Stroke care in MENA: challenges, progress, and promising pathways

Sep 23, 2023

By Praseeda Nair | May 29, 2023

The personal cost of a stroke is immeasurable, as anyone who has lost a loved one or knows a survivor can attest. The devastating effects of stroke can include loss of mobility, impaired brain function and communication, chronic fatigue, depression, and memory loss. This year alone, 12.2 million people worldwide are projected to have their first stroke, and 6.5 million will die as a result. These sobering statistics emphasise the importance of preventive measures, early detection, effective treatment, and rehabilitation services in addressing the global impact of stroke.

Stroke also comes at a financial cost that affects more than just patients and their immediate support networks. Beyond lost wages and out-of-pocket expenses incurred by stroke survivors and their families, there is also the wider economic cost that inhibits sustainable development in markets already grappling with the complexities of delivering primary health care. Annually, the cost of stroke treatment, rehabilitation, and indirect expenses is estimated to exceed US$700 billion. If current trends persist, the economic impact of stroke on a global scale is conservatively set to exceed US$1 trillion by 2030.

Related: Updated guidelines make stroke management easier

Public health initiatives, investment in stroke care infrastructure, advancements in medical technology, and research efforts are crucial in reducing the burden of stroke on global healthcare systems and improving patient outcomes. Globally, the estimated return on investment for every US$1 spent on preventing stroke and cardiovascular disease is US$10.90. The global stroke diagnostic and therapeutic market size was valued at US$32.69 billion in 2021 and is predicted to hit over US$65.45 billion by 2030. In the Middle East, the stroke diagnostics market is expected to reach US$222.27 million by 2028.

In the United Arab Emirates, between 8,000 and 10,000 individuals experience a stroke each year. Globally, 80 per cent of stroke victims are aged 65 or older, but in the UAE, nearly 50 per cent of stroke patients are under the age of 45.

Related: Atrial Fibrillation: A silent condition that increases risk of stroke by five times

"According to the World Health Organization, one in four people runs the risk of having a stroke in their lifetime. In the UAE, about 25 per cent of adults have hypertension, which puts our population at greater risk of having a stroke," says Dr. Khalil Zahra, Chief of Neuro-Interventional Surgery at the Neurological Institute of Cleveland Clinic Abu Dhabi. "Here, stroke is the leading cause of disability and the third leading cause of death. It has never been more crucial to have the most innovative technology available for treating patients."

Multiple high-tech examples abound: Saudi Arabia's Seha Virtual Hospital, which connects patients to a network of medical experts across 130 hospitals; SSMC Abu Dhabi's state-of-the-art angio suites; the UAE Ministry of Health and Prevention's (MoHAP) neurorehab center's virtual reality physiotherapy; and more. The region has made massive strides in using technology to speed up stroke detection and diagnosis in recent years.

"One thing about the MENA market is that they generally tend to adopt technologies very fast. Innovation is happening in leaps and bounds, so there are new systems, tools, and techniques every six months that continue to improve precision and quality," says Dr. Malathi Arshanapalai, Chief Medical and Quality Officer at Aster DM.

Investing in high-end equipment has an inherently high capex cost, so replacing it every six months is hardly feasible. In most cases, it's not required, she explains. When investing in precision care, Arshanapalai says that hospitals need to analyse what is in the best interest of the patients. "Every institution should consider a financial study that looks at precision, quality, and speed. Of course, the technology also has to be affordable for patients, so it depends on the numbers. Weighing the pros and cons and bearing in mind the speed with which you can diagnose (conditions) accurately should be the prime criteria for investing in new technologies."

In 2022, Cleveland Clinic Abu Dhabi adopted the ARTIS Icono, an advanced stroke interventional system that works with 2D and 3D imaging and artificial intelligence to speed up diagnostics and treatment. With victims of ischemic stroke, the most common type of stroke, timing is crucial. Rapid diagnosis and immediate medical treatment administered in less than 60 minutes, known as the ‘golden hour’, can reduce the chances of further complications. "Typically, we aim for a maximum of about six hours from symptom onset to perform a neuro-thrombectomy, a procedure that dissolves the clot in a patient's brain," adds Zahra.

Traditional stroke intervention begins with a CT scan, and surgeons manually study the data before operating to break the blood clot. Using AI to provide high-resolution medical imaging for greater visibility, surgeons can immediately start treatment without needing a CT scan.

"Improving the visualisation of bleedings that occur anywhere in the cranial area can make it possible to skip prior conventional imaging for certain patients with a suspected stroke, which means that these patients can be taken directly to the angio lab for diagnosis and treatment, shortening the lead time before the vascular occlusion is removed," says Michael Scheuering, Head of Interventional Radiology at Siemens Healthineers, the company behind ARTIS Icono. "Any time saved in treating strokes can mean the difference between living independently and living in a wheelchair."

Computer-orchestrated thrombectomy is another ground-breaking advancement in the treatment of stroke. California-based health tech firm Penumbra developed the Lightning Flash mechanical thrombectomy system to remove venous and pulmonary clots more quickly and safely than earlier tools. For improved clot removal speed while still minimising blood loss, the most recent version now has two algorithms—one for pressure and one for flow. The company aims to break US$1 billion in annual revenue for the first time in 2023 with its slated launch of more computer-aided aspiration products for arterial clots and ischemic strokes. Currently, this technology is only available in the US and Europe, but it has potential in the Middle East as an early adopter of medtech.

