Trend of Stroke Incidence in a Japanese Population: Takashima Stroke Registry, 1990-2001

Incidence, case fatality, and functional outcome of intracerebral haemorrhage, according to age, sex, and country income level: a systematic review and meta-analysis

Background

Intracerebral haemorrhage (ICH) accounts for approximately 28% of all strokes worldwide. ICH has a high case fatality, and only few survivors recover to independent living. Over the past decades, demographic changes, and changes in prevalence and management of risk factors may have influenced incidence. Widespread implementation of stroke units and improved care in general may have affected case fatality and outcome. We aimed to update the evidence on incidence, case fatality, and functional outcome of ICH, according to age, sex, and country income level.

Methods

We systematically searched PubMed and Embase from 2008 to April 2023 for prospective population-based studies on incidence, case fatality, or functional outcome of first-ever ICH. We excluded studies in which less than 80% of cases was confirmed with imaging or autopsy. Quality of the studies was assessed based on the used case finding methods. We used inverse variance-based random-effects meta-analyses to pool the crude incidence, case fatality at 1 month, and the percentage of patients with good functional outcome after 3, 6, or 12 months, as defined by the authors of the individual studies. Time trends were assessed using weighted linear meta-regression. Funnel plots were constructed to study publication bias. The review was registered on PROSPERO (CRD42023413314).

Findings

We identified 70 eligible studies, describing 19,470 ICH patients from 26 different countries. Of these, 62 studies reported on crude incidence, 41 on case fatality, and 10 on functional outcome. Overall crude incidence was 29.2 per 100,000 person-years (95% CI 23.3-36.4; I2 = 100%). Incidence was lower in women than in men and increased with age. Incidence was highest in lower-middle income countries, followed by high and upper-middle income countries. Case fatality at 1 month was 35.5% (95% CI 32.3-38.9; I2 = 90%). The percentage of patients with good functional outcome (mRS 0-2 in nine studies, mRS 0-3 in one) after 3-12 months was 31.2% (95% CI 24.7-38.6; I2 = 76%). We found no time trends in incidence, case fatality, or functional outcome.

Interpretation

Our results demonstrate the persistently high burden and devastating consequences of ICH, stressing the need for better preventive strategies and acute treatments.

Funding

None.

Diverging Temporal Trends in Stroke Incidence in Younger vs Older People: A Systematic Review and Meta-analysis

Importance

Overall stroke incidence is falling in high-income countries, but data on time trends in incidence of young stroke (ie, stroke in individuals younger than 55 years) are conflicting. An age-specific divergence in incidence, with less favorable trends at younger vs older ages, might be a more consistent underlying finding across studies.

Objective

To compare temporal trends in incidence of stroke at younger vs older ages in high-income countries.

Data Sources

PubMed and EMBASE were searched from inception to February 2022. One additional population-based study (Oxford Vascular Study) was also included.

Study Selection

Studies reporting age-specific stroke incidence in high-income countries at more than 1 time point.

Data Extraction and Synthesis

For all retrieved studies, 2 authors independently reviewed the full text against the inclusion criteria to establish their eligibility. Meta-analysis was performed with the inverse variance-weighted random-effects model. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed.

Main Outcomes and Measures

The main outcome was age-specific divergence (<55 vs ≥55 years) in temporal trends in stroke incidence (relative temporal rate ratio [RTTR]) in studies extending to at least 2000. RTTRs were calculated for each study and pooled by random-effects meta-analysis, with stratification by administrative vs prospective population-based methodology, sex, stroke subtype (ischemic vs intracerebral hemorrhage vs subarachnoid hemorrhage) and geographical region.

Results

Among 50 studies in 20 countries, 26 (13 prospective population-based and 13 administrative studies) reported data allowing calculation of the RTTR for stroke incidence at younger vs older ages across 2 or more periods, the latest extending beyond 2000. Reported trends in absolute incidence of young individuals with stroke were heterogeneous, but all studies showed a less favorable trend in incidence at younger vs older ages (pooled RTTR = 1.57 [95% CI, 1.42-1.74]). The overall RTTR was consistent by stroke subtype (ischemic, 1.62 [95% CI, 1.44-1.83]; intracerebral hemorrhage, 1.32 [95% CI, 0.91-1.92]; subarachnoid hemorrhage, 1.54 [95% CI, 1.00-2.35]); and by sex (men, 1.46 [95% CI, 1.34-1.60]; women, 1.41 [95% CI, 1.28-1.55]) but was greater in studies reporting trends solely after 2000 (1.51 [95% CI, 1.30-1.70]) vs solely before (1.18 [95% CI, 1.12-1.24]) and was highest in population-based studies in which the most recent reported period of ascertainment started after 2010 (1.87 [95% CI, 1.55-2.27]).

Conclusions and Relevance

Temporal trends in stroke incidence are diverging by age in high-income countries, with less favorable trends at younger vs older ages, highlighting the urgent need to better understand etiology and prevention of stroke at younger ages.

Incidence and Long-Term Survival of Spontaneous Intracerebral Hemorrhage Over Time: A Systematic Review and Meta-Analysis

Background and Purpose

Recent epidemiological data indicate that the absolute number of hemorrhagic stroke cases increased by 47% between 1990 and 2010 and continued to cause high rates of death and disability. The last systematic review and meta-analysis of incidence and long-term survival of intracerebral hemorrhage (ICH) were published 11 and 7 years ago, respectively, and lacked comparison between different income groups, therefore, a more up to date analysis is needed. We aim to investigate the ICH incidence and long-term survival data in countries of different income groups.

Materials Methods

We systematically searched Ovid Medline for population-based longitudinal studies of first-ever spontaneous ICH published from January 2000 to December 2020. We performed meta-analyses on the incidence and survival rate in countries of 4 different income groups with random-effects models (severe inconsistency). The I² was used to measure the heterogeneity. Heterogeneity was further investigated by conducting the meta-regression on the study mid-year. Time trends of the survival rate were assessed by weighted linear regression.

