RESOURCE: The Lancet Neurology, Current Issue, Volume 6, Number 6, June 2007 /Lancet Neurology 2007; 6:553-561DOI:10.1016/S1474-4422(07)70005-4全文分八部分，请各位战友认领翻译校对TITLE: Acute treatment and long-term management of stroke in developing countriesAUTHOR: Prof Michael Brainin MD , Yvonne Teuschl PhD and Lalit Kalra MD第一部分SummaryDeveloping countries have some of the highest stroke mortality rates in the world that account for over two-thirds of stroke deaths worldwide. Hospital-based studies suggest that the patterns of stroke types and causes of stroke differ between developing and developed countries, resulting in differing needs for acute and long-term care. Data on stroke care provision in developing countries are sparse and most of the available studies are biased towards urban settings in reasonably resourced health-care systems. A general overview shows that the quality and quantity of stroke care is largely patchy in low-income and middle-income countries, with areas of excellence intermixed with areas of severe need, depending upon patients' location, socioeconomic status, education, and cultural beliefs. Here we review the available literature on acute and long-term stroke management in developing countries. On the basis of available studies, largely from developed countries, we discuss the need to develop basic organised stroke-unit care in developing countries.IntroductionStroke is the second commonest cause of mortality worldwide1 and remains a leading cause of adult physical disability. Developments in stroke care over the past two decades, particularly in acute management as well as in rehabilitation and long-term care, have greatly reduced mortality and dependence in many developed countries. Indeed, 10 year stroke mortality rates collected by the WHO MONICA project in Europe and China showed that changes in mortality rates in nine countries were mainly due to changes in case fatality rather than to changes in stroke incidence, suggesting that changes in the quality of stroke care may be responsible for changes in stroke mortality.2,3 By contrast, there has been limited progress in the management of patients with stroke in developing countries, despite increasing incidence of stroke and high stroke mortality rates that account for over two-thirds of stroke deaths worldwide.4 The slow uptake of evidence into clinical practice can be attributed to several reasons mainly relating to geography, limited health-care provision for the population as a whole, socioeconomic considerations, and health behaviour of different populations. In addition, hospital-based studies suggest differences in the type and causes of stroke between developed and developing countries, with higher incidence of haemorrhagic stroke and higher prevalence of stroke due to infective or inflammatory causes. Although many of the advances associated with reduced stroke mortality and morbidity will be equally applicable to developing countries, differences in types and causes of stroke, limitations posed by geography, accessibility of health care, availability of resources, social beliefs, and cultural expectations need to be taken into account when extrapolating stroke-management strategies from the developed to developing countries.5第二部分Specific issues in the treatment of stroke in developing countriesResearch on stroke-care provision in developing countries is sparse and most of the available studies are biased towards urban settings in affluent economies with reasonably resourced health-care systems. A general overview shows that the quality and quantity of stroke care is largely patchy in low-income and middle-income countries (or low-developed and medium-developed as defined by the United Nations Development Program6), with areas of excellence intermixed with areas of severe need depending upon location, socioeconomic status, education, and cultural beliefs.Stroke awareness and use of hospitalsThe importance of stroke awareness has been highlighted in many studies, which show poor recognition of stroke symptoms in developing countries. Only one in 25 patients attending a stroke clinic and 27% of patients presenting to the stroke services in a tertiary hospital in India were aware that they had suffered a stroke.7,8 Equally importantly, 80% of the patients in the first study thought that the organ affected was the heart and only 33% of patients in the tertiary hospital setting knew that the brain was involved in stroke. Moreover, 29% of patients with stroke in the second study did not know a single warning sign. However, in another study in the same hospital in India, 55% of the relatives of patients without history of stroke identified the brain as the affected organ, and only 23% could not cite a single stroke symptom.9 A study in a university hospital in Oman found that 35% of patients with high risk of stroke stated that the organ affected by a stroke is the brain and 68% identified at least one stroke symptom.10 However, stroke awareness and knowledge is poor even in developed countries and varies as in developing countries9,10 with income, education, age, and sex.11–15 The proportion of people correctly identifying the brain as the organ involved in stroke in developed countries was between 45% and 73%,11,12,15,16 and between 30% and 90% knew at least one stroke warning sign.11–18The multiplicity of health-care options, many of which may not be rooted in biological sciences, may be a significant impediment to early intervention in patients with acute stroke. In an Indian study in an urban setting, 59% of patients with stroke consulted a private doctor before seeking hospital care and only 38% of patients presented directly to hospital.8 Studies in rural South Africa show that 40–80% of patients complement medical care with help from traditional healers or churches and as many as 10–33% of patients may go to traditional healers first rather than seek medical help.19,20 The rural–urban split in access to stroke treatment is also reflected in studies from Taiwan and Bolivia, which show that 10% and 50%, respectively, of patients with stroke in rural settings do not go to hospital or see a doctor.21,22 Hospital is the first point of investigation and treatment for many patients. Overall, the proportion of patients with incident stroke who present to hospitals in poorly developed or moderately developed countries is difficult to estimate. A hospital-based study from the Philippines suggests 81% of patients present at hospitals;23 whereas a prospective population study from the Ukraine showed that 66% were hospitalised.24 These estimates are derived from regions with reasonably well-developed health services and may not be representative of other developing countries.