Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries

Global Insights on Prehospital Stroke Care: A Comprehensive Review of Challenges and Solutions in Low- and Middle-Income Countries

Stroke is a leading cause of disability and mortality worldwide, and it disproportionately affects low- and middle-income countries (LMICs), which account for 88% of stroke fatalities. Prehospital stroke care delays are a crucial obstacle to successful treatment in these settings, especially given the limited therapeutic window for thrombolytic treatments, which may greatly improve recovery chances when initiated early after stroke onset. These delays are caused by a lack of public understanding of stroke symptoms, sociodemographic and cultural variables, and insufficient healthcare infrastructure. This review discusses these issues in detail, emphasizing the disparities in stroke awareness and reaction times between locations and socioeconomic classes. Innovative options for reducing these delays include the deployment of mobile stroke units and community-based educational campaigns. This review also discusses how technology improvements and personalized educational initiatives might improve stroke awareness and response in LMICs. The primary goal is to give a thorough assessment of the challenges and potential remedies that might serve as the foundation for policy reforms and healthcare improvements in LMICs, eventually improving stroke care and lowering disease-related mortality and disability.

Mechanical Thrombectomy Workshops Improve Procedural Knowledge and Skills Among Neurointerventional Teams in Low- to Middle-Income Countries

BACKGROUND

While mechanical thrombectomy (MT) is proven to be lifesaving and disability sparing, there remains a disparity in its access in low- to middle-income countries. We hypothesized that team-based MT workshops would improve MT knowledge and skills.

METHODS

We designed a 22-hour MT workshop, conducted as 2 identical events: in English (Jamaica, January 2022) and in Spanish (Dominican Republic, May 2022). The workshops included participating neurointerventional teams (practicing neurointerventionalists, neurointerventional nurses, and technicians) focused on acute stroke due to large vessel occlusion. The course faculty led didactic and hands-on components, covering topics from case selection and postoperative management to device technology and MT surgical techniques. Attendees were evaluated on stroke knowledge and MT skills before and after the course using a multiple choice exam and simulated procedures utilizing flow models under fluoroscopy, respectively. Press conferences for public education with invited government officials were included to raise stroke awareness.

RESULTS

Twenty-two physicians and their teams from 8 countries across the Caribbean completed the didactic and hands-on training. Overall test scores (n=18) improved from 67% to 85% (P<0.002). Precourse and postcourse hands-on assessments demonstrated reduced time to completion from 36.5 to 21.1 minutes (P<0.001). All teams showed an improvement in measures of good MT techniques, with 39% improvement in complete reperfusion. Eight teams achieved a Thrombolysis in Cerebral Infarction score of 3 on pre-course versus 15 of 18 teams on post-course. There was a significant reduction in total potentially dangerous maneuvers (70% pre versus 20% post; P<0.002). Universally, the workshop was rated as satisfactory and likely to change practice in 93% Dominican Republic and 75% Jamaica.

CONCLUSIONS

A team-based hands-on simulation approach to MT training is novel, feasible, and effective in improving procedural skills. Participants viewed these workshops as practice-changing and instrumental in creating a pathway for increasing access to MT in low- to middle-income countries.

Burden of stroke in China and the different SDI regions over the world

Background

Stroke is a significant global health issue, ranking as the second leading cause of death and the third leading cause of death and disability combined. This study aimed to examine the changes and differences in stroke burden from 1990 to 2019 in China and various global socio-demographic index (SDI) regions.

Methods

Data were obtained from the Global Burden of Diseases Study 2019, which included the incidence, prevalence, mortality, disability-adjusted life years (DALY), years of life with disability (YLD), and years of life lost (YLL) of stroke. The change trend of stroke burden was assessed based on age-standardised rates per 100 000 person-years and estimated annual percentage changes. The average annual rate of change in stroke burden was analysed using the average annual percentage change from 1990 to 2019. Pearson correlation analysis was used to explore the strength and direction of the correlation between stroke burden and SDI.

Results

Regions with high SDI showed the largest decline in age-standardised incidence, death, DALY, YLD, and YLL rates of stroke from 1990 to 2019. China experienced the largest increase in age-standardised prevalence and YLD rates of stroke from 1990 to 2019. There were significant differences in the average annual percent change in stroke burden among the majority of SDI regions. The burden for stroke at the national level was inversely correlated with SDI, despite some exceptions (Incidence: R = -0.417, P < 0.001; prevalence: R = -0.297, P < 0.001; mortality: R = -0.510, P < 0.001; DALY: R = -0.550, P < 0.001; YLD: R = -0.125, P = 0.075; YLL: R = -0.569, P < 0.001).

Conclusions

There were significant differences in the stroke burden across different regions with varying SDI levels from 1990 to 2019. The age-standardised prevalence rate and attributable disability burden of stroke remain substantial in different SDI regions, making it a major contributor to the overall disease burden. The severe burden of stroke highlights the importance of primary and secondary stroke-prevention strategies. Therefore, future strategies to prevent and reduce the burden of stroke should be formulated and implemented according to the SDI of each country.

