NISAN - the National Institute for Stroke and Applied Neurosciences

Permanent link for this collection

https://hdl.handle.net/10292/10244

Institute Director: Professor Valery Feigin

Deputy Director: Associate Professor Alice Theadom

The National Institute for Stroke and Applied Neurosciences (NISAN) conducts epidemiological studies and clinical trials to improve health and outcomes in people with major neurological disorders. Current research programmes focus on:

Stroke
Traumatic brain injury
Neuromuscular disorders

Research with this aim is unique in New Zealand and NISAN is a hub for information sharing and developing a cohesive network between existing research and clinical groups with interests in:

Neuroepidemiology
Public health
Neurorehabilitation
Neuropsychology
Biostatistics

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Now showing 1 - 20 of 20

Assessing the Individual Risk of Stroke in Caregivers of Patients with Stroke
(Georg Thieme Verlag KG, 2024-03-11) Marquez-Romero, Juan Manuel; Romo-Martínez, Jessica; Hernández-Curiel, Bernardo; Ruiz-Franco, Angélica; Krishnamurthi, Rita; Feigin, Valery
BACKGROUND: Genetic factors influence the risk of developing stroke. Still, it is unclear whether this risk is intrinsically high in certain people or if nongenetic factors explain it entirely. OBJECTIVE: To compare the risk of stroke in kin and nonkin caregivers. METHODS: In a cross-sectional study using the Stroke Riskometer app (AUT Ventures Limited, Auckland, AUK, New Zealand), we determined the 5- and 10-year stroke risk (SR) among caregivers of stroke inpatients. The degree of kinship was rated with a score ranging from 0 to 50 points. RESULTS: We studied 278 caregivers (69.4% of them female) with a mean age of 47.5 ± 14.2 years. Kin caregivers represented 70.1% of the sample, and 49.6% of them were offspring. The median SR at 5 years was of 2.1 (range: 0.35-17.3) versus 1.73 (range: 0.04-29.9), and of 4.0 (range: 0.45-38.6) versus 2.94 (range: 0.05-59.35) at 10 years for the nonkin and kin caregivers respectively. In linear logistic regression controlled for the age of the caregivers, adding the kinship score did not increase the overall variability of the model for the risk at 5 years (R2 = 0.271; p = 0.858) nor the risk at 10 years (R2 = 0.376; p = 0.78). CONCLUSION: Caregivers of stroke patients carry a high SR regardless of their degree of kinship.
Association of Early Blood-Based Biomarkers and Six-Month Functional Outcomes in Conventional Severity Categories of Traumatic Brain Injury: Capturing the Continuous Spectrum of Injury
(Elsevier BV, 2024) Wilson, L; Newcombe, VFJ; Whitehouse, DP; Mondello, S; Maas, AIR; Menon, DK; Ackerlund, C; Amrein, K; Andelic, N; Andreassen, L; Anke, A; Antoni, A; Audibert, G; Azouvi, P; Azzolini, ML; Bartels, R; Barzó, P; Beauvais, R; Beer, R; Bellander, BM; Belli, A; Benali, H; Berardino, M; Beretta, L; Blaabjerg, M; Bragge, P; Brazinova, A; Brinck, V; Brooker, J; Brorsson, C; Buki, A; Bullinger, M; Cabeleira, M; Caccioppola, A; Calappi, E; Calvi, MR; Cameron, P; Lozano, GC; Carbonara, M; Castaño-León, AM; Cavallo, S; Chevallard, G; Chieregato, A; Citerio, G; Clusmann, H; Coburn, MS; Coles, J; Cooper, JD; Correia, M; Čović, A; Curry, N; Czeiter, E; Czosnyka, M; Dahyot-Fizelier, C; Dark, P; Dawes, H; De Keyser, V; Degos, V; Della Corte, F; Boogert, HD; Depreitere, B; Đilvesi, Đ; Dixit, A; Donoghue, E; Dreier, J; Dulière, GL; Ercole, A; Esser, P; Ezer, E; Fabricius, M; Feigin, VL; Foks, K; Frisvold, S; Furmanov, A; Gagliardo, P; Galanaud, D; Gantner, D; Gao, G; George, P; Ghuysen, A; Giga, L; Glocker, B; Golubović, J; Gomez, PA; Gratz, J; Gravesteijn, B; Grossi, F; Gruen, RL; Gupta, D; Haagsma, JA; Haitsma, I; Helbok, R; Helseth, E; Horton, L; Huijben, J; Hutchinson, PJ; Jacobs, B; Jankowski, S; Jarrett, M; Jiang, JY
Background: Traumatic brain injury is conventionally categorised as mild, moderate, or severe on the Glasgow Coma Scale (GCS). Recently developed biomarkers can provide more objective and nuanced measures of the extent of brain injury. Methods: Exposure–response relationships were investigated in 2479 patients aged ≥16 enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) prospective observational cohort study. Neurofilament protein-light (NFL), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and glial fibrillary acidic protein (GFAP) were assayed from serum sampled in the first 24 h; concentrations were divided into quintiles within GCS severity groups. Relationships with the Glasgow Outcome Scale-Extended were examined using modified Poisson regression including age, sex, major extracranial injury, time to sample, and log biomarker concentration as covariates. Findings: Within severity groups there were associations between biomarkers and outcomes after adjustment for covariates: GCS 13–15 and negative CT imaging (relative risks [RRs] from 1.28 to 3.72), GCS 13–15 and positive CT (1.21–2.81), GCS 9–12 (1.16–2.02), GCS 3–8 (1.09–1.94). RRs were associated with clinically important differences in expectations of prognosis. In patients with GCS 3 (RRs 1.51–1.80) percentages of unfavourable outcome were 37–51% in the lowest quintiles of biomarker levels and reached 90–94% in the highest quintiles. Similarly, for GCS 15 (RRs 1.83–3.79), the percentages were 2–4% and 19–28% in the lowest and highest biomarker quintiles, respectively. Interpretation: Conventional TBI severity classification is inadequate and underestimates heterogeneity of brain injury and associated outcomes. The adoption of circulating biomarkers can add to clinical assessment of injury severity. Funding: European Union 7th Framework program (EC grant 602150), Hannelore Kohl Stiftung, One Mind, Integra LifeSciences, Neuro-Trauma Sciences, NIHR Rosetrees Trust.
Comparative Effectiveness of Decompressive Craniectomy Versus Craniotomy for Traumatic Acute Subdural Hematoma (CENTER-TBI): An Observational Cohort Study
(Elsevier BV, 2023) van Essen, TA; van Erp, IAM; Lingsma, HF; Pisică, D; Yue, JK; Singh, RD; van Dijck, JTJM; Volovici, V; Younsi, A; Kolias, A; Peppel, LD; Heijenbrok-Kal, M; Ribbers, GM; Menon, DK; Hutchinson, PJA; Manley, GT; Depreitere, B; Steyerberg, EW; Maas, AIR; de Ruiter, GCW; Peul, WC; Åkerlund, C; Amrein, K; Andelic, N; Andreassen, L; Anke, A; Antoni, A; Audibert, G; Azouvi, P; Azzolini, ML; Bartels, R; Barzó, P; Beauvais, R; Beer, R; Bellander, BM; Belli, A; Benali, H; Berardino, M; Beretta, L; Blaabjerg, M; Bragge, P; Brazinova, A; Brinck, V; Brooker, J; Brorsson, C; Buki, A; Bullinger, M; Cabeleira, M; Caccioppola, A; Calappi, E; Calvi, MR; Cameron, P; Lozano, GC; Carbonara, M; Castaño-León, AM; Cavallo, S; Chevallard, G; Chieregato, A; Citerio, G; Clusmann, H; Coburn, MS; Coles, J; Cooper, JD; Correia, M; Čović, A; Curry, N; Czeiter, E; Czosnyka, M; Dahyot-Fizelier, C; Dark, P; Dawes, H; De Keyser, V; Degos, V; Della Corte, F; Boogert, HD; Đilvesi, Đ; Dixit, A; Donoghue, E; Dreier, J; Dulière, GL; Ercole, A; Esser, P; Ezer, E; Fabricius, M; Feigin, VL; Foks, K; Frisvold, S; Furmanov, A; Gagliardo, P; Galanaud, D; Gantner, D; Gao, G; George, P; Ghuysen, A; Giga, L; Glocker, B; Golubović, J; Gomez, PA; Gratz, J; Gravesteijn, B
Background: Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. Methods: We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014–2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Findings: Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12–26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7–1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0–3.4), n = 200]). Interpretation: We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Funding: Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.
