Stroke: A Global Killer on the Rise Najib E. El Tecle 1 , Tarek Y. El Ahmadieh 1 , Allan D. Nanney III 1 , Jamal McClendon, Jr. 1 , Bernard R. Bendok 1,2 How a disease ranks vis-à-vis morbidity and mortality will dictate the allocation of clinical and research resources. This ranking can define strategic planning for national and international health organizations as well as biomedical corporations. With ever diminishing resources, the need to understand healthcare priori- ties and reduce disease burden on society is more critical than ever. In an effort to gain greater insight into this issue, Lozano et al., part of the Global Burden of Disease 2010 team, spent 5 years researching all available data related to mortality in 187 countries between 1980 and 2010. Their work was recently published in the Lancet (1). Lozano et al. present a complex and thorough analysis of the collected data with the aim of determining cause-specific mortality per age group, year, and country. A stepwise method- ology was used to collect and analyze data. Sources included medical certification of causes of death, verbal autopsy data, population-based cancer registries, police and crime reports, demographic and health surveys, as well as data on deaths in health facilities. The data collection and study analysis consumed a daunting 5 years, with countless hours dedicated to imperfect data processing. The study period was over 30 years, but because data prior to 1990 were deemed insufficient for robust analysis, the final analysis was done for the years 1990e2010. Data were then processed using complex statistical models. For the modeling of individual causes of death, the Cause of Death ensemble Modeling was used for all major causes of death except HIV/AIDS and measles. For rare causes of death, the authors used fixed proportion models. Finally, the authors combined the results for individual causes of death to generate a final model. In their final analysis, the 2 leading causes of death worldwide between 1990 and 2010 remain ischemic heart disease and stroke. Ischemic heart disease was responsible for 13.3% among all causes of death in 2010; stroke followed at 11.1%, roughly split equally between ischemic stroke and hemorrhagic stroke. Combined, ischemic heart disease and all forms of stroke resulted in 12.9 million deaths in 2010, a quarter of the global total, compared with one fifth of the global total 20 years earlier. These numbers, however, should be cautiously interpreted in light of a parallel increase in life expectancy and success in treatment and management of communicable diseases. One potential cause for this shift in proportions is an apparent decrease in the number of fatalities due to communicable, maternal, neonatal, and nutri- tional disorders as relative to noncommunicable diseases and injuries. Another potential cause for this shift is a decrease in the number of fatalities due to acute causes as compared to chronic conditions, with an increase in death due to diabetes and hypertension, which are major risk factors for stoke and ischemic heart disease (Figure 1). As life expectancy continues to increase and stroke risk factors also increase concordantly in prevalence, stroke and heart disease will presumably remain leading global killers. Lozano et al. also analyzed the impact of diseases on years lost relative to life expectancy (years of life lost) between 1990 and 2010. Stroke moved from fifth position in 1990 to third position after ischemic heart disease and lower respiratory infections in 2010. This is possibly related to improvements that occurred in the management of diarrhea and preterm birth complications, which were the second and third causes of years of life lost, respectively, in 1990. Thus, not only is stroke a more prevalent disease that is resulting in more deaths worldwide, it is also a leading cause of loss of productivity among people who could potentially have lived longer, healthier, and more fruitful lives. The analysis by Lozano et al. is an indication that a greater proportion of national and international resources should now be focused on stroke prevention, diagnosis, and treatment. Global efforts to combat malnutrition, infection, and infant mortality have resulted in stroke rising as a global health concern. Modern stroke management requires multi-modal prevention strategies, rapid and reliable diagnosis, and effective surgical therapies. As technological advances both improve current surgical tools and add additional modalities to our armamentarium to combat stroke, neurosurgeons will be increasingly more essential in this global effort. Neurosurgeons in outpatient settings, inpatient settings, laboratory settings, clinical trial centers, and in govern- ment and industry circles can play a profound role in combating stroke in all its forms (2). 2 www.SCIENCEDIRECT.com 80 [1/2]: 2-12, JULY/AUGUST 2013 WORLD NEUROSURGERY