Stroke Organization Research Articles

European Stroke Organisation (ESO) standard operating procedure for white papers (expert consensus based clinical guidance).

Promoting the highest quality, evidence-based research across Europe is a priority of the European Stroke Organisation (ESO). The ESO Guideline Board communicate and promote evidence-based recommendations for clinical practice through their Guidelines. However, there are many aspects of stroke care where robust scientific evidence may be unavailable or difficult to obtain. Thus, there is a need for practical, consensus guidance, produced following robust, consistent, and transparent methods, that is suitable for high-priority clinical scenarios where evidence is currently lacking. The ESO Guideline Board developed methods for producing practical clinical guidance based on expert consensus in response to this need. These ESO' White Papers' are intended to complement standard ESO Guidelines. Here, we outline the ESO White Papers' standard operating procedure (SOP). We will describe the motivation for creating White Papers, the preferred composition of writing groups and expert consensus panellists, the methods for achieving consensus, and how results will be communicated. To ensure that all voting members have an equal voice, our methods are based upon the Delphi process of repeated rounds of anonymous voting, feedback and review. We hope that the White Papers will add further value to the clinical practice guidance that is offered by ESO. We look forward to receiving suggestions for White Paper topics from the stroke community.

Global challenges in the access of endovascular treatment for acute ischemic stroke (global MT access).

Mechanical thrombectomy (MT) is the standard of care for eligible acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) since 2015. Our aim was to determine the key challenges for MT implementation and access worldwide. We conducted an international online survey consisting of 37 questions, distributed through the World Stroke Organization network and as invited by co-authors between December 2022 and March 2023. The survey included a preamble outlining its purpose, questions on respondent demographics, imaging availability, MT service availability, MT selection criteria, barriers to MT, and training status in each country. We received 526 responses from 89 countries distributed across 7 continents. One hundred and sixteen (22.1%) respondents did not have available MT service, 43 (8.2%) had available MT only during working hours, 362 (68.8%) had 24/7 MT availability. Regarding neuroimaging protocols, 13.5% used non-contrast computed tomography (NCCT) only, 40.1% used NCCT/CT angiography, 37.5% used NCCT/CT angiography/CT perfusion), 0.4% used magnetic resonance imaging (MRI) only, and 7.8% used MRI/MR angiography. The most common reasons for not receiving MT were cost, late presentation, and lack of availability of qualified neurointerventional services within reasonable distance. There were 59.1% of respondents who reported having a well-structured MT training program. Lack of qualified trainers, financial support, support from higher authorities, and lack of collaboration between departments were the most common obstacles against developing a training program. Our study highlights significant variations in MT availability, accessibility, patient selection criteria, and MT service training programs worldwide. Financial costs and a shortage of trained neurointerventionalists were the main challenges in low- and middle-income countries.

Time to consider health services dedicated for adults living with cerebral small vessel disease: Report of a ESO scientific seminar.

Cerebral small vessel disease (cSVD) is a highly prevalent disorder leading to physical, cognitive and functional decline. We report key barriers in the management of individuals with cSVD, the potential benefit of cSVD-dedicated health services, and evidence from existing models of care for adults with cSVD. We examined information from a scientific seminar developed between seven experts in cSVD during the eighth European Stroke Organisation Conference that discussed the optimal health care for adults with cSVD and what health services dedicated to cSVD should include. Barriers in cSVD care include unrecognised symptoms and modifiable risk factors, heterogeneity of clinical presentations, inefficient inter/intra-clinical services communication/organisation, and uncertainties regarding what assessments/treatments should be routinely done, when and by whom. However, existing health services and research studies suggest models of care in cSVD. Multi-step approaches can be used for identification and aetiological workup in individuals with cSVD, including basic and selected advanced evaluations, for example, monogenic cSVD testing. Although current guidelines for management of cSVD illlustrate limitations, there are recommendations on risk factors and lifestyle considerations, as well as pharmacological and non-pharmacological interventions for people with cSVD. Existing healthcare models do not provide optimal care for individuals with cSVD. Lack of awareness of heterogeneous clinical presentations and uncertainty in threshold of cSVD 'burden' for referral to specialist multidisciplinary services, are key challenges for health services to overcome. Creating cSVD-dedicated services may prevent underdiagnosing and achieve standardised holistic management to improve outcomes in people with cSVD. However, adequate prevention and early management should be offered at all levels of care.

