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Background Stroke is a major public health concern, affecting millions of people worldwide. Care of the condition however, remain inconsistent in developing countries. The purpose of this scoping review was to document evidence of stroke care and service delivery in low and middle-income countries to better inform development of a context-fit stroke model of care. Methods An interpretative scoping literature review based on Arksey and O’Malley’s five-stage-process was executed. The following databases searched for literature published between 2010 and 2017; Cochrane Library, Credo Reference, Health Source: Nursing/Academic Edition, Science Direct, BioMed Central, Cumulative Index to Nursing and Allied Health Literature (CINNAHL), Academic Search Complete, and Google Scholar. Single combined search terms included acute stroke, stroke care, stroke rehabilitation, developing countries, low and middle-income countries. Results A total of 177 references were identified. Twenty of them, published between 2010 and 2017, were included in the review. Applying the Donebedian Model of quality of care, seven dimensions of stroke-care structure, six dimensions of stroke care processes, and six dimensions of stroke care outcomes were identified. Structure of stroke care included availability of a stroke unit, an accident and emergency department, a multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies. Stroke care processes that emerged were assessment and diagnosis, referrals, intravenous thrombolysis, rehabilitation, and primary and secondary prevention strategies. Stroke-care outcomes included quality of stroke-care practice, functional independence level, length of stay, mortality, living at home, and institutionalization. Conclusions There is lack of uniformity in the way stroke care is advanced in low and middle-income countries. This is reflected in the unsatisfactory stroke care structure, processes, and outcomes. There is a need for stroke care settings to adopt quality improvement strategies. Health ministry and governments need to decisively face stroke burden by setting policies that advance improved care of patients with stroke. Stroke Units and Recombinant Tissue Plasminogen Activator (rtPA) administration could be considered as both a structural and process necessity towards improvement of outcomes of patients with stroke in the LMICs.

Background Health system constraints challenge the organisation of acute ischaemic stroke care in low- and middle-income countries (LMICs). While stroke unit effectiveness is well established in high-income settings, evidence gaps remain regarding the implementation and sustainability of organised stroke services in LMICs. This study aimed to describe and analyse the longitudinal implementation, adaptation, and sustainability of organised ischaemic stroke care in a public hospital in rural India. Methods We conducted a seven-year mixed-methods longitudinal implementation case study at a 1,000-bed teaching hospital in Punjab, India. Data were collected from a prospective ischaemic stroke registry and routine process documentation. Quantitative data captured patient demographics, risk factors, treatments, process indicators, and outcomes for adults admitted with acute ischaemic stroke. Qualitative data included clinician narratives and contemporaneous process records, analysed thematically using the WHO Health System Building Blocks and RE-AIM frameworks to assess service evolution, adaptations, and sustainability. Lessons from cumulative implementation experience informed an emergent, practice-derived framework. Results Between 2017 and 2023, 1,880 adults with acute ischaemic stroke were registered. Admissions increased from 249 in 2017 to 402 in 2018, then declined during the COVID-19 pandemic (232 in 2020; 225 in 2021), and stabilised thereafter (204 in 2022; 208 in 2023) (χ² = 355.5, p  < 0.001). The mean age was 60 ± 14 years, and 61% were males. Hypertension ( n  = 1428, 76%) and diabetes ( n  = 789. 42%) were the most common risk factors. Intravenous thrombolysis was administered to 3% ( n  = 62) of patients, with a median door-to-needle time of 83 min (IQR 70–96). Functional outcome data at three months were available for 1,504 patients (80%), of whom 73% ( n  = 1098) achieved independence (mRS 0–2). Qualitative analysis identified five interconnected organisational learning processes that formed a Stroke Unit Corridor (SUC), a coordinated, non-physical model that integrates emergency, imaging, and neurology services through standardised workflows rather than dedicated infrastructure. Conclusions Organised ischaemic stroke care in resource-constrained public hospitals may be developed and sustained through iterative organisational learning, even without external funding or dedicated facilities. The SUC framework highlights how adaptive coordination using existing resources may strengthen hospital readiness for acute stroke care. However, hospital-level improvements alone may be insufficient, and strengthening pre-hospital, referral, and post-acute systems is likely necessary to improve access and stroke outcomes. Clinical trial registration Clinical trial number: not applicable.

