Global stroke statistics

Global stroke statistics

Amanda G. Thrift1,2*, Dominique A. Cadilhac1,2,3, Tharshanah Thayabaranathan1,George Howard4, Virginia J. Howard5, Peter M. Rothwell6, and Geoffrey A. Donnan2,3

In many countries, stroke is a lower priority than other dis-eases despite its public health impact. One issue is a lack ofreadily accessible comparative data to help make the case forthe development of national stroke strategies. To assist in thisprocess, we need to have a common repository of the latestpublished information on the impact of stroke worldwide. Weaim to provide a repository of the most current incidence andmortality data on stroke available by country and illustratethe gaps in these data. We plan to update this repositoryannually and expand the scope to address other aspects of theburden of stroke. Data were compiled using two approaches:(1) an extensive literature review with a major focus on pub-lished systematic reviews on stroke incidence (between 1980and May 14, 2013); and (2) direct acquisition and collation ofdata from the World Health Organization to present the mostcurrent estimates of stroke mortality for each country recog-nized by the World Health Organization. For mortality, ICD8,ICD9, and ICD10 mortality codes were extracted. Using popu-lation denominators crude stroke mortality was calculated, aswell as adjusting for the World Health Organization worldpopulation. We used only the most recent year reported tothe World Health Organization. Incidence rates for strokewere available for 52 countries, with some countries havingincidence studies undertaken in more than one region. Whenadjusted to the World Health Organization world standardpopulation, incidence rates for stroke ranged from 41 per 100000 population per year in Nigeria (1971–74) to 316/ 100 000/year in urban Dar-es-Salaam (Tanzania). Some regions hadthree to fivefold greater incidence than other countries. Ofthe 123 countries reporting mortality data, crude mortalitywas greatest in Kazhakstan (in 2003). In many regions datawere very old or nonexistent. Such country-level data areimportant for citizens, clinicians, and policy makers so thatlocal and global strategies to reduce the overall burden ofstroke can be implemented. Through this first annual reviewof country-specific stroke epidemiology, we hope to promotediscussion and provide insights into the worldwide burden ofstroke.

Key words: country-specific, epidemiology, global, incidence, mortality,stroke

Introduction

Stroke is often of a lower priority for clinical services and research

than other diseases with a similar or lower public health impact

(1,2). The reasons for this are complex and vary between coun-

tries. However, a common theme is the lack of readily accessible

comparative data to help mount a political case for the develop-

ment of national strategies to address the burden of stroke. When

reliable data on stroke burden are available, health care planning

can be more effectively undertaken, ideally with the generation of

longitudinal data to usefully monitor the effectiveness of any

interventions.

When incidence and mortality rates are available, there is a

considerable variability between countries and regions, presum-

ably because of differences in exposure to environmental and

other risk factors, lifestyle differences, genetic factors, stroke man-

agement practices, and in part because of differences in method-

ology used to report these statistics. In spite of this latter issue, it

is becoming increasingly possible to present a reasonable assess-

ment of the burden of diseases such as stroke in a concise and

comparative way as evidenced by the highly influential Global

Burden of Disease (GBD) publications funded by the Bill and

Melinda Gates Foundation (3,4). However, although the GBD

publications contain much valuable information on stroke, their

broader focus makes simple geographic comparisons for specific

diseases (such as stroke) more difficult.

There is a clear need to have a common repository of the latest

published information on major determinants of the burden of

stroke worldwide: stroke incidence and mortality. We see this as

an obvious extension of the role of the World Stroke Organization

and the International Journal of Stroke (IJS) as its flagship publi-

cation. Our aim is to present comparative data for stroke in a

readily accessible way, both in tabular and graphic form, com-

mencing with the fundamental data on incidence and mortality

for different countries using the latest available data at the time

of publication which can be extracted from public records. We

believe that such a compilation of data will be a useful resource

for all health care and related professions. In this initial report, we

will focus on a description of mortality and incidence; however, it

is the intent of this effort to expand to describe other indices of

the burden of stroke in future reports.

Although we recognize that presenting data in a comparative

way might highlight differences that will sometimes be artificial,

presentation of the data might stimulate regions or countries to

provide more accurate data, perhaps accompanied by public

health programs to instigate downward trends.

Correspondence: Amanda G. Thrift*, Stroke and Ageing ResearchCentre (STARC), Department of Medicine, Southern Clinical School,Monash University, Clayton, Vic. 3168, Australia.E-mail: [email protected] of Medicine, Stroke and Ageing Research Centre, SouthernClinical School, Monash University, Clayton , Vic., Australia2Florey Institute of Neuroscience and Mental Health, Heidelberg , Vic.,Australia3The University of Melbourne, Vic., Australia4Department of Biostatistics, School of Public Health, University ofAlabama at Birmingham, Birmingham, AL, USA5Department of Epidemiology, School of Public Health, University ofAlabama at Birmingham, Birmingham, AL, USA6Stroke Prevention Research Unit, Nuffield Department of ClinicalNeurosciences (Clinical Neurology), University of Oxford, Oxford, UK

Conflicts of interest: None declared.

DOI: 10.1111/ijs.12245

Global stroke statistics

© 2013 The Authors.International Journal of Stroke © 2013 World Stroke Organization

6 Vol 9, January 2014, 6–18

Aims

Our aims are to (1) provide a repository of the most recent

worldwide data on stroke by country; (2) determine the gaps in

global incidence and mortality data; and (3) determine the cur-

rency of incidence and mortality data on stroke worldwide.

Methods

Incidence and mortality data were compiled using two

approaches: (1) an extensive literature review with a major focus

on published systematic reviews on these topics and (2) direct

acquisition and summation of data from the World Health

Organization (WHO) using the most current available estimates

of stroke mortality for each country recognized by the

WHO. We therefore sought to present incidence and mortality

data for 199 countries (source: http://www.infoplease.com/

countries.html) out of which 192 are recognized by WHO

(source: http://www.who.int/countries/en/), 193 countries are

members of the United Nations (source: http://www.un.org/en/

members/), and 194 countries are recognized by the World Bank

(source: http://www.worldbank.org/en/country). Because the

majority of publications on stroke mortality obtain their source

data from the WHO databases, we decided that for completeness

and consistency, we would directly export and summarize those

mortality data for this publication. Further details are provided

hereafter.

