1. Neurologic disorders are the leading cause of disability (11.6% of global disability-adjusted life years [DALYs]) and the second leading cause of death worldwide (16.5% of the global burden of mortality).

2. The global burden of neurologic disease disproportionately affects low- and middle-income countries (LMIC) as compared to high-income countries (HIC).

1. There are on average 4.75 neurologists per 100,000 citizens of HIC, whereas there are on average only 0.03 neurologists per 100,000 citizens in low-income countries.

2. There are approximately 42 computed tomography (CT) scanners per 1 million population in HIC compared to approximately 0.32 per 1 million population in low-income countries. Even where neurodiagnostic tests are available in certain resource-limited settings, they are commonly inaccessible and/or unaffordable for many patients.

1. In 2019, there were an estimated approximately 12.2 million strokes, 6.55 million deaths caused by stroke, and 143.2 million DALYs due to stroke, making stroke the second leading cause of death and third leading cause of disability worldwide.

2. Stroke incidence rate, mortality rate, and mortality-to-incidence ratio are all higher in LMIC compared to HIC.

3. The proportion of strokes due to intracerebral hemorrhage (ICH) is higher in lower-income regions, estimated to be as high as 34% in parts of sub-Saharan Africa (compared to approximately 10% in high-income regions).

4. Higher incidence of stroke, mortality because of stroke, DALYs lost because of stroke, and proportion of ICH as a cause of stroke are correlated with lower per capita income even after adjustment for cardiovascular risk factors, suggesting that limitations in resources to screen for and modify stroke risk factors and treat stroke contribute to greater burden of stroke, stroke-related mortality, and stroke-related disability in LMIC.

1. A key branch point in the acute management of stroke is determining whether the stroke is caused by an ischemic infarct or ICH. However, CT is unavailable in many resource-limited regions to make this distinction.

2. Clinical signs at stroke onset such as coma, neck stiffness, seizures, diastolic pressure >110 mm Hg, vomiting, and headache suggest ICH as the underlying etiology of acute stroke, but no individual symptom/sign or group thereof is sufficiently specific to distinguish between ICH and ischemic stroke on clinical grounds alone. Therefore, strategies for acute stroke management in resource-limited settings must account for the fact that it is often unknown whether a stroke is ischemic or hemorrhagic.

1. Many elements of acute supportive management of acute ischemic stroke and acute ICH are shared, including maintenance of euglycemia and euthermia, prevention of aspiration and deep venous thrombosis, and treatment of seizures if they occur (see Chapter 6). If CT is unavailable to distinguish ischemic stroke from ICH, prophylactic anticoagulation to prevent deep venous thrombosis should be deferred until 2 days following stroke.

2. Blood pressure is generally allowed to autoregulate in patients with acute ischemic stroke, whereas it should be reduced in ICH (see Chapter 6). Where CT is unavailable to distinguish between ischemic stroke and ICH, one can consider lowering systolic blood pressure to slightly below 180 mm Hg in the acute setting. This would provide benefit in ICH, and is likely also safe if the stroke is ischemic as blood pressure lowering to this degree is indicated when patients with ischemic stroke receive intravenous tissue plasminogen activator. In rare cases in which patients clinically worsen when blood pressure is reduced, blood pressure could be raised with a bolus of IV normal saline and subsequently allowed to autoregulate.

3. Antithrombotic therapy is administered to patients with acute ischemic stroke, whereas this is not recommended in acute ICH due to the risk of hematoma expansion. Thrombolysis is unavailable in most LMIC, so the question with respect to antithrombotic therapy in acute stroke in resource-limited settings is whether it is safe to administer aspirin when it is unknown whether stroke is ischemic or due to ICH. Aspirin is beneficial to patients with acute ischemic stroke when administered within 48 hours but could lead to hematoma expansion in patients with acute ICH. Because the period of highest risk of hematoma expansion is in the first 24 hours after ICH and because the International Stroke Trial and Chinese Acute Stroke Trial trials demonstrated that the benefit of aspirin for acute ischemic stroke requires it to be given in the first 48 hours, I recommend considering aspirin administration to patients with stroke of unknown etiology between 25 and 48 hours after stroke onset unless clinical signs point convincingly toward ICH. Decision analysis modeling suggests this strategy has less risk than is commonly perceived.

1. Approximately 90% of the world’s patients with epilepsy live in LMIC, where yearly incidence rate of epilepsy is nearly twice as high as that of HIC.

2. Epilepsy rates are likely higher in LMIC because of three factors:

3. All these risk factors for epilepsy are potentially modifiable through improved road safety and increased use of motorcycle helmets, expanding access to vaccination against pathogens that cause bacterial meningitis, improved hygiene, and animal husbandry to reduce transmission of cysticercosis, and improvement in access to prenatal and perinatal care.

4. The treatment gap for epilepsy is defined as the percentage of patients with epilepsy who require treatment but remain untreated. The treatment gap is 75% or greater in low-income countries as compared to less than 10% in HIC.