Semin Neurol 2024; 44(02): 119-129
DOI: 10.1055/s-0044-1782617
Review Article

Developing Systems of Care for Stroke in Resource-limited Settings

Gisele Sampaio Silva
1   Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
2   Department of Neurology, Hospital Israelita Albert Einstein, São Paulo, Brazil
Eva Rocha
1   Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
› Author Affiliations


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.

Publication History

Article published online:
21 March 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Feigin VL. et al; GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol 2021; 20 (10) 795-820
  • 2 Lanas F, Seron P. Facing the stroke burden worldwide. Lancet Glob Health 2021; 9: e235-e236 Accessed March 01, 2024 at:
  • 3 Ma Q, Li R, Wang L. et al. Temporal trend and attributable risk factors of stroke burden in China, 1990-2019: an analysis for the Global Burden of Disease Study 2019. Lancet Public Health 2021; 6 (12) e897-e906
  • 4 Ouriques Martins SC, Sacks C, Hacke W. et al. Priorities to reduce the burden of stroke in Latin American countries. Lancet Neurol 2019; 18 (07) 674-683
  • 5 Owolabi MO, Akarolo-Anthony S, Akinyemi R. et al; Members of the H3Africa Consortium. The burden of stroke in Africa: a glance at the present and a glimpse into the future. Cardiovasc J S Afr 2015; 26 (2 suppl 1) S27-S38
  • 6 Zeng X, Deng A, Ding Y. The INTERSTROKE study on risk factors for stroke. Lancet 2017; 389 (10064): 35
  • 7 Langhorne P, O'Donnell MJ, Chin SL. et al; INTERSTROKE collaborators. Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study. Lancet 2018; 391 (10134): 2019-2027
  • 8 Silva GS, Rocha ECA, Pontes-Neto OM, Martins SO. Stroke care services in Brazil. J Stroke Med 2018; 1: 51-54
  • 9 de Carvalho FA, Schwamm LH, Kuster GW, Bueno Alves M, Cendoroglo Neto M, Sampaio Silva G. Get with the guidelines stroke performance indicators in a brazilian tertiary hospital. Cerebrovasc Dis Extra 2012; 2 (01) 26-35
  • 10 Martins SCO, Borelli WV, Secchi TL. et al. Disparities in stroke patient-reported outcomes measurement between healthcare systems in Brazil. Front Neurol 2022; 13: 857094
  • 11 Yusuf S, Rangarajan S, Teo K. et al; PURE Investigators. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med 2014; 371 (09) 818-827
  • 12 Hammond G, Luke AA, Elson L, Towfighi A, Joynt Maddox KE. Urban-rural inequities in acute stroke care and in-hospital mortality. Stroke 2020; 51 (07) 2131-2138
  • 13 Cano-Nigenda V, Castellanos-Pedroza E, Manrique-Otero D. et al. Barriers to optimal acute management of stroke: perspective of a stroke center in Mexico City. Front Neurol 2021; 12: 690946
  • 14 Schwingshackl L, Hoffmann G. Diet quality as assessed by the Healthy Eating Index, the Alternate Healthy Eating Index, the Dietary Approaches to Stop Hypertension score, and health outcomes: a systematic review and meta-analysis of cohort studies. J Acad Nutr Diet 2015; 115 (05) 780-800.e5
  • 15 Chow CK, Teo KK, Rangarajan S. et al; PURE (Prospective Urban Rural Epidemiology) Study Investigators. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA 2013; 310 (09) 959-968
  • 16 Ghandehari K. Barriers of thrombolysis therapy in developing countries. Stroke Res Treatment 2011; 2011: 1-4
  • 17 Nakibuuka J, Sajatovic M, Katabira E, Ddumba E, Byakika-Tusiime J, Furlan AJ. Knowledge and perception of stroke: a population-based survey in Uganda. ISRN Stroke 2014; 2014: 1-7
  • 18 Pontes-Neto OM, Silva GS, Feitosa MR. et al. Stroke awareness in Brazil: alarming results in a community-based study. Stroke 2008; 39 (02) 292-296
  • 19 Ye S, Hu S, Lei Z. et al. Shenzhen stroke emergency map improves access to rt-PA for patients with acute ischaemic stroke. Stroke Vasc Neurol 2019; 4 (03) 115-122
  • 20 Kuster GW, Bueno Alves M, Cendoroglo Neto M, Silva GS. Determinants of emergency medical services use in a Brazilian population with acute ischemic stroke. J Stroke Cerebrovasc Dis 2013; 22 (03) 244-249
  • 21 Kim J, Olaiya MT, De Silva DA. et al. Global Stroke Statistics 2023: Availability of reperfusion services around the world. Int J Stroke 2024; 17 474930231210448
  • 22 Frija G, Blažić I, Frush DP. et al. How to improve access to medical imaging in low- and middle-income countries?. EClinicalMedicine 2021; 38: 101034
  • 23 Roushdy T, Aref H, Kesraoui S. et al. Stroke services in Africa: What is there and what is needed. Int J Stroke 2022; 17 (09) 972-982
