Abstract

Background

Ischemic stroke, accounting for 85% of stroke cases, leads to severe disabilities and increased mortality. Its global incidence rose by 87.55% from 1990 to 2019, posing significant health and economic burdens. The BRICS-plus nations鈥擝razil, Russia, India, China, South Africa, and five others鈥攔epresent a large global population, presenting unique public health challenges. This study aims to evaluate the epidemiological trends and variations in the burden of ischemic stroke across BRICS-plus nations in a timely manner.

Methods

Data on the number, all-age rate, age-standardized rate, and relative change in ischemic stroke disability-adjusted life years (DALYs) from 1992 to 2021 within BRICS-plus were obtained from the Global Burden of Disease Study (GBD) 2021. Relationships between the DALYs rate and the Socio-demographic Index (SDI) were evaluated using Pearson correlation analyses. Additionally, age-period-cohort modeling was employed to estimate net drift, local drift, age, period, and cohort effects over the past three decades.

Results

From 1992 to 2021, total DALYs due to ischemic stroke increased by 47.14%, while the age-standardized DALYs rate decreased by 33.79%. All BRICS-plus countries exhibited a declining trend in the age-standardized DALYs rate over the past three decades. Egypt reported the highest age-standardized DALYs rate (2,462.60 per 100,000 population) in 2021, whereas听the most substantial reduction of 59.37% was observed in Brazil. The annual net drift in the ischemic stroke DALYs rate ranged from -3.04% for Brazil to -0.48% for Egypt among the ten countries. A significant positive correlation was observed between the DALYs rate of ischemic stroke and SDI values. Countries exhibited similar age effect patterns, with an increasing risk of DALYs rate with advancing age. Period and cohort effects highlighted declines in observed nations, indicating improved ischemic stroke management strategies.

Conclusion

The burden of ischemic stroke showed an overall declining trend across the BRICS-plus from 1992 to 2021, but persistent health inequalities between these countries were driven by socioeconomic disparities. Furthermore, it emphasizes the necessity for targeted interventions across age, period, and cohort dimensions to address the distinct challenges posed by ischemic stroke in these rapidly developing countries.

Introduction

Ischemic stroke, accounting for approximately 85% of all stroke cases [1], is characterized by an occlusion of blood flow to part of the brain due to hypoperfusion, most commonly caused by a thrombus or embolism. It is defined as an episode of neurological dysfunction resulting from focal cerebral, spinal, or retinal infarction. Survivors are significantly affected by this condition, often experiencing severe long-term disabilities, decreased quality of life, and increased mortality risk. Reports indicate that the global incidence of ischemic stroke has increased by 88.0% from 1990 to 2019 [2, 3]. As a pressing public health challenge worldwide, ischemic stroke imposes substantial healthcare costs and social burdens on families and healthcare systems [3, 4]. Therefore, understanding its evolving epidemiology is crucial for policymakers and healthcare providers in developing strategies to mitigate its impact on individuals and health systems.

Brazil, the Russian Federation, India, China, and South Africa, collectively known as BRICS, represent 43% of the global population. World Health Organization (WHO) Director-General Margaret Chan noted that these nations contribute a dynamic and innovative perspective to global health matters [5]. Beginning January 1, 2024, BRICS is set to expand to include Saudi Arabia, Egypt, United Arab Emirates, Iran, and Ethiopia, forming what is now termed BRICS-plus, a group encompassing 10 countries. This expansion underscores the growing importance of examining public health within these rapidly changing regions. Given the geopolitical and economic influence of the BRICS countries, it is crucial to investigate the epidemiology and impact of ischemic stroke on this extended group. Previous research utilizing the Global Burden of Disease (GBD) 2019 data highlighted significant regional differences in ischemic stroke burdens [2, 3]. These studies revealed notable discrepancies in health challenges and healthcare access across various regions, particularly in developing nations. Traditional descriptive epidemiology, however, often fails to capture the evolving nature of disease patterns and their related factors. The Age-Period-Cohort (APC) model provides a comprehensive analytical approach, offering insights into how temporal factors influence stroke epidemiology [6]. The recently published GBD 2021 data allows for an in-depth exploration of ischemic stroke trends and regional disparities within BRICS-plus [7,8,9]. This updated information serves as a detailed foundation for identifying changing disease patterns and assessing the efficacy of current healthcare strategies.

