Stroke is one of the most common neurological disorders worldwide with direct and indirect economic consequences [9].

Its burden has declined in high-income countries (HICs) owing to placing it as a top priority with continuous improvements in care provided to patients in addition to continuous research in the field of stroke and adequate funding [10].

On the contrary, the incidence of stroke has increased in LMIC, given that nearly all African countries belong to LMIC except for Seychelles which despite belonging to HIC still has a shortage of services [11]. This shortage reflects that the economic status of countries is not the only factor that could hinder stroke services, but it is the arrangement of priorities among governments. Stroke in Africa needs to be prioritized especially that the burden is rising owing to many factors, such as longevity, hypertension, diabetes, obesity, and sedentary lifestyle, in addition, shifting from rural to urban areas is associated with stress. All such factors ought to push governments and non-governmental organizations to prioritize stroke care [12].

African countries can make use of the WSO roadmap that divides stroke care from minimal services, through essential services, up to advanced services. So, governments could check the current stroke service availabilities in their countries and follow the roadmap [13].

Stroke services are improving in Latin America owing to joining efforts between governments and international organizations in the field of stroke; African countries might make use of the process that took place in Brazil and in different Latin American countries and approach stroke in a similar manner [4, 14].

Continuous basic and advanced research in the field of stroke is much needed in Africa knowing that the incidence of stroke is as high as 316 per 100,000, the prevalence sums up to 1460 per 100,000 and fatality within 3 years is around 84% [15].

The current study found that the African population is continuously growing with more than 60 million increases within the last 3 years. Despite that more than half of the participating countries had an increase in the working neurologists yet still not mounting to the minimal World Health Organization (WHO) recommendations of at least 1 per 100,000 persons in most countries [16]. Only Algeria, Egypt, and Tunisia have more than 1 neurologist per 100,000, and only Egypt has 7.06 in 2024, thus exceeding the European estimates of 4.84 neurologists per 100,000 [17].

Such deficiency in manpower is one of the obstacles facing stroke service in Africa moreover, the available neurologists are unevenly distributed in some countries between hospitals and between urban and rural areas as found in Ethiopia, Kenya, South Africa, and Zambia.

Facing manpower deficiency is approachable through different aspects and some of these aspects were tried in some African countries and have proven efficacy. In Nigeria task shifting and task sharing as an approach to deal with non-communicable diseases and face deficiencies in some medical specialties as neurology was made use of by the federal ministry of health [18].

Other ways of dealing with manpower deficiencies include partnerships between ministries of health in developing countries and developed ones. There are also faculties as the Wessex-Ghana Stroke partnership to train neurologists who in turn train their deputies and continue the cycle of training and auditing under the term train the trainer [19].

Implementing a training residency program where young neurologists can be trained through importing expertise to developing countries as the program implemented in Ethiopia could be tried in different African countries [20]. However, we need to tailor the programs of developed countries to fit in developing ones taking into consideration the deficiency in resources [21].

In the acute phase of stroke management, it was found that the number of countries with stroke units increased, where 13 countries have a total of 121 stroke units and 4 countries have 65 stroke centers.

Although Egypt has the maximum number of 80 units and 60 centers yet, this number is still defective given that Egypt has an annual incidence of 150,000–250,000 stroke cases and thus needs approximately 500 units [22]. Also, this number seems much lower than that reported by De Sousa and colleagues of 2165 stroke units in 44 European countries in 2019 [23].

According to testimonials from representatives from sub-Saharan Africa as well as from North Africa, deficiency in stroke units and centers was considered a major obstacle to acute stroke care in 58.8% of countries.

African countries might make use of ongoing initiatives from international organizations such as the WSO to implement stroke services including building expertise to take over the management of stroke units and be a nidus for replication. This should take into consideration the equality in distributing stroke services in underrepresented areas as rural regions, borders, and governorates away from capitals [24, 25].

Meanwhile, patients in their communities are to be approached either by stroke specialists or through training general practitioners and primary care providers to triage patients and refer those in need of acute management to central hospitals or available stroke units and centers. This approach might facilitate accessibility to services for the majority of the population until stroke services are implemented in a proper geographical representation. Adapting the “use of map stroke”, that was applied in Brazil and took into consideration the population density, the burden of stroke, and the needed stroke units and its catchment area, might be of benefit in Africa [26].