World Stroke Organization: Global Stroke Fact Sheet 2025.

Among non-communicable disorders (NCDs), stroke remains the second leading cause of death and the third leading cause of death and disability combined (as expressed by disability-adjusted life-years lost-DALYs) in the world. The study was aimed to estimate global, regional and nationa burden of stroke and its risk factors from 1990 to 2021. Finding presented in this paper were derived mainly from the Global Burden of Disease 2021 Study on stroke burden published in The Lancet Neurology 2024:23:973-1003. The estimated global cost of stroke is over US$890 billion (0.66% of the global GDP). From 1990 to 2021, the burden (in terms of the absolute number of cases) increased substantially (70.0% increase in incident strokes, 44.0% deaths from stroke, 86.0% prevalent strokes, and 32% DALYs), with the bulk of the global stroke burden (87.0% of deaths and 89.0% of DALYs) residing in lower-income and lower-middle-income countries (LMICs). Stroke attributable to metabolic risks constituted 69.0% of all strokes, environmental risks constituted 37.0%, and behavioral risks constituted 35.0%. This World Stroke Organization (WSO) Global Stroke Fact Sheet 2025 provides the most updated information that can be used to inform communication with all internal and external stakeholders; all statistics have been reviewed and approved for use by the WSO Executive Committee and leaders from the Global Burden of Disease research group.

Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement.

Secondary stroke prevention in patients with atrial fibrillation (AF) is one of the fastest growing areas in the field of cerebrovascular diseases. This scientific statement from the World Stroke Organization Brain & Heart Task Force provides a critical analysis of the strength of current evidence on this topic, highlights areas of current controversy, identifies knowledge gaps, and proposes priorities for future research. We select topics with the highest clinical relevance and perform a systematic search to answer specific practical questions. Based on the strength of available evidence and knowledge gaps, we identify topics that need to be prioritized in future research. For this purpose, we adopt a novel classification of evidence strength based on the availability of publications in which the primary population is patients with recent (<6 months) cerebrovascular events, the primary study endpoint is a recurrent ischemic stroke, and the quality of the studies (e.g. observational versus randomized controlled trial). Priority areas include AF screening, molecular biomarkers, AF subtype classification, anticoagulation in device-detected AF, timing of anticoagulation initiation, effective management of breakthrough strokes on existing anticoagulant therapy, the role of left atrial appendage closure, novel approaches, and antithrombotic therapy post-intracranial hemorrhage. Strength of currently available evidence varies across the selected topics, with early anticoagulation being the one showing more consistent data. Several knowledge gaps persist in most areas related to secondary stroke prevention in AF. Prioritizing research in this field is crucial to advance current knowledge and improve clinical care.

Knowledge Acquisition and Audience Retention in Stroke Education: Results From a Global Study by the World Stroke Organization.