Results

We identified 84 eligible papers, including 68 publications reporting incidence and 24 publications on the survival rate. The pooled incidence of ICH per 100,000 per person-years was 26.47 (95% CI: 21.84–32.07) worldwide, 25.9 (95% CI: 22.63–29.63) in high-income countries (HIC), 28.45 (95% CI: 15.90–50.88) in upper-middle-income countries, and 31.73 (95% CI: 18.41–54.7) in lower-middle-income countries. The 1-year pooled survival rate was from 50% (95% CI: 47–54%; n = 4,380) worldwide to 50% (95% CI: 47–54%) in HIC, and 46% (95% CI: 38–55%) in upper-middle income countries. The 5-year pooled survival rate was 41% (95% CI: 35–48%; n = 864) worldwide, 41% (95% CI: 32–50%) in high-income and upper-middle countries. No publications were found reporting the long-term survival in lower-middle-income and low-income countries. No time trends in incidence or survival were found by meta-regression.

Conclusion

The pooled ICH incidence was highest in lower-middle-income countries. About half of ICH patients survived 1 year, and about two-fifths survived 5 years. Reliable population-based studies estimating the ICH incidence and long-term survival in low-income and low-middle-income countries are needed to help prevention of ICH.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170140, PROSPERO CRD42020170140.

Impact of retinal vein occlusion on cardiovascular events in elderly Japanese patients

To assess the relationship between retinal vein occlusion (RVO) and the incidence of cardiovascular (CV) events.This was a single-institution, retrospective cohort study. We enrolled 57 patients diagnosed with RVO between January 2012 and December 2019, and 125 non-RVO patients who had undergone cataract surgery by a single surgeon between January and April 2012. We compared the relative risk and incidence rate ratio of CV events between the 2 groups. In addition, survival analysis was performed to calculate the hazard ratio (HR) using the Cox proportional hazards model. RVO, age, sex, blood pressure, body mass index, presence of diabetes, blood sample data, and smoking were considered confounders.The mean observation period (± standard deviation) for the RVO and non-RVO groups was 2.68 ± 2.04 and 2.81 ± 2.70 years, respectively. Seven CV events were observed in the RVO group and 2 in the non-RVO group. Relative risk and incidence rate ratio were 7.68 (95% confidence interval [CI]: 1.65-35.8) and 8.07 (95% CI: 1.54-79.6), respectively. Multivariate analysis revealed that the RVO group had a high HR for CV events (HR: 16.13 [95% CI: 2.29-113.74]) and older age (HR: 1.26 [95% CI: 1.06-1.49]).RVO can predict future CV events, especially in the elderly population. Fundus observations should be shared between ophthalmologists and internists to prevent future CV events.

Relationship of Ambient Temperature Parameters to Stroke Incidence in a Japanese Population - Takashima Stroke Registry, Japan, 1988-2010

BACKGROUND

Using a population-based stroke registry system, we evaluated the relationship between ambient temperature parameters and stroke incidence in a Japanese population.

METHODS AND RESULTS

We analyzed data from the Takashima Stroke Registry, which records all stroke occurrences in Takashima City, Japan. The study period of 8,401 days was divided into quintiles of daily weather parameters, and the middle quintile was used as the reference category. Incidence rates (IR per 100,000 person-years) were calculated across the quintiles. Poisson regression analysis was used to calculate the effect of temperature parameters on stroke incidence. There were 2,405 first-ever strokes (1,294 men), including 1,625 ischemic, 545 cerebral hemorrhages, 213 subarachnoid hemorrhages, and 22 unclassified strokes. The stroke IR was higher in the middle quintile of average temperature, 357.3 (328.4-388.8), and for other parameters. After adjustment for age and sex, for all stroke, the incidence rate ratio (IRR) in the highest (Q5: IRR 0.81, 95% confidence interval (CI) 0.71-0.92) and the second-highest (Q4: IRR 0.80, 95% CI 0.71-0.91) quintile was lower than that in the middle quintile (Q3: Reference). Analogous results were observed for the minimum, maximum, and lag-days temperatures, also in the subtypes and across ≥65 years of age, also in females.

CONCLUSIONS

Higher temperatures, irrespective of the parameter (average, minimum, or maximum), had a protective effect against stroke occurrence in Japan.

Importance of Considering Malnutrition and Sarcopenia in Order to Improve the QOL of Elderly Hemodialysis Patients in Japan in the Era of 100-Year Life

In the current aging society of Japan, malnutrition and resultant sarcopenia have been widely identified as important symptomatic indicators of ill health and can cause impairments of longevity and quality of life in older individuals. Elderly individuals are recommended to have sufficient calorie and protein intake so as to enjoy a satisfactory quality of life, including maintaining activities of daily living in order to avoid emaciation and sarcopenia. The prevalence of emaciation and sarcopenia in elderly hemodialysis (HD) patients in Japan is higher than in non-HD elderly subjects due to the presence of malnutrition and sarcopenia associated with chronic kidney disease (CKD). Furthermore, comorbidities, such as diabetes and osteoporosis, induce malnutrition and sarcopenia in HD patients. This review presents findings regarding the mechanisms of the development of these early symptomatic conditions and their significance for impaired QOL and increased mortality in elderly HD patients.

Trends in Stroke Incidence in High-Income Countries in the 21st Century: Population-Based Study and Systematic Review

Background and Purpose- Population-based studies provide the most reliable data on stroke incidence. A previous systematic review of population-based studies suggested that stroke incidence in high-income countries decreased by 42% between the 1970s and early 2000s. However, it is uncertain whether this trend of steady decline has been maintained in more recent periods. Methods- Data from OCSP (Oxfordshire Community Stroke Project; 1981-1986) and OXVASC (Oxford Vascular Study; 2002-2017) along with other published population-based stroke incidence studies that reported temporal trends of stroke incidence since 1990 in high-income countries were included. Age-standardized relative incidence rate ratios were calculated for each study and then pooled with inverse-variance weighted random-effects meta-analysis. Projection estimates were calculated for the number of incident stroke patients in the United Kingdom from year 2015 to 2045. Results- In Oxfordshire, stroke incidence fell by 32% from OCSP to OXVASC, with a similar trend before or after year 2000. With the projected aging population, if the age-specific stroke incidence continued to decrease at its current rate (6% every 5 years), there would still be a 13% increase of the number of first-ever strokes in the United Kingdom up to year 2045. Incorporating the Oxfordshire data with other 12 population-based studies, stroke incidence declined steadily between the 1990s and 2010s within each study, resulting in a 28% decline over an average period of 16.5 years (pooled incidence rate ratio, 0.72 [95% CI, 0.66-0.79]; P<0.0001). The trend was the same for men (0.69 [95% CI, 0.61-0.77]; P<0.0001) and women (0.66 [95% CI, 0.59-0.74]; P<0.0001) and remained consistent after year 2010 in OXVASC. Proportion of disabling or fatal stroke also decreased over time (early versus later period, 53.6% versus 46.1%; P=0.02). Conclusions- Stroke incidence is continuing to decline with steady rate in Oxfordshire and in other high-income settings. However, the absolute number of strokes occurring is not falling.

