From the Departments of Neurology (J.B., T.B., R.M., J.G., D.M., L.M.),
Emergency Medicine (R.K., A.P.), and Environmental Health (J.K., R.S.),
University of Cincinnati Medical Center, Cincinnati, Ohio.
Correspondence to Joseph Broderick, MD, University of Cincinnati Medical Center, Department of Neurology, 231 Bethesda Ave, Room 4010, Cincinnati, OH 45267-0525. E-mail broderjp{at}ucsmtp.edu
Methods—We are identifying all hospitalized and autopsied cases
of stroke and transient ischemic attack (TIA) among the 1.3
million inhabitants of a five-county region of Greater
Cincinnati/Northern Kentucky for the period 7/1/93–6/30/94. We have
already prospectively monitored for out-of-hospital stroke and TIAs for
this same time period at 128 screening sites, including a random sample
of all primary care physicians and nursing homes in the region. We have
already identified all hospitalized and autopsied cases of stroke and
TIA among blacks for 1/1/93–6/30/93 and report preliminary incidence
rates for this 6-month period.
Results—The overall incidence rate for all first-ever
hospitalized or autopsied stroke (excluding TIAs) among blacks in the
Greater Cincinnati region was 288 per 100 000 (95% CI, 250 to 325,
age- and sex-adjusted to 1990 US population). The overall incidence
rate for first-ever and recurrent stroke (excluding TIAs) was 411 per
100 000 (95% CI, 366 to 456). By comparison, the overall incidence
rate of first-ever stroke among whites in Rochester, Minn, during the
period 1985–1989 was 179 per 100 000 (95% CI, 164 to 194, age-
and-sex adjusted to 1990 US population). The incidence rates among
blacks in Greater Cincinnati were substantially greater than the rates
among whites in Rochester, Minn, for all age categories except ages 75
and older, for which the rates were similar.
Conclusions—We conservatively estimate that 731 100 first-ever
or recurrent strokes occurred in the United States during 1996. Studies
of first-ever as well as total stroke among biracial and
representative populations are critical for
understanding temporal trends in the incidence rate and the burden of
stroke in the US population.
The Greater Cincinnati/Northern Kentucky Stroke Study was
designed to be the first large, population-based metropolitan study of
temporal trends in stroke incidence rates and outcome within a biracial
population.4 5 Our population is similar to that
of the United States in terms of age, economic status, and proportion
of blacks (Table 1
The unique methodology for this study as well as the first 6 months of
case ascertainment and data analysis among hospitalized or
autopsied blacks are presented in this report.
Screening for Hospitalized and Autopsied Strokes
The study nurses also reviewed all autopsied cases from the coroner's
offices of the five study counties from 1/1/93 to 12/31/94 with stroke
listed as a primary or secondary cause of death. In addition, we
obtained from the Ohio and Kentucky departments of vital statistics the
death certificates for all residents of the five Ohio and Kentucky
counties who died during the period 1/1/93–2/28/95 and had stroke
listed as a primary or secondary cause of death.
Nonhospitalized, Nonautopsied Stroke Cases
We also randomly selected 50 of the 878 family medicine physicians and
internists in the five-county region (identified from all names in the
Greater Cincinnati/Northern Kentucky Yellow Pages). Only two physicians
refused to participate in the study. The study was discussed with each
physician and his or her office staff. A study form was given to the
office staff to record the names of any potential cases of stroke
or TIA. A study nurse called the physician's office staff monthly to
check whether any new stroke cases had been detected. If potential
cases were noted, the study nurse abstracted the medical record.
Two large groups of primary care physicians provided us estimates of
the average annual number of patient visits per physician
(approximately 3700 outpatient visits per year). Thus, our screening of
50 physicians represents screening of approximately 185 000
annual visits.
In addition, a 15% sample of the 193 nursing homes in the five-county
region was selected randomly (total number of participating nursing
home beds during 1993–1994 was 2702). Only four nursing homes that
were contacted refused to participate in the study. The study was
discussed in detail with the head nurse/administrator at each nursing
home. A study form was posted to record potential cases. Each
nursing home was contacted every month for identification of potential
cases. After a release of information form was signed, the study nurse
reviewed and abstracted the nursing home records. Finally, all
emergency department visits during the study year were screened by
review of emergency department logs at all 18 regional adult
hospitals.
All cases of stroke in our database are cross-matched with vital
statistic data from the states of Ohio and Kentucky as well as the US
Death Index database to determine long-term survival status.
Abstraction of Clinical and Imaging Data From the Medical
Records
After the nurse completed abstraction of a study case, the computer
files were downloaded into another portable computer to be reviewed by
the study neurologist. The neurologist reviewed the database for each
case as well as all associated CT, MR, and angiographic reports and
films, noting the location of any lesions on CT and/or MR brain imaging
that were consistent with the clinical
presentation. Using all clinical and
radiographic information, the study neurologist made the
final determination of whether the patient met the criteria for a
stroke or TIA and also determined the subtype of stroke and TIA.
Case Criteria
Calculations and Comparison of Incidence Rates
Incidence rates were calculated for each age, sex, and race category.
For comparison with other studies, including the 1988 Cincinnati study
of ICH and SAH and the 1985 to 1989 stroke incidence study in
Rochester, Minn, the incidence rates for all stroke and for each stroke
subtype were adjusted to the 1990 US population. Only cases of
first-ever stroke were included unless specifically noted. For
calculation of preliminary incidence rates among blacks for the period
1/1/93–6/30/93, only cases of hospitalized and autopsied stroke or TIA
were used. The 95% CIs for the incidence rates were calculated using a
Poisson distribution. The 95% CI for the difference in rates by race,
gender, etc, incorporate a pooled estimate of the variance in the
incidence rates.14
Of the 213 first-ever stroke cases (excluding TIAs), 209 patients
(98%) had a CT scan (93%) or MRI (22%) of the brain or an autopsy of
the brain (1.4%), and 61% had a neurologist who was involved with
their hospital care. Of the 213 first-ever stroke cases, 30% of the
patients had a decrease in the level of consciousness, 75% had motor
weakness or incoordination, and 63% had speech or language problems as
part of their presenting symptoms. Twenty-four percent of the 198
patients with a first-ever stroke who had a head CT scan as part of
their diagnostic evaluation had a "silent" infarct
outside of the distribution of their presenting stroke.