Abstract Introduction Although epidemiological studies often group the Baltic states together, they differ significantly in national stroke care legislation and infrastructure. Our study aimed to explore and compare the current state of stroke care in Lithuania, Latvia and Estonia. Patients and methods We analysed the Stroke Action Plan for Europe (SAP-E) Stroke Service Tracker data from 2022, including data from the respective National Health Insurance Funds and direct centre-level queries. Geographic Information System-based modelling assessed population access to stroke-ready hospitals within 1 h. Key metrics, including hospitalised stroke incidence, stroke unit admission, recanalisation therapy and in-hospital as well as 30-day mortality, were compared using Z-tests for proportions. Results The hospitalised stroke incidence per 100,000 inhabitants was similar in Lithuania (353) and Latvia (354), but lower in Estonia (246), despite similar population structures. Lithuania had the highest proportion of its population (94.0%) with access to a stroke-ready hospital within 1 h, followed by Latvia (87.1%) and Estonia (84.7%, P < .001). Estonia had the highest proportion of stroke unit admission rates and the lowest mortality rates—9.6% (in-hospital) and 15.0% (30-day) for ischaemic stroke. Endovascular treatment was most frequent in Lithuania (8.6% of all strokes, P < .001), while Estonia had the highest rate of intravenous thrombolysis (29.0%, P < .001). Conclusions Despite broadly comparable populations and formal SAP-E alignment, the Baltic states exhibit marked differences in stroke access, treatment and outcomes. High stroke unit admissions and high recanalisation rates in Estonia may be associated with lower ischaemic stroke mortality, underscoring the importance of system design beyond geographic coverage alone. Graphical Abstract Graphical Abstract

The awareness of care provided by stroke care unit (SCU) nurses in Japan to patients with an acute cerebrovascular accident (CVA) and the characteristic differences in their actual nursing practice were evaluated. A cross-sectional web-based questionnaire survey was administered to 1040 SCU nurses. Data collection and reporting procedures followed the STROBE Statement Checklist for cross-sectional studies. Exploratory factor analysis, using 52 observation items, identified eight factors with a factor loading > 0.4. For all factors, the actual practice was significantly lower than the awareness of the importance of nursing care for patients with acute CVA. Awareness and actual practice of recognition of patients’ physical changes (RPPCs) were high. The actual practice of RPPCs and preventing the worsening of acute stroke and related symptoms varied, depending on years of experience in acute phase stroke care. RPPCs in actual practice had a significantly higher score among certified nurses or certified nurse specialists. Their awareness of the importance of collaborating with therapists was low. On-the-job training can improve nurses’ competence and prevent worsening conditions in patients with CVA. An emphasis on enhancing practice experience toward patients with acute CVA and facilitating the deployment of certified nurses in SCUs can improve nursing care practice.

Background Major system reform is complex but can yield improved outcomes at multiple levels. We aimed to evaluate the impact of implementing a hub and spoke model of stroke care across metropolitan Adelaide (population 1.2 million), South Australia on mortality, morbidity, service and quality stroke indicators. Methods Analysis of 24 months of prospectively collected, patient-level data covering all metropolitan stroke admissions during the contiguous pre-, during- and post-implementation time periods, linked to mortality data from the National Death Index. The three metropolitan tertiary hospital-based stroke units undertook the implementation of a centralised ‘hub and spoke’ model: one central comprehensive stroke centre offering 24 h stroke reperfusion therapies, and two primary stroke centres providing 12 h thrombolysis. The main outcome measures were mortality (any cause) up to 180 days post-admission; reperfusion treatment proportions and timings; stroke care quality composite metric; length of stay. Results There were 3917 confirmed stroke admissions over the 24-month period (3325 (84.9%) ischaemic) and 650 deaths (19.6%) within 180 days. Compared to the baseline period, post-intervention mortality and discharge disability did not differ, although a possible temporary increase in ischaemic stroke mortality during implementation was seen. Rates of endovascular thrombectomy (EVT) (5.7% vs. 12.5%, adjusted Rate Ratio (aRR) = 1.94, 95%CI 1.21,3.10) and timeliness of EVT (median 126 min (IQR 83, 154) vs. 95 min (53, 132), p  < 0.001) improved as did the composite stroke quality metric indicator (0.60, 95% CI 0.50, 0.70 vs. 0.64, 95% CI 0.50, 0.75; adjusted difference 0.041, 95% CI 0.015, 0.066). Length of stay decreased for ischaemic stroke (8.2 (SD 12.4) vs. 7.9 (SD 8.9) days, adjusted geometric mean ratio = 0.83, 95% CI 0.73. 0.94) but not for intracerebral haemorrhage. Conclusion The major implementation of a metropolitan centralised ‘hub and spoke’ model of acute stroke care was associated with overall significant improvements in process indicators but a possible temporary increase in ischaemic stroke mortality during implementation.

Developing nations face the double burden of communicable and noncommunicable diseases. Bhutan is a developing country and has achieved significant milestones in its health indicators. Increasing burden of stroke and the lack of evidence-based stroke care system in the country’s hospitals are proving to be a challenge to provide quality stroke care. Despite the logistical challenge of referring stroke patients on time, lack of trained health care professionals and resources, Bhutan has recently started various initiatives to improve stroke care with the help of WHO-SEARO, WHO-Geneva, and Christian Medical College, Ludhiana, India.