第三部分Thrombolysis and hospital careIn developing countries, there is great variation in the time taken by patients with stroke to present to hospitals and the imaging or treatment facilities available for their management (table 1).23,25–35 Most studies suggest that patients with stroke who present to hospital, do so fairly soon after symptom onset. Studies from The Gambia show that most patients were admitted within 48 h of symptom onset,26 the median time to admission being 8 h.25 A study from Ethiopia reported a median time of 13·5 h before presenting to hospital.36 Studies from urban hospitals in India and the Philippines report that up to 35% of patients with stroke present within 3 h of symptom onset,8,23,30 which is no different to the times to presentation reported from developed countries.37Table 1. Acute management of stroke in developing countriesThe use of imaging also differs considerably between settings (table 1). In 1998, 18 African countries had no CT scanners and 13 countries had one each. Only northern African countries and South Africa had an appropriate number of CT and some MRI scanners.38 CT scanning facilities were not available in 27% of hospitals in the Philippines,23 but 83% patients with stroke in a general hospital in China had either CT (65%) or MRI (43%) scans.29 In 1998, Shanghai (China) and Malaysia had about one or two MRI scanners per million population whereas in Thailand, the Indian state Tamil Nadu, Indonesia, and the Philippines fewer than 0·5 scanners per million population were available.39The reported rates for thrombolysis also vary substantially, ranging from 2·1% in a large study in 1624 patients in Thailand32 to 7% in a smaller study of 489 patients from India.31 Intravenous alteplase (recombinant tissue plasminogen activator; rtPA) is registered and introduced in many countries with medium development and some with low levels of development. Affordability was an important determinant of both investigations and treatment in some settings: only 101 of 1102 (9%) patients with stroke in Nigeria could afford to have CT scans;40 in Ethiopia, CT scan was only done in 38·3% of patients due to its high price;41 and 10% of 489 patients with incident stroke who meet all criteria for thrombolysis were not given the treatment in an Indian study because they could not afford alteplase.31The length of hospital stay varied substantially according to region and affordability. The median hospital stay in Pakistan was only 3 days,35 compared with 32 days for insured patients in China.29 There is very little information on specialised stroke-unit care in developing countries. A study from Brazil showed no differences in outcome measured at 10 days after stroke onset or length of hospital stay between those managed on a stroke unit and those on general wards.34 However, there was a trend towards lower mortality at 1 month, 3 months, and 6 months in patients managed on the stroke unit, which did not achieve statistical significance, possibly because of the small sample size. Another study from Thailand that compared hospital care with hospitalisation and early supported discharge showed no differences in mortality but better patient perceptions of the care received in those managed at home.33第四部分Access to and availability of adequate rehabilitation facilities is also limited in countries with low or medium development. Only 47% of hospitalised patients with stroke were seen by a therapist in The Gambia;26 and in large teaching hospitals in southern China, routine care included no regular professional physiotherapy during the whole hospitalisation period.42 The mean duration between stroke onset and admission to a rehabilitation facility is 53 days in Thailand and 63 days and 76 days in two Turkish studies.43–45 In South Africa, only 39% of old and 56% of young patients with stroke attended outpatients' physiotherapy clinics once a week or once a month after hospital discharge.46Secondary preventionMost studies show poor outcomes in patients with stroke in terms of mortality and implementation of secondary prevention measures (table 2).19,25,26,33,34,42–51 Many of the problems of poor concordance with secondary prevention measures have been attributed to lack of equipment for the monitoring of blood pressure or other risk factors, non-availability of drugs, and affordability of treatment.19,50 A Chinese study showed that lower socioeconomic status was associated with higher 3 year mortality in patients with ischaemic stroke.49 Cost-effective secondary prevention has been proposed by WHO guidelines for low-income and middle-income populations, suggesting lifestyle changes and affordable, accessible, and effective pharmacological antihypertensive treatments, antiplatelet treatments, and blood-cholesterol reduction.52 Aspirin has been recommended as the most cost-effective antiplatelet medical therapy worldwide because it is cheap and easily available everywhere in the world but compliance with treatment is commonly poor.52–54 Studies from The Gambia26 and South Africa19 reported that although 65% and 83% respectively of stroke patients were treated with antihypertensive drugs at the time of discharge, only 13% of stroke survivors in The Gambia and 8% of survivors in South Africa were taking antihypertensive treatment after 1 year. Similarly, of the 71% of patients discharged on aspirin in The Gambia, only 7% were still taking aspirin 1 year later.26 In another study from The Gambia, 33% of stroke survivors were treated with antihypertensive medication at 6 months after stroke; 3–4 years later only 15% were satisfactorily controlled for hypertension and 15% received aspirin regularly.25 The WHO PREMISE study of ten medium developed countries (Brazil, Egypt, India, Indonesia, Islamic Republic of Iran, Pakistan, Russian Federation, Sri Lanka, Tunisia, and Turkey) reported high percentages of patients with cerebrovascular diseases using drugs for secondary prevention. Aspirin use ranged from 31% to 90%, the use of beta-blockers from 6·8% to 46%, angiotensin-converting-enzyme inhibitor use from 5% to 59%, and statin use from 2% to 37%.50 94% of these patients reported that their blood pressure had been measured within the past 12 months. Patients in this study were recruited from outpatient clinics, which may reflect better access to health services and greater acceptance of drug treatment than among the general population in these settings.Table 2. Long-term management of stroke in developing countries第五部分Little information is available on lifestyle modification after stroke in developing countries. The PREMISE study suggests that 77–89% of patients have knowledge of the benefits of smoking cessation, diet modification, and regular physical activity. However, 52·5% did not engage in regular moderate physical activity, and 35% had difficulties in complying with dietary advice due to the expense and lack of availability of healthy food items.50 On the Kinmen islands, China, 36% of stroke survivors eat meat less than once per week and 36% exercise more than once per week compared with 19% and 18% respectively for people who had not had stroke.21 The figure shows the location of the studies covered in this Review.Figure. Locations of the studies covered by this reviewPurple circles indicate studies reporting data on stroke care in the strict sense; yellow circles indicate studies reporting data on additional care-relevant subjects according to high (green), medium (blue) and low (red) human development based on the Human development report 2005.1Differences in stroke type and causeRecent