Literature search and data extraction for incidenceWe searched multiple databases (Medline, Scopus, Pubmed,

Google Scholar, WHO library and WHO regional databases) in

order to identify relevant review articles published from 1980 and

until May 14, 2013 for data on stroke incidence around the globe.

The databases searched were chosen for their wide coverage of

relevant journals.

The search strategies developed consisted of terms for stroke

epidemiology (including stroke incidence, burden of stroke,

stroke review articles, men, women, world, countries, and rates).

Literature reviews were included if they met or potentially met the

predefined inclusion criteria of providing data on the overall

incidence of stroke or provided data on men and women sepa-

rately. Papers where incidence of any stroke subtype was reported,

or where data were reported for men and women separately, were

also assessed in case the article contained overall incidence rates

relevant to our aims, but the data on subtypes and gender differ-

ence are not reported here.

Citations identified from literature databases were initially

screened based on the title and abstract provided to exclude cita-

tions of studies that clearly did not report data of interest. Full

texts were obtained for the citations that were included after this

first screening stage, and these were screened again based on the

contents of their full texts. Screening was conducted by a single

reviewer (T. T.). Only systematic reviews clearly meeting the

inclusion criteria (as just stated) were included at this stage. All

abstracts were screened, and any publication that might have

contained relevant information read in full.

In addition to database searches, the reference lists and citation

history of key papers were screened to identify any potentially

missing review articles. In line with the reviews included from the

literature databases, data were only included from reference lists

on the incidence of stroke, which adhered to the criteria for the

database searches.

When data from one country were reported in more than one

publication or online source, the sources were linked to prevent

double counting of data. Information from each paper was

extracted by one reviewer and discussed between three reviewers

(T. T.,A. G. T., D.A. C.).All authors scrutinized the list of identified

papers to assess whether any known key papers were missing.

In order to prepare the map of stroke incidence, we used avail-

able data adjusted to the WHO world population and three

studies where rates were adjusted to Segi’s world population

(5–7). In some instances, data were not available using these stan-

dards, or the adjusted incidence rates excluded some age bands.

To ensure that data for each country in the map were comparable,

we excluded those studies in which incidence rates did not include

the full age spectrum.

Incidence and mortality by age categoryWe assessed the relationship between the crude incidence and/or

mortality for each country relative to the proportion of the popu-

lation that were aged ≥65 years using the population provided by

each country to the WHO. When possible, the population data

used were from the same year that incidence was assessed. When

incidence was assessed over more than one-year, the population

data used was the midyear of data collection for the incidence

study. When the incidence studies spanned an even number of

years, then the more recent of the two midyears was used. Some

incidence data could not be compared in this way because the

countries had not reported their population data to the WHO. In

some instances, there were no population data for the year in

which the incidence study was conducted. In this instance, the

closest available year was used. For mortality, the year of data

available for mortality was linked to the population data.

Incidence rates were adjusted to three different standards,

including the European standard population, Segi’s world popu-

lation, and the WHO world standard population (8,9). Because

one of the largest reviews included adjustment to the WHO world

standard population (10), the majority of studies on stroke inci-

dence are reported using this standard.

Collation and analysis of mortality dataData for mortality and population denominators were obtained

from the WHO website at http://www.who.int/whosis/mort/

download/en/index.html. These are data that are obtained from

country civil registration systems and are then forwarded to

WHO on an annual basis. The latest data files from WHO were

updated on May 1, 2013. Because not all countries report mortal-

ity data to WHO, and because some provide data using nonstan-

dard codes or the deaths are not medically certified, not all

countries are listed in the mortality files provided by WHO.

The files used in this analysis include data on population

denominators, country codes, and mortality data. Mortality data

Global stroke statisticsA. G. Thrift et al.

© 2013 The Authors.International Journal of Stroke © 2013 World Stroke Organization

Vol 9, January 2014, 6–18 7

are presented from countries in which ICD8, ICD9, and ICD10

codes have been used (Table 1).

All of the records for these cerebrovascular disease deaths were

then merged with the population denominators for the same year

as that in which mortality was coded.

To obtain crude mortality of stroke per 100 000 population,

the overall deaths from cerebrovascular diseases for each

country were divided by the total population and multiplied by

100 000. This calculation was also conducted for men and

women separately. Next, the age-specific death rates were calcu-

lated using the WHO world population (8). Where possible,

adjustments were made using five-year age bands. In some

instances, data on mortality were only provided in 10-year age

bands, and so, 10-year age bands are used. We also needed to

take into account that some countries had different upper age

bands for mortality. The upper age band for 46 countries was 95

years and over, whereas 71 countries had an upper age band of

85 and over, five countries had an upper age band of 75 and

over, whereas in the Islamic Republic of Iran (which reported

for cities only), the upper age band was 65 and over. For each

country, we used the best available data and adjusted for age

using the maximum number of categories. We were then left

with a list of countries by year for both age-adjusted and crude

mortality.

Table 1 International disease classification codes used to estimate stroke mortality rates

International diseaseclassification code Codes used for mortality estimates by country Comment

ICD8 The codes used for ICD8 are 431, 432, 433, and 434, and for those countries using thecondensed list of ICD codes, the codes used were A085 and B030.

ICD9 For ICD9, the codes used were B29, B290, B291, B292, B293, and B294, which are thecodes obtained using the basic tabulation list. For China, the code used was C051.

These codes equate to ICD9codes 430–438.

ICD10 The codes used in the ICD10 database were I60, I600, I601, I602, I603, I604, I605, I606,I607, I608, I609, I61, I610, I611, I612, I613, I614, I615, I616, I618, I619, I62, I620, I621,I629, I63, I630, I631, I632, I633, I634, I635, I636, I638, I639, I64, I67, I670, I671, I672,I673, I674, I675, I676, I677, I678, I679, I69, I690, I691, I692, I693, I694, and I698.

These codes equate to ICD10codes I60, I61, I62, I63,I64, I67, and I69.

Records identified through database searching

(n = 62)

Screen

ing

Includ

edEligibility

Iden

tificati

on

Additional records identified through other sources

(n = 105)

Records after duplicates removed (n = 151)

Identified articles’ titles/abstracts on stroke

burden in various countries (n = 151)

Titles/abstracts excluded (n = 73)

• Not related to stroke• Unable to find full text• Original studies

Review articles providing information on the incidence of stroke and selected for full text

review(n = 78)

Full-text articles excluded, (n = 46)

• Costs• Prevalence• Case-fatality• Editorials• Unable to find full text• Not most recent data

Total incidence & gender-specific

incidence(n = 18)

Reviews include incidence rates

(n = 32)

Total incidence only(n = 10)

Gender-specific incidence only

(n = 4)

Fig. 1 Screening and selection of review articles.

