What is the optimal management approach for reducing the global burden of stroke?

Optimal Management Approach for Reducing the Global Burden of Stroke

The optimal management approach for reducing the global burden of stroke requires implementation of a comprehensive stroke system of care that integrates organized stroke units, reperfusion therapies, multidisciplinary rehabilitation, and robust secondary prevention strategies across all resource settings. 1

Comprehensive Stroke Systems of Care

A well-organized stroke system of care encompasses eight critical domains:

1. Public Education and Primordial/Primary Prevention

   • Implement public education programs about stroke signs and the need for emergency care 1
   • Address modifiable risk factors: hypertension, diabetes, smoking, obesity, and physical inactivity 1
   • Target both population-level and high-risk individual interventions 2

2. Early Diagnosis and Pre-Hospital Care

   • Utilize emergency transportation systems with validated pre-hospital stroke assessment tools 1
   • Establish pre-hospital notification protocols to prepare receiving hospitals 1
   • Develop regional systems for rapid transfer to appropriate stroke centers 1

3. Acute Hospital Care

   • Implement reperfusion therapies for acute ischemic stroke (strong recommendation) 1
   • Establish organized stroke units with multidisciplinary teams 1
   • Develop protocols for emergency stroke evaluation using validated screening tools 1

4. Secondary Prevention

   • Establish etiological diagnosis for targeted treatment 1
   • Manage hypertension, diabetes, lipids, and lifestyle modifications 1
   • For ischemic stroke: manage atrial fibrillation, provide appropriate antithrombotics 1, 3
   • For hemorrhagic stroke: apply prothrombin complex concentrate with IV vitamin K for vitamin K-associated ICH 1

5. Rehabilitation and Recovery

   • Provide organized stroke unit care and multidisciplinary rehabilitation 1
   • Implement task-specific training and fitness training 1
   • Deliver specific interventions for post-stroke impairments 1

6. Surveillance and Quality Improvement

   • Monitor stroke quality metrics 1, 4
   • Implement strategies to track performance indicators 1
   • Establish stroke registries to guide improvements 4

Resource-Stratified Implementation

The World Stroke Organization recommends adapting stroke care based on available resources 1:

Minimal Resource Settings

• Focus on bedside clinical skills, teaching, and prevention
• Implement public education about stroke recognition
• Train first responders in basic stroke assessment
• Establish protocols for emergency transfers

Essential Resource Settings

• Ensure access to CT scans and IV thrombolysis
• Implement telemedicine/telestroke resources where on-site expertise is unavailable
• Develop emergency stroke evaluation protocols
• Establish organized stroke units

Advanced Resource Settings

• Provide comprehensive stroke centers with endovascular treatment capabilities
• Implement multimodal imaging
• Develop regional systems for rapid transfer to specialized centers
• Offer advanced rehabilitation services

Critical Challenges and Pitfalls

1. Geographic and Economic Disparities

   • The burden of stroke is increasing faster in low and middle-income countries 4, 5
   • By 2050, projections indicate 21.43 million new stroke cases and 12.05 million deaths globally 5
   • Upper-middle-income countries face the most severe projected burden 5

2. Implementation Gaps

   • Most guidelines come from high-income countries and don't address resource limitations 1
   • Limited consideration of comorbidities in guideline development 1
   • Insufficient patient and public involvement in guideline development 1

3. Quality Monitoring Challenges

   • Lack of standardized performance metrics across different settings 1
   • Limited implementation tools and advice in many guidelines 1

Pragmatic Solutions for Implementation

1. Establish national frameworks to monitor stroke burden and service quality 4

2. Prioritize hypertension control as the most effective prevention strategy 4, 2

3. Develop stroke units even in resource-limited settings, as they significantly improve outcomes 1

4. Train community health workers to expand rehabilitation capacity 4

5. Utilize mobile technology (mHealth) for prevention and management 2

6. Create advocacy ecosystems including all relevant stakeholders 4

7. Reduce redundancy in guideline development through closer collaboration between organizations 1

The evidence clearly shows that implementing organized stroke systems of care with strong emphasis on prevention, acute treatment, and rehabilitation is essential to reduce the global burden of stroke. Without urgent action, the global stroke burden will continue to increase, with projected growth in absolute numbers despite declining age-adjusted rates 5.