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(Stroke. 2000;31:1054.)
© 2000 American Heart Association, Inc.

Original Contributions

A Multinational Comparison of Subarachnoid Hemorrhage Epidemiology in the WHO MONICA Stroke Study

Timothy Ingall, MD; Kjell Asplund, MD; Markku Mähönen, MD; Ruth Bonita, PhD for the WHO MONICA Project

From the Department of Neurology, Mayo Clinic, Scottsdale, Ariz (T.I.); Department of Medicine, University Hospital, Umea, Sweden (K.A.); National Public Health Institute, Helsinki, Finland (M.M.); and WHO, Geneva, Switzerland (R.B.).

Correspondence and reprint requests to Prof Kjell Asplund, Department of Medicine, University Hospital, SE-9012 95 Umea, Sweden. E-mail Kjell.Asplund{at}medicin.umu.se

Background and Purpose—By official, mostly unvalidated statistics, mortality from subarachnoid hemorrhage (SAH) show large variations between countries. Using uniform criteria for case ascertainment and diagnosis, a multinational comparison of attack rates and case fatality rates of SAH has been performed within the framework of the WHO MONICA Project.

Methods—In 25- to 64-year-old men and women, a total of 3368 SAH events were recorded during 35.9 million person-years of observation in 11 populations in Europe and China. Strict MONICA criteria were used for case ascertainment and diagnosis of stroke subtype. Case fatality was based on follow-up at 28 days after onset.

Results—Age-adjusted average annual SAH attack rates varied 10-fold among the 11 populations studied, from 2.0 (95% CI 1.6 to 2.4) per 100 000 population per year in China-Beijing to 22.5 (95% CI 20.9 to 24.1) per 100 000 population per year in Finland. No consistent pattern was observed in the sex ratio of attack rates in the different populations. The overall 28-day case fatality rate was 42%, with 2-fold differences in age-adjusted rates between populations but little difference between men and women. Case fatality rates were consistently higher in Eastern than in Western Europe.

Conclusions—Using a uniform methodology, the WHO MONICA Project has shown very large variations in attack rates of SAH across 11 populations in Europe and China. The generally accepted view that women have a higher risk of SAH than men does not apply to all populations. Marked differences in outcome of SAH add to the wide gap in the burden of stroke between East and West Europe.

Key Words: epidemiology • incidence • mortality • subarachnoid hemorrhage • World Health Organization

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				Bibliography Scand J Public Health, November 1, 2003; 31(61_suppl): 85 - 91. [PDF]

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