  • 24 Ghandehari K. Barriers of thrombolysis therapy in developing countries. Stroke Res Treat 2011; 2011: 686797
  • 25 Singh S, Kate M, Samuel C. et al. Rural stroke surveillance and establishment of acute stroke care pathway using frontline health workers in rural northwest India: The Ludhiana experience. Neuroepidemiology 2021; 55 (04) 297-305
  • 26 Owolabi MO, Thrift AG, Martins S. et al; Stroke Experts Collaboration Group. The state of stroke services across the globe: Report of World Stroke Organization-World Health Organization surveys. Int J Stroke 2021; 16 (08) 889-901
  • 27 Berkowitz AL, Mittal MK, McLane HC. et al. Worldwide reported use of IV tissue plasminogen activator for acute ischemic stroke. Int J Stroke 2014; 9 (03) 349-355
  • 28 de Carvalho JJF, Alves MB, Viana GÁ. et al. Stroke epidemiology, patterns of management, and outcomes in Fortaleza, Brazil: a hospital-based multicenter prospective study. Stroke 2011; 42 (12) 3341-3346
  • 29 Martins SO, Mont'Alverne F, Rebello LC. et al; RESILIENT Investigators. Thrombectomy for stroke in the public health care system of Brazil. N Engl J Med 2020; 382 (24) 2316-2326
  • 30 Asif KS, Otite FO, Desai SM. et al; Global Executive Committee of the MT-GLASS Study. Mechanical Thrombectomy Global Access For Stroke (MT-GLASS): A Mission Thrombectomy (MT-2020 Plus) Study. Circulation 2023; 147 (16) 1208-1220
  • 31 Goldstein JN, Rosand J, Schwamm LH. Warfarin reversal in anticoagulant-associated intracerebral hemorrhage. Neurocrit Care 2008; 9 (02) 277-283
  • 32 Rivillas J, Llanos-Leyton N, Moreno-Vargas E. et al. Barriers in access to idarucizumab in ischemic stroke in a middle-income country. Neurohospitalist 2024; 14 (01) 44-51
  • 33 Pham X, Ray J, Neto AS. et al. Association of neurocritical care services with mortality and functional outcomes for adults with brain injury: a systematic review and meta-analysis. JAMA Neurol 2022; 79 (10) 1049-1058
  • 34 Evans A, Harraf F, Donaldson N, Kalra L. Randomized controlled study of stroke unit care versus stroke team care in different stroke subtypes. Stroke 2002; 33 (02) 449-455
  • 35 Kalra L, Evans A, Perez I, Knapp M, Donaldson N, Swift CG. Alternative strategies for stroke care: a prospective randomised controlled trial. Lancet 2000; 356 (9233): 894-899
  • 36 Feigin VL, Owolabi MO. World Stroke Organization–Lancet Neurology Commission Stroke Collaboration Group. Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission. Lancet Neurol 2023; 22 (12) 1160-1206
  • 37 Kayola G, Mataa MM, Asukile M. et al. Stroke rehabilitation in low- and middle-income countries: challenges and opportunities. Am J Phys Med Rehabil 2023; 102 (2S suppl 1) S24-S32
  • 38 Pandian JD, Kalkonde Y, Sebastian IA, Felix C, Urimubenshi G, Bosch J. Stroke systems of care in low-income and middle-income countries: challenges and opportunities. Lancet 2020; 396 (10260): 1443-1451
  • 39 Audebert HJ, Saver JL, Starkman S, Lees KR, Endres M. Prehospital stroke care: new prospects for treatment and clinical research. Neurology 2013; 81 (05) 501-508
  • 40 de la Ossa NP, Sánchez-Ojanguren J, Palomeras E. et al. Influence of the stroke code activation source on the outcome of acute ischemic stroke patients. Neurology 2008; 70 (15) 1238-1243
  • 41 Chen C-H, Tang SC, Tsai LK. et al. Stroke code improves intravenous thrombolysis administration in acute ischemic stroke. PLoS ONE 2014; 9 (08) e104862
  • 42 Abanto C, Valencia A, Calle P. et al. Challenges of thrombolysis in a developing country: characteristics and outcomes in Peru. J Stroke Cerebrovasc Dis 2020; 29 (07) 104819
  • 43 Mehrpour M, Aghaei M, Motamed MR. Safety and feasibility of intravenous thrombolytic therapy in Iranian patients with acute ischemic stroke. Med J Islam Repub Iran 2013; 27 (03) 113-118
  • 44 Hubert GJ, Müller-Barna P, Audebert HJ. Recent advances in TeleStroke: a systematic review on applications in prehospital management and Stroke Unit treatment or TeleStroke networking in developing countries. Int J Stroke 2014; 9 (08) 968-973
  • 45 Campbell BCV, Mitchell PJ, Churilov L. et al; EXTEND-IA TNK Investigators. Tenecteplase versus Alteplase before thrombectomy for ischemic stroke. N Engl J Med 2018; 378 (17) 1573-1582
  • 46 Parsons M, Spratt N, Bivard A. et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med 2012; 366 (12) 1099-1107
  • 47 Tsivgoulis G, Katsanos AH, Sandset EC. et al. Thrombolysis for acute ischaemic stroke: current status and future perspectives. Lancet Neurol 2023; 22 (05) 418-429
