The World Stroke Academy: A World Stroke Organization global pathway to improve knowledge in stroke care

Inhibition of the cGAS-STING pathway: contributing to the treatment of cerebral ischemia-reperfusion injury

The cGAS-STING pathway plays an important role in ischemia-reperfusion injury in the heart, liver, brain, and kidney, but its role and mechanisms in cerebral ischemia-reperfusion injury have not been systematically reviewed. Here, we outline the components of the cGAS-STING pathway and then analyze its role in autophagy, ferroptosis, cellular pyroptosis, disequilibrium of calcium homeostasis, inflammatory responses, disruption of the blood-brain barrier, microglia transformation, and complement system activation following cerebral ischemia-reperfusion injury. We further analyze the value of cGAS-STING pathway inhibitors in the treatment of cerebral ischemia-reperfusion injury and conclude that the pathway can regulate cerebral ischemia-reperfusion injury through multiple mechanisms. Inhibition of the cGAS-STING pathway may be helpful in the treatment of cerebral ischemia-reperfusion injury.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Effect of Virtual Reality-Based Training on Upper Limb Dysfunction during Post-Stroke Rehabilitation: A Meta-Analysis Combined with Meta-Regression

BACKGROUND

Recently, there has been a surge in virtual reality (VR)-based training for upper limb (UL) rehabilitation, which has yielded mixed results. Therefore, we aimed to explore the effects of conventional therapy combined with VR-based training on UL dysfunction during post-stroke rehabilitation.

METHODS

Studies published in English before May 2023 were retrieved from PubMed, Embase, and the Cochrane Library. We also included randomized controlled trials that compared the use of conventional therapy and VR-based training with conventional therapy alone in post-stroke rehabilitation. The meta-analysis was performed using Review Manager Software (version 5.3; The Nordic Cochrane Centre, The Cochrane Collaboration; Copenhagen, Denmark) and Stata/MP 17.0 (StataCorp, LLC, College Station, TX, USA). Univariate and multivariate meta-regression analyses were performed to investigate the effects of stroke duration, VR characteristics, and type of conventional therapy on VR-based training.

RESULTS

In total, 27 randomized controlled trials were included, which enrolled 1354 patients. Our results showed that conventional therapy plus VR-based training is better than conventional therapy alone in UL motor impairment recovery measured using Fugl-Meyer Upper Extremity (standardized mean difference [SMD] = 0.32, 95% confidence interval [CI]: 0.07-0.57, Z = 2.52, p = 0.01). Meta-regression showed that stroke duration had independent effects on Fugl-Meyer Upper Extremity scores of VR-based training in rehabilitation (p = 0.041). Furthermore, in subgroup analysis based on stroke duration, stroke duration >6 months was statistically significant (SMD = 0.20, 95% CI: 0.01-0.39, Z = 2.06, p = 0.04). No relevant publication bias (p = 0.1303), and no significant difference in activity limitation assessed using the Box-Block Test (mean difference [MD] = 2.79, 95% CI: -0.63-6.20, Z = 1.60, p = 0.11) was observed. Regarding the functional independence measured using the Functional Independence Measure scale, studies presented no significant difference between the experimental and control groups (MD = 1.15, 95% CI: -1.84-4.14, Z = 0.76, p = 0.45).

CONCLUSIONS

Conventional therapy plus VR-based training is superior to conventional therapy alone in promoting the recovery of UL motor function after stroke. Therefore, VR-based training may be a potential option for improving UL motor function. The study was registered on PROSPERO (https://www.crd.york.ac.uk/prospero/), registration number: CRD42023472709.

Addressing disparities in the global epidemiology of stroke

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.

Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings

Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.

Developing Systems of Care for Stroke in Resource-limited Settings

Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.

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

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.

Understanding social media: how its popularity could be used to advance medical education in stroke care?

The wide availability of social media (SM) has revolutionized human interactions and education in different settings (e.g., household, workplace, academic, hospitals). Nearly 60% of the global population spend a daily average of over 6 h of screen time. By facilitating audio, video, and interactive material, SM has reshaped users' perceptions, choices, and communication. The science behind SM can be explained by the activation of the brain reward pathways which explains the success of SM platforms lead by user-generated content (i.e., TikTok). Our understanding of SM user's interests, mode of access, time spent with screens, and internet are critical to advance medical education by applying new learning technologies to advance medical education and stroke care. For example, the top 20 most visited websites and the most searched hashtags on TikTok in 2022 did not include any health-related topics, reflecting a challenging competition for attention of different segments of the population. We must overcome current gaps in medical education such as increased curricular activities, increasingly demanding tasks, differences in personal preferences between residents and faculty members, etc. New strategies using more engaging learning technologies and SM platforms (e.g., stroke simulations, interactive diagnostic and therapeutic decisions, tracking user's attention to assess knowledge transfer) are needed. This would allow a more effective delivery of educational content by stimulating the curiosity and participation of students, patients, and physicians offering more rewarding experiences across the continuum of stroke care.