Stroke is the second leading cause of death worldwide.The burden of disability after a stroke is also large, and isincreasing at a faster pace in low-income and middleincomecountries than in high-income countries.Alarmingly, the incidence of stroke is increasing in youngand middle-aged people (ie, age <55 years) globally.Should these trends continue, Sustainable DevelopmentGoal 3.4 (reducing the burden of stroke as part of thegeneral target to reduce the burden of non-communicablediseases by a third by 2030) will not be met.In this Commission, we forecast the burden of strokefrom 2020 to 2050. We project that stroke mortality willincrease by 50%—from 6·6 million (95% uncertaintyinterval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million(8·0 million–11·6 million) in 2050—with disabilityadjustedlife-years (DALYs) growing over the same periodfrom 144·8 million (133·9 million–156·9 million) in 2020,to 189·3 million (161·8 million–224·9 million) in 2050.These projections prompted us to do a situational analysisacross the four pillars of the stroke quadrangle:surveillance, prevention, acute care, and rehabilitation. Wehave also identified the barriers to, and facilitators for, theachievement of these four pillars.On the basis of our assessment, we have identifiedand prioritised several recommendations. For each ofthe four pillars (surveillance, prevention, acute care, andrehabilitation), we propose pragmatic solutions forthe implementation of evidence-based interventionsto reduce the global burden of stroke. The estimateddirect (ie, treatment and rehabilitation) and indirect(considering productivity loss) costs of stroke globally arein excess of US$891 billion annually. The pragmaticsolutions we put forwards for urgent implementationshould help to mitigate these losses, reduce the globalburden of stroke, and contribute to achievementof Sustainable Development Goal 3.4, the WHOIntersectoral Global Action Plan on epilepsy and otherneurological disorders (2022–2031), and the WHO GlobalAction Plan for prevention and control of noncommunicablediseases.Reduction of the global burden of stroke, particularlyin low-income and middle-income countries, byimplementing primary and secondary stroke preventionstrategies and evidence-based acute care and rehabilitationservices is urgently required. Measures tofacilitate this goal include: the establishment of aframework to monitor and assess the burden of stroke(and its risk factors) and stroke services at a nationallevel; the implementation of integrated population-leveland individual-level prevention strategies for people atany increased risk of cerebrovascular disease, withemphasis on early detection and control of hypertension;planning and delivery of acute stroke care services,including the establishment of stroke units with accessto reperfusion therapies for ischaemic stroke andworkforce training and capacity building (andmonitoring of quality indicators for these servicesnationally, regionally, and globally); the promotion ofinterdisciplinary stroke care services, training forcaregivers, and capacity building for community healthworkers and other health-care providers workingin stroke rehabilitation; and the creation of astroke advocacy and implementation ecosystem thatincludes all relevant communities, organisations, andstakeholders.