Quality of stroke guidelines in low- and middle-income countries: a systematic review

Comparing Interventions Used in Randomized Controlled Trials of Upper Extremity Motor Rehabilitation Post-stroke in High-Income Countries and Low-to-Middle-Income Countries

OBJECTIVE

To identify and compare interventions for upper extremity (UE) motor recovery poststroke in randomized controlled trials (RCTs) conducted in high-income countries (HICs) and low-to-middle-income countries (LMICs).

DATA SOURCE

Systematic searches were conducted for RCTs published in English in 5 databases (CINAHL, Embase, PubMed, Scopus, and Web of Science) up to April 2021, in line with PRISMA guidelines.

STUDY SELECTION

RCTs, including crossover design, were included if they were in English and evaluated an intervention for poststroke UE motor rehabilitation, in an adult population (≥18y) diagnosed with stroke.

DATA EXTRACTION

Data on country of origin and type of intervention in each RCT were extracted using a data extraction template in Covidence software. Study screenings and data extraction were performed by 2 independent reviewers.

DATA SYNTHESIS

A total of 1276 RCTs met the inclusion criteria, with 978 RCTs conducted in HICs and 298 in LMICs. A significantly larger proportion of RCTs evaluating robotics and task-specific training interventions were conducted in HICs, compared to LMICs (P<.009). In contrast, a higher proportion of RCTs conducted in LMICs examined acupuncture (P<.001) and repetitive transcranial magnetic stimulation (rTMS) (P=.001) when compared to HICs.

CONCLUSIONS

Poststroke rehabilitation in LMICs is conducted in a lower resource environment when compared to HICs. Some differences exist in the use of UE motor rehabilitation interventions between LMICs and HICs such as robotics, task-specific training, rTMS, and acupuncture; however, there was no significant difference between HICs and LMICs for most interventions.

Global, regional and national trends in the burden of intracranial hemorrhage, 1990-2021: Results from the Global Burden of Disease study

Intracerebral hemorrhage (ICH) is a significant global public health issue that is characterized by a rapid start, severe symptoms, and a poor prognosis. It is the most common type of hemorrhagic stroke. We analyzed global intracranial hemorrhage incidence, mortality, disability-adjusted life years (DALYs), and corresponding age-standardized rates (ASRs) and estimated annual percentage changes (EAPCs) by using GBD 2021 data. The data were further stratified by age, sex, and region to assess the global burden of ICH from 1990 to 2021, providing the most up-to-date epidemiologic reference data for public health prevention and treatment strategies. In 2021, there were 3,444,300 (95 % UI, 305.30 to 381.20) new cases, 3,308,400 (302.11-359.47) deaths and 79,457,400 (7230.45-8548.02) DALYs. The burden of intracranial hemorrhage was higher in Oceania and Southeast Asia (Age-standardized DALY rates of 2582.46 per 100,000 and 1976.78 per 100,000), but lower in Australasia (126.59), high-income North America (221.19), and Western Europe (161.23). Of the 204 countries and territories globally, the burden of intracranial hemorrhage is higher in countries such as Nauru, Solomon Islands and Marshall Islands. From 1990 to 2021, global age-standardized incidence rates (ASIR), age-standardized mortality rates (ASMR), and age-standardized DALY rates (ASDR) declined, corresponding to EAPCs of -1.52, -1.63 and -1.75, with females declining more than males. In 2021, the most significant risk factor for ICH was high systolic blood pressure, accounting for 56.4 % of total DALYs for intracranial hemorrhage. Other major risk factors include: ambient particulate matter pollution, smoking, solid fuel pollution of household air, high sodium diet, and renal dysfunction. We need to target interventions at relevant risk factors, such as hypertension management, environmental particulate management, smoking cessation campaigns, focusing on high-risk groups and high-burden areas, and continue to deepen the implementation of the universal primary prevention strategy.

Methodological quality and clinical recommendations of guidelines on the management of dyslipidaemias for cardiovascular disease risk reduction: a systematic review and an appraisal through AGREE II and AGREE REX tools

BACKGROUND

Clinical practice guidelines (CPGs) are statements to assist practitioners and stakeholders in decisions about healthcare. Low methodological quality guidelines may prejudice decision-making and negatively affect clinical outcomes in non-communicable diseases, such as cardiovascular diseases worsted by poor lipid management. We appraised the quality of CPGs on dyslipidemia management and synthesized the most updated pharmacological recommendations.

