By Zdravka Poljakovic

Pragmatic Solutions, Pathways to Impact and Success Stories for Reducing the global burden of stroke: World Stroke Organization – Lancet Neurology Commission on Stroke (joint with WSO)

This highly important session was devoted to all aspects of global efforts from WSO – Lancet Neurology Commission on Stroke to reduce burden of stroke worldwide, but especially to low-income countries who are in the most need of improvement of all parts of stroke chain care. In that sense, the members encourage us to read and implement the document issued by the Commission where problems as well as possible solutions are highlighted and proposed.

First speaker, presenting his talk on-line,  was Professor Mayowa Owolabi from College of Medicine University in Ibadan, Nigeria who briefly introduced Lancet Commission and made an introduction about the importance of stroke and burden of stroke worldwide. In addition, he pointed out the fact that incidence of stroke is growing, especially in low income countries, showing that absolute numbers are, and will continue, to increase. One of the goals of the Commission is also to visit and implement the action plan especially where it is mostly needed. Tools for activities were summarized as well as analysis and projections, and evidence-based interventions according to recommendations, taking also care about PLEASE (political, legal, ethical, anthropological and socio-economic contextualization). He introduced four pillars of stroke: surveillance-prevention-acute care-rehabilitation as well as pragmatic solutions for detected problems. By all means, the audience was invited to read published papers from prof Owolabi which offer pragmatic solutions to reduce global burden of stroke based also on the results from the survey he initiated. 

Second presenter was Professor Muideen Olaiya, from Monash University, presenting the topic of Surveillance of stroke and its risk factors. In his talk, he started by defining quantitative and qualitative risk factors, showing the importance of identification (of risk factors specific for every country), reviewing (existing data about risk factors but also data about mortality from stroke) and finally analysis of data which consists of a description of coverage, recency and content-mapping. He also presented surprising data from his own research work which discovered that we have only 10 ideal stroke incidence studies in the last 10 years, only 14% of countries, WHO members, have optimal stroke registries, and only 22% of those are from low and middle-income countries. Considering death data, 64% of countries submitted those data in the past 30 years. Surveys for risk factors have much better implementation, and 90% of countries have some surveys including at least one risk factor for stroke, but only 57% of countries actually measured those risk factors, and only 20% of the surveys were supported by national agencies or government. However only 32% included all relevant stroke factors, and not less than 92% actually measured just lifestyle factors. In his talk he emphasized the barriers and facilitators for national surveillance systems in stroke and for registries which are condition for stroke care improvement. An important facilitator is and should be AI and digital technology which can be implemented into existing systems and contribute to wide data collection for stroke risk factors. He ended his talk with the invitation for establishing programs to determine the real incidence of stroke risk factors with the help of dedicated funding, collaboration and help of health professionals and government in raising the awareness of importance of controlling those factors in the whole community.

Next presentation was given by Professor Bo G. Norrrving, from Lund, Sweden about the Prevention of stroke. The main message from his talk is that prevention will and should have the largest overall impact on the burden of stroke, being at the same time the most cost-effective method which is required in order to match the costs of stroke. WHO’s plan for noncommunicable diseases has 9 targets who might ensure healthy life and promote well-being for all at all ages. And at least two of those targets can be reached by prevention of stroke and heart diseases, which might have big impact on cumulative deaths already till 2030. And very important, the fact is that 5 modifiable risk factors explain 80% of strokes, and 10 modifiable risk factors explain even 90% of strokes, which shows the importance of treating them. Also, we have to be aware that 80% of strokes occur in people with low or moderate stroke risk. In order to achieve needed prevention rates, we could use population wide prevention methods which could reduce stroke by 90%, but this is not a realistic way. Next possibility would be targeting high-risk patients (and reducing the stroke incidence by 11%) and maybe the most useful method would be motivational mass prevention strategy combined with conventional risk factor awareness activities which could bring high 50% of stroke reduction and is also a realistic method. In order to implement this method countries should have help from the government with endorsed policies, stroke awareness campaigns and also continuous monitoring of results. A big help are also actions again tobacco, alcohol, salt and/or sugar, physical activity, transportation systems, air pollutions… but those actions are often politically unpopular and counteracted from industry, so they are not always widely implemented. Finally, individual approach should not be forgotten, but sometimes also challenging as we have to take care not to moralize, but to use a motivational approach using simple “improvements”, like avoiding terms as nutrition and diet, and using food and meals, or avoiding terms physical activity and exercise and using playing and dancing, for example…The talk was concluded by emphasizing also the importance of secondary prevention (as up to 30% of strokes are recurrent and successful secondary prevention could reduce the burden of stroke by about 25%). However, this kind of prevention has also challenges especially in lack of health care staff. Still there are a lot of optimistic examples, like declining rates of stroke in some countries in the last 20 years (like in Sweden), and programs like HEARTS, SAPE, STROKE-CARD program, which give hope and motivation for further work.