Global stroke statistics A. G. Thrift et al.

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Comparison of crude incidence and crude mortalityWe assessed the relationship between the crude incidence and

mortality for each country using the same year for incidence and

mortality, where possible. When incidence was assessed over more

than one-year, we used the population data that occurred in the

midyear of data collection for the incidence study. Some countries

could not be included because no population data had been

reported to the WHO. In some instances, there were no popula-

tion data for the year in which the incidence study was conducted.

In this instance, the closest available year was used.

Results

Overall there were 51 countries in which incidence was reported

and 124 countries in which mortality data had been reported to

the WHO. However, the population data for Malaysia (27 567)

provided in the WHO database were clearly incorrect, and so, this

left 123 countries for which these data could be reported.

IncidenceThe literature search yielded 167 publications. Figure 1 shows our

selection process. In the first stage of screening, we retrieved 151

potential review articles. There were review articles that reported

incidence measures for 51 countries, recognized by WHO, across

the world (study period is from 1971 to 2010). In 18 of these

reviews, total stroke incidence and separate rates for men and

women were reported (5,6,11–26). In 10 of these reviews, only

total stroke incidence was reported for the country (7,10,27–34),

whereas in four reviews, only gender-specific incidence rates were

provided (35–38).

The crude incidence of stroke varies greatly between countries

(Supporting Information Table S1). The greatest crude stroke

incidence rates were observed in Frederiskberg, Denmark (1989–

90) at 306/100 000 population per year and rural Porto, Portugal

(1998–2000) at 305/100 000 population per year, but both regions

had a relatively large proportion of the population aged ≥65 years

(both >15%). In the Netherlands (1978–80), the incidence was

high (289/100 000) despite having a relatively modest population

aged ≥65 years (Fig. 2a). Sesto Fiorentino (Italy, 2004–05) has a

relatively low crude incidence of stroke (170·4/100 000 popula-

tion per year) despite having a relatively high proportion of the

population in this same older age group (19·2%). Dijon (France)

also has a crude incidence of stroke (113·5/100 000 population)

that is well below the regression line, and 16·3% of the population

of France is aged at least 65 years. Similar data are available for

men and women in some regions (Supporting Information

Table S2). There was no difference in incidence according to the

year that the study was conducted (Fig. 2b).

Incidence rates were adjusted according to various standards

and are higher when adjusted to the European population than

the other population standards as shown by the few studies (e.g.

Dijon, Barbados) in which more than one standardization was

provided (Fig. 3 and Supporting Information Fig. S1). Using the

WHO world standard population, the age-adjusted incidence

rates range from 41 per 100 000 population per year in Nigeria

(1971–74) to 316/100 000/year in urban Dar-es-Salaam (Figs 3

and 4, and Supporting Information Table S3). Dijon (France) has

a very low adjusted incidence at 58/100 000/year. Further data are

also provided for men and women (Table 2).

MortalityThe most recent mortality data for stroke were available for 2011

(25 countries), 2010 (19 countries), 2009 (nine countries), and

the remainder was spread across the years 1976–2008 (see Sup-

porting Information Table S4).

Crude stroke mortality (number of deaths per 100 000 popu-

lation per year) was greater in Kazhakstan (in 2003) than any of

the other countries reporting mortality data to WHO (Fig. 5 and

Supporting Information Table S5). The Russian Federation (in

1998), Bulgaria (2011), Greece (2010), and Romania (2010) were

all countries with statistics demonstrating very high mortality

from stroke. Countries with lower mortality rates include Papua

New Guinea (1977), Bahrain (2009), Nicaragua (1978), and

Kuwait (2011).

Fig. 2 Crude incidence from stroke according to (a) the proportion of thepopulation aged ≥65 years (Y = 8·849* X + 72·31, P < 0·0001), and(b) the midyear that the study was conducted (Y = 1·265* X – 2353,P = 0·37). These are for all countries that have reported crude incidence,and for which population estimates were reported to the World HealthOrganization (5,6,10,11,14,15,17,19,23,24,26–28,32,38–62).

Global stroke statisticsA. G. Thrift et al.

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The crude stroke mortality rate appears to be lower in many

of the low- to middle-income countries (LMICs) listed than in

high-income countries (HICs). However, this may simply be

attributable to the number of people in the population who are

at the age where stroke more commonly occurs (Fig. 6a). Coun-

tries such as Montserrat, Kazhakstan, and Albania have very

high stroke mortality rates as well as a low proportion of the

population who are aged ≥65 years. Other countries, such as

Kyrgyzstan, Trinidad and Tobago, and Uzbekistan have less than

7% of the population aged ≥65 years, but they have a crude

stroke mortality rate similar to that in HICs. This suggests that

lower mortality rates in these LMICs are actually higher than

they should be based on the age structure of their population

(i.e. a large younger population). In contrast, Japan has a rela-

tively moderate crude mortality rate from stroke despite having

a large proportion (approximately 23%) of the population aged

≥65 years.

There was a positive association between the year that the mor-

tality data were collected and their crude mortality rates (Fig. 6b),

suggesting that crude mortality has increased over the 40 years

from 1970.

When assessing mortality rates for stroke adjusted to the new

world population, Kazakhstan has the greatest mortality rate

overall, as well as the greatest stroke mortality rate among men

(427 per 100 000 population in 2003; Figs 7 and 8; Supporting

Information Table S5). The greatest stroke mortality rate among

women is in Montserrat (471 per 100 000 population in 1979),

but it is likely that the current rate in women in Montserrat is very

different to this.

There are some countries in which the mortality rates of stroke

are particularly high, even in more recent years. These include

Kyrgyzstan, Macedonia, Azerbaijan, and the Ukraine. Countries

with the lowest mortality rates in more recent years include

Bahrain, France, Israel, and the Netherlands.

There were 31 countries that had both crude incidence of

stroke reported (all ages included) as well as mortality data pro-

vided to the WHO. Overall, there was a strong positive association

between incidence and mortality from stroke (Fig. 9).

