Tamer Roushdy

Background: Telestroke services represent a crucial strategy for expanding access to acute stroke care in regions with limited local stroke expertise. However, existing recommendations and guidelines are predominantly derived from evidence generated in high-income countries and based on generally resource-intensive models. Such models and evidence may not be directly transferable to resource-limited settings. This Scientific Statement aims to summarize current knowledge on telestroke in resource-limited settings, highlight key considerations for establishing networks, and provide practical recommendations to guide future implementation and research. Methods: Evidence from a systematic literature review of telestroke networks in resource-limited settings was integrated with results of a structured survey and consensus-building process involving the World Stroke Organization (WSO) Telestroke Committee, who also served as the writing panel. Key domains relevant to the organization, setup, and quality assurance of telestroke services were identified and synthesized into pragmatic, context-sensitive recommendations. Results: The panel defines telestroke as a model of care that includes hyperacute decision-making but also extends toward comprehensive stroke unit support. Recommendations are structured around essential and advanced components, covering organizational setup, technical requirements, clinical workflows, and quality assurance. Emphasis is placed on pragmatic, minimum viable solutions, suggesting adaptable technical configurations, standardized operating procedures, and feasible quality-monitoring frameworks. Conclusion: This statement provides practical guidance to support the safe and feasible implementation of telestroke services across diverse resource settings. Future research should focus on defining minimum effective models, evaluating individual components of telestroke systems, and addressing economic, regulatory, and cross-border implementation challenges. This scientific statement has been reviewed and approved by the WSO Executive.

Background: Intravenous thrombolysis (IVT) for acute ischemic stroke in the Middle-East and North African (MENA) countries has increased in the last decade, but long-term outcomes and quality of care are less well studied. Methods: This was a prospective observational study to examine 3-month outcomes of IVT-treated patients in MENA stroke units using the SITS Registry. Findings: There were 2768 patients in MENA and 7163 patents in non-MENA treated with IVT and registered in SITS between August 2021 and September 2023. Compared to non-MENA, MENA patients were younger (65 vs 72 years-old), had higher NIH Stroke Scale scores at baseline (11 vs 9) and shorter door-to-needle times (30 vs 54 min). The most common risk factors in MENA were hypertension (64.9 vs 69.8 %) and diabetes (30.8 vs 20.1%). Functional independence at 3 months was similar (56.6% vs 57.7%); however, mortality at 7 and 30 days was significantly higher in MENA (8.3% vs 5.3% and 20.7 vs 14.5%). Symptomatic intracranial hemorrhage rates were low in both groups (<1.2% per SITS-MOST). Early mortality rates related to stroke were comparable (56.7 vs 59.2%) but early deaths caused by myocardial infarction, pneumonia, pulmonary embolism and sepsis were more frequent in MENA (14.2 vs 4.6%, 6.7 vs 4.6%, 1.5 vs 0.4% and 3 vs 1.8%). Interpretation: The overall mortality of IVT-treated patients was increased in MENA at 7 and 90 days post-stroke. Differences in risk factors at baseline may account for mortality but the treatment of medical complications in MENA stroke units warrants further study.

Background: It is estimated that 30% of acute stroke patients present with aphasia. Thus, proper analysis of aphasia through a valid and culturally adapted scale seems mandatory. The Western Aphasia Battery is a well-recognized scale used universally to assess aphasia. It has an edge over other scales in its ability to grade the severity of aphasia and classify it into different forms. The current study aims to develop a culturally adapted Cairene Egyptian Arabic version of form one of the Western Aphasia Battery—Revised (CEA-WAB-R) to fit Arabic-speaking aphasic patients. Results: A total of 40 cases and 60 controls matched for age, sex, and education were subjected to the adapted version. The psychometric properties of the scale showed very high specificity and sensitivity, proper internal consistency, and inter-rater and test–retest reliability. Conclusion: The developed CEA-WAB-R form one is valid and suitable to be used on Arabic-speaking aphasic patients.

In this chapter, we outline the trends in incidence, prevalence, and the burden of stroke in developing countries (lower- and middle-income countries—LMICs) over recent decades. We highlight the changes in risk factors and types of stroke (ischemic vs. hemorrhagic) in LMICs, comparing them to high-income countries (HIC). We will also use statistics from specific countries as case examples. The lack of resources and its impact on stroke management will be discussed. The authors include stroke physicians who are part of the World Stroke Organization Future Leaders Program and have carried out quality improvement projects in Sub-Saharan Africa, among other initiatives.

