Background: In Spain, stroke is a major public health concern, but large population-based studies are scarce and date from the 1990s. We estimated the incidence and in-hospital mortality of stroke through a multicentered population-based stroke register in 5 geographical areas of Spain, i.e. Lugo, Almería, Segovia, Talavera de la Reina and Mallorca, representing north, south, central (×2) and Mediterranean areas of Spain, respectively, the aim and novelty being that all methodologies were standardized, and diagnoses were verified by a neurologist using neuroimaging techniques. Methods: The register identified subjects >17 years of age who suffered a first-ever stroke or transient ischemic attack (TIA) between 1 January and 31 December 2006. Stroke and TIA were defined according to the WHO criteria. The Lausanne Stroke Registry definitions were used to classify ischemic stroke subtypes, as follows: (1) large-artery atherosclerosis (LAA); (2) cardioembolism (CE); (3) lacunar stroke or small-artery occlusion (SAO); (4) stroke of other infrequent cause (SIC), and (5) stroke of undetermined cause (UND). We used several complementary data sources such as hospital discharge registers, emergency room registers and primary care surveillance systems. Results: In the 1-year study period, we identified 2,700 first-ever cerebrovascular episodes (53% men; 2,257 strokes + 443 TIA episodes). Brain CT in the acute stage was performed in 99% of cases. Of a total of 2,257 stroke patients, 1,817 (81%) had cerebral infarction, 350 (16%) had intracerebral hemorrhage, 59 (3%) had subarachnoid hemorrhage (SAH) and 31 (1%) had unclassifiable stroke. The overall unadjusted annual incidence for all cerebrovascular events was 187 per 100,000 [95% confidence interval (CI) 180–194; incidence for men: 202, 95% CI 189–210; incidence for women: 187, 95% CI 180–194]. The subtype of ischemic stroke could be determined in 1,779 patients and was classified as LAA in 624 (35%), CE in 352 (20%), SAO in 316 (18%), SIC in 56 (3%) and UND in 431 (24%). The incidence rates per 100,000 (95% CI) standardized to the 2006 European population were as follows: all cerebrovascular events, 176 (169–182); all stroke (non-TIA), 147 (140–153); TIA, 29 (26–32); ischemic stroke, 118 (112–123); intracerebral hemorrhage, 23 (21–26), and SAH, 4.2 (3.1–5.2). Incidence rates clearly increased with age in both genders, with a peak at or above 85 years of age. The in-hospital mortality was 14%. Conclusions: Our results show that the incidence of stroke and TIA in Spain is moderate compared to other Western and European countries. However, it is expected that these figures will change due to progressively aging populations.

Keywords:
Epidemiology, Stroke, Incidence, Transient ischemic attack, Subarachnoid hemorrhage
1.
Bonita R, Mendis S, Truelsen T, Bogousslavsky J, Toole J, Yatsu F: The Global Stroke Initiative. Lancet Neurol 2004;3:391–393.
2.
Thorvaldsen P, Asplund K, Kuulasmaa K, Rajakangas AM, Shroll M: Stroke incidence, case fatality, and mortality in the WHO MONICA project. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease. Stroke 1995;26:361–367.
3.
Asplund K, Bonita R, Kuulasmaa K, Rajakangas AM, Schaedlich H, Suzuki K, Thorvaldsen P, Tuomilehto J: Multinational comparisons of stroke epidemiology. Evaluation of case ascertainment in the WHO MONICA Stroke Study. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease. Stroke 1995;26:355–360.
4.
Medrano Alberto MJ, Boix Martinez R, Cerrato Crespan E, Ramirez Santa-Pau M: Incidence and prevalence of ischaemic heart disease and cerebrovascular disease in Spain: a systematic review of the literature. Rev Esp Salud Pública 2006;80:5–15.
5.
Díaz-Guzmán J, Egido-Herrero JA, Gabriel-Sánchez R, Barberà G, Fuentes B, Fernández-Pérez C, Abilleira S; Proyecto Ictus del Grupo de Estudio de Enfermedades Cerebrovasculares de la Sociedad Española de Neurología: Incidence of strokes in Spain. Methodological foundations of the Iberictus Study (in Spanish). Rev Neurol 2008;47:617–623.
6.
Population 2005 census of the Spanish National Institute of Statistics. http://www.ine.es (accessed March 2011).
7.
Malmgren R, Warlow C, Bamford J, Sandercork P: Geographical and secular trends in stroke incidence. Lancet 1987;2:1197–1198.
8.
Sudlow CLM, Warlow CP: Comparing stroke incidence worldwide: what makes studies comparable? Stroke 1996;27:550–558.
9.
Aho K, Harmsen P, Hatano S, Marquardsen J, Smirnov VE, Strasser T: Cerebrovascular disease in the community: results of a WHO collaborative study. Bull World Health Organ 1980;58:113–130.
10.
Castillo V, Bogousslavski J: Early classification of stroke. Cerebrovasc Dis 1997;7(suppl 3):5–11.
11.
Díaz-Guzmán J, Egido-Herrero JA, Fuentes B, Fernández-Pérez C, Gabriel-Sánchez R, Barberà G, Abilleira S; Proyecto Ictus del Grupo de Estudio de Enfermedades Cerebrovasculares de la Sociedad Española de Neurología: Incidence of strokes in Spain: the Iberictus study. Data from the pilot study. Rev Neurol 2009;48:61–65.
12.
Spain demographics. http://www.ine.es (accessed March 2011).