Demographic Disparities in the Incidence and Case Fatality of Subarachnoid Haemorrhage: An 18-Year Nationwide Study from New Zealand
(Elsevier, 2024) Rautalin, I; Krishnamurthi, Rita; Anderson, CS; Barber, PA; Barker-Collo, S; Bennett, D; Boet, R; Correia, JA; Douwes, J; Law, A; Nair, B; Thrift, AG; Te Ao, B; Tunnage, B; Ranta, A; Feigin, VL
Background Although the incidence and case-fatality of subarachnoid haemorrhage (SAH) vary within countries, few countries have reported nationwide rates, especially for multi-ethnic populations. We assessed the nationwide incidence and case-fatality of SAH in New Zealand (NZ) and explored variations by sex, district, ethnicity and time. Methods We used administrative health data from the national hospital discharge and cause-of-death collections to identify hospitalised and fatal non-hospitalised aneurysmal SAHs in NZ between 2001 and 2018. For validation, we compared these administrative data to those of two prospective Auckland Regional Community Stroke Studies. We subsequently estimated the incidence and case-fatality of SAH and calculated adjusted rate ratios (RR) with 95% confidence intervals to assess differences between sub-populations. Findings Over 78,187,500 cumulative person-years, we identified 5371 SAHs (95% sensitivity and 85% positive predictive values) resulting in an annual age-standardised nationwide incidence of 8.2/100,000. In total, 2452 (46%) patients died within 30 days after SAH. Compared to European/others, Māori had greater incidence (RR = 2.23 (2.08–2.39)) and case-fatality (RR = 1.14 (1.06–1.22)), whereas SAH incidence was also greater in Pacific peoples (RR = 1.40 (1.24–1.59)) but lesser in Asians (RR = 0.79 (0.71–0.89)). By domicile, age-standardised SAH incidence varied between 6.3–11.5/100,000 person-years and case fatality between 40 and 57%. Between 2001 and 2018, the SAH incidence of NZ decreased by 34% and the case fatality by 12%. Interpretation Since the incidence and case-fatality of SAH varies considerably between regions and ethnic groups, caution is advised when generalising findings from focused geographical locations for public health planning, especially in multi-ethnic populations.
Differing Definitions of First-Ever Stroke Influence Incidence Estimates More Than Trends: A Study Using Linked Administrative Data
(S. Karger AG, 2023-09-26) Youens, David; Katzenellenbogen, Judith; Srinivasa Ragavan, Rathina; Sodhi-Berry, Nita; Carson, Jennie; Zemedikun, Dawit; Thrift, Amanda G; Feigin, Valery; Nedkoff, Lee
Introduction Researchers apply varying definitions when measuring stroke incidence using administrative data. We aimed to investigate the sensitivity of incidence estimates to varying definitions of stroke and lookback periods, and to provide updated incidence rates and trends for Western Australia (WA). Methods We used linked state-wide hospital and death data from 1985-2017 to identify incident strokes from 2005-2017. A standard definition was applied which included strokes coded as the principal hospital diagnosis or the underlying cause of death, with a 10-year lookback used to clear prevalent cases. Alternative definitions were compared against the standard definition by percentage difference in case numbers. Age-standardised incidence rates were calculated, and age- and sex-adjusted Poisson regression models used to estimate incidence trends. Results The standard definition with a 10-year lookback period captured 31,274 incident strokes. Capture increased by 19.3% when including secondary diagnoses, 4.1% when including nontraumatic subdural and extradural haemorrhage, and 8.1% when including associated causes of death. Excluding death records reduced capture by 11.1%. A 20-year lookback reduced over-ascertainment by 2.0% and a 1-year lookback increased capture by 13.3%. Incidence declined 0.6% annually (95% confidence interval -0.9, -0.3). Annual reductions were similar for most definitions except when death records were excluded (-0.1%, CI -0.4, 0.2) and with the shortest lookback periods (greatest annual reduction). Conclusion Stroke incidence has declined in WA. Differing methods of identifying stroke influence estimates of incidence to a greater extent than estimates of trends. Reductions in stroke incidence over time are primarily driven by declines in hospitalised stroke.
Ethnic Differences in Stroke Outcomes in Aotearoa New Zealand: A National Linkage Study
(SAGE Publications, 2023-03-05) Denison, Hayley; Corbin, Marine; Douwes, Jeroen; Thompson, Stephanie; Harwood, Matire; Davis, Alan; Fink, John N; Barber, P Alan; Gommans, John; Cadilhac, Dominique; Levack, William; McNaughton, Harry; Kim, Joosup; Feigin, VL; Abernethy, Virginia; Girvan, Jackie; Wilson, Andrew; Ranta, Annemarei
BACKGROUND: Ethnic differences in post-stroke outcomes have been largely attributed to biological and socioeconomic characteristics resulting in differential risk factor profiles and stroke sub-types, but evidence is mixed. AIMS: This study assessed ethnic differences in stroke outcome and service access in New Zealand (NZ) and explored underlying causes in addition to traditional risk factors. METHODS: This national cohort study used routinely collected health and social data to compare post-stroke outcomes between NZ Europeans, Māori, Pacific Peoples, and Asians, adjusting for differences in baseline characteristics, socioeconomic deprivation, and stroke characteristics. First and principal stroke public hospital admissions during November 2017-October 2018 were included (N=6,879). Post-stroke unfavourable outcome was defined as being dead, change in residence, or unemployed if working pre-stroke. RESULTS: In total, 5,394 NZ Europeans, 762 Māori, 369 Pacific Peoples and 354 Asians experienced a stroke during the study period. Median age was 65 years for Māori and Pacific Peoples, and 71 and 79 years for Asians and NZ Europeans, respectively. Compared with NZ Europeans, Māori were more likely to have an unfavourable outcome at all three time-points (OR=1.6 (95%CI=1.3-1.9); 1.4 (1.2-1.7); 1.4 (1.2-1.7), respectively). Māori also had increased odds of death at all time-points (1.7 (1.3-2.1); 1.5 (1.2-1.9); 1.7 (1.3-2.1)) and unemployment at twelve months (2.5 (1.2-5.2). There was evidence of differences in post-stroke secondary prevention medication by ethnicity. CONCLUSIONS: We found ethnic disparities in care and outcomes following stroke, independent of traditional risk factors raising concern for potential unconscious bias and institutional racism in stroke services.
Frequency and Predictors of Headache in the First 12 Months After Traumatic Brain Injury: Results from CENTER-TBI
(BMC, 2024-03-25) Howe, Emilie Isager; Andelic, Nada; Brunborg, Cathrine; Zeldovich, Marina; Helseth, Eirik; Skandsen, Toril; Olsen, Alexander; Fure, Silje CR; Theadom, Alice; Rauen, Katrin; Madsen, Benedikte Å; Jacobs, Bram; van der Naalt, Joukje; Tartaglia, Maria Carmela; Einarsen, Cathrine Elisabeth; Storvig, Gøril; Tronvik, Erling; Tverdal, Cathrine; von Steinbüchel, Nicole; Røe, Cecilie; Hellstrøm, Torgeir; CENTER-TBI Participants and Investigators
BACKGROUND: Headache is a prevalent and debilitating symptom following traumatic brain injury (TBI). Large-scale, prospective cohort studies are needed to establish long-term headache prevalence and associated factors after TBI. This study aimed to assess the frequency and severity of headache after TBI and determine whether sociodemographic factors, injury severity characteristics, and pre- and post-injury comorbidities predicted changes in headache frequency and severity during the first 12 months after injury. METHODS: A large patient sample from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) prospective observational cohort study was used. Patients were stratified based on their clinical care pathway: admitted to an emergency room (ER), a ward (ADM) or an intensive care unit (ICU) in the acute phase. Headache was assessed using a single item from the Rivermead Post-Concussion Symptoms Questionnaire measured at baseline, 3, 6 and 12 months after injury. Mixed-effect logistic regression analyses were applied to investigate changes in headache frequency and associated predictors. RESULTS: A total of 2,291 patients responded to the headache item at baseline. At study enrolment, 59.3% of patients reported acute headache, with similar frequencies across all strata. Female patients and those aged up to 40 years reported a higher frequency of headache at baseline compared to males and older adults. The frequency of severe headache was highest in patients admitted to the ICU. The frequency of headache in the ER stratum decreased substantially from baseline to 3 months and remained from 3 to 6 months. Similar trajectory trends were observed in the ICU and ADM strata across 12 months. Younger age, more severe TBI, fatigue, neck pain and vision problems were among the predictors of more severe headache over time. More than 25% of patients experienced headache at 12 months after injury. CONCLUSIONS: Headache is a common symptom after TBI, especially in female and younger patients. It typically decreases in the first 3 months before stabilising. However, more than a quarter of patients still experienced headache at 12 months after injury. Translational research is needed to advance the clinical decision-making process and improve targeted medical treatment for headache. TRIAL REGISTRATION: ClinicalTrials.gov NCT02210221.
