Stroke in South America

A Systematic Review of Incidence, Prevalence, and Stroke Subtypes

Gustavo Saposnik, MD; Oscar H. Del Brutto, MD; for the Iberoamerican Society of
Cerebrovascular Diseases

Background and Purpose—Stroke is a leading cause of mortality and disability in South America because of an increase
in life expectancy and changes in the lifestyle of the population. Because epidemiological and clinical characteristics of
stroke vary according to regional factors, we need to know the peculiarities of stroke on this continent.
Methods—We performed a systematic review of articles on stroke in South America, with emphasis on those providing
information on the incidence and prevalence of stroke (community-based studies) and the pattern of stroke subtypes
(hospital-based studies).
Results—Seven papers provided information on stroke epidemiology; 11 gave data on the pattern of stroke subtypes.
Community-based studies showed crude stroke prevalence rates ranging from 1.74 to 6.51 per 1000 and annual
incidence rates from 0.35 to 1.83 per 1000. Hospital-based stroke registries consistently reported a high frequency of
intracranial hemorrhages, which accounted for 26% to 46% of all strokes. Among patients with cerebral infarctions,
intracranial atherosclerotic lesions and small-vessel disease have been common pathogenic mechanisms underlying the
stroke. In most studies, hypertensive arteriolopathy was the most common cause of both infarctions and hemorrhages.
Conclusions—Stroke has been poorly studied in South America. Available data suggest that the prevalence and incidence
of stroke are lower than in developing countries. The pattern of stroke subtypes seems to be different from that reported
in other regions of the world, with a higher frequency of cerebral hemorrhages, small-vessel disease, and intracranial
atherosclerotic lesions. Such differences may be related to genetic, environmental, or sociocultural factors and to
differences in the control of stroke risk factors. (Stroke. 2003;34:2103-2108.)
Key Words: epidemiology 䡲 ethnicity 䡲 incidence 䡲 intracerebral hemorrhage 䡲 prevalence 䡲 primary prevention
䡲 South America 䡲 stroke 䡲 stroke classification
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C urrent knowledge of stroke risk factors and epidemiology is

based mostly on North American or European studies; scarce
data have been published from developing countries. Stroke will be
a public health problem in South America during the next decades
because of an increase in life expectancy and changes in the lifestyle
of the population. Because epidemiological and clinical character-
istics of stroke vary according to environmental, racial, and socio-
cultural factors, we need to be aware of the peculiarities of stroke on
this continent to reduce the impact burden of this epidemic. Here,
we review published evidence relevant to epidemiology and sub-
types of stroke in South America.
See Editorial Comment, page 2107
included if the design of the study was adequately described
in the methods section and if stroke was diagnosed on the
basis of neuroimaging findings.
Results
Only 18 of more than 200 reviewed papers met inclusion
criteria (the Figure). Seven1–7 provided information on stroke
epidemiology; 11 gave data on the pattern of stroke
subtypes.8 –18

Methods Studies on Stroke Epidemiology

We used electronic databases to search for community- or hospital-
based studies including information on stroke in South America.
Community-based studies were included if data were collected
through standarized questionnaires and if raw population numbers
were available for data confirmation. Age adjustments were de-
scribed as originally reported. Hospital-based stroke registries were
Of the 7 community-based studies meeting inclusion criteria,
3 were designed primarily to assess the prevalence or inci-
dence of stroke1–3; the other 4 were conducted to determine
the prevalence or incidence of major neurological diseases4 –7
(Table 1).

Received May 7, 2003; final revision received May 28, 2003; accepted May 30, 2003.
From the Stroke Unit, Department of Neurology, Ramos Mejia Hospital, Buenos Aires University, Argentina (G.S.), and Stroke Unit, Department of
Neurological Sciences, Hospital-Clínica Kennedy, Guayaquil, Ecuador (O.H. Del B.).
Correspondence to Gustavo Saposnik, MD, Charcas 4431 4 “10,” Buenos Aires 1425, Argentina. E-mail gsaposnik@intramed.net.ar
© 2003 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000088063.74250.DB