Fig. 3 Incidence of stroke, adjusted to World Health Organization world population (5–7,10,11,14,15,17,19,23,32,33,38–40,42,46,48,49,51–54,58,59,61–72). High-income countries are shown in the white bars, and low- and middle-income countries are shown in the black bars.

Global stroke statistics A. G. Thrift et al.

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10 Vol 9, January 2014, 6–18

Discussion

In this paper, we present a comprehensive review of the most

recent available stroke incidence and mortality data for individual

countries. This is unlike other previous reviews that have taken a

defined time period and explored the changes in incidence and

mortality over a set time frame (10,34,74–76). This review is

important as stroke remains a leading cause of death and one of

the greatest causes of overall disease burden in both HICs and

LMICs (3,4,77).

Our review shows that there are clear discrepancies in the inci-

dence and mortality from stroke when individual countries are

explored. From our review, we are able to report that for countries

such as Tanzania, Portugal, and West Ukraine, there is a three to

fivefold greater age-adjusted incidence of stroke than in many

other countries such as Australia, England, India, and France.

Variations in the patterns of stroke incidence and mortality for

men and women were also seen. For example, men in Croatia and

Italy appear to have about a 1·5 times greater incidence of stroke

than women from these countries, whereas men in Montserrat

were much less likely to die from stroke than women from this

country. The review also highlights that information on incidence

and mortality rates is unavailable for many countries. For

example, we found that about 41% of WHO-recognized countries

(79/192) have not reported mortality data to the WHO since

1976, whereas there were some data on islands and regions that

are not, or are no longer, recognized by WHO (16). One hundred

and forty-eight countries have not undertaken an incidence study

to our knowledge; in 13 countries, the data are rather old [greater

than 20 years or more (1971–93)], and some high-quality studies

had restricted age bands thereby limiting their comparability.

Similarly, some of the mortality data, such as those for Nicaragua

and Papua New Guinea, are quite old, and so, it is possible that

these figures do not represent what is occurring in these countries

in more contemporaneous years.

The strong association between country-specific mortality

from stroke and incidence of stroke provides evidence that differ-

ences in mortality are largely attributable to incidence. There may

also be other factors that contribute to mortality such as treat-

ment and stroke severity. However, the data provided support the

notion that differences in stroke incidence are a major driver for

differences in mortality between countries.

Country-level data provide important information for citizens,

clinicians, and policy makers in understanding where an indi-

vidual country sits as part of the global picture of stroke. For

example, countries with poor rankings might reduce their burden

by taking up effective policies for stroke prevention and manage-

ment that have been implemented in a peer country with a better

rank. Differences in the prevalence of risk factors might explain

part of the variability, but access to appropriate health care ser-

vices and support, or lack of effective prevention or treatment

policies, might also contribute to a greater incidence or mortality

from stroke between countries with similar socioeconomic or

demographic profiles. Therefore, as a global community, there

may be much we can do, through data such as these, to explore

what might be effective options to combat rising incidence and

excess mortality above what might be expected in a particular

country. This is of particular importance because despite evidence

Fig. 4 Heat map showing incidence of stroke adjusted to the World Health Organization world population by quartiles (8).

Global stroke statisticsA. G. Thrift et al.

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Vol 9, January 2014, 6–18 11

of declines in incidence and mortality rates over the last 20 years,

the absolute numbers of stroke continue to rise (10). This is

particularly important for LMICs where more people of working

age (<65 years) are affected (78).

The main strengths of this review include its comprehensive-

ness and having no time period restrictions. However, there are

some limitations. Firstly, we are only able to provide information

using the best available data reported for a country, and methods

for these types of studies can vary. It is likely that data from

LMICs on stroke incidence and mortality are less complete with

variable quality. For example, some of the variability in how

deaths are captured and coded in different countries may lead to

over- or under-estimation of deaths. In addition, not all countries

elect to report data on mortality to WHO; an important source of

omission. Reports such as this can only assist in supporting better

data capture on the epidemiology of stroke in different countries

and highlight the need for agreed standardized approaches to

gathering this information. Further, stroke incidence studies,

because of their intensive and high resource requirements in

meeting ‘ideal’ criteria for case capture (e.g. including hospital-

ized and nonhospitalized cases using multiple overlapping

sources by hot and cold pursuit methods) (Supporting Informa-

tion Appendix S1), are usually only undertaken in a single geo-

graphical location within a country. It may be that these data are

not representative of other geographical locations within a

country, and there may be some over or underestimation of stroke

incidence rates. This situation was demonstrated in this review for

Australia whereby age-adjusted stroke incidence estimates for

Perth provided the ranking for Australia by 13 places lower when

compared with data from the east coast available for Melbourne.

These data also highlight the issue of potentially changing inci-

dence rates over time. The only longitudinal population-based

incidence data available for Australia come from the Perth Com-

munity Stroke Study where incidence was assessed in 1989–90,

and then again in 1995–96 and 2000–01. The authors reported an

average annual decline in the attack rate over the 11-year period

of 5·5% (39). The fact that not all countries repeat their incidence

studies may mean that some of the differences noted are artificial.

As data capture methods and technology evolve, such as the

greater use of electronic health record and data linkage, incidence

studies may become less resource intensive and more comparable

across and between countries.

Another limitation is that stroke mortality rates may change

over time as there is evidence that these rates have been declining

over the last 20 years (10). This means that where a country is

ranked may be influenced, in part, by the time frame of when the

Table 2 Adjusted incidence of stroke in men and women

Country, study period

Incidence rate per 100 000 population(95% confidence interval) Standard

criteriamet*Men Women

Age adjusted to the European standard populationBelarus (Grodno), 2001–2003 (19) 356 (334–377) 236 (222–250) YesCroatia (Varaždin county), 2007–2009 (38) 282 (256–309·9) 181·1 (165·6–197·6) NoFrance (Dijon), 2000–2006 (11) 107·5 (98·3–116·8) 68·9 (62·7–75) YesItaly (Sesto Fiorentino), 2004–2006 (48,62) 101·2 (82·5–123) 63 (48·5–80·7) YesItaly (Valley d’ Aosta), 2004–2005 (15) 159 (127–190) 100 (75–125) YesKuwait, 1989, 1992, 1993 (40) 35·48 (35·39–35·56) 16·66 (16·59–16·73) NoLithuania (Kaunas), 2004 (56) 239·3 (209·9–271·6) 158·7 (135–185·4) YesPoland (Warsaw), 2005 (23) 140 (132–147) 120 (114–127) YesSpain (Castilla y Leon, Extremadura, and Coumunitat

