(Stroke. 1999;30:363-370.)
© 1999 American Heart Association, Inc.
Original Contributions |
Stroke Incidence and Case Fatality in Southern Greece
The Arcadia Stroke Registry
From the Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra Hospital, Athens, Greece (K.N.V., G.S.S., S.S.); Julius Center for Patient Oriented Research, University Medical Center Utrecht, Utrecht, Netherlands (M.L.B., D.E.G.); Department of Medicine, General Arcadia Hospital Evaggelistria, Tripoli, Greece (P.K.T.); and Department of Neurology, University of Athens School of Medicine, Aiginition Hospital, Athens, Greece (V.P.Z.).
Correspondence to Kostas N. Vemmos, MD, Acute Stroke Unit, Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra Hospital, 80 Vasilissis Sofias and Lourou Str, 11528, Athens, Greece. E-mail vemmosk{at}ath.forthnet.gr
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionAppendix 1Appendix 2References |
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Background and Purpose—For Greece, information on incidence of stroke and distribution of type of stroke has not been reported. We determined the incidence of first-ever stroke in men and women, the incidence of stroke by type, and the associated case fatality.
Methods—A population-based registry was established in the Arcadia province, located in eastern central Peloponessos, in the southern part of Greece. Between November 1, 1993, and October 31, 1995, all subjects with a first-ever stroke were identified. For case ascertainment, information from death certificates, hospital records, public health centers, and general practitioners was used.
Results—During a 24-month period, 555 subjects with a first-ever
stroke were registered. The incidence rates (per 100 000) by age group
(18 to 34, 35 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84, 
85
years) for men were 5, 31, 113, 240, 662, 1275, and 3218, respectively.
For women, the rates were 11, 18, 48, 196, 478, 1166, and 2137,
respectively. Age- and sex-standardized to the European
population, the annual incidence rate for subjects aged 45 to 84 years
was 319.4/100 000 (95% CI, 283 to 356). In men, cerebral infarction
was diagnosed in 81% of cases, intracerebral
hemorrhage in 16%, and subarachnoid hemorrhage
in 2%. For women, these figures were 85%, 12%, and 3%,
respectively. The 28-day case fatality rate was 26.6% (95% CI, 22.9%
to 30.2%), with no differences between men and women. Case-fatality
increased with age and was higher for intracerebral
hemorrhage than for cerebral infarction.
Conclusions—The incidence of stroke in our population-based study ranks low part compared with other European studies. The distribution of stroke types and case fatality rate appear to be similar to those of other industrialized countries.
Key Words: incidence • fatal outcome • Greece • mortality
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1Appendix 2References |
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Stroke is the third leading cause of death and a major cause of long-term disability in most developed countries.1 Stroke mortality has declined during the last decades in the United States and in most Western and Northern European countries.2 3 In contrast, in Eastern Europe stroke mortality has remained stable or even increased during this period.2 These secular trends point toward a great potential for prevention of stroke through beneficial changes in risk factors and case fatality. For a Mediterranean country like Greece, prospective population studies on stroke incidence and case fatality rates have not been performed, and thus one must rely on national mortality statistics.4 On the basis of these statistics, stroke mortality rates in Greece are higher than those of other industrialized European countries. Whether this reflects the true situation and, if so, whether this is due to differences in incidence, case fatality, or both is unknown.