2103
 2104 Stroke September 2003

South American map showing the geo-

graphic distribution of community-based
studies and hospital-based stroke
registries.
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The first study designed to assess stroke epidemiology was
performed in Cuzco, a Peruvian city of 210 000 inhabitants
located 3380 m above sea level.1 Twenty-one cases of
first-ever stroke were found among 3246 screened individuals
⬎15 years old. This gave a crude prevalence rate of 6.2 per
1000 population. Six of these 21 stroke cases occurred in the
year before the study, giving a crude annual incidence rate of
1.83 per 1000. Age, alcohol consumption, polycythemia, and
high income levels were positively associated with stroke
prevalence. The authors noted the importance of environmen-
tal factors and lifestyle as contributors to stroke occurrence.
In a Colombian study conducted in the city of Sabaneta, 76
of 13 588 screened people (from 17 659 inhabitants) had a
stroke.8 This gave a crude stroke prevalence rate of 5.6 per

TABLE 1. Community-Based Studies on Stroke Prevalence and Incidence in South America

Data Ethnic Population Crude Age-Adjusted
Collection Group,* Studied, Prevalence Prevalence Incidence
Study Year % n Rates† Rates† Rates†
Cuzco, Peru1 1988 Quechuas 97 3246 6.2 5.74‡ 1.83
Sabaneta, Colombia2 1992–1993 䡠䡠䡠 13 588 5.6 䡠䡠䡠 0.89
Santa Cruz, Bolivia3 1994 Mestizos 70, Guaranies 30 9955 1.74 3.22‡ 䡠䡠䡠
Quiroga, Ecuador4 1982 Quechuas 1113 3.6 䡠䡠䡠 䡠䡠䡠
Colombia5
Rural areas 䡠䡠䡠 7746 4.1 䡠䡠䡠 䡠䡠䡠
Urban centers 1983–1992 䡠䡠䡠 8286 9.6 䡠䡠䡠 䡠䡠䡠
Total 䡠䡠䡠 16 032 6.51 䡠䡠䡠 䡠䡠䡠
Aratoca, Colombia6 1995–1996 䡠䡠䡠 544 4.7 䡠䡠䡠 䡠䡠䡠
Chávez, Bolivia7 1995–1996 Chiquitanos 1514 䡠䡠䡠 䡠䡠䡠 0.35
*Quechuas, refers to interbreeding of the white descendants of the Hispanic population with the Amerindian
population; Mestizos, descendants of intermarriage between Spaniards and natives; Guaranies, Indians; and
Chiquitanos, native tribe from the southern Amazon region in Bolivia.
†Per 1000 population.
‡All ratios and rates were adjusted for age to the World Health Organization population according to the original
descriptions.
 Saposnik and Del Brutto Stroke in South America: A Systematic Review 2105

TABLE 2. Proportion of Ischemic and Hemorrhagic Stroke Subtypes in South

American Hospital-Based Stroke Registries
Cerebral Intracranial
Strokes, Ethnic Infarction, Hemorrhage, Other,*
Stroke Registry n Group % % %
Guayaquil, Ecuador8 500 Mestizos† 62.6 37.4 䡠䡠䡠
Joinville, Brazil9 429 䡠䡠䡠 73.4 25.9 0.7
Santiago, Chile10 450 䡠䡠䡠 51 46 3
Buenos Aires, Argentina 11 361 Whites 73 27 䡠䡠䡠
Natives 66 34 䡠䡠䡠
*Includes patients with transient ischemic attacks, intracranial venous thrombosis, and unclassified
strokes.
†Mestizos⫽a racial admixture between Spaniards and Ecuadorian natives.

