Burden of intracerebral hemorrhage and its risk factors in China: findings from the Global Burden of Disease Study 2021_West China Medical Journal

Authors：

GAO Zijing , YAN Siyu , LIU Yifan , TIAN Rui ,  YOU Chao

Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

YOU Chao, Email: youchao@vip.126.com

Keywords：

Intracerebral hemorrhage; burden of disease; trend analysis; decomposition analysis; risk factors; China

DOI：

10.7507/1002-0179.202501101

Video：

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Objective To analyze the trends in the burden of intracerebral hemorrhage (ICH) and its related risk factors in China from 1990 to 2021, providing evidence for targeted prevention and control. Methods Based on public data from the Global Burden of Disease Study 2021, four epidemiological indicators, including incidence, prevalence, deaths, and disability-adjusted life-years (DALYs) were selected to describe the burden of ICH in China in 2021. Change rates and estimated annual percentage changes (EAPC) were calculated to evaluate the trends in disease burden from 1990 to 2021. The Das Gupta method was used to decompose the effects of population growth, population aging and epidemiological changes on the burden during this period. Finally, the attributable burden of risk factors related to ICH was analyzed. Results In 2021, the age-standardized incidence, prevalence, mortality, and DALY rates of ICH in China were 61.2/100000, 222.1/100000, 68.8/100000, and 1351.6/100000, respectively, all higher than global estimates. From 1990 to 2021, although these rates showed a declining trend (EAPC: −2.24, −1.26, −2.38, and −2.47, respectively), the absolute disease burden, including the absolute number of prevalence cases, incidence cases, deaths, and DALYs, continued to rise, with an increase ranging from 20.57% to 51.59%. In addition, the burden of ICH in China varied by age and sex, with older adults and males experiencing a higher burden. Decomposition analysis indicated that population aging and growth were the primary drivers of the increasing ICH burden in China, while epidemiological changes mitigated this trend. Metabolic factors were the predominant attributable risk factors for ICH. High systolic blood pressure, ambient particulate matter pollution, and diet high in sodium were important risk factors common to both genders. The DALY burden attributable to smoking and alcohol use was higher in men, whereas impaired kidney function and secondhand smoke had a greater impact on women. Conclusions The burden of ICH in China has continued to increase from 1990 to 2021, and it may further escalate in the context of population aging. Risk factor control remains a key priority for prevention. Future strategies should incorporate age- and sex-specific interventions to reduce the ICH burden in China.

