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Stroke Prevention
and Treatment
Second Edition
Stroke Prevention
and Treatment
An Evidence-based Approach
Second Edition

Edited by
Jeffrey L. Saver
David Geffen School of Medicine, University of California

Graeme J. Hankey
Medical School, The University of Western Australia
University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre,
New Delhi – 110025, India
79 Anson Road, #06–04/06, Singapore 079906

Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning, and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107113145
DOI: 10.1017/9781316286234
© Cambridge University Press 2005, 2021
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2005
Reprinted 2006
Second edition 2021
Printed in the United Kingdom by TJ Books Ltd, Padstow Cornwall
A catalogue record for this publication is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Saver, Jeffrey L., editor. | Hankey, Graeme J., editor. | Hankey, Graeme J. Stroke treatment and prevention.
Title: Stroke prevention and treatment : an evidence-based approach / edited by Jeffrey L. Saver, Graeme J. Hankey.
Other titles: Stroke treatment and prevention.
Description: Second edition. | Cambridge, United Kingdom ; New York, NY : Cambridge University Press, 2020. | Preceded by
Stroke treatment and prevention : an evidence-based approach / Graeme J. Hankey. 2005. | Includes bibliographical references and
index.
Identifiers: LCCN 2019038966 (print) | LCCN 2019038967 (ebook) | ISBN 9781107113145 (hardback) | ISBN 9781316286234
(ebook)
Subjects: MESH: Stroke – prevention & control | Stroke – therapy | Stroke Rehabilitation | Evidence-Based Medicine
Classification: LCC RC388.5 (print) | LCC RC388.5 (ebook) | NLM WL 356 |DDC 616.8/1–dc23
LC record available at https://lccn.loc.gov/2019038966
LC ebook record available at https://lccn.loc.gov/2019038967
ISBN 978-1-107-11314-5 Hardback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
................................................................................................................................

Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted
standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to
disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical standards are constantly changing through research
and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from
the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Stroke Prevention
and Treatment
Second Edition
Stroke Prevention
and Treatment
An Evidence-based Approach
Second Edition

Edited by
Jeffrey L. Saver
David Geffen School of Medicine, University of California

Graeme J. Hankey
Medical School, The University of Western Australia
University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre,
New Delhi – 110025, India
79 Anson Road, #06–04/06, Singapore 079906

Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning, and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107113145
DOI: 10.1017/9781316286234
© Cambridge University Press 2005, 2021
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2005
Reprinted 2006
Second edition 2021
Printed in the United Kingdom by TJ Books Ltd, Padstow Cornwall
A catalogue record for this publication is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Saver, Jeffrey L., editor. | Hankey, Graeme J., editor. | Hankey, Graeme J. Stroke treatment and prevention.
Title: Stroke prevention and treatment : an evidence-based approach / edited by Jeffrey L. Saver, Graeme J. Hankey.
Other titles: Stroke treatment and prevention.
Description: Second edition. | Cambridge, United Kingdom ; New York, NY : Cambridge University Press, 2020. | Preceded by
Stroke treatment and prevention : an evidence-based approach / Graeme J. Hankey. 2005. | Includes bibliographical references and
index.
Identifiers: LCCN 2019038966 (print) | LCCN 2019038967 (ebook) | ISBN 9781107113145 (hardback) | ISBN 9781316286234
(ebook)
Subjects: MESH: Stroke – prevention & control | Stroke – therapy | Stroke Rehabilitation | Evidence-Based Medicine
Classification: LCC RC388.5 (print) | LCC RC388.5 (ebook) | NLM WL 356 |DDC 616.8/1–dc23
LC record available at https://lccn.loc.gov/2019038966
LC ebook record available at https://lccn.loc.gov/2019038967
ISBN 978-1-107-11314-5 Hardback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
................................................................................................................................

Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted
standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to
disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical standards are constantly changing through research
and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from
the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
Stroke Prevention
and Treatment
Second Edition
Stroke Prevention
and Treatment
An Evidence-based Approach
Second Edition

Edited by
Jeffrey L. Saver
David Geffen School of Medicine, University of California

Graeme J. Hankey
Medical School, The University of Western Australia
University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
477 Williamstown Road, Port Melbourne, VIC 3207, Australia
314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre,
New Delhi – 110025, India
79 Anson Road, #06–04/06, Singapore 079906

Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning, and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107113145
DOI: 10.1017/9781316286234
© Cambridge University Press 2005, 2021
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2005
Reprinted 2006
Second edition 2021
Printed in the United Kingdom by TJ Books Ltd, Padstow Cornwall
A catalogue record for this publication is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Saver, Jeffrey L., editor. | Hankey, Graeme J., editor. | Hankey, Graeme J. Stroke treatment and prevention.
Title: Stroke prevention and treatment : an evidence-based approach / edited by Jeffrey L. Saver, Graeme J. Hankey.
Other titles: Stroke treatment and prevention.
Description: Second edition. | Cambridge, United Kingdom ; New York, NY : Cambridge University Press, 2020. | Preceded by
Stroke treatment and prevention : an evidence-based approach / Graeme J. Hankey. 2005. | Includes bibliographical references and
index.
Identifiers: LCCN 2019038966 (print) | LCCN 2019038967 (ebook) | ISBN 9781107113145 (hardback) | ISBN 9781316286234
(ebook)
Subjects: MESH: Stroke – prevention & control | Stroke – therapy | Stroke Rehabilitation | Evidence-Based Medicine
Classification: LCC RC388.5 (print) | LCC RC388.5 (ebook) | NLM WL 356 |DDC 616.8/1–dc23
LC record available at https://lccn.loc.gov/2019038966
LC ebook record available at https://lccn.loc.gov/2019038967
ISBN 978-1-107-11314-5 Hardback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
................................................................................................................................

Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted
standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to
disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical standards are constantly changing through research
and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from
the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
From Jeffrey L. Saver – I thank Don Easton, Ed Feldmann, Jose Biller, and
Lou Caplan for introducing me to evidence-based stroke medicine, and my
parents (Harry and Esther), wife (Kay), and son (Dash) for introducing me
to the world and evidence of its wonder.
From Graeme J. Hankey – I thank Charles Warlow, Peter Sandercock and
Jan van Gijn for introducing me to evidence-based stroke medicine, my
parents (Jean and John) and daughters (Genevieve and Michelle), and my
wife Claire for her longstanding love and support.
Contents
List of Contributors page ix
Preface – Jeffrey L. Saver and Graeme J. Hankey xiii

Part I Foundations 9 Acute Antiplatelet Therapy for the Treatment

of Ischaemic Stroke and Transient Ischaemic
1 Stroke: The Size of the Problem 1 Attack 154
Graeme J. Hankey Jeffrey L. Saver
2 Understanding Evidence 10 10 Acute Anticoagulant Therapy for
Jeffrey L. Saver and Graeme J. Hankey the Treatment of Acute Ischaemic
Stroke and Transient Ischaemic
Attack 179
Part II Systems of Care Xinyi Leng and Lawrence K.S. Wong
3 Prehospital Stroke Care and Regionalized 11 Treatment of Brain Oedema 199
Stroke Systems 35 Jeffrey L. Saver and Salvador Cruz-Flores
Kori Sauser Zachrison and Lee
H. Schwamm 12 Neuroprotection for Acute Brain
Ischaemia 214
4 Organized Stroke Care 59 Nerses Sanossian and Jeffrey L. Saver
Peter Langhorne

Part IV Acute Treatment

Part III Acute Treatment of of Haemorrhagic Stroke
Ischaemic Stroke and Transient
13 Acute Treatment of Intracerebral
Ischaemic Attack Haemorrhage 239
5 Supportive Care during Acute Cerebral Tom Moullaali, Rustam Al-Shahi Salman,
Ischaemia 77 and Craig Anderson
Askiel Bruno, Subhashini Ramesh, and 14 Acute Treatment of Subarachnoid
Jeffrey L. Saver Haemorrhage 260
6 Reperfusion of the Ischaemic Brain by Sherri A. Braksick and Alejandro
Intravenous Thrombolysis 98 A. Rabinstein
Jeffrey L. Saver and Joanna Wardlaw
7 Reperfusion of the Ischaemic Brain by Part V Prevention
Endovascular Thrombectomy and
Thrombolysis 127 15 Prevention of Stroke by Lowering Blood
Pressure 289
Meng Lee and Jeffrey L. Saver
Meng Lee, Jeffrey L. Saver, and Bruce
8 Collateral Flow Enhancement: Blood Pressure Ovbiagele
Lowering and Alteration of Blood
Viscosity 146 16 Prevention of Stroke by Lowering Blood
Cholesterol Concentrations 297
Else Charlotte Sandset and Eivind Berge
Maurizio Paciaroni

vii
 Contents

17 Prevention of Stroke by Modification of Part VI Stroke Rehabilitation

Additional Vascular and Lifestyle Risk
Factors 308 and Recovery
Amytis Towfighi and Jeffrey L. Saver 23 Evidence-based Motor Rehabilitation after
18 Drugs, Devices, and Procedural Therapies to Stroke 485
Prevent Recurrent Cardiogenic Embolic Gert Kwakkel and Janne M. Veerbeek
Stroke 337 24 Language and Cognitive Rehabilitation after
Graeme J. Hankey Stroke 501
19 Long-term Antithrombotic Therapy for Large Marian C. Brady and Jonathan J. Evans
and Small Artery Occlusive Disease 384 25 Using Pharmacotherapy to Enhance Stroke
Graeme J. Hankey Recovery 517
20 Carotid and Vertebral Artery Larry B. Goldstein
Revascularization 412 26 Electrical and Magnetic Brain Stimulation to
Mandy D. Müller, Leo H. Bonati, and Enhance Post-stroke Recovery 532
Martin M. Brown Mark Parsons and Jodie Marquez
21 Cervical Artery Dissection and Cerebral
Vasculitis 450
Philippe A. Lyrer, Christopher Traenka,
and Stefan T. Engelter Index 551
22 Prevention of Intracerebral and
Subarachnoid Haemorrhage 463
James P. Klaas and Robert D. Brown, Jr.