systematic reviews of population-based studies show only moderate geographical variations in stroke incidence in the world.55 Most of the stroke incidence in developing countries is likely accounted for by the increasing prevalence of conventional risk factors such as hypertension, diabetes, hypercholesterolaemia, and smoking as populations adopt a more urbanised lifestyle. However, there are some important differences in stroke type and cause between developed and developing countries, which become important from a management perspective. Many hospital-based studies suggest a significantly high proportion of stroke patients have intracranial haemorrhage, the proportion varying between 19–60% in various studies.23,26,40,41,47,48,56–61 However, hospital-based studies are likely to be biased towards the more severe end of the stroke spectrum in developing countries because of factors such as distance from hospital, access to transport, ability to afford hospital fees, and local beliefs about hospital attendance, which reduce rates of hospitalisation for patients with mild stroke. There are very few community-based studies in these settings and, therefore, a paucity of reliable data on stroke subtype prevalence in developing countries.第六部分Uncontrolled and commonly undiagnosed hypertension remains the most important cause of intracerebral haemorrhage in developing countries, but a high proportion is attributable to aneurysms and arteriovenous malformations.28,62 Although the prevalence of atherosclerotic and cardioembolic stroke seems to be the same in developing and developed countries, cardioembolic strokes occur at a younger age and are more commonly caused by valvular involvement in rheumatic or congenital heart disease in developing countries;62,63 there is also a higher prevalence of strokes caused by sickle-cell disease, vasculitis due to infection, or inflammation and coagulopathies (table 3).64,65Table 3. Causes of stroke specific to developing countries65Implementing evidence-based management in developing countriesA major development over the past decade has been the setting up of specialised stroke centres in many developed countries to provide early thrombolysis and clot removal therapy for acute patients with ischaemic stroke, on the basis of the principle that “time is brain”.66,67 The approval and licensing of thrombolytic therapy for ischaemic stroke in North America and Europe has helped to spread the practice of specialised stroke care from tertiary academic centres to large networks of acute stroke units in local hospitals and the emergence of guidelines for the management of acute stroke.68,69 There are now precise North American and European definitions of the organisation of acute stroke centres that take into account the range of interventions and imaging facilities.67,70 While large tertiary academic centres may offer a range of highly specialised therapy options—such as interventional neuroradiological and neurosurgical therapies, including the technical set-up for intra-arterial thrombolysis, haematoma evacuation, hemispheric craniotomy, and carotid surgery—local stroke units in regional hospitals may offer a smaller, less costly, but nevertheless effective service including rapid diagnosis assisted by CT imaging; intravenous thrombolysis in eligible patients; acute stroke care to maintain physiological homoeostasis and prevent stroke-related complications; management of dysphagia, nutrition, and communication; early mobilisation; and therapy for sensorimotor and cognitive impairments. Despite limited access to highly specialised procedures, local centres have the potential to deal with most strokes and stroke-related complications and selected patients need to be transferred to large centres only rarely.第七部分The mainstay of management in any setting, whether a highly specialised tertiary stroke centre or a low-level local stroke unit, is a structured approach towards patients with acute stroke and their continuous management in the postacute phase by dedicated staff trained to recognise, monitor, and treat stroke-related problems.71 There is general consensus among stroke specialists that the most effective components of acute stroke that improve overall outcomes consist of rapid and precise diagnosis, proactive general measures for prevention, and early recognition of complications and early mobilisation.72 Hankey and Warlow have extrapolated data from randomised studies to efficiency measures with a population-based approach and shown that the benefits of treatment in stroke units are much greater than those of treatment with intravenous thrombolysis.73 This is because the proportion of patients likely to be treated in stroke units is much greater than that treated with thrombolysis at present.Many developing countries have stroke centres that can provide imaging and interventional facilities comparable to major academic centres in developed countries. However, a high rate of thrombolysis does not reflect the overall quality of stroke care, but only represents a good prehospital setup and an effective rapid response to stroke presenting as an emergency. Although thrombolysis may result in significant improvements for individual patients, its effectiveness as an intervention to improve population outcomes is likely to be diluted because of its limited use in highly selected patients presenting early to specialist centres. The highest priority for providers of a stroke service in less well organised or less affluent settings must be to establish a stroke unit and multidisciplinary team to deliver organised stroke care.73 This approach has been widely adopted in developed countries, where the bulk of stroke care is provided by networks of local stroke units. Countries with low and medium levels of development might be best off aiming for a stepwise development of specialist stroke services, which favours the establishment of a basic stroke unit before setting up specialised teams for thrombolysis. This is particularly important because a higher proportion of patients in developing countries have haemorrhagic stroke and it may be difficult to implement sophisticated management paradigms for time-dependent interventions in patients with ischaemic stroke because of inadequate prehospital facilities and unreliable transportation.