Presentation, Evaluation, Management, and Outcomes of Acute Stroke in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

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.