WSO - July 2023 - 632

1181677
WSO
International Journal of StrokeEditorial
Editorial
The global burden of stroke
International Journal of Stroke
2023, Vol. 18(6) 632 -633
© 2023 World Stroke Organization
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/17474930231181677
journals.sagepub.com/home/wso
https://doi.org/10.1177/17474930231181677
Keywords
Stroke, global, epidemiology, disparities, Africa, South America, Japan, New Zealand, lacunar, small vessel disease,
Angels Initiative
Stroke remains an enormous global burden for us all regardless
of geographical location or ethnicity. However, there
are marked variations in incidence and outcome which are
important to highlight, so that we can target optimal
approaches to both prevent stroke and reduce its devastating
consequences.1 To help us do this, we need robust data
describing stroke incidence and outcomes across the world.
To address this the International Journal of Stroke (IJS) has
commissioned articles reviewing the burden of stroke in
different geographical regions. In previous issues we have
covered stroke in China2 and in India.3 In this issue we have
definitive reviews of stroke in both Africa and South
America. Okekunle et al.4 performed a systematic review
of epidemiological data from Africa which shows a high
incidence and poor outcome. They also highlight a dearth
of high-quality data and provide guidance of how this could
be best obtained using the World Health Organization
STEPwise approach to Surveillance (WHO STEPS) framework.
Their conclusions are consistent with an epidemiological
study from Sierra Leone which found stroke affected
younger people and resulted in high rates of fatality and
functional impairment relative to global averages.5 Delfino
et al.6 from South Africa also highlight the need for studies
to better understand the burden of stroke, and how it varies,
across South America.
The importance of ethnic differences in stroke risk factors
and stroke subtypes has been debated. While there do
appear to be some geographical differences, for example,
increased intracranial stenosis in Far Eastern populations,7
differences in access to services are likely to be more
important in determining stroke outcome. This is highlighted
in a study by Denison et al.8 from New Zealand in
which they showed worse stroke outcomes in Maori, compared
with European, New Zealanders. Importantly, they
report that disparities in care and outcomes following stroke
were independent of traditional risk factors, suggesting
they may be attributable to differences in stroke service
delivery rather than patient factors.
Reductions in stroke incidence require public health
measures, including governmental action and education,
and it is positive that stroke incidence continues to decline
in some parts of the world, as evidenced by a study in this
International Journal of Stroke, 18(6)
issue from Japan.9 However, we ourselves can help improve
the outcome in patients who have suffered of stroke, by
training and education of health professionals. The need for
improved services in Africa has been highlighted in a recent
review,10 and national organizations who can take formal
continent wide measures to improve care, such as the
recently formed African Stroke Organization, are important.11
The World Stroke Organization (WSO) is also working
hard, with its recently invigorated World Stroke
Academy12 (do access it for some excellent free online educational
material here: https://www.world-stroke-academy.
org/), and its association with the Angels program.
Established in 2016, the Angels Initiative is an international,
not-for-profit, public-private partnership run in collaboration
with the WSO, European Stroke Organisation, and
regional and national stroke societies in over 50 countries.13
The Angels Initiative aims to increase the global number of
stroke-ready hospitals and to optimize the quality of existing
stroke units by enlisting stroke professionals from
throughout the world to help. The Angels Initiative has supported
over 1700 hospitals (>1000 in low- and middleincome
countries (LMICs)) that did not previously treat
stroke patients to become " stroke ready. " Since its inception
in 2016, the Angels Initiative has impacted the health outcomes
of an estimated 7.46 million stroke patients globally
(including an estimated 4.68 million patients in LMICs).
Small vessel disease accounts for a quarter of all strokes
(lacunar strokes and deep intracerebral hemorrhage) and is
the major vascular pathology contributing to dementia.14
All clinicians who look after lacunar stroke patients are
aware of a significant proportion in whom there is an early
neurological deterioration (END) over the first few days.
The mechanisms underlying this deterioration, and how it
can be prevented, remain poorly understood. We do not
even know whether the trigger for lacunar stroke is thrombosis
in a perforating artery, or hemodynamic alterations.
This makes a paper by Tan et al.15 in this issue particularly
relevant. They studied 638 lacunar stroke patients,
16.9% of whom developed END. In 95% of cases, this
occurred within 72 h of admission. Factors associated with
an increased risk of END included admission National
Institutes of Health Stroke Scale (NIHSS) score, female
http://www.sagepub.com/journals-permissions https://www.doi.org/10.1177/17474930231181677 http://journals.sagepub.com/home/wso https://www.world-stroke-academy.org/
WSO - July 2023

Table of Contents for the Digital Edition of WSO - July 2023