第八部分Specialised stroke units are an ideal opportunity for education and information on stroke prevention to patients and their families. Studies have shown that patients provided with structured information on measures to prevent further strokes in such settings have the highest adherence to long-term medication and lifestyle changes after stroke in developed countries.74 Non-compliance for long-term treatment—even for aspirin—is relatively high in developing countries. Education on behavioural modification and medical therapies during hospitalisation by specialists using simple messages adapted to patients' education and cultural background may be an opportunity to increase adherence to secondary prevention measures. The family has an important role in developing countries and should be included in health education to encourage and help patients with drug intake and lifestyle changes.ConclusionsDeveloping countries have some of the highest stroke mortality rates in the world that comprise over two-thirds of stroke deaths worldwide. Patterns of stroke types and causes of stroke differ between developing and developed countries but there are few studies of acute stroke care or long-term management to guide clinical practice. The quality and quantity of stroke care is patchy in developing countries, with areas of excellence intermixed with areas of severe need depending upon patients' location, local hospital facilities, ability to pay, education, and cultural, social, or religious beliefs. A population-based approach to improving acute care and rehabilitation for stroke is needed, which is evidence based and maximises the effectiveness of such care. Existing literature, largely from developed countries, supports the development of basic organised stroke-unit care, which must be tailored by health needs, service patterns, and affordability of individual settings. Further research is also needed to develop customised acute care and rehabilitation strategies most appropriate to the needs and circumstances of developing countries to help them alleviate the growing burden of stroke.第一部分Summary概述Developing countries have some of the highest stroke mortality rates in the world that account for over two-thirds of stroke deaths worldwide. Hospital-based studies suggest that the patterns of stroke types and causes of stroke differ between developing and developed countries, resulting in differing needs for acute and long-term care. Data on stroke care provision in developing countries are sparse and most of the available studies are biased towards urban settings in reasonably resourced health-care systems. A general overview shows that the quality and quantity of stroke care is largely patchy in low-income and middle-income countries, with areas of excellence intermixed with areas of severe need, depending upon patients' location, socioeconomic status, education, and cultural beliefs. Here we review the available literature on acute and long-term stroke management in developing countries. On the basis of available studies, largely from developed countries, we discuss the need to develop basic organised stroke-unit care in developing countries.世界上发展中国家的某些脑卒中死亡率最高，占全世界因脑卒中而死亡的2/3以上。医院患者研究表明发展中国家与发达国家之间的各种类型脑卒中的发病模式与病因有所不同，从而紧急救治与长期管理也应有所区别。资料显示发展中国家缺少脑卒中管理条件，由于城市合理的医疗保健体系资源，许多针对城市医院的可用研究存在偏差。通常总体印象显示低收入和中等收入的国家的脑卒中保健的数量与质量很大程度不协调，状况好坏参差不齐，这依赖于患者所在地、社会经济状况、教育程度及文化观念。本文我们对发展中国家脑卒中紧急救治和长期管理有关的可用的文献进行了综述。在可利用的研究基础之上，大部分来自发达国家，我们讨论了发展中国家建立基本的组织化脑卒中医疗单元的必要性。Introduction引言Stroke is the second commonest cause of mortality worldwide1 and remains a leading cause of adult physical disability. Developments in stroke care over the past two decades, particularly in acute management as well as in rehabilitation and long-term care, have greatly reduced mortality and dependence in many developed countries. Indeed, 10 year stroke mortality rates collected by the WHO MONICA project in Europe and China showed that changes in mortality rates in nine countries were mainly due to changes in case fatality rather than to changes in stroke incidence, suggesting that changes in the quality of stroke care may be responsible for changes in stroke mortality.2,3 By contrast, there has been limited progress in the management of patients with stroke in developing countries, despite increasing incidence of stroke and high stroke mortality rates that account for over two-thirds of stroke deaths worldwide.4 The slow uptake of evidence into clinical practice can be attributed to several reasons mainly relating to geography, limited health-care provision for the population as a whole, socioeconomic considerations, and health behaviour of different populations. In addition, hospital-based studies suggest differences in the type and causes of stroke between developed and developing countries, with higher incidence of haemorrhagic stroke and higher prevalence of stroke due to infective or inflammatory causes. Although many of the advances associated with reduced stroke mortality and morbidity will be equally applicable to developing countries, differences in types and causes of stroke, limitations posed by geography, accessibility of health care, availability of resources, social beliefs, and cultural expectations need to be taken into account when extrapolating stroke-management strategies from the developed to developing countries.5脑卒中是全世界第二大常见的死亡原因，仍是成人残疾的首要原因。发达国家中过去20多年脑卒中保健方面的进展，尤其是紧急救治、康复及长期管理方面，大大降低了死亡率和患者依赖程度。实际上，WHO心血管病人群监测（MONICA）计划在欧洲和中国收集的10年脑卒中死亡率表明9个国家死亡率的变化主要是由于个案死亡率的变化而不是脑卒中发病率的变化，这意味着脑卒中保健质量的提高可能是脑卒中死亡率下降的原因。与之相比，尽管发展中国家脑卒中发病率及死亡率越来越高，占世界脑卒中死亡2/3以上，但脑卒中患者管理的进步有限。这种缓慢的临床实践进步迹象是由于多种原因，主要与地理位置、所有人口的有限医疗保健条件、社会经济状况以及不同人群的健康行为。另外，医院患者研究表明发达国家与发展中国家脑卒中类型与病因差别，如出血性脑卒中发病率、因感染或炎症引起的脑卒中的盛行率更高。虽然降低脑卒中死亡率和发病率相关的许多进展可同样在发展中国家实施，但将发达国家脑卒中管理策略推行到发展中国家过程中，必须考虑脑卒中类型与病因差别、地理位置造成的局限性、健康保健程度、医疗资源利用率、社会信仰以及文化传统上的期望。第一部分编译：（793字）概述世界上发展中国家的某些脑卒中死亡率最高，占全世界因脑卒中而死亡的2/3以上。医院患者研究表明发展中国家与发达国家之间的各种类型脑卒中的发病模式与病因有所不同，从而紧急救治与长期管理也应有所区别。资料显示发展中国家缺少脑卒中管理条件，由于城市合理的医疗保健体系资源，许多针对城市医院的可用研究存在偏差。通常总体印象显示低收入和中等收入的国家的脑卒中保健的数量与质量很大程度不协调，状况好坏参差不齐，这依赖于患者所在地、社会经济状况、教育程度及文化观念。本文我们对发展中国家脑卒中紧急救治和长期管理有关的可用的文献进行了综述。在可利用的研究基础之上，大部分来自发达国家，我们讨论了发展中国家建立基本的组织化脑卒中医疗单元的必要性。引言脑卒中是全世界第二大常见的死亡原因，仍是成人残疾的首要原因。发达国家中过去20多年脑卒中保健方面的进展，尤其是紧急救治、康复及长期管理方面，大大降低了死亡率和患者依赖程度。实际上，WHO心血管病人群监测（MONICA）计划在欧洲和中国收集的10年脑卒中死亡率表明9个国家死亡率的变化主要是由于个案死亡率的变化而不是脑卒中发病率的变化，这意味着脑卒中保健质量的提高可能是脑卒中死亡率下降的原因。与之相比，尽管发展中国家脑卒中发病率及死亡率越来越高，占世界脑卒中死亡2/3以上，但脑卒中患者管理的进步有限。这种缓慢的临床实践进步迹象是由于多种原因，主要与地理位置、所有人口的有限医疗保健条件、社会经济状况以及不同人群的健康行为。另外，医院患者研究表明发达国家与发展中国家脑卒中类型与病因差别，如出血性脑卒中发病率、因感染或炎症引起的脑卒中的盛行率更高。虽然降低脑卒中死亡率和发病率相关的许多进展可同样在发展中国家实施，但将发达国家脑卒中管理策略推行到发展中国家过程中，必须考虑脑卒中类型与病因差别、地理位置造成的局限性、健康保健程度、医疗资源利用率、社会信仰以及文化传统上的期望。本人已认领该文第二、三部分编译，48小时后若未提交译文，请其他战友自由认领本人已认领该文第五部分编译，48小时后若未提交译文，请其他战友自由认领第二部分发展中国家治疗脑卒中的具体问题发展中国家关于脑卒中保健的研究比较分散，而且大多数现有的研究偏重于经济富裕且医疗保健系统资源合理的城市。一篇总体概述显示，脑卒中保健的质量和数量在低收入和中等收入国家（或由联合国发展计划界定的欠发达国家和中等发达国家6）相当不均衡。一部分地区（的质量和数量）非常好，而另一部分地区需求十分迫切，这取决于其地理位置，社会经济学地位，教育和文化信仰。脑卒中的认知和医院的使用许多研究已突出强调了脑卒中认知的重要性，同时也显示出发展中国家对脑卒中症状的认知水平的低下。25名患者中只有1名去了脑卒中门诊（4％），而在印度的一家三级医院中接受脑卒中治疗的患者中仅有27％意识到其曾遭受脑卒中。7 ,8同样重要的是，在第一个研究中80％的患者认为其受影响的器官是心脏，而在三级医院中只有33％的患者知道脑卒中累及了大脑。此外，在第二个研究中29％的脑卒中患者连一个预警信号都不知道。然而，在印度的同一所医院所作的另一项研究表明，55％的无脑卒中史的患者家属确认脑部为（脑卒中）的累及器官，仅有23％（的患者家属）连一种脑卒中的症状都无法列举出来。9在阿曼的一所大学附属医院的研究发现，35％的脑卒中高危病人表示脑卒中受累器官是大脑，68％的病人至少列举一种脑卒中的症状。10不过即使在发达国家脑卒中的认知和了解人就是不够的，在发展中国家又因收入、教育、年龄及性别不同而不同。11-15发达国家有45％-73％的人正确的认识到脑卒中受累器官是大脑,而30％-90％至少知道一种预警信号。11-18健康保健选择的多样性，其中许多未必根源于生物科学，可能是对急性脑卒中患者进行早期干预一个重大障碍。在一个印度城市进行的研究中，59％的脑卒中患者均先求诊于私人医生，再去医院寻求治疗，仅有38％的患者直接去医院。8在南非乡村地区的研究显示，40-80％的患者会在巫师或教堂的帮助下寻求“补充医疗”的照顾，多达10-33％的患者会先找巫师，而不是寻求医疗救助。19,20 台湾和玻利维亚的研究也反映出获得治疗脑卒中治疗中的城乡差别，其中显示分别有10％和50％的农村脑卒中患者不去医院或看医生。21,22医院是大多患者进行调查和处理的第一点。总体而言，欠发达或中等发达的国家就诊于医院的发生脑卒中的患者比例是难以估计的。一个菲律宾基于医院的研究表明，81％的患者就诊于医院23而乌克兰的前瞻性研究显示，66％的患者被送入院。24这些估计均来自相当完善的医疗服务的地区，不一定能代表其他发展中国家（的水平）。第三部分溶栓治疗和住院治疗在发展中国家，脑卒中患者被送入院的时间、影像学或治疗设备均有很大差异（见表1）。23,25-35研究显示，脑卒中患者在症状出现后应尽快入院进行治疗。来自冈比亚的研究显示，大多数患者出现症状后48小时内入院，26入院时间的中位数是8小时。25来自埃塞俄比亚的研究报道，入院时间的中位数13.5小时。36来自印度和菲律宾城区医院的研究指出，多达35％的脑卒中患者症状出现后3小时内入院，8,23,30与发达国家所报道的（入院）时间无差异。