Stroke services in Africa: What is there and what is needed

Background: Over the past few years, the incidence and prevalence of stroke has been rising in most African countries and has been reported as one of the leading causes of morbidity and mortality. To study this problem, we need to realize the quality and availability of stroke care services as a priori to improve them. Methods and Results: In this study, we investigated the availability of different stroke-related services in 17 countries from different African regions. An online survey was conducted and fulfilled by stroke specialists and included primary prevention, acute management, diagnostic tools, medications, postdischarge services, and stroke registries. The results showed that although medications for secondary prevention are available, yet many other services are lacking in various countries. Conclusion: This study displays the deficient aspects of stroke services in African countries as a preliminary step toward active corrective procedures for the improvement of stroke-related health services.

Abstract 1122‐000134: Social and Cultural Barriers to Global Stroke Care

Introduction : Comprehensive stroke centers require resource‐intensive patient care and supportive divisions. Resource underutilization can include: traditional beliefs about etiology of stroke, transportation barriers, or an inability to recognize early symptoms of stroke. We explore the available literature to determine region‐specific social and cultural barriers to obtaining stroke care. Methods : A literature review was performed to identify studies that described stroke care in low‐income and middle‐income countries (LMICs). We used the search term “stroke” along with the following terms: “burden”, “incidence”, “prevalence”, “awareness”, “transportation”, “stroke services”, “rehabilitation” “tissue plasminogen activator”, “acute stroke”, “emergency care”, “infrastructure”, “stroke services”, “quality improvement”, and “stroke units”, between January 1st, 2015 and August 1st, 2021. Forty‐five articles were identified. Results : We identified two broad limitations to expanding stroke care across the globe: infrastructure and education/ culture. We subdivided stroke care regionally into Middle East and North Africa (MENA), Europe, Asia, Latin America, and Subsaharan Africa. In MENA, religious health fatalism scores on questionnaires are negatively correlated with adherence to rehabilitative protocols and stroke outcome. Increased faith engagement conversely is strongly correlated with improved psychiatric outcome following stroke, indicating a role in properly educating Middle Eastern citizens regarding stroke etiology and urgency of treatment. In Europe stroke mortality and incidence is greater in rural areas in the region, likely indicating transit‐related difficulties in obtaining stroke care or deficits in education regarding lifestyle‐based measures to reduce vascular disease. Low per capita numbers of stroke‐specific care units in southern and eastern countries indicate a significant care access need in rural and low‐resource regions. For Asia, a lack of major infrastructure obstacles to wider accessibility of EVT, especially among developing countries. Only 6.5% in a nationwide survey in China were aware that there was a therapeutic window for thrombolytic therapy in 2016, increased to 32.8% after a 2 year nationwide campaign. The adept use of social media to target high‐risk populations can improve awareness of therapeutic windows. Ethnic and socioeconomic disparities are especially pronounced in this region. The RESILIENT trial demonstrated the effectiveness of EVT in Brazilian public hospitals, which helped convince the government to change policy and promote the use of EVT. Similar trials could be used to convince other governments to shift policy and promote the use of EVT as standard of care in public hospital systems. Some African communities consider stroke to be an illness of debilitating/ paralytic, ghost, or shivering etiology. Many communities rely on non medical means of care. A survey at Ignance Deen Neurology ward in 2014 revealed that only 2% of stroke patients arrived in an ambulance while 46% came by public transport and 27% arrived by personal car. Conclusions : Social and cultural barriers to obtaining stroke care are based on lack of availability and patient trust. Trust in care and compliance with preventive/rehabilitative measures may be helped by connecting NGOs such as Stroke Angels and Mission Thrombectomy 2020 with community‐based/ religious leaders to correct assumptions about origin and treatment. Targeted, culturally‐relevant messaging may help to increase awareness about symptoms, risk factors, and etiology.

Establishing Stroke Services in the Republic of Georgia

<b><i>Introduction:</i></b> This article summarizes the medical experience in establishing stroke units and systemic thrombolysis in Georgia, which, like many other post-Soviet countries, still faces problems in organizing stroke care even after 30 years of independence. <b><i>Patients and Methods:</i></b> We created an example of treating acute stroke with systemic thrombolysis and introduced stroke units in several hospitals in the country, including standardization of the diagnostic and treatment process, consistent evaluation, and monthly feedback to the stroke unit staff. <b><i>Results:</i></b> Systemic thrombolysis has become a clinical routine in some large hospitals and is meanwhile reimbursed by the state insurance. The data of consecutive 1,707 stroke patients in 4 major cities demonstrated significant time lost at the prehospital level, due to failure in identifying stroke symptoms, delay in notification, or transportation. The consequent quality reports resulted in a dramatic increase in adherence to the European and national guidelines. A mandatory dysphagia screening and subsequent treatment led to a decrease in pneumonia rates. <b><i>Discussion:</i></b> We discuss our experience and suggestions on how to overcome clinical, financial, and ethical problems in establishing a stroke services in a developing country. <b><i>Conclusion:</i></b> The Georgian example might be useful for doctors in other post-Soviet countries or other parts of the world.

