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Summary Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.

The socioeconomic and health effect of stroke and other noncommunicable disorders (NCDs) that share many of the same risk factors with stroke, such as heart attack, dementia, and diabetes mellitus, is huge and increasing. [1][2][3][4] Collectively, NCDs account for 34.5 million deaths (66% of deaths from all causes) 3 and 1344 million disability-adjusted life years lost worldwide in 2010. 2 The burden of NCDs is likely to burgeon given the aging of the world's population and the epidemiological transition currently observed in many low-to middle-income countries (LMICs). 5,6 In addition, there is low awareness in the population about these NCDs and their risk factors, 7-10 particularly in LMICs.11 These factors, coupled with underuse of strategies for primary prevention of stroke/NCDs on an individual level and the lack of accurate data on the prevalence and effect of risk factors in different countries and populations have been implicated in the ever-increasing worldwide burden of the NCDs. [12][13][14][15] Of particular concern is a significant increase in the number of young adults (aged <65 years) affected by stroke, 16 and the increasing epidemic of overweight/obesity 17 and diabetes mellitus worldwide. 18 If these trends continue, the burden of stroke and other major NCDs will increase even faster. The increasing burden of stroke and other major NCDs provide strong support for the notion that the currently used primary prevention strategies for stroke and other major NCDs (business as usual) are not sufficiently effective. The most pertinent solution to this problem is the implementation of new, effective, widely available, and cost-effective prevention and treatment strategies to reduce the incidence and severity distribution of stroke and other major NCDs. Issues With Population-Wide Prevention StrategiesThe recent INTERSTROKE case-control study, conducted in 22 countries worldwide, provided evidence that, collectively, 10 risk factors accounted for 88.1% (99% confidence interval, 82.3%-92.2%) of the population-attributable risk for all stroke. 19 Because many (but not all) of these risk factors are modifiable, the INTERSTROKE data suggest that interventions that reduce blood pressure, promote physical activity, smoking cessation, and a healthy diet, could substantially reduce the burden of stroke. Although a combination of population-wide and individual high-risk prevention strategies were initially advocated >30 years ago, 20 and have since been repeatedly recommended as the most promising strategies to reduce stroke and NCDs burden, there is still no country in the world where both these prevention strategies have been implemented in full. There are major hurdles to implementing population-wide primary prevention strategies, including the need for policy and legislative changes that are often not supported by major industries (such as salt reduction in processed food, reduction of exposure to cigarette smoking, alcohol, and fast food). In addition, there are significant costs associated with the imple...

The exclusive photoproduction of Upsilon state Υ(1S) and its radially excited states Υ(2S, 3S) is investigated in the context of ultra-peripheral collisions at the LHC energies. Predictions are presented for their production in proton-proton, proton-nucleus and nucleus-nucleus collision at the energies available at the LHC run 2. The rapidity and transverse momentum distributions are shown, and the robustness of the model is tested against the experimental results considering ψ(1S, 2S) and Υ(1S) states. The theoretical framework considered in the analysis is the light-cone color dipole formalism, which includes consistently parton saturation effects and nuclear shadowing corrections.

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The exclusive photoproduction of the heavy vector mesons J=Ψ is investigated in the context of peripheral lead-lead collisions for the energies available at the LHC, ffiffi ffi s p ¼ 2.76 TeV and ffiffi ffi s p ¼ 5.02 TeV.Using the light-cone color dipole formalism, the rapidity distribution was calculated in two centrality bins at 50%-70% and 70%-90% in order to evaluate its robustness in extrapolating down to a smaller impact parameter. A modified photon flux is introduced, without change in the photonuclear cross section in relation to the ultraperipheral (UPC) case. Results were obtained for the two regions analyzed, which presented a maximum difference of 27% in frontal rapidity for the two regions. Comparing the results for ffiffi ffi s p ¼ 2.76 TeV and ffiffi ffi s p ¼ 5.02 TeV, an increase was verified of approximately half the one obtained in the ultraperipheral regime in the central rapidity region.

The increasing burden of stroke and dementia emphasizes the need for new, well-tolerated and cost-effective primary prevention strategies that can reduce the risks of stroke and dementia worldwide, and specifically in low- and middle-income countries (LMICs).  This paper outlines conceptual frameworks of three primary stroke prevention strategies: (a) the “polypill” strategy; (b) a “population-wide” strategy; and (c) a “motivational population-wide” strategy.  (a) A polypill containing generic low-dose ingredients of blood pressure and lipid-lowering medications (e.g. candesartan 16 mg, amlodipine 2.5 mg, and rosuvastatin 10 mg) seems a safe and cost-effective approach for primary prevention of stroke and dementia.  (b) A population-wide strategy reducing cardiovascular risk factors in the whole population, regardless of the level of risk is the most effective primary prevention strategy. A motivational population-wide strategy for the modification of health behaviors (e.g. smoking, diet, physical activity) should be based on the principles of cognitive behavioral therapy. Mobile technologies, such as smartphones, offer an ideal interface for behavioral interventions (e.g. Stroke Riskometer app) even in LMICs.  (c) Community health workers can improve the maintenance of lifestyle changes as well as the adherence to medication, especially in resource poor areas. An adequate training of community health workers is a key point. Conclusion An effective primary stroke prevention strategy on a global scale should integrate pharmacological (polypill) and lifestyle modifications (motivational population-wide strategy) interventions. Side effects of such an integrative approach are expected to be minimal and the benefits among individuals at low-to-moderate risk of stroke could be significant. In the future, pragmatic field trials will provide more evidence.

transient ischemic attacks until first ischemic stroke affecting the left frontal lobe. During hospitalization, he presented four ischemic strokes in multiple territories. Arteriography exhibited multiple distal irregularities in all arterial territories, suggesting cerebral vasculitis. Even with corticosteroids, cyclophosphamide and intravenous immunoglobulin no response was observe and he died 4 weeks latter. Conclusion: Isolated neurosarcoidosis is a big diagnostic challenge and, owing to its life-threatening consequences, the recognition of cerebral vasculitis in these patients is necessary for proper treatment and, therefore, to achieve better clinical outcomes.