37表1 . 发展中国家对脑卒中的紧急救治不同地区间在成像系统的使用也有很大的差别(见表1)。1998年，18个非洲国家没有一台CT扫描仪，13个国家只有1台。只有北非的国家及南非有一定数量的CT扫描仪和核磁共振仪。38菲律宾的医院有27％无CT扫描设备，23但83％的中国综合性医院脑卒中患者可进行CT检查（65％）或MRI（43％）。291998年，中国上海和马来西亚的每百万人口已拥有约1-2台磁共振扫瞄仪,而在泰国、印度的泰米尔纳德邦、印度尼西亚及菲律宾，每百万人口可及的扫描仪器少于0.5台。39溶栓治疗报道率也不尽相同，从泰国一项大规模的、针对1624例患者的研究（2.1％）到印度一项较小规模、针对489例患者的研究（7％）不等。31静脉注射阿替普酶（重组组织型纤溶酶原激活剂，rtPA）已注册，并在许多中等发达国家和一些发展水平较低的国家推广。（经济）承受能力对于某些地区的调查和治疗仍是重要的因素。1102名尼日利亚的脑卒中患者仅有101人有钱做CT扫描（9％）。40在埃塞俄比亚，由于其高昂的代价，仅有38.3％的患者做了CT扫描。41印度一项研究中显示，489名患者中有10％尽管符合溶栓治疗的所有标准，却因无法负担阿替普酶而没能得到治疗。31留院时间的长短因地区和承受能力不同，差别也很大。巴基斯坦的平均住院时间仅3天，35而中国的参保病人则为32天。29目前关于发展中国家的专业化脑卒中诊疗处的资料很少。一项巴西的研究表明，在脑卒中诊疗处和普通门诊接受治疗的患者在发作10天后结局变量或住院时间长短上并无明显差异。34不过，在脑卒中诊疗处接受治疗的患者在1月，3月，6月时点上的死亡率存在较低的趋势，未达到统计上的意义可能是由于其样本太小。另一项来自泰国的研究显示，早期支持性出院和住院治疗的患者相比两组的死亡率无明显差异，但在家接受治疗的患者更能感知所接受的医疗保健。33 screen.width-333)this.width=screen.width-333" width=640 height=400 title="Click to view full 1.JPG (718 X 449)" border=0 align=absmiddle>Little information is available on lifestyle modification after stroke in developing countries. The PREMISE study suggests that 77–89% of patients have knowledge of the benefits of smoking cessation, diet modification, and regular physical activity. However, 52•5% did not engage in regular moderate physical activity, and 35% had difficulties in complying with dietary advice due to the expense and lack of availability of healthy food items.50 On the Kinmen islands, China, 36% of stroke survivors eat meat less than once per week and 36% exercise more than once per week compared with 19% and 18% respectively for people who had not had stroke.21 The figure shows the location of the studies covered in this Review.有关发展中国家人们卒中后生活方式改变方面的信息很少，PREMISE研究表明有77-89 %的病人了解戒烟、改变饮食习惯、经常参加体育活动的益处。然而，还是有52.5%的人没有经常进行适度运动，35%的人由于费用问题及对健康食品的种类缺乏了解而难于改变饮食习惯。50在中国的金门岛，脑卒中幸存者每周吃肉少于一次的有36%，每周参加一次以上体育锻炼的也有36%，而与之相比，没有得过卒中的人分别为19%和18%。21此图显示了这项综述涵盖的研究地点。图:此项综述中涵盖的研究地点Purple circles indicate studies reporting data on stroke care in the strict sense; yellow circles indicate studies reporting data on additional care-relevant subjects according to high (green), medium (blue) and low (red) human development based on the Human development report 2005.1紫色部分表示其范围内的研究报告了按照严格意义进行卒中护理的数据；黄色部分表示其范围内的研究报告了关于额外护理相关主题的数据，这些主题是基于2005年1月的人类发展报告划分的高(绿色) 、中等(蓝色)和低(红色)人类发展程度。Differences in stroke type and causeRecent systematic reviews of population-based studies show only moderate geographical variations in stroke incidence in the world.55 Most of the stroke incidence in developing countries is likely accounted for by the increasing prevalence of conventional risk factors such as hypertension, diabetes, hypercholesterolaemia, and smoking as populations adopt a more urbanised lifestyle. However, there are some important differences in stroke type and cause between developed and developing countries, which become important from a management perspective. Many hospital-based studies suggest a significantly high proportion of stroke patients have intracranial haemorrhage, the proportion varying between 19–60% in various studies.23,26,40,41,47,48,56–61 However, hospital-based studies are likely to be biased towards the more severe end of the stroke spectrum in developing countries because of factors such as distance from hospital, access to transport, ability to afford hospital fees, and local beliefs about hospital attendance, which reduce rates of hospitalisation for patients with mild stroke. There are very few community-based studies in these settings and, therefore, a paucity of reliable data on stroke subtype prevalence in developing countries.有关脑卒中类型及原因的差别近期对以人群为基础的研究进行的系统性回顾表明，世界上脑卒中发病率只有轻微的地域差异性。55发展中国家大部分的卒中发病原因可能是其传统危险因素，如高血压、糖尿病、高胆固醇血症、吸烟。这些因素随着人们采取更都市化的生活方式而日益流行。但是，发达国家和发展中国家之间的脑卒中类型及原因之间存在着一些重要的差别，从管理的角度看这些差别很重要。许多以医院为基础的研究表明：有很高比例的卒中患者会颅内出血，这一比例随研究的不同在19-60%之间变化。23 ，26，40，41，47，48，56-61不过，以医院为基础的研究可能会使发展中国家的卒中谱向更严重的方向偏离，这是由于一些因素如与医院的距离、交通是否便利、负担住院费的能力和当地对住院治疗效果的信心等降低了轻度卒中病人的住院率。还有这里以社区为基础的研究很少，因此缺乏可靠的数据以确定发展中国家流行的卒中亚型。第五部分:有关发展中国家人们卒中后生活方式改变方面的信息很少，PREMISE研究表明有77-89 %的病人了解戒烟、改变饮食习惯、经常参加体育活动的益处。然而，还是有52.5%的人没有经常进行适度运动，35%的人由于费用问题及对健康食品的种类缺乏了解而难于改变饮食习惯。50在中国的金门岛，脑卒中幸存者每周吃肉少于一次的有36%，每周参加一次以上体育锻炼的也有36%，而与之相比，没有得过卒中的人分别为19%和18%。21此图显示了这项综述涵盖的研究地点。图:此项综述中涵盖的研究地点紫色部分表示其范围内的研究报告了按照严格意义进行卒中护理的数据；黄色部分表示其范围内的研究报告了关于额外护理相关主题的数据，这些主题是基于2005年1月的人类发展报告划分的高(绿色) 、中等(蓝色)和低(红色)人类发展程度。有关脑卒中类型及原因的差别近期对以人群为基础的研究进行的系统性回顾表明，世界上脑卒中发病率只有轻微的地域差异性。55发展中国家大部分的卒中发病原因可能是其传统危险因素，如高血压、糖尿病、高胆固醇血症、吸烟。这些因素随着人们采取更都市化的生活方式而日益流行。但是，发达国家和发展中国家之间的脑卒中类型及原因之间存在着一些重要的差别，从管理的角度看这些差别很重要。许多以医院为基础的研究表明：有很高比例的卒中患者会颅内出血，这一比例随研究的不同在19-60%之间变化。23 ，26，40，41，47，48，56-61不过，以医院为基础的研究可能会使发展中国家的卒中谱向更严重的方向偏离，这是由于一些因素如与医院的距离、交通是否便利、负担住院费的能力和当地对住院治疗效果的信心等降低了轻度卒中病人的住院率。还有这里以社区为基础的研究很少，因此缺乏可靠的数据以确定发展中国家流行的卒中亚型。第八部分Specialised stroke units are an ideal opportunity for education and information on stroke prevention to patients and their families. Studies have shown that patients provided with structured information on measures to prevent further strokes in such settings have the highest adherence to long-term medication and lifestyle changes after stroke in developed countries.74 Non-compliance for long-term treatment—even for aspirin—is relatively high in developing countries. Education on behavioural modification and medical therapies during hospitalisation by specialists using simple messages adapted to patients' education and cultural background may be an opportunity to increase adherence to secondary prevention measures. The family has an important role in developing countries and should be included in health education to encourage and help patients with drug intake and lifestyle changes.专业的脑卒中医疗单元对患者和他们的家属来说是一个接受教育和获取信息的理想机会。研究表明发达国家的患者在这种环境中拥有预防进一步脑卒中方法的结构性信息，他们最能够坚持脑卒中后长期治疗和生活方式的改变。在发展中国家患者对长期治疗甚至对阿司匹林没有顺应性的比例是很高的。在住院期间，专家使用适合患者教育和文化背景的简单信息对患者进行行为方式和医疗的教育或许是一个增加患者坚持后期预防措施的机会。在发展中国家，家属是一个重要角色，应该将他们包括在健康教育中来鼓励和帮助患者坚持服药和改变生活方式。ConclusionsDeveloping countries have some of the highest stroke mortality rates in the world that comprise over two-thirds of stroke deaths worldwide. Patterns of stroke types and causes of stroke differ between developing and developed countries but there are few studies of acute stroke care or long-term management to guide clinical practice. The quality and quantity of stroke care is patchy in developing countries, with areas of excellence intermixed with areas of severe need depending upon patients' location, local hospital facilities, ability to pay, education, and cultural, social, or religious beliefs. A population-based approach to improving acute care and rehabilitation for stroke is needed, which is evidence based and maximises the effectiveness of such care. Existing literature, largely from developed countries, supports the development of basic organised stroke-unit care, which must be tailored by health needs, service patterns, and afford ability of individual settings. Further research is also needed to develop customised acute care and rehabilitation strategies most appropriate to the needs and circumstances of developing countries to help them alleviate the growing burden of stroke.结论世界上发展中国家的某些脑卒中死亡率最高，占全世界因脑卒中而死亡的2/3以上。发展中国家与发达国家之间的各种类型脑卒中的发病模式与病因有所不同，但是在发展中国家很少有指导临床实践的紧急救治与长期管理的研究。