Global Stroke Statistics 2023: Availability of Reperfusion Services Around the World
(SAGE Publications, 2023-10-18) Kim, Joosup; Olaiya, Muideen T; De Silva, Deidre Anne; Norrving, Bo; Bosch, Jackie; Aguiar de Sousa, Diana; Christensen, Hanne; Ranta, Anna; Donnan, Geoffrey; Feigin, Valery L; Martins, Sheila; Schwamm, Lee; Werring, David; Howard, George; Owolabi, Mayowa; Pandian, Jeyaraj Durai; Mikulik, Robert; Thayabaranathan, Tharshanah; Cadilhac, Dominique
BACKGROUND: Disparities in the availability of reperfusion services for acute ischaemic stroke are considerable globally, and require urgent attention. Contemporary data on the availability of reperfusion services in different countries provide the necessary evidence to prioritise where access to acute stroke treatment is needed. AIMS: To provide a snapshot of published literature on the provision of reperfusion services globally, including when facilitated by telemedicine or mobile stroke unit services. Methods: We searched PubMed to identify original papers, published up to January 2023, with the most recent, representative and relevant data for each country. Keywords included thrombolysis and telemedicine. We also screened reference lists of review papers, citation history of papers, and the grey literature. The information is provided as a narrative summary. RESULTS: Of 11,222 potentially eligible papers retrieved, 148 were included for review following de-duplications and full text review. Data were also obtained from national stroke clinical registry reports, Registry of Stroke Care Quality (RES-Q) and Pre-hospital Stroke Treatment Organization (PRESTO) repositories, and other national sources. Overall, we found evidence of the provision of intravenous thrombolysis services in 70 countries (6463% high-income countries (HICs)) and endovascular thrombectomy services in 33 countries (68% HICs), corresponding to far less than half of the countries in the world. Recent data (from 2019 or later) were lacking for 35 of 67 countries with known year of data (52%). We found published data on 74 different stroke telemedicine programs (93% in HICs) and 14 active mobile stroke unit pre-hospital ambulances services (80% in HICs) around the world. CONCLUSION: Despite remarkable advancements in reperfusion therapies for stroke, it is evident from available data that their availability remains unevenly distributed globally. Contemporary published data on availability of reperfusion services remain scarce, even in HICs, thereby making it difficult to reliably ascertain current gaps in the provision of this vital acute stroke treatment around the world.
Global, Regional, and National Burden of Disorders Affecting the Nervous System, 1990–2021: A Systematic Analysis for the Global Burden of Disease Study 2021
(Elsevier BV, 2024) Steinmetz, Jaimie D; Seeher, Katrin Maria; Schiess, Nicoline; Nichols, Emma; Cao, Bochen; Servili, Chiara; Cavallera, Vanessa; Cousin, Ewerton; Hagins, Hailey; Moberg, Madeline E; Mehlman, Max L; Abate, Yohannes Habtegiorgis; Abbas, Jaffar; Abbasi, Madineh Akram; Abbasian, Mohammadreza; Abbastabar, Hedayat; Abdelmasseh, Michael; Abdollahi, Mohammad; Abdollahi, Mozhan; Abdollahifar, Mohammad-Amin; Abd-Rabu, Rami; Abdulah, Deldar Morad; Abdullahi, Auwal; Abedi, Aidin; Abedi, Vida; Abeldaño Zuñiga, Roberto Ariel; Abidi, Hassan; Abiodun, Olumide; Aboagye, Richard Gyan; Abolhassani, Hassan; Aboyans, Victor; Abrha, Woldu Aberhe; Abualhasan, Ahmed; Abu-Gharbieh, Eman; Aburuz, Salahdein; Adamu, Lawan Hassan; Addo, Isaac Yeboah; Adebayo, Oladimeji M; Adekanmbi, Victor; Adekiya, Tayo Alex; Adikusuma, Wirawan; Adnani, Qorinah Estiningtyas Sakilah; Adra, Saryia; Afework, Tsion; Afolabi, Aanuoluwapo Adeyimika; Afraz, Ali; Afzal, Saira; Aghamiri, Shahin; Agodi, Antonella; Agyemang-Duah, Williams; Ahinkorah, Bright Opoku; Ahmad, Aqeel; Ahmad, Danish; Ahmad, Sajjad; Ahmadzade, Amir Mahmoud; Ahmed, Ali; Ahmed, Ayman; Ahmed, Haroon; Ahmed, Jivan Qasim; Ahmed, Luai A; Ahmed, Muktar Beshir; Ahmed, Syed Anees; Ajami, Marjan; Aji, Budi; Ajumobi, Olufemi; Akade, Seyed Esma'il; Akbari, Morteza; Akbarialiabad, Hossein; Akhlaghi, Shiva; Akinosoglou, Karolina; Akinyemi, Rufus Olusola; Akonde, Maxwell; Al Hasan, Syed Mahfuz; Alahdab, Fares; AL-Ahdal, Tareq Mohammed Ali; Al-amer, Rasmieh Mustafa; Albashtawy, Mohammed; AlBataineh, Mohammad T; Aldawsari, Khalifah A; Alemi, Hediyeh; Alemi, Sharifullah; Algammal, Abdelazeem M; Al-Gheethi, Adel Ali Saeed; Alhalaiqa, Fadwa Alhalaiqa Naji; Alhassan, Robert Kaba; Ali, Abid; Ali, Endale Alemayehu; Ali, Liaqat; Ali, Mohammed Usman; Ali, Musa Mohammed; Ali, Rafat; Ali, Shahid; Ali, Syed Shujait Shujait; Ali, Zahid; Alif, Sheikh Mohammad; Alimohamadi, Yousef; Aliyi, Ahmednur Adem; Aljofan, Mohamad; Aljunid, Syed Mohamed; Alladi, Suvarna; Almazan, Joseph Uy; Almustanyir, Sami; Al-Omari, Basem; Alqahtani, Jaber S; Alqasmi, Ibrahim; Alqutaibi, Ahmed Yaseen; Al-Shahi Salman, Rustam; Altaany, Zaid; Al-Tawfiq, Jaffar A; Altirkawi, Khalid A; Alvis-Guzman, Nelson; Al-Worafi, Yaser Mohammed; Aly, Hany; Aly, Safwat; Alzoubi, Karem H; Amani, Reza; Amindarolzarbi, Alireza; Amiri, Sohrab; Amirzade-Iranaq, Mohammad Hosein; Amu, Hubert; Amugsi, Dickson A; Amusa, Ganiyu Adeniyi; Amzat, Jimoh; Ancuceanu, Robert; Anderlini, Deanna; Anderson, David B; Andrei, Catalina Liliana; Androudi, Sofia; Angappan, Dhanalakshmi; Angesom, Teklit W; Anil, Abhishek; Ansari-Moghaddam, Alireza; Anwer, Razique; Arafat, Mosab; Aravkin, Aleksandr Y; Areda, Demelash; Ariffin, Hany; Arifin, Hidayat; Arkew, Mesay; Ärnlöv, Johan; Arooj, Mahwish; Artamonov, Anton A; Artanti, Kurnia Dwi; Aruleba, Raphael Taiwo; Asadi-Pooya, Ali A; Asena, Tilahun Ferede; Asghari-Jafarabadi, Mohammad; Ashraf, Muhammad; Ashraf, Tahira; Atalell, Kendalem Asmare; Athari, Seyyed Shamsadin; Atinafu, Bantalem Tilaye Tilaye; Atorkey, Prince; Atout, Maha Moh'd Wahbi; Atreya, Alok; Aujayeb, Avinash; Avan, Abolfazl; Ayala Quintanilla, Beatriz Paulina; Ayatollahi, Haleh; Ayinde, Olatunde O; Ayyoubzadeh, Seyed Mohammad; Azadnajafabad, Sina; Azizi, Zahra; Azizian, Khalil; Azzam, Ahmed