viii
Contributors

Rustam Al-Shahi Salman, MA, PhD, FRCP Edin Salvador Cruz-Flores, MD, MPH, FAHA, FCCM,
Centre for Clinical Brain Sciences, University of FAAN, FNCS
Edinburgh, Edinburgh, UK Department of Neurology, Paul L. Foster School of
Medicine; Texas Tech University Health Sciences
Craig Anderson, MBBS, PhD, FRACP, Center El Paso, El Paso, TX, USA
FAHMS
The George Institute for Global Health, Faculty of Stefan T. Engelter, MD, FESO, FEAN
Medicine, University of New South Wales, Sydney, Department of Neurology and Stroke Center,
Australia University Hospital Basel, Department of Clinical
Research, and Neurology and Neurorehabilitation,
Eivind Berge, MD, PhD, FESO University Department of Geriatric Medicine Felix
Department of Internal Medicine, Oslo University Platter; University of Basel, Basel, Switzerland
Hospital Oslo, and Institute of Clinical Medicine,
University of Tromsø, Norway Jonathan J. Evans, BSc (Hons), DipClinPsychol, PhD
Institute of Health & Wellbeing, University of
Leo H. Bonati, MD Glasgow, Glasgow, Scotland
Department of Neurology and Stroke Center,
University Hospital Basel, University of Basel, Larry B. Goldstein, MD, FAAN, FANA, FAHA
Switzerland Department of Neurology and Kentucky
Neuroscience Institute, University of Kentucky,
Marian C. Brady, BSc (Hons), PhD, FRCSLT Lexington, KY, USA
Nursing, Midwifery and Allied Health Professions
Research Unit, Glasgow Caledonian University, Graeme J. Hankey, MBBS, MD, FRACP, FRCP, FRCP
Glasgow, Scotland Edin, FAHA, FESO, FWSO, FAAHMS
Professor of Neurology, Medical School, The University
Sherri A. Braksick, MD of Western Australia; Consultant Neurologist, Sir
Department of Neurology, Division of Neurocritical Charles Gairdner Hospital, Perth, Australia
Care, Mayo Clinic, Rochester, MN, USA
James P. Klaas, MD
Martin M. Brown, MA, MD, FRCP Department of Neurology, Mayo Clinic, Rochester,
Stroke Research Centre, UCL Queen Square Institute MN, USA
of Neurology, University College London, London, UK
Gert Kwakkel, PhD, PT
Robert D. Brown, Jr., MD, MPH Department of Rehabilitation Medicine, MOVE
Department of Neurology, Mayo Clinic, Rochester, Research Institute Amsterdam, Amsterdam
MN, USA Neurosciences, Amsterdam University Medical Centre,
Askiel Bruno, MD, MS location VUmc, The Netherlands; Rehabilitation
Research Centre, Reade, The Netherlands; and
Department of Neurology, Section of Vascular
Department of Physical Therapy and Human
Neurology, Medical College of Georgia, Augusta
Movement Sciences, Northwestern University, Chicago,
University, Augusta, GA, USA
IL, USA

ix
 List of Contributors

Peter Langhorne, PhD, FRCP Subhashini Ramesh, MD

Institute of Cardiovascular and Medical Sciences, Department of Medicine, Section of Critical
University of Glasgow, Glasgow, UK Care Medicine, Inova Fairfax Medical Campus,
Inova Health System, Falls Church, VA,
Meng Lee, MD USA
Department of Neurology, Chang Gung University
College of Medicine, Chang Gung Memorial Hospital, Else Charlotte Sandset, MD, PhD, FESO
Chiayi Branch, Chiayi, Taiwan Department of Neurology, Oslo University Hospital,
Oslo, Norway
Xinyi Leng
Department of Medicine & Therapeutics, The Nerses Sanossian, MD
Chinese University of Hong Kong, Hong Kong SAR, Department of Neurology, Keck School of Medicine,
China University of Southern California, Los Angeles, CA,
USA
Philippe A. Lyrer, MD, FESO
Department of Neurology and Stroke Center, Jeffrey L. Saver, MD, FAHA, FAAN
University Hospital Basel, University of Basel, Department of Neurology, David Geffen School of
Switzerland Medicine, University of California, Los Angeles, CA,
USA
Jodie Marquez, BAppSc, PhD
Faculty of Health and Medicine, University of Lee H. Schwamm, MD
Newcastle, Callaghan, Australia Department of Neurology, Massachusetts General
Hospital and Harvard Medical School,
Tom Moullaali, MBBS, MRCP Boston, MA, USA
Centre for Clinical Brain Sciences, University of
Edinburgh, Edinburgh, UK and The George Institute Amytis Towfighi, MD, FAHA
for Global Health, Faculty of Medicine, University of Department of Neurology, Keck School of Medicine
New South Wales, Sydney, Australia of University of Southern California, Los Angeles,
CA, USA
Mandy D. Müller, MD
Department of Neurology and Stroke Center, Christopher Traenka, MD
University Hospital Basel, University of Basel, Basel, Department of Neurology and Stroke Center,
Switzerland University Hospital Basel, Department of Clinical
Research, and Neurology and Neurorehabilitation,
Bruce Ovbiagele, MD University Department of Geriatric Medicine, Felix
Department of Neurology, University of California, Platter, University of Basel, Basel, Switzerland
San Francisco, CA, USA
Janne M. Veerbeek, PhD, PT
Maurizio Paciaroni, MD Department of Rehabilitation Medicine, Amsterdam
Stroke Unit and Division of Cardiovascular Medicine, Neurosciences and Amsterdam Movement Sciences,
Santa Maria della Misericordia Hospital, University of Amsterdam, The Netherlands; Division of Vascular
Perugia, Perugia, Italy Neurology and Neurorehabilitation, Department of
Mark Parsons, BMed, PhD, FRACP Neurology, University of Zurich and University Hospital
Zurich, Zurich, Switzerland; and cereneo, center for
Department of Medicine and Neurology, Melbourne
Neurology and Rehabilitation, Vitznau, Switzerland
Brain Centre at the Royal Melbourne Hospital,
Australia Joanna Wardlaw, FRCR, FRSE, FMedSci, FAHA
Alejandro A. Rabinstein, MD Centre for Clinical Brain Sciences and UK Dementia
Research Institute, University of Edinburgh,
Department of Neurology, Mayo Clinic, Rochester,
Edinburgh, UK
MN, USA

x
 List of Contributors

Lawrence K.S. Wong MBBS(NSW), MHA(NSW), MD Kori Sauser Zachrison, MD, MSc
(NSW), MRCP(UK), FHKAM(Medicine), FRCP(Lond) Department of Emergency Medicine, Massachusetts
Department of Medicine & Therapeutics, The General Hospital and Harvard Medical School
Chinese University of Hong Kong, Hong Kong SAR, Boston, MA, USA
China