在发展中国家脑卒中保健的数量与质量是不均衡的，状况好坏参差不齐，这依赖于患者所在地、当地医院设施、支付能力、教育和文化、社会或宗教信仰。一项基于人口的改善脑卒中的紧急救治和康复的措施是必须得，这是立足的根据，也使这样的保健取得最大效果。目前大量从发达国家来源的文献支持基本的组织化脑卒中医疗单元的发展，这种医疗单元必须根据个体所处环境的健康需要、服务方式和支付能力进行修改。需要更多的研究来发展用户化的紧急救治和康复策略，使之最适合发展中国家的需要和环境，帮助他们减轻越来越严重的脑卒中负担。第八部分编译：（595字）专业的脑卒中医疗单元对患者和他们的家属来说是一个接受教育和获取信息的理想机会。研究表明发达国家的患者在这种环境中拥有预防进一步脑卒中方法的结构性信息，他们最能够坚持脑卒中后长期治疗和生活方式的改变。在发展中国家患者对长期治疗甚至对阿司匹林没有顺应性的比例是很高的。在住院期间，专家使用适合患者教育和文化背景的简单信息对患者进行行为方式和医疗的教育或许是一个增加患者坚持后期预防措施的机会。在发展中国家，家属是一个重要角色，应该将他们包括在健康教育中来鼓励和帮助患者坚持服药和改变生活方式。结论世界上发展中国家的某些脑卒中死亡率最高，占全世界因脑卒中而死亡的2/3以上。发展中国家与发达国家之间的各种类型脑卒中的发病模式与病因有所不同，但是在发展中国家很少有指导临床实践的紧急救治与长期管理的研究。在发展中国家脑卒中保健的数量与质量是不均衡的，状况好坏参差不齐，这依赖于患者所在地、当地医院设施、支付能力、教育和文化、社会或宗教信仰。一项基于人口的改善脑卒中的紧急救治和康复的措施是必须得，这是立足的根据，也使这样的保健取得最大效果。目前大量从发达国家来源的文献支持基本的组织化脑卒中医疗单元的发展，这种医疗单元必须根据个体所处环境的健康需要、服务方式和支付能力进行修改。需要更多的研究来发展用户化的紧急救治和康复策略，使之最适合发展中国家的需要和环境，帮助他们减轻越来越严重的脑卒中负担。本人认领该文第六部分编译，48小时后若未提交译文，请其他战友自由认领本人认领该文第四部分编译，48小时后若未提交译文，请其他战友自由认领Access to and availability of adequate rehabilitation facilities is also limited in countries with low or medium development. Only 47% of hospitalised patients with stroke were seen by a therapist in The Gambia;26 and in large teaching hospitals in southern China, routine care included no regular professional physiotherapy during the whole hospitalisation period.42 The mean duration between stroke onset and admission to a rehabilitation facility is 53 days in Thailand and 63 days and 76 days in two Turkish studies.43–45 In South Africa, only 39% of old and 56% of young patients with stroke attended outpatients' physiotherapy clinics once a week or once a month after hospital discharge.46中低等发展程度的国家中人们能利用的康复设施也是很有限。在冈比亚脑卒中住院患者中只有47%的人接受了专业医师的治疗； 26在中国华南地区的大型教学型医院中，住院期间的常规护理不包括正规的专业理疗。42在泰国从卒中发作到能够使用康复设施的平均持续时间是53天，而在土耳其的两项研究中分别为63天及76天。43 - 45 在南非脑卒中患者出院后只有39%的老人及56%的青年每周或每月会去一次门诊病人的理疗诊所。46Secondary preventionMost studies show poor outcomes in patients with stroke in terms of mortality and implementation of secondary prevention measures (table 2).19,25,26,33,34,42–51 Many of the problems of poor concordance with secondary prevention measures have been attributed to lack of equipment for the monitoring of blood pressure or other risk factors, non-availability of drugs, and affordability of treatment.19,50 A Chinese study showed that lower socioeconomic status was associated with higher 3 year mortality in patients with ischaemic stroke.49 Cost-effective secondary prevention has been proposed by WHO guidelines for low-income and middle-income populations, suggesting lifestyle changes and affordable, accessible, and effective pharmacological antihypertensive treatments, antiplatelet treatments, and blood-cholesterol reduction.52 Aspirin has been recommended as the most cost-effective antiplatelet medical therapy worldwide because it is cheap and easily available everywhere in the world but compliance with treatment is commonly poor. 52–54 Studies from The Gambia26 and South Africa19 reported that although 65% and 83% respectively of stroke patients were treated with antihypertensive drugs at the time of discharge, only 13% of stroke survivors in The Gambia and 8% of survivors in South Africa were taking antihypertensive treatment after 1 year. Similarly, of the 71% of patients discharged on aspirin in The Gambia,only 7% were still taking aspirin 1 year later.26 In another study from The Gambia, 33% of stroke survivors were treated with antihypertensive medication at 6 months after stroke; 3–4 years later only 15% were satisfactorily controlled for hypertension and 15% received aspirin regularly.25 The WHO PREMISE study of ten medium developed countries (Brazil, Egypt, India, Indonesia, Islamic Republic of Iran, Pakistan, Russian Federation, Sri Lanka, Tunisia, and Turkey) reported high percentages of patients with cerebrovascular diseases using drugs for secondary prevention. Aspirin use ranged from 31% to 90%, the use of beta-blockers from 6•8% to 46%, angiotensin-converting-enzyme inhibitor use from 5% to 59%, and statin use from 2% to 37%.50 94% of these patients reported that their blood pressure had been measured within the past 12 months. Patients in this study were recruited from outpatient clinics, which may reflect better access to health services and greater acceptance of drug treatment than among the general population in these settings.二级预防大部分研究中卒中患者的预后以死亡率和实施二级预防措施的形式表现较差(表2 ) 。19，25，26，33，34，42-51与二级预防措施表现不一致的问题的原因可归结为缺乏监测血压及其它危险因子的设备，药物匮乏，和负担不起医疗费。19，50中国一项研究显示：低社会经济地位与缺血性脑卒中患者较高的3年期死亡率有关。49世界卫生组织向中低等收入人群推荐了成本效益型二级预防的指导原则，此原则建议改变生活方式、应用价廉、易得及有效的降压药物、抗血小板治疗及降低血液中胆固醇水平。52阿司匹林由于价廉易得已被推荐为世界上最符合成本效益的抗血小板药物。但研究显示对它的应用并不广泛。52– 54来自冈比亚26和南非19 研究报道说，这两国脑卒中患者出院时虽然分别有65%和83%的人在以药物进行抗高血压治疗，但一年后还坚持治疗的分别只有13%和8%。同样，在冈比亚出院时有71%的病人在服用阿司匹林，而1年后仍在服用的人只有7%。26来自冈比亚另一项研究显示，在脑卒中后6个月内有33%的患者在服用降压药物以控制高血压；而3-4年后，只有15%的人的高血压得到了满意的控制，同时也只有15%的人在有规律的服用阿司匹林。25世界卫生组织关于10个中等发达国家（巴西、埃及、印度、印尼、伊朗伊斯兰共和国、巴基斯坦、俄罗斯联邦、斯里兰卡、突尼斯和土耳其）的PREMISE研究报告显示，有很高比例的脑血管病患者在服用药物进行二级预防，阿斯匹服用的比例范围是31%至90%，β受体阻滞药的使用是6.8%至46%，血管紧张素转换酶抑制剂的使用是5%到59%，而他汀类药物的使用是2%至37P这些患者中有94%的人报告说，他们曾在过去的12个月内测过血压。 此研究的中的患者是从门诊病人中招募的，这反映了这些患者可能比这些地区的一般人群能更好地享有卫生服务并对药物治疗有更大程度的接受。第六部分：Uncontrolled and commonly undiagnosed hypertension remains the most important cause of intracerebral haemorrhage in developing countries, but a high proportion is attributable to aneurysms and arteriovenous malformations. Although the prevalence of atherosclerotic and cardioembolic stroke seems to be the same in developing and developed countries, cardioembolic strokes occur at a younger age and are more commonly caused by valvular involvement in rheumatic or congenital heart disease in developing countries;62,63 there is also a higher prevalence of strokes caused by sickle-cell disease, vasculitis due to infection, or inflammation and coagulopathies (table 3). 在发展中国家，未治疗的和未诊断的高血压是脑出血最主要的病因，但是仍有相当一部分脑出血是由于动脉瘤和动静脉畸形引起的28,62。尽管动脉粥样硬化性和动脉粥样硬化性和心脏栓子性脑中风的发病率在发展中国家和发达国家基本一致，但是在发展中国家心源性脑卒中多见于年龄较轻的病人而且病因主要是风湿性或者先天性心脏病瓣膜受累造成的;62,63同时在发展中国家，由于镰状红细胞病，感染性脉管炎，炎症和凝血紊乱造成的脑卒中也较发达国家更常见64,65。（表3）Table 3. Causes of stroke specific to developing countries65 screen.width-333)this.width=screen.width-333" width=640 height=419 title="Click to view full 1.JPG (800 X 524)" border=0 align=absmiddle>表3：发展中国家脑卒中的病因 screen.width-333)this.width=screen.width-333" width=640 height=424 title="Click to view full 2.JPG (800 X 530)" border=0 align=absmiddle>Implementing evidence-based management in developing countriesA major development over the past decade has been the setting up of specialised stroke centres in many developed countries to provide early thrombolysis and clot removal therapy for acute patients with ischaemic stroke, on the basis of the principle that “time is brain”.66,67 The approval and licensing of thrombolytic therapy for ischaemic stroke in North America and Europe has helped to spread the practice of specialised stroke care from tertiary academic centres to large networks of acute stroke units in local hospitals and the emergence of guidelines for the management of acute stroke.68,69 There are now precise North American and European definitions of the organisation of acute stroke centres that take into account the range of interventions and imaging facilities.67,70 While large tertiary academic centres may offer a range of highly specialised therapy options—such as interventional neuroradiological and neurosurgical therapies, including the technical set-up for intra-arterial thrombolysis, haematoma evacuation, hemispheric craniotomy, and carotid surgery—local stroke units in regional hospitals may offer a smaller, less costly, but nevertheless effective service including rapid diagnosis assisted by CT imaging; intravenous thrombolysis in eligible patients; acute stroke care to maintain physiological homoeostasis and prevent stroke-related complications; management of dysphagia, nutrition, and communication; early mobilisation; and therapy for sensorimotor and cognitive impairments. Despite limited access to highly specialised procedures, local centres have the potential to deal with most strokes and stroke-related complications and selected patients need to be transferred to large centres only rarely.