Y; Babaei, Mahsa; Badar, Muhammad; Badiye, Ashish D; Baghdadi, Soroush; Bagherieh, Sara; Bai, Ruhai; Baig, Atif Amin; Balakrishnan, Senthilkumar; Balalla, Shivanthi; Baltatu, Ovidiu Constantin; Banach, Maciej; Bandyopadhyay, Soham; Banerjee, Indrajit; Baran, Mehmet Firat; Barboza, Miguel A; Barchitta, Martina; Bardhan, Mainak; Barker-Collo, Suzanne Lyn; Bärnighausen, Till Winfried; Barrow, Amadou; Bashash, Davood; Bashiri, Hamideh; Bashiru, Hameed Akande; Basiru, Afisu; Basso, João Diogo; Basu, Sanjay; Batiha, Abdul-Monim Mohammad; Batra, Kavita; Baune, Bernhard T; Bedi, Neeraj; Begde, Ahmet; Begum, Tahmina; Behnam, Babak; Behnoush, Amir Hossein; Beiranvand, Maryam; Béjot, Yannick; Bekele, Alehegn; Belete, Melaku Ashagrie; Belgaumi, Uzma Iqbal; Bemanalizadeh, Maryam; Bender, Rose G; Benfor, Bright; Bennett, Derrick A; Bensenor, Isabela M; Berice, Betyna; Bettencourt, Paulo JG; Beyene, Kebede A; Bhadra, Abhishek; Bhagat, Devidas S; Bhangdia, Kayleigh; Bhardwaj, Nikha; Bhardwaj, Pankaj; Bhargava, Ashish; Bhaskar, Sonu; Bhat, Ajay Nagesh; Bhat, Vivek; Bhatti, Gurjit Kaur; Bhatti, Jasvinder Singh; Bhatti, Rajbir; Bijani, Ali; Bikbov, Boris; Bilalaga, Mariah Malak; Biswas, Atanu; Bitaraf, Saeid; Bitra, Veera R; Bjørge, Tone; Bodolica, Virginia; Bodunrin, Aadam Olalekan; Boloor, Archith; Braithwaite, Dejana; Brayne, Carol; Brenner, Hermann; Briko, Andrey; Bringas Vega, Maria L; Brown, Julie; Budke, Christine M; Buonsenso, Danilo; Burkart, Katrin; Burns, Richard A; Bustanji, Yasser; Butt, Muhammad Hammad; Butt, Nadeem Shafique; Butt, Zahid A; Cabral, Lucas Scotta; Caetano dos Santos, Florentino Luciano; Calina, Daniela; Campos-Nonato, Ismael R; Cao, Chao; Carabin, Hélène; Cárdenas, Rosario; Carreras, Giulia; Carvalho, Andre F; Castañeda-Orjuela, Carlos A; Casulli, Adriano; Catalá-López, Ferrán; Catapano, Alberico L; Caye, Arthur; Cegolon, Luca; Cenderadewi, Muthia; Cerin, Ester; Chacón-Uscamaita, Pamela R Uscamaita; Chan, Jeffrey Shi Kai; Chanie, Gashaw Sisay; Charan, Jaykaran; Chattu, Vijay Kumar; Chekol Abebe, Endeshaw; Chen, Hui; Chen, Jianqi; Chi, Gerald; Chichagi, Fatemeh; Chidambaram, Saravana Babu; Chimoriya, Ritesh; Ching, Patrick R; Chitheer, Abdulaal; Chong, Yuen Yu; Chopra, Hitesh; Choudhari, Sonali Gajanan; Chowdhury, Enayet Karim; Chowdhury, Rajiv; Christensen, Hanne; Chu, Dinh-Toi; Chukwu, Isaac Sunday; Chung, Eric; Coberly, Kaleb; Columbus, Alyssa; Comachio, Josielli; Conde, Joao; Cortesi, Paolo Angelo; Costa, Vera Marisa; Couto, Rosa AS; Criqui, Michael H; Cruz-Martins, Natália; Dabbagh Ohadi, Mohammad Amin; Dadana, Sriharsha; Dadras, Omid; Dai, Xiaochen; Dai, Zhaoli; D'Amico, Emanuele; Danawi, Hadi A; Dandona, Lalit; Dandona, Rakhi; Darwish, Amira Hamed; Das, Saswati; Das, Subasish; Dascalu, Ana Maria; Dash, Nihar Ranjan; Dashti, Mohsen; De la Hoz, Fernando Pio; de la Torre-Luque, Alejandro; De Leo, Diego; Dean, Frances E; Dehghan, Amin; Dehghan, Azizallah; Dejene, Hiwot; Demant, Daniel; Demetriades, Andreas K; Demissie, Solomon; Deng, Xinlei; Desai, Hardik Dineshbhai; Devanbu, Vinoth Gnana Chellaiyan; Dhama, Kuldeep; Dharmaratne, Samath Dhamminda; Dhimal, Meghnath; Dias da Silva, Diana; Diaz, Daniel; Dibas, Mahmoud; Ding, Delaney D; Dinu, Monica; Dirac, M Ashworth; Diress, Mengistie; Do, Thanh Chi; Do, Thao Huynh Phuong; Doan, Khanh Duy Khanh; Dodangeh, Milad; Doheim, Mohamed Fahmy; Dokova, Klara Georgieva; Dongarwar, Deepa; Dsouza, Haneil Larson; Dube, John; Duraisamy, Senbagam; Durojaiye, Oyewole Christopher; Dutta, Sulagna; Dziedzic, Arkadiusz Marian; Edinur, Hisham Atan; Eissazade, Negin; Ekholuenetale, Michael; Ekundayo, Temitope Cyrus; El Nahas, Nevine; El Sayed, Iman; Elahi Najafi, Mohammad Amin; Elbarazi, Iffat; Elemam, Noha Mousaad; Elgar, Frank J; Elgendy, Islam Y; Elhabashy, Hala Rashad; Elhadi, Muhammed; Elilo, Legesse Tesfaye; Ellenbogen, Richard G; Elmeligy, Omar Abdelsadek Abdou; Elmonem, Mohamed A; Elshaer, Mohammed; Elsohaby, Ibrahim; Emamverdi, Mehdi; Emeto, Theophilus I; Endres, Matthias; Esezobor, Christopher Imokhuede; Eskandarieh, Sharareh; Fadaei, Abdolmajid; Fagbamigbe, Adeniyi Francis; Fahim, Ayesha; Faramarzi, Ali; Fares, Jawad; Farjoud Kouhanjani, Mohsen; Faro, Andre; Farzadfar, Farshad; Fatehizadeh, Ali; Fathi, Mobina; Fathi, Saeid; Fatima, Syeda Anum Fatima; Feizkhah, Alireza; Fereshtehnejad, Seyed-Mohammad; Ferrari, Alize J; Ferreira, Nuno; Fetensa, Getahun; Firouraghi, Neda; Fischer, Florian; Fonseca, Ana Catarina; Force, Lisa M; Fornari, Arianna; Foroutan, Behzad; Fukumoto, Takeshi; Gadanya, Muktar A; Gaidhane, Abhay Motiramji; Galali, Yaseen; Galehdar, Nasrin; Gan, Quan; Gandhi, Aravind P; Ganesan, Balasankar; Gardner, William M; Garg, Naval; Gau, Shuo-Yan; Gautam, Rupesh K; Gebre, Teshome; Gebrehiwot, Mesfin; Gebremeskel, Gebreamlak Gebremedhn; Gebreslassie, Haftay Gebremedhin; Getacher, Lemma; Ghaderi Yazdi, Bardiya; Ghadirian, Fataneh; Ghaffarpasand, Fariborz; Ghanbari, Reza; Ghasemi, MohammadReza; Ghazy, Ramy Mohamed; Ghimire, Sailaja; Gholami, Ali; Gholamrezanezhad, Ali; Ghotbi, Elena; Ghozy, Sherief; Gialluisi, Alessandro; Gill, Paramjit Singh; Glasstetter, Logan M; Gnedovskaya, Elena V; Golchin, Ali; Golechha, Mahaveer; Goleij, Pouya; Golinelli, Davide; Gomes-Neto, Mansueto; Goulart, Alessandra C; Goyal, Anmol; Gray, Richard J; Grivna, Michal; Guadie, Habtamu Alganeh; Guan, Bin; Guarducci, Giovanni; Guicciardi, Stefano; Gunawardane, Damitha Asanga; Guo, Hanbing; Gupta, Bhawna; Gupta, Rajeev; Gupta, Sapna; Gupta, Veer Bala; Gupta, Vivek Kumar; Gutiérrez, Reyna Alma; Habibzadeh, Farrokh; Hachinski, Vladimir; Haddadi, Rasool; Hadei, Mostafa; Hadi, Najah R; Haep, Nils; Haile, Teklehaimanot Gereziher; Haj-Mirzaian, Arvin; Hall, Brian J; Halwani, Rabih; Hameed, Sajid; Hamiduzzaman, Mohammad; Hammoud, Ahmad; Han, Hannah; Hanifi, Nasrin; Hankey, Graeme J; Hannan, Md Abdul; Hao, Junwei; Harapan, Harapan; Hareru, Habtamu Endashaw; Hargono, Arief; Harlianto, Netanja I; Haro, Josep Maria; Hartman, Nicholas Nathaniel; Hasaballah, Ahmed I; Hasan, Faizul; Hasani, Hamidreza; Hasanian, Mohammad; Hassan, Amr; Hassan, Shoaib; Hassanipour, Soheil; Hassankhani, Hadi; Hassen, Mohammed