Background: Awareness about stroke symptoms and management is an important and pivotal step in any stroke service as it will positively affect onset to door, which will affect rates of thrombolysis and thrombectomy, reduce mortality, and improve outcomes. The current study aimed to explore public knowledge about acute stroke in Egypt and how it is dealt with. Methods: A cross-sectional observational survey-based study was conducted throughout 6 months starting from May 2023. An online Google form was disseminated via WhatsApp and different social media services assessing the public and healthcare professionals’ awareness about stroke symptoms, risk factors, how, where, when, and who to deal with it. Results: 2109 submissions were received. Mean age was 34.3 (± 11.8). Females represented 67.4%. Health care professionals were 12.8%. Participants with a close family history of stroke were 29.2%. Less than half of the responders gave correct answers to most of the questions. Hypertension was the only risk factor to get a consensus higher than 50%, while only 27% recognized diabetes as a risk factor. Only 14.1% realized the term ‘transient ischemic attack’ yet, 68.2% agreed upon seeking medical advice if encountered. 50.2% defined a neurologist as the one to deal with stroke. Healthcare professionals’ answers were more accurate yet still deficient in the time window, route of administration of thrombolytic therapy, and specialty to deal with stroke. Conclusions: This study throws light on the lack of awareness about stroke that ought to be properly dealt with so as to reflect on stroke thrombolysis rates, management and outcome.

Background: As one of the most common non-communicable diseases in Africa, Stroke ought to be dealt with properly with intensifying efforts to control its burden and to face obstacles in its management. Methods and Results: In this follow-up study we reanalyzed stroke services and related obstacles in 17 African countries that were previously studied in 2021/22 in aspects related to manpower, acute stroke services, rehabilitation programs, number of stroke units/centers, telestroke services, awareness campaigns, and national and international stroke registries through a survey that was sent to stroke specialists and national stroke societies. Overall, there is an improvement in many fields yet many obstacles in the implementation of telestroke services, acute management, secondary prevention, post-discharge services, and follow-ups whether governmental, medical, or societal are prevalent. Conclusion: Stroke services in Africa are improving in 2024 compared to 2021/22 in many fields, stationary in some fields, and regressing in a few. Managing obstacles that are raised by stroke specialists collectively and on individual countries basis will pave the way for better services for the wellness of stroke victims in Africa.

Background: Stroke is one of the commonest encountered brain and neurological disorders worldwide. Stroke management has had a major shift in the last 50 years and precisely since the discovery and approval of thrombolysis as an acute management followed by multiple trials on mechanical thrombectomy and its approval. Yet, Stroke is as old as the history of mankind. Historically stroke symptoms’ description is older than the descriptions of the Greco-Roman civilization (500 BC – 800 AD). Before Stroke, the term apoplexy was described in ancient civilizations and evidence of suffering and managing it is preserved within the mummies, inscriptions, and papyri of the Egyptian civilization, clay tablets of the Mesopotamian civilization, medical books of the Chinese civilization, and although physicians and scientists consider the Greco-Roman civilization the base for modern medicine, yet the golden age of Islam (800 – 1200 AD) might have shared more in identifying bases of stroke. The European Renaissance beginning from 1400 AD with its famous anatomists and physicians greatly contributed too to stroke localization and vascular supply. Conclusions: As medicine and science are in a continuous chain from the past to the future through the present, the current comprehensive review highlights the major important and documented shifts in the history of stroke over more than 4500 years starting from ancient civilizations BC up to 2024 AD.

Objective Pain is one of the most common nonmotor symptoms in Parkinson’s disease (PD), with variable characteristics among populations. This multicenter Egyptian study aimed to translate and validate the King’s Parkinson’s Disease Pain Scale (KPPS) and Questionnaire (KPPQ) into Arabic versions and to investigate the pain characteristics in Egyptian people with PD (PWP).Methods A total of 192 PWP and 100 sex- and age-matched controls were evaluated by the KPPS-Arabic and KPPQ-Arabic. Both tools were assessed for test–retest reliability, floor or ceiling effects, construct validity and convert validity. PWP were also assessed by the Movement Disorders Society-Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), Hoehn and Yahr scale (H&Y), Non-Motor Symptom Scale (NMSS), PD Questionnaire-39, and Non-Motor Fluctuation Assessment (NoMoFA).Results The KPPS-Arabic and KPPQ-Arabic showed inter- and intrarater consistency and high validity, with an acceptable ceiling effect. A total of 188 PWP (97.9%) reported at least 1 type of pain (p < 0.001). The severity and prevalence of all pain domains in the KPPS-Arabic were significantly higher among PWP than among controls (p < 0.001). Fluctuation-related and musculoskeletal pains were the most common (81.3% and 80.7%, respectively). In the PD group, the total and domains of KPPS-Arabic were significantly correlated to the MDS-UPDRS total score and the scores of Parts I, II, III, postural instability gait disorder, axial, and H&Y but not with age or age of onset. The predictors of KPPS-Arabic scores included the total MDS-UPDRS, the part III-OFF, disease duration, the total NMSS, and the NoMoFA scores.Conclusion The current multicenter study provided validated Arabic versions of the KPPS and KPPQ, which exhibited high reliability and validity, and demonstrated a high prevalence and severity of pain within Egyptian PWP and characterized its determinants.