xi
Preface

Since the first edition of this book was published in In this second edition of Stroke Treatment and
2005, the global burden of stroke has continued to Prevention we aim to update stroke clinicians and
rise. The number of new strokes each year, alive stroke practitioners with the optimal evidence for strategies
survivors, disability-adjusted life-years (DALYs) lost and interventions to treat stroke and prevent first and
to stroke annually, and stroke-related deaths per year recurrent stroke. Where available, randomized con-
have increased, despite stable or mildly declining age- trolled trials (RCTs) and systematic reviews of RCTs
adjusted stroke incidence rates and improved out- of the interventions are described and sourced pre-
comes among individuals experiencing stroke. The dominantly from the Cochrane Library.
increase in overall stroke numbers, despite reductions We have assembled an international panel of lead-
in rates, reflects global population growth, increasing ing experts who have kindly and generously contrib-
life expectancy, ageing of populations in developed uted chapters in their field of expertise. We trust that
countries, and heightened risks of non-communicable you will enjoy, and be enlightened by, their appraisal
disease in the developing world – and signals an of the best available evidence and their interpretation
ongoing need for this volume. The reduction in rates of its implications for clinical practice and future
reflects improved prevention and treatment of stroke, research. We are also grateful to John Wiley and
which has coincided with the development, rigorous Sons Limited for granting permission to reproduce
evaluation, and implementation into practice of an the forest plot figures from the Cochrane Library.
expanding array of effective treatments – testament
to the success of the collaborative, international accu- Jeffrey L. Saver
mulation of evidence to support best stroke care prac-
tices collated herein. Graeme J. Hankey

xiii
 Part I Foundations
Chapter
Stroke: The Size of the Problem

1 Graeme J. Hankey

The global and regional burden of stroke during Ischaemic Stroke

1990–2015 has been estimated by the Global Burden
In 2010, the age-standardized incidence of IS was 176
of Disease (GBD) studies of 2010, 2013, and 2015
(161–192) per 100,000 person-years (Bennett et al.,
(Krishnamurthi et al., 2013, 2015; Feigin et al., 2014,
2014) (Table 1.1).
2015; GBD 2015 Neurological Disorders Collaborator
In 2010, there were approximately 11,569,000
Group, 2017).
incident IS events (63% in LMIC) (Bennett et al., 2014).
The GBD 2010 study group undertook a systema-
tic review which identified 119 relevant studies (58
from high-income countries [HIC] and 61 from low- Haemorrhagic Stroke
and middle-income countries [LMIC]) that were pub- In 2010, the overall age-standardized incidence rate of
lished between 1990 and 2010 and from which regio- haemorrhagic stroke (HS) (intracerebral and subarach-
nal and country-specific estimates of the incidence, noid haemorrhage) was 81.52 (95% confidence interval
prevalence, mortality, and disability-adjusted life- [CI]: 72.27–92.82) per 100,000 person-years globally.
years (DALYs) lost by age group (<75 years, ≥75 In 2010, there were 5.3 million cases of HS; 80%
years, and in total) and country income level of first- were in LMIC (Krishnamurthi et al., 2013, 2014).
ever ischaemic and haemorrhagic stroke in all 21 There were significant regional differences in inci-
regions of the world for 1990, 2005, and 2010 could dence rates of HS, with the highest rates in LMIC
be calculated (Feigin et al., 2014). Pathological sub- regions such as sub-Saharan Africa and East Asia,
types of stroke were confirmed by brain imaging or and lowest rates in high-income North America and
autopsy in at least 70% of cases. Western Europe.
The GBD estimates of stroke incidence in all The overall age-standardized incidence rates of HS
regions were therefore obtained using a systematic per 100,000 person-years were 48.41 (95% CI: 45.44–
approach which allows comparison across disease 52.13) in HIC and 99.43 (95% CI: 85.37–116.28) in
states. Complementary estimates of stroke incidence, LMIC. Hence, LMIC had a 40% higher incidence of
based on epidemiological studies of stroke incidence HS than did HIC.
using ideal methods, and also adjusted to the World
Health Organization (WHO) world population figures, Trends in Stroke Incidence Rates
are provided by Thrift and Kim and colleagues (2020).
From 1990 to 2010, the age-standardized incidence of
stroke per 100,000 person-years remained fairly stable,
Incidence being 251 (95% CI: 230–273) in 1990 and 258 (95% CI:
In 2010, the age-standardized incidence rate of stroke 234–284) in 2010 (Feigin et al., 2014) (Table 1.1).
was 258 (234–284) per 100,000 person-years (Feigin However, from 1990 to 2010, the absolute number
et al., 2014) (Table 1.1). of people with a first stroke increased significantly by
The absolute number of people who experienced 68%, from 10 million to 16.9 million.
a first stroke was 16.9 million in 2010; 68.6% were From 1990 to 2010, the age-standardized inci-
resident in LMIC and 62% were aged younger than 75 dence of stroke per 100,000 person-years significantly
years (Feigin et al., 2014) (Table 1.1). In 2013, there decreased by 12% (95% CI: 6–17) in HIC, and
were 10.3 million new strokes (67% ischaemic stroke increased by 12% (95% CI: –3–22) in LMIC, albeit
[IS]) (Feigin et al., 2015). non-significantly.

1
Table 1.1 Age-adjusted annual incidence and mortality rates (per 100,000 person-years), prevalence (per 100,000 people), and disability-adjusted life-years (DALYs) lost (number, and per
100,000) for all stroke, ischaemic stroke, and haemorrhagic stroke, in 1990, 2005, 2010, and 2015

All Stroke 1990 2005 2010 2015 Change from 1990–2015

Number Rate (95% Number Rate (95% Number Rate (95% Number of Rate (95% Number of Rate (95% UI)
of events CI) per of events CI) per of events CI) per events UI) per events per 100,000
100,000 100,000 100,000 100,000
Incidence 10,078,935 251 (230–273) 14,734,124 256 (232–284) 16,894,536 258 (234–284) Not reported Not reported 68%↑ (to 2010) 12% (6–17%) ↓ HIC
(to 2010)
12% (–3–22%) ↑
LMIC (to 2010)
Prevalence 17,915,338 435 (389–497) 28,495,582 490 (437–558) 33,024,958 502 (451–572) 42,431,000 627 (621–631) 59.2% (58–60%) ↑ 9.8% (9–10%) ↓
(42.068 m –
42.767 m)
DALYs lost 86,010,384 2063 101,951,696 1750 102,232,304 1554 118,627,000 1777 21.7% (18–26%)↑ 32.3% (30–34%) ↓
(1950–2280) (1569–1831) (1374–1642) (114.862 m – (1721–1835)
111.627 m)
Deaths 4,660,449 117 (112–130) 5,684,970 99 (89–104) 5,874,182 88 (80–94) 6,326,000 101 (99–104) 36.4% (32–41%) ↑ 30% (28–32%) ↓
(6.175 m –
6.493 m)
Ischaemic stroke
Incidence 7,238,758 181 (167–196) 10,097,297 175 (160–192) 11,569,538 176 (161–192) 37% ↑ 13% (6–18%) ↓ HIC
6% (–7–18%) ↑ LMIC
DALYs lost 32,128,220 796 (734–906) 38,571,908 668 (617–774) 39,389,408 598 (560–692) 18% ↑ 34% (16–36%) ↓ HIC
17% (–11–19%) ↓ LMIC
Mortality 2,241,077 58 (54–64) 2,701,873 47 (44–54) 2,835,419 42 (40–49) 21% ↑ 37% (19–39%) ↓ HIC
14% (9–19%) ↓ LMIC

Haemorrhagic stroke
Incidence 2,840,177 69 (62–77) 4,636,828 80 (71–92) 5,324,997 82 (72–93) 47% ↑ 18.5% ↑ globally
8% (1–15%) ↓ HIC
22% (5–30%) ↑ LMIC
DALYs lost 53,882,164 1267 63,379,792 1081 62,842,896 956 14% ↑ 39% (32–44%) ↓ HIC
(1068–1484) (935–1234) (828–1104)
25% (7–38%) ↓ LMIC
Mortality 2,419,372 60 (51–70) 2,983,097 52 (45–59) 3,038,763 46 (40–53) 20% ↑ 38% (32–43%) ↓ HIC
23% (–7–36%) ↓ LMIC

Source: Adapted from Krishnamurthi et al., 2013, 2014; Feigin et al., 2014; Bennett et al., 2014, and GBD 2015 Neurological Disorders Collaborator Group, 2017.
CI: confidence interval. HIC: high-income countries. LMIC: low- and middle-income countries. UI: uncertainty interval.
 Graeme J. Hankey