The purpose of our study was to determine the incidence and case fatality of first-ever stroke in a defined population of southern Greece, with a typical Mediterranean lifestyle, from data gathered from the first prospective community-based stroke registry in Greece.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1Appendix 2References |
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Study Base and Population
A population-based registry was established in the Arcadia province, 1 of 51 prefectures located in eastern central Peloponessos, in the southern part of Greece. The permanent resident population in 1991 aged
20 years consisted of 41 864 men and 38 910 women, for a
total of 80 774 inhabitants. The estimated population of Arcadia
decreased 1.32% for the years 1994–1995 compared with the 1991
census. The capital city of Tripoli (22 463 inhabitants) is located in
the center of the province, and the remotest village is 120 km from
Tripoli. Twenty-two percent of the population live in urban areas, 11%
in suburban areas, and 67% in rural areas. Since the establishment of
the National Health System in 1983, the medical care in this area is
provided by 51 general practitioners (GPs) who serve the
rural areas, by 27 private family physicians, by 5 health centers, and
by the local General Arcadia Hospital (GAH). Generally subjects
register with a GP or at 1 of the 5 Health Centers. In urban
communities, private family physicians collaborated in the study. The
GAH, located in Tripoli, served as a referral hospital for stroke
patients. Inhabitants can contact their physicians free of charge.
All patients with first-ever stroke that occurred from November 1,
1993, to October 31, 1995, and who were residents in the study area
were registered. Subjects aged 
18 years, those with a recurrent
stroke, and those with a transient ischemic attack (TIA) were
not included in the registry.
Case Ascertainment
We requested that all collaborating physicians (GPs, internists,
cardiologists, neurologists) notify us of patients suspected to have
cerebrovascular disease. This was accomplished by letter, lectures, and
personal contact. Subjects were enrolled in the study in one of the
following ways: (1) medical records for hospitalized subjects;
(2) notifications from GPs and private family physicians; (3)
medical records from health centers; and (4) death
certificates.
If someone experienced a possible stroke, the patient was promptly examined by the local GP and transported by ambulance to the nearest health center. Most patients would then be transferred to GAH. Hospitalized patients were examined soon after admission by one of the authors (P.K.T.) and were monitored frequently until discharge. CT scans were made as soon as possible but primarily during the first week after stroke onset. All CT scans were reviewed in a blinded manner by a neuroradiologist and the principal investigator (K.N.V.). On a monthly basis, the health centers were visited by one of the investigators, and information was obtained from the medical records for patients with stroke or suspected stroke who were not transferred to GAH. In addition, GPs and private family practitioners were contacted every month by telephone to ask about patients with suspected stroke. In the case of patients with suspected stroke who were not hospitalized at GAH, one of the investigators contacted the family and examined the patient at home.
Certificates of death were used only in a few cases. Subjects were registered only if death was preceded by a clinical stroke according to the study definition. We used the medical records for those patients who had been hospitalized. In the remaining cases we used information from the attending physician or relatives when applicable. For both nonhospitalized and hospitalized patients, detailed information was collected on signs and symptoms, neuroimaging, and other additional examinations.
We used the World Health Organization (WHO) definition of stroke as a rapid onset of clinical signs of a local or global disturbance of cerebral function, lasting >24 hours or leading to death, with no apparent nonvascular cause.5 Stroke events were classified into subtypes of stroke with the use of international criteria (Appendix 1).6 7 8 Subjects without CT scan were classified on the basis of the most likely clinical diagnosis according to the Guy's Hospital Stroke Diagnostic Score (GHSDS).8 9 Case fatality was defined as death from stroke at 28 days after stroke onset.
Data Collection and Follow-Up
Medical history was obtained, and the presence of risk factors
such as arterial hypertension, diabetes mellitus, smoking,
TIAs, hypercholesterolemia, coronary
and valvular heart disease, and atrial fibrillation were
screened (Appendix 2). Information on stroke characteristics was
obtained, including signs and symptoms, time of onset, delay of
admission, and temporal profile. Neuroimaging was performed when
possible. Additional examinations comprised chest
radiography, standard ECG, Doppler examination of
the carotid arteries, transthoracic
echocardiography, and routine laboratory tests. For
each stroke case, a Glasgow Coma Score was obtained in hospitalized
patients by one of the authors (P.K.T.) on the day of admission. For
those not hospitalized, we used information from notifications of the
health centers and attending physicians. For each stroke patient, a
modified Rankin Scale was applied at discharge from the hospital and at
the final follow-up in July 1996.10 Handicap for
nonhospitalized patients was obtained by questionnaire from attending
physicians or by examination of the patient at home by one of us.
