BACKGROUND: Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization-World Health Organization-Lancet Neurology Commission on Stroke conducted a survey of the status of stroke services in low and middle-income countries (LMICs) compared to high-income countries. METHODS: Using a validated World Stroke Organization comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across World Health Organization regions and economic strata. The World Health Organization also conducted a survey of non-communicable diseases in 194 countries in 2019. RESULTS: Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys, and participation in research) were reported in low-income countries than high-income countries. The overall global score for prevention was 40.2%. Stroke units were present in 91% of high-income countries in contrast to 18% of low-income countries (p < 0.001). Acute stroke treatments were offered in ∼ 60% of high-income countries compared to 26% of low-income countries (p = 0.009). Compared to high-income countries, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol. CONCLUSIONS: There is an urgent need to improve access to stroke units and services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.

Center for Genomic and Precision Medicine College of Medicine University of Ibadan Nigeria

Christian Medical College Ludhiana Punjab India

Department of Clinical Sciences Lund University Sweden

Department of Neurology Kasr Alainy School of Medicine Cairo University Cairo Egypt

Department of Neurology Monash Health and School of Clinical Sciences Monash University Melbourne Australia

Department of Neurology University College Hospital Ibadan Nigeria

Epidemiology and Prevention Division Stroke and Ageing Research School of Clinical Sciences Monash University Melbourne Australia

Hospital de Clínicas de Porto Alegre Universidade Federal do Rio Grande do Sul Hospital Moinhos de Vento and Brazilian Stroke Network

International Clinical Research Center and Neurology Department of St Anne's University Hospital and Masaryk University Brno Czech Republic

Loma Linda Hospital Murrieta CA USA

Menzies Institute for Medical Research University of Tasmania Australia

National Institute for Stroke and Applied Neurosciences School of Clinical Sciences Auckland University of Technology New Zealand

Non communicable Disease Department World Health Organization Geneva Switzerland

Nossal Institute of Global Health University of Melbourne Australia

NUI Galway Health Research Board Clinical Research Coordination Galway Ireland

Peninsula Clinical School Monash University and Developmental Imaging Group Murdoch Children's Research Institute Melbourne Australia

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