Valenciana regions), 2005 (26)99 (81–117) 66 (53–80) No

Spain (Menorca), 2004–2006 (48,62) 116·3 (96·1–139·5) 65·8 (50·9–83·8) NoUnited Kingdom (South London), 2004–2006 (25) 121·1 (100·5–144·7) 78·1 (61·8–97·5) Yes

Age adjusted to Segi’s World populationChina (Beijing), 2000 (6) 147·6 (134·6–162·6) 124 (113–137·4) NoChina (Changsha), 2000 (6) 190 (175·2–207·3) 119·1 (108·5–132·3) NoChina (Shanghai), 2000 (6) 87·3 (78·5–98·2) 68·1 (61–77·3) NoFrance (Dijon), 2000–2006 (11) 72·5 (65·9–79·1) 47·3 (45·5–52) YesIran (Mashhad), 2006–2007 (5) 208 (180–236) 198 (170–226) Yes

Age adjusted to WHO world standard populationBelarus (Grodno), 2001–2003 (19) 266 (250–282) 180 (169–191) YesBulgaria (Rural), 2002 (73) 909 (729·67–1132·41) 667 (529·24–840·61) NoBulgaria (Urban), 2002 (73) 597 (491·2–725·59) 322 (255·14–406·637) NoCroatia (Varaždin county), 2007–2009 (38) 213·1 (194–233·3) 137·6 (126·3–150·9) NoIndia (Trivandrum, rural), 2005 (33) 163·4 (122·4–204·4) 115·3 (83–147·6) YesIndia (Trivandrum, urban), 2005 (33) 141·7 (122·1–161·3) 130·1 (113·3–146·9) YesIndia (Kolkata), 2003–2005 (83) 117·1 (87·8–152·6) 178·0 (102·4–223·2) YesItaly (Valley d’ Aosta), 2004–2005 (15) 122 (94–150) 77 (55–99) Yes

*Standard criteria = multiple overlapping sources, World Health Organization definition of stroke, incidence cases, no upper age limit, and prospectivedesign.

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12 Vol 9, January 2014, 6–18

Fig. 5 Crude mortality from stroke in the most recent year reported to the World Health Organization, ordered according to the average mortality for menand women. Note that mortality data for China are for selected regions only and represent <10% of all deaths in the country.

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Vol 9, January 2014, 6–18 13

data were obtained. In this review, data capture for mortality

ranged from 1976 in Saint Pierre and Miquelon to 2011 in 25

different countries. Adjusting rates based on known time trends

for declines in incidence might alter the ranking of a country

considerably.

It is also important to consider crude vs. age-standardized rates

for a country. In this review, we provide age-standardized rates

adjusted for the WHO world population for the majority of coun-

tries (8). Crude rates provide valuable information that reflect the

public health burden of stroke given the age distribution for the

country (i.e. if a specific country has a large number of strokes

because it has a relatively large elderly population, they must

nevertheless care for this larger number of people), whereas

adjusted rates allow a more comparable basis between the risk of

stroke across the life course of residents of the country. However,

crude rates may underestimate the impact of stroke on a country,

particularly when strokes are occurring at younger ages. Because

adjusted rates are obtained using a standard population, these

differences in age structure of the population are removed. People

who have their strokes or die at younger ages contribute more to

the adjusted incidence and mortality rates than do older people.

Therefore, adjusted rates provide a better comparison of the

overall impact of stroke between countries. Providing figures for

crude mortality and incidence is also useful for informing policy

and practice. This is a large piece of work and requires that epi-

demiologists publish their crude incidence or mortality rates

based on agreed age categories by gender. This may be something

that this IJS publication may provide in the future for countries

where these data are available. We might also review in each

country where stroke is ranked as a cause of death.

Mortality figures are usually obtained from national mortality

registers, which are available from a larger number of countries.

However, different countries have different policies about report-

ing deaths, and there can be misclassification of causes of death,

particularly when there are multiple comorbidities. These comor-

bidities occur more often at older ages, and so, classification of

mortality in these older age groups can therefore be less accurate

than in those who are younger. Mortality rates between countries

must be compared using a standard population having a particu-

lar age structure (e.g. the New World standard population) (8).

This allows us to adjust for the different age structures of popu-

lations, and guards against obtaining false impressions.

This is the first issue of what is planned as an annual review. It

is important that epidemiologists from around the world con-

tinue to undertake high-quality studies of stroke and share their

data. We provide various ways in which researchers from around

the world may submit information to assist us in updating this

review and ensuring the data we report are current (see http://

onlinelibrary.wiley.com/journal/10·1111/%28ISSN%291747-

4949 for details. This link will have details of the ways that

researchers can download the data used in this review and provide

updates of their own data).

In conclusion, these data may provide a useful overview of the

major differentials between all countries around the world in

relation to two fairly robust metrics – stroke incidence and mor-

tality. These data should inform local, regional, and global discus-

sion about the critical need to reduce disparities between

countries. The first step is to be aware of which countries may be

in more urgent need of support and attention. The second is to

undertake work to understand the factors that may contribute to

these differentials in ranking. Knowing where a country is ranked

might help drive research or greater policy attention in this field,

so that modifiable disparities that are within the control of health

funders and providers of health care may be tackled with greater

gusto and are allocated greater resources. Much can be learned

from countries that are managing to keep stroke incidence and

mortality rates at low levels relative to other countries with similar

demographic or socioeconomic circumstances. The third step is

to ensure that what is learned from better performing countries is

adapted for implementation in other countries and that there is

continued monitoring to show the benefits of the policy and

reactive changes over time. This requires that well-designed,

community-based stroke surveillance studies continue to be

undertaken and that agreed standards in performing and

Fig. 6 Crude mortality from stroke according to (a) the proportion of thepopulation aged at least 65 years (Y = 5·877* X + 26·32, P < 0·0001) and(b) the year (Y = 1·262* X – 2440, P = 0·013). These are for all countriesthat have reported mortality to the World Health Organization and are forthe most recent country year reported for each individual country.

