke, and 80% were hypertensive. The median of the National Institutes of Health Stroke Scale score was 16. There were 101 ischemic stroke patients and 45 hemorrhagic stroke patients. In the ischemic stroke patients, logistic regression analysis identified low systolic blood pressure as an independent ominous prognostic factor and the optimal cut off was a mean of systolic blood pressure ≤ 131 mmHg during the first 48 hours from admission for prediction of death. No association was found for hemorrhagic stroke. There was a negative association between systolic blood pressure and case fatality ratio of acute phase stroke in ischemic stroke intensive care patients.

Stroke case-fatality and marital status.

Most studies show that marriage conveys a survival advantage. Whether this is valid also for stroke patients is unclear. Results of studies have been inconsistent and conflicting. We studied 1-week and 1-month stroke case-fatality in relation to marital status (married, unmarried, divorced, and widowed) in all patients admitted to hospital for incident stroke in Denmark during 2003-2012. We used information from Danish registries on stroke merged to information on age, sex, marital status, stroke severity, stroke subtype, socioeconomic status, cardiovascular risk profile, and causes of death. We studied deaths due to the index stroke within the first week and month after stroke. Multivariate Cox regression models were applied to estimate cause-specific hazards and relative risks. We included 60507 patients with an incident stroke of which 51.19% were married, 9.47% were unmarried, 13.29% were divorced, and 26.05% were widowers. Death within the first week and first month was caused by stroke in 2110 (3.5%) and 3423 (5.7%) patients, respectively. Compared to married stroke patients, 1-week/1-month case-fatality (by stroke) was lower for the unmarried (HR (hazard ratio):0.69/0.74), divorced (HR:0.69/0.72), and widowed (HR:0.80/0.74) men and the unmarried (HR:0.84/0.86), divorced (HR:0.82/0.80), and widowed (HR:0.87/0.88) women with stroke. One-week and one-month case-fatality by stroke was lower among the unmarried, divorced, and widowed than among the married stroke patients. Selection by so-called mortality displacement linked to shorter life expectancy among divorced, widowed, and singles may explain our findings.

Stroke in-hospital survival and its predictors: the first results from Tabriz Stroke Registry of Iran.

ObjectiveThe aim of this study was to determine the in-hospital survival of patients referred to the 2 stroke centers in North-West of Iran during a full seasonal year from April 2015.MethodsAll the consecutive patients with stroke admitted to the 2 main stroke centers at Tabriz (Imam Reza University Hospital and Razi University Hospital) were recruited in this study. Stroke patients from both ischemic and hemorrhagic subtypes were selected based on the registry data and International Classification of Diseases, 10th edition. At admission, details of examination including vital signs, neurologic and systemic examination, Modified Rankin Scale, and Glasgow Coma Scale were recorded. Baseline hematological and biochemical parameter assessments as well as computerized tomographic scanning were conducted. Cox regression was used to investigate and detect potential predictors of in-hospital survival.ResultsA total of 1,990 patients with stroke were studied. Males comprised 52.1% (1,036) of the subjects. The mean age of the patients was 65.8 years. Three hundred and fifty-seven (17.9%) patients had hemorrhagic stroke vs 1,633 (82.1%) with ischemic stroke. In-hospital case-fatality proportion was 12.5% (95% CI: 11.1–14). Based on modified Rankin Scale score at admission, 1,377 of 1,990 patients (69.2%) had a poor outcome (modified Rankin Scale score ≥3) at the admission time. The regression analysis showed that at least 7 variables could independently predict hospital survival of patients with stroke including age ≥65 years, higher admission modified Rankin Scale score, lower admission Glasgow Coma Scale score, hemorrhagic stroke nature, diabetes, having valvular heart disease, and having aspiration pneumonia.ConclusionThe case-fatality of stroke in the present study setting is high and needs to be appropriately addressed through prevention or management of some of these factors such as diabetes, pneumonia, and valvular heart diseases.

In Hospital Stroke Mortality: Rates and Determinants in Southwestern Saudi Arabia.

Objectives: The present study analyzed in-hospital first-time stroke mortality in southwestern Saudi Arabia over one-year to assess the in-hospital stroke case fatality rate, mortality rate and explore the factors associated with in-hospital stroke mortality. Study Design: Hospital based follow-up study. Methods: First-time stroke patients admitted to all hospitals in Asser region over one-year period (January through December 2016) were included in the study. Data about personal characteristics, pre-stroke history and clinical criteria, on admission clinical criteria, in-hospital complications and survival status were collected. The last reported Aseer region population was used to calculate age and sex stroke mortality rate per 100,000 population/year. Hazard ratios (HR) and concomitant 95% confidence intervals (95% CI) were computed using multivariate Cox regression survival analysis. Kaplan-Meier curve survival analysis for stroke patients were plotted. Results: A total of 121 in-hospital deaths out of 1249 first-time stroke patients giving an overall case fatality rate (CFR) of 9.7%. Non-significant difference with gender and age were observed in CFR. Overall, in-hospital stroke mortality rate was 5.58 per 100,000/year. Males and elders showed a significantly higher mortality rates. Multivariable Cox regression analyses revealed pre-stroke smoking (HR = 2.36), pre-stroke hypertension (HR = 1.77), post-stroke disturbed consciousness (HR = 6.86), poor mobility (HR = 2.60) and developing pulmonary embolism (HR = 2.63) as significant predictors of in-hospital stroke mortality. Conclusions: In Southwestern Saudi Arabia, the in-hospital stroke mortality rate is higher in men and increases with aging. The prognosis of acute stroke could be improved by smoking cessation, better control of hypertension and prevention of in hospital complication particularly pulmonary embolism.

