The global burden of stroke continues to increase as stroke still remains amongst the highest causes of morbidity and mortality worldwide. Per the 2013 global burden of disease (GBD) report1, a greater than 3-fold increase in the burden of stroke was reported over the past two decades. A total of 11.6 million incident ischemic stroke cases were reported worldwide in the past two decades, of which one third occurred in those less than age 65, thus adding significantly more to the disability adjusted life years (DALYs) and economic burden of stroke worldwide. Beyond DALYs lost, stroke also has a large physical, psychological, and financial impact on the millions of patients affected, their families, the health care system, and the society at large, therefore suggesting that the true global burden of ischemic stroke is perhaps much more than what we measure it to be2,3.
Stroke is a leading cause of death and a major source of disability worldwide. A Brazilian study performed by Martins and colleagues found that the percentage of hospitals with stroke centers, Emergency Medical Services (EMS), telemedicine, and endovascular services increased significantly between 2008 and 2017, after implementing a task force on stroke by neurologists with the assistance of the Brazilian Ministry of Health. However, these hospitals, equipped with specialized stroke centers, were concentrated in dense urban areas, neglecting the impoverished areas.
Now, the Brazilian Stroke Network aims to expand this model already tested in the urban regions to other parts of the country. Using mobile health technology and telemedicine, it has successfully provided the patients direct access to senior neurologists, who can diagnose complex cases and recommend treatment, hence shortening door-to-needle time and achieving better functional outcomes after stroke. However, it is still too expensive to be implemented nationwide.
Stroke recovery is a global endeavor currently affecting about 80 million people living in the world today. More than 50 million stroke survivors live with some form of permanent disability.
Join the fight against stroke! In 2015, The World Stroke Campaign focused on raising awareness of stroke prevention and risk among women using the tagline, “I am Woman – Stroke Affects Me, Stroke Affects Everyone.” In 2016, World Stroke Day was marked by recognizing that although stroke is a complex medical issue, there are ways to significantly reduce its impact. The World Stroke Organization built a campaign to underscore that “Stroke is Treatable.” Last year, the World Stroke Day 2017 campaign focused on risk awareness and prevention. This year, World Stroke Day 2018, emphasizes that there are resources and a network to assist those who have suffered from stroke. You are not in it alone! There is a well-developed network for caregivers, families, and friends affected by stroke who can help their loved ones #UpAgainAfterStroke.
I am writing this blog post on stroke care in India given my strong interest and a recent encounter with one of my family members requiring stroke care services in Chennai and New Delhi.
The stroke burden in India is enormous with more than 1.5 million stroke cases per year, much higher than Western industrialized countries. Stroke is the second most common cause of death in India. The most common cause of ischemic stroke in India is intracranial atherosclerosis as per some of the studies conducted in large academic centers from northern and southern India. There are reports of a high proportion of young stroke (first-ever stroke onset below 40 years of age), ranging between 15 and 30% of ischemic strokes.
On World Stroke Day 2018, we are fortunate to have many therapies that reduce the burden of stroke, including intravenous thrombolysis, endovascular therapy, acute stroke unit care, primary and secondary prevention, and multi-modality rehabilitation. We have recently discovered that the substantial benefits achieved with intravenous thrombolysis and endovascular therapy can extend to imaging-selected patients with wake-up stroke, whilst dual anti-platelet therapy with aspirin and clopidogrel is associated with maximum benefit and lowest risk in the first 21 days after high-risk TIA or minor stroke. However, access to effective treatments for stroke remains limited in many developed countries, and basic aspects of stroke care are not available in many developing countries. There is clear global and regional variation in access to stroke care when we speak with colleagues and friends from around the world.
Robert W. Regenhardt, MD, PhD
Regenhardt RW, Biseko MR, Shayo AF, Mmbando TN, Grundy SJ, Xu A, et al. Opportunities for intervention: stroke treatments, disability and mortality in urban Tanzania. International Journal for Quality in Health Care. 2018
As the second leading cause of death in the world, stroke is a global problem. With the recent advances in treatment of acute stroke from large vessel occlusion, World Stroke Day reminds us that in many parts of the world, these therapies are unavailable. There are large disparities between high- and low-income countries and opportunities to dramatically influence outcomes by implementing system changes in resource-limited settings. As stroke care providers, there are different levels within stroke care systems where we can implement changes to improve care. These levels include prevention at the population level, access to acute therapies at the community infrastructure level, guideline adherence during the acute admission at the hospital system level, and rehabilitation and follow-up care thereafter. Each of these is critically important.
Kara Jo Swafford, MD
Stroke can be a devastating disease that afflicts millions of individuals and their families worldwide. Many survivors are left with long-term disability, compromising their quality of life. Stroke, however, is largely preventable and treatable, with new approaches for improving poststroke recovery being developed. Advances such as the use of thrombolytic therapy (clot busting drugs) and the advent of the use of clot removing devices can now minimize the effects of stroke and increase selected patients’ chances for survival and recovery.
World Stroke Day is an opportunity for us to recognize that the burden of cerebrovascular diseases is not equally distributed throughout the world. As North America, Western Europe, and other regions of the world with advanced care struggle with issues such as implementation of endovascular coverage, most of the world struggles with issue of basic stroke care, including diagnosis and prevention.
The World Stroke Congress (WSC) held earlier this month in Montreal was an opportunity to learn about the disparities in stroke pathophysiology, systems, and care throughout the world. The World Stroke Organization (WSO) is a leading organization tasked with reducing the global burden of stroke and sponsors the WSC. Improvements in stroke care in developing nations has to be one of the priorities among WSO representatives from nations with excellent stroke infrastructure, but how can this be achieved? This is one of the challenges that the stroke community faces.
Nerses Sanossian, MD, and José G. Merino, MD
Blogging Stroke Editors
World Stroke Day is an opportunity to focus on how to reduce the global burden of the deadliest and most morbid brain disease. Stroke is a global disease that exerts a particularly high burden on developing nations, where it is the second leading cause of death. Stroke remains a leading cause of death and disability throughout the United States and Europe despite many recent advances in stroke care. However, World Stroke Day also allows us an opportunity to recognize breakthroughs in stroke care and review priorities for the future.
Advances in acute stroke have created major disparities in care nationwide and worldwide. The four most impactful stroke treatments of the past 30 years — stroke units, intravenous thrombolysis, emergency/prehospital systems, and endovascular therapy — are currently available to the minority of people around the word. Most countries are just starting to develop stroke units. Intravenous thrombolysis is unavailable or beyond the financial means for most people in the world. Emergency systems of care are non-existent in most countries. Many countries do not have a single neuroendovascular practitioner. In a world where basic medical care is limited, how can advances in stroke care be translated into meaningful results?