Targeted Public Health Training for Neurosurgeons: An Essential Task for the Prioritization of Neurosurgery in the Evolving Global Health Landscape

The gap between the tremendous burden of neurological disease requiring surgical management and the limited capacity for neurosurgical care has fueled the growth of the global neurosurgical movement. It is estimated that an additional 23 300 neurosurgeons are needed to meet the burden posed by essential cases across the globe. Initiatives to increase neurosurgical capacity through systems strengthening and workforce development are key elements in correcting this deficit. Building on the growing interest in global health among neurosurgical trainees, we propose the integration of targeted public health education into neurosurgical training, in both high-income countries and low- and middle-income countries. This effort will ensure that graduates possess the fundamental skillsets and experience necessary to participate in and lead capacity-building efforts in the developing countries. This additional public health training can also help neurosurgical residents to achieve the core competencies outlined by accreditation boards, such as the Accreditation Committee on Graduate Medical Education in the United States. In this narrative review, we describe the global burden of neurosurgical disease, establish the need and role for the global neurosurgeon, and discuss pathways for implementing targeted global public health education in the field of neurosurgery.

Incidence, lethality, and post-stroke functional status in different Brazilian macro-regions: The SAMBA study (analysis of stroke in multiple Brazilian areas)

Background

Stroke is the second leading cause of death in Brazil. The social and financial burden of stroke is remarkable; however, the epidemiological profile remains poorly understood.

Objective

The aim of this study was to report the incidence, lethality, and functional status at 30 and 90 days post-stroke in the cities of different Brazilian macro-regions.

Methods

This is an observational, prospective, and population-based study, led in Canoas (South), Joinville (South, reference center), Sertãozinho (Southeast), and Sobral (Northeast) in Brazil. It was developed according to the three-step criteria recommended by the World Health Organization to conduct population-based studies on stroke. Using different sources, all hospitalized and ambulatory patients with stroke were identified and the same criteria were kept in all cities. All first events were included, regardless of sex, age, or type of stroke. Demographic and risk factor data were collected, followed by biochemical, electrocardiographic, and radiological test results. Functional status and lethality were obtained using the mRankin scale through telephonic interview (validated Brazilian version).

Results

In 1 year, 932 stroke cases were registered (784 ischemic stroke, 105 hemorrhagic stroke, and 43 subarachnoid hemorrhage). The incidence rates per 100,000 inhabitants, adjusted for the world population, were 63 in Canoas, 106 in Joinville, 72 in Sertãozinho, and 96 in Sobral. The majority (70.8%) were followed for 90 days. Kaplan-Meier curves showed that 90-day survival was different among cities. Sobral, which has the lowest socioeconomic indexes, revealed the worst results in terms of lethality and functional status.

Conclusion

This study expands the knowledge of stroke epidemiology in Brazil, a middle-income country with enormous socioeconomic and cultural diversity. The discrepancy observed regarding the impact of stroke in patients from Joinville and Sobral highlights the need to improve the strategic allocation of resources to meet the health priorities in each location.

Outcomes of stroke patients undergoing thrombolysis in Sri Lanka; an observational prospective study from a low-middle income country

BACKGROUND

Stroke related deaths are relatively higher in low- and middle-income countries where only a fraction of eligible patients undergo thrombolysis. There is also limited evidence on post-thrombolysis outcomes of patients from Asian countries in these income bands.

METHODS

This is a single center prospective observational study of a patient cohort with acute ischaemic stroke, undergoing thrombolysis with alteplase (low and standard dose), over a 24-month period in 2019/2020. Modified Rankin scale (mRS) for dependency at 3 months (primary outcome), duration of hospital stay, incidence of symptomatic intracranial haemorrhages and all-cause mortality at 3 months (secondary outcomes) were recorded. Demographic, clinical and treatment related factors associated with these outcomes were explored.

RESULTS

Eighty-nine patients (males - 61, 69%, mean age: 60 years ±12.18) were recruited. Time from symptom onset to reperfusion was 174 min ± 56.50. Fifty-one patients were independent according to mRS, 11 (12.4%) patients died, and 11 (12.5%) developed symptomatic intracranial haemorrhages by 3 months. Functional independence at 3 months was independently associated with National Institutes of Health Stroke Scale (NIHSS) on admission (p < 0.05). Thrombolysis with low dose alteplase did not lead to better or worse outcomes compared to standard dose.

CONCLUSIONS

On admission NIHSS is predictive of functional independence at 3 months post-thrombolysis. Low dose alteplase may be as efficacious as standard dose alteplase with associated cost savings, but this needs to be confirmed by a prospective clinical trial for the Sri Lankan population.