Bheser; Haubold, Johannes; Hay, Simon I; Hayat, Khezar; Hegazy, Mohamed I; Heidari, Golnaz; Heidari, Mohammad; Heidari-Soureshjani, Reza; Hesami, Hamed; Hezam, Kamal; Hiraike, Yuta; Hoffman, Howard J; Holla, Ramesh; Hopf, Kathleen Pillsbury; Horita, Nobuyuki; Hossain, Md Mahbub; Hossain, Md Belal; Hossain, Sahadat; Hosseinzadeh, Hassan; Hosseinzadeh, Mehdi; Hostiuc, Sorin; Hu, Chengxi; Huang, Junjie; Huda, Md Nazmul; Hussain, Javid; Hussein, Nawfal R; Huynh, Hong-Han; Hwang, Bing-Fang; Ibitoye, Segun Emmanuel; Ilaghi, Mehran; Ilesanmi, Olayinka Stephen; Ilic, Irena M; Ilic, Milena D; Immurana, Mustapha; Iravanpour, Farideh; Islam, Sheikh Mohammed Shariful; Ismail, Faisal; Iso, Hiroyasu; Isola, Gaetano; Iwagami, Masao; Iwu, Chidozie CD; Iyer, Mahalaxmi; Jaan, Ali; Jacob, Louis; Jadidi-Niaragh, Farhad; Jafari, Mahboobeh; Jafarinia, Morteza; Jafarzadeh, Abdollah; Jahankhani, Kasra; Jahanmehr, Nader; Jahrami, Haitham; Jaiswal, Abhishek; Jakovljevic, Mihajlo; Jamora, Roland Dominic G; Jana, Somnath; Javadi, Nilofer; Javed, Saad; Javeed, Saad; Jayapal, Sathish Kumar; Jayaram, Shubha; Jiang, Heng; Johnson, Catherine Owens; Johnson, Walter D; Jokar, Mohammad; Jonas, Jost B; Joseph, Abel; Joseph, Nitin; Joshua, Charity Ehimwenma; Jürisson, Mikk; Kabir, Ali; Kabir, Zubair; Kabito, Gebisa Guyasa; Kadashetti, Vidya; Kafi, Fatemeh; Kalani, Rizwan; Kalantar, Farnaz; Kaliyadan, Feroze; Kamath, Ashwin; Kamath, Sagarika; Kanchan, Tanuj; Kandel, Amit; Kandel, Himal; Kanmodi, Kehinde Kazeem; Karajizadeh, Mehrdad; Karami, Jafar; Karanth, Shama D; Karaye, Ibraheem M; Karch, André; Karimi, Aliasghar; Karimi, Hanie; Karimi Behnagh, Arman; Kasraei, Hengameh; Kassebaum, Nicholas J; Kauppila, Joonas H; 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Kumar, Ashish; Kumar, G Anil; Kumar, Manasi; Kumar, Nithin; Kumsa, Netsanet Bogale; Kundu, Satyajit; Kurniasari, Maria Dyah; Kusuma, Dian; Kuttikkattu, Ambily; Kyu, Hmwe Hmwe; La Vecchia, Carlo; Ladan, Muhammad Awwal; Lahariya, Chandrakant; Laksono, Tri; Lal, Dharmesh Kumar; Lallukka, Tea; Lám, Judit; Lami, Faris Hasan; Landires, Iván; Langguth, Berthold; Lasrado, Savita; Latief, Kamaluddin; Latifinaibin, Kaveh; Lau, Kathryn Mei-Ming; Laurens, Matthew B; Lawal, Basira Kankia; Le, Long Khanh Dao; Le, Thao Thi Thu; Ledda, Caterina; Lee, Munjae; Lee, Sang-woong; Lee, Seung Won; Lee, Wei-Chen; Lee, Yo Han; Leonardi, Matilde; Lerango, Temesgen L; Li, Ming-Chieh; Li, Wei; Ligade, Virendra S; Lim, Stephen S; Linehan, Christine; Liu, Chaojie; Liu, Jue; Liu, Wei; Lo, Chun-Han; Lo, Warren David; Lobo, Stany W; Logroscino, Giancarlo; Lopes, Graciliana; Lopukhov, Platon D; Lorenzovici, László; Lorkowski, Stefan; Loureiro, Joana A; Lubinda, Jailos; Lucchetti, Giancarlo; Lutzky Saute, Ricardo; Ma, Zheng Feei; 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Naghavi, Pirouz; Naik, Ganesh R; Nainu, Firzan; Nair, Tapas Sadasivan; Najmuldeen, Hastyar Hama Rashid; Nakhostin Ansari, Noureddin; Nambi, Gopal; Namdar Areshtanab, Hossein; Nargus, Shumaila; Nascimento, Bruno Ramos; Naser, Abdallah Y; Nashwan, Abdulqadir JJ; Nasoori, Hadis; Nasreldein, Ahmed; Natto, Zuhair S; Nauman, Javaid; Nayak, Biswa Prakash; Nazri-Panjaki, Athare; Negaresh, Mohammad; Negash, Hadush; Negoi, Ionut; Negoi, Ruxandra Irina; Negru, Serban Mircea; Nejadghaderi, Seyed Aria; Nematollahi, Mohammad Hadi; Nesbit, Olivia D; Newton, Charles Richard James; Nguyen, Dang H; Nguyen, Hau Thi Hien; Nguyen, Hien Quang; Nguyen, Ngoc-Trinh Thi; Nguyen, Phat Tuan; Nguyen, Van Thanh; Niazi, Robina Khan; Nikolouzakis, Taxiarchis Konstantinos; Niranjan, Vikram; Nnyanzi, Lawrence Achilles; Noman, Efaq Ali; Noroozi, Nafise; Norrving, Bo; Noubiap, Jean Jacques; Nri-Ezedi, Chisom Adaobi; Ntaios, George; Nuñez-Samudio, Virginia; Nurrika, Dieta; Oancea, Bogdan; Odetokun, Ismail A; O'Donnell, Martin James; 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Sethi, Yashendra; SeyedAlinaghi, SeyedAhmad; Seylani, Allen; Shabani, Mohammad; Shabany, Maryam; Shafie, Mahan; Shahabi, Saeed; Shahbandi, Ataollah; Shahid, Samiah; Shahraki-Sanavi, Fariba; Shahsavari, Hamid R; Shahwan, Moyad Jamal; Shaikh, Masood Ali; Shaji, KS; Sham, Sunder; Shama, Adisu Tafari T; Shamim, Muhammad Aaqib; Shams-Beyranvand, Mehran; Shamsi, Mohammad Anas; Shanawaz, Mohd; Sharath, Medha; Sharfaei, Sadaf; Sharifan, Amin; Sharma, Manoj; Sharma, Rajesh; Shashamo, Bereket Beyene; Shayan, Maryam; Sheikhi, Rahim Ali; Shekhar, Shashank; Shen, Jiabin; Shenoy, Suchitra M; Shetty, Pavanchand H; Shiferaw, Desalegn Shiferaw; Shigematsu, Mika; Shiri, Rahman; Shittu, Aminu; Shivakumar, KM; Shokri, Fereshteh; Shool, Sina; Shorofi, Seyed Afshin; Shrestha, Sunil; Siankam Tankwanchi, Akhenaten Benjamin; Siddig, Emmanuel Edwar; Sigfusdottir, Inga Dora; Silva, João Pedro; Silva, Luís Manuel Lopes Rodrigues; Sinaei, Ehsan; Singh, Balbir Bagicha; Singh, Garima; Singh, Paramdeep; Singh, Surjit; Sirota, Sarah Brooke; Sivakumar, Shravan; Sohag, Abdullah Al Mamun; Solanki, Ranjan; Soleimani, Hamidreza; Solikhah, Solikhah; Solomon, Yerukneh; Solomon, Yonatan; Song, Suhang; Song, Yimeng; Sotoudeh, Houman; Spartalis, Michael; Stark, Benjamin A; Starnes, Joseph R; Starodubova, Antonina V; Stein, Dan J; Steiner, Timothy J; Stovner, Lars Jacob; Suleman, Muhammad; Suliankatchi Abdulkader, Rizwan; Sultana, Abida; Sun, Jing; Sunkersing, David; Sunny, Angel; Susianti, Hani; Swain, Chandan Kumar; Szeto, Mindy D; Tabarés-Seisdedos, Rafael; Tabatabaei, Seyyed Mohammad; Tabatabai, Shima; Tabish, Mohammad; Taheri, Majid; Tahvildari, Azin; Tajbakhsh, Ardeshir; Tampa, Mircea; Tamuzi, Jacques JL Lukenze; Tan, Ker-Kan; Tang, Haosu; Tareke, Minale; Tarigan, Ingan Ukur; Tat, Nathan Y; Tat, Vivian Y; Tavakoli Oliaee, Razieh; Tavangar, Seyed Mohammad; Tavasol, Arian; Tefera, Yibekal Manaye; Tehrani-Banihashemi, Arash; Temesgen, Worku Animaw; Temsah, Mohamad-Hani; Teramoto, Masayuki; Tesfaye, Amensisa Hailu; Tesfaye, Edosa Geta; Tesler, Riki; Thakali, Ocean; Thangaraju, Pugazhenthan; Thapa, Rajshree; Thapar, Rekha; Thomas, Nikhil Kenny; Thrift, Amanda G; Ticoalu, Jansje Henny