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Santos et al. Vessel Plus 2021;5:21 https://dx.doi.org/10.20517/2574-1209.2020.69 Page 9 of 16

Regarding endovascular thrombectomy, several United States-based studies have similarly grouped
Indigenous Peoples with other minority groups and shown racial disparities [69,70] .

[63]
Attenello et al. separated racial groups when they examined the 2008 NIS database. They reported that
White, Hispanic and Asian/Pacific Islander received endovascular thrombectomy at higher rates than Black
and Native Americans (P < 0.001). Additionally, they noted that, compared to Whites, Native American
patients were less frequently admitted to hospitals that could perform thrombectomy than other racial
groups (P < 0.001).

DISCUSSION
Within the constraints of a narrative review, stroke incidence rates appear variable between the Indigenous
and non-Indigenous populations, depending on the country. From the available studies in our review,
incidence rates are greater for Indigenous groups of Australia [11,14-16] , New Zealand , Sweden , and
[17]
[32]
[20]
Israel . There are conflicting reports from the United States [23-26] and Canada [27,28,30] and incidence rates are
either similar or lower in South America , Russia and Tibet .
[31]
[33]
[19]
There is overwhelming evidence from the literature that Indigenous Peoples are affected by stroke at a
younger average age, in comparison to the non-Indigenous people in the same region [11,14-17,40-43] . This not
only affects the individual, due to longer time spent with disability and reduced quality of life, but also has a
domino effect on their family and community. There are additional economic considerations for countries,
with the indirect costs after IS estimated to be 6 times greater for adults aged < 65 years compared with
[47]
adults aged ≥ 65 years in the United States . Cardiovascular risk factors are generally more prevalent
amongst the Indigenous population compared to the non-Indigenous population in Australia [36,40-42,52] ,
[50]
United States [37,44,45] and Canada [5,26] but not in Chile , Ecuador , Taiwan and Norway [54,55] . Drawing
[51]
[57]
conclusions regarding guideline-directed treatment with intravenous thrombolysis and/or endovascular clot
retrieval is problematic due to the lack of studies designed to specifically address this question. However,
from the studies included in this review, there was clear evidence that Indigenous patients in Australia [40,42] ,
United States [65-70] and Canada were less likely to receive treatment with thrombolysis or undergo
[62]
endovascular clot retrieval in comparison to their non-Indigenous counterparts.
Similar to the general health of all populations, stroke and its outcomes are the result of the complex
interactions between different factors that act at the individual, community, societal, and service levels. As
shown in our hierarchical framework, human rights factors and the social determinants of health resulting
from these, trigger a cascade of events leading to stroke and stroke inequities that are particularly marked in
Indigenous Peoples worldwide [Figure 1]. In particular, colonisation (including the cultural and material
losses associated with it), is a major indirect driver of disparities in lifestyle, biological and other risk factors
for stroke in Indigenous Peoples [12,45] .

Our findings suggest that a rapid shift must occur in those countries where Indigenous patients have greater
incidence rates of stroke, more prevalent comorbidities, and lesser treatment rates than non-Indigenous
patients. In particular, there is an urgent need for the provision of evidence-based care to increase the
[41]
opportunities for optimal health outcomes preventing stroke . However, before this occurs, improvement
of social infrastructure and an emphasis on the importance of culture for Indigenous People, should become
the norm. The loss of traditional cultural practices, dispossession from the land, loss of connectedness, loss
of Indigenous identity and the misalignment of what “health” means to Indigenous Peoples continue to
underpin the foundations of the health gap. Coupled with discrimination and disadvantage (including
[71]
economic, environmental and educational) [5,36] there are issues such as institutional racism ,