METHODS

A systematic review following international recommendations was performed. Searches to retrieve CPG on pharmacological treatments in adults with dyslipidaemia were conducted in PubMed, Scopus, and Trip databases. Eligible articles were assessed using AGREE II (methodological quality) and AGREE-REX (recommendation excellence) tools. Descriptive statistics were used to summarize data. The most updated guidelines (published after 2019) had their recommendations qualitatively synthesized in an exploratory analysis.

RESULTS

Overall, 66 guidelines authored by professional societies (75%) and targeting clinicians as primary users were selected. The AGREE II domains Scope and Purpose (89%) and Clarity of Presentation (97%), and the AGREE-REX item Clinical Applicability (77.0%) obtained the highest values. Conversely, guidelines were methodologically poorly performed/documented (46%) and scarcely provided data on the implementability of practical recommendations (38%). Recommendations on pharmacological treatments are overall similar, with slight differences concerning the use of supplements and the availability of drugs.

CONCLUSION

High-quality dyslipidaemia CPG, especially outside North America and Europe, and strictly addressing evidence synthesis, appraisal, and recommendations are needed, especially to guide primary care decisions. CPG developers should consider stakeholders' values and preferences and adapt existing statements to individual populations and healthcare systems to ensure successful implementation interventions.

Stroke Rehabilitation Clinical Practice Guidelines in Low- and Middle-Income Countries: A Systematic Review of Quality and Unique Features

INTRODUCTION

Efforts toward reducing stroke burden have been an immense challenge. One important reasons could be the scope and quality of clinical practice guidelines (CPGs) developed for stroke rehabilitation in low- and middle-income countries (LMICs), restricting its translation to clinical practice. This systematic review aimed to assess the availability, scope and quality of CPGs for stroke rehabilitation in LMICs.

METHODS

Following PRISMA guidelines, CPGs for stroke rehabilitation in LMICs were searched across four major electronic databases (Medline, Embase, CINAHL, and PEDro). Additional studies were identified from grey literature and a hand search of key bibliographies and search engines. The availability and content of the CPGs were narratively summarized and quality of de novo CPGs was analyzed using "Appraisal of Guidelines REsearch and Evaluation" (AGREE) tools: version II & Recommendations Excellence (REX) version. Features of contextualizations/adaptations of non-de novo CPGs were narratively summarized.

RESULTS

Twelve CPGs from 10 countries were included. CPGs from Pakistan, Sri Lanka, India, and China were developed de novo. CPGs from Kenya, Philippines, South Africa, Cameroon, Mongolia, and Ukraine were contextualized/adapted based on existing guidelines from high-income countries. Most contextualized CPGs had limited stakeholder involvement, local health systems/patient pathway analyses. All ten countries included recommendations for physiotherapy, seven for communication, swallowing, and five for occupational therapy services poststroke. Quality assessment using AGREE-REX and AGREE-II for de novo guidelines was poor, especially scoring low in development and applicability.

CONCLUSION

Contextualized CPGs for stroke rehabilitation in LMICs were scarcely available and not meeting required quality. There is a need for development of context-specific, culturally relevant CPGs for stroke rehabilitation in LMICs to improve implementation/translation into clinical practice.

Epidemiological trends of subarachnoid hemorrhage at global, regional, and national level: a trend analysis study from 1990 to 2021

BACKGROUND

Subarachnoid hemorrhage (SAH) is a subtype of hemorrhagic stroke characterized by high mortality and low rates of full recovery. This study aimed to investigate the epidemiological characteristics of SAH between 1990 and 2021.

METHODS

Data on SAH incidence, mortality, and disability-adjusted life-years (DALYs) from 1990 to 2021 were obtained from the Global Burden of Disease Study (GBD) 2021. Estimated annual percentage changes (EAPCs) were calculated to evaluate changes in the age-standardized rate (ASR) of incidence and mortality, as well as trends in SAH burden. The relationship between disease burden and sociodemographic index (SDI) was also analyzed.