This study utilizes the updated GBD 2021 data to investigate the temporal trends and geographic variations in the burden of ischemic stroke across the ten BRICS countries from 1992 to 2021. Employing the APC model, this research aims to fill gaps identified in prior studies. The findings will inform evidence-based health policy development, enhancing stroke prevention and management strategies that are specifically tailored to the distinct needs and circumstances within the BRICS-plus context.

Methods

Data sources

This research employed data from the GBD 2021 public dataset, available via the Global Health Data Exchange GBD Results Tool (). The GBD 2021 offers comprehensive insights into the disease burden for 371 conditions spanning 204 countries and territories worldwide [7,8,9,10]. This extensive dataset is critical for comprehending global health issues, encompassing a wide array of data on disease burden, risks, mortality, and disability. Notably, the GBD 2021 includes several significant enhancements: the addition of 19,189 new data sources for disability-adjusted life years (DALYs), the introduction of 12 new health conditions, and various methodological improvements. Furthermore, it incorporates the effects of the COVID-19 pandemic on the global burden of disease.

In the GBD 2021, ischemic stroke is defined using the International Classification of Diseases, both 9th edition (ICD-9: 433鈥�435.9, 437.0鈥�437.2, 437.4鈥�437.9) and 10th edition (ICD-10: G45-G46.8, I63-I63.9, I65-I66.9, I67.2-I67.848, I69.3-I69.4) [10]. We collected data on the number of DALYs, all-age DALYs rate, and age-standardized DALYs rate attributed to ischemic stroke globally and within the ten BRICS countries. DALYs are calculated to assess the overall burden of disease by combining the years of life lost due to premature mortality with the years lived with disability, providing a comprehensive measure of the impact on public health. This data covers various age groups from 0 to 94听years for the period from 1992 to 2021. To estimate the 95% uncertainty intervals (UIs), we leveraged the model selection, parameter estimation, and data quality characteristics inherent in the GBD database. These intervals were determined by simulating samples 1000 times, with the bounds defined by the 2.5th and 97.5th percentiles of the resulting distribution [7]. Additionally, the GBD 2021 updated and introduced a Socio-demographic Index (SDI) for BRICS-plus nations. Detailed methodologies and modeling approaches used in GBD 2021 are available in other publications [7,8,9,10]. The data were anonymized and made publicly accessible, with the informed consent waiver approved by the University of Washington Institutional Review Board.

Data analysis

Analysis of overall temporal trends in ischemic stroke DALYs

This study examined the burden of ischemic stroke, focusing on spatial and temporal trends from 1992 to 2021. We evaluated temporal trends in DALYs by analyzing the number of DALYs, all-age DALYs rate, age-standardized DALYs rate, and the percentage change from 1992 to 2021. Pearson correlation coefficient was employed to explore the relationship between the Socio-demographic Index (SDI) values and age-standardized DALYs rate across ten countries. Additionally, we analyzed the age distribution of ischemic stroke burden by grouping DALYs into five age categories: 0鈥�4, 5鈥�19, 20鈥�39, 40鈥�64, and 65鈥�94听years, and calculated the DALYs proportion within each age stratum.

Age period cohort modelling analysis

The APC model, grounded in the Poisson distribution, is a statistical tool employed to uncover and interpret disease trends [11, 12]. In this study, we utilized the APC model to decompose DALYs into three dimensions: age, period, and birth cohort, to assess their distinct effects on ischemic stroke DALYs [11, 12]. In this framework, age effects indicate variations in risk across different age groups. Period effects capture temporal changes impacting all age groups simultaneously, while cohort effects reveal variations in outcomes among groups sharing the same birth year. The APC model can be expressed with the following formulation:

$${{g(Y}_{j}/\mu )=log(\lambda }_{j})=u+\alpha {age}_{j}+\beta { period}_{j}+\gamma { cohort}_{j}$$

where ${\lambda }_{j}$ represents the response variable of the net effect on ischemic stroke DALYs rate for group $j$; ${Y}_{j}$ and $\upmu$ represent the number of DALYs and the population at risk, respectively. $\alpha$, $\beta$, and $\gamma$ represent the coefficients of age, period, and birth cohort of the APC model, respectively. $u$ represents the intercept of the model.