14.
Feigin VL, Lawes CMM, Bennett DA, Anderson CS: Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurol 2003;2:43–53.
15.
Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE, Bull LM, Gutnikov SA, Edwards P, Mant D, Sackley CM, Farmer A, Sandercock PA, Dennis MS, Warlow CP, Bamford JM, Anslow P; Oxford Vascular Study: Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 2004;363:1925–1933.
16.
Vibo R, Körv J, Haldre S, Roose M: First-year results of the Third Stroke Registry in Tartu, Estonia. Cerebrovasc Dis 2004;18:227–231.
17.
Wolf CDA, Giroud M, Kolomisky-Rabas P, Dundas R, Lemesle M, Heuschmann P, Rudd A: Variations in stroke incidence and survival in 3 areas of Europe. European Registries of Stroke (EROS) Collaboration. Stroke 2000;31:2074–2079.
18.
Kolominsky-Rabas PL, Sarti C, Heuschmann PU, Graf C, Siemonsen S, Neundoerfer B, Katalinic A, Lang E, Gassmann KG, von Stockert TR: A prospective community-based study of stroke in Germany – the Erlangen Stroke Project (ESPro). Stroke 1998;29:2501–2506.
19.
Carolei A, Marini C, Di Napoli M, Di Gianfilippo G, Santalucia P, Baldassarre M, De Matteis G, di Orio F: High stroke incidence in the prospective community-based L’Aquila registry (1994–1998). First year’s results. Stroke 1997;28:2500–2506.
20.
Ellekjaer H, Holmen J, Indredavik B, Terent A: Epidemiology of stroke in Inherred, Norway, 1994 to 1996. Stroke 1997;28:2180–2184.
21.
Johansson B, Norrving B, Lindgren A: Increased stroke incidence in Lund-Orup, Sweden, between 1983 to 1985 and 1993 to 1995. Stroke 2000;31:481–486.
22.
Brown RD, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO: Stroke incidence, prevalence, and survival: secular trends in Rochester, Minnesota, through 1989. Stroke 1996;27:373–380.
23.
European Registers of Stroke (EROS) Investigators: Incidence of stroke in Europe at the beginning of the 21st Century. Stroke 2009;40:1557–1563.
24.
Béjot Y, Rouaud O, Jacquin A, Osseby GV, Durier J, Manckoundia P, Pfitzenmeyer P, Moreau T, Giroud M: Stroke in the very old: incidence, risk factors, clinical features, outcomes and access to resources – a 22-year population-based study. Cerebrovasc Dis 2010;29:111–21
25.
Mihalka L, Smolanka V, Bulecza B, Mulesa S, Bereczki D: A population study of stroke in West-Ukraine. Stroke 2001;32:2227–2231.
26.
Vemmos KN, Bots ML, Tsibouris PK, et al: Stroke incidence and case-fatality in Southern Greece. Stroke 1999;30:36–70.
27.
Correia M, Silva MR, Matos I, Magalhaes R, Castro J, Ferro JM: Prospective community-based study of stroke in Northern Portugal. Incidence and case fatality in rural and urban populations. Stroke 2004;35:2048–2053.
28.
de Rooij NK, Linn FHH, van der Plas JA, Algra A, Rinkel GJE: Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007;78:1365–1372.
29.
Feigin VL, Shishkin SV, Tzirkin GM, Vinogradova TE, Tarasov AV, Vinogradov SP, Nikitin YP: A population-based study of transient ischemic attack incidence in Novosibirsk, Russia, 1987–1988 and 1996–1997. Stroke 2000;51:9–13.
30.
Edlow JA, Kim S, Pelletier AJ, Camargo CA Jr: National study on emergency department visits for transient ischemic attack, 1992–2001. Acad Emerg Med 2006;13:666–672.
31.
Kleindorfer D, Panagos P, Pancioli A, Khoury J, Kissela B, Woo D, Schneider A, Alwell K, Jauch E, Miller R, Moomaw C, Shukla R, Broderick JP: Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke 2005;36:720–723.
32.
Rothwell PM, Warlow CP: Timing of TIAs preceding stroke: time window for prevention is very short. Neurology 2005;64:817–820.
33.
Correia M, Silva MR, Magalhaes R, Guimaraes L, Silva MC: Transient ischemic attacks in rural and urban northern Portugal: incidence and short-term prognosis. Stroke 2006;37:50–55.
34.
Ueda K, Kiyohara Y, Hasuo Y, Yanai T, Kawano H, Wada J, Kato I, Kajiwara E, Omae T, Fujishima M: Transient cerebral ischemic attacks in a Japanese community, Hiyasama, Japan. Stroke 1987;18:844–848.
35.
Urakami K, Igo M, Takahashi K: An epidemiologic study of cerebrovascular disease in Western Japan: with special reference to transient ischemic attacks. Stroke 1987;18:396–401.
36.
Vaartjes I, Reitsma JB, de Bruin A, Berger-van Sijl M, Bos MJ, Breteler MM, Grobbee DE, Bots ML: Nationwide incidence of first stroke and TIA in the Netherlands. Eur J Neurol 2008;15:1315–1323.
37.
Amort M, Fluri F, Schäfer J, Weisskopf F, Katan M, Burow A, Bucher HC, Bonati LH, Lyrer PA, Engelter ST: Transient ischemic attack versus transient ischemic attack mimics: frequency, clinical characteristics and outcome. Cerebrovasc Dis 2011;32:57–64.
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2012
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