Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan.
JAMA Neurol. 2022 Jan 1;79(1):61-69. doi: 10.1001/jamaneurol.2021.4346.
Whether recent changes in demographic characteristics and therapeutic technologies have altered stroke outcomes remains unknown.
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.
Time.
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.
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.
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.
最近人口特征和治疗技术的变化是否改变了卒中的结局仍不清楚。
使用大型人群，按性别确定急性卒中患者初始神经严重程度和短期功能结局的长期变化。
设计、地点和参与者：本全国性、基于医院的多中心前瞻性登记队列研究使用了日本卒中数据库，纳入了 2000 年 1 月至 2019 年 12 月期间发生急性卒中的患者。研究对象为发病后 7 天内登记的卒中患者，包括缺血性和出血性卒中患者。所有患者在出院时均采用改良 Rankin 量表评分进行评估。
时间。
初始严重程度通过国立卫生研究院卒中量表评估缺血性卒中和脑出血，通过世界神经外科学会分级评估蛛网膜下腔出血。改良 Rankin 量表评分为 0 至 2 分的为预后良好，5 至 6 分的为预后不良。
在 183080 例患者中，135266 例（53800 例女性[39.8%]；中位[IQR]年龄，74 [66-82] 岁）发生缺血性卒中，36014 例（15365 例女性[42.7%]；中位[IQR]年龄，70 [59-79] 岁）发生脑出血，11800 例（7924 例女性[67.2%]；中位[IQR]年龄，64 [53-75] 岁）发生蛛网膜下腔出血。在所有 3 种卒中类型中，发病年龄呈上升趋势，在多变量分析中，国立卫生研究院卒中量表和世界神经外科学会评分在 20 年期间均呈下降趋势。在缺血性卒中患者中，在年龄调整后，良好结局的比例随着时间的推移而增加（女性的优势比[OR]为 1.020；95%CI 为 1.015-1.024，男性的 OR 为 1.015；95%CI 为 1.011-1.018），但在包括再灌注治疗在内的多变量调整后，这种趋势停滞不前，甚至在男性中呈下降趋势（女性的 OR 为 0.997；95%CI 为 0.991-1.003，男性的 OR 为 0.990；95%CI 为 0.985-0.994）。男女两性的不良结局和院内死亡均减少。在脑出血患者中，两性的良好结局均减少，而不良结局和死亡仅在女性中减少。蛛网膜下腔出血患者中，良好结局的比例保持不变，不良结局和死亡的比例在两性中均减少。
在本研究中，过去 20 年，缺血性卒中患者的功能结局有所改善，这可能部分归因于急性再灌注治疗的发展。同期出血性卒中患者的结局并未明显改善。