Data Analysis
The incidence of stroke is expressed as the number of first-ever
strokes per 100 000 person-years by age and sex with corresponding
95% CI. To compare our stroke incidence with that observed in other
studies, we standardized our incidence data for groups aged 45 to 84
years according to the Segi's European population, as described
earlier.11 12 Since our estimates of case fatality rate
are based on very small numbers and therefore lack precision, a formal
standardization was not performed.
We applied the 4 key criteria of data quality that were proposed by the Monitoring Trends and Determinants in Cardiovascular Disease (MONICA) project13 : (1) the ratio of the number of stroke deaths to number of stroke deaths according to the mortality statistics for Greece in 1990 <0.75 is indicative of underreporting of stroke deaths; (2) the number of fatal cases outside the hospital relative to all stroke deaths <10% is indicative of underreporting of outside hospital stroke deaths; (3) 28-day case fatality should not be extremely high, otherwise underreporting of nonfatal cases is likely; and (4) a very low proportion of surviving stroke patients cared for outside the hospital reflects a less optimal case ascertainment.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1Appendix 2References |
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The distribution of the study population compared with Greece at the 1991 census is presented in the Figure
. Twenty-one percent of the Arcadia
population is aged >65 years compared with 14% of the entire country.
From November 1, 1993, to October 31, 1995, a total of 555 first-ever
strokes were registered during a follow-up period of 165 548
person-years. More than 90% of the subjects were hospitalized (n=513),
6.5% of registrations came from health centers (n=36), and 1.1% came
from death certificates (n=6). First contact with the patients
was by GPs and health centers in 387 (70%), emergency service of the
referral hospital in 84 (15%), and private family physicians in 78
(14%). In a few cases (n=5), patients were transferred directly to
hospitals out of the study area. Thirty-seven patients who were
initially registered as stroke patients at the health centers were
later excluded after admission to the hospital when clinical
reevaluation and laboratory investigations were available. Discharge
diagnosis for these cases were subdural hematoma in 10, tumor in 9,
meningitis in 4, dementia in 5, migraine in 4, multiple sclerosis in 2,
and peripheral neuropathy in 3. In addition, 15
cases with suspected stroke that were not hospitalized were excluded
because they did not fulfill the study criteria. There were 309 men
(56%) and 246 women (44%). The mean±SD age was 75±11.9 years for
men and 76±11.2 years for women. For hospitalized patients, 43% of
the stroke patients arrived within the first 3 hours after onset of
symptoms, and 64% arrived within 6 hours.
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CT scans were available for 454 (81.8%) of the cases, with a median delay of 7 days from stroke onset. In the remainder of the patients, type of stroke was assessed with the GHSDS. In these subjects, CT scan was not performed because 21 died very early, 29 were very old or received only home care, 30 refused, and in 15 there was equipment breakdown. One hundred fourteen patients died during hospitalization (20.5%), and 30 patients transferred to tertiary hospitals in Athens. For patients who died very early and in whom CT scan was not performed, autopsy records were checked, although autopsy is performed very rarely in Greece. Among the 441 survivors, only 12 patients were transferred to long-stay institutions (4 in rest homes and 8 in nursing homes), while the majority of the patients returned to their home or to a relative's home.
Among patients with ischemic strokes for whom CT scan was
available, the most frequent stroke subtype was cardioembolic stroke
(22.7%), followed by infarction of unknown cause (18.7%), stroke due
to large-vessel atherosclerosis (13.5%), and lacunar
stroke (12.6%) (Table 1). Overall, in
men cerebral infarction was diagnosed in 81% of cases,
intracerebral hemorrhage in 16%, and
subarachnoid hemorrhage in 2%. For women, these
figures were 85%, 12%, and 3%, respectively. In 17 subjects (3.1%),
a distinction of stroke type could not be made with the available
information. Stroke risk factors were hypertension in 81.1% of the
subjects, current smoking in 19.9%, diabetes mellitus in 29.2%,
coronary heart diseases in 20.2%, atrial fibrillation in
34.1%, and TIAs in 16.6%.