The GBD 2021 estimates for ischemic stroke DALYs and the population data of each country or region were utilized as inputs for the APC model using the intrinsic estimator (IE) method [13]. This method effectively addresses the indeterminacy of parameters within the age, period, and cohort components of the APC model. Further methodological details can be found in existing literature [13, 14]. The model requires equal intervals for age and period; thus, the population aged 0鈥�94听years was divided into 19 five-year age groups (0鈥�4, 5鈥�9, 鈥�, 90鈥�94). To account for short-term fluctuations, such as those from the COVID-19 pandemic, the GBD data were organized into a unified framework using DALYs and population counts from the mid-year of six discrete time points (1994, 1999, 鈥�, 2019) instead of 5-year averages to capture specific periods. The study input included 19 age brackets and 21 consecutive cohorts, determined by mid-year birth intervals from 1900鈥�1904 (median 1902) to 2015鈥�2019 (median 2017).

This study primarily focuses on several key estimable functions. Net drift represents the overall annual percentage change in DALYs rate over the study period. Local drift indicates annual percentage changes for each age group, dissected by period and cohort. The longitudinal age curve demonstrates the fitted longitudinal age-specific rates, adjusted for period deviations within a reference cohort. The period (or cohort) rate ratio (RR) compares age-specific rates in each period (or cohort) relative to a reference period. APC analyses were conducted using the National Cancer Institute鈥檚 age-period-cohort web-based tool () [15], with further data visualization and statistical analysis performed in R (version 4.2.3). Statistical significance was evaluated using the Wald 蠂² test, with all tests being two-tailed.

Results

DALYs of ischemic stroke trends from 1992 to 2021

Table 1 presents the population, total DALYs, all-age DALYs rate, age-standardized DALYs rate, and net drift of DALYs for the world and the ten BRICS countries. Over the past three decades, the number of DALYs due to ischemic stroke experienced an increase, from 47,818.21 thousand (95% UI 44,602.98 to 50,976.86) in 1992 to 70,357.91 thousand (95% UI 64,329.58 to 76,007.06) in 2021, corresponding to a 47.14% increase (Table听1 and Fig.听1). The age-standardized DALYs rate demonstrated a decrease, changing from 1,264.65 (95% UI 1,178.13 to 1,347.75) per 100,000 population in 1992 to 837.36 (95% UI 763.73 to 904.98) per 100,000 population in 2021, indicating a 33.79% decrease (Table听1 and Fig.听1). The APC model estimated a net drift of -1.34% (95% confidence interval [CI] -1.40 to -1.27) in the rate of ischemic stroke DALYs globally from 1992 to 2021 (Table听1).

Table听1 Trends in ischemic stroke disability-adjusted life years across the ten BRICS countries, 1992鈥�2021

Fig.听1

The numbers (A) and age-standardized rate (B) of DALYs of ischemic stroke in global and BRICS plus from 1992 to 2021. DALYs鈥�=鈥塂isability-adjusted life years

The DALYs of ischemic stroke have significantly increased in all BRICS countries, except for the Russian Federation (Table听1 and Fig.听1). A particularly notable increase was observed in the United Arab Emirates, which showed the most substantial rise, measuring 268.35%. In 2021, the all-age DALYs rate for ischemic stroke ranged from 179.76 (95% UI 145.20 to 227.27) per 100,000 population in Ethiopia to 2849.77 (95% UI 2643.43 to 3068.90) per 100,000 population in Russian Federation, respectively. The age-standardized DALY rate was reported to be the lowest in Ethiopia, with a range of 515.13 (95% UI 412.03 to 653.85) per 100,000 population; whereas Egypt had the highest rate, at 2462.60 (95% UI 1969.06 to 3002.37) per 100,000 population. All BRICS-plus countries exhibited a declining trend in the age-standardized DALYs rate from 1992 to 2021. Among these nations, the most substantial reduction of 59.37% was observed in Brazil, whereas South Africa showed the smallest decrease of 10.90%. According to the APC model estimates, an annual net drift was observed, ranging from -3.04% (95% UI -3.33 to -2.75) for Brazil to -0.48% (95% UI -0.71 to -0.24) for Egypt within ten countries (Table听1). Furthermore, a significant positive correlation was identified between the DALYs rate of ischemic stroke and SDI values (r鈥�=鈥�0.37, p鈥�<鈥�0.001) (Fig.听2).