The World Stroke Academy (WSA), the educational platform of the WSO, provides high-quality stroke education to health care professionals worldwide. Understanding the learning needs and preferences of WSA members is crucial for effective knowledge translation. This study aims to (1) assess demographics and professional backgrounds of WSA members, (2) identify preferences in knowledge acquisition, and (3) evaluate audience retention during WSA webinars. A survey was developed using Qualtrics and distributed via email to all WSA members from May 8 to May 23, 2023. The survey included multiple-choice, rating scale, and ranking questions. Audience retention data were obtained from the latest 6 WSA webinars (May 2023-December 2023). Descriptive variables were reported, and χ2 analysis and multinomial regression models were used. A random sample of 1065 WSO members received the survey; 327 initiated it (participation rate, 30.7%), and 236 completed it (completion rate, 72.2%). The mean age (SD) of participants was 46.7 (±11.6) years; 57.2% identified as male. Most respondents were stroke specialist physicians (65.3%) and were based in Europe (35.2%). Online journal articles represented 41.6% of the total time allocated for stroke education, with 17% allocated to webinars. Social media usage patterns showed X (formerly Twitter) as the top choice (34.7%). Age, profession, and location significantly influenced social media platform use. Audience retention was at 50% at the 57-minute mark and 44.3% at the end of webinars. Tailoring WSA webinar content to meet health care professionals' needs and enhancing interactive components can improve audience retention. These insights will guide the future development of the WSA portfolio.

World Stroke Organization and World Hypertension League Position Statement on Hypertension Control Strategies in Prevention and Management of Stroke.

The goal of this consensus is to provide a comprehensive set of recommendations regarding hypertension control strategies for the prevention and management of stroke. This document is intended for prehospital care providers, physicians, allied health professionals, and hospital administrators and health care policy makers. Members of the writing group were representatives of the World Stroke Organization and World Hypertension League. The writing group reviewed articles searched from PubMed and Google Scholar using selected search strings. The document was sent to 12 peer reviewers. The writing group considered the feedback from peer reviewers and made revisions accordingly. Every member of the writing group gave their approval of the final document. This article details the various techniques for blood pressure (BP) measurement, BP classification, BP and stroke risk, antihypertensive drug therapy for the primary and secondary prevention of stroke, choice of antihypertensive drug therapy, optimal BP targets, non-drug approaches to the prevention of stroke through BP lowering, BP management separately for acute ischemic stroke and spontaneous intracerebral hemorrhage, and the implementation of BP prevention,treatment and control in the community. This article provides general recommendations based on currently available evidence to guide healthcare practitioners caring for adults with hypertension to prevent and manage stroke. Future studies are needed to better define approaches to hypertension control in the community and high-risk groups. BP: Blood Pressure, SBP: Systolic Blood Pressure, HIC: High Income Countries, LMIC: Low and Middle Income Countries, CVD: Cardiovascular diseases, WSO: World Stroke Organization, WHL:World Hypertension League, K: Karotkoff, ABPM: Ambulatory BP measurements, HBPM: Home BP Monitoring, CPG: Clinical practice guidelines, ACC: American College of Cardiology, AHA: American Heart Association, DASH: Dietary Approaches to Stop Hypertension, CCB: calcium channel blockers, ACEI: Angiotensin converting enzyme inhibitors, ARB: angiotensin receptor blockers, SPC: single pill combination, ACCORD BP: Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure trial (ACCORD BP), SPRINT: Systolic Blood Pressure Intervention Trial, RESPECT: Recurrent Stroke Prevention Clinical Outcome Trial , and ESPRIT-:Effects of intensive Systolic blood Pressure lowering treatment in reducing RIsk of vascular evenTs, OPTIMAL-Diabetes: OPtimal Type 2 dIabetes Management, SVIN: Society of Vascular and Interventional Neurology, ICH: intracerebral haemorrhage, NICE-:National Institute for Health and Clinical Excellence.

A direct aspiration first-pass technique (ADAPT) for acute ischemic stroke thrombectomy: Indications, technique, and emerging devices.

To date, the use of the most suitable first-pass technique for Mechanical Thrombectomy is still debated. In last years, several observational studies have suggested noninferiority or superiority of A Direct Aspiration first-Pass Technique (ADAPT) technique to achieve better reperfusion in comparison to stent retriever. While ASA/AHA 2018 guidelines recommend that patients with AIS should receive Mechanical Thrombectomy with a stent retriever, last European Stroke Organization guidelines report no evidence that stent retriever compared with contact aspiration could improve reperfusion rate. ADAPT is based on aspiration alone as the primary mechanism of thrombectomy and, if initially unsuccessful, then incorporating adjunctive alternatives. ADAPT improvement is also related to last generation of aspiration catheters. The purpose of this review is to report ADAPT principles, technique, efficacy, and safety as first-line treatment for acute ischemic stroke with the latest generation of reperfusion devices.