The outcome of stroke: A six month follow-up study

Background and objective: Stroke is an increasing problem in developing countries and is the principal cause of disability and dependency in the western world. This study aimed to find out the one- and six-month case fatality, dependency and recurrence rates of stroke in Erbil teaching hospitals. Methods: This hospital-based prospective study included 293 stroke patients hospitalized in Erbil teaching hospitals from January 1st, 2015 through December 31st, 2015. Stroke was diagnosed by a consultant internist or neurologist and confirmed by brain CT-scan and/or MRI. Patients were followed-up for six months, then one- and six-month outcomes were measured including case-fatality, dependency and recurrences rates. Results: The one and six month case fatality rates were 28.3% and 37.5%, respectively. The rates in females (33.3%, 42.6%, respectively) were higher than that in males (23.7%, 32.9%, respectively), but there was no significant association between case-fatality rate and gender. A total of 74.3% and 45.4% of patients at one- and six-month were functionally dependent. The majority (88.9%) of diabetic patients were functionally dependent. Also, the one and six month recurrence rates of stroke patients were 15.7% and 23.2%, respectively. For both one and six month post stroke more recurrence occurred from ischemic (16.2%, 14.3%, respectively) than from hemorrhagic (24.5%, 19.5%, respectively) strokes, but there was no significant association between the recurrence and stroke subtype (P = 0.691, P = 0.367, respectively). Conclusion: The reported outcomes are relatively comparable to that reported in other developing countries, although it is still more than the rates of developed countries. Outcome measures can help to give information and develop guidelines for clinical practice and research.

Temporal Trends of Stroke Epidemiology in Southern Sweden: A Population-Based Study on Stroke Incidence and Early Case-Fatality

Background: Up-to-date epidemiological stroke studies are important for healthcare planning and evaluating prevention strategies. This population-based study investigates temporal trends in stroke incidence and case-fatality in southern Sweden. Methods: First-ever stroke cases in the local catchment area of Skåne University Hospital in Lund, Sweden, between March, 2015 and February, 2016, were included from several sources, including 2 prospective hospital-based registers, retrospective screening of primary care visits, and autopsy registers. Stroke incidence and 28-day case-fatality rates were compared with data from this area obtained through similar methodology between March, 2001 and February, 2002. Results: Altogether, 456 and 413 first-ever stroke patients were identified during the earlier and later time periods respectively. The age- and sex-standardized stroke incidence rates decreased from 246 (95% CI 224–270) to 165 (95% CI 149–182) per 100,000 people. However, incidence remained unaltered among those <65 years. Early case-fatality decreased from 14 to 11% (p = 0.165). ­Conclusion: First-ever stroke incidence in southern Sweden has decreased with 33% since the beginning of this millenni­um. Incidence rates have decreased among the elderly but remain unchanged among younger age groups. Our findings warrant further studies on trends in risk factor profiles and effects of prevention strategies, and heightened focus on stroke in the young.

Socioeconomic disparities in first stroke incidence, quality of care, and survival: a nationwide registry-based cohort study of 44 million adults in England

SummaryBackgroundWe aimed to estimate socioeconomic disparities in the incidence of hospitalisation for first-ever stroke, quality of care, and post-stroke survival for the adult population of England.MethodsIn this cohort study, we obtained data collected by a nationwide register on patients aged 18 years or older hospitalised for first-ever acute ischaemic stroke or primary intracerebral haemorrhage in England from July 1, 2013, to March 31, 2016. We classified socioeconomic status at the level of Lower Super Output Areas using the Index of Multiple Deprivation, a neighbourhood measure of deprivation. Multivariable models were fitted to estimate the incidence of hospitalisation for first stroke (negative binomial), quality of care using 12 quality metrics (multilevel logistic), and all-cause 1 year case fatality (Cox proportional hazards).FindingsOf the 43·8 million adults in England, 145 324 were admitted to hospital with their first-ever stroke: 126 640 (87%) with ischaemic stroke, 17 233 (12%) with intracerebral haemorrhage, and 1451 (1%) with undetermined stroke type. We observed a socioeconomic gradient in the incidence of hospitalisation for ischaemic stroke (adjusted incidence rate ratio 2·0, 95% CI 1·7–2·3 for the most vs least deprived deciles) and intracerebral haemorrhage (1·6, 1·3–1·9). Patients from the lowest socioeconomic groups had first stroke a median of 7 years earlier than those from the highest (p<0·0001), and had a higher prevalence of pre-stroke disability and diabetes. Patients from lower socioeconomic groups were less likely to receive five of 12 care processes but were more likely to receive early supported discharge (adjusted odds ratio 1·14, 95% CI 1·07–1·22). Low socioeconomic status was associated with a 26% higher adjusted risk of 1-year mortality (adjusted hazard ratio 1·26, 95% CI 1·20–1·33, for highest vs lowest deprivation decile), but this gradient was largely attenuated after adjustment for the presence of pre-stroke diabetes, hypertension, and atrial fibrillation (1·11, 1·05–1·17).InterpretationWide socioeconomic disparities exist in the burden of ischaemic stroke and intracerebral haemorrhage in England, most notably in stroke hospitalisation risk and case fatality and, to a lesser extent, in the quality of health care. Reducing these disparities requires interventions to improve the quality of acute stroke care and address disparities in cardiovascular risk factors present before stroke.FundingNHS England and the Welsh Government.