The overall incidence rate for all first-ever stroke among blacks in
the Greater Cincinnati region during the first 6 months 1993 was 288
per 100 000 (95% CI, 250 to 325, age- and sex-adjusted to 1990 US
population, excludes TIA). The incidence rate of all stroke (first-ever
and recurrent stroke, excludes TIA) for blacks in Greater Cincinnati
during the first 6 months of 1993 was 411 per 100 000, (95% CI, 366
to 456, age- and sex-adjusted to the 1990 US population). By
comparison, the overall rate of first-ever stroke among whites in
Rochester, Minn, during 1985–1989 was 179 per 100 000 (95% CI, 164
to 194, age- and-sex adjusted to 1990 US
population).1 2 The incidence rates among blacks
in Greater Cincinnati during 1993 were substantially greater than those
among whites in Rochester, Minn, during 1985 to 89 for all age
categories except for ages 75 and older, in which the rates were
similar (Fig 2
Our preliminary analysis comparing the incidence rates of
hemorrhagic stroke among African Americans in Greater Cincinnati during
first 6 months of 1993 with rates among blacks during 1988 (both
incidence rates age- and sex-adjusted to the 1990 US population)
indicate that the rate of SAH during the first 6 months of 1993 (11 per
100 000; 95% CI, 3 to 18) remained similar to the rate during 1988
(11 per 100 000; 95% CI, 6 to 16). The rate of ICH during the first 6
months of 1993 (38 per 100 000; 95% CI, 25 to 52) increased
significantly from the rate among blacks in Greater Cincinnati during
1988 (18 per 100 000; 95% CI, 11 to 24). The incidence rate of
first-ever cerebral infarction among blacks for the first 6 months of
1993 was 246 per 100 000; 95% CI, 211 to 280.
The final diagnosis of the study nurses and the final diagnosis of the
physician agreed in 83% of potential cases. Only two of the 38 cases
(37 first-ever, 1 recurrent) of hemorrhagic stroke were classified as
ischemic stroke by the nurses. One of the two patients was
coded as ICD-9-CM 436 (acute but ill-defined cerebrovascular disease)
and the other 435 (TIA). The initial CT (1 patient) and MRI (1 patient)
reports in the chart did not mention hemorrhage and
differentiation between the diagnosis of brain hemorrhage
versus hemorrhagic infarction was not clear in the medical record.
After review of the films by the study physician, both subjects clearly
had a primary intracerebral hemorrhage (one
large, one small). In 20 cases, the nurses judged a stroke or TIA to
have occurred whereas on final review the physician investigator did
not. Almost all of these cases had acute change in central nervous
system function (eg, change in level of consciousness), but the
physician judged that the symptoms were not focal enough to meet the
strict definition of a stroke. The only other area of some disagreement
was the distinction between TIA and ischemic stroke in which
the question of duration of symptoms and signs (>24 hours or
<24 hours) was the difficult issue. The accuracy and yield of
ICD-9-CM codes for the first 6 months of potential black cases of
stroke and TIA are presented in Table 2
Blacks in Greater Cincinnati under the age of 65 had a two to four
times greater incidence rates of first-ever stroke compared with rates
among whites of similar age in the Rochester population. Age-specific
stroke incidence rates were similar for elderly blacks and whites.
These differences between blacks and whites with respect to stroke
incidence rates mirrors the differences in stroke mortality rates
between blacks and whites in the US population.15
Possible explanations for the much higher stroke incidence rates among
blacks include a higher prevalence of
hypertension,16 17 higher rates of smoking among
young blacks,18 19 a higher prevalence of
diabetes,20 and a lower and more stressful
socioeconomic lifestyle.20 However, at least 50%
of the large age-related differences in incidence rates among blacks
and whites has yet to be explained.20
The incidence rate of total stroke (excluding TIAs) was 43% greater
than that of first-ever stroke among blacks in the Greater Cincinnati
population. The epidemiology of total stroke,
that is, first-ever stroke and recurrent stroke, is understudied and
yet is a better index of the overall burden of stroke in the
population. Since the methods of data collection as well as the
documentation of prior deficits in the medical record vary among
community-based stroke studies, ascertainment of a history of prior
stroke will also vary among these epidemiological studies of stroke
incidence rates. One way to compare the accuracy of historical
information concerning prior stroke among various community studies is
to compare the frequency of "silent" infarcts on baseline CT scans
that were obtained to evaluate the presenting strokes. Our 24%
rate of "silent" infarcts on the baseline CT in patients with a
first-ever stroke is lower than rates reported for two other
population-based studies of hospitalized first-ever strokes in
Copenhagen (29%) and Umbria, Italy (38%), during the CT
era.21 22
The American Heart Association's 1997 Heart and Stroke
Statistical Update states that approximately 500 000 Americans
suffer a first-ever or recurrent stroke each
year.23 This statement is based on the all-white
cohort study of Framingham, Mass. Our incidence data indicate
that the figure of 500 000 strokes substantially underestimates the
actual stroke burden for the United States. Application of our
total stroke incidence rates among blacks to the projected 1996
black population of the United States would indicate that there were
approximately 138 100 strokes among blacks in the United States during
1996. The recurrence rate of stroke among whites in the
Rochester population is not known (personal communication, Dr Robert
Brown, Mayo Clinic, 1997). However, if we assume that the ratio of
first-ever to recurrent stroke for whites in Rochester is similar to
that for blacks in Greater Cincinnati, we would expect that the
incidence rate of total stroke in Rochester, Minn, would be 256 per
100 000 population or 43% greater than the incidence rate of
first-ever stroke. Application of this rate of total stroke to the
remainder of the 1996 United States population would indicate that
there were 593 000 strokes among whites and nonblack segments of the
population during 1996. Thus, we conservatively estimate that
there were 731 100 first-ever or recurrent strokes in the United
States during 1996. This figure is probably an underestimate,
since it assumes that stroke incidence rates among the affluent middle-
to upper-class whites of Rochester are similar to stroke incidence
rates among all whites, Hispanics, Asians, and other ethnic populations
in the United States.
Many epidemiological studies utilize ICD-9-CM stroke-related discharge
codes as surrogate markers for incidence cases of stroke. Our data
indicates that studies which use primary and secondary ICD-9-CM
discharge codes 430 to 438 to measure stroke occurrence will
overestimate the number of hospitalized strokes in the population by a
factor of 2. ICD-9-CM discharge codes 430 to 436 provide nearly
complete ascertainment of hospitalized strokes but still overestimate
stroke occurrence by 39%. Using only primary discharge diagnosis of
ICD-9-CM codes 430 to 436 increases the true positive rate for stroke
or TIA from 72% to 83% but decreases the yield of cases of stroke and
TIA from 97% to 84%. Thus, primary stroke-related discharge diagnoses
430 to 436 probably provide the best estimate of the true incidence
rate of hospitalized stroke and could be used to estimate temporal
trends in the incidence rate of hospitalized stroke within a given
community. This observation assumes that coding practices remain
unchanged over time and that investigators understand the limitations
of this method.
