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International Journal of Stroke 19(3)
Figure 2. Map showing the availability of intravenous thrombolysis and endovascular thrombectomy services around the world.
game-changing treatment for stroke. The policy objectives
of the Stroke Action Plan for Europe also include targets by
2030 for guaranteeing access to reperfusion services to
95% of eligible patients, and achieving intravenous thrombolysis
rates above 15% and endovascular therapy above
5% in all European countries.2 Therefore, the data reported
in this review are necessary for underpinning these objectives
and targets, commensurate with investments in workforce
and system improvements that are required to ensure
equitable access to reperfusion services.
Telemedicine services facilitate access to intravenous
thrombolysis, especially in more remote areas or smaller
hospitals, with this service requiring a robust technical
setup, both at the hub and spoke hospitals. Targets to provide
all people within a country access to acute stroke reperfusion
services may be ambitious. For example in France,
a national strategy to have a stroke telemedicine service
that began in 2011 is still in progress.146 However, the
required investments are economical compared with other
solutions (e.g. MSUs or stroke air ambulances).147,148 In
addition, stroke telemedicine services are used in many
regions, but nationwide approaches are rare, and solutions
are often regionally based and not standardized. Significant
progress has been made in the United States (2019), where
it was estimated that 96% of the population had access to a
stroke center or stroke telemedicine service.149 Also, there
is evidence from Germany that wider adoption of stroke
telemedicine service is feasible and safe, with 38,895
consultations successfully undertaken across 14 telemedicine
networks in nine German states.128
The availability and extent of MSU services varied
widely within each country, and implementation was often
limited to specific regions or cities. MSUs were more common
in the United States, with several cities successfully
integrating MSUs into their emergency response systems.
Investments to establish MSUs are considerable, including
costs of procuring equipment, training, and integrating into
existing health care systems. However, the benefits offset
the upfront investment with reductions in time to diagnosis
and earlier provision of time-critical treatments, especially
in settings requiring extensive time to travel to hospital.150
An important finding from this review is that contemporary
patient-level data on availability of reperfusion services
remain scarce, even in HICs. Based on published
data, intravenous thrombolysis and endovascular thrombectomy
services were notably absent in low-income countries.
Potential barriers to providing reperfusion services in
these countries include lack of necessary infrastructure,
equipment, and trained personnel, and high costs associated
with procuring reperfusion drugs/devices. For countries
with no data available on provision of reperfusion services,
it is difficult to ascertain current gaps in this important
aspect of stroke in these countries. We also found huge
variations in access to reperfusion services in HICs, which
underlines the need for investment in robust stroke care services
and infrastructure globally.
International Journal of Stroke, 19(3)
WSO - March 2024

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