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Stroke incidence increased with age from 7.28 per 100 000 person-years
in subjects aged 18 to 34 years to 2661.1 per 100 000 person-years in
subjects aged 85 years (Table 2).
Stroke rates were generally lower in women than in men. The
age-standardized incidence rate for subjects aged 45 to 84 years was
319.4 (95% CI, 283 to 356) per 100 000 person-years (362.4 for men
and 276.1 for women). The incidence of cerebral infarction and
intracerebral hemorrhage increased with age in
men and women (Table 3). Again,
stroke-specific rates were lower in women than in men. The number of
cases with a subarachnoid hemorrhage was too small to
provide reliable age- and sex-specific incidence rates.
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The overall 28-day case fatality rate was 26.6% (95% CI, 22.9% to
30.2%), which increased with age. No differences were noted in case
fatality between men and women (Table 4).
The case fatality rate was generally higher for hemorrhagic stroke than
for cerebral infarction. After 1 year, 35.9% of the men and 41.8% of
the women had died, bud the difference was not statistically
significant.
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Application of the 4 data quality criteria proposed by the WHO MONICA investigators13 showed that for this registry the ratios of 28-day mortality to number of stroke deaths according to mortality statistics for Greece in 1990 28-days mortality/routine statistics were 0.64 for men and 0.41 for women, whereas the ratios of 1-year mortality to mortality statistics for Greece one -year mortality/routine statistics were 0.87 and 0.63, respectively. The 28-day proportion of deaths outside the hospital to all stroke deaths was 4.1%. In the present registry, the 28-day proportion of fatal in-hospital deaths to all events was 24.3%, and the proportion of fatal out-of-hospital deaths to all events was 1.1%. For nonfatal strokes, these proportions were 68.1% and 5.1%, respectively.
In a substudy we analyzed the data from the National Routine Mortality Statistics (NRMS) for the capital city of Tripoli from November 1, 1993, to October 31, 1995, and compared them with the findings from the Arcadia Stroke Registry. Of the 95 cases that were coded by the NRMS as having died of a stroke, 46 subjects died of a first stroke, 19 subjects died of a recurrent stroke, and 14 subjects died of the sequelae of a stroke that occurred >4 weeks later. Three subjects had died and were diagnosed as having a subdural hematoma. For 10 subjects who died, the relatives from these elderly subjects had no recall of death due to stroke but merely indicated that the subjects had dementia, died of "natural causes," or died because of a high fever. Three deaths were found to be due to true stroke and were included in the registry. Thus, of 95 deaths due to stroke, according to the NRMS, only 49 (52%) could be confirmed as being first stroke.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1Appendix 2References |
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The present study is the first population-based study that provides data for Greece on incidence of stroke, case fatality rate from stroke, and incidence and case fatality rates for cerebral infarction and intracerebral hemorrhage.
Population-based registries on stroke incidence involve a number of problems, the most important being completeness of case ascertainment, particularly in areas in which a considerable proportion of stroke patients may not be diagnosed and treated in the hospital. The WHO MONICA project has proposed a number of data quality indicators.13 A somewhat low proportion of nonfatal out-of-hospital events in the present study (5.1%) has been taken in the MONICA project as a possible indication of an underreporting of nonfatal strokes and may point toward a less optimal case ascertainment. Similar to the MONICA project, in the present study the utmost effort was made to have all possible stroke patients registered through regular personal contact with the physicians involved. A considerable number of patients suspected of stroke had neuroimaging studies performed, and in contrast to the MONICA project, the diagnosis was based on these findings. We thereby excluded 37 patients (6.2%) from the registry when neuroimaging and other laboratory tests were available. Although medical care is provided free of charge and our policy is that all stroke patients should be hospitalized, we cannot exclude the possibility that some very elderly people who lived in rural areas did not consult their physician. Similarly, mild cases may be missed because of cross-boundary medical care. In addition, the Arcadia population is mostly rural and older compared with the whole of Greece, and this may reflect a small limitation of our study.
