Pragmatic solutions for the global burden of stroke

The recent Commission by Valery L Feigin, Mayowa O Owolabi, and colleagues1Feigin VL Owolabi MO Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization–Lancet Neurology Commission.Lancet Neurol. 2023; 22: 1160-1206Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar effectively analyses the burden of stroke, but falls short in offering pragmatic solutions for tangible improvements in outcomes. Additionally, the recommendations lack the necessary assertiveness, particularly in areas where evidence and recommendations are well established. The Commission overlooks the crucial need for empowering local stroke providers in advocating for shifts in knowledge, attitude, and policy at regional and federal levels. Such advocacy is crucial to achieve systemic changes in stroke care. Intravenous thrombolytic therapy has revolutionised the treatment of stroke, transforming the field from a state of nihilism into active therapy. This paradigm shift has led to substantial advancements, such as the development of stroke units and endovascular therapy. However, in low-income countries, intravenous thrombolytic therapy remains inaccessible mainly due to prohibitive costs.2Berkowitz AL Mittal MK McLane HC et al.Worldwide reported use of IV tissue plasminogen activator for acute ischemic stroke.Int J Stroke. 2014; 9: 349-355Crossref PubMed Scopus (41) Google Scholar, 3Durai Pandian J Padma V Vijaya P Sylaja PN Murthy JMK Stroke and thrombolysis in developing countries.Int J Stroke. 2007; 2: 17-26Crossref PubMed Scopus (126) Google Scholar The Commission should have advocated more strongly for making intravenous thrombolytic therapy freely available to all eligible patients, considering its established cost-effectiveness for patients, communities, and countries.4Tan Tanny SP Busija L Liew D Teo S Davis SM Yan B Cost-effectiveness of thrombolysis within 4.5 hours of acute ischemic stroke: experience from Australian stroke center.Stroke. 2013; 44: 2269-2274Crossref PubMed Scopus (43) Google Scholar Such a recommendation would help to enhance the entire stroke care continuum. Additionally, the Commission does not have a robust recommendation for developing and maintaining emergency services and the establishment and certification of stroke centres in low-income countries, such as the use of minimum service standards, for instance, in Nepal.5Dangal G Kashim Shah M Minimum service standard: a hospital strengthening program that facilitates hospitals' attainment of quality-of-care standards.J Nepal Health Res Counc. 2022; 20: i-iiiPubMed Google Scholar The establishment and monitoring of advanced and essential stroke centres, accessible by ambulance or helicopter even from remote areas, need to be emphasised. There is a necessity for country-level task forces to create online, multilingual living guidelines based on the World Stroke Organization's core stroke guidelines. Furthermore, implementing an affordable, secure electronic medical record system in low-income countries, possibly using smartphone apps as personal health records and educational tools, could be crucial for quality care and data collection. The World Stroke Organization should lead the development of awareness campaigns for stroke symptoms across countries and in different languages. Finally, the Commission does not address the urgent need for stroke-related workforce development in low-income countries. It should have provided recommendations on enhancing neurological and stroke education across various levels of medical training and simplifying neurology residency programmes. Training emergency physicians, family physicians, and other relevant specialists as stroke providers could mitigate the severe shortage of neurologists in these regions. In summary, while the Commission is a valuable analysis of the global stroke burden, more actionable and assertive recommendations are needed to impact stroke care and achieve health-related Sustainable Development Goals in low-income countries. We declare no competing interests. During the preparation of this work, AK used ChatGPT to proofread for grammatical errors. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization–Lancet Neurology CommissionStroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met. Full-Text PDF