Fig.听2

The associations between the SDI and age-standardized DALYs rates per 100,000 population of ischemic stroke across ten BRICS countries. SDI, Sociodemographic Index, DALYs鈥�=鈥塂isability-adjusted life years

Time trends in ischemic stroke DALYs across different age groups

Figure S1 depicts the annual percentage change in DALYs rate for ischemic stroke across each 5-year age group spanning from 0 to 94听years. Generally speaking, negative local drift values were identified across all age groups, signifying a decline in the DALYs rate of ischemic stroke worldwide. Similar patterns were also evident in almost age groups among BRICS-plus nations. Only obvious positive local drift values were observed in the United Arab Emirates for older age groups. It is noteworthy that males aged over 60 in Egypt and the United Arab Emirates exhibited more negative net drift values compared to their female counterparts. Figure S2 depicts the temporal trends in DALYs numbers for ischemic stroke segmented by age group. Overall, most global ischemic stroke DALYs were concentrated among middle and older age groups (40听years and over), with similar distributions noted across all BRICS-plus countries. The age distribution of ischemic stroke DALYs remained relatively stable globally and across most BRICS-plus nations during the period from 1992 to 2021. Concurrently, an emerging shift of DALYs was noted from the older (65鈥�94听years) to the middle-aged (40鈥�64听years) population in Saudi Arabia.

Age, period and cohort effects on ischemic stroke DALYs

Figure听3 depicts the estimated age effects derived from the APC model for both global and BRICS-plus countries. Overall, similar age effect patterns were observed across all nations, with the DALYs rate attributed to ischemic stroke showing an upward trend as age increases (five years and over) within the reference cohort after adjusting for period effects. Figure听4 presents the estimated period effects, differentiated by sex, during the entire study period. Globally, a continuous decline in period effects was observed, indicating effective control of ischemic stroke DALYs rates over time. This trend was mirrored in six member nations (Brazil, India, the Russian Federation, the United Arab Emirates, Iran, and Ethiopia), where the most significant decline occurred in Brazil. In China and South Africa, slow initial growth in period effects was noted, followed by a decline over the past three decades. In contrast, Saudi Arabia and Egypt demonstrated patterns of two declines and a relatively stable phase, resembling a 鈥渟tep鈥� model. Notably, elevated period risks for females were identified, alongside a downward trend for males, from 2007鈥�2011 to 2017鈥�2021 in the United Arab Emirates, compared to the reference period (2002鈥�2006). Cohort effects globally demonstrated a continuous decline among successive birth cohorts over the past 30听years. This pattern was particularly evident in the majority of member countries, including Brazil, China, India, the Russian Federation, Saudi Arabia, Iran, and Ethiopia. In South Africa and Egypt, initial risk ratio stability was followed by a decline. However, a modest increasing trend was noted in the United Arab Emirates before the reference cohort (1957s), followed by a decrease (Fig.听5).

Fig.听3

Age effects on ischemic stroke DALYs in global and BRICS plus. Age effects are shown by the fitted longitudinal age curves of DALYs rate (per 100,000 person-years) adjusted for period deviations. The dots denote DALYs rate. DALYs, Disability-adjusted life years

Fig.听4

Period effects on ischemic stroke DALYs in global and BRICS plus. Period effects are shown by the relative risk of DALYs rate (DALYs rate ratio) and computed as the ratio of age-specific rates from 1992鈥�1996 to 2017鈥�2021, with the referent cohort set at 2002鈥�2006. The dots denote DALYs rate ratios. DALYs, Disability-adjusted life years

Fig.听5

Cohort effects on ischemic stroke DALYs in global and BRICS plus. Cohort effects are shown by the relative risk of DALYs rate and computed as the ratio of age-specific rates from the 1902 cohort to the 2017 cohort, with the referent cohort set at 1957. The dots denote DALYs rate ratios. DALYs, Disability-adjusted life years

Discussion

The study examines significant variations in the global burden of ischemic stroke and within BRICS-plus countries from 1992 to 2021. Our analysis indicates a substantial 47.14% increase in the number of DALYs, despite a 33.79% decrease in the age-standardized DALYs rate, with notable discrepancies among the ten BRICS members. These findings highlight the complex epidemiology of ischemic stroke and emphasize significant health disparities, underscoring potential prioritization strategies to mitigate its burden across age, period, and birth cohort dimensions within the BRICS-plus region.