Professor Sheila Cristina Ouriques Martins, the actual President of World Stroke organization and professor of Universidade Federal of Rio Grande do Sul in Brazil gave a colorful talk about actions of the Lancet Commission considering acute and hyperacute stroke treatment. In her talk she first emphasized challenges in acute stroke care, most of which are low stroke awareness especially in low income countries, untrained personal, partial implementation of stroke awareness and on the other hand also high cost of treatments, and lack of government action plans and funding. In order to achieve improvement in acute stroke treatment in low income countries WSO online road map was constructed, serving mostly for exploring the own situation in the country, with an easy virtual program. On-site visits were implemented as well (like visits in Ethiopia, Columbia, Indonesia…). Telestroke program called “Telestroke without boarder” was established and showed itself as a big help in decision important moments. The team organized teaching courses, hold on-line and in person. And finally, certification process started with  now more than 80 hospital in Latin America certificated, according to strict criteria. The Commission continues its work globally under umbrella of Global Stroke Alliance and moto “Stroke without frontiers”.

Professor Jeyaraj Pandian, member of the Commission, as a next speaker, discussed the problems and approaches to neurorehabilitation after stroke.

He started his talk with the fact that only 16% of low-impact countries have a Stroke Unit in comparison with high-impact countries where more than 90% of countries have Stroke Units as a standard stroke care. The same reflects also for neurorehabilitation where low impact countries experience low level of knowledge, non-inclusion of rehabilitation in national guidelines, neurorehabilitation is not recognized in the government, and very often relatives become caregivers and must hire a home physiotherapist. In all – rehabilitation is an “outpatient thing”. In order to enlight the problem Professor Pandian discussed the results of several trials which cover neurorehabilitaion (ATTEND, RECOVER),  focus on motivation (ADHERE) or even use help of AI and online rehabilitation (ATTEND 2). He presented also the results of traditional methods as Ayurveda treatment investigated in RESTORE trial. He concluded his talk by emphasizing the need of stroke registry for neurorehabilitation, implementation of low-cost technologies (like robot-like game based home programme), and including government in whole rehabilitation process and programs.

The final talk in this Session with the topic “Reducing the global burden of stroke” was given by Dr Taskeen Khan, representative of the World Health Organization from Department of Non-Communicable disease. Dr Khan in the first part of her talk actually explained the role of WHO in global actions and plans, stating that WHO serves as a “secretariat” which support the health agenda defined and given by member countries, as it will again happen in about of 10 days in Geneva. It is also very well accepted that cardiovascular diseases, including Stroke, still remain the largest cause of death globally,  being responsible for 38% of  17 millions of premature deaths (under the age of 70). She also showed that unfortunately there was nearly no epidemiological transition within risk factors (between 1990 and 2019) with only a small place change of high BMI and tobacco, with hypertension still holding the first place. Hypertension is still a leading factor for cerebrovascular diseases and striking fact is that 1.3 billions of adult suffer from it, with only 1 person among 5 who has the disease under control. So government actions are desperately needed, as the statistics shows that if we control only 50% of hypertensive patients we could, by preventing only this one risk factor, save 76 million deaths. She ended her talk with the presentation of WHO HEARTS – program of hypertension control, as well as with the fact that WHO list of essential medicines includes antihypertensives on the first place, followed by alteplase and priority medical devices.