International Stroke Conference
February 6–8, 2019

Victor J. Del Brutto, MD

I had the pleasure to attend the session “Cost Effective Stroke Interventions in Low and Middle Income Countries” moderated by Dr. Salvador Cruz-Flores during the International Stroke Conference held in Honolulu, HI, last week.

Dr. Sheila Martins, founder of the Brazilian Stroke Network, initiated the session, sharing her experience on the implementation of dozens of stroke centers across Brazil as part of a National Stroke Project, as well as the accomplishment of stroke telemedicine, rehabilitation programs and initiatives to increase stroke awareness among the population. Martins emphasized the mortality reduction achieved by such government policies, as well as the future expectations of creating systems able to deliver acute endovascular therapies and establishing a national stroke registry.

Dr. Hugo Aparicio from Boston University followed Martin’s presentation with a discussion on the cost of different approaches for acute stroke care and primary prevention in different world regions. Aparicio highlighted several local initiatives done in Africa and South America directed to understand stroke risk factors inherent to each region and conclude that stroke care systems do not act as a one-size-fits-all, thus should be designed according to local needs in order to improve cost-benefit results.

Dr. Valery Feigin from New Zealand addressed a more general aspect of stroke prevention based on government policies directed to modify health behavior across the population including diet, physical activity, obesity, and smoking, as well as access to healthcare focused on controlling modifiable risk factors such as hypertension and hyperglycaemia.

Finally, Dr. Jeyaraj D. Pandian from India talked about the implementation of realistic stroke units in Asia, an intervention that has shown to improve outcomes in low-income countries.

Overall, the speakers highlighted the compelling evidence that the burden of stroke has been increasing fast over the last decades in the developing world as a result of the aging population and westernization of life habits. Stroke is considered a preventable disease in around 80% of the cases, and as such, investing in policies directed to primary stroke prevention seems to be the most cost-effective approach to the problem. The interventions exposed during the session faced the challenge of social disparities, limited government support, and lack of epidemiologic studies coming from such regions. These types of sessions are important to identify those obstacles and create collaborative work groups to address this emergent issue.

In regards to acute stroke management in low-income countries, listening to this session left me with some personal thoughts. Current guidelines are based on healthcare systems that assume resources are infinite. It’s a common thought that developing countries are “few years behind” in healthcare advances. However, the reality is that some countries might never been able to implement complex healthcare systems able to effectively deliver time-sensitive high-complexity interventions. For example, implementing systems to deliver thrombolysis and endovascular thrombectomy in some regions of the world seems utopic. In addition to the need for trained vascular neurologists and stroke centers appropriately equipped, several resources that are taken for granted in developed countries, including ambulance systems, trained EMS personal, and rapid access to neuroimaging, require building up from scratch and enormous investment. The experiences from Dr. Martins in Brazil and Dr. Pandian in India are positive examples that some progress is possible and should be used as local models of adaptation of the current evidence to low budget systems.