Worldwide Incidence of Aneurysmal Subarachnoid Hemorrhage According to Region, Time Period, Blood Pressure, and Smoking Prevalence in the Population: A Systematic Review and Meta-analysis

Importance

Subarachnoid hemorrhage (SAH) from ruptured intracranial aneurysms is a subset of stroke with high fatality and morbidity. Better understanding of a change in incidence over time and of factors associated with this change could facilitate primary prevention.

Objective

To assess worldwide SAH incidence according to region, age, sex, time period, blood pressure, and smoking prevalence.

Data Sources

We searched PubMed, Web of Science, and Embase for studies on SAH incidence published between January 1960 and March 2017. Worldwide blood pressure and smoking prevalence data were extracted from the Noncommunicable Disease Risk Factor and Global Burden of Disease data sets.

Study Selection

Population-based studies with prospective designs representative of the entire study population according to predefined criteria.

Data Extraction and Synthesis

Two reviewers independently extracted data according to PRISMA guidelines. Incidence of SAH was calculated per 100 000 person-years, and risk ratios (RRs) including 95% CIs were calculated with multivariable random-effects binomial regression. The association of SAH incidence with blood pressure and smoking prevalence was assessed with linear regression.

Main Outcomes and Measures

Incidence of SAH.

Results

A total of 75 studies from 32 countries were included. These studies comprised 8176 patients with SAH were studied over 67 746 051 person-years. Overall crude SAH incidence across all midyears was 7.9 (95% CI, 6.9-9.0) per 100 000 person-years; the RR for women was 1.3 (95% CI, 0.98-1.7). Compared with men aged 45 to 54 years, the RR in Japanese women older than 75 years was 2.5 (95% CI, 1.8-3.4) and in European women older than 75 years was 1.5 (95% CI, 0.9-2.5). Global SAH incidence declined from 10.2 (95% CI, 8.4-12.5) per 100 000 person-years in 1980 to 6.1 (95% CI, 4.9-7.5) in 2010 or by 1.7% (95% CI, 0.6-2.8) annually between 1955 and 2014. Incidence of SAH declined between 1980 and 2010 by 40.6% in Europe, 46.2% in Asia, and 14.0% in North America and increased by 59.1% in Japan. The global SAH incidence declined with every millimeter of mercury decrease in systolic blood pressure by 7.1% (95% CI, 5.8-8.4) and with every percentage decrease in smoking prevalence by 2.4% (95% CI, 1.6-3.3).

Conclusions and Relevance

Worldwide SAH incidence and its decline show large regional differences and parallel the decrease in blood pressure and smoking prevalence. Understanding determinants for regional differences and further reducing blood pressure and smoking prevalence may yield a diminished SAH burden.

Disabled life expectancy with and without stroke: a 10-year Japanese prospective cohort study

PURPOSE

A stroke is a debilitating condition that can cause lifelong disability, severely limiting the ability of individuals to perform daily activities. In Japan, strokes are the fourth leading cause of death; however, no previous studies have examined the influence of strokes on a disabled or disability-free life for older Japanese residents. This study aims to address this gap.

METHODS

The study used data from the Nihon University Japanese Longitudinal Study of Aging (NUJLSOA) and incidence-based multistate life tables to estimate disabled and disability-free life expectancy based on the stroke status of Japanese residents aged 65 and older.

RESULTS

Japanese stroke survivors aged 65 who experienced an initial disability-free state could expect to live approximately 3 fewer total years of life, 4-5 fewer years in a disability-free state, and 1-2 more years in a disabled state compared to those without history of a stroke (p < 0.05). For those disabled at the beginning of the survey interval, the differences between individuals with and without stroke history were also similar to those disability-free at the beginning of the survey interval (2-4 and 5-6 fewer total and disability-free years, respectively) (p < 0.05). The same pattern was observed for older age groups.

CONCLUSION

Older adults who have experienced a stroke could experience a shorter total life expectancy, shorter disability-free life expectancy, and longer disabled life expectancy than those who have not experienced a stroke. These results can inform policymakers and rehabilitation practitioners on stroke survivor long-term care needs and their post-stroke health status.

Dementia in 'super-aged' Japan: challenges and solutions

Japan, as a 'super-aged' society, is at the forefront of the socioeconomic change resulting from the unprecedented demographic shift of aging societies, and is an exemplar for other countries. Within neurodegenerative disorders, a deeper understanding of the issues faced by aging societies, and their ramifications on the mental well being and cognitive health of older adults, is important. Japan's pioneering approaches in assistive technology and 'gerontotechnology' have the potential to enhance the field of dementia in terms of assessment, diagnosis and care. This article is a narrative review of the issue of aging and dementia in Japan by discussing demographics, implications of a 'super-aged' society, challenges and potential solutions to the growing issue of dementia in the world's most aged nation.

Factors influencing the incidence and treatment of intracranial aneurysm and subarachnoid hemorrhage: time trends and socioeconomic disparities under an universal healthcare system

Background

Despite increasing usage of endovascular treatments for intracranial aneurysms, few research studies have been conducted on the incidence of unruptured aneurysm (UA) and subarachnoid hemorrhage (SAH), and could not show a decrease in the incidence of SAH. Moreover, research on socioeconomic disparities with respect to the diagnosis and treatment of UA and SAH is lacking.

