Elsevier

The Lancet Neurology

Volume 9, Issue 2, February 2010, Pages 167-176
The Lancet Neurology

Articles
Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis

https://doi.org/10.1016/S1474-4422(09)70340-0Get rights and content

Summary

Background

Since the early 1980s, imaging techniques have enabled population-based studies of intracerebral haemorrhage. We aimed to assess the incidence, case fatality, and functional outcome of intracerebral haemorrhage in relation to age, sex, ethnic origin, and time period in studies published since 1980.

Methods

From PubMed and Embase searches with predefined inclusion criteria, we identified population-based studies published between January, 1980, and November, 2008. We calculated incidence and case fatality. Incidences for multiple studies were pooled in a random-effects binomial meta-analysis. Time trends of case fatality were assessed with weighted linear-regression analysis.

Findings

36 eligible studies described 44 time periods (mid-year range 1983–2006). These studies included 8145 patients with intracerebral haemorrhage. Incidence did not decrease between 1980 and 2008. Overall incidence was 24·6 per 100 000 person-years (95% CI 19·7–30·7). Incidence was not significantly lower in women than in men (overall incidence ratio 0·85, 95% CI 0·61–1·18). Using the age group 45–54 years as reference, incidence ratios increased from 0·10 (95% CI 0·06–0·14) for people aged less than 45 years to 9·6 (6·6–13·9) for people older than 85 years. Median case fatality at 1 month was 40·4% (range 13·1–61·0) and did not decrease over time, and was lower in Japan (16·7%, 95% CI 15·0–18·5) than elsewhere (42·3%, 40·9–43·6). Six studies reported functional outcome, with independency rates of between 12% and 39%. Incidence of intracerebral haemorrhage per 100 000 person-years was 24·2 (95% CI 20·9–28·0) in white people, 22·9 (14·8–35·6) in black people, 19·6 (15·7–24·5) in Hispanic people, and 51·8 (38·8–69·3) in Asian people.

Interpretation

Incidence of intracerebral haemorrhage increases with age and has not decreased between 1980 and 2006. Case fatality is lower in Japan than elsewhere, increases with age, and has not decreased over time. More data on functional outcome are needed.

Funding

Netherlands Heart Foundation.

Introduction

Intracerebral haemorrhage is the second most common cause of stroke, and has a high case fatality.1 Since 1980,2 knowledge of the epidemiology of stroke has increased with the increasing availability of brain-imaging techniques.

Age-adjusted stroke incidence in high-income countries has decreased by 42% in the past four decades,1 mostly owing to a reduction in incidence of ischaemic stroke. Whether incidence of intracerebral haemorrhage has also fallen is unclear. In Perth, Australia, the incidence of intracerebral haemorrhage decreased between 1989 and 2001.3 Between 1981 and 2006, in Oxfordshire, UK, there was a decrease in incidence of intracerebral haemorrhage associated with premorbid hypertension in patients less than 75 years of age, whereas the incidence associated with antithrombotic medication and the incidence of non-hypertensive lobar bleed in patients over 75 years of age increased.4 By contrast, incidence rates were stable between 1985 and 2004 in Dijon, France, and from 1983 to 1997 in Finland.5, 6

Overall, stroke case fatality has not decreased substantially over the past four decades,1 but crude case fatality of subarachnoid haemorrhage decreased by 17% between 1972 and 2002.7 Whether the case fatality rate of intracerebral haemorrhage has changed has not been studied in detail. Although numerous population-based studies have reported intracerebral haemorrhage epidemiology,1 few data are available from developing countries. Data on intracerebral haemorrhage incidence, case fatality, and functional outcome in age and sex subgroups are also scarce.

Although worldwide stroke epidemiology has been reviewed previously,1 a more detailed analysis of intracerebral haemorrhage epidemiology is important for future research and management. We therefore did a meta-analysis on the incidence, case fatality, and functional outcome of intracerebral haemorrhage in relation to age, sex, ethnic origin, and time trends.

Section snippets

Search strategy and selection criteria

We searched PubMed and Embase for population-based studies of intracerebral haemorrhage epidemiology from January, 1980, to November, 2008, with different combinations of the following key words: “h(a)emorrhagic stroke” or “intracranial” or “cerebral” or “intracerebral” or “intraparenchymal” and “h(a)emorrhage” or “h(a)ematoma” and “population (based)” or “region(al)” or “community (based)” or “stroke register/registry” and “incidence” or “fatality” or “mortality” or “trend” (see webappendix

Results

47 articles reported 36 studies3, 6, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57 (figure 1). A total of 9 151 929 people from 21 countries were studied. 8145 of the 9 151 929 people had had an intracerebral haemorrhage and were observed for a total of 28 034 233 person-years. All 36 studies reported incidence, 26 case fatality, and six functional outcome. Two

Discussion

Overall, we did not find a substantial decrease in incidence of intracerebral haemorrhage between January, 1980, and November, 2008. We have reported overall higher incidence of intracerebral haemorrhage in men compared with women, especially in Japanese studies; a two times higher rate of intracerebral haemorrhage incidence in Asian people compared with other ethnic groups; and an increasing incidence of intracerebral haemorrhage with increasing age.

Case fatality at 1 month was low in Japanese

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