Ischaemic Stroke (95% UI: 3.548–3.871 million) (Krishnamurthi et al.,

2015).
From 1990 to 2010, the age-standardized incidence of IS
per 100,000 person-years remained fairly stable, being
181 (95% CI: 167–196) in 1990 and 176 (95% CI: Trends in Prevalence
161–192) in 2010 From 1990 to 2010, the absolute number of stroke
From 1990 to 2010, there was a significant increase survivors increased significantly by 84%, from
in the absolute number of people with incident IS 18 million to 33 million (Feigin et al., 2014).
from 7.2 million to 11.6 million (37% increase). Between 1990 and 2015, the absolute number of
Age-standardized IS incidence in HIC declined stroke survivors increased globally by 59.2% (58.4–
by about 13% (95% uncertainty interval [UI]: 59.9%), whereas the age-standardized prevalence rate
6–18%). However, in LMIC there was a modest of stroke fell by 9.8% (9.4–10.3% reduction) (GBD
6% increase in the age-standardized incidence of 2015 Neurological Disorders Collaborator Group, 2017).
IS (95% UI: –7–18%).
Ischaemic and Haemorrhagic Stroke
Haemorrhagic Stroke Between 1990 and 2013, there were significant
The age-standardized incidence of HS increased by increases in absolute numbers and prevalence rates
18.5% worldwide between 1990 and 2010, from 69 of both HS and IS for younger adults globally
(62–77) to 82 (72–93) per 100,000 person-years. (Krishnamurthi et al., 2015).
From 1990 to 2010, there was a 47% increase
worldwide in the absolute number of HS cases, from Mortality
2.8 million to 5.3 million. In 2010, the age-standardized mortality rate of stroke
In HIC, there was a reduction in incidence of HS by was 88 (80–94) per 100,000 person-years, and the
8% (95% CI: 1–15%) in the past 2 decades. However, in absolute number of stroke-related deaths was
low-income and middle-income countries there was a 5.9 million (Feigin et al., 2014)
significant increase in the incidence of HS by 22% (95% In 2015, the age-standardized mortality rate of
CI: 5-30%), which is one rate that has increased over the stroke was 101 (99–104) per 100,000 person-years,
past two decades, particularly in people younger than 75 and the number of stroke deaths was 6.3 million
years (19% increase in HS in past two decades, 95%CI: (95% UI: 6.2–6.5 million) (GBD 2015 Neurological
5–30% increase). Disorders Collaborator Group, 2017).
The percentage of estimated total global mortality
Prevalence due to stroke in 2013 was 11.3%, which exceeds that of
In 2010, the prevalence of stroke survivors was 502 HIV/AIDS, tuberculosis, and malaria combined
(451–572) per 100,000 people and the absolute num- (7.2%) by more than 50% (GBD 2013 Mortality and
ber of stroke survivors was 33 million. Causes of Death Collaborators, 2015).
In 2015, the prevalence of stroke survivors was 627
(95% UI: 621–631) per 100,000 people and the absolute Ischaemic Stroke
number of stroke survivors was 42.431 million (95% In 2010, the age-standardized mortality rate of IS was
UI: 42.068–42.767 million) (GBD 2015 Neurological 42 (40–49) per 100,000 person-years, and there were
Disorders Collaborator Group, 2017). approximately 2.835 million deaths from IS (57% in
LMIC) (Bennett et al., 2014).
Ischaemic Stroke
In 2013, in younger adults aged 20–64 years, the Haemorrhagic Stroke
global prevalence of IS was 7.258 million cases (95% In 2010, the age-standardized mortality rate of HS was
UI: 6.996–7.569 million) (Krishnamurthi et al., 2015). 46 (40–53) per 100,000 person-years, and there were
3.0 million deaths due to HS.
Haemorrhagic Stroke Hence, HS caused more than half (51.7%) of the
In 2013, in younger adults aged 20–64 years, the 5.9 million stroke-related deaths in 2010, despite
global prevalence of HS was 3.725 million cases causing less than one-third of all strokes.

4
 Stroke: The Size of the Problem

The largest proportion of HS deaths occurred DALYs Lost

in LMIC countries. Low- and middle-income
In 2010, the rate of DALYs lost due to stroke was 1554
countries had a 77% higher mortality from HS
(1374–1643) per 100,000, and the absolute number of
than did HIC.
DALYs lost was 102 million.
The highest mortality rates in 2010 were in low-
In 2015, the rate of DALYs lost due to stroke was
income Central Asia, Southeast Asia, and sub-Saharan
1777 (1721–1835) per 100,000 and the absolute number
Africa, whereas the lowest mortality rates were in high-
of DALYs lost was 118.627 million (114.862–
income North America, Australasia, and Western
122.627 million) (GBD 2015 Neurological Disorders
Europe.
Collaborator Group, 2017; GBD 2016 DALYs and
In 2013, in younger adults aged 20–64 years, the
HALE Collaborators, 2017).
number of deaths from HS (1.047 million [95% UI:
0.945–1.184 million]) was significantly higher than
the number of deaths from IS (0.436 million [95% Ischaemic Stroke
UI: 0.354–0.504 million]) (Krishnamurthi et al., In 2010, there were approximately 39.4 million
2015). DALYs lost due to IS (64% in LMIC) (Bennett et al.,
2014).
Trends in Stroke Mortality Rates
From 1990 to 2010, mortality rates decreased signifi- Haemorrhagic Stroke
cantly from 117 (112–130) to 88 (80–94) per 100,000. In 2010, there were 62.8 million DALYs lost (86% in
The fall was in both HIC (37%, 31–41) and LMIC LMIC) due to HS.
(20%, 15–30). However, the absolute number of Consequently, HS caused three-fifths (61.5%) of
stroke-related deaths significantly increased by 26%, the 102.2 million DALYs lost due to stroke through-
from 4.7 million to 5.9 million. out the world.
Between 1990 and 2015, the absolute number of Low- and middle-income countries had 65%
stroke deaths increased globally by 36.4% (32.4– higher DALY rates of HS than did HIC.
40.8%), whereas the age-standardized mortality rate of
stroke fell by 30% (27.7–32.0% reduction) (GBD 2015 Trends in DALYs Lost
Neurological Disorders Collaborator Group, 2017). From 1990 to 2010, the age-standardized rate of
DALYs lost per 100,000 decreased from 2063 (1950–
Ischaemic Stroke 2280) to 1554 (1374–1642), but the absolute number
From 1990 to 2010, mortality rates due to IS decreased of DALYs lost increased by 12% from 86 million to
by one-fifth, from 58 (54–64) to 42 (40–49) per 100,000. 102 million.
However, the absolute number of deaths from IS Between 1990 and 2015, the age-standardized rate
increased from 2.24 million to 2.84 million (21% of DALYs lost per 100,000 decreased by 32.3%
increase). (30.0–34.4% decrease), but the absolute number of
Age-standardized mortality in HIC declined by DALYs lost increased by 21.7% (17.8–25.7%) (GBD
about 37% (95% UI: 19–39%). 2015 Neurological Disorders Collaborator Group,
In LMIC, there were modest reductions in mor- 2017).
tality rates.
Ischaemic Stroke
Haemorrhagic Stroke From 1990 to 2010, the age-standardized rate of
From 1990 to 2010, mortality rates due to HS DALYs lost per 100,000 decreased from 796 (734–
decreased from 60 (51–70) to 46 (40–53) per 100,000. 906) to 598 (560–692), but the absolute number of
There was a significant reduction in HS mortality DALYs lost due to IS increased by 18%, from
by 38% (95% CI: 32–43%) in HIC and by 23% (95% 32 million to 39 million.
CI: –3–36%) in LMIC . Age-standardized DALYs lost in HIC declined by
However, the number of deaths globally from HS about 34% (95% UI: 16–36%).
increased by 20% from 2.4 million to 3.0 million. The bulk of DALYs lost were in LMIC.