Method

Trends in the incidences of newly detected UA and SAH and trends in the treatment modalities used were assessed from 2005 to 2015 using the nationwide database of the Korean National Health Insurance Service in South Korea. We also evaluated the influence of demographic characteristics including socioeconomic factors on the incidence and treatment of UA and SAH.

Result

The rates of newly detected UA and SAH were 28.3 and 13.7 per 100 000 of the general population, respectively, in 2015. The incidence of UA increased markedly over the 11-year study period, whereas that of SAH decreased slightly. UA patients were more likely to be female, older, employee-insured, and to have high incomes than SAH patients. In 2015, coiling was the most common treatment modality for both UA and SAH patients. Those who were female, employee-insured, or self-employed, with high income were likely to have a higher probability to be treated for UA and SAH.

Conclusion

The marked increase in the detection and treatment of UA might have contributed to the decreasing incidence of SAH, though levels of contribution depend on socioeconomic status despite universal medical insurance coverage.

Characteristics of hospitalizations due to acute stroke in the Silesian Province, Poland, between 2009 and 2015

INTRODUCTION

The available data on acute stroke (AS) in Poland come mainly from non-representative cohorts or are outdated. Therefore, the current study was done to access the most recent data on AS in the industrial region that covers 12% (4.6mln) of the country's population.

OBJECTIVE

To evaluate the epidemiological data of AS in the Silesian Province, Poland.

PATIENTS AND METHODS

Analysis of the data from stroke questionnaires, obligatory for all patients hospitalized due to AS and administered by the only public health insurer in Poland (the National Health Fund) between 2009 and 2015 (n=81,193).

RESULTS

The annual number of hospitalizations due to AS in the analyzed period was between 239 and 259 per 100,000 inhabitants of the Silesian Province. Haemorrhagic stroke constituted 13.3%, ischaemic stroke - 85.5%, and unspecified stroke - 1.2%. The average age of patients was 71.6±12.2 years (M 68.2±11.9, F 74.8±11.9, P<0.05). The mean duration of hospitalization was 17±16 days for haemorrhagic stroke, and 14±11 days for ischaemic stroke. Large-artery atherosclerosis (36.1%) and cardioembolism (18.7%) constituted the main causes of ischaemic stroke. Overall hospital mortality for AS was 18% (haemorrhagic - 40.8%, ischaemic - 14.9%). A decreasing trend in mortality was observed in ischaemic but not in haemorrhagic stroke. In-hospital mortality was significantly higher in women than in men (P<0.05).

CONCLUSIONS

This comprehensive long-term analysis of the epidemiological situation related to AS in the industrial region of Poland should encourage further development of educational and treatment programmes for improvement in the health status of the population.

Incidence, Management and Short-Term Outcome of Stroke in a General Population of 1.4 Million Japanese - Shiga Stroke Registry

BACKGROUND

This study determined the current status of the incidence, management, and prognosis of stroke in Japan using a population-based stroke registry.

METHODS AND RESULTS

Shiga Stroke Registry is an ongoing population-based registry that covers approximately 1.4 million residents of Shiga Prefecture. Cases of acute stroke were identified using standard definitions through surveillance of both all acute-care hospitals with neurology/neurosurgery facilities and death certificates in 2011. A total of 2,956 stroke cases and 2,176 first-ever stroke cases were identified. The age- and sex-adjusted incidence rate for first-ever stroke using the 2013 European Standard Population as standard was per 100,000 person-years: 91.3 for ischemic stroke, 36.4 for intracerebral hemorrhage, and 13.7 for subarachnoid hemorrhage. It was estimated that approximately 220,000 new strokes occurred in 2011 in Japan. Among the 2,956 cases, most stroke patients underwent neuroimaging, 268 received surgical or endovascular treatment, and 2,158 had rehabilitation therapy; 78 patients received intravenous thrombolysis. A total of 1,846 stroke patients had died or were dependent at hospital discharge, and 390 died within 28 days of onset.

CONCLUSIONS

Incidence rates of stroke by subtypes were clarified and the total number of new strokes in Japan was estimated. More than half of stroke patients die or become dependent after a stroke. This study re-emphasized the importance of public health measures in reducing the burden of stroke in Japan.

Low cholesterol level associated with severity and outcome of spontaneous intracerebral hemorrhage: Results from Taiwan Stroke Registry

The relationship between cholesterol level and hemorrhagic stroke is inconclusive. We hypothesized that low cholesterol levels may have association with intracerebral hemorrhage (ICH) severity at admission and 3-month outcomes. This study used data obtained from a multi-center stroke registry program in Taiwan. We categorized acute spontaneous ICH patients, based on their baseline levels of total cholesterol (TC) measured at admission, into 3 groups with <160, 160–200 and >200 mg/dL of TC. We evaluated risk of having initial stroke severity, with National Institutes of Health Stroke Scale (NIHSS) >15 and unfavorable outcomes (modified Rankin Scale [mRS] score >2, 3-month mortality) after ICH by the TC group. A total of 2444 ICH patients (mean age 62.5±14.2 years; 64.2% men) were included in this study and 854 (34.9%) of them had baseline TC <160 mg/dL. Patients with TC <160 mg/dL presented more often severe neurological deficit (NIHSS >15), with an adjusted odds ratio [aOR] of 1.80; 95% confidence interval [CI], 1.41–2.30), and 3-month mRS >2 (aOR, 1.41; 95% CI, 1.11–1.78) using patients with TC >200 mg/dL as reference. Those with TC >160 mg/dL and body mass index (BMI) <22 kg/m² had higher risk of 3-month mortality (aOR 3.94, 95% CI 1.76–8.80). Prior use of lipid-lowering drugs (2.8% of the ICH population) was not associated with initial severity and 3-month outcomes. A total cholesterol level lower than 160 mg/dL was common in patients with acute ICH and was associated with greater neurological severity on presentation and poor 3-month outcomes, especially with lower BMI.