The Greater Cincinnati population is similar to the United States
population and results from our study are likely generalizable to the
populations of whites and blacks in the United States as a whole. By
replication of our study methodology every 5 years, we intend to study
the relation between temporal trends in stroke incidence rate and
outcome and advances in the treatment of stroke, the prevalence of
stroke risk factors within the population,24 and
the knowledge of stroke warning signs and stroke risk factors in the
population.24 Such data will be critical for
development of public health strategies and new clinical trials that
seek to further decrease the mortality and morbidity due to
stroke.
A. Cerebral infarction associated with a major cardiac source of
emboli
[Rochester criteria13 ] This category
includes myocardial infarction within 6 weeks of stroke onset; acute
congestive heart failure; mitral stenosis confirmed by clinical
examination, echocardiography, or autopsy;
artificial heart valve; atrial fibrillation or atrial flutter on
electrocardiography; thrombus in the atrium,
ventricle, or on the aortic or mitral valve identified by
echocardiography or coronary angiography;
left ventricular aneurysm identified by
echocardiography or coronary angiography;
sick sinus syndrome identified by monitoring of cardiac rhythm.
Patients with an akinetic or hypokinetic wall segment by echocardiogram
are also included.
B. Cerebral infarction associated with significant atherosclerotic
disease in an appropriate extracranial artery
This means
C. Cerebral infarction associated with significant intracranial
arterial disease
This is defined as occlusion or partial occlusion (>50%
diameter stenosis by angiogram or MR angiography) of the
intracranial carotid and vertebral arteries; the basilar artery; or the
middle, anterior, and posterior cerebral artery trunks. Distinction
between resolving embolism and primary disease of the intracranial
vessel will be made by the neuroradiologist.
D. Cerebral infarction in the distribution of a small artery or
arteriole
[Either condition a, b, or c is true] Condition a:
Brain images show a deep infarct of
E. Cerebral infarction associated with another identified cause of
stroke
F. Cerebral infarction of unclear cause
II. Intracerebral Hemorrhage:
III. Subarachnoid Hemorrhage:
IV. Stroke of Uncertain Type:
V. Transient Ischemic Attack:
Received September 8, 1997;
revision received October 28, 1997;
accepted November 4, 1997.
2.
Broderick JP, Phillips SJ, Whisnant JP, O'Fallon WM,
Bergstralh EJ. Incidence rates of stroke in the eighties: the end
of the decline in stroke? Stroke. 1989;20:577–582.
3.
Bonita R, Beaglehole R. The enigma of the decline in
stroke deaths in the United States: the search for an explanation.
Stroke. 1996;27:370–372.
4.
Broderick JP, Brott T, Kothari R, Miller R, Mills D,
Sauerbeck L, Khoury J, Minneci L. Establishing an epidemiologic
laboratory for stroke.
Neuroepidemiology. 1996;15:19.
5.
Broderick J, Brott T, Kothari R, Miller R, Mills D,
Minneci L, Khoury J. Incidence rates of stroke and stroke subtypes
among blacks. Stroke. 1997;28:266. Abstract.
6.
Brott TG, Labutta RJ, Kempczinski RF. Changing
patterns in the practice of carotid endarterectomy
in a large metropolitan area. JAMA. 1986;255:2609–2612.
7.
Brott T, Thalinger K. The practice of carotid
endarterectomy in a large metropolitan area.
Stroke. 1984;15:950–955.
8.
Broderick JP, Brott T, Tomsick T, Huster G, Miller R.
The risk of subarachnoid and intracerebral
hemorrhages in blacks as compared with whites. N
Engl J Med. 1992;326:733–736.[Abstract]
9.
Brott T, Thalinger K, Hertzberg V. Hypertension as a
risk factor for spontaneous intracerebral
hemorrhage. Stroke. 1986;17:1078–1083.
10.
Broderick JP, Talbot GT, Prenger E, Leach A, Brott T.
Stroke in children within a major metropolitan area: the surprising
importance of intracerebral hemorrhage. J
Child Neurol. 1993;8:250–255.
11.
Special report from the National Institute of
Neurological Disorders and Stroke. Classification of cerebrovascular
diseases III. Stroke. 1990;21:637–676.
12.
Sacco SE, Whisnant JP, Broderick JP, Phillips SJ,
O'Fallon WM. Epidemiological characteristics of lacunar infarcts in a
population. Stroke. 1991;22:1236–1241.
13.
Broderick JP, Phillips SJ, O'Fallon WM, Frye RL,
Whisnant JP. Relationship of cardiac disease to stroke occurrence,
recurrence, and mortality. Stroke. 1992;23:1250–1256.
14.
Keyfitz N. Sampling variance of standardized mortality
rates. Hum Biol. 1966;38:309–317.[Medline]
[Order article via Infotrieve]
15.
National Center for Health Statistics. Current
estimates for the National Health Interview Survey, Series 10, No 173.
Hyattsville, US Department of Health and Human Services;
1989.
16.
Burt VL, Whelton P, Roccella EJ, Brown C, Cutler JA,
Higgins M, Horan MJ, Labarthe D. Prevalence of hypertension in the US
adult population. Hypertension. 1995;25:305–313.
17.
Burt VL, Cutler JA, Higgins M, Horan MJ, Labarthe D,
Whelton P, Brown C, Roccella EJ. Trends in the prevalence, awareness,
treatment, and control of hypertension in the adult US population: data
from the Health Examination Surveys, 1960 to 1991.
Hypertension. 1995;26:60–69.
18.
Sacco RL, Kargman DE, Zamanillo MC. Race-ethnic
differences in stroke risk factors among hospitalized patients with
cerebral infarction: the Northern Manhattan Stroke Study.
Neurology. 1995;45:659–663.
19.
Rohr J, Kittner S, Feeser B, Hebel R, Whyte MG,
Weinstein A, Kanarak N, Buchholz D, Earley C, Johnson C, Macko R, Price
T, Sloan M, Stern B, Wityk R, Wozniak M, Sherwin R. Traditional risk
factors and ischemic stroke in young adults: the
Baltimore-Washington Cooperative Young Stroke Study. Arch
Neurol. 1996;53:603–607.
