The state of stroke services across the globe: Report of World Stroke Organization–World Health Organization surveys
Authors: Owolabi Mayowa O , Thrift Amanda G , Martins Sheila , Johnson Walter , Pandian Jeyaraj , Abd-Allah Foad , Varghese Cherian , Mahal Ajay , Yaria Joseph , Phan Hoang T , Roth Gregory , Gall Seana L , Beare Richard , Phan Thanh G , Mikulik Robert , Norrving Bo , Feigin Valery L ,   The Stroke Experts Collaboration Group, Abera S.F. , Addissie A. , Adeleye A. , Adilbekov Y. , Adilbekova B. , Adoukonou T.A. , Aguiar de Sousa D. , Akhmetzhanova Z. , Akinyemi R.O. , Akpalu A. , Ameriso S.F. , Andonova S. , Abanto C. , Awoniyi F.E. , Bakhiet M. , Basri H. , Bath P.M. , Bereczki D. , Beretta S. , Berkowitz A.L. , Bernhardt J. , Berzina G. , Bhavsar B. , Bisharyan M.S. , Bovet P. , Brainin M. , Budincevic H. , Cabral N.L. , Cadilhac D A. , Caso V. , Chen C. , Chin J.H. , Christensen H , Chwojnicki K. , Conforto A.B. , Cruz V.T. , D'Amelio M. , Danielyan K.E. , Davis S. , Demarin V , Dempsey R.J. , Dichgans M. , Dokova  , Donnan G. , Duran J. , Elizondo M.A.B. , Elkind M.S. , Endres M. , Etedal I. , Faris M.E. , Fischer U. , Gankpe F. , Gavidia M. , Gaye-Saavedra A. , Giroud M. , Gongora-Rivera F. , Hachinski V. , Hacke W. , Hamadeh R.R. , Hamzat T.K. , Hankey G.J. , Heldner M.R. , Ibrahim N.M. , Inoue M. , Jee S. , Jiann-Shing J. , Johnston S. , Kalkonde Y. , Kamenova S. , Kelly P. , Khan T. , Kiechl S. , Kondybayeva A. , Kõrv J. , Kravchenko M. , Krishnamurthi R. , Langhorne P. , Kang Z.L. , Kruja J. , Lavados P.M. , Lebedynets D. , Leung T.W. , Liebeskind D.S. , Lindsay P. , Liu L. , López-Jaramillo P. , Lotufo P.A. , Machline-Carrion J.M. , Markus H.S. , Marquez-Romero J.M. , Medina M.T. , Medukhanova S. , Mehndiratta M.M. , Mirrakhimov E. , Mohl S. , Murphy S. , Musa K.I. , Nasreldein A. , Nogueira R. , Nolte C.H. , Norrving B. , Noubiap J.J. , Novarro-Escudero N. , O'Donnell M. , Ogun V. , Oraby M.I. , Ovbiagele B. , Ōrken D.N. , Ōzdemir A.O. , Ozturk S. , Paccot M. , Peters A. , Piradov M. , Platz T. , Potpara T. , Ranta A. , Rathore F.A. , Roth G. , Sacco R.L. , Sahathevan R. , Santos I.C. , Saposnik G. , Sarfo F.S. , Sharma M. , Sheth K.N. , Shobhana A. , Silva S.N. , Suwanwela N. , Sylaja P.N. , Thakur K. , Toni D. , Topcuoglu M.A. , Torales J. , Towfighi A. , Truelsen T. , Tsiskaridze A. , Tsong-Hai L. , Tulloch-Reid M. , Useche J.N. , Vanacker P. , Vassilopoulou S. , Venketasubramanian N. , Vukorepa G. , Vuletic V. , Wahab K.W. , Wang W. , Wijeratne T. , Wolfe C , Yifru M.Y. , Yock-Corrales A. , Yonemoto N. , Yperzeele L. 
Published: May 2021

Background Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization–World Health Organization– 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. Methods Using a validated World Stroke Organization 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 World Health Organization regions and economic strata. The World Health Organization 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 than high-income countries. The overall global score for prevention was 40.2%. Stroke units were present in 91% of high-income countries in contrast to 18% of low-income countries (p < 0.001). Acute stroke treatments were offered in ∼ 60% of high-income countries compared to 26% of low-income countries (p = 0.009). Compared to high-income countries, 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 access to stroke units and 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.