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14 Vol 9, January 2014, 6–18

Fig. 7 Age-adjusted mortality from stroke in the most recent year reported to the World Health Organization, ordered according to the average mortalityfor men and women. Note that mortality data for China are for selected regions only and represent <10% of all deaths in the country.

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Vol 9, January 2014, 6–18 15

reporting these studies are used to ensure maximal use of the

information.

References1 National Stroke Foundation. National stroke audit: acute services

clinical. Audit report 2011. Melbourne, Australia. 2011. Available athttp://strokefoundation.com.au/site/media/National_stroke_audit_acute_services_clinical_audit_report_2011.pdf (accessed 21 Septem-ber 2013).

2 Rothwell PM. The high cost of not funding stroke research: a com-parison with heart disease and cancer. Lancet 2001; 357:1612–6.

3 Lozano R, Naghavi M, Foreman K et al. Global and regional mortalityfrom 235 causes of death for 20 age groups in 1990 and 2010: asystematic analysis for the Global Burden of Disease Study 2010.Lancet 2012; 380:2095–128.

4 Vos T, Flaxman AD, Naghavi M et al. Years lived with disability (YLDs)for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematicanalysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2163–96.

5 Azarpazhooh MR, Etemadi MM, Donnan GA et al. Excessive inci-dence of stroke in Iran: evidence from the Mashhad Stroke IncidenceStudy (MSIS), a population-based study of stroke in the Middle East.Stroke 2010; 41:e3–e10.

6 Jiang B, Wang WZ, Chen H et al. Incidence and trends of stroke and itssubtypes in China: results from three large cities. Stroke 2006; 37:63–8.

7 Syme PD, Byrne AW, Chen R, Devenny R, Forbes JF. Community-based stroke incidence in a Scottish population: the Scottish BordersStroke Study. Stroke 2005; 36:1837–43.

8 Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJL, Lozano R, InoueM. Age Standardization of Rates: A New WHO World Standard.Geneva, World Health Organization, 2001. GPE discussion paperseries: No. 31. Available at http://www.who.int/whosis/indicators/compendium/2008/1mst/en/ (accessed 6 January 2010).

9 Waterhouse J, Muir C, Correa P, Powell J. Cancer Incidence in FiveContinents. Lyon, IARC, 1976.

10 Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V.Worldwide stroke incidence and early case fatality reported in 56population-based studies: a systematic review. Lancet Neurol 2009;8:355–69.

11 Bejot Y, Osseby GV, Aboa-Eboule C et al. Dijon’s vanishing lead withregard to low incidence of stroke. Eur J Neurol 2009; 16:324–9.

12 Boysen G, Nyboe J, Appleyard M et al. Stroke incidence and riskfactors for stroke in Copenhagen, Denmark. Stroke 1988; 19:1345–53.

13 Connor MD, Walker R, Modi G, Warlow CP. Burden of stroke inblack populations in sub-Saharan Africa. Lancet Neurol 2007; 6:269–78.

Fig. 8 Heat map showing mortality from stroke adjusted to the World Health Organization world population by quintiles (8).

Fig. 9 Regression of crude mortality from stroke vs. incidence. These arefor all countries that have reported mortality to the World Health Orga-nization and also have assessed the incidence of stroke for a similar year(Y = 0·4284* X + 128·4, P < 0·0001).

Global stroke statistics A. G. Thrift et al.

© 2013 The Authors.International Journal of Stroke © 2013 World Stroke Organization

16 Vol 9, January 2014, 6–18

14 Corbin DOC, Poddar V, Hennis A et al. Incidence and case fatalityrates of first-ever stroke in a black Caribbean population: the Barba-dos Register of Strokes. Stroke 2004; 35:1254–8.

15 Corso G, Bottacchi E, Giardini G et al. Community-based study ofstroke incidence in the Valley of Aosta, Italy. CARe-cerebrovascularAosta Registry: years 2004–2005. Neuroepidemiology 2009; 32:186–95.

16 Damasceno A, Gomes J, Azevedo A et al. An epidemiological study ofstroke hospitalizations in Maputo, Mozambique: a high burden ofdisease in a resource-poor country. Stroke 2010; 41:2463–9.

17 Kelly PJ, Crispino G, Sheehan O et al. Incidence, event rates, and earlyoutcome of stroke in Dublin, Ireland: the North Dublin PopulationStroke Study. Stroke 2012; 43:2042–7.

18 Khealani BA, Wasay M. The burden of stroke in Pakistan. Int J Stroke2008; 3:293–6.

19 Kulesh SD, Filina NA, Frantava NM et al. Incidence and case-fatality ofstroke on the east border of the European Union. Stroke 2010;41:2726–30.

20 Owolabi M. Taming the burgeoning stroke epidemic in Africa: strokequadrangle to the rescue. West Indian Med J 2011; 60:412–21.

21 Sajjad A, Chowdhury R, Felix JF et al. A systematic evaluation of strokesurveillance studies in low- and middle-income countries. Neurology2013; 80:677–84.

22 Saposnik G, Del Brutto OH, Society I, Cerebrovascular D. Stroke inSouth America: a systematic review of incidence, prevalence, andstroke subtypes. Stroke 2003; 34:2103–7.

23 Sienkiewicz-Jarosz H, Gluszkiewicz M, Pniewski J et al. Incidence andcase fatality rates of first-ever stroke – comparison of data from twoprospective population-based studies conducted in Warsaw. NeurolNeurochir Pol 2011; 45:207–12.

24 Sugama C, Isa K, Okumura K, Iseki K, Kinjo K, Ohya Y. Trends in theincidence of stroke and cardiovascular risk factors on the isolatedIsland of Okinawa: the Miyakojima Study. J Stroke Cerebrovasc Dis2013; 22:e118–23.

25 The European Registers of Stroke Investigators. Incidence of stroke inEurope at the beginning of the 21st century. Stroke 2009; 40:1557–63.

26 Vega T, Zurriaga O, Ramos JM et al. Stroke in Spain: epidemiologicincidence and patterns; a health sentinel network study. J Stroke Cere-brovasc Dis 2009; 18:11–6.

27 Benamer HT, Grosset D. Stroke in Arab countries: a systematic litera-ture review. J Neurol Sci 2009; 284:18–23.

28 Danielyan KE, Oganesyn HM, Nahapetyan KM et al. Stroke burden inadults in Armenia. Int J Stroke 2012; 7:248–9.

29 Feigin VL, Lawes CM, Bennett DA, Anderson CS. Stroke epidemiol-ogy: a review of population-based studies of incidence, prevalence,and case-fatality in the late 20th century. Lancet Neurol 2003; 2:43–53.