Acute phase intervention whether through IVT or MT has progressed in 2024 compared to 2021 with the introduction of three and two additional countries for IVT and MT respectively. Nevertheless, this is still insufficient taking into account that both managements are cornerstones in acute stroke care [22]. Still, Somalia and Zambia are deficient in both, and Cameron, Democratic Republic of Congo, Ethiopia, Libya, Niger, Seychelles, and Tanzania are deficient in MT.

Deficiencies in IVT and MT have two facets. The first one is the under-established infrastructure from angio-suites to availability of materials for MT and vials for IVT. This needs campaigns targeting policymakers and stakeholders with data showing that the financial burden from disability arising from stroke exceeds the budget needed for revascularization. Such a campaign was initiated in Egypt and could persuade the government with the importance of endorsing both IVT and MT [9, 27].

The second facet is the deficiency in expertise, and this could be solved by training and hands-on workshops that can improve hand skills and reduce door to groin as was shown by Inoa and colleagues [28].

Code Stroke showed a stationary status in 2024 compared to 2021 being available only in 3 countries. This was attributed to the lack of emergency stroke medical services in 9 countries and to stroke being non-priority for governments in 3 countries. Code Stroke is an item within any acute stroke service management so once more stroke units and centers are implemented; code stroke will be in turn applied within the stroke pathway of such units and centers.

Despite rehabilitation services availability maintained its status in the 2024 analysis with a total of 13 countries. Physiotherapy showed a true decline in Ethiopia after the diversion of services to victims of violence due to civil unrest. Physiotherapy and speech therapy were introduced in Tanzania in 2024 compared to 2021, yet still, 4 countries lack physiotherapy, and 6 countries don’t provide speech therapy owing to being a non-priority, lack of funding, and high cost of service in addition to a lack of awareness of its importance.

In contradistinction to 2021, Tunisia started to become active in the SITS database in 2024. Nigeria began to participate in RESQ according to confirmation from Brno, Czech Republic RESQ headquarters. Mauritius initiated a National Stroke Registry through local governmental initiatives and Ethiopia through cooperation between the government and the WSO and its future stroke leaders’ initiatives, while Kenya no longer became active in the SITS database.

All countries became active in awareness campaigns except for Egypt, Libya, Somalia, and Zambia [29]. This came through engagement of many countries with international organizations either the Angels, the Stroke Awareness Day of the ASO, WSO, or both [12].

Despite the introduction of awareness campaigns, still social awareness is lacking in 11 countries which negatively impacts acute management since patients fail to arrive at hospitals within the window. It similarly impacted secondary prevention strategies, post-discharge, and compliance regarding follow-ups. Governmental and non-governmental engagement in awareness campaigns using information services like broadcasting, banners, and audiovisual sources to educate the entire population about stroke management whether in the acute or post-acute phase will reduce stroke burden on a long-term basis.

Finally, it was found that telestroke services are present in only four countries owing to governmental nonpriority, poor communication infrastructure, and high implementation costs.

The current study has points of power as it succeeded in involving the same countries included in the 2021/22 studies. It also could confirm data accuracy through verification from neutral sources as is the case in international database quality registries. This study throws light on obstacles facing stroke services from a testimonial perspective of those incorporated in managing stroke in their countries and through different national stroke societies. Meanwhile, the current study has some limitations, being a comparative study to that held in 2021/22 made it difficult to include new countries and in turn obstacles facing stroke services could not be generalizable to all African countries. The current study failed to analyze the total number of patients receiving IVT or MT per country and only mentioned availability. Within the current study management of stroke risk factors and primary management was not analyzed as screening programs and availability of medications for various vascular risk factors of stroke were optimum in 2021/22 studies. Despite being a study that analyzes stroke service in one continent, Africa still has some variabilities in its countries such as those related to the economic and socio-political status that might have a positive or negative influence on stroke services and encountered obstacles so future studies approaching stroke services based on socio-political and health-economics is recommended.