5
 Graeme J. Hankey

• 62.0% of new strokes,

Haemorrhagic Stroke
• 69.8% of prevalent strokes,
From 1990 to 2010, the age-standardized rate of
• 45.5% of deaths from stroke, and
DALYs lost per 100,000 decreased from 1267 (1068–
1484) to 956 (828–1104). In HIC, there was a reduction • 71.7% of DALYs lost because of stroke (Feigin
in DALYs lost due to HS by 39% (95% CI: 32–44%), et al., 2014) (Table 1.2).
and in LMIC countries, there was a reduction in People younger than 75 years also accounted for
DALYs lost by 25% (95% CI: 7–38%). • 62% of incident IS and 78% of HS, and
However, from 1990 to 2010, the absolute number • 63% of DALYs lost due to IS and 83% due to HS.
of DALYs lost due to HS increased by 14% from
54 million to 63 million.
Children and Young Adults
In 2010, 5.2 million (31%) strokes occurred in chil-
Special Populations dren (aged <20 years) and young and middle-aged
adults (20–64 years).
Low- and Middle-Income Countries Children from LMIC contributed almost 74,000
In 2010, most of the burden of IS and HS was in (89%) strokes, and young and middle-aged adults from
LMIC, which accounted for LMIC contributed almost 4.0 million (78%) strokes.
• 63% of incident IS and 80% of HS, In 2013, in younger adults aged 20 to 64 years, there
• 57% of deaths due to IS and 84% of deaths due to were 1.483 million (95% UI: 1.340–1.659 million) stroke
HS, and deaths globally (Krishnamurthi et al., 2015). The total
• 64% of DALYs lost due to IS and 86% due to HS DALYs from all strokes in those aged 20–64 years was
(Krishnamurthi et al., 2013). 51.429 million (95% UI: 46.561–57.320 million)
The average age of incident and fatal IS and HS was 6 (Krishnamurthi et al., 2015).
years younger in LMIC than in HIC. Among younger adults, death rates for all strokes
The greater burden of stroke in LMIC is not sim- declined significantly between 1990 and 2013, in both
ply because a larger proportion of the world’s popula- developing countries, from 47 (95% UI: 42.6–51.7) in
tion lives in LMIC. The rates (i.e. number per 100,000 1990 to 39 (95% UI: 35.0–43.8) in 2013, and in developed
population) of stroke incidence, DALY loss, and mor- countries, from 33.3 (95% UI: 29.8–37.0) in 1990 to 23.5
tality due to stroke are higher in LMIC, correlating (95% UI: 21.1–26.9) in 2013 (Krishnamurthi et al., 2015).
inversely with country-level macroeconomic status
indicators. Thus, not only are individuals in LMIC Summary
more likely to have strokes, but these strokes are also • In 2010, an estimated 16.9 million strokes occurred
more likely to lead to death and disability. worldwide, or 1 every 2 seconds, at an incidence
The disproportionate stroke burden in LMIC is rate of 258 (234–284) per 100,000 persons
also not mediated by a greater prevalence of cardio- per year. Approximately 70% of these strokes
vascular risk factors in LMIC. Cardiovascular risk is occurred in low- and middle-income countries
actually lower in low-income countries. However, (LMIC). The 16.9 million incident strokes were
national per capita income correlates inversely with added to a pool of 33 million prevalent stroke
stroke mortality and DALY loss rates independent of survivors (502 [451–572) per 100,000 people).
There were 5.9 million stroke-related deaths, at
cardiovascular risk. It is therefore likely that subopti-
a rate of 88 (80–94 per 100,000 person-years), and
mal resources in LMIC to invest in stroke prevention, 102 million disability-adjusted life-years (DALYs)
treatment, and rehabilitation have contributed to, and lost due to stroke at a rate of 1554 (1374–1642) per
perpetuate, substantial inequities in stroke incidence 100,000 people.
and outcomes, beyond the burden of stroke risk • In 2010, stroke was the second leading cause of
factors. death and the third leading cause of DALYs
worldwide.
People Younger than 75 Years of Age • In 2010, most of the global burden of stroke was
In 2010, much of the burden of stroke was borne by due to haemorrhagic stroke (HS), and most of the
people younger than 75 years, who accounted for burden of HS was borne by LMIC. Although HS was

6
Another Random Scribd Document
with Unrelated Content
welcome. This application for entertainment was always made
according to the custom of the people, and in their own vernacular,
which I will illustrate by an example.
In my horseback-journeyings I had reached the tall, dense, heavy
forests of the bottom-lands of the Mississippi River, about a dozen
miles from the Father of Waters. As the sun was about setting, I
came upon a large "dead'ning," where the underbrush had been cut
out and burned off, the large trees had been girdled and had died,
and a crop of corn had been raised among the dead forest-trees,
before the new-comer in this wilderness had been able to completely
clear a field around his newly-erected log-cabin. Turning off from the
corduroy-road upon which I had been traveling, I took a footpath,
and, following that, was soon as near the cabin as a high rail-fence
would allow me to approach on horseback. A short distance from this
log-cabin was a still smaller one occupied by a colored aunty and her
family, and used for a kitchen; and not far off still another log-
building, used for a barn and stable.
The most of my readers in the older sections of the country will
suppose that I had now only to dismount, hitch my horse, climb the
fence, rap at the door, and so gain admittance to my resting-place for
the night. Far otherwise. Only the most untraveled and
inexperienced in the Brush would undertake so rash an experiment.
Sitting upon my horse, I called out in a loud voice, "Hello there!" That
call was for the same purpose that the city pastor mounts the stone
steps and rings the bell at the door of his parishioner. It was rather
more effective.
A large pack of hounds and various other kinds of dogs responded
with a barking chorus, a group of black pickaninnies rushed from the
adjacent kitchen, followed to the door by their sable mother, with
arms a-kimbo and hands fresh from mixing the pone or corn-dodger
for the family supper; all, with distended eyes and mouth, and
shining ivory, staring at the stranger with excited and pleased
curiosity. At almost the same instant, the mistress of the incipient
plantation approached the door of her cabin, stockingless and
shoeless, with a dress of woolsey woven in her own loom by her own
hands, and cut and made by her own skill, with face not less pleased
and excited than the others, and her cordial greeting of "How d'y,
stranger—how d'y, sir? 'Light, sir! [alight]—'light, sir!"
Remaining upon my horse, I replied: "I am a stranger in these parts,
madam. I have ridden about fifty miles since morning and am very
tired. Can I get to stay with you to-night, madam?"
"Oh, yes," she replied, promptly, "if you can put up with our rough
fare. We never turn anybody away."
I told her I should be very glad to stay with her, and dismounted. The
dogs, who would otherwise have resisted my approach to the door
by a combined attack, obeyed their instructions not to harm me, and
granted me a safe entrance as a recognized friend.
Such was the universal training of the dogs, and such the uniform
method of approaching and gaining admittance to the houses of the
people in the Brush. My hostess informed me that her husband was
at work in the "dead'ning," but that he would soon be at home and
take care of my horse.
I told her that I could do that myself, and she sent her little son along
with me to the stable, where I bestowed that kind and, I may say,
affectionate care that one who journeys for years on horseback
learns to bestow upon his faithful horse. I then entered the cabin,
and received that warm welcome that awaits the traveler in our
Western wilds.
Shall I describe my home for the night? It was a new log-house, less
than twenty feet square, and advanced to a state of completeness
beyond many in which I had lodged, inasmuch as the large openings
between the logs had been filled with "chink and daubing." The
chimney, built upon the outside of the house, was made of split
sticks, laid up in the proper form, and thoroughly "daubed" with mud,
so as to prevent them from taking fire. A large opening cut through
the logs communicated with this chimney, and formed the ample
fireplace. The roof was made of "shakes"—pieces of timber rived out
very much in the form of staves, but not shaved at all. These were
laid upon the roof like shingles, except that they were not nailed on,
but "weighted on"—kept in their places by small timbers laid across
each row of "shakes" over the entire roof. These timbers were kept
in their places by shorter ones placed between them, transversely,
up and down the roof. In this manner the pioneer constructs a roof
for his cabin, by his own labor, without the expenditure of a dime for
nails. With wooden hinges and a wooden latch for his door, he needs
to purchase little but glass for his windows, to provide a comfortable
home for his family. His latch-string, made of hemp or flax that he
has raised, or from the skin of the deer which he has pursued and
slain in the chase, which, as the old song has it—
"Hangs outside the door,"
symbolizes the cordial welcome and abounding hospitality to be
