Jose Merino, MD

Two weeks ago the Mexican Academy of Neurology (AMN) held its 37th Annual Meeting in the beautiful city of Merida, Yucatan, a culinary, musical and archaeological paradise. I was honoured to participate, along with Drs. Antonio  Arauz, José Luis Ruiz-Sandoval  and Marco Antonio Alegría, in a symposium on developing stroke systems of care organized by Dr. Fernando Barinagarrementería.




Mexico is an upper middle-income country (GDP $1.178 trillion) with 121 million inhabitants. It has a long tradition of implementing public health initiatives and now has universal health care coverage. The life expectancy at birth is 77 years. But almost 20 years after the publication of the NINDS tPA study, <3% of patients with a stroke are treated with lytics or other acute interventions, despite the fact that 24% of patientsarrive to the hospital within 3 hours of onset (almost half get to the hospital within 6 hours.) As in many other countries, including the US, many factors contribute to this low treatment rate, including a fragmented health care system, the lack of a coordinated EMS and in-hospital response, unavailability of lytics in some hospitals, limited access to imaging, poor knowledge of stroke signs and symptoms among the general population, and physicians’ fear about the risks of acute stroke treatments.

But these challenges highlight several opportunities for intervention. The symposium participants and the audience agreed on the need to implement a coordinated system of stroke care in Mexico that involves the public, civil society, physician groups, first responders, hospitals, public health organizations and the government. I was encouraged to see that representatives from the Ministry of Health and the Seguro Popular were in the audience, and my hope is that they left the meeting with a greater awareness of the burden of stroke and the human, social and economic benefits of rapid diagnosis, transportation and treatment of stroke patients.

The Mexican Stroke Association (AMEVASC) is the largest organization of stroke physicians in the country. It is a small but very active group whose members work together to increase public awareness of stroke and its warning signs, promote high quality stroke care in hospitals, and engage in stroke research. They have established national ischemic stroke and ICH registries and participate in investigator-led and multicentre international stroke studies such as IST-3 and SPS3. They have also developed practice guidelines for stroke treatment and prevention. All the speakers at the symposium (myself included) are members of AMEVASC, the organization that is leading the effort to improve care at the state and national level.

At the end of the symposium participants endorsed the Merida Declaration, a call to action to physicians, hospitals, EMS providers, the public, NGOs and state and national governments to work together to develop stroke systems of care throughout the country. This is the first step in the development of a system of care that will identify stroke centres and promote the rapid and accurate identification of stroke patients, swift transport to hospitals, prompt attention in the emergency room, and access to effective treatments for patients with stroke in Mexico.