20.
Giles WH, Kittner SJ, Hebel JR, Losonczy KG, Sherwin
RW. Determinants of black-white differences in the risk of cerebral
infarction. Arch Intern Med. 1995;155:1319–1324.
21.
Jorgensen HS, Nakayama H, Raaschou HO, Gam J, Olsen TS.
Silent infarction in acute stroke patients: prevalence, localization,
risk factors, and clinical significance: The Copenhagen Stroke Study.
Stroke. 1994;25:97–104.[Abstract]
22.
Ricci S, Celani MG, La Rosa F, Righetti E, Duca E,
Caputo N. Silent brain infarction in patients with first-ever stroke: a
community-based study in Umbria, Italy. Stroke. 1993;24:647–651.
23.
American Heart Association. Heart and Stroke
Statistical Update. Dallas, Tex, AHA, 1997.
24.
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© 1998 American Heart Association, Inc.
Original Contributions
The Greater Cincinnati/Northern Kentucky Stroke Study
Preliminary First-Ever and Total Incidence Rates of Stroke Among Blacks
Abstract
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
Appendix 1
References
Background and Purpose—The Greater
Cincinnati/Northern Kentucky Stroke Study was designed to be the first
large, population-based metropolitan study of temporal trends in stroke
incidence rates and outcome within a biracial population.
Key Words: cerebral infarction • epidemiology • intracerebral hemorrhage • racial differences • subarachnoid hemorrhage
Introduction
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
Appendix 1
References
The population
of Rochester, Minn, has provided the only data addressing temporal
trends in the incidence rate of stroke in the United States over the
past 45 years.1 2 3 However, the small, affluent,
nearly all-white Rochester population contains only 1% blacks and is
not representative of the entire US population (Table 1
). Stroke mortality rates in Rochester
are lower than elsewhere in the United States, and the decline in
stroke mortality rates in Rochester before 1980 was more rapid than
that in the United States as a whole.3 Thus,
temporal trends in stroke incidence and mortality rates seen within the
nearly all-white and affluent Rochester population of 70 000 may not
reflect trends within the US population, particularly among the
minority populations of blacks, Hispanics, and Asians. Larger
population-based studies of temporal stroke trends are needed that
complement the Rochester database and include a substantial proportion
of blacks or other minority populations.
View this table:
[in a new window]
Table 1. Comparison of the Greater Cincinnati, Rochester
(Minn), and US Populations by 1990 US Census Tract Data 
). Previous community studies using this population
have included studies of carotid
endarterectomy,6 7
ICH,5 8 9 SAH,5 8 9 and
stroke in children.10 The present
population-based study includes all hospitalized and autopsied stroke
patients as well as a sample of all out-of-hospital strokes during 1993
to 1994.
Subjects and Methods
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
Appendix 1
References
Study Population
The study population is defined as all residents of the Greater
Cincinnati/Northern Kentucky region, which includes two southern Ohio
counties and three contiguous Northern Kentucky counties that abut the
Ohio River (Fig 1). Most persons in Ohio,
Kentucky, and southeastern Indiana who live in counties adjacent to the
defined study region also receive hospitalized medical care at the 19
study hospitals within the Greater Cincinnati/Northern Kentucky study
region. However, residents of these surrounding counties are not
included as cases. Past surveys of stroke admissions at the closest
hospitals outside of the study region demonstrated no patients with
ischemic or hemorrhagic stroke who were residents of our
defined five-county study region.8
View larger version (33K):
[in a new window]
Figure 1. Map of the five-county study region, with hospital
and out-of-hospital screening sites.
A study nurse reviewed the medical records of all persons
who were discharged from one of the 19 acute-care hospitals in the
study region (Fig 1) from 7/1/93 to 8/1/94 with an ICD-9-CM code
(primary or secondary discharge diagnoses) of 430 (SAH), 431 (ICH), 432
(other and unspecified intracranial hemorrhage), 433 (occlusion
and stenosis of precerebral arteries), 434 (occlusion of
cerebral arteries),435 (TIA), 436 (acute but ill-defined
cerebrovascular disease), 437 (other and ill-defined cerebrovascular
disease), 438 (late effects of cerebrovascular disease), 747.81
(anomalies of the cerebrovascular system), 674.0 (cerebrovascular
disorders in the puerperium), or 325 (phlebitis and thrombophlebitis of
intracranial venous sinuses). All primary and secondary discharge
diagnoses listed for a potential patient were used in the screening
process. The screening lists generated from hospital data systems
excluded most potential cases who resided at zip codes outside of the
study region. Because discharge diagnoses were used to screen for
potential cases, the additional 2 months of screening ensured inclusion
of stroke patients who had the onset of stroke within the study year
but who were discharged after the study year had ended. To ensure an
adequate number of cases of stroke among different age subgroups among
the black population, the study nurses also examined the medical
records of all black patients with the same ICD-9-CM discharge
diagnoses for the period 1/1/93–6/30/93. Thus, on completion of the
study, we will have screened for strokes among whites for 1 year and
among blacks for 11/2 years.
Because the labor and cost of identifying all out-of-hospital
strokes among 1.3 million people are prohibitive, we estimated the
number of nonhospitalized stroke cases by prospectively monitoring all
stroke or TIA-related diagnoses at the following health care settings:
(1) all Cincinnati and Northern Kentucky Public Health Clinics during
7/1/93–8/31/94 (90 000 visits; the Cincinnati Public Health Clinics
serve approximately 15% of the city of Cincinnati population,
including much of the indigent population); (2) all hospital-based
outpatient visits at the University of Cincinnati medicine and
neurology outpatient clinics (26 000 visits); (3) seven University of
Cincinnati affiliate family practice centers (101 000 outpatient
visits); (4) the neurology and general medicine clinics at the Veterans
Administration Medical Center (33 500 visits); (5) the general
medicine clinics at Good Samaritan Hospital (3900 visits), The Christ
Hospital (5750 visits), and Jewish Hospital (6400 visits); and (6) the
family medicine residents clinics at St Elizabeth Hospital (20 100
visits) and Bethesda Hospital (14 000 visits).
