estimated loss in national income between 2005 and 2015 as a result of premature deaths caused by CHD, stroke, and diabetes was $558 billion (WHO, Preventing Chronic Diseases: A vital investment, Geneva, Switzerland, 2005). Inpatient hospital costs for acute stroke accounts for 70% of first-year poststroke costs.11 Severe strokes (National Institutes of Health Stroke Scale [NIHSS] > 20) cost twice as much as mild strokes, despite similar diagnostic testing.11 Costs and loss due to DALYs depend on the level of disability, and are generally higher for hemorrhagic versus ischemic stroke.12,13 Evidence that specialized stroke rehabilitation reduces long-term disability and stroke-related costs exists for different countries and health care systems, including Switzerland,14 the United Kingdom,15,16 and Japan.17 Cost effectiveness depends on the severity of disability: patients with moderate disability benefit more than those with severe or mild stroke severity.17 Comorbidities such as ischemic heart disease and atrial fibrillation predict higher costs.11 The American Heart Association projects the total cost of stroke, which encompasses both direct and indirect spending, to increase from $105.2 billion in 2012 to $240.7 billion by 2030.18 It is likely that estimates of morbidity and cost burden, based on traditional measures such as physical disability and health care costs, underestimate the burden of cerebrovascular disease. It is increasingly appreciated, for example, that subclinical cerebrovascular disease—including so-called silent infarctions identified on brain imaging in 28% of the population aged > 65 years19—is associated with memory loss, dementia, gait impairment, and other functional disability.20 Stroke Disparities Stroke disparities are widespread and universal. Complex interwoven issues of inability to afford optimal medical infrastructure and personnel, unequal access to medical care (if available), low medical literacy, and problems with adherence and compliance all limit the effectiveness of primary and secondary prevention in stroke care.21 Factors such as geography, age, sex, ethnicity, and socioeconomic status (SES) interact and modify the incidence and prevalence of stroke. Age and Geography The burden of stroke in people younger than 65 years has increased over the last few decades, with the incidence increasing worldwide by 25% among adults aged 20 to 64 years.7 There is a concerning shift in the overall stroke burden toward younger age groups, particularly in low- and middle-income countries. The epidemic rise in cardiovascular risk factors in young adults in some regions such as Russia, China, and India has contributed to the increase in stroke burden among the younger population.22–27 About 12% of strokes in India occur in the population younger than 40 years.28 Stroke is an especially serious problem in Asia, which includes more than 60% of the world’s population, and many of its countries are “developing” economies. Stroke mortality is higher in Asia than in Western Europe, the Americas, or Australasia, and is more similar to Eastern Europe.29 Table 1 Absolute number of DALYs, deaths, incident, and prevalent cases of ischemic and hemorrhagic stroke (with 95% uncertainty intervals [UIs]) in the world in 1990 and 20135 Parameter 1990 2013 Ischemic stroke et al. Neuroepidemiology. 2015;45(3):161–176. doi:10.1159/000441085. Seminars in Neurology Vol. 38 No. 2/2018 Global Burden of Stroke Katan, Luft 209 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Paradoxically, increases in stroke risk and mortality in developing countries are associated with increasing SES, but decreases in stroke risk and mortality in developed countries are associated with increasing SES.30 In rural villages in China, higher incomes brought prosperity but also brought higher stroke risk.31 It is likely that when new monies enter a previously impoverished area, certain unhealthy behaviors are initially adopted.32 Ethnicity Besides geographical disparities, there are also clear disparities between different race and ethnic groups. For example, there is a 200 to 300% excess mortality for blacks age 45 to 65 years compared with the Caucasian population in the United States.33–35 In a similar fashion, Mexican Americans had a higher cumulative incidence of ischemic stroke at younger ages.36 But also, in non-U.S. developed countries greater stroke risk and worse outcome is observed in ethnic minority populations compared with European origin populations.37,38 About 50% of this excess is explained by traditional risk factors, mainly hypertension, as well as differences in SES, highlighting the importance of stroke prevention interventions aimed at minority groups.39 Socioeconomic Status Stoke burden is clearly affected by SES, with greater odds of disability found in patients with lower education and income.40 The South London Stroke registry found a 75% increased chance of poor outcome among the lowest SES group compared with the highest after controlling for clinical variables, including stroke severity.41 The potent effect of SES on stroke outcomes suggests a tremendous need for improved resources for those recovering from stroke.21 Sex Inequality in stroke mortality is also observed in women compared with men in many regions around the