Changes in stroke incidence, outcome, and associated factors in Porto between 1998 and 2011

Objective

Year 2000 marked a turning point in stroke prevention and treatment in Portugal. In face of high incidence rates stroke awareness campaigns, close surveillance of vascular risk factors and implementation of hospital stroke units were advanced by the National Health Authorities. To understand the effect of such measures, we assessed changes in stroke incidence and short-term outcome using data from two community-based registers undertaken in Porto in 1998–2000 and 2009–2011.

Methods

We used standard diagnostic criteria and multiple overlapping sources of case-ascertainment for first-ever strokes. Short-term outcome was measured by the modified Rankin Scale; disabling stroke was defined whenever post-stroke mRS score>pre-stroke mRS and >1.

Results

Globally, 462 and 405 first-ever stroke cases were registered in 1998–2000 and 2009–2011, respectively. Stroke incidence decreased by 23%, from 261 to 203/100,000 after adjustment for the Portuguese population. Significant reduction was found in those aged <75 years (31%) and in women (32%). Incidence of disabling strokes was reduced by 29%. Fatal strokes decreased by 46%, while intracerebral hemorrhage decreased by 51%. Risk of disability from stroke decreased by 11% (RR = 0.89; 95%CI, 0.81–0.98) in 2009–2011, as found after adjusting for patient/stroke characteristics in a Poisson model. Moreover, when patients arrived hospital within 3 h from stroke onset, the risk of disabling stroke was 0.76 (95%CI, 0.67–0.87) in 2009–2011 vs. 1998–2000, compared to 1.03 (95%CI, 0.89–1.12) for late arrival.

Conclusion

Risk of stroke, mainly of hemorrhagic stroke, was substantially reduced over time. Timely action in acute phase was responsible for the decline in disability across periods.

30-Year Trends in Stroke Rates and Outcome in Auckland, New Zealand (1981-2012): A Multi-Ethnic Population-Based Series of Studies

Background

Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years.

Methods

Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981–1982, 1991–1992, 2002–2003 and 2011–2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution.

Results

5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Māori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Māori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients.

Conclusions

In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.

Acute Case-Fatality Rates of Stroke and Acute Myocardial Infarction in a Japanese Population: Takashima Stroke and AMI Registry, 1989–2005

Background

Few comprehensive stroke and acute myocardial infarction registries of long duration exist in Japan to illustrate trends in acute case-fatality of stroke and acute myocardial infarction with greater precision. We examined 17-year case-fatality rates of stroke and acute myocardial infarction using an entire community-monitoring registration system to investigate trends in these rates over time in a Japanese population.

Methods

Data were obtained from the Takashima Stroke and AMI Registry covering a stable population of approximately 55 000 residents of Takashima County in central Japan. We divided the total observation period of 17 years into four periods, 1989–1992, 1993–1996, 1997–2000, and 2001–2005. We calculated gender, age-specific and age-adjusted acute case-fatality rates (%) of stroke and acute myocardial infarction across these four periods.

Results

During the study period of 1989–2005, there were 341 fatal cases within 28 days of onset among 2239 first-ever stroke events and 163 fatal cases among 433 first-ever acute myocardial infarction events. The age-adjusted acute case-fatality rate of stroke was 14·9% in men and 15·7% in women. The age-adjusted acute case-fatality rate of acute myocardial infarction was 34·3% in men and 43·3% in women. The age-adjusted acute case-fatality rates of stroke and acute myocardial infarction showed insignificant differences across the four time periods. The average annual change in the acute case-fatality rate of stroke (–0·2%; 95% CI: −2·4–2·1) and acute myocardial infarction (2·7%; 95% CI: −0·7–6·1) did not change significantly across the study years.

Conclusions

The acute case-fatality rates of stroke and acute myocardial infarction have remained stable from 1989 to 2005 in a rural and semi-urban Japanese population.

The Mataró Stroke Registry: a 10-year registry in a community hospital

INTRODUCTION

A prospective stroke registry leads to improved knowledge of the disease. We present data on the Mataró Hospital Registry.

METHODS

In February-2002 a prospective stroke registry was initiated in our hospital. It includes sociodemographic data, previous diseases, clinical, topographic, etiological and prognostic data. We have analyzed the results of the first 10 years.

RESULTS

A total of 2,165 patients have been included, 54.1% male, mean age 73 years. The most frequent vascular risk factor was hypertension (65.4%). Median NIHSS on admission: 3 (interquartile range, 1-8). Stroke subtype: 79.7% ischemic strokes, 10.9% hemorrhagic, and 9.4% TIA. Among ischemic strokes, the etiology was cardioembolic in 26.5%, large-vessel disease in 23.7%, and small-vessel in 22.9%. The most frequent topography of hemorrhages was lobar (47.4%), and 54.8% were attributed to hypertension. The median hospital stay was 8 days. At discharge, 60.7% of patients were able to return directly to their own home, and 52.7% were independent for their daily life activities. After 3 months these percentages were 76.9% and 62.9%, respectively. Hospital mortality was 6.5%, and after 3 months 10.9%.

CONCLUSIONS

Our patient's profile is similar to those of other series, although the severity of strokes was slightly lower. Length of hospital stay, short-term and medium term disability, and mortality rates are good, if we compare them with other series.

Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden.

METHODS

Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions.

CONCLUSIONS

The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Trends in the incidence and survival of intracerebral hemorrhage by its location in a Japanese community

BACKGROUND

No previous population-based studies have examined secular trends in the incidence of intracerebral hemorrhage (ICH) by its location.

METHODS AND RESULTS

 We established 3 cohorts consisting of residents of Hisayama, Japan, aged ≥40 years without a history of stroke or myocardial infarction in 1961 (the first cohort, n=1,618), in 1974 (the second cohort, n=2,038), and in 1988 (the third cohort, n=2,637). Each cohort was followed for 13 years. The age- and sex-adjusted incidence of ICH significantly declined from the first to the second cohort and showed no further change in the third cohort. With regard to the ICH location, the incidence of putaminal hemorrhage decreased steadily, mainly in subjects aged 60-69 years, whereas the incidence of thalamic hemorrhage increased, especially in those aged ≥70 years. Both hypertension and alcohol intake were strong risk factors for ICH in the first cohort, but their influence declined with time. Blood pressure levels in hypertensive subjects decreased significantly, and the proportion of current drinkers decreased slightly over the study period.

