ESJ Comment: Acute stroke care: where are we and where are we going?

Original research article
Access to and delivery of acute ischaemic stroke treatments: A survey of national scientific societies and stroke experts in 44 European countries
European Stroke Journal DOI:

Comment by Linxin Li

Acute stroke care: where are we and where are we going?

Despite decreasing in age-standardised stroke incidence and mortality over the last two decades in all European countries, stroke is still the second most common single cause of death in Europe. Whilst prevention strategies are vital in reducing stroke-related disability, acute stroke care, including acute stroke unit (SU), intravenous thrombolysis (IVT) and endovascular treatment (EVT) also significantly improve the outcome for patients with ischaemic stroke. However, data on access and delivery of acute stroke care throughout Europe are lacking.

To close the gap, the European Stroke Organisation (ESO), the European Society of Minimally Invasive Neurological Therapy (ESMINT), the European Academy of Neurology (EAN) and the Stroke Alliance for Europe (SAFE) surveyed 51 European countries to collect the national data on access to and delivery rates for acute SU care, IVT and EVT throughout Europe. The fruitful outcome of this huge collaborative effort has paid off and in this issue of the ESJ, the ESO ESMINT EAN SAFE Survey on Stroke Care collaborators reported their findings.

Overall data were available from 44 countries.

  • 42/44 countries provided data on SU care. There were 2139 acute SUs in 42 countries, corresponding to a pooled mean number of 2.9 SUs per million inhabitants (95%CI 2.3-2.6) and 1.5 per 1000 annual incident strokes (95%CI 1.1-1.9).
  • IVT was provided in 42/44 countries and the total annual number of patients receiving IVT was 113,267. The estimated mean annual number of IVT was 142.0 per million inhabitants (95%CI 107.4-176.7) and 72.7 per 1000 annual incident strokes (95%CI 54.2-91.2). The two most frequent reasons for not performing IVT were late patient presentation and a lack of personnel with stroke expertise on site.
  • EVT was available in 40/44 countries with 27,505 procedures annually. The mean annual number of EVT was 37.1 per million inhabitants (95%CI 26.7-47.5) and 19.3 per 1000 annual incident strokes (95%CI 13.5-25.1). The most common reasons for not being able to provide the service were lack of expertise, lack of facilities and costs.

Perhaps somewhat expected, the authors also observed major inequalities not only between but also within the surveyed countries. For example, whilst on average 7.3% of incident ischaemic stroke patients received IVT, this rate varied hugely between countries, with the highest rates being 20.6% (Netherlands) and the lowest <1%.

The comprehensive data clear showed where we are now. More importantly, the data will be important in guiding decision makers implementing tailored stroke care programmes so that we also are clear about where we are heading for. One of the priorities is of course to make sure that all stroke patients can receive the same level of treatment wherever they live in Europe. With us working together as a group, on a platform such as the European Angels Initiative and guided by the ESO and SAFE Stroke Action Plan, we are confident that we will improve acute stroke care across Europe in the very near future.

The full paper can be found at