30 Heng DM, Lee J, Chew SK, Tan BY, Hughes K, Chia KS. Incidence ofischaemic heart disease and stroke in Chinese, Malays and Indians inSingapore: Singapore Cardiovascular Cohort Study. Ann Acad MedSingapore 2000; 29:231–6.

31 Koton S, Tanne D, Bornstein NM. Burden of stroke in Israel. Int JStroke 2008; 3:207–9.

32 Minelli C, Fen LF, Minelli DP. Stroke incidence, prognosis, 30-day, and1-year case fatality rates in Matao, Brazil: a population-based prospec-tive study. Stroke 2007; 38:2906–11.

33 Sridharan SE, Unnikrishnan JP, Sukumaran S et al. Incidence, types,risk factors, and outcome of stroke in a developing country: theTrivandrum Stroke Registry. Stroke 2009; 40:1212–8.

34 Zhang Y, Chapman AM, Plested M, Jackson D, Purroy F. The inci-dence, prevalence, and mortality of stroke in France, Germany, Italy,Spain, the UK, and the US: a literature review. Stroke Res Treat 2012.doi: 10.1155/2012/436125.

35 Bhatnagar P, Scarborough P, Smeeton N, Allender S. The incidence ofall stroke and stroke subtype in the United Kingdom, 1985 to 2008: asystematic review. BMC Public Health 2010; 10:539.

36 Heuschmann PU, Grieve AP, Toschke AM, Rudd AG, Wolfe CD.Ethnic group disparities in 10-year trends in stroke incidence and

vascular risk factors: the South London Stroke Register (SLSR). Stroke2008; 39:2204–10.

37 Hong KS, Kim J, Cho YJ et al. Burden of ischemic stroke in Korea:analysis of disability-adjusted life years lost. J Clin Neurol 2011; 7:77–84.

38 Pikija S, Cvetko D, Malojcic B et al. A population-based prospective24-month study of stroke: incidence and 30-day case-fatality ratesof first-ever strokes in croatia. Neuroepidemiology 2012; 38:164–71.

39 Islam MS, Anderson CS, Hankey GJ et al. Trends in incidence andoutcome of stroke in Perth, Western Australia during 1989 to 2001: thePerth Community Stroke Study. Stroke 2008; 39:776–82.

40 Abdul-Ghaffar NU, El-Sonbaty MR, el-Din Abdul-Baky MS, MarafieAA, al-Said MM. Stroke in Kuwait: a three-year prospective study.Neuroepidemiology 1997; 16:40–7.

41 Al-Jishi AA, Mohan PK. Profile of stroke in Bahrain. Neurosciences2000; 5:30–4.

42 Correia M, Silva MR, Matos I et al. Prospective-community basedstudy of stroke in Northern Portugal: incidence and case fatality inrural and urban populations. Stroke 2004; 35:2048–53.

43 Del Brutto OH, Mosquera A, Sanchez X, Santos J, Noboa CA.Stroke subtypes among hispanics living in Guayaquil, Ecuador:results from the Luis Vernaza Hospital stroke registry. Stroke 1993;24:1833–6.

44 Ellekjaer H, Holmen J, Indredavik B, Terent A. Epidemiology of strokein Innherred, Norway, 1994 to 1996. Incidence and 30 day case-fatalityrate. Stroke 1997; 28:2180–4.

45 Feigin V, Carter K, Hackett M et al. Ethnic disparities in incidence ofstroke subtypes: Auckland Regional Community Stroke Study, 2002–2003. Lancet Neurol 2006; 5:130–9.

46 Feigin VL, Wiebers DO, Nikitin YP et al. Epidemiology of stroke indifferent regions of Siberia, Russia, 1987–1988: population-basedstudy in Novosibirsk, Krasnoyarsk, Tynda and Anadyr. Eur J Neurol1996; 3:16–22.

47 Hallstrom B, Jonsson AC, Nerbrand C, Norrving BAL. Stroke inci-dence and survival in the beginning of the 21st century in southernSweden: comparisons with the late 20th century and projections intothe future. Stroke 2008; 39:10–5.

48 Heidrich J, Heuschmann PU, Kolominsky-Rabas P, Rudd AG, WolfeCDA. Variations in the use of diagnostic procedures after acute strokein Europe: results from the BIOMED II study of stroke care. Eur JNeurol 2007; 14:255–61.

49 Herman B, Leyten AC, Van Lujik JH, Frenken CW, Op DCAA, SchulteBP. Epidemiology of stroke in Tilburg, the Netherlands. Thepopulation-based stroke incidence register: 2. Incidence, initial clinicalpicture and medical care, and three-week case fatality. Stroke 1982;13:629–34.

50 Jaillard AS, Hommel MM. Prevalence of stroke at high altitude(3380m) in Cuzco, a town in Peru: a population-based study. Stroke1995; 26:562–8.

51 Kolominsky-Rabas PL, Sarti C, Heuschmann PU. A prospectivecommunity-based study of stroke in germany. The Erlangen strokeproject (ESPro): incidence and case fatality at 1, 3, and 12 months.Stroke 1998; 29:2501–6.

52 Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B,Heuschmann PU. Epidemiology of ischemic stroke subtypes accord-ing to TOAST criteria: incidence, recurrence, and long-term survivalin ischemic stroke subtype: a population-based study. Stroke 2001;32:2735–40.

53 Lavados PM, Sacks C, Prina L et al. Incidence, 30-day case-fatality rate,and prognosis of stroke in Iquique, Chile: a 2-year community-basedprospective study (PISCIS project). Lancet 2005; 365:2206–15.

54 Mihalka L, Smolanka V, Bulecsa B, Mulesa S, Bereczki DA. A popula-tion study of stroke in west Ukraine: incidence, stroke services, and30-day case fatality. Stroke 2001; 32:2227–31.

55 Numminen H, Kotila M, Waltimo O, Aho K, Kaste M. Decliningincidence and mortality rates of stroke in Finland from 1972–1991:

Global stroke statisticsA. G. Thrift et al.

© 2013 The Authors.International Journal of Stroke © 2013 World Stroke Organization

Vol 9, January 2014, 6–18 17

results of three population-based stroke registries. Stroke 1996;27:1487–91.