Tenecteplase vs Alteplase in Acute Ischemic Stroke Within 4.5 Hours: A Systematic Review and Meta-Analysis of Randomized Trials.

The current European Stroke Organisation expedited recommendation on tenecteplase (TNK) for acute ischemic stroke (AIS) advocates that TNK 0.25 mg/kg can be used alternatively to alteplase (tissue plasminogen activator [TPA]) for AIS of <4.5 hours duration, based on a meta-analytical approach establishing noninferiority. Since the publication of these guidelines, 4 additional randomized controlled clinical trials (RCTs) have provided further insight. We conducted an updated systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of TNK 0.25 mg/kg compared with TPA for the treatment of AIS within 4.5 hours of onset. The primary outcome was defined as the excellent functional outcome at 3 months (modified Rankin Scale [mRS] score 0-1), whereas good functional outcome (mRS score 0-2), reduced disability at 3 months (≥1-point reduction across all mRS scores), symptomatic intracranial hemorrhage (sICH), and 3-month mortality were evaluated as secondary outcomes. Pooled estimates were calculated with random-effects model. A prespecified subgroup analysis was performed stratifying for TNK formulation, that is, original TNK vs biocopy: recombinant human TNK tissue-type plasminogen activator that is available in China and has a different production process. Eleven RCTs were included comprising a total of 3,788 patients treated with TNK vs 3,757 patients treated with TPA. TNK was associated with higher likelihood of excellent functional outcome (risk ratio [RR] 1.05, 95% CI 1.01-1.10; p = 0.012; I2 = 0%; risk difference 2.95%; 95% CI 0.76%-5.14%; p = 0.008; I2 = 0%) and reduced disability at 3 months (common odds ratio 1.10, 95% CI 1.01-1.19; p = 0.034; I2 = 0%) compared with TPA while good functional outcome (RR 1.03, 95% CI 0.99-1.07; p = 0.142; I2 = 28%) was similar between the groups. Regarding safety outcomes, similar rates of sICH (RR 1.12, 95% CI 0.83-1.53; p = 0.456; I2 = 0%) and 3-month mortality (RR 0.97, 95% CI 0.82-1.15; p = 0.727; I2 = 12%) were observed. When stratified for TNK regimen (original vs biocopy), statistical significance in achieving an excellent functional outcome at 3 months was retained for the original TNK (RR 1.05, 95% CI 1.00-1.10; p = 0.044; I2 = 0%). The updated meta-analysis confirms similar safety between TNK 0.25 mg/kg and TPA, while showing that TNK is superior to TPA regarding excellent functional outcome and reduced disability at 3 months. These findings support transitioning to TNK in clinical practice.

Perception and acquaintance of stroke specialists on non-inferiority trials: An international survey

IntroductionThe adoption of non-inferiority trial designs for assessing new interventions in stroke treatment is on the rise. We designed a survey to assess stroke specialists' understanding and familiarity with non-inferiority trials and margins. MethodsA brief web-based questionnaire was sent to the members of the World Stroke Organization (WSO). The median acceptable non-inferiority margins in different research settings provided by responders were summarized and reported according to the acquaintance of responders with non-inferiority trials. ResultsA total of 120 WSO members from 42 countries responded to the survey. Thirty-two percent (32 %) of respondents self-identified as being very familiar with non-inferiority trials, while 6 % identified as extremely familiar. When asked about the impact of non-inferiority trials on improving stroke patient care, 42 % rated it as high and 45 % as moderate. 83 % of responders reported that the findings of non-inferiority trials affect their clinical practice. Ease of administration, relative effect of the standard treatment, clinical implications of inappropriately introducing the new treatment, availability, price, ease of storage and shipping were all considered as factors that should influence the size of the non-inferiority margin. The magnitude and variability of acceptable non-inferiority margins were seen to decrease as the acquaintance of responders with non-inferiority trials increased. ConclusionAlthough responders acknowledge the importance of non-inferiority trials, most have limited acquaintance with this research design. Educational activities are needed to enhance literacy in non-inferiority trials and the interpretation of non-inferiority margins.