1000. The annual incidence rate of stroke was 0.89 per 1000.
This low incidence rate could be related to the implementa-
tion of campaigns directed at teaching the community about
the hazards of stroke risk factors. Another prevalence study
was conducted in rural areas of Santa Cruz (Bolivia).3 Of
9955 screened inhabitants, 16 had a stroke. This gave a crude
prevalence of stroke of 1.74 per 1000. The prevalence was
2-fold higher in men than in women. It was suggested that
this low prevalence rate could be related to a high number of
stroke fatalities.
In a study designed to assess the epidemiology of neuro-
logical diseases in the Andean village of Quiroga (Ecuador),
4 of 1113 screened people had a stroke, yielding a crude
prevalence rate of 3.6 per 1000.4 In a Colombian study
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rhagic strokes,8 –13 4 included patients with ischemic
stroke,14 –17 and 1 evaluated patients with intracranial hemor-
rhages.18 Eight of the 11 studies included adult patients of all
ages,8 –12,14,15,17 and the other 3 were restricted to young
adults.13,16,18
In Guayaquil, 500 Ecuadorian mestizos with stroke were
evaluated.8 The authors found 37.4% of strokes were intra-
cranial hemorrhages and 62.6% were cerebral infarctions.
Hypertensive arteriolopathy was the cause of 64% of the
hemorrhages and 43% of the infarctions. Lacunar infarctions
were seen in 39% of patients with ischemic stroke. This was
the first study to suggest that stroke patterns in South
America are different from those seen in developed countries.
Subsequent studies confirmed that intracranial hemorrhages

screening 16 032 people from 7 different rural and urban

communities, the crude stroke prevalence rate was 6.5 per
1000, which was higher in people living in urban areas (9.6
per 1000) compared with that found in those living in rural
areas (4.1 per 1000).5 In another Colombian study conducted
in the rural area of Aratoca, 10 of 544 screened people (from
6664 inhabitants) had a stroke; this gave a crude prevalence
rate of 4.7 per 1000.6 In a Bolivian study on the incidence of
neurological diseases among a small Amazonian tribe, 2 of
1514 individuals followed up over 1 year had a stroke,
yielding an annual incidence rate of 0.35 per 1000.7
Studies on Stroke Subtypes
Of the 11 hospital-based stroke registries meeting inclusion
criteria, 6 evaluated patients with both ischemic and hemor-
are more prevalent (Table 2) and that the pattern of ischemic
strokes is different in South America than in developed
countries (Table 3).
In Joinville (Brazil), 73.4% of 429 stroke patients had a
cerebral infarction, 25.9% had an intracranial hemorrhage,
and 0.7% had unclassified stroke.9 Arterial hypertension was
the most common risk factor for ischemic and hemorrhagic
strokes. Similar figures were observed in a stroke registry
from Santiago (Chile) that included 450 patients.10 Of them,
51% had ischemic strokes, 34% had cerebral hemorrhages,
12% had subarachnoid hemorrhages, and 3% had transient
ischemic attacks. Arterial hypertension was observed in 64%
of these patients and was the most common cause of both
infarctions and hemorrhages.

