Prehospital stroke care in low- and middle-income countries: A World Stroke Organisation (WSO) Scientific Statement

Evidence-based prehospital stroke care is effective in reducing stroke-related mortality and morbidity. The crucial period from symptom awareness to presentation at hospital, the first step in the World Stroke Organization Road Map to Quality Care, is under-resourced in the majority of low- and middle-income countries (LMICs). Key challenges focus on a lack of stroke action awareness as well as human resources trained in stroke care We aimed to identify prehospital stroke practices in LMICs and identify where innovation may address service gaps. We conducted scoping reviews focussed on key domains of prehospital stroke care in LMICs that include organization of services, stroke action awareness in the community, educating primary care physicians and traditional/faith healers, diagnostic tools for prehospital stroke detection, and emergency medical service provision. We sought to determine current practices and gaps in LMICs, and evidence on effective interventions to address gaps in each domain. Recommendations are provided identifying priority considerations in each domain, based on evidence, and where lacking, expert opinion. Key recommendations include the need for: adequately funded national-level strategies for pre-hospital stroke care, stroke action awareness education for the public, primary care physicians, community health workers, emergency medical services (EMS), and traditional and faith healers, affordable imaging solutions, and approaches to create or improve prehospital EMS (e.g., protocols). We found that efforts, although few, have been made to address gaps in LMICs; however, they have rarely been evaluated, and it is unclear if they are sustained. The required elements necessary to improve prehospital services and stroke outcomes are known. Creativity is required for implementation and perseverance to ensure sustainability. This scientific statement has been reviewed and approved by the World Stroke Organisation Executive

Telemedicine networks for acute stroke: An analysis of global coverage, gaps, and opportunities

Background:: Despite the proven efficacy of telestroke in improving clinical outcomes by providing access to specialized expertise and allowing rapid expert hyperacute stroke management and decision-making, detailed operational evidence is scarce, especially for less developed or lower income regions. Aim:: We aimed to map the global telestroke landscape and characterize existing networks. Methods:: We employed a four-tiered approach to comprehensively identify telestroke networks, primarily involving engagement with national stroke experts, stroke societies, and international stroke authorities. A carefully designed questionnaire was then distributed to the leaders of all identified networks to assess these networks’ structures, processes, and outcomes. Results:: We identified 254 telestroke networks distributed across 67 countries. High-income countries (HICs) concentrated 175 (69%) of the networks. No evidence of telestroke services was found in 58 (30%) countries. From the identified networks, 88 (34%) completed the survey, being 61 (71%) located in HICs. Network setup was highly heterogeneous, ranging from 17 (22%) networks with more than 20 affiliated hospitals, providing thousands of annual consultations using purpose-built highly specialized technology, to 11 (13%) networks with fewer than 120 consultations annually using generic videoconferencing equipment. Real-time video and image transfer was employed in 64 (75%) networks, while 62 (74%) conducting quality monitoring. Most networks established in the past 3 years were located in low- and middle-income countries (LMICs). Conclusion:: This comprehensive global survey of telestroke networks found significant variation in network coverage, setup, and technology use. Most services are in HICs, and a few services are in LMICs, although an emerging trend of new networks in these regions marks a pivotal moment in global telestroke care. The wide variation in quality monitoring practices across networks, with many failing to report key performance metrics, underscores the urgent need for standardized, resource-appropriate, quality assurance measures that can be adapted to diverse settings

Implementing Acute Stroke Services in sub-Saharan Africa: Steps, Progress and Perspectives from the Tanzania Stroke Project

Stroke is a leading cause of morbidity and mortality globally, with Africa bearing a disproportionately high burden of poor outcomes. In sub-Saharan Africa, acute stroke care remains inconsistent, with organized stroke units being either absent or rarely available, contributing to the high stroke mortality rates in the region. To address this issue, the Tanzania Stroke Project (TSP) was launched, aimed at establishing acute stroke services at two of the largest tertiary care centers in collaboration with the Tanzanian Ministry of Health, the World Stroke Organization and Hospital Directorates

Predictors of Recurrence in Symptomatic Large Artery Atherosclerosis and Cryptogenic Strokes—A Comparative Study

Background and Purpose: Ischemic stroke has highest recurrence risk in the first-year, ranging from 5.7% to 14%, depending on etiology, with highest reported following cardioembolism and large artery atherosclerosis (LAA), while it is not negligible in cryptogenic strokes. We evaluated the utility of clinical, imaging parameters along with electrographic and echocardiographic biomarkers of atrial dysfunction in 2 etiological groups, namely LAA and cryptogenic strokes and compared the predictors of recurrence risk at 1 year. Methodology: All acute ischemic strokes admitted to Comprehensive Stroke Care Centre, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India for 1 year (July 2019 till June 2020) with 1 year completed follow-up were screened from electronic records. Strokes secondary to LAA and undetermined cause were compared for their clinical, imaging, and cardiac variables to predict risk of recurrence in the first year. Results: Of the 179 patients, 93 had strokes secondary to LAA and 86 had cryptogenic strokes (CS). Seventy-five patients had more than 1 event at presentation/follow-up. Recurrence risk did not differ between the 2 etiological subgroups at 1 year. Hypertension ( P = .016), multiple territory strokes ( P = .02), and dilated left ventricle (LA) chamber ( P = .047) were independently associated with recurrence risk in the entire cohort as well as within the undetermined group. Early hospitalization within 48 h reduced the overall recurrence risk ( P = .01), thus emphasizing the role of early etiological evaluation and initiation of secondary prevention in reducing future events, irrespective of etiology. Conclusion: In optimally managed LAA and cryptogenic strokes, presence of hypertension, multiterritorial infarcts, and dilated LA chambers increases the recurrence risk pointing to a likely cardiac substrate itself contributing to future stroke risk. </jats:sec

Applying the World Stroke Organization roadmap in planning a model for stroke service implementation in Matrouh Governorate-Egypt : a World Stroke Organization young future stroke leaders’ analytical study

Background: The global incidence of stroke is on the rise, primarily due to an increase in the aging population and the prevalence of vascular risk factors among the elderly. However, stroke is a treatable condition if promptly recognized and managed effectively. To optimize stroke management, it is crucial to establish a well-prepared infrastructure comprising adequately trained physicians working in collaboration with multidisciplinary teams. Equipped stroke units, easily accessible emergency medical services with a stroke code, and interconnected telestroke networks, further enhance stroke care delivery. Along with the current study, conducted by a task force from the World Stroke Organization’s Future Stroke Leaders Program, an assessment of the stroke infrastructure within Matrouh governorate in Egypt for stepwise implementation of stroke services, based on the World Stroke Organization’s stroke roadmap took place. The study consisted of two levels: Level One involved analyzing existing gaps that may impede the implementation of stroke services, while Level Two proposed strategies to address these gaps using a problem-solving approach. Results: The study identified the Matrouh governorate as a suitable region for stroke service implementation. The region exhibits a blend of urban and rural areas and is geographically distant from major healthcare centers. Matrouh also possesses a diverse population, subject to seasonal variations. Currently, it offers a mix of minimum and essential stroke services, which can be expanded and improved through a step-by-step approach guided by the World Stroke Organization’s stroke roadmap. Conclusions: Mapping stroke infrastructures allows for the identification of potential gaps to optimize the potential for implementation of stroke services