Vera; Tillawi, Tala; Toghroli, Razie; Tonelli, Marcello; Tovani-Palone, Marcos Roberto; Traini, Eugenio; Tran, Nghia Minh; Tran, Ngoc-Ha; Tran, Phu Van; Tromans, Samuel Joseph; Truelsen, Thomas Clement; Truyen, Thien Tan Tri Tai; Tsatsakis, Aristidis; Tsegay, Guesh Mebrahtom; Tsermpini, Evangelia Eirini; Tualeka, Abdul Rohim; Tufa, Derara Girma; Ubah, Chukwudi S; Udoakang, Aniefiok John; Ulhaq, Inam; Umair, Muhammad; Umakanthan, Srikanth; Umapathi, Krishna Kishore; Unim, Brigid; Unnikrishnan, Bhaskaran; Vaithinathan, Asokan Govindaraj; Vakilian, Alireza; Valadan Tahbaz, Sahel; Valizadeh, Rohollah; Van den Eynde, Jef; Vart, Priya; Varthya, Shoban Babu; Vasankari, Tommi Juhani; Vaziri, Siavash; Vellingiri, Balachandar; Venketasubramanian, Narayanaswamy; Verras, Georgios-Ioannis; Vervoort, Dominique; Villafañe, Jorge Hugo; 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Zaki, Nazar; Zali, Alireza; Zamagni, Giulia; Zand, Ramin; Zandieh, Ghazal GZ; Zangiabadian, Moein; Zarghami, Amin; Zastrozhin, Mikhail Sergeevich; Zeariya, Mohammed GM; Zegeye, Zelalem Banjaw; Zeukeng, Francis; Zhai, Chunxia; Zhang, Chen; Zhang, Haijun; Zhang, Yunquan; Zhang, Zhi-Jiang; Zhao, Hanqing; Zhao, Yang; Zheng, Peng; Zhou, Hengxing; Zhu, Bin; Zhumagaliuly, Abzal; Zielińska, Magdalena; Zikarg, Yossef Teshome; Zoladl, Mohammad; Murray, Christopher JL; Ong, Kanyin Liane; Feigin, Valery L; Vos, Theo; Dua, Tarun
Global, Regional, and National Burden of Stroke and Its Risk Factors 1990-2021: A Systematic Analysis for the Global Burden of Disease Study 2021
(Elsevier, 2024) Feigin, Valery; Nair, B; Rautalin, I; Bhatia, A; GBD 2021 Stroke Risk Factor Collaborators
Background Up-to-date estimates of stroke burden and attributable risks and their trends at global, regional, and national levels are essential for evidence-based health care, prevention, and resource allocation planning. We aimed to provide such estimates for the period 1990–2021. Methods We estimated incidence, prevalence, death, and disability-adjusted life-year (DALY) counts and age-standardised rates per 100 000 people per year for overall stroke, ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage, for 204 countries and territories from 1990 to 2021. We also calculated burden of stroke attributable to 23 risk factors and six risk clusters (air pollution, tobacco smoking, behavioural, dietary, environmental, and metabolic risks) at the global and regional levels (21 GBD regions and Socio-demographic Index [SDI] quintiles), using the standard GBD methodology. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline. Findings In 2021, stroke was the third most common GBD level 3 cause of death (7·3 million [95% UI 6·6–7·8] deaths; 10·7% [9·8–11·3] of all deaths) after ischaemic heart disease and COVID-19, and the fourth most common cause of DALYs (160·5 million [147·8–171·6] DALYs; 5·6% [5·0–6·1] of all DALYs). In 2021, there were 93·8 million (89·0–99·3) prevalent and 11·9 million (10·7–13·2) incident strokes. We found disparities in stroke burden and risk factors by GBD region, country or territory, and SDI, as well as a stagnation in the reduction of incidence from 2015 onwards, and even some increases in the stroke incidence, death, prevalence, and DALY rates in southeast Asia, east Asia, and Oceania, countries with lower SDI, and people younger than 70 years. Globally, ischaemic stroke constituted 65·3% (62·4–67·7), intracerebral haemorrhage constituted 28·8% (28·3–28·8), and subarachnoid haemorrhage constituted 5·8% (5·7–6·0) of incident strokes. There were substantial increases in DALYs attributable to high BMI (88·2% [53·4–117·7]), high ambient temperature (72·4% [51·1 to 179·5]), high fasting plasma glucose (32·1% [26·7–38·1]), diet high in sugar-sweetened beverages (23·4% [12·7–35·7]), low physical activity (11·3% [1·8–34·9]), high systolic blood pressure (6·7% [2·5–11·6]), lead exposure (6·5% [4·5–11·2]), and diet low in omega-6 polyunsaturated fatty acids (5·3% [0·5–10·5]). Interpretation Stroke burden has increased from 1990 to 2021, and the contribution of several risk factors has also increased. Effective, accessible, and affordable measures to improve stroke surveillance, prevention (with the emphasis on blood pressure, lifestyle, and environmental factors), acute care, and rehabilitation need to be urgently implemented across all countries to reduce stroke burden.
Insights From ARCOS-V's Transition to Remote Data Collection During the Covid-19 Pandemic: A Descriptive Study
(S. Karger AG, 2024) Henry, Nathan IN; Nair, Balakrishnan; Ranta, Anna; Krishnamurthi, Rita; Bhatia, Anjali; Feigin, Valery
INTRODUCTION: The ARCOS-V study, an epidemiological study on stroke and transient ischemic attack (TIA), faced the challenge of continuing data collection amidst the COVID-19 pandemic. This study aims to describe the methodological changes and challenges encountered during the transition from paper-based methods to digital data collection for the ARCOS-V study, and to provide insights into the potential of using digital tools to transform epidemiological research. METHODS: The study adapted to remote data collection using REDCap and Zoom, involving daily health record reviews, direct data entry by trained researchers, and remote follow-up assessments. The process was secured with encryption and role-based access controls. The transition period was analyzed to evaluate the effectiveness and challenges of the new approach. RESULTS: The digital transition allowed for uninterrupted monitoring of stroke and TIA cases during lockdowns. Using REDCap and Zoom improved data reach, accuracy, and security. However, it also revealed issues such as the potential for systematic data entry errors and the need for robust security measures to protect sensitive health information. CONCLUSION: The ARCOS-V study's digital transformation exemplifies the resilience of epidemiological research in the face of a global crisis. The successful adaptation to digital data collection methods highlights the potential benefits of such tools, particularly as we enter a new age of Artificial Intelligence (AI).