found within.
At the end of the room opposite the fireplace there was a bed in
each corner, under one of which there was a "trundle-bed" for the
children. There was no chamber-floor or chamber above to obstruct
the view of the roof. There was no division into apartments, not even
by hanging up blankets, a device I have seen resorted to in less
primitive regions. From floor to roof, from wall to wall, all was a single
"family" room, which was evidently to be occupied by the family and
myself in common. A rough board table, some plain chairs, and a
very few other articles completed the inventory of household
furniture of the pioneer's home to which I had been welcomed.
Such a home was the birthplace of Lincoln, and many other of the
greatest, wisest, and best men that have ever blessed our country.
Such homes have been crowned with abundance, and have been
the scenes of as much real comfort and joy as any others in our
land.
I have found that curiosity is a trait that is not monopolized by any
one section of country or class of people. It belongs to all localities,
and to all grades and kinds of people. I therefore, in accordance with
what a pretty wide experience had taught me was the best course to
pursue, proceeded at once to gratify the curiosity of my hostess as to
who her guest was, and what business had brought him to this wild
region. I told her my name, and that I was a Presbyterian preacher,
and an agent of the American Bible Society. This not only satisfied
her curiosity, but was very gratifying information to her, and I
received a renewed and cordial welcome to her home as a minister
of the gospel.
In the course of the ordinary conversation and questions that attend
such a meeting of strangers in the Brush, I learned that she and her
husband had emigrated from a county some hundreds of miles east,
which I had several times visited in the prosecution of my mission,
and I was able to give her a great deal of information in regard to her
old neighbors and friends. We were in the midst of an earnest
conversation in regard to these people, when her husband came in
from his labors. On being introduced to me, and informed in regard
to my mission, he repeated the welcome his wife had already given
me to the hospitality of their cabin.
Our supper was such as is almost universally spread in the wilds of
the Southwest. It consisted of an abundance of hot corn-bread, fried
bacon, potatoes, and coffee. A hard day's labor and a long day's ride
prepared us to do it equal justice.
The evening wore rapidly away in conversation. Such pioneers are
not dull, stupid men. Their peculiar life gives activity to mind as well
as body. My host was anxious and glad to hear from the great
outside active world, with which I had more recently mingled, and
had questions to ask and views to give as to what was going on in
the political and religious world.
At length our wearied bodies made a plea for rest that could not be
refused, and I was invited to conduct their family worship. This
invitation was extended in the language and manner peculiar to the
Southern and Southwestern sections of the country. This is
universally as follows:
The Bible and hymn-book are brought forward by the host, and laid
upon the table or stand, when he turns to the preacher and says,
"Will you take the books, sir?"
That is the invitation to lead the devotions of the family in singing and
prayer. It has been my happy lot to receive and respond to that
invitation—as I did that night—in many hundreds of families and in
some of the wildest portions of our land.
The method of extending an invitation to "ask a blessing" before a
meal is quite as peculiar. Being seated at the table, the host, turning
to the preacher, says, "Will you make a beginning, sir?"—all at table
reverently bowing their heads as he extends the invitation, and while
the blessing is being asked.
So, too, I have "made a beginning" at many a hospitable board in
many different States. I did not that night make the mistake that is
reported of an inexperienced home-missionary explorer, in similar
circumstances, who, laboring under the impression that "to retire"
and "to go to bed" were synonymous terms, said, "Madam, I will
retire, if you please."
"Retire!" she rejoined; "we never retires, stranger. We just goes to
bed."
Sitting with the family before the large fireplace, I said, "Madam, I
have ridden a long distance to-day, and am very tired."
"You can go to bed at any time you wish, sir," said she. "Just take the
left-hand bed."
I withdrew behind their backs to "lay my garments by," took the left-
hand bed, turned my face to the left-hand wall, and slept soundly for
the night.
When I awoke in the morning, husband and wife had arisen and left
the room, he to feed his team, and she to attend to her household
duties in the kitchen. After an early breakfast, and again leading their
family devotions, I bade them good-by, with many thanks for their
kindness, and with repeated invitations on their part to be sure to
spend the night with them should I ever come that way again. But I
have never seen them since.
I have very often recalled a hospitable reception in the Brush, of a
very different character, the recollection of which has always been
exceedingly pleasant to me. Wishing to visit a rough, wild, remote
region, at a season of the year when the roads were almost
impassable on account of the spring rains and the mud, I concluded
to go the greater part of the distance by steamboats, down one river
and up another, and then ride about fifty miles in a stage or mail-
wagon. The roads would scarcely be called roads at all in most parts
of the country, and I shall not be able to give to many of my readers
any true idea of the exceeding roughness of that ride. A considerable
part of the way was through the bottom-lands of one of the smaller
Southwestern rivers that swell the volume of the Mississippi. A
recent freshet had left the high-water mark upon the trees several
feet higher than the backs of our horses; and as we jolted over the
small stumps and great roots of the trees, from which the earth had
been washed away by the freshet, I was wearied, exceedingly
wearied, by the rough road and comfortless vehicle in which I
traveled.
At length we came upon a very pleasant plantation, with a
comfortable house and surroundings, where the driver, a boy about
fifteen years old, told me he would feed his team, and we would get
our dinner. It was not an hotel. Mail-contractors in this region often
make such arrangements to procure feed for their horses and meals
for the few passengers that they carry, at private houses. As I
entered the house I was greeted with one of those calm, mild, sweet
faces that one never forgets. I should think that my hostess was
between thirty-five and forty years old. I was too weary to engage in
much conversation, and she was quiet, and said very little to me. As
I observed her movements about the room in preparing the dinner, I
thought I had never seen a face that presented a more perfect
picture of contentment and peace. I felt perfectly sure that she was a
Christian—that her face bespoke "the peace of God that passeth all
understanding." When she invited the driver and myself to take seats
at the table, I said, "Shall I ask a blessing, madam?"
With a smile she bowed assent, and, as I concluded and looked up,
her face was all radiant with joy, and she said excitedly, "You are a
preacher, sir!"
I replied, "Yes, madam."
"Well," she responded, "I am glad to see you. I love to see
preachers. I love to cook for them, and take care of them. I love to
have them in my house."
I told her who I was, explained the character of my mission, and
expressed, I trust with becoming warmth, my gratification at the
cordiality of her welcome.
"Oh," said she, "if I was a man, I know what I would do. I would do
nothing but preach. I'd go, and go, and go; and preach, and preach,
and preach. I wouldn't have anything to pester me. I wouldn't marry
nary woman in the world. I'd go, and go, and go—and preach, and
preach, and preach, until I could preach no longer; and then I'd lie
down—close my eyes—and—go on."
Was there ever a more graphic and truthful description of an earnest,
apostolic life? Was there ever a more simple, beautiful description of
a peaceful Christian death? They recall the statement of Paul, "This
one thing I do"; and the story of Stephen, "And when he had said
this, he fell asleep."
The people who have spent their lives deep in the Brush, as this
good woman had, have no other idea of a preacher of the gospel but
one whose duty and mission it is to "go" and "preach." They have
been accustomed to hearing but one message, or at most a few
messages, from their lips, and then hear their farewell words, listen
to their farewell songs, shake hands with them, and see them take
their departure to "go" and "preach" to others who, like them, dwell in
lone and solitary wilds. Meetings and partings like these have
originated and given their peculiar power to such refrains as—
"Say, brothers, will you meet us—
Say, brothers, will you meet us—
Say, brothers, will you meet us
On Canaan's happy shore?

