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. 2022 Jan 1;79(1):61-69.
doi: 10.1001/jamaneurol.2021.4346.

Twenty-Year Change in Severity and Outcome of Ischemic and Hemorrhagic Strokes

Kazunori Toyoda  1 , Sohei Yoshimura  1 , Michikazu Nakai  2 , Masatoshi Koga  1 , Yusuke Sasahara  2 , Kazutaka Sonoda  3 , Kenji Kamiyama  4 , Yukako Yazawa  5 , Sanami Kawada  6 , Masahiro Sasaki  7 , Tadashi Terasaki  8 , Kaori Miwa  1 , Junpei Koge  1 , Akiko Ishigami  1 , Shinichi Wada  2 , Yoshitaka Iwanaga  2 , Yoshihiro Miyamoto  2 , Kazuo Minematsu  9 , Shotai Kobayashi  10 ; Japan Stroke Data Bank Investigators
Collaborators, Affiliations

Twenty-Year Change in Severity and Outcome of Ischemic and Hemorrhagic Strokes

Kazunori Toyoda et al. JAMA Neurol. .

Abstract

Importance: Whether recent changes in demographic characteristics and therapeutic technologies have altered stroke outcomes remains unknown.

Objective: To determine secular changes in initial neurological severity and short-term functional outcomes of patients with acute stroke by sex using a large population.

Design, setting, and participants: This nationwide, hospital-based, multicenter, prospective registry cohort study used the Japan Stroke Data Bank and included patients who developed acute stroke from January 2000 through December 2019. Patients with stroke, including ischemic and hemorrhagic strokes, who registered within 7 days after symptom onset were studied. Modified Rankin Scale scores were assessed at hospital discharge for all patients.

Exposure: Time.

Main outcomes and measures: Initial severity was assessed by the National Institutes of Health Stroke Scale for ischemic stroke and intracerebral hemorrhage and by the World Federation of Neurological Surgeons grading for subarachnoid hemorrhage. Outcomes were judged as favorable if the modified Rankin Scale score was 0 to 2 and unfavorable if 5 to 6.

Results: Of 183 080 patients, 135 266 (53 800 women [39.8%]; median [IQR] age, 74 [66-82] years) developed ischemic stroke, 36 014 (15 365 women [42.7%]; median [IQR] age, 70 [59-79] years) developed intracerebral hemorrhage, and 11 800 (7924 women [67.2%]; median [IQR] age, 64 [53-75] years) developed subarachnoid hemorrhage. In all 3 stroke types, median ages at onset increased, and the National Institutes of Health Stroke Scale and World Federation of Neurological Surgeons scores decreased throughout the 20-year period on multivariable analysis. In ischemic stroke, the proportion of favorable outcomes showed an increase over time after age adjustment (odds ratio [OR], 1.020; 95% CI, 1.015-1.024 for women vs OR, 1.015; 95% CI, 1.011-1.018 for men) but then stagnated, or even decreased in men, on multivariate adjustment including reperfusion therapy (OR, 0.997; 95% CI, 0.991-1.003 for women vs OR, 0.990; 95% CI, 0.985-0.994 for men). Unfavorable outcomes and in-hospital deaths decreased in both sexes. In intracerebral hemorrhage, favorable outcomes decreased in both sexes, and unfavorable outcomes and deaths decreased only in women. In subarachnoid hemorrhage, the proportion of favorable outcomes was unchanged, and that of unfavorable outcomes and deaths decreased in both sexes.

Conclusions and relevance: In this study, functional outcomes improved in patients with ischemic stroke during the past 20 years in both sexes presumably partly owing to the development of acute reperfusion therapy. The outcomes of patients with hemorrhagic stroke did not clearly improve in the same period.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Toyoda reported personal fees from Daiichi Sankyo, Bayer, Bristol Myers Squibb, and Takeda outside the submitted work. Dr Koga reported honoraria from Bayer, Bristol Myers Squibb, Otsuka, Daiichi Sankyo, and Boehringer Ingelheim; research funds from Takeda, Daiichi Sankyo, Boehringer Ingelheim, Astellas Pharma, Pfizer, and Shionogi; and serves on the scientific advisory board for Ono. Dr Sonoda reported grants from Japan Society for the Promotion of Science during the conduct of the study; personal fees from Medtronic, Stryker, Medico’s Hirata, and Daiichi Sankyo; and cooperation in clinical trials from Bayer outside the submitted work. Dr Kamiyama reported personal fees from Daiichi Sankyo and Bristol Myers Squibb outside the submitted work. Dr Yazawa reported personal fees from Daiichi Sankyo, Bristol Myers Squibb, Otsuka, Medico’s Hirata, Stryker, Nestle, Abbott, Medtronic, and Mitsubishi Tanabe outside the submitted work. Dr Minematsu reported personal fees from Bayer, Bristol Myers Squibb, CSL Behring, Daiichi Sankyo, EPS Corporation, FUJIFILM Pharmaceuticals, Healios, Mitsubishi Tanabe, Nippon Chemiphar, Otsuka, Pfizer, Sanofi, and Stryker outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Age, National Institutes of Health Stroke Scale (NIHSS) Scores, and World Federation of Neurological Surgeons (WFNS) Grades at the Emergent Visit by Sex
Boxes represent interquartile range, and lines across boxes indicate median values. Whiskers represent 10th percentile and 90th percentile values. All P values for sex differences in age are <.001. All P values for sex differences in NIHSS scores for ischemic stroke are <.001. P values for sex differences in NIHSS scores for intracerebral hemorrhage are .06 in 2000-2005, .006 in 2006-2010, .002 in 2011-2015, and <.001 in 2016-2019. P values for sex differences in WFNS grades are <.001 in 2000-2005, .81 in 2006-2010, 0.11 in 2011-2015, and .02 in 2016-2019. All P values for trends of age and NIHSS scores are <.001 in both sexes. P values for trends of WFNS grades are .28 for women and .64 for men.
Figure 2.
Figure 2.. Modified Rankin Scale Scores at Discharge by Sex
See this image and copyright information in PMC

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