在发展中国家实施循症治疗过去十年，在“时间就是脑“这个基础上，（治疗脑卒中的）主要的进展是在很多发达国家建立了专门的脑卒中中心，可以为患缺血性脑卒中的急性期病人提供早期溶栓和清除血块的治疗66,67。正是得益于溶栓疗法治疗缺血性脑卒中在北美和欧洲获得了认可和批准，这种专门的脑卒中治疗方式逐渐由第三方学术中心提供的专门脑卒中治疗中心推广到地方医院的急性脑卒中治疗科室。并且出现了治疗急性脑卒中的指导方针68,69。现在，参考治疗的范围和影像设备，在北美和欧洲已经对急性脑卒中（诊疗）中心的组织有了严谨的定义67,70。尽管大的第三方学术中心（急性脑卒中中心）能够提供一系列极其专业的治疗措施-像介入神经放射和神经外科治疗，包括可用于动脉内溶栓，血肿吸除，大脑半球开颅手术，经动脉手术的技术设备，地方医院的脑卒中科室则可以提供较小的，较经济的，然而很有效的治疗措施包括CT影像辅助的快速诊断；对有适应症的病人进行静脉溶栓治疗；急性脑卒中护理以便维持生理稳态和预防相关并发症；对吞咽困难，营养和交流进行处理；早期活动；以及对感觉运动和认知障碍进行治疗。尽管地方医院提供的专业治疗方法有限，但是他们仍然有能力处理大多数的脑卒中类型和相关并发症。很少有病人需要转院到大的治疗中心。第六部分编译：（1009字）在发展中国家，未治疗的和未诊断的高血压是脑出血最主要的病因，但是仍有相当一部分脑出血是由于动脉瘤和动静脉畸形造成的28,62。尽管发展中国家和发达国家动脉粥样硬化性和心源性脑卒中的发病率基本一致，但是在发展中国家心源性脑卒中发病年龄较轻而且主要是由于风湿性心脏病或者先天性心脏病瓣膜受累造成的;62,63同时在发展中国家，由于镰状红细胞病以及由于感染，炎症和凝血紊乱引起的血管炎造成的脑卒中也较发达国家常见64,65。(表3)在发展中国家实施循症治疗过去十年，基于“治疗越早效果越好（或者译为：治疗越早脑损伤越小）“这个原则，（治疗脑卒中的）主要的进展是在很多发达国家建立了专门的脑卒中诊疗中心，为患急性缺血性脑卒中的病人提供早期溶栓和血肿清除治疗66,67。正是得益于溶栓疗法在北美和欧洲获得了认可和批准，这种专门的脑卒中治疗方式逐渐由专业的脑卒中诊疗中心广泛推广到各个地方医院的急性脑卒中病房。并且出现了针对急性脑卒中治疗的指导方针68,69。现在，北美和欧洲已经对急性脑卒中（诊疗）中心的组织构成进行了严格的规定，主要的指标是治疗的专业程度和影像设备的水平， 67,70。专业的急性脑卒中诊疗中心能够提供一系列极其专业的治疗措施-像神经介入放射和神经外科治疗，包括动脉内溶栓，血肿吸除，大脑半球开颅手术，颈动脉手术，地方医院的脑卒中科室则可以提供较小的，较经济的，然而很有效的治疗措施，包括CT影像辅助的快速诊断；对有适应症的病人进行静脉溶栓治疗；急性脑卒中护理以便维持病人生理状态平衡和预防相关并发症；对吞咽困难，摄入营养和交流障碍进行处理；早期恢复性锻炼；以及对感觉运动功能和认知障碍进行治疗。尽管地方医院提供的专业治疗方法有限，但是他们仍然有能力处理大多数的脑卒中类型和相关并发症。因此，只有极少数病人需要转送到大的治疗中心进行处理。蓝色部分为意译的，请各位战友帮助我分析一下翻译的合适吗？另外，不会发多张图片，大家见谅。表3：发展中国家脑卒中的病因 screen.width-333)this.width=screen.width-333" width=640 height=424 title="Click to view full 2.JPG (800 X 530)" border=0 align=absmiddle>第四部分:中低等发展程度的国家中人们能利用的康复设施也是很有限。在冈比亚脑卒中住院患者中只有47%的人接受了专业医师的治疗； 26在中国华南地区的大型教学型医院中，住院期间的常规护理不包括正规的专业理疗。42在泰国从卒中发作到能够使用康复设施的平均持续时间是53天，而在土耳其的两项研究中分别为63天及76天。43 - 45 在南非脑卒中患者出院后只有39%的老人及56%的青年每周或每月会去一次门诊病人的理疗诊所。46二级预防大部分研究中卒中患者的预后以死亡率和实施二级预防措施的形式表现较差(表2 ) 。19，25，26，33，34，42-51与二级预防措施表现不一致的问题的原因可归结为缺乏监测血压及其它危险因子的设备，药物匮乏，和负担不起医疗费。19，50中国一项研究显示：低社会经济地位与缺血性脑卒中患者较高的3年期死亡率有关。49世界卫生组织向中低等收入人群推荐了成本效益型二级预防的指导原则，此原则建议改变生活方式、应用价廉、易得及有效的降压药物、抗血小板治疗及降低血液中胆固醇水平。52阿司匹林由于价廉易得已被推荐为世界上最符合成本效益的抗血小板药物。但研究显示对它的应用并不广泛。52– 54来自冈比亚26和南非19 研究报道说，这两国脑卒中患者出院时虽然分别有65%和83%的人在以药物进行抗高血压治疗，但一年后还坚持治疗的分别只有13%和8%。同样，在冈比亚出院时有71%的病人在服用阿司匹林，而1年后仍在服用的人只有7%。26来自冈比亚另一项研究显示，在脑卒中后6个月内有33%的患者在服用降压药物以控制高血压；而3-4年后，只有15%的人的高血压得到了满意的控制，同时也只有15%的人在有规律的服用阿司匹林。25世界卫生组织关于10个中等发达国家（巴西、埃及、印度、印尼、伊朗伊斯兰共和国、巴基斯坦、俄罗斯联邦、斯里兰卡、突尼斯和土耳其）的PREMISE研究报告显示，有很高比例的脑血管病患者在服用药物进行二级预防，阿斯匹服用的比例范围是31%至90%，β受体阻滞药的使用是6.8%至46%，血管紧张素转换酶抑制剂的使用是5%到59%，而他汀类药物的使用是2%至37P这些患者中有94%的人报告说，他们曾在过去的12个月内测过血压。 此研究的中的患者是从门诊病人中招募的，这反映了这些患者可能比这些地区的一般人群能更好地享有卫生服务并对药物治疗有更大程度的接受。 表2.发展中国家脑卒中的长期管理已将第四部分表格翻译出来,没有时间校对,请哪位高手帮忙校对一下做成图片传上来吧.请斑竹将分加给那位做图的战友. 新建 Microsoft Excel 工作表.xls (20.0k)第七部分The mainstay of management in any setting, whether a highly specialised tertiary stroke centre or a low-level local stroke unit, is a structured approach towards patients with acute stroke and their continuous management in the postacute phase by dedicated staff trained to recognise, monitor, and treat stroke-related problems.71 There is general consensus among stroke specialists that the most effective components of acute stroke that improve overall outcomes consist of rapid and precise diagnosis, proactive general measures for prevention, and early recognition of complications and early mobilisation.72 Hankey and Warlow have extrapolated data from randomised studies to efficiency measures with a population-based approach and shown that the benefits of treatment in stroke units are much greater than those of treatment with intravenous thrombolysis.73 This is because the proportion of patients likely to be treated in stroke units is much greater than that treated with thrombolysis at present.在任何环境中，无论是在高专业水平的三级脑卒中治疗中心还是在低水平的地方脑卒中医疗病房，脑卒中治疗主要是针对急性脑卒中患者及急性期后持续管理的一种有组织的措施，通过对专业医务人员培训，来识别、监护和治疗脑卒中相关问题。脑卒中治疗专家对急性脑卒中改善全部预后的最有效的组成部分上认识一致，包括迅速和精确的诊断、积极的综合预防措施和早期识别并发症及早期活动。Hankey 和 Warlow已经从随机研究资料中推断出基于人口措施的有效方法并且表明在脑卒中医疗病房治疗比静脉溶栓治疗获益更大。这是因为目前愿意在脑卒中医疗病房治疗的患者比例远大于溶栓治疗的患者比例。Many developing countries have stroke centres that can provide imaging and interventional facilities comparable to major academic centres in developed countries. However, a high rate of thrombolysis does not reflect the overall quality of stroke care, but only represents a good prehospital setup and an effective rapid response to stroke presenting as an emergency. Although thrombolysis may result in significant improvements for individual patients, its effectiveness as an intervention to improve population outcomes is likely to be diluted because of its limited use in highly selected patients presenting early to specialist centres. The highest priority for providers of a stroke service in less well organised or less affluent settings must be to establish a stroke unit and multidisciplinary team to deliver organised stroke care.73 This approach has been widely adopted in developed countries, where the bulk of stroke care is provided by networks of local stroke units. Countries with low and medium levels of development might be best off aiming for a stepwise development of specialist stroke services, which favours the establishment of a basic stroke unit before setting up specialised teams for thrombolysis. This is particularly important because a higher proportion of patients in developing countries have haemorrhagic stroke and it may be difficult to implement sophisticated management paradigms for time-dependent interventions in patients with ischaemic stroke because of inadequate prehospital facilities and unreliable transportation.许多发展中国家有脑卒中治疗中心，这里能够提供影像诊断和介入设备，相当于发达国家的主要学术中心。然而，高的溶栓率并不能反映脑卒中治疗的全部特性，而仅仅代表脑卒中作为急症发生时一个好的院前措施和有效的快速反应。虽然溶栓对个别的患者可能会显著地改善症状，但是它作为一种介入来改善全部患者预后的作用可能并不大，因为它被限制使用在专业中心对高选择性早期患者。在缺乏良好组织或缺乏充分设施的地方，能够提供脑卒中康复的最佳的医疗机构必须建立脑卒中医疗病房和多学科康复医疗小组来进行系统的脑卒中治疗。发达国家已经广泛采用这种方法，他们有网络化的地方脑卒中医疗病房可以提供大量的脑卒中治疗。中低等发展程度国家应建立的最好目标或许是一个逐次建立的专业脑卒中治疗，既在建立溶栓的专门治疗组织之前应该先建立基础的脑卒中医疗病房。这是特别重要的，因为在发展中国家脑卒中患者中出血性脑卒中比例很高，并且由于院前设施不足和后送不可靠，在这些患者中应用高端设备进行时间依从性（越早治疗效果越好）介入治疗是非常困难的。编译：（717字）在任何环境中，无论是在高专业水平的三级脑卒中治疗中心还是在低水平的地方脑卒中医疗病房，脑卒中治疗主要是针对急性脑卒中患者及急性期后持续管理的一种有组织的措施，通过对专业医务人员培训，来识别、监护和治疗脑卒中相关问题。脑卒中治疗专家对急性脑卒中改善全部预后的最有效的组成部分上认识一致，包括迅速和精确的诊断、积极的综合预防措施和早期识别并发症及早期活动。Hankey 和 Warlow已经从随机研究资料中推断出基于人口措施的有效方法并且表明在脑卒中医疗病房治疗比静脉溶栓治疗获益更大。这是因为目前愿意在脑卒中医疗病房治疗的患者比例远大于溶栓治疗的患者比例。许多发展中国家有脑卒中治疗中心，这里能够提供影像诊断和介入设备，相当于发达国家的主要学术中心。