Aims: We performed a systematic review to evaluate stroke presentation, evaluation, management, and outcomes among studies conducted in low- and middle-income countries (LMIC). Methods: We searched MEDLINE (Ovid), Embase (Elsevier), and the Global Health (EBSCOhost) databases between January 2005 and June 2017 for studies conducted in LMICs defined by the World Bank. We pooled prevalence estimates using an inverse-variance weighting method and stratified by the country income group. Results: The search identified 36 hospital-based studies (64,256 participants) in LMICs. Mean (SD) age ranged from 51 (14) to 72 (12) years, and 29–56% of patients were women. Hypertension was the most commonly reported risk factor (64% [95% CI 59–69]). In settings where MRI was not used, head CT scans were reported among 90% patients (95% CI 79–97). Overall, 3% (95% CI 2–4) of patients were treated with tissue plasminogen activator, and 78% (95% CI 66–88) were treated with antiplatelet therapy. Overall, the rate of in-hospital mortality was 14% (95% CI 10–19), and the rate of in-hospital pneumonia was 17% (95% CI 14–20). Conclusions: Our review revealed the low use of evidence-based practices for acute stroke care in LMIC. The true use in hospitals that do not conduct this research is probably even lower. Strategies to evaluate and improve health system performance for acute stroke care, including implantation of stroke units and making thrombolysis more available and affordable are needed in LMIC. Registration in Prospero: CRD42017069325.

Objective To describe the difference in clinical presentation, including race, of ischemic stroke between patients with and without novel coronavirus disease 2019 (COVID-19), and the association of inflammatory response with stroke severity. Methods This is a retrospective, observational, cross-sectional study of patients (n ​= ​60) admitted with ischemic stroke between late March and early May 2020. All patients were tested for COVID-19 during admission. Demographic, clinical, and laboratory data was collected through electronic medical record review. Descriptive statistics was performed to observe the differences between stroke patients with and without COVID-19 Results 60 hospitalized patients with acute ischemic stroke were included in the analysis. Nine were positive for COVID-19. African-Americans comprised of 55.6% of those that had COVID-19 and stroke and 37.7% of those with only stroke. Stroke patients with COVID-19 had a significantly higher NIHSS [18.4 (8.8)] and neutrophil-to-lymphocyte ratio (NLR) [7.3 (4.2) vs 3.8 (2.8); P ​= ​0.0137] than those without. Those with COVID-19 also had a significantly higher mortality rate (44.4% vs. 7.6%; p ​< ​0.001). Conclusion We observed a cohort of patients, including a large proportion of African-Americans, who developed ischemic stroke with or without COVID-19. An exaggerated inflammatory response, as indicated by NLR, likely plays a role in stroke severity among COVID-19 patients that concurrently develop ischemic stroke.

Background Ischemic stroke can impact a patient's quality of life, but the extent is unknown. Objective To evaluate the association between gait measures during inpatient rehabilitation with quality‐of‐life scores and function at 3 months in patients with stroke. Setting Single‐Center inpatient rehabilitation facility. Participants Eight five patients with ischemic stroke. Methods A 6‐Minute Walk Test and a 10‐Meter Walk Test were recorded on admission to rehabilitation. We analyzed the association between gait function at rehabilitation and 3‐month quality of life and poor functional outcome (modified Rankin Scale score >2) using multivariable logistic regression. Main Outcome Measures 3‐month health related quality of life. Results Eighty‐five patients (mean age 68.3 14.9 years; 54.3% male) were enrolled. In adjusted analyses, an increase of 0.31 m/s (ie, 1 SD) on the 10‐meter walk test was linked with a decreased odds of impaired lower extremity quality of life by 94% (odds ratio [OR] 0.06, 95% confidence interval [CI] 0.01–0.52; P =.01), and decreased odds of poor functional outcome by 98% (OR 0.02, 95% CI <0.01‐0.47; P =.01). For the 6‐minute walk test, an increase of 109.5 meters (ie, 1 SD) was linked with decreased odds of having impaired lower extremity quality of life by 1% (OR 0.99, 95% CI 0.98–1.00; P < .01) and poor functional outcome by 1% (OR 0.99, 95% CI 0.99–1.00; P = .04). Conclusion Gait measurements at rehabilitation can predict 3‐month lower extremity quality of life and function

Major advances have been made during the past few decades in stroke prevention, treatment, and rehabilitation. These advances have been translated into practice in many high-income countries, but their uptake remains suboptimal in low- and middle-income countries. The review highlights the resources required to providing optimal acute stroke care in settings with limited resources. These resource levels were divided into minimal, essential, and advanced resources depending on the availability of stroke expertise, diagnostics, and facilities. Resources were described for the three stages of acute care: early diagnosis and management, acute management and prevention of complications, and early discharge and rehabilitation. Barriers to providing acute care at each of these stages in low- and middle-income countries are reviewed, explaining that some barriers persist in essential or advanced settings where some aspects of organized stroke units are available.

BACKGROUND AND PURPOSE:The effect of white matter hyperintensities as measured by FLAIR MR imaging on functional impairment and recovery after ischemic stroke has been investigated thoroughly. However, there has been growing interest in investigating normal-appearing white matter microstructural integrity following ischemic stroke onset with techniques such as DTI.MATERIALS AND METHODS: Fifty-two patients with acute ischemic stroke and 36 without stroke were evaluated with a DTI and FLAIR imaging protocol and clinically assessed for the severity of motor impairment using the Motricity Index within 72 hours of suspected symptom onset.RESULTS: There were widespread decreases in fractional anisotropy and increases in mean diffusivity and radial diffusivity for the acute stroke group compared with the nonstroke group. There was a significant positive association between fractional anisotropy and motor function and a significant negative association between mean diffusivity/radial diffusivity and motor function. The normal-appearing white matter ROIs that were most sensitive to the Motricity Index were the anterior/posterior limb of the internal capsule in the infarcted hemisphere and the splenium of the corpus callosum, external capsule, posterior limb/ retrolenticular part of the internal capsule, superior longitudinal fasciculus, and cingulum (hippocampus) of the intrahemisphere/ contralateral hemisphere. CONCLUSIONS:The microstructural integrity of normal-appearing white matter is a significant parameter to identify neural differences not only between those individuals with and without acute ischemic stroke but also correlated with the severity of acute motor impairment. ABBREVIATIONS: AD 4 axial diffusivity; ADC 4 apparent diffusion coefficient; DTI 4 diffusion tensor imaging; DWI 4 diffusion-weighted imaging; FA 4 fractional anisotropy; InfHem 4 infarcted hemisphere; IQR 4 interquartile range; NAWM 4 normal-appearing white matter; MD 4 mean diffusivity; RD 4 radial diffusivity; WMH 4 white matter hyperintensities