56 Rastenyte D, Sopagiene D, Virviciute D, Juriene K. Diverging trends inthe incidence and mortality of stroke register in Kaunas, Lithuania.Scand J Public Health 2006; 34:488–95.

57 Rosman KD. The epidemiology of stroke in an urban black popula-tion. Stroke 1986; 17:667–9.

58 Thrift AG, Dewey HM, Sturm JW et al. Incidence of stroke subtypes inthe North East Melbourne Stroke Incidence Study (NEMESIS): differ-ences between men and women. Neuroepidemiology 2009; 32:11–8.

59 Tsiskaridze A, Djibuti M, van Melle G et al. Stroke incidence and30-day case-fatality in a suburb of Tbilisi: results of the first prospec-tive population-based study in Georgia. Stroke 2004; 35:2523–8.

60 Vemmos KN, Bots ML, Tsibouris PK et al. Stroke incidence and casefatality in southern Greece: the Arcadia stroke registry. Stroke 1999;30:363–70.

61 Vibo R, Korv J, Roose M. The third stroke registry in Tartu, Estonia:decline of stroke incidence and 28-day case -fatality rate since 1991.Stroke 2005; 36:2544–8.

62 Wolfe CD, Tilling K, Beech R, Rudd AG. Variations in case fatality anddependency from stroke in western and central Europe. The EuropeanBIOMED Study of Stroke Care Group. Stroke 1999; 30:350–6.

63 Appelros P, Nydevik I, Seiger A, Terent A. High incidence rates ofstroke in Orebro, Sweden: further support for regional incidence dif-ferences within Scandinavia. Cerebrovasc Dis 2002; 14:161–8.

64 Brown RD, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO. Strokeincidence, prevalence, and survivial: secualr trends in Rochester, Min-nesota, through 1989. Stroke 1989; 27:550–8.

65 Carolei A, Marini C, Di Napoli M et al. High stroke incidence in theprospective community-based L’Aquila registry (1994–1998). Firstyear’s results. Stroke 1997; 28:2500–6.

66 Di Carlo A, Inzitari D, Galati F et al. A prospective community-basedstudy of stroke in southern Italy: the Vibo Valentia incidence of strokestudy (VISS). Methodology, incidence and case fatality at 28 days, 3and 12 months. Cerebrovasc Dis 2003; 16:410–7.

67 Du X, Sourbutts J, Cruickshank K et al. A community based strokeregister in a high risk area for stroke in north west England. J EpidemiolCommunity Health 1997; 51:472–8.

68 Jerntorp P, Berglund G. Stroke registry in Malmo, Sweden. Stroke1992; 23:357–61.

69 Lauria G, Gentile M, Fassetta G et al. Incidence and prognosis ofstroke in the Belluno Province, Italy: first-year results of a community-based study. Stroke 1995; 26:1787–3.

70 Ricci S, Celani MG, La Rosa F et al. SEPIVAC: a community-basedstudy of stroke incidence in Umbria, Italy. J Neurol Neurosurg Psychia-try 1991; 54:695–8.

71 Smadja D, Cabre P, May F et al. Epidemiology of stroke in Martinique,French West Indies: part I: methodology, incidence, and 30-day casefatality rate. Stroke 2001; 32:2741–7.

72 Walker R, Whiting D, Unwin N et al. Stroke incidence in rural andurban Tanzania: a prospective, community-based study. Lancet Neurol2010; 9:786–92.

73 Powles J, Kirov P, Feschieva N, Stanoev M, Atanasova V. Stroke inurban and rural populations in north-east Bulgaria: incidence andcase-fatality finidings from a ‘hot pursuit’ study. BMC Public Health2002; 2:24 doi:10.1186/1471-2458-2-24.

74 Mirzaei M, Truswell AS, Arnett K, Page A, Taylor R, Leeder SR. Cere-brovascular disease in 48 countries: secular trends in mortality 1950–2005. J Neurol Neurosurg Psychiatry 2012; 83:138–45.

75 Redon J, Olsen MH, Cooper RS et al. Stroke mortality and trends from1990 to 2006 in 39 countries from Europe and Central Asia: implica-tions for control of high blood pressure. Eur Heart J 2011; 32:1424–31.

76 Sarti C, Rastenyte D, Cepaitis Z, Tuomilehto J. International trends inmortality from stroke, 1968 to 1994. Stroke 2000; 31:1588–601.

77 Johnston SC, Mendis S, Mathers CD. Global variation in strokeburden and mortality: estimates from monitoring, surveillance, andmodelling. Lancet Neurol 2009; 8:345–54.

78 Vaartjes I, O’Flaherty M, Capewell S, Kappelle J, Bots M. Remarkabledecline in ischemic stroke mortality is not matched by changes inincidence. Stroke 2013; 44:591–7.

79 Hatano S. Experience from a multicentre stroke register: a preliminaryreport. Bull World Health Organ 1976; 54:541–53.

80 Malmgren R, Warlow C, Bamford J, Sandercock P. Geographical andsecular trends in stroke incidence. Lancet 1987; 2:1196–200.

81 Sudlow CL, Warlow CP. Comparing stroke incidence worldwide: whatmakes studies comparable? Stroke 1996; 27:550–8.

82 Coull AJ, Silver LE, Bull LM, Giles MF, Rothwell PM. Direct assess-ment of completeness of ascertainment in a stroke incidence study.Stroke 2004; 35:2041–5.

83 Das SK, Banerjee TK, Biswas A et al. A prospective community-basedstudy of stroke in Kolkata, India. Stroke 2007; 38:906–10.

Supporting information

Additional Supporting Information may be found in the online

version of this article at the publisher’s web-site:

Fig. S1. Incidence of stroke adjusted to (a) the European popu-

lation and (b) Segi’s World population (1–10).

Table S1. Studies of stroke incidence: crude incidence rates (men

and women combined).

Table S2. Studies of stroke incidence: crude incidence rates in

men and women.

Table S3. Adjusted incidence of stroke in men and women

combined.

Table S4. Latest year available for mortality data.

Table S5. Mortality of stroke in countries that have reported data

to the World Health Organization since 1976: data are reported as

crude rates, and rates age-adjusted to the New World population.

Appendix S1. ‘Ideal’ criteria for stroke incidence studies.

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18 Vol 9, January 2014, 6–18