Acute stroke care in low and middle-income countries.

The purpose of this article is to discuss the global impact of stroke, the disparities and barriers to implement stroke care, and the global efforts to improve access to acute treatments in low and middle-income countries (LMICs). Disparities in access to stroke care are influenced by socioeconomic inequalities, geographic disparities, and limited healthcare infrastructure, particularly in LMICs. Effective stroke care requires a coordinated approach involving emergency services, rapid diagnosis, timely treatment, and early rehabilitation. However, there are significant delays in implementing evidence-based practices, particularly in areas where stroke care resources are scarce.Key barriers include geographic disparities, economic constraints, insufficient healthcare infrastructure, low public awareness, and weak policy frameworks. Addressing these challenges requires strengthening health systems, promoting universal health coverage, enhancing public and healthcare provider education, leveraging technology like telemedicine, and fostering international collaboration. Global efforts, including initiatives by the World Stroke Organization, focus on improving stroke care through infrastructure development, workforce training, and policy advocacy. These recommended strategies aim to make stroke care accessible and effective for everyone, regardless of location or socioeconomic status, ultimately helping to reduce the global burden of stroke.

Abstract 211: Building a Stroke Program in Urban Tanzania: Needs Assessment and a Plan to Move Forward

Introduction Stroke is a leading cause of morbidity and mortality globally with high social and economic burden that disproportionately effects low‐ and middle‐income countries (LMICs). Mechanical thrombectomy (MT) is an effective treatment for stroke but is not available in the majority of LMICs. Tanzania (TZ) lacks MT and has limited access to thrombolytics with very few patients receiving any intervention for acute ischemic stroke (AIS). Key stakeholders in TZ are motivated to build a stroke program and provide treatment of AIS, including MT. Here we present the initial needs assessment and model for developing a system of stroke care in TZ. Methods A needs assessment was performed in TZ through discussion with a multidisciplinary team. Key leaders from the national hospital leadership, Emergency Medicine, Neurology, Neurosurgery, Radiology, Interventional Radiology, and international stroke teams were involved in discussions regarding current stroke management and goals for the future. Key stakeholders provided insight into the current state of stroke management within their health system, including the referral system within TZ, review of data from an existing stroke registry, review of standard operating procedures (SOPs) in place for patients presenting with AIS. Recommendations for improving access to acute stroke treatment were identified and discussed. Results Existing infrastructure and systems within TZ designed to care for patients with AIS include: two newly established, thrombolysis ready stroke units; AIS registry which involves 8 referral hospitals. The barriers to providing AIS treatment include: delayed presentation to healthcare due to lack of public awareness; lack of affordable and rapid access to appropriate imaging; lack of established consulting service between emergency physicians and stroke neurology; lack of epidemiological data as to the true incidence of AIS at the district level, lack of access to endovascular treatment. A model to develop AIS program in TZ was identified consisting of three partially overlapping avenues and targeted at the public, healthcare systems and medical teams. Public: sensitization of the public with media campaigns and education will be focused on identification of stroke symptoms and knowledge about treatments. Healthcare systems: development of a formalized consultation service between district emergency teams and stroke neurology; development and implementation of new SOPs for diagnosis and access to imaging at the district level; expansion of stroke registry to include district level hospitals. Medical teams: continued mentorship through the World Stroke Organization for neurology on identification and acute management of patients with stroke; development of the first endovascular neuro‐intervention training program in collaboration with Mission Thrombectomy 2020. Conclusions There is significant need for a system of stroke care for patients in TZ. Key stakeholders are motivated to establish this system and bring acute interventions, including thrombolysis and MT. to patients suffering from AIS in TZ. This endeavor will require significant effort by many groups, but concurrent efforts in these three domains can help bring this important care to the people of TZ.