The rise in DALYs of ischemic stroke over the past three decades is likely attributed to population growth. However, a pronounced heterogeneity in the DALYs rate and long-term trends is evident across the BRICS-plus countries. Six out of ten members exhibit decreases in the all-age DALYs rate, whereas China, South Africa, Saudi Arabia, and Iran show increases. Adjusting for age distribution changes, shifts in the age-standardized DALYs of ischemic stroke from 1992 to 2021 suggest that besides demographic changes, other underlying factors are contributing to the variation in ischemic stroke burden. Over the past thirty years, notable progress has been observed in neurological health programs, as well as in medical and public health sectors [16,17,18]. Despite the advantages of economic development, our findings reveal a significant positive correlation between the DALYs rate of ischemic stroke and SDI, suggesting a paradox where increased wealth might initially heighten the burden of ischemic stroke. Economic advances often precipitate lifestyle changes, such as higher consumption of calorie-dense diets, sedentary lifestyles, and increased stress, all recognized risk factors for ischemic stroke [19,20,21,22]. Furthermore, urbanization, along with enhanced healthcare infrastructure and diagnostic capabilities in economically developing regions, may lead to higher detection and reporting of ischemic stroke cases. The results underscore the urgent need for public health policies that address both economic growth and health outcomes. It is crucial for these nations to allocate resources towards public health initiatives aimed at reducing ischemic stroke risk factors, thereby ensuring that economic development does not inadvertently amplify health burdens.

The observed trends in the burden of ischemic stroke across various age groups align with global advances in healthcare access and stroke management practices. This overall decrease in DALYs rate indicates enhanced primary prevention strategies, improved acute care, and effective rehabilitation services that have been implemented over the past decades [23, 24]. BRICS-plus have mirrored this global trend, indicating similar advancements and health policy implementations within these rapidly developing nations. Positive local drift values noted in individuals aged over 60听years in the United Arab Emirates highlight potential areas of concern, possibly reflecting the expanding aging population and the corresponding rise in age-related comorbidities [25]. Gender differences observed, particularly more negative net drift values in males in Egypt and the United Arab Emirates, necessitate further investigation into gender-specific risk factors and health-seeking behaviors. Previous studies have demonstrated that females may experience distinct stroke risk profiles and outcomes compared to males, influenced by factors such as hormonal changes, pregnancy-related complications, and differences in managing cerebrovascular risk factors [26, 27]. The observed shift in the burden of ischemic stroke DALYs in Saudi Arabia, from older populations (65鈥�94听years) to middle-aged groups (40鈥�64听years), may indicate that middle-aged individuals are increasingly affected by risk factors traditionally associated with older age groups [28].

Significant disparities in ischemic stroke DALYs rates are observed across different countries. It is crucial for policymakers to assess their nation鈥檚 specific characteristics within this context. By comparing their standing to that of other countries, they can make better-informed decisions. The factors triggering ischemic stroke often raise questions, highlighting the need for further investigation into age, period, and cohort effects. In response to these considerations, this study focused on examining the ischemic stroke burden patterns globally and within BRICS-plus countries through the APC framework. Similar age-related patterns indicate that the severe health impacts of ischemic stroke are predominantly felt later in life, with the burden risk heightening as individuals age. Aging is linked with systemic inflammation and oxidative stress, both implicated in the pathogenesis of atherosclerosis and thromboembolism, critical pathways in the development of ischemic stroke [29, 30]. Moreover, the prevalence of traditional risk factors for ischemic stroke, including hypertension, atrial fibrillation, diabetes mellitus, and hyperlipidemia, was found to be more common in older individuals [31, 32]. Another critical perspective is the global increase in life expectancy, resulting in a larger elderly demographic [8]. This demographic shift underscores a transition in prevalent health issues from infectious diseases to chronic non-communicable diseases, such as cerebrovascular disorders.

