Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Abstract

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met.

In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs)

The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health

On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases.

Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

Figure 1:. The four pillars of the quadrangle to tackle the burden of stroke: surveillance, prevention, acute care, and rehabilitation

Surveillance strategies include establishing a framework for regular monitoring and assessment of the burden of stroke and its risk factors, and of health-care services at a national level via community-based surveys, data linkage, and electronic health records. These strategies provide the necessary evidence for planning and monitoring prevention, acute care, and rehabilitation interventions. Primordial, primary, and secondary prevention involve implementation of integrated population-wide strategies to reduce modifiable risk factors, such as hypertension and diabetes. Prevention strategies can reduce the incidence, mortality, and prevalence of stroke, and people who develop stroke benefit from secondary prevention (in addition to acute care). Acute stroke care should result in early diagnosis and involves evidence-based management that reduces mortality and improves functional outcomes. Finally, rehabilitation services provide interdisciplinary care for stroke survivors, with the aim of reducing disability-adjusted life-years and improving quality of life. Adapted with permission from Owolabi et al, 2023.

Figure 2:. Estimates of DALYs due to stroke, 2020 and 2050, by GBD super-region

Data are absolute counts of DALYs and rates per 100 000 person-years. For comparison, the data are also represented by World Bank income group. Shaded areas represent 95% uncertainty intervals. GBD=Global Burden of Disease. DALYs=disability-adjusted life-years.

Figure 3:. Estimates of mortality due to stroke, 2020 and 2050, by GBD super-region

Data are absolute counts of deaths and rates per 100 000 person-years. For comparison, the data are also represented by World Bank country income group. Shaded areas represent 95% uncertainty intervals. GBD=Global Burden of Disease.

Figure 4:. Estimated direct costs and income losses associated with stroke, 2017 and 2050, by World Bank region

Our comparison is based on the forecast of regional means in table 1.

Figure 5:. Availability of national surveillance systems for risk factors of stroke

Surveys were considered recent if they were done in or after 2018, and comprehensive if they included measurements of blood pressure, anthropometrics (eg, weight, waist circumference), biochemical measures (eg, blood lipid profile, blood glucose), lifestyle factors (eg, smoking, diet, physical activity, alcohol intake), and diagnosis of metabolic conditions (eg, hypertension, overweight or obesity, dyslipidaemia, diabetes, atrial fibrillation). *Biochemical measurements refers to measurement of blood lipid profiles and blood glucose concentrations.

Figure 6:. Strategies for stroke prevention

Major strategies for control of stroke risk factors for stroke at the population and individual levels are shown.

Figure 7:. Overview of the services offered by minimal, essential, and advanced stroke services

Advanced stroke centres offer all the services provided at essential stroke centres in addition to thrombectomy or referral for thrombectomy, and essential stroke centers offer multidisciplinary care and thrombolytic therapy in addition to services offered by minimal stroke service centres.

Figure 8:. Global ecosystem for the management, implementation, and dissemination of tangible actions to reduce stroke burden devised by the World Stroke Organization—Lancet Neurology Commission

Monitoring and reducing the global burden of stroke necessitates equitable and inclusive pragmatic solutions for maximum effect. Therefore, we adopted a synergistic approach to motivate all relevant stakeholders. Bidirectional arrows show a symbiotic bottom-to-top and top-to-bottom approach and intend to convey a sense of joint ownership, which should help to attract global resources. The WSO executive committee implementation task force and the operations committee will communicate with global implementation partners. The operations committee, comprising stroke experts from the six WHO regions, can also advocate for the necessary implementation work through the commissioners. Coordination of the ecosystem by the implementation task force and executive committee will include contextualisation of the key performance indicators and targets, and implementation of the pragmatic solutions across the six WHO regions in collaboration with regional stroke organisations. In addition to WHO, which co-initiated our Commission, our international partners will include the World Federation of Neurology, the World Federation for Neurorehabilitation, the World Hypertension League, the World Heart Federation, the Global Coalition for Circulatory Health, and the Non-Communicable Disease Alliance. Implementation partners will include national stroke support organisations and national ministries of health. The World Bank and other agencies and philanthropists will be approached for funding and support by the executive committee or by the implementation task force. Adapted versions of the global ecosystem will be adopted as regional and national ecosystems to suit local environments. Commissioners will become country ambassadors. WSO=World Stroke Organization. Adapted with permission from Owolabi et al, 2023.