Mechanical Mapping of the Common Carotid Artery in Healthy Individuals Aged 2 to 40 Years.

(1) Background: In 2022, the World Stroke Organization said there were more than 12.2 million new cases of stroke each year, between all ages and sexes. Six and a half million people die each year from stroke. Ischemic stroke accounts for 7.6 million (62%) cases, with 3.3 million (51%) deaths. Stroke is mainly linked to the atherosclerosis of a large artery. (2) Objective: Since the carotid artery directly supplies the brain, we used age-dependent mechanical mapping on the healthy common carotid artery (CCA) with the aim of being able to predict and thus potentially prevent ischemic stroke. (3) Methods: We assessed the CCA stiffness of 95 healthy control (CTL) females (2.23-39.46 years) and 107 healthy CTL males (2.85-40 years). Cine-loops of B-mode CCA data were digitally recorded with conventional medical ultrasound devices. Arterial wall elastic moduli were estimated offline using a proprietary non-invasive imaging-based biomarker algorithm (ImBioMark). Statistical analyzes were carried out with Excel software. (4) Results: Females showed a linear regression profile of CCA elastic moduli ranging from 41 ± 2 kPa to 54 ± 17 kPa (R2 = 0.88), while males showed one ranging from 38 ± 5 kPa to 63 ± 22 kPa (R2 = 0.83). For qualitative and quantitative illustrations, the elastic modulus data of CTLs were compared with those of subjects with Kawasaki disease and subjects born prematurely, respectively. (5) Conclusions: This study introduced some fundamental features of the mechanical evolution of the CCA as a function of age (2-40 years). Since atherosclerotic arteriopathy starts early in life, this gives the ability to predict risks of stroke and other cardiovascular diseases with the possibility of applying a more comprehensive range of potential preventive measures early in life. This is consistent with preventive medicine objectives which aim to be more predictive to implement pre-emptive measures as opposed to diagnostic and curative approaches.

Navigating the road to recovery after stroke

This article considers the patient experience of rehabilitation after stroke, the current situation and how things might be in the future. It draws on presentations given at the European Stroke Organisation's conference this year in Switzerland, and draws conclusions about unmet needs, and health and social care services.

Monitoring a patient following an acute ischaemic stroke

Stroke is a leading cause of death and disability, causing around 38000 deaths each year in the UK, while approximately 1.3million people live with the effects of stroke. The World Stroke Organisation reported that 1 in 4 adults over the age of 25 years will experience stroke in their lifetime, with a loss of 143million healthy years lost each year. Monitoring a patient following an acute ischaemic stroke is critical to assess recovery, prevent complications, and optimise treatment. The initial phase focuses on stabilising and monitoring changes in the patient's condition. Continuous monitoring of vital signs alongside neurological assessment and haemodynamic and metabolic monitoring is necessary to determine changes in the person's condition and any progression of stroke symptoms. Early detection of post-stroke complications can significantly impact recovery and close monitoring allows for prompt intervention. Nurses play a significant role in the care of the person following an acute ischaemic stroke and, together with the multidisciplinary team, ensure comprehensive care is provided. This article outlines the key aspects of monitoring a patient after an acute ischaemic stroke and how the likelihood of complications can be reduced.