Pragmatic Solutions to Reduce Global Stroke Burden: World Stroke Organization – Lancet Neurology Commission Report
(S. Karger AG, 2023-11-23) Krishnamurthi, Rita V; Gall, Seana; Martins, Sheila O; Norrving, Bo; Pandian, Jeyaraj D; Feigin, Valery L; Owolabi, Mayowa O
Pragmatic Solutions to Reduce the Global Burden of Stroke: A World Stroke Organization-Lancet Neurology Commission
(Elsevier, 2023-10-09) Feigin, Valery L; Owolabi, Mayowa O; World Stroke Organization–Lancet Neurology Commission Stroke Collaboration Group
Prognostic Models for Global Functional Outcome and Post-concussion Symptoms Following Mild Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (Center-TBI) Study
(Mary Ann Liebert Inc, 2023-08-16) Mikolić, A; Steyerberg, EW; Polinder, S; Wilson, L; Zeldovich, M; von Steinbueche, N; Newcombe, VFJ; Menon, DK; van der Naalt, J; Lingsma, HF; Maas, AIR; van Klaveren, D; Åkerlund, C; Amrein, K; Andelic, N; Andreassen, L; Anke, A; Antoni, A; Audibert, G; Azouvi, P; Azzolini, ML; Bartels, R; Barzó, P; Beauvais, R; Beer, R; Bellander, BM; Belli, A; Benali, H; Berardino, M; Beretta, L; Blaabjerg, M; Bragge, P; Brazinova, A; Brinck, V; Brooker, J; Brorsson, C; Buki, A; Bullinger, M; Cabeleira, M; Caccioppola, A; Calappi, E; Calvi, MR; Cameron, P; Carbayo Lozano, G; Carbonara, M; Cavallo, S; Chevallard, G; Chieregato, A; Citerio, G; Clusmann, H; Coburn, M; Coles, J; Cooper, JD; Correia, M; Čović, A; Curry, N; Czeiter, E; Czosnyka, M; Fizelier, CD; Dark, P; Dawes, H; De Keyser, V; Degos, V; Della Corte, F; den Boogert, H; Depreitere, B; Ðilvesi, Ð; Dixit, A; Donoghue, E; Dreier, J; Dulière, GL; Ercole, A; Esser, P; Ezer, E; Fabricius, M; Feigin, VL; Foks, K; Frisvold, S; Furmanov, A; Gagliardo, P; Galanaud, D; Gantner, D; Gao, G; George, P; Ghuysen, A; Giga, L; Glocker, B; Golubovic, J; Gomez, PA; Gratz, J; Gravesteijn, B; Grossi, F; Gruen, RL; Gupta, D; Haagsma, JA; Haitsma, I; Helbok, R; Helseth, E; Horton, L; Huijben, J
After mild traumatic brain injury (mTBI), a substantial proportion of individuals do not fully recover on the Glasgow Outcome Scale Extended (GOSE) or experience persistent post-concussion symptoms (PPCS). We aimed to develop prognostic models for the GOSE and PPCS at 6 months after mTBI and to assess the prognostic value of different categories of predictors (clinical variables; questionnaires; computed tomography [CT]; blood biomarkers). From the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, we included participants aged 16 or older with Glasgow Coma Score (GCS) 13-15. We used ordinal logistic regression to model the relationship between predictors and the GOSE, and linear regression to model the relationship between predictors and the Rivermead Post-concussion Symptoms Questionnaire (RPQ) total score. First, we studied a pre-specified Core model. Next, we extended the Core model with other clinical and sociodemographic variables available at presentation (Clinical model). The Clinical model was then extended with variables assessed before discharge from hospital: early post-concussion symptoms, CT variables, biomarkers, or all three categories (extended models). In a subset of patients mostly discharged home from the emergency department, the Clinical model was extended with 2-3–week post-concussion and mental health symptoms. Predictors were selected based on Akaike’s Information Criterion. Performance of ordinal models was expressed as a concordance index (C) and performance of linear models as proportion of variance explained (R2). Bootstrap validation was used to correct for optimism. We included 2376 mTBI patients with 6-month GOSE and 1605 patients with 6-month RPQ. The Core and Clinical models for GOSE showed moderate discrimination (C = 0.68 95% confidence interval 0.68 to 0.70 and C = 0.70[0.69 to 0.71], respectively) and injury severity was the strongest predictor. The extended models had better discriminative ability (C = 0.71[0.69 to 0.72] with early symptoms; 0.71[0.70 to 0.72] with CT variables or with blood biomarkers; 0.72[0.71 to 0.73] with all three categories). The performance of models for RPQ was modest (R2 = 4% Core; R2 = 9% Clinical), and extensions with early symptoms increased the R2 to 12%. The 2-3-week models had better performance for both outcomes in the subset of participants with these symptoms measured (C = 0.74 [0.71 to 0.78] vs. C = 0.63[0.61 to 0.67] for GOSE; R2 = 37% vs. 6% for RPQ). In conclusion, the models based on variables available before discharge have moderate performance for the prediction of GOSE and poor performance for the prediction of PPCS. Symptoms assessed at 2-3 weeks are required for better predictive ability of both outcomes. The performance of the proposed models should be examined in independent cohorts.
Stroke Is Not an Accident: An Integrative Review on the Use of the Term ‘Cerebrovascular Accident’
(S. Karger AG, 2024) Burns, Catherine; Sanders, Ailie; Sanders, Lauren M; Dalli, Lachlan L; Feigin, Valery; Cadilhac, Dominique A; Donnan, Geoffrey; Norrving, Bo; Olaiya, Muideen T; Nair, Balakrishnan; Henry, Nathan; Kilkenny, Monique F
BACKGROUND: Cerebrovascular accident (CVA) is an outdated term for describing stroke as it implies stroke is an accident. We conducted an integrative review to determine use of CVA in terms of 1) frequency in major medical journals over time; 2) associated publication characteristics (e.g., number of authors, senior author country, topic); and 3) frequency in medical records. METHODS: We searched Google Scholar for publications in leading neurology and vascular journals (Quartile 1) across two 5-year periods (1998-2002 and 2018-2022) using the terms "cerebrovascular accident" or "CVA." Two reviewers independently reviewed full-text publications and recorded the frequency of CVA use. Rates of use (per 1,000 articles/year) were calculated for each journal and time period. Associations of publication characteristics with CVA use were determined using multivariable logistic regression models. In addition, admission and discharge forms in the Auckland Regional Community Stroke Study (ARCOS V) were audited for frequency of use of the term CVA. RESULTS: Of the 1,643 publications retrieved, 1,539 were reviewed in full. Of these, CVA was used ≥1 time in 676 publications, and ≥2 times in 276 publications (129 in 1998-2002; 147 in 2018-2022). The terms CVA and stroke both appeared in 57% of publications where CVA was used ≥2 times in 1998-2002, compared to 65% in 2018-2022. Majority of publications were on the topic of stroke (22% in 1998-2002; 20% in 2018-2022). There were no associations between publication characteristics and the use of CVA. The highest rate of CVA use in 2018-2022 was in Circulation, and increased over time from 1.3 uses per 1,000 publications in 1998-2002 to 1.8 uses per 1,000 publications in 2018-2022. The largest reduction the use of CVA was in Neuroepidemiology (2.0 uses per 1,000 publications in 1998-2002 to 0 uses in 2018-2022). The term CVA was identified in 0.2% of stroke admission and discharge forms audited (17/7808). CONCLUSION: We found evidence of changes in the use of CVA in the scientific literature over the past two decades. Editors, authors and clinicians should avoid the use of the term CVA as it perpetuates the use of a non-specific, non-diagnostic, and non-scientific term.
Symptoms and Engagement in Anti-social Behaviour 10 Years Following Mild Traumatic Brain Injury Within a Community Civilian Sample: A Prospective Cohort Study with Age-Sex Matched Control Group.
(Elsevier, 2023) Theadom, Alice; Jones, Kelly; Starkey, Nicola; Barker-Collo, Suzanne; Ameratunga, Shanthi; Faulkner, Josh; Ao, Braden Te; Feigin, V
OBJECTIVE: To determine if there are longer-term impacts on symptoms, health status, mood and behaviour 10-years following a mild traumatic brain injury (mTBI). DESIGN: Prospective cohort study SETTING: Community-based, civilian sample PARTICIPANTS: Adults aged ≥16 years at follow up who experienced a mTBI 10-years ago, and an age and sex-matched non-injured control group. INTERVENTIONS: Not applicable MAIN OUTCOME MEASURES: MTBI cases and controls were asked to complete self-report assessments of functioning (WHODAS 2.0), symptoms (Rivermead Post-Concussion Symptom Questionnaire), health status (100-point scale), alcohol (AUDIT-C) and substance use (ASSIST), and whether they had engaged in any anti-social behaviours over the past 12-months. RESULTS: Data were analysed for 368 participants (184 mTBI cases and 184 age-sex matched controls). Just over a third of mTBI cases (64, 34.8%) reported that they were still affected by their index mTBI 10-years later. After adjusting for education and ethnicity, the mTBI group had statistically higher overall symptom burden (F=22.32, p<0.001, ηp2 =0.07) compared to controls. This difference remained after excluding those who experienced a recurrent TBI. The mTBI group were more than three times as likely to have engaged in anti-social behaviour during the previous 12-months (F=5.89, p=0.02). There were no group differences in health status, functioning, or problematic alcohol or substance use 10-years post-injury. CONCLUSIONS: This study provides evidence of potential longer-term associations between mTBI, post-concussion symptoms and anti-social behaviour which warrants further evaluation. Future research should also examine if longer-term effects may be preventable with access to early rehabilitation post-injury.