The study nurse wrote a short summary of the presenting
stroke symptoms and physical findings at the time of first medical
evaluation of the potential stroke. An NIH Stroke Scale score was
estimated by the study nurse from the physician examination. Detailed
information was abstracted from the medical record regarding
demographics, prior medical history, medications taken before stroke,
prehospital evaluation, emergency department evaluation, neurological
evaluation, admission vital signs and cardiac examination, neurological
evaluation, diagnostic tests, treatments, outcome, type of
insurance, and current address. (The address identified which census
tract to consult for population demographic information, eg, mean
education level and mean income.). All data were directly entered into
a laptop computer at the site of medical record review. The study
nurse recorded the source of the information and made a
determination of whether a stroke or TIA had occurred. The study nurses
were instructed to include all borderline cases and frequently review
difficult cases by telephone with a study physician.
To qualify as an incidence case, a person must have met criteria
for one of the five stroke/TIA subcategories listed in Appendix 1,
lived at a zip code within the five-county region at the time of stroke
onset, and had the onset of stroke between 1/1/93 and 6/30/94 for
blacks and between 7/1/93 and 6/30/94 for whites. The criteria that
define the various diagnostic categories of stroke,
including ischemic stroke subtypes, were adapted from the
Classification of Cerebrovascular Diseases III11
and from epidemiological studies of stroke in Rochester,
Minn.1 12 13 Strokes were classified as
first-ever or recurrent based on evidence of prior clinical stroke in
the written history and physical examination of the admitting
physician, emergency department physician, consulting neurologist, and
nurse. The date and type of each prior stroke or TIA were recorded,
and any neurological deficit that was present before the current
stroke or TIA was documented. Cases of first-ever stroke by history
whose imaging studies indicate an additional old "silent" cerebral
infarct were classified as a first-ever cerebral infarction for
incidence-rate calculations. Grounds for excluding potential cases of
stroke were the following: (1) the patient had no clinical history of
stroke, and the only evidence of stroke was a diagnosis on the death
certificate, an area of low density on a head CT scan, or an old lesion
in the brain at autopsy; (2) the patient had a clinical diagnosis of
stroke and died within 24 hours of the onset of symptoms but had no
focal neurological deficit, no autopsy, and no head CT scan. All
excluded cases and the reason for exclusion were recorded.
Recurrent strokes were classified as per the criteria for first stroke.
Cases that met criteria for cerebral infarction were sorted by the
operational categories listed in the Appendix. A patient could qualify
for one or several of the six categories of cerebral infarction (for
instance, a patient may have had a potential cardiac source of embolism
and 
50% stenosis of an appropriate extracranial carotid
artery). In cases that met criteria for more than one category, the
study physician made a final judgment about the most likely cause of
cerebral infarction.
The denominators for incidence-rate calculations were based on
linear extrapolations of county populations in race, sex, and age
subcategories for the years 1993 and 1988. The 1980 and 1990 US Census
population figures for each of the five counties by race, age, and sex
were used to calculate the linear function.
Results
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
Appendix 1
References
During 1/1/93–6/30/93, we reviewed records of 1003 black
patient encounters at the 19 regional hospitals and five coroners'
offices that were coded as potential strokes or TIAs. Of the 1003
encounters, 733 occurred in blacks who were residents of the study
region and had their event during 1/1/93–6/30/93. Of the 733
encounters, 332 blacks had 351 events that led to hospitalization or
autopsy and met the criteria for a stroke or TIA during the study
period after review of all clinical and imaging data by the study
physicians. Of the 332 subjects with a stroke or TIA, 213 had a
first-ever stroke (prior TIA allowed) and 27 a first-ever TIA. The
213 persons with a first-ever stroke had the following stroke subtypes:
cerebral infarction, 179 (84%);ICH, 21 (10%); SAH, 8 (4%);
intraventricular hemorrhage, 1 (0.5%); and
unspecified type, 4 (2%). Two additional subjects with a first-ever
cerebral infarction had a prior ICH, and 5 with a first-ever cerebral
infarction had a prior stroke of unknown type. These 7 subjects with a
prior stroke of unknown type or ICH are not included as first-ever
strokes, but the 2 cases with a prior ICH are included in the incidence
rates of first-ever cerebral infarction. Similarly, 6 of the 27
subjects with a first-ever ICH and 1 of the 9 subjects with a
first-ever SAH had a prior cerebral infarction and are not included as
first-ever strokes, but they are included in the incidence rates of
first-ever ICH or SAH. One patient had a recurrent ICH and is not
included in the incidence rate of first-ever stroke or first-ever
ICH. ).
View larger version (27K):
[in a new window]
Figure 2. Age-specific incidence rates of first-ever stroke
among blacks in Greater Cincinnati during the first 6 months of 1993
and among whites in Rochester, Minn, during 1985–1989. . If we use only primary and secondary
ICD-9-CM codes 430–436, we would detect 97% of all strokes and TIAs
and the true positive rate for stroke is 72±2%. Only 9 of 351 strokes
were identified by ICD-9-CM codes 437–438, but these codes
represented 39% of record reviews. Using only primary
discharge diagnoses of ICD-9-CM codes 430–436, increases the true
positive rate to 83±2%, but decreases the yield of cases of stroke
and TIA to 84%.
View this table:
[in a new window]
Table 2. Accuracy and Yield of ICD-9-CM Codes (Primary and
Secondary Discharge Codes)1
for All 337 Black Hospitalized and
Autopsied Subjects With Stroke or TIA During 1/1/93-6/30/93
Discussion
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
Appendix 1
References
The incidence rate of first-ever hospitalized or autopsied stroke
among blacks the Greater Cincinnati population during 1993 was 1.6
times greater than the overall age- and sex-adjusted incidence rate of
stroke among the white population of Rochester, Minn, during
1985–1989. These data indicate that studies of biracial populations
are critical for determining the true incidence rate and burden of
stroke in the United States population. In addition, the difference in
incidence rates between blacks and whites is an underestimate for two
reasons. First, outpatient strokes among blacks were not included in
the first 6 months of our ongoing study in Greater Cincinnati. Second,
the denominators used for calculations of the Rochester incidence rates
subtract the estimated prevalence of persons who already have had a
stroke. Because the prevalence of stroke in Rochester among the elderly
is appreciable (eg, approximately 10% in persons 85 years and
older),1 the incidence rates in the oldest age
groups are proportionally increased. Such prevalence estimates are not
yet available for the Greater Cincinnati population.