RESULTS

In 2021, the incidence of SAH was found to be 37.09% higher than that in 1990; however, the age-standardized incidence rates (ASIRs) showed a decreased [EAPC: -1.52; 95% uncertainty interval (UI) -1.66 to -1.37]. Furthermore, both the number and rates of deaths and DALYs decreased over time. It was observed that females had lower rates compared to males. Among all regions, the high-income Asia Pacific region exhibited the highest ASIR (14.09/100,000; 95% UI 12.30/100,000 - 16.39/100,000) in 2021, with an EPAC for ASIR < 0 indicating decreasing trend over time for SAH ASIR. Oceania recorded the highest age-standardized mortality rates (ASMRs) and age-standardized DALYs rates among all regions in 2021 at values of respectively 8.61 (95% UI 6.03 - 11.95) and 285.62 (95% UI 209.42 - 379.65). The burden associated with SAH primarily affected individuals aged between 50 - 69 years old. Metabolic risks particularly elevated systolic blood pressure were identified as the main risk factors contributing towards increased disease burden associated with SAH when compared against environmental or occupational behavioral risks evaluated within the GBD framework.

CONCLUSIONS

The burden of SAH varies by gender, age group, and geographical region. Although the ASRs have shown a decline over time, the burden of SAH remains significant, especially in regions with middle and low-middle SDI levels. High systolic blood pressure stands out as a key risk factor for SAH. More specific supportive measures are necessary to alleviate the global burden of SAH.

Comparative global analysis of stroke rehabilitation recommendations across income levels

OBJECTIVE

Successful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC).

STUDY DESIGN AND SETTING

We conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P's, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC.

RESULTS

The inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P's criteria) and integration of ethical, legal, social, and economic considerations.

CONCLUSION

There are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.

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.

Global trends and burden of stroke attributable to particulate matter pollution from 1990 to 2019

OBJECTIVE

To investigate the association between particulate matter and the incidence, disability, and mortality of stroke, we reported the burden of stroke attributable to particulate matter (PM2.5) pollution, including ambient particulate matter pollution (APMP) and household air pollution from solid fuels (HAP), from 1990 to 2019.

METHODS

We retrieved the detailed data on the burden of stroke attributable to PM2.5 from the Global Burden of Disease (GBD) 2019. The number of disability-adjusted life-years (DALYs) and deaths, age-standardized death rates (ASMR), and age-standardized disability-adjusted life-years rates (ASDR) attributable to PM2.5 were estimated by age, sex, geographical location, socio-demographic index (SDI), and stroke subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage). The estimated annual percentage change (EAPC) was calculated to assess the trends in ASDR and ASMR during the period 1990-2019.

RESULTS

Regarding stroke subtypes, the proportion of ischemic stroke burden is increasing, while intracerebral hemorrhage carries the heaviest burden. Both APMP and HAP contributed the most to stroke-related deaths and DALYs of stroke among the elderly populations and males. The highest ASDR and ASMR of stroke attributable to APMP were in the middle SDI regions, especially in East Asia. For HAP, the highest ASDR and ASMR were in the low SDI regions, mainly in Oceania. From 1990-2019, in terms of the EAPC results, APMP caused an increased burden of stroke, whereas the impact of HAP significantly fell. The most pronounced increase in ASDR and ASMR for strokes attributed to APMP were in the low-middle SDI and low SDI regions, particularly among the 25-35 age group.

CONCLUSIONS

Stroke attributed to PM2.5 is a global health problem, and the patterns and trends were heterogeneous across APMP and HAP. Targeted interventions should be formulated for APMP and HAP.

Diagnosis and management of subarachnoid haemorrhage

Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.

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.

Critical quality appraisal and algorithm development of clinical practice guidelines for management of poststroke sensory loss: a systematic review

OBJECTIVES

This study aimed to assess the methodological quality of clinical practice guidelines (CPGs) associated with the management of poststroke sensory loss and develop an algorithm for health professionals.

METHODS

We conducted a systematic review for relevant CPGs published between 2017 and 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist. Appraisal of Guidelines for Research and Evaluation II instrument was used to assess methodological quality. Recommendations for managing poststroke sensory loss from high and average-quality CPGs were summarised and developed into an algorithm.

RESULTS

First, 1458 records were identified from the database searches and other sources. Finally, four CPGs were included: three were rated as high quality and one as average quality. Twenty-two recommendations were summarised from these CPGs and used to develop a draft algorithm. Then, we revised the draft algorithm developed by the authors based on expert feedback to form the final version.

CONCLUSIONS

The four CPGs included in this study had good quality. Based on these CPGs, we developed an algorithm to facilitate health professionals' adherence to CPGs and contribute to evidence-based medicine. In the future, more high-quality CPGs are required to give further scientific and convincing evidence to manage poststroke sensory loss.

Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs): Protocol for systematic review

INTRODUCTION

Stroke rehabilitation guidelines promoteclinical decision making, enhance quality of healthcare delivery, minimize healthcare costs, and identify gaps in current knowledge to guide future research. However, there are no published reviews that have exclusively evaluated the quality of existing Clinical Practice Guidelines (CPGs) for stroke rehabilitation from Low- and Middle-Income Countries (LMICs) or provided any insights into the cultural variation, adaptations, or gaps in implementation specific to LMICs.

OBJECTIVES

To identify CPGs developed by LMICs for stroke rehabilitation and evaluate their quality using AGREE-II and AGREE-REX tool.

METHODS

The review protocol is prepared in accordance with the PRISMA-P guidelines and the review was registered in PROSPERO (CRD42022382486). The search was run in Medline, EMBASE, CINHAL, PEDro for guidelines published between 2000 till July 2022. Additionally, SUMSearch, Google, and other guideline portals and gray literature were searched. The included studies were then subjected to data extraction for the following details: Study ID, title of the CPG, country of origin, characteristics of CPG (Scope-national/regional, level of care, multidisciplinary/uni-disciplinary), and information on stroke rehabilitation relevant recommendations. The quality of the included CPGs will be subsequently evaluated using AGREE-II and AGREE-REX tool.

RESULTS & CONCLUSION

This systematic review aims to explore the gaps in existing CPGs specific to LMICs and will aid in development/adaptation/contextualization of CPGs for implementation in LMICs.

Global synergistic actions to improve brain health for human development

The global burden of neurological disorders is substantial and increasing, especially in low-resource settings. The current increased global interest in brain health and its impact on population wellbeing and economic growth, highlighted in the World Health Organization's new Intersectoral Global Action Plan on Epilepsy and other Neurological Disorders 2022-2031, presents an opportunity to rethink the delivery of neurological services. In this Perspective, we highlight the global burden of neurological disorders and propose pragmatic solutions to enhance neurological health, with an emphasis on building global synergies and fostering a 'neurological revolution' across four key pillars - surveillance, prevention, acute care and rehabilitation - termed the neurological quadrangle. Innovative strategies for achieving this transformation include the recognition and promotion of holistic, spiritual and planetary health. These strategies can be deployed through co-design and co-implementation to create equitable and inclusive access to services for the promotion, protection and recovery of neurological health in all human populations across the life course.

A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization

BACKGROUND

There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines.

AIMS

To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).

SUMMARY OF REVIEW

Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited.

CONCLUSION

The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.

Standardized tools for assessing balance and mobility in stroke clinical practice guidelines worldwide: A scoping review

Background

Use of standardized tools to assess balance and mobility limitations is a recommended practice in stroke rehabilitation. The extent to which clinical practice guidelines (CPGs) for stroke rehabilitation recommend specific tools and provide resources to support their implementation is unknown.

Purpose

To identify and describe standardized, performance-based tools for assessing balance and/or mobility and describe postural control components challenged, the approach used to select tools, and resources provided for clinical implementation, in CPGs for stroke.

Methods

A scoping review was conducted. We included CPGs with recommendations on the delivery of stroke rehabilitation to address balance and mobility limitations. We searched seven electronic databases and grey literature. Pairs of reviewers reviewed abstracts and full texts in duplicate. We abstracted data about CPGs, standardized assessment tools, the approach for tool selection, and resources. Experts identified postural control components challenged by each tool.

Results

Of the 19 CPGs included in the review, 7 (37%) and 12 (63%) were from middle- and high-income countries, respectively. Ten CPGs (53%) recommended or suggested 27 unique tools. Across 10 CPGs, the most commonly cited tools were the Berg Balance Scale (BBS) (90%), 6-Minute Walk Test (6MWT) (80%), Timed Up and Go Test (80%) and 10-Meter Walk Test (70%). The tool most frequently cited in middle- and high-income countries was the BBS (3/3 CPGs), and 6MWT (7/7 CPGs), respectively. Across 27 tools, the three components of postural control most frequently challenged were underlying motor systems (100%), anticipatory postural control (96%), and dynamic stability (85%). Five CPGs provided information in varying detail on how tools were selected; only 1 CPG provided a level of recommendation. Seven CPGs provided resources to support clinical implementation; one CPG from a middle-income country included a resource available in a CPG from a high-income country.