CONCLUSIONS

Our findings suggest that the ICH incidence steeply declined from the 1960s to the 1970s in Japan as a result of the reduced influence of hypertension and alcohol intake, but that this decline has leveled off since then, probably because of the increased incidence of thalamic hemorrhage in the elderly in recent years. 

Stroke types in rural and urban northern portugal: incidence and 7-year survival in a community-based study

BACKGROUND/AIM

Differences in stroke incidence and mortality between regions could stem from differences in the incidence of particular stroke types and long-term prognosis. The aim of this study was to investigate whether different risk profiles and stroke types underlie the difference in stroke incidence and patient long-term survival in rural and urban populations.

METHODS

All suspected first-ever-in-a-lifetime strokes occurring between October 1998 and September 2000 in 37,290 residents of rural municipalities and in 86,023 individuals living in the city of Porto were entered into a population-based registry. Standard definitions of stroke types and overlapping comprehensive sources of information were used for patient identification. Patients were examined by neurologists at 3 months, 1 year and 7 years after the index event.

RESULTS

From a total of 688 patients included (226 in rural and 462 in urban areas), 76.2% had an ischaemic stroke (IS; 75.3 vs. 77.9%), 16.1% a primary intracerebral haemorrhage (PICH; 16.3 vs. 14.6%) and 3.3% a subarachnoid haemorrhage (SAH; 2.7 vs. 3.7%); in 4.4% (4.9 vs. 4.1%), the stroke type could not be determined. The annual incidence rate per 1,000 was 2.13 (95% CI, 1.95-2.31), 0.45 (95% CI, 0.37-0.53), 0.09 (95% CI, 0.06-0.14) and 0.12 (95% CI, 0.08-0.17), respectively. The age-specific rural/urban incidence rate ratios for IS in the youngest group (<55 years) was 0.27 (95% CI, 0.11-0.69), increasing to 1.47 (95% CI, 1.07-2.01) for those aged 65-74 years and to 1.87 (95% CI, 1.39-2.52) for those between 75 and 84 years. Rural compared to urban patients with an IS were predominantly men, had a prevalence ratio (PR) of 1.28 (95% CI, 1.05-1.56), were 65 years or older (PR = 1.18; 95% CI, 1.08-1.30) and had in general a lower prevalence of risk factors. There was no evidence of rural/urban differences in 28-day case fatality for the stroke types, although IS tended to be less fatal among urban patients (10.3 vs. 13.1%), whereas PICH (33.3 vs. 24.2%) and SAH (35.3 vs. 16.7%) were less fatal among rural patients. Independently of rural/urban residence, predictors of poor survival after the acute phase (28 days) were age >65 years (HR = 3.57; 95% CI, 2.6-4.9), diabetes (HR = 1.5; 95% CI, 1.2-1.9), ischaemic heart disease (HR = 1.8; 95% CI, 1.3-2.6), atrial fibrillation (HR = 1.5; 95% CI, 1.1-2.0) and smoking habits (HR = 1.6; 95% CI, 1.1-2.3).

CONCLUSIONS

The age pattern of IS incidence marks the difference between rural and urban populations; the youngest urban and the oldest rural residents were at a higher risk. Although patients from rural areas were older, the relatively lower prevalence of simultaneously occurring risk and prognostic factors among them as well as the similar management of rural and urban patients may justify why rurality is not associated with long-term survival.

Secular trends in cardiovascular disease and its risk factors in Japanese: half-century data from the Hisayama Study (1961-2009)

BACKGROUND

Changes in lifestyle and advances in medical technology during the past half century are likely to have affected the incidence and mortality of cardiovascular disease and the prevalence of its risk factors in Japan.

METHODS AND RESULTS

We established 5 cohorts consisting of residents aged ≥40 years in a Japanese community, in 1961 (n=1618), 1974 (n=2038), 1983 (n=2459), 1993 (n=1983), and 2002 (n=3108), and followed up each cohort for 7 years. The age-adjusted incidence of stroke decreased greatly, by 51% in men and by 43% in women, from the 1960s to the 1970s, but this decreasing trend slowed from the 1970s to the 2000s. Among the stroke subtypes, ischemic stroke in both sexes and intracerebral hemorrhage in men showed a similar pattern. Stroke mortality decreased as a result of the decline in incidence and a significant improvement in survival rate. Although the incidence of acute myocardial infarction did not change in either sex, disease mortality declined slightly in women. From the 1960s to the 2000s, blood pressure control among hypertensive individuals improved significantly and the smoking rate decreased, but the prevalence of glucose intolerance, hypercholesterolemia, and obesity increased steeply.

CONCLUSIONS

Our findings suggest that in Japanese, the decreasing trends in the incidence of ischemic stroke have recently slowed down, and there has been no clear change in the incidence of acute myocardial infarction, probably because the benefits of hypertension control and smoking cessation have been negated by increasing metabolic risk factors.

Incidence rate of cerebrovascular diseases in northern Japan determined from the Iwate Stroke Registry with an inventory survey system

BACKGROUND

Long-term stroke registries in large populations often fail to maintain accuracy. This study presents an inventory survey system for stroke registries and the incidence rate of cerebrovascular diseases in a region with the highest stroke mortality rate in Japan.

METHODS

Using the data of the stroke registry determined with the inventory survey from 2004 to 2008 in northern Iwate Prefecture, with a population of 235,280 (111,584 men and 123,696 women), the age-specific annual incidence rates, the age-adjusted annual incidence rates, and the ratio of incidence rate relative to mortality rate of the cerebrovascular diseases were investigated.

RESULTS

A total of 3415 cases (1714 men and 1701 women) were registered and analyzed in this study. The age-adjusted incidence rates by the 1985 model population of Japan and by the world standard population (range 35-64 years) were 100.4 and 89.4 per 100,000 population in men and 49.8 and 29.7 in women for cerebral infarction; 53.6 and 77.2 in men and 34.2 and 39.5 in women for intracerebral hemorrhage; 12.9 and 23.3 in men and 21.1 and 34.6 in women for subarachnoid hemorrhage; and 166.9 and 189.8 in men and 105.0 and 103.7 in women for all subtypes. The ratios of incidence rate relative to mortality rate were 1.66 for all stroke subtypes, 1.69 for cerebral infarction, 1.76 for intracerebral hemorrhage, and 1.31 for subarachnoid hemorrhage.