A low ratio of 28-day mortality to routine statistics of stroke mortality, as observed in the present study, has been taken as an indicator of underreporting of stroke deaths.13 A number of factors may additionally have contributed to the low ratio in the present study. The present study is restricted to first-ever stroke, which may result in a lower ratio compared with routine stroke mortality statistics. Furthermore, a 28-day limit for the assessment of stroke mortality may influence the ratio, since a considerable proportion of the stroke patients may die beyond that limit. When deaths up to 1 year were used in the present study, the ratio increased to a more acceptable level, ie, 0.87 for men and 0.63 for women. More importantly, it is well known that the quality of routine mortality statistics for stroke shows considerable differences across countries.13 14 Approximately 45% of cases with stroke as the underlying cause of death did not meet the WHO criteria, according to a study from Auckland.15 Similar to our substudy, only 52% of stroke deaths in the Tripoli area could be confirmed as first-ever stroke. This finding results in doubling of the ratios that are then well in line with the MONICA criteria. It therefore seems that the low ratio can be largely explained by the misclassification of stroke diagnosis as cause of death in routine mortality statistics. Thus, an underreporting of stroke deaths in our registry is unlikely.
Comparison of our results on stroke incidence with those from other population-based studies is hampered by differences across studies in methods for case ascertainment, in stroke definition and classification, and in presentation of the data in terms of age- and sex-specific or standardized results of stroke incidence.13 16 For men aged 45 to 84 years, the observed age-standardized incidence rate for stroke in the present study of 362.4 per 100 000 ranks in the lower portion, while the respective 276.1 incidence rate for women ranks in the middle portion. The overall standardized incidence rate (319.4/100 000) in both sexes for the same age group is similar to that reported from Auckland17 and notably lower than that of other studies throughout Europe and other parts of the world.12
Moreover, when standardized incidence rates are compared by
pathological type for subjects aged 45 to 84 years with estimates
available from other studies, rates for intracerebral
hemorrhage (51/100 000) and subarachnoid
hemorrhage (11/100 000) are almost similar to those from
Umbria (Italy),18 Perth (Australia),19
Rochester (Minn),20 Oxfordshire (UK),8 Aosta
(Italy),21 Frederiksberg (Denmark),22 and
Söderhamm (Sweden)12 (Table 5). Therefore, the standardized rate of
cerebral infarction (249/100 000) ranks in the lower portion among
studies reported from the International Stroke Incidence
Collaboration.12 The fact that the incidence rate
for cerebral infarction was low explains the low overall stroke
incidence rate, since cerebral infarction is the most frequent subtype
(81%). This may reflect a true low incidence rate or may be due to
underreporting of cases, as previously discussed. The population of
Arcadia is mostly rural and consumes high rates of products such as
olive oil, fruits, vegetables, and other fiber-containing foods, ie,
the so-called Mediterranean diet.24 It is well known that
populations with a high intake of such products have low
coronary heart and peripheral atherosclerotic
disease.25 26 In addition, it is likely that this diet
prevents secondary complications after myocardial infarction, including
stroke.27 28 It may be speculated that the high intake of
antioxidants in our population may explain in part the low incidence of
cerebral infarction that is associated with
atherosclerosis, while hypertensive
intracerebral hemorrhage has a higher
incidence.