TABLE 3. Proportion of Ischemic Stroke Subtypes in South American

Hospital-Based Stroke Registries
Mean Large-Artery Cerebral Small-Artery Other
Age, Disease, Embolism, Disease, Causes, Unknown,
Stroke Registry y % % % % %
Guayaquil8 (n⫽313) 58 7.4 14 43.1 6 29.5
Santiago10 (n⫽233) 64 33.5 32.6 14.1 5.2 14.6
Buenos Aires (n⫽250)
12 62 12 21 42 6 18
Whites (n⫽123) 11 20 48 5 16
Natives (n⫽126) 13 22 36 8 21
Bogota14 (n⫽119) 66 19 18 19 12 32
Santiago15 (n⫽110) 67 7 14 43 6 29
Denominators of ischemic stroke are in parentheses.
 2106 Stroke September 2003
Another study conducted in Buenos Aires (Argentina)
identified differences in risk factors and stroke subtypes
between Argentinian natives and whites.11 The authors found
a high frequency of hemorrhagic strokes and small-vessel
disease in both ethnic groups. Hemorrhages were signifi-
cantly higher in Argentinian natives than in whites (34%
versus 27%), and whites had a nonsignificantly higher ten-
dency of penetrating artery disease than natives (35% versus
24%). The same authors compared the frequency of stroke
subtypes among whites living in Buenos Aires and Boston
and found that the former had a higher frequency of hemor-
rhagic strokes (27% versus 15%) and small-vessel disease
(35% versus 21%).12
Among 119 patients with cerebral infarction studied in
Bogota (Colombia), only 19% had large-vessel atherosclero-
sis as the cause of stroke.14 In Santiago, 2 study of 110
patients with ischemic stroke suggested that the prevalence of
extracranial carotid artery atherosclerosis is low among Chil-
ean patients with cerebral infarctions,15 and other study from
Guayaquil showed that 60% of Ecuadorian mestizos with
cerebral infarctions related to large-artery atherosclerosis had
intracranial lesions, located mostly in the middle cerebral
artery stem.17
Stroke subtypes in young adults have also been evaluated
in some studies. In a series from Sao Paolo (Brazil) that
included 106 patients 15 to 40 years of age with cerebral
infarction, cardioembolism was the most common pathoge-
netic mechanism of stroke in the subgroup of patients 30 to 40
years of age, whereas other determined causes of stroke were
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most often seen among patients ⬍29 years of age. Lacunar
infarctions were more common in patients ⬎30 years of
age.16 There was a predominance of women among patients
⬍29 years of age and of men in patients 30 to 40 years of age.
The authors concluded that the pathogenesis of ischemic
stroke in young adults varies according to age and sex. In a
series of 151 young adults (15 to 44 years of age) with
intracranial hemorrhage from Guayaquil, hypertensive arte-
riolopathy was the leading cause of bleeding (39.7% of
cases).18 In Curitiba (Brazil), another series of 164 young
adults with stroke (86% ischemic) also showed that arterial
hypertension was the most common risk factor for the
occurrence of both ischemic and hemorrhagic strokes.13
Discussion
Valuable information can be extracted from the scarce pub-
lications of stroke in South America. Stroke prevalence is
lower than that in developed countries, probably because of
some unknown protective ethnic factors or differences in
dietary habits or lifestyles.1,2 This hypothesis is supported by
the finding that stroke prevalence is even lower in rural than
in urban areas. It has also been suggested that low prevalence
rates are related to an increased mortality in patients during
the acute disease.3 However, 4 of the 6 community-based
studies on stroke prevalence in South America have been
conducted in Colombia2,5,6 and Ecuador,4 where stroke mor-
tality is low. The other 2 studies came from Peru1 and
Bolivia,3 where no information on adjusted stroke mortality
rates is available.
Stroke incidence is more difficult to assess than preva-
lence when resources that allow prospective follow-up of a
community are limited. The 3 studies on stroke incidence
in South America yielded rates ranging from 0.35 to 1.83
per 1000 population,1,2,5 which are lower than that of
developed countries. However, those geographically re-
stricted studies may not reflect the situation of the entire
continent.
Another conclusion that can be drawn from South
American studies is the consistently reported high percent-
age of patients with intracranial hemorrhages among stroke
sufferers, which is 2 to 3 times higher than that seen in
people living in developed countries.8 –12 Several factors
may explain such differences, including a higher preva-
lence of uncontrolled arterial hypertension, dietary habits,
widespread abuse of over-the-counter medications that
predispose to bleeding, and alcohol abuse. Among patients
with ischemic strokes, stroke registries suggest that intra-
cranial atherosclerotic lesions and penetrating small-vessel
disease are more common in South America than in
developed countries.8,10 –12,14 –16
An unsolved puzzle is the contribution of racial-ethnic
factors to the particular expression of stroke patterns. The
South American population is heterogeneous and includes
native Indians, immigrants of all races, and a number of racial
admixtures. Therefore, it is difficult to group the patients