CONCLUSIONS

High incidence rates of cerebrovascular diseases were revealed in the stroke registry with a good inventory survey in northern Iwate Prefecture, Japan.

Trends in the prevalence of dementia in Japan

There is a paucity of data regarding trends in dementia and its subtype prevalence in Japan. Our aims in the current paper are to: (1) summarize epidemiological studies of dementia in Japan including relevant details of study protocol and diagnostic criteria, (2) compare the age-specific prevalence of all-cause dementia among studies, and (3) assess the trends in Alzheimer's disease (AD) versus vascular dementia (VaD) over time. We reviewed diagnostic criteria, all-cause dementia prevalence, and the AD/VaD ratio from 8 large population studies of dementia in Japan. Compared with the Okinawa 1992 study, studies conducted in 1994, 1998, 2005, and 2008 had a higher prevalence of all-cause dementia using Poisson regression models, after controlling for age and sex. In contrast to the US and some European countries, all-cause dementia prevalence is increasing in Japan. The prevalence of AD as opposed to VaD seems to be increasing over time, but large variability in diagnostic criteria, possible regional variability, and differences in prevalence of subtypes of dementia between men and women make it difficult to draw a conclusion about this trend at the national level. Further studies, for example, comparing the population attributable risk of vascular diseases to the prevalence and incidence of dementia could help to clarify the regional variations in etiological subtypes.

Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.

CONCLUSIONS

aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

Premature mortality due to stroke and trend in stroke mortality in Japan (1980-2005)

BACKGROUND

Although a downward trend in stroke mortality over the last decades has been observed in many countries, stroke remains an important contributor to the total burden of disease. In the present study, we provided additional measures, namely years of life lost (YLLs) and average years of life lost (AYLLs) to reflect the burden of this condition in Japan.

METHODS

We obtained stroke mortality data for Japan from the World Health Organization mortality database for the period 1980-2005 to analyze trends of age-standardized rates (ASRs) per 100,000 of stroke mortality. YLLs and AYLLs were also estimated according to Japanese life tables.

RESULTS

Decreases in ASRs by 68% in men and by 74% in women were observed at the end of this study period. In men, there were total of 1,684,482 YLLs in 1980; 776,350 in 1995 and 745,636 in 2005, corresponding to an overall AYLLs for all stroke deaths of 20.6; 11.2 and 11.7 years earlier than expected, respectively. In women, the respective numbers were 1,567,817 YLLs in 1980; 810,135 in 1995 and 726,650 in 2005, corresponding to an overall AYLLs for all stroke deaths of 19.4; 10.5 and 10.5 years.

CONCLUSIONS

The findings showed shorter AYLLs due to stroke in Japan, suggesting that stroke patients died from this condition at older age at the end of the study period. This change in premature mortality was consistent with decreased trend in the stroke mortality.

Residual lifetime risk of cardiovascular diseases in Japan

Risk assessment of cardiovascular diseases (CVD) is shifting from the relative risk to an absolute risk approach. The residual lifetime risk (LTR), which provides an absolute risk assessment, is an epidemiologic measure that expresses the probability of someone of a given age and sex developing a disease condition during their remaining lifespan. The LTR estimation is important because it could be more easily comprehended by clinicians and patients. The LTR for CVD was not estimated for the Japanese population until recently, when the LTR of stroke and acute myocardial infarction (AMI) was reported. The reported LTR of stroke and AMI for middle-aged adults is substantial. The observed probabilities illustrated that approximately 1 in 5 men and women of middle age will suffer from a stroke in their remaining lifetime. On the other hand, approximately 1 in 6 men and 1 in 9 women of middle age will suffer from AMI in their remaining lifetime. Aaginst the backdrop of the aging population and worsening risk factor scenario, these estimates re-emphasize that CVD is a public health burden that requires preventive interventions. These estimates provide a means to communicate the absolute risk of CVD to the lay population, policy makers, as well as health service providers in predicting the disease burden of CVD. This easily comprehended knowledge can be used as an important index to assist in public health education and planning.

Lifetime risk of stroke and impact of hypertension: estimates from the adult health study in Hiroshima and Nagasaki

Very few reports have been published on lifetime risk (LTR) of stroke by blood pressure (BP) group. This study included participants in the Radiation Effects Research Foundation Adult Health Study who have been followed up by biennial health examinations since 1958. We calculated the LTR of stroke for various BP-based groups among 7847 subjects who had not been diagnosed with stroke before the index age of 55 years using cumulative incidence analysis adjusting for competing risks. By 2003, 868 subjects had suffered stroke (512 (58.9%) were women and 542 (62.4%) experienced ischemic stroke). BP was a significant factor in determining risk of stroke for men and women, with distributions of cumulative risk for stroke significantly different across BP groups. The LTR of all-stroke for normotension (systolic BP/diastolic BP < 120/80 mm Hg), prehypertension (120-139/80-89 mm Hg), stage 1 hypertension (140-159/90-99 mm Hg) and stage 2 hypertension (> 160/100 mm Hg) were 13.8-16.9-25.8-25.8% in men and 16.0-19.9-24.0-30.5% in women, respectively (P < 0.001 among BP groups in both sexes). The estimates did not differ significantly (P = 0.16) between normotensive and prehypertensive subjects. One in five Japanese atomic bomb survivor subjects experienced stroke over their lifetime from the age of 55 years. Long-term stroke risks were elevated in those with hypertension (> 140/90 mm Hg) at any of the index ages of 45, 55, 65 and 75 years.