然而，高的溶栓率并不能反映脑卒中治疗的全部特性，而仅仅代表脑卒中作为急症发生时一个好的院前措施和有效的快速反应。虽然溶栓对个别的患者可能会显著地改善症状，但是它作为一种介入来改善全部患者预后的作用可能并不大，因为它被限制使用在专业中心对高选择性早期患者。在缺乏良好组织或缺乏充分设施的地方，能够提供脑卒中康复的最佳的医疗机构必须建立脑卒中医疗病房和多学科康复医疗小组来进行系统的脑卒中治疗。发达国家已经广泛采用这种方法，他们有网络化的地方脑卒中医疗病房可以提供大量的脑卒中治疗。中低等发展程度国家应建立的最好目标或许是一个逐次建立的专业脑卒中治疗，既在建立溶栓的专门治疗组织之前应该先建立基础的脑卒中医疗病房。这是特别重要的，因为在发展中国家脑卒中患者中出血性脑卒中比例很高，并且由于院前设施不足和后送不可靠，在这些患者中应用高端设备进行时间依从性（越早治疗效果越好）介入治疗是非常困难的。引用 ：“在发展中国家，未治疗的和未诊断的高血压是脑出血最主要的病因，但是更多是由于动脉瘤和动静脉畸形所致。尽管发展中国家和发达国家动脉粥样硬化性和心源性脑卒中的发病率基本一致，但是在发展中国家心源性脑卒中发病年龄较轻而且主要是由于风湿性心脏病或者先天性心脏病瓣膜受累造成的;同时在发展中国家，由于镰状红细胞病以及由于感染，炎症和凝血紊乱引起的血管炎造成的脑卒中也较发达国家常见。(表3)”高血压是脑出血占首位的病因，这是无须质疑的。而动脉瘤和动静脉畸形是其他的常见病因。现在的翻译明显不对，会让人误认为动脉瘤造成的脑出血比高血压更多。建议改为“在发展中国家，未治疗的和未诊断的高血压是脑出血最主要的病因，但是有相当一部分脑出血是由于动脉瘤和动静脉畸形造成的。”这样更符合原文的意思。结合以上各位战友的翻译和校对，进一步校对（文中下划线部分）后全文编译发展中国家脑卒中的紧急救治与长期管理概述世界上发展中国家的某些脑卒中死亡率最高，占全世界因脑卒中而死亡的2/3以上。医院患者研究表明发展中国家与发达国家之间的各种类型脑卒中的发病模式与病因有所不同，从而紧急救治与长期管理也应有所区别。资料显示发展中国家缺少脑卒中管理条件，由于城市合理的医疗保健体系资源，许多针对城市医院的可用研究存在偏差。通常总体印象显示低收入和中等收入的国家的脑卒中保健的数量与质量很大程度不协调，状况好坏参差不齐，这依赖于患者所在地、社会经济状况、教育程度及文化观念。本文我们对发展中国家脑卒中紧急救治和长期管理有关的可用的文献进行了综述。在可利用的研究基础之上，大部分来自发达国家，我们讨论了发展中国家建立基本的组织化脑卒中医疗单元的必要性。引言脑卒中是全世界第二大常见的死亡原因，仍是成人残疾的首要原因。发达国家中过去20多年脑卒中保健方面的进展，尤其是紧急救治、康复及长期管理方面，大大降低了死亡率和患者依赖程度。实际上，WHO心血管病人群监测（MONICA）计划在欧洲和中国收集的10年脑卒中死亡率表明9个国家死亡率的变化主要是由于个案死亡率的变化而不是脑卒中发病率的变化，这意味着脑卒中保健质量的提高可能是脑卒中死亡率下降的原因。与之相比，尽管发展中国家脑卒中发病率及死亡率越来越高，占世界脑卒中死亡2/3以上，但脑卒中患者管理的进步有限。这种缓慢的临床实践进步迹象是由于多种原因，主要与地理位置、所有人口的有限医疗保健条件、社会经济状况以及不同人群的健康行为。另外，医院患者研究表明发达国家与发展中国家脑卒中类型与病因差别，如出血性脑卒中发病率、因感染或炎症引起的脑卒中的盛行率更高。虽然降低脑卒中死亡率和发病率相关的许多进展可同样在发展中国家实施，但将发达国家脑卒中管理策略推行到发展中国家过程中，必须考虑脑卒中类型与病因差别、地理位置造成的局限性、健康保健程度、医疗资源利用率、社会信仰以及文化传统上的期望。发展中国家治疗脑卒中的具体问题发展中国家缺少有关脑卒中管理指南的研究，而且大多数现有的研究偏重于经济富裕且医疗保健系统资源合理的城市。一篇综述显示，脑卒中管理的质量和数量在低收入和中等收入国家（或由联合国发展计划署界定的欠发达国家和中等发达国家）相当不均衡。一部分地区（的质量和数量）非常好，而另一部分地区需求十分迫切，这取决于其地理位置，社会经济学地位，教育和文化信仰。脑卒中的认知和医院的利用许多研究已突出强调了脑卒中认知的重要性，同时也显示出发展中国家对脑卒中症状的认知水平的低下。25名患者中只有1名就诊于脑卒中门诊（4％），而在印度的一家三级医院中接受脑卒中治疗的患者中仅有27％意识到其曾遭受脑卒中。同样重要的是，在第一个研究中80％的患者认为其受影响的器官是心脏，而在三级医院中只有33％的患者知道脑卒中累及了大脑。此外，在第二个研究中29％的脑卒中患者连一个预警信号都不知道。然而，在印度的同一所医院所作的另一项研究表明，55％的无脑卒中史的患者家属确认脑部为（脑卒中）的累及器官，仅有23％（的患者家属）连一种脑卒中的症状都无法列举出来。在阿曼的一所大学附属医院的研究发现，35％的脑卒中高危病人表示脑卒中受累器官是大脑，68％的病人至少列举一种脑卒中的症状。然而发达国家对脑卒中的认知与知识也不好，在发展中国家又因收入、教育、年龄及性别不同而不同。发达国家有45％-73％的人正确的认识到脑卒中受累器官是大脑,而30％-90％至少知道一种预警信号。健康管理选择的多样性，其中许多未必根源于生物科学，可能是对急性脑卒中患者进行早期干预一个重大障碍。在一个印度城市进行的研究中，59％的脑卒中患者均先求诊于私人医生，再去医院寻求治疗，仅有38％的患者直接去医院。在南非乡村地区的研究显示，40-80％的患者会在巫师或教堂的帮助下寻求补充医疗，多达10-33％的患者会先找巫师，而不是寻求医疗救助。台湾和玻利维亚的研究也反映出接受脑卒中治疗的城乡差别，研究显示分别有10％、50％的农村脑卒中患者不去医院或看医生。医院是研究和治疗多数患者的首个地方。总之，欠发达或中等发达的国家就诊于医院的脑卒中患者比例难以估计。一个菲律宾基于医院的研究表明，81％的患者就诊于医院，而乌克兰的前瞻性研究显示，66％的患者被送入院。这些估计均来自相当完善的医疗服务的地区，不一定能代表其他发展中国家的状况。溶栓治疗和住院治疗在发展中国家，脑卒中患者被送入院的时间、影像学或治疗设备均有很大差异（见表1）。研究显示，脑卒中患者在症状出现后应尽快入院进行治疗。来自冈比亚的研究显示，大多数患者出现症状后48小时内入院，入院时间的中位数是8小时。来自埃塞俄比亚的研究报道，入院时间的中位数13.5小时。来自印度和菲律宾城区医院的研究指出，多达35％的脑卒中患者症状出现后3小时内入院，与发达国家所报道的（入院）时间无差异。表1 . 发展中国家对脑卒中的紧急救治不同地区间在成像系统的使用也有很大的差别(见表1)。1998年，18个非洲国家没有一台CT扫描仪，13个国家只有1台。只有北非的国家及南非有一定数量的CT扫描仪和核磁共振仪。菲律宾27％医院无CT扫描设备，但中国83％综合性医院脑卒中患者可进行CT检查（65％）或MRI（43％）。1998年，中国上海和马来西亚的每百万人口已拥有约1-2台磁共振机,而在泰国、印度的泰米尔纳德邦、印度尼西亚及菲律宾，每百万人口可及的扫描仪器少于0.5台。溶栓治疗报道率也不尽相同，从泰国一项大规模的、针对1624例患者的研究（2.1％）到印度一项较小规模、针对489例患者的研究（7％）不等。许多中等发达国家和一些发展水平较低的国家已经注册和进口静脉注射阿替普酶（重组组织型纤溶酶原激活剂，rtPA） 。经济承受能力是某些地区的研究和治疗的重要决定因素。1102名尼日利亚的脑卒中患者仅有101人有钱做CT扫描（9％）。在埃塞俄比亚，由于价钱昂贵，仅有38.3％的患者做了CT扫描。印度一项研究显示，489名患者中有10％尽管符合溶栓治疗的所有标准，却因无法负担阿替普酶而没能得到治疗。住院时间的长短因地区和承受能力不同，差别也很大。巴基斯坦的平均住院时间仅3天，而中国的参保病人则为32天。目前关于发展中国家的专业化脑卒中病房的资料很少。一项巴西的研究表明，在脑卒中病房与普通门诊接受治疗的患者脑卒中发作10天后的结局或住院时间长短无明显差异。不过，在脑卒中病房接受治疗的患者在1个月、3个月、6个月时的死亡率存在更低的趋势，可能由于样本量太小未达到统计上的意义。另一项来自泰国的研究显示，早期支持性出院和住院治疗的患者相比两组的死亡率无明显差异，但在家接受治疗的患者的医疗观念更好。中低等发展程度国家充足的康复设施的使用权及适用程度也有限制。在冈比亚脑卒中住院患者中只有47%的人接受了专业医师的治疗； 在中国华南地区的大型教学型医院中，住院期间的常规医疗不包括正规的专业理疗。在泰国从卒中发作到能够使用康复设施的平均持续时间是53天，而在土耳其的两项研究中分别为63天及76天。在南非脑卒中患者出院后只有39%的老人及56%的青年每周或每月会去一次门诊病人的理疗诊所。二级预防多数研究中卒中患者根据死亡率与实施二级预防措施所得出的结果差(表2 ) 。与二级预防措施表现不一致的问题的原因可归结为缺乏监测血压及其它危险因子的设备，药物匮乏，和负担不起医疗费。一项中国研究显示缺血性脑卒中患者3年期死亡率较高与社会经济地位低有关。世界卫生组织向中低等收入人群推荐了成本效益型二级预防的指导原则，此原则建议改变生活方式、应用价廉、易得及有效的降压药物、抗血小板治疗及降低血液中胆固醇水平。阿司匹林由于价廉易得已被推荐为世界上最符合成本效益的抗血小板药物。但研究显示它的应用并不广泛。来自冈比亚和南非研究报道说，这两国脑卒中患者出院时虽然分别有65%和83%的人在以药物进行抗高血压治疗，但一年后还坚持治疗的分别只有13%和8%。同样，在冈比亚出院时有71%的病人在服用阿司匹林，而1年后仍在服用的人只有7%。来自冈比亚另一项研究显示，在脑卒中后6个月内有33%的患者在服用降压药物以控制高血压；而3-4年后，只有15%的人的高血压得到了满意的控制，同时也只有15%定期服用阿司匹林。世界卫生组织关于10个中等发达国家（巴西、埃及、印度、印尼、伊朗伊斯兰共和国、巴基斯坦、俄罗斯联邦、斯里兰卡、突尼斯和土耳其）的PREMISE研究报告显示，有很高比例的脑血管病患者在服用药物进行二级预防，阿斯匹服用的比例范围是31%至90%，β受体阻滞药的使用是6.8%至46%，血管紧张素转换酶抑制剂的使用是5%到59%，而他汀类药物的使用是2%至37%，这些患者中有94%的人报告说，他们曾在过去的12个月内测过血压。 此研究的中的患者来自门诊病人，这反映了这些患者可能比这些地区的一般人群能更好地享有卫生服务并能更多接受药物治疗。 表2.发展中国家脑卒中的长期管理有关发展中国家人们卒中后生活方式改变方面的资料很少，PREMISE研究表明有77-89 %的病人了解戒烟、改变饮食习惯、定期参加体育活动的益处。然而，还是有52.5%的人没有进行定期适度运动，35%的人由于费用问题及对健康食品的种类缺乏了解而难于改变饮食习惯。中国金门岛，脑卒中幸存者每周吃肉少于一次的有36%，每周参加一次以上体育锻炼的也有36%，而与之相比，没有得过卒中的人分别为19%和18%。此图显示了这项综述涵盖的研究地点。图:此项综述中涵盖的研究地点紫色部分表示其范围内的研究报告了按照严格意义进行卒中护理的数据；黄色部分表示其范围内的研究报告了关于额外护理相关主题的数据，这些主题是基于2005年1月的人类发展报告划分的高(绿色) 、中等(蓝色)和低(红色)人类发展程度。有关脑卒中类型及原因的差别近期对以人群为基础的研究进行的系统性回顾表明，世界上脑卒中发病率只有轻微的地域差异性。发展中国家大部分的卒中发病原因可能是其传统危险因素，如高血压、糖尿病、高胆固醇血症、吸烟。这些因素随着人们采取更都市化的生活方式而日益盛行。但是，发达国家和发展中国家之间的脑卒中类型及原因之间存在着一些重要的差别，从管理的角度看这些差别很重要。许多以医院为基础的研究表明：有很高比例的卒中患者会颅内出血，这一比例随研究的不同在19-60%之间变化。不过，以医院为基础的研究可能会使发展中国家的卒中谱向更严重的方向偏离，这是由于一些因素如与医院的距离、交通是否便利、住院费的支付能力和对当地住院治疗效果的信心等降低了轻度卒中病人的住院率。还有这里以社区为基础的研究很少，因此缺乏可靠的数据以确定发展中国家流行的卒中亚型。在发展中国家，未治疗的和未诊断的高血压是脑出血最主要的病因，但是更多是由于动脉瘤和动静脉畸形所致。尽管发展中国家和发达国家动脉粥样硬化性和心源性脑卒中的发病率基本一致，但是在发展中国家心源性脑卒中发病年龄较轻而且主要是由于风湿性心脏病或者先天性心脏病瓣膜受累造成的;同时在发展中国家，由于镰状红细胞病以及由于感染，炎症和凝血紊乱引起的血管炎造成的脑卒中也较发达国家常见。(表3)表3：发展中国家脑卒中的病因 在发展中国家实施循症治疗过去十年，基于治疗越早效果越好这一原则，很多发达国家脑卒中治疗的主要进步是建立了专门的脑卒中诊疗中心，为患急性缺血性脑卒中的病人提供早期溶栓和血肿清除治疗。正是得益于溶栓疗法在北美和欧洲获得了认可和批准，这种专门的脑卒中治疗方式逐渐由专业的脑卒中诊疗中心广泛推广到各个地方医院的急性脑卒中病房。并且出现了针对急性脑卒中治疗的指南。现在，北美和欧洲已经对急性脑卒中诊疗中心的组织构成进行了严格的规定，主要的指标是治疗的专业程度和影像设备的水平。专业的急性脑卒中诊疗中心能够提供一系列极其专业的治疗措施-像神经介入放射和神经外科治疗，包括动脉内溶栓，血肿吸除，大脑半球开颅手术，颈动脉手术，地方医院的脑卒中科室则可以提供较小的、较经济的、但很有效的治疗措施，包括：CT影像辅助的快速诊断，对有适应症的病人进行静脉溶栓治疗，急性脑卒中管理以便维持病人生理动态平衡和预防相关并发症，对吞咽困难、摄入营养和交流障碍进行管理，早期锻炼；以及对感觉运动功能和认知障碍进行治疗。尽管地方医院提供的专业治疗方法有限，但是他们仍然有潜力处理多数的脑卒中及其相关并发症，只有极少数病人需要转送到大的治疗中心。无论是在专业水平高的三级脑卒中中心抑或是低水平的地方脑卒中医疗病房，都是脑卒中医疗重要之地，通过对专业医务人员的培训，诊断、监护和治疗脑卒中相关问题，这是针对急性脑卒中患者及急性期后持续管理的一种有组织的措施。脑卒中治疗专家对急性脑卒中最有效的改善总体预后的办法总体认识一致，包括快速且准确的诊断、积极的综合预防措施、早期识别并发症以及早期康复锻炼。Hankey 和 Warlow已经从随机研究资料中推断出基于人口措施的有效方法并且表明在脑卒中病房治疗比静脉溶栓治疗获益更大。这是因为目前愿意在脑卒中病房治疗的患者比例远大于溶栓治疗的患者比例。许多发展中国家有脑卒中治疗中心，这里能够提供影像诊断和介入设备，相当于发达国家的主要学术中心。然而，高的溶栓率并不能反映脑卒中医疗的全部特征，而仅仅代表脑卒中作为急症发生时一个好的院前措施和有效的快速反应。虽然溶栓对个别的患者可能会显著地改善症状，但是它作为一种介入来改善全部患者预后的作用可能并不大，因为它被限制使用在专业中心对高选择性早期患者。在缺乏良好组织或缺乏充分设施的地方，能够提供脑卒中康复的最佳的医疗机构必须建立脑卒中医疗病房和多学科康复医疗小组来进行系统的脑卒中治疗。发达国家已经广泛采用这种方法，他们有网络化的地方脑卒中医疗病房可以提供大量的脑卒中治疗。中低等发展程度国家应建立的最好目标或许是一个逐次建立的专业脑卒中治疗，既在建立溶栓的专门治疗组织之前应该先建立基础的脑卒中医疗病房。这点尤为重要，因为在发展中国家患者中出血性脑卒中比例更高，由于院前设施不足和后送不及时，对出血性脑卒中这类越早治效果越好的患者实施精细化管理模式非常困难。 专科脑卒中病房对患者及其家属来说是一个接受教育和获取有关脑卒中的知识的理想机会。研究表明发达国家的患者在这种病房中接受预防再次脑卒中的结构化知识，脑卒中后最能坚持长期治疗和生活方式的改变。发展中国家患者长期治疗（即使是阿司匹林）的依从性相对低。在住院期间，专家使用适合患者教育和文化背景的简单知识对患者进行行为方式和医疗教育或许是一个增加患者坚持二级预防措施的机会。在发展中国家，家庭具有重要作用，应当参与健康教育，鼓励和帮助患者坚持服药和改变生活方式。结论世界上发展中国家的某些脑卒中死亡率最高，占全世界因脑卒中而死亡的2/3以上。发展中国家与发达国家之间的各种类型脑卒中的发病模式与病因有所不同，但是在发展中国家很少有指导临床实践的紧急救治与长期管理的研究。在发展中国家脑卒中保健的数量与质量是不均衡的，状况好坏参差不齐，这依赖于患者所在地、当地医院设施、支付能力、教育和文化、社会或宗教信仰。一项基于人口的改善脑卒中的紧急救治和康复的措施是必需的，这以证据为基础并使这样的医疗效果最大化。目前大量从发达国家来源的文献支持基本的专业化脑卒中医疗病房的发展，这种医疗病房必须根据个体所处环境的健康需要、服务方式和支付能力进行修改。需要更多的研究来发展专业化的紧急救治和康复策略，使之最适合发展中国家的需要和环境，帮助他们减轻越来越严重的脑卒中负担。漂亮瓶 如果能将上面的图表也换成中文的才好。仔细的校对也是好的工作呀谢谢班竹谢谢了!非常感谢!