Purines for Rapid Identification of Stroke Mimics (PRISM): study protocol for a diagnostic accuracy study

Background Rapid treatment of stroke improves outcomes, but accurate early recognition can be challenging. Between 20 and 40% of patients suspected to have stroke by ambulance and emergency department staff later receive a non-stroke ‘mimic’ diagnosis after stroke specialist investigation. This early diagnostic uncertainty results in displacement of mimic patients from more appropriate services, inappropriate demands on stroke specialist resources and delayed access to specialist therapies for stroke patients. Blood purine concentrations rise rapidly during hypoxic tissue injury, which is a key mechanism of damage during acute stroke but is not typical in mimic conditions. A portable point of care fingerprick test has been developed to measure blood purine concentration which could be used to triage patients experiencing suspected stroke symptoms into those likely to have a non-stroke mimic condition and those likely to have true stroke. This study is evaluating test performance for identification of stroke mimic conditions. Methods Design: prospective observational cohort study Setting: regional UK ambulance and acute stroke services Participants: a convenience series of two populations will be tested: adults with a label of suspected stroke assigned (and tested) by attending ambulance personnel and adults with a label of suspected stroke assigned at hospital (who have not been tested by ambulance staff). Index test: SMARTChip Purine assay Reference standard tests: expert clinician opinion informed by brain imaging and/or other investigations will assign the following diagnoses which constitute the suspected stroke population: ischaemic stroke, haemorrhagic stroke, TIA and stroke mimic conditions. Sample size: ambulance population (powered for mimic sensitivity) 935 participants; hospital population (powered for mimic specificity) 377 participants. Analyses: area under the receiver operating curve (ROC) and optimal sensitivity, specificity, and negative and positive predictive values for identification of mimic conditions. Optimal threshold for the ambulance population will maximise sensitivity, minimum 80%, and aim to keep specificity above 70%. Optimal threshold for the hospital population will maximise specificity, minimum 80%, and aim to keep sensitivity above 70%. Discussion The results from this study will determine how accurately the SMARTChip purine assay test can identify stroke mimic conditions within the suspected stroke population. If acceptable performance is confirmed, deployment of the test in ambulances or emergency departments could enable more appropriate direction of patients to stroke or non-stroke services. Trial registration Registered with ISRCTN (identifier: ISRCTN22323981) on 13/02/2019 http://www.isrctn.com/ISRCTN22323981

The State of Stroke Services across the Globe: Report of World Stroke Organization-World Health Organization Surveys

Background: Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization (WSO)-World Health Organisation (WHO)-Lancet Neurology Commission on Stroke conducted a survey of the status of stroke services in low and middle income countries (LMICs) compared to high income countries (HICs). Methods: Using a validated WSO comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across WHO regions and economic strata. The WHO also conducted a survey of non-communicable diseases in 194 countries in 2019. Results: Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys and participation in research) were reported in low-income countries (LICs) than HICs. The overall global score for prevention was 40.2%. Stroke units were present in 91% of HICs in contrast to 18% of LICs (p<0.001). Acute stroke treatments were offered in ~60% of HICs compared to 26% of LICs (p=0.009). Compared to HICs, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol. Conclusions: There is an urgent need to improve stroke services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.

Exploring advanced nursing practice in stroke services: a scoping review

Background: Stroke care is becoming increasingly reliant on advanced nursing practice (ANP); however, little is known about these roles within the stroke specialty. Aims: To explore the current knowledge of advanced nursing practice in stroke services internationally, specifically, the conceptualisation of ANP and the rationale for its implementation. Methods: Arskey and O'Malley's scoping review methodology was employed, and six academic databases were used. Findings: Two key themes were identified; ‘role development’ and ‘four pillars of advanced practice’. The review identifies that ANP is implemented primarily to provide acute stroke care. Conclusions: Current research does not clarify the rationale for implementing these posts or how ANP is conceptualised. This review does identify that stroke ANP incorporates the four pillars of advanced practice (clinical, research, leadership and education) and was implemented to improve the quality of stroke care. Barriers and facilitators to implementation were also identified.