according to race or ethnic group even after considering skin
color or last names. Likewise, lifestyles, dietary habits, and
environmental conditions are not uniform in South America,
and results from a given study may not extrapolate to the
entire region. It is important to describe ethnic subgroups to
better understand stroke differences among different popula-
tions. The term “Hispanic,” used in US stroke studies to refer
to people coming from Latin America, should be banned from
South American studies attempting to evaluate the role of
race-ethnicity in the pattern of disease expression. A more
specific classification using terms such as whites, blacks,
mestizos, mulattos, and natives may be of more value in this
setting.
In summary, much has to be learned about stroke in South
America. Large-scale, multicentric community- and hospital-
based studies with standarized designs that make them
comparable to each other are urgently needed to increase our
knowledge of the epidemiology and patterns of stroke sub-
types in South America.
Acknowledgments
Drs Mario Muñoz (Bogotá, Colombia) and Ayrton Massaro (Sao
Paulo, Brazil) provided useful information for inclusion in this
review. We thank Dr Exuperio Diez Tejedor for his kind support.
References
1. Jaillard AS, Hommel M, Mazetti. Prevalence of stroke at high altitude
(3380 m) in Cuzco, a town in Peru: a population-based study. Stroke.
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2. Uribe CS, Jimenez I, Mora MO, Arana A, Sánzhez JL, Zuluaga L, Muñoz
A, Tobón J, Cardona EA, Buriticá OF, Villa LA. Epidemiología de las
enfermedades cerebrovasculares en Sabaneta, Colombia (1992–1993).
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 Saposnik and Del Brutto
alence of stroke: a door-to-door survey in rural Bolivia. Stroke. 2000;31:
882– 885.
4. Cruz ME, Schoemberg BS, Ruales J, Barberis P, Proaño J, Bossano J,
Sevilla F, Bolis CL. Pilot study to detect neurologic disease in Ecuador
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5. Pradilla G, Pardo CA, Daza JS, Zúñiga A. Neuroepidemiología en
Colombia: estudios en 16.032 individuos. Acta Neurol Colombiana.
1995;11:129 –133.
6. Pradilla-Ardilla G, Vesga-Angarita BE, León-Sarmiento FL. Estudio neu-
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7. Heckmann JG, Duran JC, Galeoto J. Vorkommen neurologischer
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8. Del Brutto OH, Mosquera A, Sánchez X, Santos J, Noboa CA. Stroke
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10. Nogales-Gaete J, Núñez L, Arriagada C, Sáez D, Figueroa T, Fernández
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Editorial Comment
Stroke Incidence and Quality Standard for Comparison
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Stroke is one of the leading causes of death in many
countries. Accordingly, the frequency of occurrence of stroke
provides essential information when planning community-
based programs intended for reduction of mortality. In
epidemiology, incidence is widely used as the measure of the
frequency of occurrence in populations. The measure is
potential of community-based studies to answer additional
questions based on an unbiased sample of incident cases
when understanding disease etiology. In addition, the inci-
dence also measures the density of events occurring during
the observation period. Because the differences in registration
procedures, case ascertainment, and diagnostic procedures1
could result in inaccurate measure of incidence, more accu-
rate ascertainment of the incidence is required. It needs to
define clearly for whom and what it uses when measuring the
incidence. If it applies to stroke, the numerator should use the
individuals defined by characteristic and background who
met the standardized criteria of stroke (including stroke
subtypes), and denominator should use those who become ill
(ie, population at risk).
Recently, stroke incidence has ranged widely among re-
ports from different regions of the world and at different
points in time using community-based stroke studies and
cohort studies in many countries.2–12 Among these reports,
there was no research for which the same diagnostic criteria,
diagnostic method, and population denominator were used.
Comparison of stroke incidence is only meaningful when
based on the same diagnostic criteria and procedures in
various parts of the world. Definitions (standard criteria) and
methods must be standardized for comparison.
Stroke in South America: A Systematic Review 2107
11. Saposnik G, Gonzalez L, Lepera S, Luraschi A, Sica REP, Caplan LR,
Rey RC. Southern Buenos Aires Stroke Project. Acta Neurol Scand.
2001;104:130 –135.
12. Saposnik G, Caplan LR, Gonzalez LA, Baird A, Dashe J, Luraschi A,
Llinas R, Lepera S, Linfante I, Chaves C, et al. Differences in stroke
subtypes among natives and Caucasians in Boston and Buenos Aires.
Stroke. 2000;31:2385–2389.
13. Flumingan-Zétola VH, Matos-Nóvak E, Ferreira-Camargo CH, Carraro-
Junior H, Coral P, Muzzio JA, Iwamoto FM, Della-Colleta MV,
Werneck LC. Acidente vascular cerebral em pacientes jovens: análise de
164 casos. Ar Qneuropsiquiatr. 2001;59:740 –745.