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2.	GBD 2021 Stroke Risk Factor Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet Neurol, 2024, 23(10): 973-1003.
3.	吴亚哲, 陈伟伟. 中国脑卒中流行概况. 心脑血管病防治, 2016, 16(6): 410-414.
4.	GBD 2021 Diseases and Injuries Collaborators. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024, 403(10440): 2133-2161.
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6.	GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol, 2021, 20(10): 795-820.
7.	Stevens GA, Alkema L, Black RE, et al. Guidelines for accurate and transparent health estimates reporting: the GATHER statement. Lancet, 2016, 388(10062): e19-e23.
8.	GBD 2021 Risk Factors Collaborators. Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024, 403(10440): 2162-2203.
9.	Qin Y, Tong X, Fan J, et al. Global burden and trends in incidence, mortality, and disability of stomach cancer from 1990 to 2017. Clin Transl Gastroenterol, 2021, 12(10): e00406.
10.	Das Gupta P. Standardization and decomposition of rates: a user’s manual. Washington, D. C.: U. S. Dept. of Commerce, Economics and Statistics Administration, Bureau of the Census: For sale by Supt. of Docs., U. S. G. P. O., 1993.
11.	Prust ML, Forman R, Ovbiagele B. Addressing disparities in the global epidemiology of stroke. Nat Rev Neurol, 2024, 20(4): 207-221.
12.	O’Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet, 2010, 376(9735): 112-123.
13.	Wang S, Zou XL, Wu LX, et al. Epidemiology of intracerebral hemorrhage: a systematic review and meta-analysis. Front Neurol, 2022, 13: 915813.
14.	国家统计局, 国务院第七次全国人口普查领导小组办公室. 第七次全国人口普查公报(第五号)——人口年龄构成情况. 中国统计, 2021(5): 10-11.
15.	任泽平. 中国老龄化报告. 发展研究, 2023, 40(2): 22-30.
16.	SPS3 Study Group, Benavente OR, Coffey CS, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet, 2013, 382(9891): 507-515.
17.	Wang Z, Chen Z, Zhang L, et al. Status of hypertension in china: results from the China Hypertension Survey, 2012-2015. Circulation, 2018, 137(22): 2344-2356.
18.	Wu Y, Huxley R, Li L, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from the China National Nutrition and Health Survey 2002. Circulation, 2008, 118(25): 2679-2686.
19.	Zhang M, Shi Y, Zhou B, et al. Prevalence, awareness, treatment, and control of hypertension in China, 2004-18: findings from six rounds of a national survey. BMJ, 2023, 380: e071952.
20.	Huang K, Liang F, Yang X, et al. Long term exposure to ambient fine particulate matter and incidence of stroke: prospective cohort study from the China-PAR project. BMJ, 2019, 367: l6720.
21.	Lin H, Tao J, Du Y, et al. Differentiating the effects of characteristics of PM pollution on mortality from ischemic and hemorrhagic strokes. Int J Hyg Environ Health, 2016, 219(2): 204-211.
22.	Yorifuji T, Suzuki E, Kashima S. Cardiovascular emergency hospital visits and hourly changes in air pollution. Stroke, 2014, 45(5): 1264-1268.
23.	Qian Y, Zhu M, Cai B, et al. Epidemiological evidence on association between ambient air pollution and stroke mortality. J Epidemiol Community Health, 2013, 67(8): 635-640.
24.	Yamazaki S, Nitta H, Ono M, et al. Intracerebral haemorrhage associated with hourly concentration of ambient particulate matter: case-crossover analysis. Occup Environ Med, 2007, 64(1): 17-24.
25.	Tsai SS, Goggins WB, Chiu HF, et al. Evidence for an association between air pollution and daily stroke admissions in Kaohsiung, Taiwan. Stroke, 2003, 34(11): 2612-2616.
26.	Neal B, Wu Y, Feng X, et al. Effect of salt substitution on cardiovascular events and death. N Engl J Med, 2021, 385(12): 1067-1077.
27.	Du S, Wang H, Zhang B, et al. Dietary potassium intake remains low and sodium intake remains high, and most sodium is derived from home food preparation for Chinese adults, 1991-2015 trends. J Nutr, 2020, 150(5): 1230-1239.
28.	中华人民共和国国家卫生健康委员会. 中国吸烟危害健康报告 2020. 北京: 人民卫生出版社, 2021.
29.	Hou L, Han W, Jiang J, et al. Passive smoking and stroke in men and women: a national population-based case-control study in China. Sci Rep, 2017, 7(1): 45542.
30.	Nishino Y, Tsuji I, Tanaka H, et al. Stroke mortality associated with environmental tobacco smoke among never-smoking Japanese women: a prospective cohort study. Prev Med, 2014, 67: 41-45.
31.	Shah RS, Cole JW. Smoking and stroke: the more you smoke the more you stroke. Expert Rev Cardiovasc Ther, 2010, 8(7): 917-932.
32.	Woodward M, Lam TH, Barzi F, et al. Smoking, quitting, and the risk of cardiovascular disease among women and men in the Asia-Pacific region. Int J Epidemiol, 2005, 34(5): 1036-1045.
33.	Smyth A, O’Donnell M, Rangarajan S, et al. Alcohol intake as a risk factor for acute stroke: the INTERSTROKE Study. Neurology, 2023, 100(2): e142-e153.
34.	Yu Z, Liu S, Guo R, et al. Putting the glass down may keep the stroke away: results from a prospective cohort study in rural China. Nutr Metab Cardiovasc Dis, 2021, 31(4): 1113-1120.
35.	Wang L, Xu X, Zhang M, et al. Prevalence of chronic kidney disease in China: results from the Sixth China Chronic Disease and Risk Factor Surveillance. JAMA Intern Med, 2023, 183(4): 298-310.
36.	Xu M, Zhang S, Liu J, et al. Kidney dysfunction is associated with a high burden of cerebral small vessel disease in primary intracerebral hemorrhage. Curr Neurovasc Res, 2018, 15(1): 39-46.
37.	Naganuma T, Takemoto Y, Shoji T, et al. Cerebral microbleeds predict intracerebral hemorrhage in hemodialysis patients. Stroke, 2015, 46(8): 2107-2112.
38.	Toyoda K, Ninomiya T. Stroke and cerebrovascular diseases in patients with chronic kidney disease. Lancet Neurol, 2014, 13(8): 823-833.
39.	Lau WL, Huisa BN, Fisher M. The cerebrovascular-chronic kidney disease connection: perspectives and mechanisms. Transl Stroke Res, 2017, 8(1): 67-76.
40.	Saulle MF, Schambra HM. Recovery and rehabilitation after intracerebral hemorrhage. Semin Neurol, 2016, 36(3): 306-312.
41.	Lee KB, Kim JS, Hong BY, et al. The motor recovery related with brain lesion in patients with intracranial hemorrhage. Behav Neurol, 2015, 2015: 258161.
42.	Daverat P, Castel JP, Dartigues JF, et al. Death and functional outcome after spontaneous intracerebral hemorrhage. A prospective study of 166 cases using multivariate analysis. Stroke, 1991, 22(1): 1-6.
43.	Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet, 2023, 402(10395): 27-40.
44.	Liu N, Cadilhac DA, Andrew NE, et al. Randomized controlled trial of early rehabilitation after intracerebral hemorrhage stroke: difference in outcomes within 6 months of stroke. Stroke, 2014, 45(12): 3502-3507.
45.	Mortensen J, Figlewski K, Andersen H. Combined transcranial direct current stimulation and home-based occupational therapy for upper limb motor impairment following intracerebral hemorrhage: a double-blind randomized controlled trial. Disabil Rehabil, 2016, 38(7): 637-643.
46.	Frolov AA, Bobrov PD, Biryukova EV, et al. Electrical, hemodynamic, and motor activity in bci post-stroke rehabilitation: clinical case study. Front Neurol, 2018, 9: 1135.
47.	Elashmawi WH, Ayman A, Antoun M, et al. A comprehensive review on brain-computer interface (BCI)-based machine and deep learning algorithms for stroke rehabilitation. Appl Sci, 2024, 14(14): 6347.

1. Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet, 2009, 373(9675): 1632-1644.
2. GBD 2021 Stroke Risk Factor Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet Neurol, 2024, 23(10): 973-1003.
3. 吴亚哲, 陈伟伟. 中国脑卒中流行概况. 心脑血管病防治, 2016, 16(6): 410-414.
4. GBD 2021 Diseases and Injuries Collaborators. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024, 403(10440): 2133-2161.
5. GBD 2021 Causes of Death Collaborators. Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024, 403(10440): 2100-2132.
6. GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol, 2021, 20(10): 795-820.
7. Stevens GA, Alkema L, Black RE, et al. Guidelines for accurate and transparent health estimates reporting: the GATHER statement. Lancet, 2016, 388(10062): e19-e23.
8. GBD 2021 Risk Factors Collaborators. Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet, 2024, 403(10440): 2162-2203.
9. Qin Y, Tong X, Fan J, et al. Global burden and trends in incidence, mortality, and disability of stomach cancer from 1990 to 2017. Clin Transl Gastroenterol, 2021, 12(10): e00406.
10. Das Gupta P. Standardization and decomposition of rates: a user’s manual. Washington, D. C.: U. S. Dept. of Commerce, Economics and Statistics Administration, Bureau of the Census: For sale by Supt. of Docs., U. S. G. P. O., 1993.
11. Prust ML, Forman R, Ovbiagele B. Addressing disparities in the global epidemiology of stroke. Nat Rev Neurol, 2024, 20(4): 207-221.
12. O’Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet, 2010, 376(9735): 112-123.
13. Wang S, Zou XL, Wu LX, et al. Epidemiology of intracerebral hemorrhage: a systematic review and meta-analysis. Front Neurol, 2022, 13: 915813.
14. 国家统计局, 国务院第七次全国人口普查领导小组办公室. 第七次全国人口普查公报(第五号)——人口年龄构成情况. 中国统计, 2021(5): 10-11.
15. 任泽平. 中国老龄化报告. 发展研究, 2023, 40(2): 22-30.
16. SPS3 Study Group, Benavente OR, Coffey CS, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet, 2013, 382(9891): 507-515.
17. Wang Z, Chen Z, Zhang L, et al. Status of hypertension in china: results from the China Hypertension Survey, 2012-2015. Circulation, 2018, 137(22): 2344-2356.
18. Wu Y, Huxley R, Li L, et al. Prevalence, awareness, treatment, and control of hypertension in China: data from the China National Nutrition and Health Survey 2002. Circulation, 2008, 118(25): 2679-2686.
19. Zhang M, Shi Y, Zhou B, et al. Prevalence, awareness, treatment, and control of hypertension in China, 2004-18: findings from six rounds of a national survey. BMJ, 2023, 380: e071952.
20. Huang K, Liang F, Yang X, et al. Long term exposure to ambient fine particulate matter and incidence of stroke: prospective cohort study from the China-PAR project. BMJ, 2019, 367: l6720.
21. Lin H, Tao J, Du Y, et al. Differentiating the effects of characteristics of PM pollution on mortality from ischemic and hemorrhagic strokes. Int J Hyg Environ Health, 2016, 219(2): 204-211.
22. Yorifuji T, Suzuki E, Kashima S. Cardiovascular emergency hospital visits and hourly changes in air pollution. Stroke, 2014, 45(5): 1264-1268.
23. Qian Y, Zhu M, Cai B, et al. Epidemiological evidence on association between ambient air pollution and stroke mortality. J Epidemiol Community Health, 2013, 67(8): 635-640.
24. Yamazaki S, Nitta H, Ono M, et al. Intracerebral haemorrhage associated with hourly concentration of ambient particulate matter: case-crossover analysis. Occup Environ Med, 2007, 64(1): 17-24.
25. Tsai SS, Goggins WB, Chiu HF, et al. Evidence for an association between air pollution and daily stroke admissions in Kaohsiung, Taiwan. Stroke, 2003, 34(11): 2612-2616.
26. Neal B, Wu Y, Feng X, et al. Effect of salt substitution on cardiovascular events and death. N Engl J Med, 2021, 385(12): 1067-1077.
