J Korean Neurosurg Soc.  2020 Jan;63(1):56-68. 10.3340/jkns.2018.0179.

Trends in the Incidence and Treatment of Cerebrovascular Diseases in Korea : Part I. Intracranial Aneurysm, Intracerebral Hemorrhage, and Arteriovenous Malformation

• Lee SU
• Kim T
• Kwon OK
• Bang JS
• Ban SP
• Byoun HS
• Oh CW

• KMID: 2501693
• DOI: http://doi.org/10.3340/jkns.2018.0179

Abstract

Objective
: To analyze the incidence and treatment trends of hemorrhagic stroke (HS), according to HS subtypes, using nationwide data in Korea from January 2008 to December 2016.
Methods
: We used data from the national health-claim database provided by the National Health Insurance Service for 2008–2016 using the International Classification of Diseases. The crude incidence and age-standardized incidence of each disease associated with HS, which included intracranial aneurysm (IA), hypertensive intracerebral hemorrhage (ICH), and arteriovenous malformation (AVM), were calculated and additional analysis was conducted according to age and sex. Changes in trends in treatment methods and number of treatments were analyzed for each cerebrovascular disease using the Korean Classification of Diseases procedure codes.
Results
: In 2016, the total number of newly diagnosed adult patients with HS was 24169, showing a decrease by 7.0% since 2008; the age-standardized incidence of HS was 46.2 per 100000 person-years. The age-standardized incidence of unruptured IA (UIA) in adults was 71.4 per 100000 person-years—increased by 2.6-fold since 2008—while that of ruptured IA (RIA) was 12.6 per 100000 person-years, which had decreased at a rate of 20.3% since 2008. The number of coil embolization (CE) for UIA increased by 3.4-fold over 9 years and exceeded that of clipping since 2008. With respect to RIA, CE increased by 2.0-fold over 9 years and exceeded that of clipping from 2014. As for spontaneous ICH in adults, the age-standardized incidence was 31.3 per 100000 personyears in 2016—decreased by 34.7% since 2008—and 14.6% of patients diagnosed with ICH were treated in 2016, which was not significantly different from the proportion of patients treated since 2008. The age-standardized incidence of unruptured AVM (UAVM) was 2.0 per 100000 person-year in 2016, while that of ruptured AVM (RAVM) was 2.4 per 100000 person-years in 2016, showing a decreasing rate of 17.2% from 2008. The total number of treated patients with AVM declined since 2014.
Conclusion
: In Korea, age-related cerebral vascular diseases, such as RIA, ICH, and RAVM, demonstrated a declining trend in agestandardized incidence; meanwhile, UIA and UAVM demonstrated an increased trend in both crude incidence and age-standardized incidence for 9 years. The increase in the elderly population, management of hypertension, and development of diagnostic and endovascular techniques appear to have influenced this trend.

Keyword

National health service; Intracranial aneurysm; Cerebral hemorrhage; Arteriovenous malformation; Incidence

Figure

• 

  Fig. 1. A : Total number of patients diagnosed with UIA and both the crude incidence and age-standardized incidence of UIA showed an increasing trend over 9 years. B : Total number of patients diagnosed with RIA and the crude incidence revealed no significant change from 2008 to 2016. Meanwhile, the age-standardized incidence of RIA steadily decreased over the 9 examined years. UIA : unruptured intracranial aneurysm, RIA : ruptured intracranial aneurysm.

• 

  Fig. 2. A and B : Crude incidence for each age group diagnosed with UIA in 2008 (A) and 2016 (B). The age-specific incidence increased for all ages over 9 years and was highest for patients in their 70s. In patients in their 20s or older, the incidence in female patients was higher than the incidence in male patients; in 2016, the largest difference was seen in patients in their 50s; the incidence in female patients was 2.0-times greater than that in male patients. C and D : Age-specific incidence for each age group diagnosed with RIA in 2008 (C) and 2016 (D). For all ages except those in their 80s, the agespecific incidence decreased over 9 years. In patients in their 50s or older, the incidence in female patients exceed that in male patients. The difference in incidence according to sex tends to increase with age; thus, in 2016, the incidence in female patients in their 60s and 70s was 1.9-times and 2.6-times higher than that in male patients, respectively. UIA : unruptured intracranial aneurysm, RIA : ruptured intracranial aneurysm.

• 

  Fig. 3. A : In the case of UIA, CE increased by 29.5% per year over 9 years and clipping increased by 16.0% per year. The percentage of patients older than 60 years who were treated with clipping and CE treatment increased from 44.3% and 44.6% in 2008 to 50.1% and 52.6% in 2016, respectively. B : For RIA, CE increased by 97.4% over 9 years, but clipping decreased by 39.2%. CE has exceeded clipping since 2014 and was reported 2.0-times more often than clipping in 2016. The number of CEs performed in patients older than 60 years increased by 114.5%, but the number of clipping cases decreased by 28.5%. Overall, the number of treated patients older than 60 years increased from 36.6% of total treated patients for RIA in 2008 to 42.2% in 2016. UIA : unruptured intracranial aneurysm, CE : coil embolization, RIA : ruptured intracranial aneurysm.

• 

  Fig. 4. A : Both the crude incidence and age-standardized incidence of ICH have declined over the past 8 years, while the decrease in age-standardized incidence is greater. B and C : Age-specific incidence for each age group diagnosed with ICH in 2008 (A) and 2016 (B). Overall, the crude incidence was higher in male patients, and decreased in all ages over 9 years. ICH : intracerebral hemorrhage.

• 

  Fig. 5. A : The total number of patients diagnosed with UAVM and both the crude incidence and age-standardized incidence of UAVM showed slight increase over 9 years, although there was no significant linear trend. B : The total number of patients diagnosed with RAVM and the crude incidence revealed no significant change from 2008 to 2016. Meanwhile, the age-standardized incidence of RAVM has been decreasing steadily for 9 years. UAVM : unruptured arteriovenous malformation, RAVM : ruptured arteriovenous malformation.

• 

  Fig. 6. A and B : Age-specific incidence for each age group diagnosed with UAVM in 2008 (A) and 2016 (B). The age-specific incidence was the highest in 60s and increased in patients older than 50 years over 9 years. Regarding the crude incidence according to sex, female patients over the age of 60 tended to have a higher crude incidence than male patients. C and D : Age-specific incidence for each age group diagnosed with RAVM in 2008 (C) and 2016 (D). The age-specific incidence of RAVM increased with age and decreased in most age groups over 9 years, except in patients older than 80 years, and did not show significant differences according to sex. UAVM : unruptured arteriovenous malformation, RAVM : ruptured arteriovenous malformation.

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  Fig. 7. Craniotomy has been declining since 2008, and only 3.5% of patients diagnosed with AVM underwent craniotomy in 2016. Embolization and SRS use increased to 11.9% in 2014 and 15.9% in 2012, respectively, and then declined to 6.1% and 11%, respectively, in 2016. SRS : stereotactic radiosurgery, AVM : arteriovenous malformation.

Reference

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