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Studies on incidence of stroke in which type of stroke has been
evaluated are more limited, and comparison between studies is even more
troublesome. Apart from case ascertainment differences, most studies
differ in terms of methods by which the type of stroke was assessed,
based on either a CT scan, a validated clinical score, or a combination
of both.16 The distribution of stroke types observed in
the present study is comparable to those from other studies in
which cerebral infarction was diagnosed in 72% to 86% of the strokes,
intracerebral hemorrhage in 8% to 15%, and
subarachnoid hemorrhage in 1% to 5%.12
Our study is probably the first population-based study in which
ischemic strokes are subclassified on the basis of the most
likely stroke mechanism. Even though a great majority of our patients
were hospitalized, we still encountered considerable difficulty in
defining stroke mechanism, as illustrated by the fact that almost one
third of patients had a stroke due to unknown cause (Table 1
).
In terms of ischemic stroke subtypes, cardioembolic stroke was
the most frequently observed in 23% of patients in whom CT scan was
available. This was probably due to the high prevalence of atrial
fibrillation in our stroke population (34%), and it may suggest
insufficient primary prevention or an actual increase in the prevalence
of that major risk factor.29 30
The age- and sex-specific case fatality rate for subjects aged 35 to 64
years (15.1% for men and 14.3% for women) ranks among the lowest
compared with studies from the MONICA project.3 31
However, studies in the MONICA project have included an average of
20% of recurrent strokes, resulting in a higher case fatality
rate.31 Although specific case fatality rates for subjects
aged 35 to 64 years are low, the overall case fatality rate in Arcadia
(26.6%; 95% CI, 22.9% to 30.2%) was similar to that in the
L'Aquila study32 (25.64%; 95% CI, 22.8% to 28.7%),
Auckland and Perth33 (23%; 95% CI, 18% to 28%), and
Novosibirsk34 (22.7%; 95% CI, 17.7% to 27.7%) but
lower than that from Tartu35 (30.2%; 95% CI, 26.6% to
34.1%) and higher than that reported from Oxfordshire8
(19%; 95% CI, 16% to 22%) and Umbria18 (20.3%; 95%
CI, 16.2% to 24.3%). The overall case fatality at 28 days for men was
similar to that for women, while the case fatality rate in women who
suffered from hemorrhagic stroke was higher than in men. As expected,
the fatality rate in patients with intracerebral
hemorrhage (46.7%) was higher than that found in patients with
cerebral infarction (20.4%). Since our estimates of case fatality by
pathological type are based on a small number of events (Table 5) and thus have little precision, a firm statement regarding
the ranking of these results compared with other European countries
cannot be made.
In conclusion, the findings from our population-based registry indicate that the incidence rates of stroke in general in Greece and the rates of cerebral infarction are lower than those of other industrialized European countries. Moreover, the overall case fatality rate appears to be similar to those reported by other studies.
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Acknowledgments |
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We thank Drs Constantinos Takis and Kostis Georgilis for valuable help in the preparation of the manuscript.
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Appendix 1 |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1Appendix 2References |
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Criteria Used for Diagnosis of Subtype of Stroke
1. Atherothrombotic Stroke
Noninvasive ultrasound in the neck is required to demonstrate occlusion or >50% linear stenosis and/or ulceration in the large-vessel supply ipsilateral to the infarct. CT scan shows low-density changes between the major cerebral arteries or in superficial fields. Clinical features include prior TIAs in the same territory, history of atherosclerotic disease, stepwise or sudden onset, cervical bruit, and absence of major source of cardioembolism. When noninvasive ultrasound or angiographic study of the neck arteries was not available in the first month after the onset of the event, classification was based on the most likely clinical choice.