Conclusion

CPGs for stroke rehabilitation do not consistently provide recommendations for standardized tools to assess balance and mobility or resources to facilitate clinical application. Reporting of processes for tool selection and recommendation is inadequate. Review findings can be used to inform global efforts to develop and translate recommendations and resources for using standardized tools to assess balance and mobility post-stroke.

Systematic Review Registration

https://osf.io/, identifier: 10.17605/OSF.IO/6RBDV.

Two-Stage Clinical Model for Screening the Suspected Cases of Acute Ischemic Stroke in Need of Imaging in Emergency Department; a Cross-sectional Study

Introduction

Just as failure to diagnose an acute ischemic stroke (AIS) in a timely manner affects the patient's outcome; an inaccurate and misplaced impression of the AIS diagnosis is not without its drawbacks. Here, we introduce a two-stage clinical tool to aid in the screening of AIS cases in need of imaging in the emergency department (ED).

Methods

This was a multicenter cross-sectional study, in which suspected AIS patients who underwent a brain magnetic resonance imaging (MRI) were included. The 18 variables from nine existing AIS screening tools were extracted and a two-stage screening tool was developed based on expert opinion (stage-one or rule in stage) and multivariate logistic regression analysis (stage-two or rule out stage). Then, the screening performance characteristics of the two-stage mode was evaluated.

Results

Data from 803 patients with suspected AIS were analyzed. Among them, 57.4 % were male, and their overall mean age was 66.9 ± 13.9 years. There were 561 (69.9%) cases with a final confirmed diagnosis of AIS. The total sensitivity and specificity of the two-stage screening model were 99.11% (95% CI: 98.33 to 99.89) and 35.95% (95% CI: 29.90 to 42.0), respectively. Also, the positive and negative predictive values of two-stage screening model were 78.20% (95% CI: 75.17 to 81.24) and 94.57% (95% CI: 89.93 to 81.24), respectively. The area under the receiver operating characteristic (ROC) curve of the two-stage screening model for AIS was 67.53% (95% CI: 64.48 to 70.58). Overall, using the two-stage screening model presented in this study, more than 11% of suspected AIS patients were not referred for MRI, and the error of this model is about 5%.

Conclusion

Here, we proposed a 2-step model for approaching suspected AIS patients in ED for an attempt to safely exclude patients with the least probability of having an AIS as a diagnosis. However, further surveys are required to assess its accuracy and it may even need some modifications.

Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings

Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.

The burden of stroke and its attributable risk factors in the Middle East and North Africa region, 1990-2019

Stroke is one of the leading causes of mortality and morbidity across the globe. Providing comprehensive data on the burden of stroke in the Middle East and North Africa (MENA) could be useful for health policy makers in the region. Therefore, this article reported the burden of stroke and its attributable risk factors between 1990 and 2019 by age, sex, type of stroke, and socio-demographic index. Data on the point prevalence, death, and disability-adjusted life-years (DALYs), due to stroke, were retrieved from the Global Burden of Disease study 2019 for the 21 countries located in the MENA region from 1990 to 2019. The counts and age-standardised rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals (UIs). In 2019, the regional age-standardised point prevalence and death rates of stroke were 1537.5 (95% UI: 1421.9–1659.9) and 87.7 (78.2–97.6) per 100,000, which represent a 0.5% (− 2.3 to 1.1) and 27.8% (− 35.4 to − 16) decrease since 1990, respectively. Moreover, the regional age-standardised DALY rate in 2019 was 1826.2 (1635.3–2026.2) per 100,000, a 32.0% (− 39.1 to − 23.3) decrease since 1990. In 2019, Afghanistan [3498.2 (2508.8–4500.4)] and Lebanon [752.9 (593.3–935.9)] had the highest and lowest age-standardised DALY rates, respectively. Regionally, the total number of stroke cases were highest in the 60–64 age group and was more prevalent in women in all age groups. In addition, there was a general negative association between SDI and the burden of stoke from 1990 to 2019. Also, in 2019, high systolic blood pressure [53.5%], high body mass index [39.4%] and ambient particulate air pollution [27.1%] made the three largest contributions to the burden of stroke in the MENA region. The stroke burden has decreased in the MENA region over the last three decades, although there are large inter-country differences. Preventive programs should be implemented which focus on metabolic risk factors, especially among older females in low SDI countries.

Primary stroke prevention worldwide: translating evidence into action

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.