Over 80 per cent of current stroke cases are preventable by lifestyle adjustments, says Dr. Suhail Abdulla Al Rukn, Neurology Consultant and Stroke Specialist, and President of the Middle East Stroke Management Organization. The first step in taking preventative action against stroke is to identify the risk factors, which may include rising diabetes, hypertension, and a high body mass index. The increased prevalence of these diseases causes several complications, such as atrial fibrillation, irregular blood flow, and a propensity for blood clotting, which calls for immediate detection and treatment to reduce the likelihood of stroke occurrence.

A stroke happens when there is an interruption or reduction in the blood flow to a specific area of the brain, depriving the brain's tissue of oxygen and nutrients. Brain cells start to degenerate within minutes. The most prevalent cardiac arrhythmia (irregular heartbeat) is atrial fibrillation (AF), which also has a significant impact on stroke risk. Blood can accumulate in the atria, the upper chambers of the heart, and cause blood clots when atrial fibrillation is present. If a blood clot forms, it may move from the heart to the brain, blocking blood flow and leading to a stroke.

"To address this, the medical community focuses on making the right choice for patients when it comes to stroke prevention through the use of oral anti-coagulants (blood thinners), which are used to treat atrial fibrillation. Studies have shown that anticoagulation can result in a 64 per cent reduction in strokes," says Al Rukn.

Developing dedicated stroke care centres will directly lead to faster and better patient outcomes, says Al Rukn. "Having such centres will decrease the mortality rates, complications, and outcomes of stroke. This is because patients lose about 120 million brain cells within one hour of suffering from a stroke incident. The underlying aim here is to deliver the right patient to the right medical facility in the right time frame." Within two years since its implementation, Rashid Hospital has succeeded in reducing the door-to-needle time frame from 95 minutes to 35 minutes, says Al Rukn.

Accessibility is crucial in the race against the clock, so implementing stroke units within hospitals has the potential to reduce the burden of stroke disability and ensure that lives are not lost as a result of not being able to reach the nearest center on time. The global benchmark for thrombolysis rates is an average of 18 to 20 per cent. This is where telestroke and mobile units have proven their success in increasing patient accessibility in urban areas. A four-year study by UTHealth demonstrates that stroke patients who are transported via a mobile stroke unit receive treatment 10 minutes faster than when they are transported via an ambulance.

Mobile stroke units can be dispatched to the scene, where a portable CT scanner can image the patient's brain, providing immediate results to determine the course of treatment. The growing elderly population and the increasing prevalence of stroke conditions such as transient ischemic attacks are expected to drive the mobile stroke unit market, which is expected to reach $12.8 billion by 2027. However, current adoption is still limited globally by driving distances, times of operation, and worldwide availability.

A multistakeholder study by the World Stroke Organization, World Health Organization, and Lancet Neurology Commission on Stroke reviewed the status of stroke services in low and middle-income countries (LMICs) compared to high-income countries. Of the 84 countries surveyed, seven in the Middle East scored higher than the global average for stroke prevention, acute care, and rehabilitation.

However, one size doesn't fit all when it comes to stroke care, especially in a region as diverse as the Middle East and North Africa with varying degrees of market maturity for stroke care. In order to improve stroke care and establish accreditation for existing programmes in the region, experts are calling for greater regional and international cooperation.

Governments in the GCC region prioritise public health, including stroke prevention and awareness campaigns, says Dr. Zemer Wang, Medical Director at Aviv Clinics Dubai. He also credits the GCC's diverse workforce as a boon for stroke care. "This expertise (in stroke care) facilitates the exchange of knowledge, best practices, and innovative approaches to stroke management," he adds.

In addition to stakeholder engagement and public awareness programs, establishing prospective registries and databases could provide valuable insights into the current state of prevention and acute stroke services in the region. "The GCC countries often collaborate on healthcare initiatives, including stroke care," Wang explains. "They develop region-specific guidelines, protocols, and quality standards for stroke management to ensure consistent and high-quality care across the region."

In 2013, a group of strokeologists and neurointerventionalists came together to improve ischaemic and hemorrhagic stroke services in the region, founding the Middle East and North Africa Stroke and Interventional Neurotherapies Organization (MENA-SINO). In addition to providing education, endovascular thrombectomy training, and awareness for stroke care providers, the group also conducts research to further locally-relevant solutions for reducing the burden of stroke on the region's healthcare systems while building a database of stroke diagnoses to learn from.

These initiatives can help gather comprehensive data on stroke cases, treatment outcomes, and quality indicators, says Aster DM's Arshanapalai. "It's about knowledge exchange, best practice sharing, and capacity building. This can contribute to standardising stroke management protocols, implementing evidence-based guidelines, and enhancing the overall quality of stroke care in the MENA region."

The region is already an early technology adopter in stroke diagnosis, acute care, and rehabilitation, bolstered by supporting public healthcare spending and policies. A future area for growth is preventative stroke care, which starts with building public awareness. Increased awareness of stroke symptoms and the need for rapid admission to the hospital can improve patient outcomes. Stakeholders can advance this area of stroke care by working together, sharing resources, and fostering partnerships so that people are aware of the importance of getting care in the vital ‘golden hour'.

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