2. Cardioembolic Stroke
Presence of a cardiac source of embolism with high-risk criteria
is required: atrial fibrillation, atrial flutter or sick sinus syndrome
with or without valvular heart disease, prosthetic
valves, anterior wall myocardial infarction within the prior 6 weeks,
aneurysm or akinetic region of left ventricular
wall, left mural thrombus, idiopathic dilated
cardiomyopathy, bacterial endocarditis, and
myxomatous mitral valve prolapse in young patients. Noninvasive
ultrasound in the neck demonstrates no significant stenosis,
<50% linear stenosis in the large-vessel supply ipsilateral
to the infarct. CT scan shows infarction in the territory of a single
cerebral artery or in combination with infarctions in multiple branches
of other divisions of the major cerebral arteries, with or without
features of hemorrhagic infarction. Clinical features include
sudden and maximal neurological deficit at onset, absence of prior
TIAs, and initial decreased consciousness.
3. Lacunar Stroke
Noninvasive ultrasound in the neck demonstrates no significant
stenosis, <50% linear stenosis in the large-vessel
supply ipsilateral to the infarct. CT scan shows small infarction <1.5
cm in the distribution of a deep penetrating artery appropriate for
clinical symptoms. Clinical features include history of hypertension
and/or diabetes mellitus and clinical presentation
consistent with one of the recognized lacunar syndromes
(pure motor hemiparesis, pure sensory stroke, pure sensorimotor
stroke, ataxic hemiparesis, dysarthria–clumsy hand
syndrome).
4. Infarction of Unknown Cause
In this subgroup we included (1) patients with 2 possible
etiologies, (2) patients with infarction on CT scan but inadequate
evaluation, and (3) patients with possible infarction according to
GHSDS. In the last subgroup were included hospitalized patients in whom
no CT scan was performed and patients from GPs, health centers, and
private family physicians, with clinical information sufficient to
derive a GHSDS <4 (90% probability of infarction).
5. Intracerebral Hemorrhage
CT scan shows hyperdense lesions on early CT scans in 1 of 5
territories: lobar, lenticulocapsular, thalamic, cerebellar, and brain
stem. Clinical features include gradual onset over minutes or days or
sudden onset of neurological signs, hypertension, bleeding diathesis,
absence of TIAs. For possible intracerebral
hemorrhage, CT scan is not available, but GHSDS is >25 (90%
probability of intracerebral hemorrhage).
6. Subarachnoid Hemorrhage
CT scan shows focal or generalized blood in subarachnoid
space. Cerebrospinal fluid is bloody. Clinical features include sudden
onset of headache, usually accompanied by vomiting and syncope, with
later recovery of consciousness. For possible subarachnoid
hemorrhage, CT scan is not available but lumbar puncture is
positive for blood in cerebrospinal fluid with
2x106/mL red blood cells or a xanthochromic
color in the centrifuged supernatant.
7. Uncertain Pathological Type
CT is scan not available. GHSDS is between 4 and 25, not
sufficient for diagnosis of infarction or hemorrhage. Cases are
from death certifications.
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Appendix 2 |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionAppendix 1Appendix 2References |
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Definition of Risk Factors
A history of hypertension was defined as systolic blood pressure >160 mm Hg or diastolic blood pressure >90 mm Hg or both, diagnosed at least twice before the stroke or treatment of hypertension had been implemented. Current smoking was considered present when a subject smoked daily previous to the stroke and was considered absent when the subject had never smoked or stopped smoking for
1 year preceding the stroke event. Presence of
diabetes mellitus was defined as use of a blood glucose–lowering
drug before the occurrence of the stroke or if the fasting blood
glucose level was >120 mg/dL. A history of a TIA was defined when a
subject had a TIA diagnosed by a neurologist as a temporary, focal
neurological deficit presumably related to ischemia and lasting
<24 hours. History of coronary heart disease (myocardial
infarction, angina pectoris, congestive heart failure) was assessed by
questionnaire without medical confirmation if it was diagnosed by a
cardiologist and the patient had received relevant therapy. Atrial
fibrillation was diagnosed by ECG for hospitalized patients; for those
not hospitalized, 1 ECG with documentation of atrial fibrillation in
the last year before the event was required. Received June 23, 1998; revision received November 7, 1998; accepted November 9, 1998.
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