An Audit of Best Medical Therapy Adherence Among Patients with Carotid Artery Stenosis Attending a Tertiary Stroke Centre

Abstract Background Carotid artery stenosis (CAS) is estimated to cause 11-28% of ischaemic strokes annually. The primary objective of this audit was to assess current adherence to best medical therapy (BMT) to patients with CAS in a tertiary stroke centre. Our secondary aim was to assess stability, regression or progression of CAS whilst on BMT. Methods A retrospective chart review was conducted in a tertiary stroke centre over a six-week period. Patients were included if they were aged over 18 years, presenting to an outpatient stroke clinic, and had a known diagnosis of either symptomatic or asymptomatic CAS. The European Stroke Organisation Guidelines were used to define BMT. Results A total of 56 charts were reviewed at three weekly outpatient clinics. Of the 27 patients meeting our inclusion criteria 66% (n=18) were male, median degree of CAS was 50-70% and 78% (n=20) had symptomatic CAS. 89% were on BMT but only 56% achieved a low-density lipoprotein cholesterol (LDL-C) target of &amp;lt;1.8 (median 1.6 (range: 0.7-4.2) and only 66% (n=18) had a documented smoking status. 81% of patients with symptomatic CAS on BMT had stable stenosis, 5% had regression and 14% had progression of stenosis. 50% of asymptomatic patients had progression of the degree of their stenosis. Conclusion Overall adherence to BMT was good at 89% but there is room for improvement particularly in terms of lipid target level and documentation of risk factor status. BMT resulted in stable stenosis and low progression rates particularly in patients with symptomatic CAS. BMT and early detection are essential for management to control progression of CAS, but we have highlighted the opportunity to improve LDL-C targets. Further research is needed to evaluate if the results of this study are translatable to the stroke population in general.

Impact of European Stroke Organisation secondary prevention guideline for ischaemic stroke / transient ischaemic attack

ObjectivesWe aimed to assess secondary prevention strategies after ischaemic stroke or transient ischaemic attack (TIA). Materials and MethodsWe investigated the impact of European Stroke Organisation (ESO) Guideline recommendations for secondary prevention on recurrent events among people with non-cardioembolic ischaemic stroke or TIA. We assessed the following interventions by survival analysis or modelling impacts from clinical trial data: two blood pressure (BP) drugs compared to one drug; LDL-cholesterol target <1.8 mmol/L; and pioglitazone therapy. Outcomes were mortality, major adverse cardiovascular events (MACE) and recurrent stroke or myocardial infarction (MI). ResultsWe included 4,037 people admitted between 01/12/2015 to 31/12/2018: mean (SD) age 68.6 (12.9) years; 1984 (49.1 %) female and median (IQR) follow-up 2.2 (1.5-3.1) years.Prescription of two BP drugs was associated with reduced mortality in our sample of 2238 people with hypertension (HR 0.64, 95 %CI 0.51-0.81; P<0.001).We estimate an LDL-cholesterol target <1.8 mmol/L could reduce MACE incidence from 128 to 114 events (95 %CI 103-127) in our sample of 1024 people with LDL-cholesterol 1.8 mmol/L who were not already prescribed intensive lipid-lowering therapy over median (IQR) 2.2 (1.5-2.9) years follow-up (ARR 1.38 %, NNT 73).We estimate pioglitazone therapy could reduce incidence of recurrent stroke or MI from 192 to 169 events (95 %CI 156-185) in our sample of 1587 people with diabetes or insulin resistance over median (IQR) 2.4 (1.7-3.2) years follow-up (ARR 1.45 %, NNT 69). ConclusionsWe estimate that implementing ESO guidelines in a Scottish population after ischaemic stroke or TIA would reduce mortality and recurrent cardiovascular events.

Stroke and Disability: Incidence, Risk Factors, Management, and Impact

Stroke is a leading cause of disability worldwide, leaving a significant portion of the population grappling with its long-term effects. The incidence of stroke is 3.6 on average higher compared to high-income countries. This study explores the global and Saudi Arabian burden of stroke-induced disability, highlighting its prevalence, risk factors, and the need for comprehensive rehabilitation strategies. The primary source of information was the international trusted databases, including Web of Science, Scopus, PubMed, and the websites and reports from international organizations such as the International Atomic Energy Agency, World Stroke Organization, and World Health Organization. The study revealed that women, especially after menopause, should be aware of their increased stroke risk and take steps to manage their risk factors such as high blood pressure, diabetes, and high cholesterol. Managing established risk factors such as high blood pressure, diabetes, and cholesterol remains the cornerstone of stroke prevention for all individuals, regardless of profession. Workplace wellness programs that promote healthy lifestyles and stress management can be beneficial for employees in any occupation. Overall, stroke presents a growing public health challenge in Saudi Arabia. While the incidence may be lower than in some high-income countries, it is on the rise. More research is needed to gain a clearer picture of stroke-related disability, develop effective prevention and treatment strategies, and solidify the connection between specific occupations and stroke incidence.