Cerebral amyloid angiopathy in East and West

Cerebral amyloid angiopathy, a vasculopathy characterised by the deposition of amyloid fibrils in the arteries and arterioles in the cerebral cortex and meninges, has been reported to be associated with intracerebral haemorrhage and cognitive impairment in the elderly. Advances in neuroimaging and validation of the clinical diagnostic criteria aid in making a correct clinical diagnosis. Associations with Alzheimer's disease, asymptomatic microbleeds and white matter changes on neuroimaging have an influence on the clinical treatment for patients with probable cerebral amyloid angiopathy. Reviewing the reports from Asian countries, we found that patients with cerebral amyloid angiopathy have a strong age-related prevalence and a consistent association with dementia, but a weaker correlation with intracerebral haemorrhage, most likely due to a higher incidence of hypertensive intracerebral haemorrhage. Involvement of the occipital lobe arteries by CAA is common in all races and ethnicities, while frontal lobe arteries may be more frequently involved in the East compared to the West. The clinical impact of cerebral amyloid angiopathy on intracerebral haemorrhage and cognitive impairment could be increasingly obvious in Asian countries with ageing populations, especially with improving control of hypertension, the leading cause of intracerebral haemorrhage.

Ischemic stroke subtypes in a Japanese population: Takashima Stroke Registry, 1988-2004

BACKGROUND AND PURPOSE

Population-based information on the epidemiology of ischemic stroke (IS) subtypes is scant. In this study, we characterized IS subtypes in terms of incidence, time trend, and risk factor profiles in a community-based population.

METHODS

We obtained data from the Takashima Stroke Registry on approximately 55 000 residents of Takashima County in central Japan and calculated age-adjusted stroke incidence rates for different IS subtypes. We determined the incidence time trend by calculating the average annual change across years and also compared risk factors between subtypes.

RESULTS

There were 1389 first-ever ischemic strokes registered during 1988 to 2004. Lacunar infarction was the most frequent etiology (54.1%) followed by cardioembolic infarction (22.9%). Age-adjusted incidence rates for different IS subtypes were lacunar, 77.1; cardioembolic, 31.5; and nonlacunar, 29.7/10(5) person-years. The average annual change was not significant for the IS subtypes except for nonlacunar infarction, which showed a decreasing trend. Risk factor analysis showed that patients with lacunar infarctions were younger and less likely to have a history of transient ischemic attack or a drinking habit than patients with nonlacunar infarctions.

CONCLUSIONS

Lacunar infarct was the most common IS subtype in our population. We found no significant change in the incidence of subtypes during the study, except a decrease in nonlacunar infarction.

Lifetime Risk of Stroke in Japan

Background and Purpose— Lifetime risk (LTR) is an epidemiologic measure that expresses the probability of disease in the remaining lifetime for an index age. The LTR for stroke has not been reported for the Japanese population.

Methods— We included all participants from the Suita Study who were cardiovascular disease–free at baseline. Age (in years) was used as the time scale. Age-specific stroke incidence and all-cause mortality were calculated with the person-year method, and we estimated the sex- and index age–specific LTRs of first-ever stroke and its subtypes, taking into account the competing risk of death.

Results— We followed up 5498 participants from 1989 to 2005 for a total of 67 475 person-years. At age 55 years, the LTR for stroke, after accounting for competing risks of death, was 18.3% for men and 19.6% for women. The LTR for cerebral infarction was 14.6% for men and 15.5% for women, and the LTR for intracerebral hemorrhage was 2.4% for men and 1.4% for women at the index age of 55 years. The LTR for stroke remained similar across other index ages of 45, 55, and 65 years.

Conclusions— The observed probabilities illustrate that ≈1 in 5 men and women of middle age will experience stroke in their remaining lifetime. This easy understandable information can be used as an important index to assist in public health education and planning.

Iron intake and associated factors in general Japanese population: NIPPON DATA80, NIPPON DATA90 and national nutrition monitoring

OBJECTIVE

The purpose of this study was to investigate the dietary iron intake and associated other dietary factors and clinical characteristics among a representative sample cohort of Japanese population.

METHODS

We obtained data from NIPPON DATA80 and 90 that were conducted with the National Nutrition Surveys in 1980 and in 1990. Then we estimated nutrient and food intakes of individuals in the National Nutrition Survey of 1980 and that of 1990, which were adjusted on the basis of data of the National Nutrition Survey of 1995. Finally, we analyzed data for the 10,422 participants (4585 men and 5837 women) in NIPPON DATA80 and 8342 participants (3488 men and 4854 women) in NIPPON DATA90 having dietary iron intake information.

RESULTS

In NIPPON DATA80 and 90, there was a significant relationship between the dietary iron intake and age for both men and women. Dietary protein intake was associated with iron intake where as dietary fat intake did not show any association. Regarding the minerals, significant relationships were observed between the different minerals and dietary iron intake. Apart from the food group of milk and dairy products, there were significant differences in other food groups according to quintiles of iron intakes for men and women.

CONCLUSIONS

We described the mean dietary iron intake and its relation with other dietary factors and clinical characteristics in Japanese adults as the baseline data in NIPPON DATA80 and in NIPPON DATA90.

Circaseptan variation in case-fatality rate for patients with acute subarachnoid hemorrhage (Takashima Stroke Registry 1988-2003)

We explored the circaseptan variation in 28-day case-fatalities for patients with subarachnoid hemorrhage (SAH) across days of the week. Data were obtained from the Takashima Stroke Registry, which covers approximately 50000 residents of central Japan. There were 169 first-ever SAH cases registered during the period 1988-2003 (68 in males, 101 in females). We divided the SAH cases into two groups according to the day on which the SAH occurred: "weekend" and "weekday". The 28-day case-fatality rate and 95% confidence interval (CI) were calculated. Multiple logistic regression analysis was used to calculate the adjusted odds ratio (95% CI) for weekday fatalities by entering all relevant patient-level variables into the model. The 28-day case-fatality rate for SAH was higher on weekdays (51.7%) than on weekends (32.6%; odds ratio 2.19; 95% CI: 1.10-4.49). The differences in fatality rate persisted after adjustment for age, sex, severity, family history of stroke and patient history of hypertension, diabetes mellitus, dyslipidemia, drinking and smoking. We observed a circaseptan variation in fatalities from SAH, with higher fatality rates during weekdays in our study population.