National and Regional Trends in Hemorrhagic Stroke Mortality in Brazil, 2000-2023

Abstract

Introduction Hemorrhagic stroke contributes disproportionately to stroke-related mortality and disability. This study examined national, regional, and sex-specific trends in hemorrhagic stroke mortality among Brazilian adults from 2000 to 2023 and assessed whether these trends changed during the COVID-19 pandemic. Materials and methods We conducted a population-based ecological time-series study using data from the Brazilian Mortality Information System. Deaths among adults aged 20 years or older were identified by International Classification of Diseases, 10th Revision codes I60-I62. Crude and age-standardized mortality rates were calculated per 100,000 population. Direct standardization used the age distribution of the 2022 Brazilian Census population. Weighted log-linear regression was used to estimate annual percentage changes (APCs) and 95% confidence intervals (CIs). Temporal slopes were compared by sex and geographic region. An interrupted time-series analysis with a fixed breakpoint at 2020 assessed immediate and postpandemic changes. Sensitivity analyses excluded 2020 and 2021 and compared crude with age-standardized rates. Results Between 2000 and 2023, 500,301 hemorrhagic stroke deaths were recorded. Annual deaths increased from 17,846 to 23,945, whereas the age-standardized mortality rate declined from 22.3 to 14.8 per 100,000 population. Mortality decreased nationally (APC, -2.09%; 95% CI, -2.36% to -1.82%) and among both men (APC, -1.98%; 95% CI, -2.25% to -1.71%) and women (APC, -2.18%; 95% CI, -2.47% to -1.90%). Regional trends differed: mortality was statistically stable in the North (APC, -0.08%; 95% CI, -0.51% to 0.35%) and Northeast (APC, -0.40%; 95% CI, -0.84% to 0.05%) and decreased in the Southeast, South, and Central-West. The interrupted time-series analysis found no significant immediate change in national mortality in 2020 (-6.3%; 95% CI, -15.6% to 4.2%). Excluding 2020 and 2021 did not materially change the direction or statistical classification of the national trend. Conclusions Age-standardized hemorrhagic stroke mortality declined in Brazil despite an increase in the absolute number of deaths, indicating that population growth and aging increased the mortality burden while age-specific risk decreased. National improvement concealed substantial regional disparities, with substantially less favorable trends in the North and Northeast than in the Southeast, South, and Central-West. These findings support prioritizing regional investigation of hypertension control, access to organized stroke care, and cause-of-death classification.