27. Du S, Wang H, Zhang B, et al. Dietary potassium intake remains low and sodium intake remains high, and most sodium is derived from home food preparation for Chinese adults, 1991-2015 trends. J Nutr, 2020, 150(5): 1230-1239.
28. 中华人民共和国国家卫生健康委员会. 中国吸烟危害健康报告 2020. 北京: 人民卫生出版社, 2021.
29. Hou L, Han W, Jiang J, et al. Passive smoking and stroke in men and women: a national population-based case-control study in China. Sci Rep, 2017, 7(1): 45542.
30. Nishino Y, Tsuji I, Tanaka H, et al. Stroke mortality associated with environmental tobacco smoke among never-smoking Japanese women: a prospective cohort study. Prev Med, 2014, 67: 41-45.
31. Shah RS, Cole JW. Smoking and stroke: the more you smoke the more you stroke. Expert Rev Cardiovasc Ther, 2010, 8(7): 917-932.
32. Woodward M, Lam TH, Barzi F, et al. Smoking, quitting, and the risk of cardiovascular disease among women and men in the Asia-Pacific region. Int J Epidemiol, 2005, 34(5): 1036-1045.
33. Smyth A, O’Donnell M, Rangarajan S, et al. Alcohol intake as a risk factor for acute stroke: the INTERSTROKE Study. Neurology, 2023, 100(2): e142-e153.
34. Yu Z, Liu S, Guo R, et al. Putting the glass down may keep the stroke away: results from a prospective cohort study in rural China. Nutr Metab Cardiovasc Dis, 2021, 31(4): 1113-1120.
35. Wang L, Xu X, Zhang M, et al. Prevalence of chronic kidney disease in China: results from the Sixth China Chronic Disease and Risk Factor Surveillance. JAMA Intern Med, 2023, 183(4): 298-310.
36. Xu M, Zhang S, Liu J, et al. Kidney dysfunction is associated with a high burden of cerebral small vessel disease in primary intracerebral hemorrhage. Curr Neurovasc Res, 2018, 15(1): 39-46.
37. Naganuma T, Takemoto Y, Shoji T, et al. Cerebral microbleeds predict intracerebral hemorrhage in hemodialysis patients. Stroke, 2015, 46(8): 2107-2112.
38. Toyoda K, Ninomiya T. Stroke and cerebrovascular diseases in patients with chronic kidney disease. Lancet Neurol, 2014, 13(8): 823-833.
39. Lau WL, Huisa BN, Fisher M. The cerebrovascular-chronic kidney disease connection: perspectives and mechanisms. Transl Stroke Res, 2017, 8(1): 67-76.
40. Saulle MF, Schambra HM. Recovery and rehabilitation after intracerebral hemorrhage. Semin Neurol, 2016, 36(3): 306-312.
41. Lee KB, Kim JS, Hong BY, et al. The motor recovery related with brain lesion in patients with intracranial hemorrhage. Behav Neurol, 2015, 2015: 258161.
42. Daverat P, Castel JP, Dartigues JF, et al. Death and functional outcome after spontaneous intracerebral hemorrhage. A prospective study of 166 cases using multivariate analysis. Stroke, 1991, 22(1): 1-6.
43. Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet, 2023, 402(10395): 27-40.
44. Liu N, Cadilhac DA, Andrew NE, et al. Randomized controlled trial of early rehabilitation after intracerebral hemorrhage stroke: difference in outcomes within 6 months of stroke. Stroke, 2014, 45(12): 3502-3507.
45. Mortensen J, Figlewski K, Andersen H. Combined transcranial direct current stimulation and home-based occupational therapy for upper limb motor impairment following intracerebral hemorrhage: a double-blind randomized controlled trial. Disabil Rehabil, 2016, 38(7): 637-643.
46. Frolov AA, Bobrov PD, Biryukova EV, et al. Electrical, hemodynamic, and motor activity in bci post-stroke rehabilitation: clinical case study. Front Neurol, 2018, 9: 1135.
47. Elashmawi WH, Ayman A, Antoun M, et al. A comprehensive review on brain-computer interface (BCI)-based machine and deep learning algorithms for stroke rehabilitation. Appl Sci, 2024, 14(14): 6347.

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Latest ArticlesBurden of intracerebral hemorrhage and its risk factors in China: findings from the Global Burden of Disease Study 2021

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