Selected Abbreviations and Acronyms
CI
=
confidence interval
ICD-9-CM
=
International Classification of Diseases, 9th Revision, Clinical
Modification
ICH
=
intracerebral hemorrhage
SAH
=
subarachnoid hemorrhage
TIA
=
transient ischemic attack
Appendix 1
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
Appendix 1
References
Criteria for Stroke and Stroke Subtypes
I. Cerebral Infarction:
A relatively rapid onset of focal neurological deficit with
signs or symptoms persisting longer than 24 hours and not attributable
to another disease process. Patients who 24 hours after the onset of
stroke have only persistent sensory symptoms with minimal sensory signs
or mild impairment of dexterity with normal muscle strength are
included. CT of the head need not show an appropriate focal area of
decreased attenuation, but will show an area of increased density only
in cases with a hemorrhagic transformation of a cerebral infarction.
Data from MRI are also reviewed and used if available. 50% stenosis of the internal carotid
artery by carotid ultrasound/duplex studies or 50% diameter
stenosis of the extracranial carotid, vertebral, or basilar
arteries by angiography in at least one plane. 
1.5 cm. in its maximal
diameter12 that is appropriate to a clinical
classical lacunar syndrome. Condition b: Brain images show
no lesion to explain the clinical syndrome, and the clinical
presentation is one (including the following) classically
associated with a small deep infarct. Pure motor hemiplegia:
Hemiparesis or hemiplegia involving the face, arm, and leg equally or
arm and leg equally, without other neurological findings. Although mild
sensory symptoms can be present, there is no sensory loss on
examination that is related to the infarct. Pure sensory
stroke: Isolated sensory loss or disturbance involving the
entire hemiface and hemibody or the hemibody alone. There may be
incidental motor weakness from another cause.
Ataxia-hemiparesis: Hemiparesis with ipsilateral ataxia.
Paresis is more commonly crural. Dysarthria–clumsy hand
syndrome: Dysarthria with a clumsy hand. Facial weakness is
possible. Hemiballismus, hemiathetosis, or hemidystonia:
Must be of acute onset. Sensorimotor stroke: Weakness and
sensory loss involving face, arm, and leg equally, without other
neurological findings. Condition c: CT scan shows a deep
infarct of <1.5 cm in its maximal diameter that is appropriate to the
clinical syndrome, but the syndrome is not one of the classical
syndromes for lacunar stroke.
Nontraumatic abrupt onset of severe headache, altered level of
consciousness, and/or focal neurological deficit that is associated
with a focal collection of blood within the brain parenchyma on CT or
at autopsy and is not due to trauma or hemorrhagic conversion of a
cerebral infarction. Cases of intraventricular
hemorrhage without ICH or SAH will be classified as ICH unless
angiogram demonstrates an aneurysm.
Nontraumatic abrupt onset of severe headache or altered level of
consciousness that is associated with blood in the subarachnoid
space on CT or at autopsy, or a clinical history and examination
consistent with SAH (sudden onset of severe headache or altered
level of consciousness), with xanthochromia and many red blood cells in
the cerebrospinal fluid. Cases that have both ICH and SAH are
classified as SAH if an aneurysmal source of bleeding is
documented or if the neuroradiologist suspects a subarachnoid
origin of the bleeding. Cases are classified as ICH if a parenchymal
source of bleeding seems most likely.
Relatively rapid onset of a major focal neurological deficit
that persists >24 hours or is fatal and cannot be attributed to
another cause. This category is used when radiographic or
pathological information is insufficient to distinguish among cerebral
infarction, ICH, and SAH.
Acute focal neurological signs and symptoms that last <24
hours. Patients with transient symptoms that are associated with an
appropriate lesion on CT scan or MRI will be noted but not included as
an incidence case of cerebral infarction.
Acknowledgments
This study was funded by NINDS grant R-01-NS30678–04.
References
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
Appendix 1
References
1.
Brown RD, Whisnant JP, Sicks JD, O'Fallon WM,
Wiebers DO. Stroke incidence, prevalence, and survival: secular trends
in Rochester, Minnesota, through 1989. Stroke. 1996;27:373–380.
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A. W. Wojner-Alexandrov, A. V. Alexandrov, D. Rodriguez, D. Persse, and J. C. Grotta Houston Paramedic and Emergency Stroke Treatment and Outcomes Study (HoPSTO) Stroke, July 1, 2005; 36(7): 1512 - 1518. [Abstract] [Full Text] [PDF]
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A. I. Qureshi, J. F. Kirmani, M. A. Sayed, A. Safdar, S. Ahmed, R. Ferguson, L. A. Hershey, K. J. Qazi, and for the Buffalo Metropolitan Area and Erie County Time to hospital arrival, use of thrombolytics, and in-hospital outcomes in ischemic stroke Neurology, June 28, 2005; 64(12): 2115 - 2120. [Abstract] [Full Text] [PDF]
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The Paul Coverdell Prototype Registries Writing Gr Acute Stroke Care in the US: Results from 4 Pilot Prototypes of the Paul Coverdell National Acute Stroke Registry Stroke, June 1, 2005; 36(6): 1232 - 1240. [Abstract] [Full Text] [PDF]
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M. L. Flaherty, D. Woo, M. Haverbusch, P. Sekar, J. Khoury, L. Sauerbeck, C. J. Moomaw, A. Schneider, B. Kissela, D. Kleindorfer, et al. Racial Variations in Location and Risk of Intracerebral Hemorrhage Stroke, May 1, 2005; 36(5): 934 - 937. [Abstract] [Full Text] [PDF]
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P. Spolaore, S. Brocco, U. Fedeli, C. Visentin, E. Schievano, F. Avossa, G. Milan, V. Toso, D. Vanuzzo, L. Pilotto, et al. Measuring Accuracy of Discharge Diagnoses for a Region-Wide Surveillance of Hospitalized Strokes Stroke, May 1, 2005; 36(5): 1031 - 1034. [Abstract] [Full Text] [PDF]
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D. Kleindorfer, P. Panagos, A. Pancioli, J. Khoury, B. Kissela, D. Woo, A. Schneider, K. Alwell, E. Jauch, R. Miller, et al. Incidence and Short-Term Prognosis of Transient Ischemic Attack in a Population-Based Study Stroke, April 1, 2005; 36(4): 720 - 723. [Abstract] [Full Text] [PDF]