Twenty Years on From the Introduction of the High Risk Strategy for Stroke and Cardiovascular Disease Prevention: A Systematic Scoping Review
(Wiley, 2023) Feigin, Valery; Martins, S; Brainin, M; Norrving, B; Kamenova, S; Giniyat, A; Kondybayeva, A; Aldyngurov, DK; Bapayeva, M; Zhanuzakov, M; Hankey, GJ
Background and purpose Early this century, the high risk strategy of primary stroke and cardiovascular disease (CVD) prevention for individuals shifted away from identifying (and treating, as appropriate) all at-risk individuals towards identifying and treating individuals who exceed arbitrary thresholds of absolute CVD risk. The public health impact of this strategy is uncertain. Methods In our systematic scoping review, the electronic databases (Scopus, MEDLINE, Embase, Google Scholar, Cochrane Library) were searched to identify and appraise publications related to primary CVD/stroke prevention strategies and their effectiveness published in any language from January 1990 to August 2023. Results No published randomized controlled trial was found on the effectiveness of the high CVD risk strategy for primary stroke/CVD prevention. Targeting high CVD risk individuals excludes a large proportion of the population from effective blood-pressure-lowering and lipid-lowering treatment and effective CVD prevention. There is also evidence that blood pressure lowering and lipid lowering are beneficial irrespective of blood pressure and cholesterol levels and irrespective of absolute CVD risk and that risk-stratified pharmacological management of blood pressure and lipids to only high CVD risk individuals leads to significant underuse of blood-pressure-lowering and lipid-lowering medications in individuals otherwise eligible for such treatment. Conclusions Primary stroke and CVD prevention needs to be done in all individuals with increased risk of CVD/stroke. Pharmacological management of blood pressure and blood cholesterol should not be solely based on the high CVD risk treatment thresholds. International guidelines and global strategies for primary CVD/stroke prevention need to be revised.
Usability and Feasibility of PreventS-MD Webapp for Stroke Prevention
(SAGE Publications, 2023-07-24) Feigin, VL; Krishnamurthi, Rita; Medvedev, Oleg; Merkin, Alexander; Nair, Bala; Kravchenko, Michael; Jalili Moghaddam, Shabnam; Barker-Collo, Suzanne Lyn; Rathnasabapathy, Yogini; Skinner, Luke; Owolabi, Mayowa; Norrving, Bo; Sachdev, Perminder S; Arroll, Bruce; Brainin, Michael; Thrift, Amanda G; Hankey, Graeme J
Background: Most strokes and cardiovascular diseases (CVDs) are potentially preventable if their risk factors are identified and well controlled. Digital platforms, such as the PreventS-MD webapp (PreventS-MD) may aid health care professionals (HCPs) in assessing and managing risk factors and promoting lifestyle changes for their patients. Methods: This is a mixed methods cross-sectional 2-phase survey using a largely positivist (quantitative and qualitative) framework. During phase 1, a prototype of PreventS-MD was tested internationally by 59 of 69 consenting HCPs of different backgrounds, age, sex, working experience and specialities using hypothetical data. Collected comments/suggestions from the study HCPs in phase 1 were reviewed and implemented. In phase 2, a near-final version of PreventS-MD was developed and tested by 58 of 72 consenting HCPs using both hypothetical and real patient (n=10) data. Qualitative semi-structured interviews with real patients (n=10) were conducted, and 1-month adherence to the preventative recommendations was assessed by self-reporting. The four System Usability Scale (SUS) groups of scores (0-50 unacceptable; 51-68 poor, 68-80.3 good; >80.3 excellent) were used to determine usability of PreventS-MD. Findings: 99 HCPs from 27 countries (45% from low- to middle-income countries) participated in the study, out of whom 10 HCPs were involved in the development of PreventS before the study, and therefore were not involved in the survey. Of the remaining 89 HCPs 69 consented to the first phase of the survey, out of whom 59 completed the first phase of the survey (response rate 86%) and 58 HCPs completed the second phase of the survey (response rate 84%). The SUS scores supported good usability of the prototype (mean score=80.2; 95% CI [77.0-84.0]) and excellent usability of the final version of PreventS-MD (mean score=81.7; 95%CI [79.1-84.3]) in the field. Scores were not affected by the age, sex, working experience or speciality of the HCPs. One month follow-up of the patients confirmed the high level of satisfaction/acceptability of PreventS-MD and (100%) adherence to the recommendations. Interpretation: The PreventS-MD webapp has a high level of usability, feasibility and satisfaction by HCPs and individuals at risk of stroke/CVD. Individuals at risk of stroke/CVD demonstrated a high level of confidence and motivation in following and adhering to preventative recommendations generated by PreventS-MD.
Using Network Analysis To Validate Domains of the Modified Telephone Interview for Cognitive Status
(Wiley, 2023) Cuong, TQ; Cervin, M; Numbers, K; Choo, CC; Bentvelzen, AC; Merkin, AG; Sachdev, PS; Feigin, V; Brodaty, H; Kochan, NA; Medvedev, ON
Background The modified Telephone Interview for Cognitive Status (TICS-M) is a widely used tool for assessing global cognitive functions and screening for cognitive impairments. The tool was conceptualised to capture various cognitive domains, but the validity of such domains has not been investigated against comprehensive neuropsychological assessments tools. Therefore, this study aimed to explore the associations between the TICS-M domains and neuropsychological domains to evaluate the validity of the TICS-M domains using network analysis. Materials and Methods A longitudinal research design was used with a large sample of older adults (aged above 70 years; n = 1037 at the baseline assessment) who completed the TICS-M and comprehensive neuropsychological assessments biennially. We applied network analysis to identify unique links between the TICS-M domains and neuropsychological test scores. Results At baseline, there were weak internal links between the TICS-M domains. The TICS-M memory and language domains were significantly related to their corresponding neuropsychological domains. The TICS-M attention domain had significant associations with executive function and visuospatial abilities. The TICS-M orientation domain was not significantly associated with any of the five neuropsychological domains. Despite an attrition of almost 50% at wave four, weak internal links between the TICS-M domains and most associations between TICS-M and neuropsychological domains that were found initially, remained stable at least over two waves within the 6-year period. Conclusions This study supports the overall structural validity of the TICS-M screener in assessing enduring global cognitive function. However, separate TICS-M cognitive domains should not be considered equivalent to the analogous neuropsychological domains.
You Only Get One Brain: Adult Reflections on Coping and Recovery After Traumatic Brain Injury in Adolescence
(Informa UK Limited, 2023) Mulligan, T; Barker-Collo, S; Gibson, K; Jones, K
Background: TBI during adolescence can result in significant acute symptoms that can persist into adulthood. This research analyzed retrospective qualitative accounts of young adults who had sustained a TBI in adolescence to explore coping and recovery processes specific to this developmental stage. Methods: Thirteen adults (aged 20–25 years; mean 23 years) who sustained a mild (n = 12) or moderate (n = 1) TBI during adolescence (aged 13–17 years at injury), approximately 7.7 years (range = 6.7–8.0 years) prior, participated. Semi-structured individual interviews, analyzed using thematic analysis, explored participants’ experiences following their TBIs. Results: Thematic data analysis produced two key categories of themes relating to recovery processes: (1) Individual factors impacting coping, with themes of learning to cope with difficulties, seeking acceptance and balance, and finding meaning; and (2) Social factors impacting coping, which included themes of feeling included, relying on family, professionals didn’t get it, and lacking someone who understands. Conclusions: Recovery following TBI sustained during adolescence could be maximized by facilitating greater understanding of specific impacts on young people among clinicians and family, longer term monitoring of symptoms including emotional reactions to symptoms, and the provision of emotional support.

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