"By the grace of God we'll meet you—

By the grace of God we'll meet you—
By the grace of God we'll meet you
On Canaan's happy shore."
This woman knew little of the great world—had little that it calls
culture; her language was that of the people among whom she lived,
and was such as she had always been accustomed to hear; but her
thoughts were deep and pure, her "peace flowed like a river," and
her communion with God lifted her to companionship with the
noblest and best of earth. Though I spent but little more than an hour
in her presence, and many years have passed since that transient
meeting, her picture still hangs in the chamber of my memory, calm,
pure, and saintly, and breathing upon my spirit a perpetual
benediction.
 CHAPTER V.
OLD-TIME BASKET-MEETINGS IN THE BRUSH.
Religious meetings, popularly denominated "basket-meetings,"
were known and recognized as established institutions in the Brush.
They were among the assemblages that had resulted from the
sparseness of the population in those regions. Where the country
was hilly and mountainous, and the settlers were scattered along the
streams in the narrow valleys; or the land was so rough and poor
that only occasional patches would reward tillage; or for various
other causes, the families were but few, and far distant from each
other, it was a very difficult matter for the people to leave their homes
day after day to attend a continuous meeting. Hence, among other
religious gatherings, they had long been accustomed to hold what
were called basket-meetings.
These meetings involved less labor and trouble than camp-meetings,
and could often be held where such a meeting would be impossible.
They were usually not as large, and did not continue as many days.
They were called "basket-meetings" from the fact that those from a
distance brought their provisions, already cooked, in large baskets,
and in quantities sufficient to last them during the continuance of the
meeting. They put up no tents or cabins on the ground. They did not
cook or sleep there. They most frequently commenced on Saturday,
and continued through the Sabbath. They generally had a prayer-
meeting and preaching on Saturday forenoon, and then adjourned
for an hour or two. During this intermission the greater part of the
people dispersed in groups among the trees, and took their dinner
after the manner of a picnic. Those living in the immediate vicinity
returned to their homes for dinner, taking with them as many of those
in attendance as they could possibly secure. Every stranger was
sure of repeated invitations to dine, both with these families and
neighborhood groups among the trees, and at the adjacent cabins.
After dinner they reassembled and had a repetition of the services of
the morning.
Unlike a camp-meeting, they had no services at night. When the
afternoon meetings were concluded, the people dispersed and spent
the night at the cabins within two or three miles around. All the
people in these cabins usually kept open house upon such an
occasion. They were present, and, after the benediction was
pronounced, they mounted the stumps and logs and extended a
general invitation to any present to spend the night with them. Not
satisfied with giving this general invitation, they jumped down and
went among the rapidly dispersing crowd and followed it with private
personal solicitations to accept their proffered hospitality.
On the Sabbath, they reassembled with augmented numbers, and
the services of Saturday were reënacted, with such additions and
variations as the circumstances might demand.
The first basket-meeting that I ever attended was so new and
strange to me in all its incidents, that, though many years have
intervened, my recollections of it are as vivid as though it had
occurred but yesterday. It was in a very rough, wild region. The
country had been settled a long time, so that those in attendance
were genuine backwoods people "to the manner born." The place of
meeting was in a tall, dense, unbroken forest. The underbrush had
been cut and cleared away, a few trees had been so felled that rude
planks, made by splitting logs, could be placed across them for seats
for the ladies, while the men mostly sat upon the trunks of other
fallen trees. The pulpit or "stand" for the preacher was original and
truly Gothic in its construction. It was made by cutting horizontal
notches immediately opposite to each other, in the sides of two large
oak-trees, standing about four feet apart, and inserting into these
notches a board about a foot wide, that had been placed across a
wagon and used for a seat by some of those present in coming to
the meeting. The preacher placed his Bible and hymn-book upon this
board, hung the indispensable saddle-bags in which he had brought
them across one end of it, and so was ready for the services. I
thought I had never seen in any cathedral a pulpit more simple and
grand. Those towering, grand old oaks, with their massive,
outstretching branches, spoke eloquently of the power and grandeur
of the God who made them. And yet, small and puny as the preacher
appeared in the contrast, it was a fitting place for him to stand and
proclaim his message to the people who worshiped beneath them.
Comparatively unlearned and ignorant as he was, he could tell them
from that open Bible what they would never learn in the
contemplation of grand old forests, or stars, or suns, or all the
sublimest works of nature. All these are mute and dumb in regard to
the story of the cross. However they may enkindle our rapture, or
excite our reverence, they will never tell us how sin may be forgiven
—how the soul may be saved.
The indispensable matter in the selection of grounds for a basket-
meeting or a camp-meeting in the Southwest was a good spring of
clear, running water. This must be so large as to furnish an
abundance of water, not only for all the people who would be
present, but for all the horses necessary to transport themselves and
their provisions to the place of meeting. In hot weather the demands
for water were large, and there was need for a "clear spring" like that
so beautifully described by the poet Bryant:
"... yon clear spring, that, midst its herbs,
Wells softly forth, and wandering, steeps the roots
Of half the mighty forest."
The sermon on this occasion was plain, sensible, and earnest. The
preacher was superior to the people, and yet in all respects one of
them. He had been born in the Brush, raised in the Brush, and had
spent many years in preaching to the people in the Brush. He
dressed as they dressed, talked as they talked, and, unconsciously
to himself, used all their provincialisms in his sermons. In his
thoughts, feelings, and manner of life he was in full sympathy with
them. He had toiled among them long, earnestly, and successfully.
He had preached to a great many congregations, scattered over a
wide extent of Brush country. He had been associated with his
brethren of different denominations in holding a great many union
basket-meetings similar to the one now in progress. He was widely
known, beloved, and honored. Perhaps the most widely known,
honored, and successful pastorate in the country has been that of
the late Rev. Dr. Gardner Spring, in New York. But I do not think that
Dr. Spring, with all his talents, culture, and learning, could possibly
have been as useful, as successful, as honored among these
people, as was this preacher. He could not have eaten their coarse
food, slept in their wretched beds, mingled with them in their daily
life, or been in such complete sympathy with them in their poverty,
struggles, temptations, and modes of thought, as to have so won
their love and reverence, and led them in such numbers to the cross
of Christ. "There are diversity of gifts, but the same spirit," etc. I
honor these noble and heroic workers in the Master's vineyard, who
thus toil on in the Brush, through scores of years, all unknown to
fame. Many of them know nothing of Latin, Greek, and Hebrew, but
they know how to win souls to Christ, and the highest authority has
said, "He that winneth souls is wise."
That congregation, when assembled, seated, and engaged in their
devotions, presented a scene not to be forgotten. The preacher,
small in stature, stood upon a rude platform at the feet of the
massive columns of his pulpit. The people were seated among the
standing trees, upon seats arranged without any of the usual
regularity and order, but lying at all points of the compass just as
they had been able to fall, the smaller trees among the larger ones.
The voice of prayer and song ascended amid those massive,
towering columns, crowned with arches formed by their outstretching
branches, and covered with dense foliage. It was the worship of God
in his own temple. It carried the thoughts back to many scenes not
unlike it, in the lives and labors of Christ and his apostles, when they
preached and taught upon the Mount of Olives, by the shores of
Gennesaret, and over the hills and valleys of Palestine. It gave new
force and beauty to the familiar words of Bryant's grand and noble
"Forest Hymn:"
"The groves were God's first temples, ere man learned
To hew the shaft and lay the architrave,
And spread the roof above them—ere he framed
The lofty vault, to gather and roll back
The sound of anthems; in the darkling wood,
Amid the cool and silence, he knelt down,
 And offered to the Mightiest solemn thanks
And supplication....
... Be it ours to meditate,
In these calm shades, thy milder majesty,
And to the beautiful order of thy works
Learn to conform the order of our lives."
At the conclusion of the morning sermon the greater part of the
congregation dispersed among the trees to take their dinner in the
manner I have already described. I was invited to go with the
preacher to a cabin about a mile distant, where we were to have our
home during the meeting. We mounted our horses and accompanied
our host through the woods to his residence. As I looked back, I saw
that we were followed by some forty or more other guests. On
reaching his home I found three buildings—a log-house, log-kitchen,
and log-stable. Our horses were put in the stable and bountifully fed
with corn in the ear and fodder. "Fodder" in these regions has a
limited signification, and is applied only to the leaves which are
stripped from the corn-stalks, tied in small bundles, and generally
stacked for preservation. The stalks are not cut, as in the North and
East, but the leaves are stripped from them while standing. This is
the usual feed for horses in the place of hay.
The house was similar to all log-houses, but, as our company was so
numerous, I had the curiosity to ask our host how large it was, and
he told me that he cut the logs just twenty feet long. Its single room
was, therefore, less than twenty feet square. We, however, received
a warm and cordial welcome, and host, hostess, and guests seemed
exceedingly happy. With a part of the company, I was soon invited
into the adjoining house to dinner. This was much smaller—not more
than ten or fifteen feet square. A loom in one corner filled a large part
of the room. This was a very important part of their household
treasures, as the greater portion of the clothing of the entire family
was woven upon it. A long, narrow table, of home construction,
occupied the space between the foot of the loom and the wall. There
was a large fireplace in front, before which the coffee was smoking.
A chair at each end and a bench on each side of the table furnished
seats for ten guests. Our bill of fare was cold barbecued shoat,
sweet potatoes roasted in the ashes, bread, honey, and coffee. Our
honey was from a "bee tree," and our bread was of the Graham
variety, from the necessities of the case. The wheat had been
ground at a "horse mill" in the neighborhood, where they had no
arrangements for separating the bran from the flour. Such a dinner
was not to be despised by hungry men. By the way, I have found that
over a very wide extent of our country the men, on such occasions,
always eat first and alone, the women meanwhile standing around
the table and waiting upon them. After we had finished our dinner,
the table was rapidly reset by the aid of the "sisters" present, and ten
more guests took their seats and dined. The same course was
repeated until the table was set five times, and fifty persons had
dined bountifully in that little log-cabin.
Having all dined, we returned to the preaching "stand," and the
congregation reassembled. I preached to them at 4 p.m., and all the
services were conducted to the close in a manner not essentially
different from preaching services elsewhere.
The audience was dismissed for the night, and dispersed among the
nearest cabins. My clerical friend and myself were joined by a young
licentiate, and returned to spend the night at the house at which we
had dined. The company was not as large as that at dinner, but to
one inexperienced in such life, as I then was, it was beyond my
comprehension how they could be entertained for the night. My
experience and observation at dinner had shown me how we could
get through with our supper. A succession of tables I understood, but
how could that be applied to sleeping arrangements? A succession
of beds was a kind of "succession" I had never heard or read of in
ecclesiastical or any other history. But my perplexities were evidently
not felt by any one else in the company, and I dismissed them.