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M. I. Chimowitz, M. J. Lynn, H. Howlett-Smith, B. J. Stern, V. S. Hertzberg, M. R. Frankel, S. R. Levine, S. Chaturvedi, S. E. Kasner, C. G. Benesch, et al. Comparison of Warfarin and Aspirin for Symptomatic Intracranial Arterial Stenosis N. Engl. J. Med., March 31, 2005; 352(13): 1305 - 1316. [Abstract] [Full Text] [PDF]
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E. M. Manno, J. L. D. Atkinson, J. R. Fulgham, and E. F. M. Wijdicks Emerging Medical and Surgical Management Strategies in the Evaluation and Treatment of Intracerebral Hemorrhage Mayo Clin. Proc., March 1, 2005; 80(3): 420 - 433. [Abstract] [PDF]
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B. M. Kissela, J. Khoury, D. Kleindorfer, D. Woo, A. Schneider, K. Alwell, R. Miller, I. Ewing, C. J. Moomaw, J. P. Szaflarski, et al. Epidemiology of Ischemic Stroke in Patients With Diabetes: The Greater Cincinnati/Northern Kentucky Stroke Study Diabetes Care, February 1, 2005; 28(2): 355 - 359. [Abstract] [Full Text] [PDF]
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J. P. Stansbury, H. Jia, L. S. Williams, W. B. Vogel, and P. W. Duncan Ethnic Disparities in Stroke: Epidemiology, Acute Care, and Postacute Outcomes Stroke, February 1, 2005; 36(2): 374 - 386. [Abstract] [Full Text] [PDF]
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 H. J. Fullerton, R. J. Adams, S. Zhao, and S. C. Johnston Declining stroke rates in Californian children with sickle cell disease Blood, July 15, 2004; 104(2): 336 - 339. [Abstract] [Full Text] [PDF]
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A. T. Schneider, B. Kissela, D. Woo, D. Kleindorfer, K. Alwell, R. Miller, J. Szaflarski, J. Gebel, J. Khoury, R. Shukla, et al. Ischemic Stroke Subtypes: A Population-Based Study of Incidence Rates Among Blacks and Whites Stroke, July 1, 2004; 35(7): 1552 - 1556. [Abstract] [Full Text] [PDF]
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H. J. Fullerton, J. S. Elkins, and S. C. Johnston Pediatric Stroke Belt: Geographic Variation in Stroke Mortality in US Children Stroke, July 1, 2004; 35(7): 1570 - 1573. [Abstract] [Full Text] [PDF]
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H. F. McGruder, A. M. Malarcher, T. L. Antoine, K. J. Greenlund, and J. B. Croft Racial and Ethnic Disparities in Cardiovascular Risk Factors Among Stroke Survivors: United States 1999 to 2001 Stroke, July 1, 2004; 35(7): 1557 - 1561. [Abstract] [Full Text] [PDF]
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D. O.C. Corbin, V. Poddar, A. Hennis, A. Gaskin, C. Rambarat, R. Wilks, C. D.A. Wolfe, and H. S. Fraser Incidence and Case Fatality Rates of First-Ever Stroke in a Black Caribbean Population: The Barbados Register of Strokes Stroke, June 1, 2004; 35(6): 1254 - 1258. [Abstract] [Full Text] [PDF]
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C. S. Ivan, S. Seshadri, A. Beiser, R. Au, C. S. Kase, M. Kelly-Hayes, and P. A. Wolf Dementia After Stroke: The Framingham Study Stroke, June 1, 2004; 35(6): 1264 - 1268. [Abstract] [Full Text] [PDF]
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T. Rundek, K. Nielsen, S. Phillips, K. C. Johnston, M. Hux, D. Watson, and for the GAIN Americas Investigators Health Care Resource Use After Acute Stroke in the Glycine Antagonist in Neuroprotection (GAIN) Americas Trial Stroke, June 1, 2004; 35(6): 1368 - 1374. [Abstract] [Full Text] [PDF]
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B. Kissela, A. Schneider, D. Kleindorfer, J. Khoury, R. Miller, K. Alwell, D. Woo, J. Szaflarski, J. Gebel, C. Moomaw, et al. Stroke in a Biracial Population: The Excess Burden of Stroke Among Blacks Stroke, February 1, 2004; 35(2): 426 - 431. [Abstract] [Full Text] [PDF]
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D. Kleindorfer, B. Kissela, A. Schneider, D. Woo, J. Khoury, R. Miller, K. Alwell, J. Gebel, J. Szaflarski, A. Pancioli, et al. Eligibility for Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke: A Population-Based Study Stroke, February 1, 2004; 35 (2): e27 - e29. [Abstract] [Full Text] [PDF]
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M. J. Alberts, D. L. Bergman, E. Molner, B. D. Jovanovic, I. Ushiwata, and J. Teruya Antiplatelet Effect of Aspirin in Patients With Cerebrovascular Disease Stroke, January 1, 2004; 35(1): 175 - 178. [Abstract] [Full Text] [PDF]
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J. P. Broderick William M. Feinberg Lecture: Stroke Therapy in the Year 2025: Burden, Breakthroughs, and Barriers to Progress Stroke, January 1, 2004; 35(1): 205 - 211. [Abstract] [Full Text] [PDF]
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 L. B. Morgenstern, L. K. Bartholomew, J. C. Grotta, L. Staub, M. King, and W. Chan Sustained Benefit of a Community and Professional Intervention to Increase Acute Stroke Therapy Arch Intern Med, October 13, 2003; 163(18): 2198 - 2202. [Abstract] [Full Text] [PDF]
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 S. L. Seliger, D. L. Gillen, D. Tirschwell, H. Wasse, B. R. Kestenbaum, and C. O. Stehman-Breen Risk Factors for Incident Stroke among Patients with End-Stage Renal Disease J. Am. Soc. Nephrol., October 1, 2003; 14(10): 2623 - 2631. [Abstract] [Full Text] [PDF]
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C. J. Winstein, J. P. Miller, S. Blanton, E. Taub, G. Uswatte, D. Morris, D. Nichols, and S. Wolf Methods for a Multisite Randomized Trial to Investigate the Effect of Constraint-Induced Movement Therapy in Improving Upper Extremity Function among Adults Recovering from a Cerebrovascular Stroke Neurorehabil Neural Repair, September 1, 2003; 17(3): 137 - 152. [Abstract] [PDF]
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A. Kirton, J. H. Wong, J. Mah, B. C. Ross, J. Kennedy, K. Bell, and M. D. Hill Successful Endovascular Therapy for Acute Basilar Thrombosis in an Adolescent Pediatrics, September 1, 2003; 112(3): e248 - 251. [Abstract] [Full Text] [PDF]
