A Systematic Review of Stroke Unit Interventions in Low- and Middle-income Countries
Aisha Mahmood1, Mustafa Siddiqui3, Joel Collier4, Deanna Saylor2
1University of North Carolina-Chapel Hill School of Medicine, 2Department of Neurology, University of North Carolina-Chapel Hill School of Medicine, 3University of Maryland School of Medicine, 4Health Sciences Library, University of North Carolina-Chapel Hill
Objective:
Through a systematic analysis of existing practices and outcomes, we aimed to assess the effectiveness of stroke units (SUs) in improving outcomes for adults with acute stroke in low- and middle-income countries (LMICs).
Background:
Stroke is the second leading cause of mortality worldwide and a leading cause of disability. Despite significant reductions in stroke burden in high-income countries (HICs), outcomes remain disproportionately poor in LMICs. Organized inpatient stroke care delivered through SUs improves survival and functional recovery in HICs, yet their implementation in LMICs is limited.
Design/Methods:
Following PRISMA guidelines, we conducted comprehensive searches of PubMed, Embase, Scopus, Global Health, and Global Index Medicus. Eligible studies included adults with acute stroke treated in SU settings in LMICs and reported clinical outcomes such as survival, functional independence, or complications. Titles, abstracts, and full texts were screened in Covidence using predefined criteria. Study quality was assessed using the LEGEND critical appraisal tool. Data analysis is ongoing, with a focus on outcomes, barriers, and facilitators.
Results:
Our search yielded 1,358 unique titles and abstracts, of which 107 advanced to full-text review. Twenty-nine studies met inclusion criteria, representing SUs across 11 LMICs in Africa (n=4), Asia (n=17), North America (n=1), and South America (n=7). Preliminary findings from the studies suggest that SU interventions in LMICs are associated with improved functional outcomes, reduced in-hospital mortality, shorter lengths of stay, and higher rates of thrombolysis compared to general ward care. Common barriers included insufficient workforce training, lack of neuroimaging equipment, funding shortages, and limited rehabilitation access. Facilitators included structured care protocols, engagement of multidisciplinary teams, institutional policy support, and integration of SUs within existing hospital systems.
Conclusions:
SU care demonstrates potential for improving outcomes in LMICs, though gaps in resources and infrastructure remain. Further synthesis is underway to better characterize effectiveness and context-specific implementation challenges.
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