Background: The global incidence of stroke is on the rise, primarily due to an increase in the aging population and the prevalence of vascular risk factors among the elderly. However, stroke is a treatable condition if promptly recognized and managed effectively. To optimize stroke management, it is crucial to establish a well-prepared infrastructure comprising adequately trained physicians working in collaboration with multidisciplinary teams. Equipped stroke units, easily accessible emergency medical services with a stroke code, and interconnected telestroke networks, further enhance stroke care delivery. Along with the current study, conducted by a task force from the World Stroke Organization’s Future Stroke Leaders Program, an assessment of the stroke infrastructure within Matrouh governorate in Egypt for stepwise implementation of stroke services, based on the World Stroke Organization’s stroke roadmap took place. The study consisted of two levels: Level One involved analyzing existing gaps that may impede the implementation of stroke services, while Level Two proposed strategies to address these gaps using a problem-solving approach. Results: The study identified the Matrouh governorate as a suitable region for stroke service implementation. The region exhibits a blend of urban and rural areas and is geographically distant from major healthcare centers. Matrouh also possesses a diverse population, subject to seasonal variations. Currently, it offers a mix of minimum and essential stroke services, which can be expanded and improved through a step-by-step approach guided by the World Stroke Organization’s stroke roadmap. Conclusions: Mapping stroke infrastructures allows for the identification of potential gaps to optimize the potential for implementation of stroke services.

Prof. Hany M. Aref (February 21, 1961–July 26, 2023), MD, Ph.D., was a Fellow of the American Academy of Neurology and the European Stroke Organization. He was a member of the European Academy of Neurology, vice president of MENA Stroke, and a Professor of Neurology at the Faculty of Medicine, Ain Shams University (ASU), Cairo, Egypt.He earned his medical degree from ASU in 1983, followed by his MD and Ph.D. in 1993. In 2003, he ascended to the position of a full professor, and in 2018, he was appointed the head of the Neuropsychiatry Department at the Faculty of Medicine, ASU.Known as the godfather of stroke in Egypt, Prof. Aref was a beacon of leadership, setting an example and mentoring many. His unwavering passion for achieving the highest standards of care inspired an entire generation. His wisdom will forever be imprinted in his students’ hearts and souls. He had a remarkable vision of transforming stroke services in Egypt, investing all his energies to realize it. Alongside his professional accomplishments, he was renowned for his extensive knowledge, as well as loving to run and participate in local marathons.Recognizing the importance of sub-specialty, he pioneered the idea of specialization after taking over the neurology department in 2018. Consequently, the rate of our international publications increased exponentially in vascular neurology, many of which were featured in high-impact peer-reviewed journals [1].Early in his career, Prof. Aref’s mother suffered a stroke when thrombolysis was unavailable in Egypt. This perhaps was the main motive that drove him to revolutionize stroke services nationwide.His enthusiasm ignited a spark that propagated all over Egypt. He was instrumental in establishing new stroke units and amplifying the reputation of vascular neurology in Egypt on international platforms. Notably, he was pivotal in persuading the Ministry of Health (MOH) to endorse intravenous thrombolysis and mechanical thrombectomy [2, 3].As the national coordinator for the safe implementation treatment for stroke, he motivated ASU stroke units and many other universities to initiate their databases, whether the safe implementation treatment for stroke or the registry of Stroke Care Quality (RES-Q). In August 2019, with his guidance and active participation, the two-stroke units of ASU hospitals earned the distinction of being the first in Egypt and Africa to receive international accreditation from LGA Germany [1].Through his wide communications, international figures became frequent speakers and chairpersons at neurology conferences in Egypt. In 2021, he embarked on a visionary project: constructing a state-of-the-art stroke unit at the ASU hospital. This unit boasts 27 beds and a built-in Angio suite. With the supportive administration by his side, he raised funds exceeding 100 million EGP, with the inauguration planned for September 5, 2023.Unfortunately, Prof. Aref suddenly passed away before he could fulfill his dream of opening the new stroke unit at ASU Hospital. The passing of Prof. Hany Aref has left a profound void in the hearts of many. As we reflect on his legacy, the words of those who knew him best resonate with the impact he made in their lives and in the field of neurology:Nevine El NahasHala El-KhawasAhmed Elbassiouny & Intervention teamTamer RoushdyHossam ShokriEman HamidMai FathyEman Abushady & Fatma KenawyNoha DawoodHe used to say: “The sky is our limit,” and “Keep the good job you are doing” so we will follow his path and realize his vision.Stroke Unit TeamWe would like to thank Ana Claudia de Souza for her efforts and support on this obituary to be submitted to Cerebrovascular Diseases.The authors have no conflicts of interest to declare.The authors declare that no financial support was received.All authors contributed equally in drafting, writing, and revising the content of this obituary.