by Günther Deuschl
The revision of the International Classification of Diseases (ICD) is a highly complicated process handled by experts in statistics at the WHO in Geneva. The influence of Neurological Societies onto the creation of a revision is through the accredited Societies which are for Neurology and Stroke the World Federation of Neurology (WFN) and the World Stroke Organisation (WSO). They are working within the Topic Advisory Group Neurology (TAGN) and can only make recommendations to the experts. April 2011 the TAGN advised to shift the section “Cerebrovascular diseases” covering all types of stroke from the “Diseases of the circulatory system” class (as it is in ICD-10) into the “Diseases of the nervous system” class (as it proposed in the draft ICD-11). This corresponds to a change of the statistical and legal placement of stroke from Internal Medicine to Neurology. This was then executed accordingly 5 years ago and stroke went under the neurological diseases (08) in the beta-version of the ICD-11. Neurologists all over the world agreed with this decision.
On September 9th 2016 the WHO classification staff decided to break the agreement with the TAGN and moved stroke back to the circulatory diseases belonging to Internal medicine. Heavy protest was coming from within the TAGN. Raad Shakir, Vladimir Hachinski and others placed a letter in the Lancet Neurology against this decision outlining the needs why stroke is a neurological disease.1 This was answered by T. Boerma of the Department for Information Evidence and Research at the WHO mentioning the fact that stroke had been sitting under vascular disease since the ICD 7 in 1955 and while acknowledging that the sequelae of stroke are related to the nervous system the acute phase and etiology are ‘clearly vascular’.2 The TAGN is only considered an advisory body and no decision was shared with them. Hence it went to the political scene and the health ministries’ of Russia, Austria and New Zealand wrote a note of protest to M. Chan, Director General of the WHO and seconded the letter written by WFN and WSO to her.
No matter which action finally led to reconsideration but Raad Skakir and Bo Norrving as the official representatives of the WFN and the WSO let us know on April 1st, 2017 that the efforts were successful and the WHO statistics and Informatics Department has finally agreed to place cerebrovascular diseases under the nervous system diseases chapter (see figure). This is a major success for Neurology. Finally this disease which has so many ramifications into other important conditions handled by neurologists like dementia, bleedings and other diseases severely affecting Quality of Life is now placed correctly in the international classification of diseases. It is not only the mention that stroke will have a neurological ICD number in patient reports but more importantly it will make evident that stroke patients should be taken care of by neurologists. The evidence in favor of stroke services for the tretament of stroke patients is overwhelming and has led to a major improvement for the patients. On the political side health statistics worldwide will show the important role of our discipline. Resources are allocated in many countries among other aspects according to the health statistics. Also statistics will then show in the future that Neurology is among the three largest disciplines in terms of patient care in medicine. This is already reality in many countries where stroke is handled in more than 95 % of the patients by neurologists.
We owe our representatives at the WHO, particularly Profs R. Shakir and B. Norrving, and the many known and unknown colleagues and health politicians our deep gratitude for their tireless work for the neurological patients and our field.
- Shakir R, Davis S, Norrving B, et al. Revising the ICD: stroke is a brain disease. Lancet 2016;388(10059):2475-2476.
- Boerma T, Harrison J, Jakob R, Mathers C, Schmider A, Weber S. Revising the ICD: explaining the WHO approach. Lancet 2016;388(10059):2476-2477.
Fig. Screenshot of the ICD Beta-Version (22.4.2017) showing the placement of cerebrovascular disease in category 08 Diseases of the Nerveous System (http://apps.who.int/classifications/icd11/browse/l-/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f843843448)