Editorials

Editorials

Stroke: a global response is needed

Walter Johnson,a Oyere Onuma,b Mayowa Owolabic & Sonal Sachdeva

Worldwide, cerebrovascular accidents countries) die within three years of items for consideration when developing
(stroke) are the second leading cause diagnosis.2 Current guidelines for the treatment guidelines for patients with
of death and the third leading cause of management of acute stroke recom- acute stroke of unknown etiology in
disability.1 Stroke, the sudden death of mend a course of treatment based on settings where there are no CT scanners.
some brain cells due to lack of oxygen the diagnosis of ischaemic stroke (ver- Berkowitz emphasized the proven effi-
when the blood flow to the brain is lost sus haemorrhagic stroke) made using cacy of supportive care measures, such
by blockage or rupture of an artery to the computed tomography (CT) scanners. as maintaining euglycaemia and euther-
brain, is also a leading cause of dementia In low-resource settings, CT scanners mia, prevention of deep-vein thrombo-
and depression.2 Globally, 70% of strokes are either unavailable or unaffordable, sis and aspiration, early mobilization
and 87% of both stroke-related deaths forcing clinicians to make difficult clini- and prompt seizure treatment for stoke
and disability-adjusted life years occur cal decisions, such as whether to antico- patients. He recommended judicious use
in low- and middle-income countries.3–5 agulate patients or not, and to what level of aspirin and provided blood pressure
Over the last four decades, the stroke to control their blood pressure without parameters for stroke patients in these
incidence in low- and middle-income a means of distinguishing between isch- circumstances. He also emphasized the
countries has more than doubled. Dur- aemic and haemorrhagic stroke. These need for secondary prevention.
ing these decades stroke incidence has patient management challenges, com- Managing acute stroke in low-
declined by 42% in high-income coun- bined with inadequate rehabilitation resource settings requires a novel ap-
tries.3 On average, stroke occurs 15 years services, lack of preventive measures, proach, one that could restart the origi-
earlier in – and causes more deaths of – as well as poor understanding of the nal WHO global stroke initiative,11 as a
people living in low- and middle-income possible unique risk factors associated collaboration between the World Health
countries, when compared to those in with stroke in low- and middle-income Organization (WHO), the World Stroke
high-income countries.2 Strokes mainly countries, may account for the dispro- Organization and the World Federation
affect individuals at the peak of their portionately large stroke burden borne of Neurology, to increase awareness of
productive life. Despite its enormous by these countries. stroke, generate better surveillance data
impact on countries’ socio-economic The reasons for the younger age and guide better prevention and man-
development, this growing crisis has of onset, higher rates of haemorrhagic agement. The WHO Package of essential
received very little attention to date. subtype and higher case fatality, are noncommunicable disease interventions
The risk factors for stroke are simi- unknown. 2 Better understanding of for primary health care in low-resource
lar to those for coronary heart disease the possible unique risk factors for settings provides protocols for cardio-
and other vascular diseases. Effective this epidemic in low- and middle- vascular risk reduction and stroke pre-
prevention strategies include targeting income countries is urgently needed. vention.12 WHO will develop guidelines
the key modifiable factors: hyperten- The Stroke Investigative Research and for the management of acute stroke in
sion, elevated lipids and diabetes. Risks Educational Network study is investi- low- and middle-income countries, and
due to lifestyle factors can also be ad- gating the underlying risk factors for aims to expand training programmes
dressed: smoking, low physical activity stroke occurrence, subtype and outcome in stroke prevention, treatment and
levels, unhealthy diet and abdominal among people of African ancestry. 9 rehabilitation through its partners. ■
obesity.6 Combinations of such preven- Understanding the genetic basis for the
tion strategies have proved effective in interactions between risk factors can References
reducing stroke mortality even in some inform targeted prevention efforts, as Available at: http://www.who.int/bulletin/vol-
low-income settings.7,8 part of a broader approach with four umes/94/9/16-181636
Furthermore, as most guidelines parts: surveillance, prevention, acute
are based on high-income country data, care and rehabilitation.2 This type of
uncertainty remains regarding best integrated approach will generate the
management of stroke of unknown type evidence base to produce the guidelines
in low- and middle-income countries. needed for stroke prevention, treatment
For example, in low- and middle-income and rehabilitation in low- and middle-
countries, 34% of strokes (versus 9% in income countries.
high-income countries) are of haemor- In the July 2016 issue of the Bul-
rhagic subtype and up to 84% of stroke letin, Aaron Berkowitz10 examined cur-
patients in low- and middle-income rent acute stroke management practice
countries (versus 16% in high income in low-resource settings and outlined

a
Department of Service Delivery and Safety, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland.
b
Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention Department, World Health Organization, Geneva, Switzerland.
c
Department of Medicine, University of Ibadan, Ibadan, Nigeria.
Correspondence to Walter Johnson (email: [email protected]).

634 Bull World Health Organ 2016;94:634–634A | doi: http://dx.doi.org/10.2471/BLT.16.181636

 Editorials

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Bull World Health Organ 2016;94:634–634A | doi: http://dx.doi.org/10.2471/BLT.16.181636 634A