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H. J. Fullerton, Y. W. Wu, S. Zhao, and S. C. Johnston Risk of stroke in children: Ethnic and gender disparities Neurology, July 22, 2003; 61(2): 189 - 194. [Abstract] [Full Text] [PDF]
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S. Olindo, P. Cabre, R. Deschamps, C. Chatot-Henry, P. Rene-Corail, P. Fournerie, M. Saint-Vil, F. May, and D. Smadja Acute Stroke in the Very Elderly: Epidemiological Features, Stroke Subtypes, Management, and Outcome in Martinique, French West Indies Stroke, July 1, 2003; 34(7): 1593 - 1597. [Abstract] [Full Text] [PDF]
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P. B. Gorelick, D. Richardson, M. Kelly, S. Ruland, E. Hung, Y. Harris, S. Kittner, and S. Leurgans Aspirin and Ticlopidine for Prevention of Recurrent Stroke in Black Patients: A Randomized Trial JAMA, June 11, 2003; 289(22): 2947 - 2957. [Abstract] [Full Text] [PDF]
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R. L. Sacco Preventing Stroke Among Blacks: The Challenges Continue JAMA, June 11, 2003; 289(22): 3005 - 3007. [Full Text] [PDF]
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R. D. Horner, J. W. Swanson, H. B. Bosworth, and D. B. Matchar Effects of Race and Poverty on the Process and Outcome of Inpatient Rehabilitation Services Among Stroke Patients Stroke, April 1, 2003; 34(4): 1027 - 1031. [Abstract] [Full Text] [PDF]
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D. M. Bravata, S.-Y. Ho, L. M. Brass, J. Concato, J. Scinto, and T. P. Meehan Long-Term Mortality in Cerebrovascular Disease Stroke, March 1, 2003; 34(3): 699 - 704. [Abstract] [Full Text] [PDF]
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 J. Huffman and T. A. Stern Acute Psychiatric Manifestations of Stroke: A Clinical Case Conference Psychosomatics, February 1, 2003; 44(1): 65 - 75. [Full Text] [PDF]
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J. Bian, E.Z. Oddone, G.P. Samsa, J. Lipscomb, and D.B. Matchar Racial differences in survival post cerebral infarction among the elderly Neurology, January 28, 2003; 60(2): 285 - 290. [Abstract] [Full Text] [PDF]
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A. T. Schneider, A. M. Pancioli, J. C. Khoury, E. Rademacher, A. Tuchfarber, R. Miller, D. Woo, B. Kissela, and J. P. Broderick Trends in Community Knowledge of the Warning Signs and Risk Factors for Stroke JAMA, January 15, 2003; 289(3): 343 - 346. [Abstract] [Full Text] [PDF]
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B. Meier and J. E. Lock Contemporary Management of Patent Foramen Ovale Circulation, January 7, 2003; 107(1): 5 - 9. [Full Text] [PDF]
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 P. Piriyawat, M. Smajsova, M. A. Smith, S. Pallegar, A. Al-Wabil, N. M. Garcia, J. M. Risser, L. A. Moye, and L. B. Morgenstern Comparison of Active and Passive Surveillance for Cerebrovascular Disease: The Brain Attack Surveillance in Corpus Christi (BASIC) Project Am. J. Epidemiol., December 1, 2002; 156(11): 1062 - 1069. [Abstract] [Full Text] [PDF]
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A. I. Qureshi, M. F. K. Suri, Y. Mohammad, L. R. Guterman, and L. N. Hopkins Isolated and Borderline Isolated Systolic Hypertension Relative to Long-Term Risk and Type of Stroke: A 20-Year Follow-Up of the National Health and Nutrition Survey Stroke, December 1, 2002; 33(12): 2781 - 2788. [Abstract] [Full Text] [PDF]
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B. S. Jacobs, B. Boden-Albala, I-F. Lin, and R. L. Sacco Stroke in the Young in the Northern Manhattan Stroke Study Stroke, December 1, 2002; 33(12): 2789 - 2793. [Abstract] [Full Text] [PDF]
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E. Z. Oddone, R. D. Horner, D. C.C. Johnston, K. Stechuchak, L. McIntyre, A. Ward, L. G. Alley, J. Whittle, L. Kroupa, and J. Taylor Carotid Endarterectomy and Race: Do Clinical Indications and Patient Preferences Account for Differences? Stroke, December 1, 2002; 33(12): 2936 - 2943. [Abstract] [Full Text] [PDF]
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S. S. Rathore, A. R. Hinn, L. S. Cooper, H. A. Tyroler, and W. D. Rosamond Characterization of Incident Stroke Signs and Symptoms: Findings From the Atherosclerosis Risk in Communities Study Stroke, November 1, 2002; 33(11): 2718 - 2721. [Abstract] [Full Text] [PDF]
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 J. S. Elkins, S. Sidney, D. R. Gress, A. S. Go, A. L. Bernstein, and S. C. Johnston Electrocardiographic Findings Predict Short-term Cardiac Morbidity After Transient Ischemic Attack Arch Neurol, September 1, 2002; 59(9): 1437 - 1441. [Abstract] [Full Text] [PDF]
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H.J. Fullerton, D.M. Chetkovich, Y.W. Wu, W.S. Smith, and S.C. Johnston Deaths from stroke in US children, 1979 to 1998 Neurology, July 9, 2002; 59(1): 34 - 39. [Abstract] [Full Text] [PDF]
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 C. J. Rodriguez, R. L. Sacco, R. R. Sciacca, B. Boden-Albala, S. Homma, and M. R. Di Tullio Physical activity attenuates the effect of increased left ventricular mass on the risk of ischemic stroke: The Northern Manhattan Stroke Study J. Am. Coll. Cardiol., May 1, 2002; 39(9): 1482 - 1488. [Abstract] [Full Text] [PDF]
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S. Ruland, P. B. Gorelick, M. Schneck, D. Kim, C. G. Moore, S. Leurgans, and A. Bhardwaj Acute Stroke Care in Illinois: A Statewide Assessment of Diagnostic and Treatment Capabilities * Editorial Comment: A Statewide Assessment of Diagnostic and Treatment Capabilities Stroke, May 1, 2002; 33(5): 1334 - 1340. [Abstract] [Full Text] [PDF]
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 K. Stavem and O.M. Ronning Survival of unselected stroke patients in a stroke unit compared with conventional care QJM, March 1, 2002; 95(3): 143 - 152. [Abstract] [Full Text] [PDF]
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 C D A Wolfe, A G Rudd, R Howard, C Coshall, J Stewart, E Lawrence, C Hajat, and T Hillen Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London Stroke Register J. Neurol. Neurosurg. Psychiatry, February 1, 2002; 72(2): 211 - 216. [Abstract] [Full Text] [PDF]
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