Delivery of acute ischaemic stroke treatments in the European region in 2019 and 2020

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Delivery of acute ischaemic stroke treatments in the European region in 2019 and 2020

Diana Aguiar de Sousa https://orcid.org/0000-0002-6702-7924, Arlene Wilkie, […], and Urs Fischer urs.fischer@usb.ch+15View all authors and affiliations

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https://doi.org/10.1177/23969873231186042

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  • Discussion
  • Conclusions
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Abstract

Introduction:

We assessed best available data on access and delivery of acute stroke unit (SU) care, intravenous thrombolysis (IVT) and endovascular treatment (EVT) in the European region in 2019 and 2020.

Patients and methods:

We compared national data per number of inhabitants and per 100 annual incident first-ever ischaemic strokes (AIIS) in 46 countries. Population estimates and ischaemic stroke incidence were based on United Nations data and the Global Burden of Disease Report 2019, respectively.

Results:

The estimated mean number of acute SUs in 2019 was 3.68 (95% CI: 2.90–4.45) per one million inhabitants (MIH) with 7/44 countries having less than one SU per one MIH. The estimated mean annual number of IVTs was 21.03 (95% CI: 15.63–26.43) per 100,000 and 17.14% (95% CI: 12.98–21.30) of the AIIS in 2019, with highest country rates at 79.19 and 52.66%, respectively, and 15 countries delivering less than 10 IVT per 100,000. The estimated mean annual number of EVTs in 2019 was 7.87 (95% CI: 5.96–9.77) per 100,000 and 6.91% (95% CI: 5.15–8.67) of AIIS, with 11 countries delivering less than 1.5 EVT per 100,000. Rates of SUs, IVT and EVT were stable in 2020. There was an increase in mean rates of SUs, IVT and EVT compared to similar data from 2016.

Conclusion:

Although there was an increase in reperfusion treatment rates in many countries between 2016 and 2019, this was halted in 2020. There are persistent major inequalities in acute stroke treatment in the European region. Tailored strategies directed to the most vulnerable regions should be prioritised.

Introduction

From 1990 to 2019, the absolute number of incident strokes increased by 70.0% and, in 2019, there were 12.2 million incident cases of stroke globally.¹ Stroke remains the second most common cause of death in Europe, where it is responsible for more than one million deaths per year and the leading cause of long-term disability.² Across European Union countries, stroke accounted for 375,000 deaths in 2017, and the number is expected to rise by one-third by 2035 due to population ageing and increases in some risk factors.³ Among all strokes, the ischaemic subtype is the most common, representing approximately 80% of cases in Europe.⁴ As a result, stroke is associated with a high use of health and social-care resources, with 8% of the 798 billion cost of brain disorders being attributable to stroke.⁵ Productivity losses cost was estimated to be 12 billion euros in Europe alone, equally split between early death and lost working days.⁶

The main pillars of acute ischaemic stroke treatment are stroke unit (SU) care^7,8 and treatments promoting reperfusion, namely intravenous thrombolysis (IVT)⁹ and endovascular treatment (EVT).¹⁰ These three interventions are highly effective in reducing mortality and morbidity. Although information on the implementation of these treatment strategies is crucial to guide any tailored measures, a single study with unified methodology designed to provide complete information for all European countries is unlikely to be feasible. In 2016, a task force of European associations representing professionals dedicated to stroke and patient organisations collected data on the access to and delivery of SU care, IVT and EVT in 44 countries in the European region.¹¹ The results of this study confirmed large disparities across Europe. Ten countries did not have at least one SU per million inhabitants, 15 countries had thrombolysis rates below 5% and the overall proportion of patients with acute ischaemic stroke treated with mechanical thrombectomy was less than 2%. Since then, large efforts have been made in several European countries in order to increase the access to acute stroke treatment. Of note, ESO and SAFE have started a programme for the implementation of the Stroke Action plan for Europe^12,13 and the ESO-EAST programme, dedicated to the improvement of stroke care in Eastern Europe countries also runs in parallel¹⁴ Moreover, the time-window for IVT and EVT has been extended, increasing the number of potentially eligible patients.⁹ In 2020, the coronavirus disease 2019 (COVID-19) pandemic placed an unprecedented burden on health systems, thus threatening their ability to operate effectively for acute conditions such as cerebrovascular disorders.^15,16

To better allocate resources to deal with stroke burden in Europe, it is crucial to identify the evolution of these metrics of delivery of acute stroke care, track the persisting asymmetries, and correctly identify the most vulnerable areas. Therefore, the European Stroke Organisation (ESO) together with the European Academy of Neurology (EAN) and the European Society of Minimally Invasive Neurological Therapy (ESMINT) and the Stroke Alliance for Europe (SAFE) surveyed the access to and delivery rates of acute SU care, IVT and EVT throughout Europe in 2019 and 2020.

 

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