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International Journal of Stroke 18(6)
Introduction
Stroke is one of the leading global causes of death and disability.1
Seventy percent of strokes occur in populations of
low-middle-income countries (LMICs), and the subsequent
burden of disease is higher than in populations of highincome
countries.1 Some previous studies of stroke showed
that incidence is increasing in low- and middle-income
countries, by contrast with high-income countries where a
42% decrease in incidence has taken place in the past four
decades.2 It is unclear if this steadily declining trend has
been sustained in recent years, particularly in view of the
continuing aging of the population and the rise of diabetes
mellitus and obesity.3 However, between 1990 and 2017,
the absolute number of people with incident strokes has
increased significantly by 81%, the number of people who
survived by 95%, and number of deaths caused by stroke
by 40%.2
Latin America, with an estimated population of 680 million
inhabitants, has a marked ethnic, cultural, and socioeconomic
heterogeneity.4 Despite the progress that has been
made in recent decades, aging and population growth have
led to an increase in the prevalence of cardiovascular risk
factors, raising absolute numbers of death and disability due
to stroke and cardiovascular diseases.5 In these countries,
the burden of stroke was 5-14 disability-adjusted life years
per 1000 population (age standardized to 2002), which is
higher than in most high-income countries.6
Research about stroke risk factors and epidemiology is
based mostly on studies from North America or Europe.
Stroke epidemiology has been poorly studied in Latin
America/Caribbean (LAC),7,8 which is primarily composed
of LMIC. The most sensitive tool to study stroke is with
standardized population-based registries, since the analysis
limited to hospital cases or the variation of criteria and definitions
can distort the results.9 The methodological differences
between case ascertainment, classification, definitions,
and reference populations for standardization are some of
the problems in the region.10 Also, environmental, racial,
and sociocultural factors can have a significant impact on
the epidemiology of stroke in such a wide area.
The aim of this systematic review was to determine
epidemiological measures of incidence, prevalence, and
1 month of case-fatality for stroke in LAC during
1997-2021.
Methods
The protocol for the review was registered in PROSPERO
(CRD42022325247). A prevalence and incidence systematic
review was developed according to the Metaanalysis
of Observational Studies in Epidemiology
(MOOSE) and Preferred Reporting Items for Systematic
reviews and Meta-Analyses (PRISMA) checklist
(Supplemental Table S.1).
International Journal of Stroke, 18(6)
Selection criteria
This review included prospective observational studies
(e.g. community-based and cohort studies) reporting the
incidence and case-fatality of stroke in 36 countries of LAC
(Supplemental Table S.2). Cross-sectional studies for the
assessment of the stroke prevalence were also included.
Study populations had to include adult participants with
a confirmed stroke diagnosis, which was defined by the
studies according to established clinical criteria, including
cerebral infarction, intracerebral hemorrhage (ICH), subarachnoid
hemorrhage (SAH), or uncertain pathological
subtypes.
Studies using retrospective recruitment (e.g. case series
and case-control), reviews, commentaries, and editorials
were excluded.
Search strategy
A structured and comprehensive literature search was carried
out to identify relevant studies from MEDLINE (Ovid),
Lilacs and Science Citation Index Expanded (SCI-
EXPANDED), Social Sciences Citation Index and Arts,
and Humanities Citation Index within ISI Web of Science
(WoS) (from inception to May 27, 2022).
The search strategy was similar to the one published by
Jones et al.11 Cochrane stroke strategy terms were combined
and filtered by epidemiology studies, including terms
for Latin America and Caribbean.12,13 Only studies published
in English, Portuguese and Spanish from 1 January
1997 to 31 December 2021 were eligible for inclusion
(Supplemental Tables S.3 to S.5). We chose 1997 as a starting
year for this review as well as the Stroke Unit Trialists'
Collaboration14 systematic review, considering this year as
a landmark in global standardization for post-stroke care, a
couple of years after the intravenous thrombolysis was
proven effective treatment for acute ischemic stroke (IS).
Selection process
Before study selection, references obtained were imported
into EndNote 20 and duplicates were removed using the
automated function, and then manually by reviewer. All
references were imported into JBI SUMARI software
(http://www.jbisumari.org/) to carry out the selection
process.15
Two independent reviewers (CD and MN) screened and
selected all titles and abstracts potentially relevant. The full
texts of these articles were independently assessed for eligibility.
In cases of multiple publications based on the same
patients' cohort, only those studies including the largest
sample size and more complete data were selected to avoid
overlapping. Disagreements were resolved by discussion
and when it was necessary, a third reviewer was involved to
reach consensus.
http://www.jbisumari.org/
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