Comparison of American and European Guideline Recommendations for Diagnostic Workup and Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack.

Guidelines help to facilitate treatment decisions based on available evidence, and also to provide recommendations in areas of uncertainty. In this paper, we compare the recommendations for stroke workup and secondary prevention of ischemic stroke and transient ischemic attack of the American Heart Association (AHA)/American Stroke Association (ASA) with the European Stroke Organization (ESO) guidelines. The primary aim of this paper is to offer clinicians guidance by identifying areas where there is consensus and where consensus is lacking, in the absence or presence of high-level evidence. We compared AHA/ASA with the ESO guideline recommendations for 7 different topics related to diagnostic stroke workup and secondary prevention. We categorized the recommendations based on class and level of evidence to determine whether there were relevant differences in the ratings of evidence that the guidelines used for its recommendations. Finally, we summarized major topics of agreement and disagreement, while also prominent knowledge gaps were identified. In total, we found 63 ESO and 82 AHA/ASA recommendations, of which 38 were on the same subject. Most recommendations are largely similar, but not all are based on high-level evidence. For many recommendations, AHA/ASA and ESO assigned different levels of evidence. For the 10 recommendations with Level A evidence (high quality) in AHA/ASA, ESO only labeled 4 of these as high quality. There are many remaining issues with either no or insufficient evidence, and some topics that are not covered by both guidelines. Most ESO and AHA/ASA Guideline recommendations for stroke workup and secondary prevention were similar. However not all were based on high-level evidence and the appointed level of evidence often differed. Clinicians should not blindly follow all guideline recommendations; the accompanying level of evidence informs which recommendations are based on robust evidence. Topics with lower levels of evidence, or those with recommendations that disagree or are missing, may be an incentive for further clinical research.

Towards improving stroke services in Africa: Results from the Africa-UK Stroke Partnership [AUKSP] surveys

BackgroundThe African Stroke Organization (ASO) in partnership with the University of Central Lancashire's Stroke Research Team launched the Africa-UK Stroke Partnership (AUKSP). AUKSP undertook two (stroke expert and hospital Stroke Unit (SU)) on-line surveys mapping existing capacity and capability to deliver African stroke care. MethodsAn on-line expert survey tool was sent to 139 stroke experts in 54 African countries October 2021-March 2022 and the hospital SU survey to 120 hospital SUs (identified from the expert survey) June-October 2022. Both survey tools were prepared according to the World Stroke Organisation's Roadmap for Delivering Quality Stroke Care. Completed responses were exported from Qualtrics into Microsoft excel and were analysed descriptively. ResultsForty-five expert responses and 62 hospital SU responses were analysed, representing 54(87%) public hospitals, 7(11%) private and 1(2%) charitable organization. In both surveys, three main priorities for improvement of stroke services were: a rapid and prompt stroke diagnosis; effective primary and secondary stroke prevention, and acute stroke management. Survey findings suggest that there is a low presence of national stroke surveillance systems and registries, and heterogeneity in availability of diagnostic services, SUs, endovascular treatments, and rehabilitation. ConclusionSignificant gaps exist in Africa's capacity and capability to deliver essential elements of effective and quality stroke care. Tackling these challenges requires urgent and sustained multi-stakeholder action including: government, administrators, policy makers and other partners. Our survey findings highlight key priority areas for multi-stakeholder engagement and crafting of a pragmatic, prioritized and context-sensitive African Stroke Action Plan.