6.

Priority diseases and reasons for inclusion

6.6 Acute stroke

See Background Paper 6.6 (BP6_6Stroke.pdf)

Background

A stroke is caused by either a sudden reduction in the blood supply to the brain or by a
haemorrhage. An acute stroke refers to the first 24-hour-period of a stroke event. Most
strokes (87%) are ischaemic (caused by thrombosis or embolisms) and the rest (13%)
are haemorrhagic (caused mainly by rupture of blood vessel or aneurysm).1 Eight to
twelve per cent of ischaemic strokes and 37% to 38% of haemorrhagic strokes result in
death within 30 days.2,3,4 Within the European Union, hospital discharges for cerebro-
vascular diseases almost doubled during the last 15 years of the twentieth century. It is
projected that in the coming years the major increase in the global stroke burden will
be in low- and middle-income countries.

Stroke is the second leading cause of disability in Europe after ischaemic heart disease
(IHD) and is the sixth leading cause worldwide (See Background Paper 6.6, Table
6.6.7). Women have a higher lifetime risk of stroke than men: about one in five women
(20% to 21%) and one in six men (14% to 17%) will suffer a stroke in their lifetime,
according to a 2006 study.5,6 The prevalence of stroke events is expected to increase
across the globe as the global population aged over 65 increases.7,8 The number of
stroke events in Europe is projected to rise from 1.1 million in 2000 to 1.5 million per
year by 2025, largely due to the ageing population.9 In the EU27 countries, the annual
economic cost of stroke is an estimated 27 billion: 18.5 billion (68.5%) for direct costs
and 8.5 billion (31.5%) for indirect costs. An additional 11.1 billion is calculated for
the value of informal care.10

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Priority Medicines for Europe and the World 2013 Update

Figure 6.6.1: Projected trends for stroke deaths by World Bank income group 2002-30

Source: Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the world.
Lancet Neurol, 2007, 6:182-187.11

The successful management of acute stroke is based on imaging such as magnetic

resonance imaging (MRI) and computerized tomography (CT) followed by two main
strategies: vascular recanalization and supportive care. The restoration or
improvement of perfusion to the ischaemic area is a key therapeutic strategy.
Secondary prevention strategies that reduce the rate of ischaemic stroke reoccurrence
include aspirin and dipyridamole.12 Current stroke therapy is mainly based on general
care and rehabilitation. The main modifiable risk factors for stroke prevention are high
blood pressure, diabetes, smoking, and heavy alcohol use. 13,14

Developments since 2004

Since 2004, there has been little progress in the R&D of medicines for treating acute
stroke (particularly in the field of neuroprotection) and surprisingly low levels of
funding for this only 10% of the investments in medicines R&D for IHD or cancer
over the past 30 years.

Several large-scale, EU-funded projects established under the EC Seventh Framework

Programme (FP7) are currently under way, and will provide further insight into the
future of stroke care.15

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 6. Priority diseases and reasons for inclusion

Remaining challenges

Despite improvements in care, the sequelae of stroke remain a major problem. While
50% to 70% of those who survive an ischaemic stroke will recover functional
independence within three months of onset, 20% will require institutional care. The
economic impact of stroke care goes beyond the costs of sophisticated acute care, and
includes costly secondary prevention (carotid endarterectomy) and the high cost of
prolonged high-dependency institutional chronic care and rehabilitation. Neither
mortality rates nor hospital discharge rates accurately reflect the level of disability
among stroke survivors, which is mainly borne by patients and their families.16

Major improvements are needed in the chain of care for identification of stroke by
relatives (education); early treatment (possibly with aspirin); the prompt referral to an
accident and emergency facility (mobile units); accurate diagnosis and fast appropriate
treatment (protocols and specialized units); improved access to expanded and more
efficacious therapeutic options; and prompt referral to rehabilitation services.

Meanwhile stroke research remains severely underfunded, despite its high burden
both in Europe and worldwide.

Research needs

Priority research topics

A breakthrough therapy has yet to be approved and there are still no highly
effective acute therapies available. Research for more efficacious therapeutic
options to prevent stroke sequelae are crucially needed. This includes the use of
stem cells, and the search for new neuroprotective agents. Promising research is
being done in the areas of hypothermia (therapeutic cooling), stem cell therapies,
and a polypill for secondary prevention of stroke.
More clinical trials that focus on the elderly and patients with comorbidities are
needed.
Due to lack of advancement in pharmaceutical treatments for acute stroke, there
should be an emphasis on prevention and improving health approaches such as
specialized stroke units.

References

1 Donnan GA, Fisher M, Madeod M, Davis SM. Stroke [Seminar]. Lancet, 2008, 371:1612-23.

2 Rosamond WD et al. Stroke incidence and survival among middle-aged adults: 9-year follow-
up of the Atherosclerosis Risk in Communities (ARIC) cohort. Stroke, 1999, 30:736-43.

3 Woo D et al. Incidence rates of first-ever ischemic stroke subtypes among blacks: a population-
based study. Stroke, 1999, 30:2517-22.

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Priority Medicines for Europe and the World 2013 Update

4 Roger VL, Go AS, Lloyd-Jones DM et al. Heart Disease and Stroke Statistics2012 Update: A
Report From the American Heart Association. Circulation, 2012, 125:e2-e220

5 The Top Ten Causes of Death- Fact Sheet No. 310. Geneva, World Health Organization, 2011.

6 Seshadri S et al. The lifetime risk of stroke: estimates from the Framingham Study. Stroke, 2006,
37:345350.

7 Rothwell PM et al. Change in stroke incidence, mortality, case-fatality, severity, and risk
factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet, 2004, 363:1925-
33.

8 Mukherjee D and Chirag PG. Epidemiology and the Global Burden of Stroke World Neurosurg,
2011, 76, 6S:S85-S90.

9 Truelsen T, Piechowski-Jozwiak B, Bonita R et al. Stroke incidence and prevalence in Europe: a

review of available data. European Journal of Neurology, 2006, 13: 581598.

10 British Geriatrics Society. Human and economic burden of stroke. Age and Ageing, 2009, 38: 4
5.

11 Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the world. Lancet
Neurol, 2007, 6:182-187.

12 Diener HC et al. European stroke prevention study. 2. Dipyridamole and acetylsalicylic acid
in the secondary prevention of stroke. J Neurol Sci, 1996, 143: 113.

13 Montagu A, Reckless IP, Buchan AM. Stroke: management and prevention. Medicine, 2012,
(40)9, 490-499.

14 The World Health Report 2002: Reducing risk, promoting healthy life. Geneva, World Health
Organization, 2003.

15 Community Research and Development Service (CORDIS). Seventh Framework Programme.

Available at http://cordis.europa.eu/fp7/understand_en.html. Accessed Nov 14, 2012.

16 British Geriatrics Society. Human and economic burden of stroke. Age and Ageing 2009; 38: 4
5.