The scoping review, led by Christoper A. Alarcon-Ruiz of Peru’s Instituto Nacional de Ciencias Neurológicas together with colleagues in Lima, Sydney, and Seattle, systematically searched four databases through April 2025 using the SPIDER framework. Of 1,210 records identified, 119 primary studies met the inclusion criteria, encompassing 131,424 Peruvian participants of any age with ischemic stroke. The designs ranged from observational cohorts and case reports to qualitative interviews, quasi-experimental pilots, and one cluster randomized clinical trial. Crucially, the team organized the findings across a socio-ecological framework spanning individual, interpersonal, organizational, community, and policy levels, allowing them to pinpoint precisely where the evidence base breaks down.

The epidemiological picture that emerges is striking. Ischemic stroke accounted for roughly 62 percent of all stroke cases in the pooled data, women represented 44 percent of patients, and overall mortality reached 12 percent, most of it occurring during hospitalization. Mean age among cases with available data was 66.9 years. Among determined etiologies, large-vessel atherosclerosis led at 27 percent, followed by cardioembolism at 24 percent, but the single largest category remained undetermined causes at 30 percent. In high-income settings, such cryptogenic stroke typically reflects residual uncertainty after exhaustive workup. In Peru, the authors argue, it more likely reflects a structural absence of the diagnostic tools needed to complete that workup, including vascular imaging, prolonged cardiac monitoring, and coagulopathy testing.

Geography is perhaps the review’s most damning finding. Seventy-five percent of all included studies were conducted in Lima, and among observational studies, 79 percent came from a single center in the capital. The representation of rural, high-altitude Andean, or Amazonian settings was almost null, despite recent population-based estimates reporting an age-standardized ischemic stroke incidence of approximately 1.65 per 10,000 persons yearly in Peru and a marked altitudinal gradient. Nationwide secondary data suggest the age-standardized incidence rate actually declined from 60.28 per 100,000 inhabitants in 1990 to 41.81 in 2021, yet mortality among Peruvians aged 85 to 89 reached as high as 853 per 100,000 in 2017. Without population-based studies that capture Peru’s cultural and geographic diversity, the true burden likely remains underestimated, potentially biasing policy decisions.

The acute care numbers tell a system-level failure story with directly actionable causes. Among patients who did receive thrombolysis, mean time from symptom onset to hospital arrival was 134.2 minutes, but across other studies, arrival times ranged from three hours to seven days. Barriers identified included poor public awareness of stroke symptoms, limited understanding of how the health system works, inadequate pre-hospital notification and transport, insufficient availability of CT and MRI scanners, and fragmented acute care flow. Adherence to American Heart Association and American Stroke Association performance measures at Peru’s national neurological reference institute averaged just 47 percent, with only five of fifteen measures achieved at 85 percent or higher. A cluster randomized trial testing a multifaceted quality improvement intervention in a Lima hospital failed to achieve significant improvements in overall adherence, underscoring how difficult implementation is in this context.

Yet the review also uncovered a surprising wellspring of innovation. Eighteen studies, mostly from Lima, proposed accessible robotic or computer-assisted solutions for post-stroke patients, including P300-based brain-computer interfaces validated for smart-home control, soft robotic exoskeletons for hand rehabilitation, virtual reality systems for upper-limb recovery, and telerehabilitation web platforms. These projects represent genuine technical promise, but nearly all remained at an early pilot stage with small samples of patients and healthy controls, no large-scale population assessment, and no clinical impact evaluation. Community prevention programs using educational and digital tools similarly engaged individuals in design and distribution but stopped short of measuring downstream effects on stroke incidence or outcomes.

The interpersonal level reveals a quieter crisis. Five qualitative studies, all from Lima, documented the experiences of informal caregivers thrust into complex medical roles without training, written information, or financial support. Caregivers described fears tied to new disabilities and invasive instruments such as nasogastric tubes, reduced social activity, unexpected financial burdens including hiring private services to fill care gaps, and emotional stress and depressive symptoms severe enough to require mental-health care. Healthcare providers themselves reported lacking correct training for stroke rehabilitation, with only nurses responsible for delivering discharge information. Patients discharged home despite needing specialized nursing or palliative support transferred the entire burden of care to family members who often lacked both technical and economic resources.

The COVID-19 pandemic layered further strain onto an already fragile system. Published research on ischemic stroke in Peru surged during this period, including case reports of stroke in children, pregnant women, and adults with SARS-CoV-2 infection. One analysis documented a relative reduction of 46.9 per 1,000 inhabitants in overall stroke volume, with an even sharper decline of 70.8 per 1,000 in intravenous tPA procedures during lockdown. Patients with concomitant COVID-19 infection showed higher baseline glucose, elevated neutrophil counts, reduced lymphocyte counts, and increased neutrophil-to-lymphocyte ratios alongside higher NIHSS scores at presentation, which the authors suggest may explain the high mortality and low functional independence observed in this subgroup. Caregivers during lockdown described fragmented telephone communication, no formal training, and telemedicine implemented only to a limited extent because of restricted internet access and limited technological literacy.

At the policy level, evaluation was scarce. Only one study reported environmental factors, ranking ambient particulate matter pollution third, household air pollution from solid fuels tenth, and lead exposure thirteenth among attributable causes of overall stroke. No studies assessed the impact of country policy changes or implementations on ischemic stroke care. The authors propose a contextually adapted framework for the Peruvian health system: establishing a national program that standardizes Code Stroke pathways across all levels of care, dividing the country into geographical zones where third-level hospitals equipped with specialized stroke units are interconnected for rapid decision-making, expanding tele-stroke networks beyond Lima based on Peru’s 2023 Telemedicine Technical Guideline, and incorporating rehabilitation centers and secondary prevention at primary and secondary levels alongside quality monitoring and multicenter research networks.

The review’s conclusion is unambiguous: research on ischemic stroke in Peru has grown but remains geographically centralized and structurally misaligned with the national burden. Major gaps persist in diagnostic capacity, implementation research, rehabilitation, caregiver support, and policy evaluation. To improve outcomes, Peru will require a nationally coordinated, regionally distributed stroke program that standardizes acute pathways, strengthens diagnostic infrastructure, and scales community-based rehabilitation, caregiver training, mental-health, and palliative services. For a country where 86 percent of ischemic stroke deaths globally occur in low- and middle-income nations, the Peruvian experience offers a sobering template for what happens when evidence, infrastructure, and policy fail to converge, and a roadmap for how they might.

Subject of Research: Neurology

Article Title: Ischemic stroke in Peru: a scoping review of trends, outcomes, and evidence gaps

Article References: Alarcon-Ruiz, C. A., Gutierrez-Arratia, J., Concha-Querevalú, L., Barrientos-Ventura, E., Moreno-Arias, J., Otiniano-Sifuentes, R., Ecos, R., Zunt, J. R., & Miranda, J. J. (2026). Ischemic stroke in Peru: a scoping review of trends, outcomes, and evidence gaps. Frontiers in Epidemiology, 6, Article 1926861. https://doi.org/10.3389/fepid.2026.1926861

Image Credits: AI Generated

DOI: 10.3389/fepid.2026.1926861

Keywords: ischemic stroke, Peru, scoping review, stroke care, thrombolysis, health systems, global health, Latin America, Ischemic, stroke, scoping, review