  • 48 Nogueira RG, Jadhav AP, Haussen DC. et al; DAWN Trial Investigators. Thrombectomy 6 to 24.  hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018; 378 (01) 11-21
  • 49 Albers GW, Marks MP, Kemp S. et al; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16.  hours with selection by perfusion imaging. N Engl J Med 2018; 378 (08) 708-718
  • 50 Jovin TG, Chamorro A, Cobo E. et al; REVASCAT Trial Investigators. Thrombectomy within 8.  hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372 (24) 2296-2306
  • 51 de Souza AC, Martins SO, Polanczyk CA. et al. Cost-effectiveness of mechanical thrombectomy for acute ischemic stroke in Brazil: results from the RESILIENT trial. Int J Stroke 2021; 17: 17 474930211055932
  • 52 Mission Thrombectomy. Accessed March 01, 2024 at:
  • 53 Cabral NL, Moro C, Silva GR, Scola RH, Werneck LC. Study comparing the stroke unit outcome and conventional ward treatment: a randomized study in Joinville, Brazil. Arq Neuropsiquiatr 2003; 61 (2A): 188-193
  • 54 Langhorne P, Ramachandra S. Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke: network meta-analysis. Cochrane Database Syst Rev 2020; 4 (04) CD000197
  • 55 John L, William A, Dawar D. et al. Implementation of a physician-based stroke unit in a remote hospital of north-east India-Tezpur Model. J Neurosci Rural Pract 2021; 12 (02) 356-361
  • 56 Nepal G, Yadav JK, Bhandari S, Gautam J, Gajurel BP. Low-cost alternatives for the management of acute ischemic stroke in low and middle-income countries. Ann Med Surg (Lond) 2021; 72: 102969
  • 57 Cisse FA, Damien C, Bah AK. et al. Minimal setting stroke unit in a sub-Saharan African public hospital. Front Neurol 2019; 10: 856
  • 58 Bernhardt J, Corbett D, Dukelow S. et al. The International Stroke Recovery and Rehabilitation Alliance. Lancet Neurol 2023; 22 (04) 295-296
  • 59 Park Y-J, Lee C-Y. Effects of community-based rehabilitation program on activities of daily living and cognition in elderly chronic stroke survivors. J Phys Ther Sci 2016; 28 (11) 3264-3266
  • 60 Cramer SC, Dodakian L, Le V. et al; National Institutes of Health StrokeNet Telerehab Investigators. Efficacy of home-based telerehabilitation vs in-clinic therapy for adults after stroke: a randomized clinical trial. JAMA Neurol 2019; 76 (09) 1079-1087
  • 61 Cacciante L, Kiper P, Garzon M. et al. Telerehabilitation for people with aphasia: A systematic review and meta-analysis. J Commun Disord 2021; 92: 106111
  • 62 Palmer R, Dimairo M, Cooper C. et al. Self-managed, computerised speech and language therapy for patients with chronic aphasia post-stroke compared with usual care or attention control (Big CACTUS): a multicentre, single-blinded, randomised controlled trial. Lancet Neurol 2019; 18 (09) 821-833
  • 63 Sun W-J. et al. Telerehabilitation for family caregivers of stroke survivors: a systematic review and meta-analysis. J Nurs Manag 2023; 2023: 1-13
  • 64 Kaseke F, Mlambo T, Stewart A, Gwanzura L, Hakim J. Supporting survivors of stroke in low resource settings. In: New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review. IntechOpen; 2020. DOI: 10.5772/intechopen.86900
  • 65 Moradi V, Babaee T, Esfandiari E, Lim SB, Kordi R. Telework and telerehabilitation programs for workers with a stroke during the COVID-19 pandemic: a commentary. Work 2021; 68: 77-80 Accessed February 11, 2024 at:
  • 66 Martins SCO, Weiss G, Almeida AG. et al. Validation of a smartphone application in the evaluation and treatment of acute stroke in a comprehensive stroke center. Stroke 2020; 51 (01) 240-246
  • 67 Ali F, Hamid U, Zaidat O, Bhatti D, Kalia JS. Role of artificial intelligence in TeleStroke: an overview. Front Neurol 2020; 11: 559322
  • 68 Fisher M, Martins S. Update of the World Stroke Organization activities. Stroke 2021; 52 (07) e356-e357
  • 69 Saposnik G, Galanos LC, Guerrero R. et al. The World Stroke Academy: a World Stroke Organization global pathway to improve knowledge in stroke care. Int J Stroke 2022; 17 (08) 829-834
  • 70 de Souza AC, Lioutas V, Sebastian I. et al. International Section for Early Career and Training Stroke Beyond Borders: building strategies to improve stroke care worldwide. Stroke 2023; 54 (08) e399-e402
  • 71 Accessed February 11, 2024 at:
  • 72 Accessed February 11, 2024 at:
  • 73 Martins SCO, Lavados P, Secchi TL. et al. Fighting against stroke in Latin America: a joint effort of medical professional societies and governments. Front Neurol 2021; 12: 743732