All seemed as happy as they could well be. Conversation was
animated. All tongues were loosed. There were stories of former
basket and other meetings, of wonderful revivals, and of remarkable
conversions. There were reminiscences of eccentric and favorite
preachers who had labored among them long years before. There
was the greatest variety of real Western and Southwestern religious
melodies and songs. These were interspersed with the conversation
during the evening, and were the source of great and unfailing
interest and joy. So the hours rolled on, and all were happy. It was
the occasion to which they had looked forward, and for which they
had planned for months—the great occasion of all the year, and it
brought no disappointment. For myself, I must say that if I ever drew
upon my stores of anecdote, and whatever powers of entertaining I
may possess, it was upon this occasion. I was quite in sympathy with
the general joy and good feeling. During the evening one and
another had called for the singing of different religious songs that
were their favorites. On such occasions there was a general appeal
to a young lady, who was quite the best singer in the company, to
know if she knew the song called for; and if she did it was sung. At
length a hymn was called for, and in response to the usual appeal
she said she did not know it. I opened a book, found the hymn and
tune, handed it to her, and said, "Here is the hymn with the tune.
Perhaps you can sing it."
She declined to take the book, saying, with the utmost frankness,
"Oh! sir, I can't read."
I now learned to my amazement that all the hymns and tunes she
had sung that evening she had learned by rote—learned by hearing
them sung by others. She was a young lady, some eighteen or
twenty years old, of more than common beauty of face and form, and
yet she had no hesitation at all in revealing the fact that she could
not read. I afterward received a similar shock on remarking to a
young lady that I met at a county-seat, whose home I had previously
visited, "I understand that a number of the young ladies in your
neighborhood can not read."
"Oh!" said she, "there are only two young ladies there that can read."
I afterward visited many neighborhoods where it was as proper to
ask a young lady if she could read as it was to ask for a drink of
water, the time of day, or any other question.
At length the evening passed, and the hour for rest and sleep came.
One of our number "took the books" and led our evening devotions.
A chapter was read, our final hymn was sung, and we all bowed in
prayer around that family altar. As we arose from our knees, the
brethren present all walked out of doors. The sisters remained
within. Some "Martha" among them had enumerated our company.
There were three beds in the cabin. These were divided, and a
sufficient number of beds made up on the bedsteads and over the
cabin-floor to furnish a sleeping-place for all our company. This
accomplished, some signal—I know not what—was given, and the
brethren returned to the house. I followed them. The sisters were all
in bed, upon the bedsteads, with their heads covered up by the
blankets. We got into our beds as though these blankets had been
thick walls. Our numbers in this room included three young ladies, a
man and his wife and child, and six other men.
When we awoke in the morning some of the brethren engaged in
conversation for a time, until Mr. W——, the preacher, remarked, "I
suppose it is time to think about getting up."
At this signal the sisters covered their heads again with their
blankets, and we arose, dressed, and departed. My companion for
the night was the young licentiate; and as we walked toward the
stable to look after our horses—the first thing usually done in the
morning by persons journeying on horseback—I remarked to him,
"Last night has been something new in my experience. I never slept
in that way before."
He looked at me with an expression of the profoundest
astonishment, and exclaimed, "You haven't!"
I said no more. I saw that I was the verdant one. I was the only one
in all the company to whom the experiences of the night suggested a
thought of anything unusual or strange. So trite and true it is that
"one half of the world does not know how the other half lives."
The Sabbath was the "great day of the feast." It brought together
some three or four hundred people—a very large congregation in
such a sparsely settled country. I made an address to them in the
morning, explaining the extended operations of the American Bible
Society in our own and other lands. I told them that the Society was
then attempting to place a copy of the Word of God in every family in
our country; that Mr. K——, a venerable and honored class-leader,
had been appointed to canvass their county; and that either by sale
or gift he would supply every family in the county with the Bible that
would receive it. All of these facts were new to the most of them, and
were listened to with the greatest interest. Large numbers of them
had no Bibles in their families; they were more than sixty miles from
a book-store, which many of them never visited, and they were glad
to have the Bible brought to their own doors, and furnished to them
at so small a price. By making these statements I gave the Bible-
distributor an introduction to the people scattered over a wide extent
of country, which prepared them to welcome him to their families and
greatly facilitated his labors.
My brief address was followed by a sermon entirely different from
those of the preacher I have already described, and deserves notice
as a type of thousands that are preached to the people in the Brush.
Scarcely a sentence in the sermon was uttered in the usual method
of speech. It was drawled out in a sing-song tone from the beginning
to the end. The preacher ran his voice up, and sustained it at so high
a pitch that he could make but little variation of voice upward. The air
in his lungs would become exhausted, and at the conclusion of every
sentence he would "catch" his breath with an "ah." As he proceeded
with his sermon, and his vocal organs became wearied with this
most unnatural exertion, the "ah" was repeated more and more
frequently, until, with the most painful contortions of face and form,
he would with difficulty articulate, in his sing-song tone:
"Oh, my beloved brethren—ah, and sisters—ah, you have all got to
die—ah, and be buried—ah, and go to the judgment—ah, and stand
before the great white throne—ah, and receive your rewards—ah, for
the deeds—ah, done in the body—ah."
From the beginning to the end of his sermon, which occupied just an
hour and ten minutes by my watch, I could not see the slightest
evidence that he had any idea what he was going to say from one
sentence to another. While "catching his breath," and saying "ah," he
seemed to determine what he would say next. There was no more
train of thought or connection of ideas than in the harangue of a
maniac. And yet many hundreds of such sermons are preached in
the Brush, and I am sorry to add that thousands of the people had
rather hear these sermons than any others. This "holy tone" has
charms for them not possessed by any possible eloquence. As the
preacher "warms up" and becomes more animated in the progress of
his discourse, the more impressible sisters begin to move their
heads and bodies, and soon all the devout brethren and sisters sway
their bodies back and forth in perfect unison, keeping time, in some
mysterious manner, to his sing-song tone.
It seemed sad to me that such a congregation, gathered from such
long distances, should have the morning hour occupied with such a
sermon. But it was a union meeting, the preacher was the
representative of his denomination, and they would have gone away
worse than disappointed—grievously outraged—if they could not
have heard this sermon with the "holy tone."
But our basket-meeting was to be signalized by an incident always
interesting in all countries, in all grades of society, among the most
rustic as well as among the most refined. After the benediction, a
part of the congregation who were in the secret remained upon their
seats, casting knowing and pleasant glances at each other. My friend
W——, who, like a good many other preachers, and some
preachers' wives, had faithfully kept a secret that a good many were
"just dying to know," took his position in front of the "stand." A
trembling, blushing, but happy pair advanced from the crowd, and
took their position before him. The groom produced from his pocket
the indispensable license. The dispersing crowd, having by some
electric influence been apprised of what was going on, came rushing
back, and mounted the surrounding stumps and logs, forming a
standing background to the sitting circle. All looked on and listened in
silence, while the preacher in a strong, clear voice proceeded to
solemnize the marriage and pronounce them husband and wife. The
scene was strange and strikingly impressive. It seemed a wedding in
Nature's own cathedral. The day was perfect. Some rays from the
sun penetrated the dense foliage above and fell upon the scene,
mingling golden hues with the shadows, as the poet, the recently
deceased A.B. Street, has so beautifully described:
"Here showers the sun in golden dots,
Here rests the shade in ebon spots,
 So blended that the very air
Seems network as I enter here."
After the usual congratulations and kisses the groom withdrew, and
reappeared in a few moments mounted upon a large gray horse. The
bride, having gained the top of a stump, mounted his horse behind
him, and the two rode away, as happy and satisfied as they could
well be.
The larger congregation of the Sabbath made larger demands upon
their hospitality; but these demands were fully met. The dinner, both
under the trees and at the cabins, was but a reënactment of the
scenes of the day before on an enlarged scale.
In the afternoon Mr. W—— preached a sensible and earnest
sermon, like that of the day before. In my pocket-diary, written at the
time, I have characterized it as a "thundering sermon." His voice was
strong, and capable of reaching the largest congregations that he
addressed in the open air. This sermon concluded the services of the
basket-meeting. As the benediction was pronounced, three
gentlemen on horseback arrived upon the ground. They were a
presiding elder, a circuit-rider, and a class-leader, on their way to
conference. They had preached some fifteen miles away in the
morning, and continued their journey to reach this meeting. I knew
them all, and had preached with and for them at their homes. As
they were strangers to most, if not all, the people, I introduced them
to the clergymen and others present. They were some twenty miles
from any hotel or public-house, and of course must spend the night
with some of these people. My host, to whom I had introduced them,
said:
"I should be very glad to have you all stay with me, but I can't take
care of your horses. I have a plenty of houseroom, but my stable is
full."
From what I have already said of the numbers who dined and lodged
with him, it will be seen that he had very enlarged ideas of the
capacity of his house. An enthusiastic neighbor, who was about as
rough a looking specimen of a backwoodsman as I ever saw,
stepped forward and said:
"I have room enough for your horses and you too. I should be glad to
have you all go with me."
The presiding elder went with him, but the preacher and the class-
leader were claimed by others.
Before leaving the grounds, it was arranged between us that we
should all meet at a designated place in the morning, and I would
travel with them to the conference, to which I was thus far on my
way. Though not an Arminian, but a Calvinist, though not a
Methodist, but a Presbyterian, I knew that a cordial welcome awaited
me as a representative of the American Bible Society. I knew that, in
addition to this official welcome, I should receive the warm greetings
of brethren beloved, with whom I had traveled many hundreds of
miles over their "circuits," and mingled in all the novel, interesting,
and eventful scenes in their wild itinerant life. When I met the elder
the next morning, I asked him the nature of the very ample
accommodations that were offered him. He said he slept upon the
floor, but he did not undertake to count the number who shared it
with him.
So ended the various incidents of our basket-meeting; but the
recollection of it has been among the pleasant memories of my life in
the Brush.
SOME EXPLANATORY WORDS.
Perhaps some statement in explanation of this "rough" but
abounding hospitality of the people in the Brush is demanded in
justice to those persons and places whose hospitality would seem to
suffer in the contrast. I might enumerate many circumstances
connected with life in a wild, unsettled country that will occur to most
readers as the cause of this abounding hospitality; but it seems to
me that the chief reason is the fact that meat, bread, and all their
provisions, excepting groceries, cost them so very little. They
estimate what they can use scarcely more than the water taken from
their springs. Beef, pork, and bread cost them almost nothing. Their
cattle run at large, and their free range includes thousands of acres
of unoccupied lands. They grow and increase in this manner with but
little attention or care. The hogs find their food in the woods the
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