A continuous decline in period effects was observed globally as well as in Brazil, India, Russia, the United Arab Emirates, Iran, and Ethiopia, suggesting effective improvements in healthcare systems, public health policies, and increased awareness and management of stroke risk factors over the study period. In Brazil, the most notable decline was attributed to substantial investments in the healthcare sector, the implementation of universal health coverage through the Unified Health System, and targeted campaigns to reduce cerebrovascular risks [33]. Brazil鈥檚 focus on primary healthcare and broad access to essential medicines likely contributed to this trend. In India, the expansion of healthcare infrastructure [34], coupled with government initiatives targeting non-communicable disease (NCD) control, may have driven the observed decline in period effects. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) played a crucial role by facilitating early detection and management of risk factors [35]. Similarly, in Russia, advancements in medical technology, improved access to healthcare, and national strategies aimed at reducing stroke burden have contributed to the decline in period effects [36]. In contrast, the initial slow growth followed by a decline in period effects in China and South Africa highlights the complex interplay of rapid urbanization, economic developments, and public health challenges. Reforms in China鈥檚 healthcare system, such as the expansion of health insurance coverage and improvements in primary care services, have been pivotal in managing the stroke burden, reflecting the eventual decline in period effects [37]. South Africa鈥檚 dual burden of infectious and non-communicable diseases, together with efforts to strengthen the healthcare system post-apartheid, might explain the observed trends [38, 39]. The 鈥渟tep鈥� pattern observed in Saudi Arabia and Egypt鈥攃haracterized by two declines and a relatively stable phase鈥攎ay reflect episodic healthcare interventions and fluctuating economic conditions. In Saudi Arabia, the Vision 2030 initiative, which emphasizes healthcare modernization, may have contributed to recent improvements [40]. Egypt鈥檚 healthcare sector has undergone reforms to expand access and improve service quality, aligning with the observed period effect patterns [41]. The United Arab Emirates presents a unique case with elevated period risks for females, while a downward trend was observed among males from 2007鈥�2011 to 2017鈥�2021. This sex-specific disparity may be influenced by cultural and lifestyle factors, including higher obesity prevalence and sedentary behavior among women, combined with targeted health campaigns focusing on cerebrovascular health [42, 43].

Cohort effects showcasing a continuous decline among successive birth cohorts across most countries, including Brazil, China, India, the Russian Federation, Saudi Arabia, Iran, and Ethiopia, further underscore the effectiveness of long-term public health strategies and improvements in healthcare delivery. These declines indicate that younger generations are benefiting from increased health education, better access to medical care, and preventive measures from early life stages [44, 45]. South Africa's focus on mitigating infectious diseases might have delayed the attention to stroke prevention, but current integrated approaches are beginning to address cohort vulnerabilities [38]. In Egypt, economic challenges and healthcare accessibility might have influenced the initial stability, but recent reforms are gradually impacting younger cohorts [41]. Interestingly, the initial modest increase in cohort effects followed by a decrease in the United Arab Emirates may reflect historical disparities in healthcare access and lifestyle changes, subsequently addressed by recent healthcare improvements and health promotion initiatives targeting younger generations [43].

Compared to the recent GBD 2021 report [46], this study provides an extensive analysis of ischemic stroke burden through the integration of age, period, and cohort effects. A significant advancement of our research is the accurate quantification of changes in age distribution burdens from 1992 to 2021, encompassing both global data and specific information from BRICS countries. This detailed understanding of regional and demographic variations enhances comprehension of the complex interplay between natural aging, epochal shifts, and socio-political commitments in addressing global health challenges such as ischemic strokes. However, several limitations must be acknowledged. First, the GBD 2021 data stem from various sources, including surveys, registries, and administrative records, with each differing in quality and completeness. This variability may introduce bias and uncertainty into the results. Second, the GBD database often depends on modeled estimates for areas with limited primary data. The assumptions in these models may not be universally applicable, particularly when considering the impact of diverse cultural, genetic, and environmental factors on the ischemic stroke burden.

Conclusion

This study offers a detailed analysis of the ischemic stroke burden across the BRICS-plus nations from 1992 to 2021. It reveals a general decline in the age-standardized DALYs rate, while also highlighting enduring health inequalities among countries that are largely driven by socioeconomic disparities. Furthermore, the study emphasizes the intricate interactions of age, period, and cohort effects on ischemic stroke. Distinct trends are observed in each country, shaped by their particular socioeconomic, cultural, and historical contexts. These findings suggest that public health strategies must be carefully tailored to effectively address and manage the ischemic stroke burden in diverse settings. Future research should focus on a thorough investigation of the effects of specific policies and interventions, ensuring a holistic approach to managing ischemic stroke in these rapidly developing regions.