Global Burden of Stroke Mira Katan, MD, MS1 Andreas Luft, MD1,2 1Department of Neurology, Stroke Center, University Hospital of Zurich, Zurich, Switzerland 2Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland Semin Neurol 2018;38:208–211. Address for correspondence Andreas R. Luft, MD, Department of Neurology, University Hospital of Zurich, Frauenklinikstrasse 26, 8091 Zürich, Switzerland (e-mail: andreas.luft@usz.ch). Global Stroke Mortality, Disability, and Costs Mortality The latest estimate from the Global Burden of Disease, Injuries, and Risk Factors Study (GBD 2015) revealed a further shift from communicable diseases, maternal, and nutritional causes toward noncommunicable diseases like stroke. This effect is likely caused by an increase and aging of the world’s population as well as by decreased death rates globally in recent decades.1 The most prominent causes of death are vascular in nature, and stroke is currently the second leading cause of death worldwide.2 Ischemic heart disease and stroke together accounted for 15.2 million deaths (15–15.6 million) in 2015.2 While ischemic strokes comprise the highest number of stroke, much of the global burden of stroke measured in proportion to mortality and by mortality and disability-adjusted life-years (DALYs) is allocated to hemorrhagic stroke.3 Low- and middle-income countries endure an 80% mortality rate with hemorrhagic stroke.3 Disability Stroke is one of the leading causes of long-term disability in the United States, especially in the elderly population in which stroke incidence is highest. From the 795,000 new sufferers of stroke, 26% remain disabled in basic activities of daily living (Framingham cohort) and 50% have reduced mobility due to hemiparesis.4 Aphasia and depression are other frequent causes of disability.4 In comparison to other causes of DALYs in the world, stroke was the second largest contributor after ischemic heart disease globally and in developing countries, and the third largest contributor to DALYs in developed countries (after ischemic heart disease and lower back and neck pain), with significant regional variation in disease burden across both developed and lowto middle-income countries.5 Stroke is preventable to a large extent due to modifiable risk factors.6 Targeting risk factors such as high blood pressure, smoking, obesity, diabetes mellitus, atrial fibrillation, dyslipidemia, and lack of physical activity may have already contributed to the observed improvement of stroke incidence and DALYs in high-income countries over the last two decades. However, the absolute numbers of incident stroke, survivors, and stroke-related death as well as DALYs has globally increased (►Table 1), partly due to the rising numbers in low- and middle-income countries.2 Moreover, an increase in stroke incidence and DALYs in adults aged 20 to 64 years has been observed. This increase was also most prevalent in developing countries, and due to hemorrhagic more than ischemic stroke.7 Costs Currently, approximately 3 to 4% of total health care expenditures in Western countries are spent on stroke.8 The mean Keywords ► stroke ► burden ► global ► epidemiology Abstract Stroke is the second leading cause of death and a major cause of disability worldwide. Its incidence is increasing because the population ages. In addition, more young people are affected by stroke in low- and middle-income countries. Ischemic stroke is more frequent but hemorrhagic stroke is responsible for more deaths and disability-adjusted life-years lost. Incidence and mortality of stroke differ between countries, geographical regions, and ethnic groups. In high-income countries mainly, improvements in prevention, acute treatment, and neurorehabilitation have led to a substantial decrease in the burden of stroke over the past 30 years. This article reviews the epidemiological and clinical data concerning stroke incidence and burden around the globe. Issue Theme Global Health Neurology; Guest Editor, Nicoline Schiess, MD, MPH Copyright © 2018 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. DOI https://doi.org/ 10.1055/s-0038-1649503. ISSN 0271-8235. 208 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. lifetime cost of ischemic stroke per person, which includes inpatient care, rehabilitation, and follow-up care, is estimated at $140,048 in the United States.9 The total annual direct costs were estimated at €26.6 billion in 2010 for the European Union (EU) plus Iceland, Norway, and Switzerland.10 The economic burden caused by stroke has not been well explored in developing countries; according to estimates by the World Health Organization (WHO), India, for example, lost $8.7 billion in 2005 due to coronary heart disease (CHD), stroke, and diabetes. These numbers were thought at the time to increase up to $54 billion by 2015, and India’s growth of gross domestic product (GDP) was estimated to fall by 1% because of the combined economic impact of CHD, stroke, and diabetes. For China, the