14. Peña I, Ruiz C, Morillo LE, Pedraza OL, Sánchez E, Santín LC, Zurek
R. Clasificación del TOAST en la práctica clínica de un hospital uni-
versitario. Acta Neurol Colombiana. 2001;17:304 –308.
15. Diaz V, Plate L, Erazo S, Cumsille MA, Venegas P. Prevalencia de la
ateromatosis carotídea en pacientes con enfermedad cerebrovascular
oclusiva. Rev Med Chil. 2001;129:161–165.
16. Siqueira-Neto JI, Santos AC, Fabio SR, Sakamoto AC. Cerebral
infarction in patients aged 15 to 40 years. Stroke. 1996;27:2016 –2019.
17. Del Brutto OH, Campos X, Tomalá M, Parrales H, Sánchez J.
Angiograhic findings in Ecuadorian mestizos with anterior circulation
occlusive cerebrovascular disease. Rev Ecuat Neurol. 1995;4:47–51.
18. Del Brutto OH, Sánchez J, Camos X, Santos J, Mosquera A. Non-
traumatic intracerebral hemorrhage in young adults living in Guayaquil,
Ecuador (South America): analysis of 151 patients. Funct Neurol.
1999;14:21–28.
In the early 1980s, the WHO MONICA (World Health
Organization Monitoring Trends and Determinants in Cardio-
vascular Disease) project was initiated to continuously regis-
ter the occurrence of stroke and myocardial infarction among
many populations by use of uniform procedures and methods
in 16 European and 2 Asian populations. Briefly, the protocol
for the stroke registers provided detailed instructions for
event registration. It included guidelines for case ascertain-
ment, outlined validation procedures, and gave specific cod-
ing rules for diagnostic category (definite stroke, unclassifi-
able, or not stroke), order of event (first or recurrent), and
case-fatality rate. Diagnostic criteria were applied to symp-
toms, clinical findings, and investigations undertaken within
28 days of onset.13
WHO MONICA provides the most reliable and multina-
tional compatible information on stroke incidence and case
fatality by using stroke registers, which can provide more
accurate estimates of incidence and mortality rates than
official routine statistics can.14 In addition, suspected stroke
events could be also classified through strictly standardized
methods and criteria.
Several studies have compared a population-based
MONICA stroke registry with hospital discharge registry.
According to Asplund et al,15 compared using the ratio of the
number of fatal stroke events in the MONICA registers to the
number of stroke deaths in routine mortality statistics, a
MONICA stroke register-to-routine mortality statistics ratio
⬍1.0 and ⱖ1 were found in 10 of the 21 populations. This
indicates that the official statistics may greatly underestimate
 2108 Stroke September 2003
or overestimate stroke mortality in many other areas. In
Swedish16 and Finnish17 MONICA populations, moreover,
10% to 13% false-positive and 14% to 17% false-negative
cases were found in the routine vital statistics. The proportion
of false-negative in nonfatal cases was slightly lower in the
population-based MONICA registry (4%) than in hospital
discharge registry (6%) and in official mortality statistics
(17%).16 Stegmayr et al18 stated, “The quality of official
mortality data varies between countries because of different
traditions and levels of reliability in assigning the cause of
death and because autopsies are not always performed. Data
based on the uniform registration procedures are likely to
give more reliable information about the total burden of
stroke among populations.”
This study provided some interesting information on epi-
demiological features of stroke in South America. First, this
study is a review based on published evidence of epidemio-
logical features of stroke in South America. Because data
used in this study was selected on the basis of prepared
inclusion criteria, it appeared that reliability and comparabil-
ity among selected studies of the results are high enough.
Second, most knowledge on stroke has mainly focused on
Eastern Europe and Northern America. There is very little
known about the peculiarities of stroke in South America. To
the best of our knowledge, this is the first study that has
systematically examined the epidemiological characteristics
of stroke in South America. Accordingly, the findings that
both the prevalence and incidence of stroke were lower in
South America than in developing countries are meaningful
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for identification of the etiologic factors of stroke.
Third, the study revealed a higher percentage of patients
with intracranial hemorrhage among stroke compared with
other countries,19 –21 although the pattern of stroke subtype
did not differ. A higher proportion of stroke patients with
arterial hypertension was also observed. Moreover, marked
differences in the pattern of stroke subtype and risk factors
other than hypertension were also observed among ethnicities
and countries.
This study provides important findings toward increasing
knowledge of the epidemiology of stroke and subsequently
leading to a plan for prevention programs of stroke in South
America.
Kazushi Okamoto, MD, PhD, Guest Editor
Department of Public Health
Aichi Prefectural College of Nursing and Health
Nagoya, Japan
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