In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80 mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Introduction Knowledge of the implementation gap would facilitate the use of intravenous thrombolysis in stroke, which is still low in many countries. The study was conducted to identify national implementation targets for the utilisation and logistics of intravenous thrombolysis. Material and Method Multicomponent interventions by stakeholders in health care to optimise prehospital and hospital management with the goal of fast and accessible intravenous thrombolysis for every candidate. Implementation results were documented from prospectively collected cases in all 45 stroke centres nationally. The thrombolytic rate was calculated from the total number of all ischemic strokes in the population of the Czech Republic since 2004. Results Thrombolytic rates of 1.3 (95%CI 1.1 to 1.4), 5.4 (95%CI 5.1 to 5.7), 13.6 (95%CI 13.1 to 14.0), 23.3 (95%CI 22.8 to 23.9), and 23.5% (95%CI 23.0 to 24.1%) were achieved in 2005, 2009, 2014, 2017, and 2018, respectively. National median door-to-needle times were 60–70 minutes before 2012 and then decreased progressively every year to 25 minutes (IQR 17 to 36) in 2018. In 2018, 33% of both university and non-university hospitals achieved median door-to-needle time ≤20 minutes. In 2018, door-to-needle times ≤20, ≤45, and ≤60 minutes were achieved in 39, 85, and 93% of patients. Discussion Thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes. Conclusion Stroke 20–20 could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.

The model of centralized stroke care in the Czech Republic was created in 2010–2012 by Ministry of Health (MH) in cooperation with professional organization—Cerebrovascular Section of the Czech Neurological Society (CSCNS). It defines priorities of stroke care, stroke centers, triage of suspected stroke patients, stroke care quality indicators, their monitoring, and reporting. Thirteen complex cerebrovascular centers (CCC) provide sophisticated stroke care, including intravenous thrombolysis (IVT), mechanical thrombectomy (MTE), as well as other endovascular (stenting, coiling) and neurosurgical procedures. Thirty-two stroke centers (SC) provide stroke care except endovascular procedures and neurosurgery. The triage is managed by emergency medical service (EMS). The most important quality indicators of stroke care are number of hospitalized stroke patients, number of IVT, number of MTE, stenting and coiling, number of neurosurgical procedures, and percentage of deaths within 30 days. Indicators provided into the register of stroke care quality (RES-Q) managed by CSCNS are time from stroke onset to hospital admission, door-to-needle time, door-to-groin time, type of ischemic stroke, and others. Data from RES-Q are shared to all centers. Within the last 5 years, the Czech Republic becomes one of the leading countries in acute stroke care. The model of centralized stroke care is highly beneficial and effective. The quality indicators serve as tool of control of stroke centers activities. The sharing of quality indicators is useful tool for mutual competition and feedback control in each center. This comprehensive system ensures high standard of stroke care. This system respects the substantial principles of personalized medicine—individualized treatment of acute stroke and other comorbidities at the acute disease stage; optimal prevention, diagnosis and treatment of possible complications; prediction of further treatment and outcome; individualized secondary prevention, exactly according to the stroke etiology. The described model of stroke care optimally meets criteria of predictive, preventive, and personalized medicine (PPPM), and could be used in other countries as well with the aim of improving stroke care quality in general.

Objectives Stroke is a leading cause for disability and morbidity associated with increased economic burden due to treatment and post-stroke care (PSC). The aim of our study is to provide information on resource consumption for PSC, to identify relevant cost drivers, and to discuss potential information gaps. Methods A systematic literature review on economic studies reporting PSC-associated data was performed in PubMed/MEDLINE, Scopus/Elsevier and Cochrane databases, Google Scholar and gray literature ranging from January 2000 to August 2016. Results for post-stroke interventions (treatment and care) were systematically extracted and summarized in evidence tables reporting study characteristics and economic outcomes. Economic results were converted to 2015 US Dollars, and the total cost of PSC per patient month (PM) was calculated. Results We included 42 studies. Overall PSC costs (inpatient/outpatient) were highest in the USA ($4850/PM) and lowest in Australia ($752/PM). Studies assessing only outpatient care reported the highest cost in the United Kingdom ($883/PM), and the lowest in Malaysia ($192/PM). Fifteen different segments of specific services utilization were described, in which rehabilitation and nursing care were identified as the major contributors. Conclusion The highest PSC costs were observed in the USA, with rehabilitation services being the main cost driver. Due to diversity in reporting, it was not possible to conduct a detailed cost analysis addressing different segments of services. Further approaches should benefit from the advantages of administrative and claims data, focusing on inpatient/outpatient PSC cost and its predictors, assuring appropriate resource allocation.