|Year : 2020 | Volume
| Issue : 5 | Page : 431-436
Is India ready to be “stroke ready”? An appraisal of our stroke preparedness
Sachin Ajitkumar Adukia1, Radhika Shriprakash Ruhatiya2, Gagan Naresh Jain3
1 Department of Neurology, Narayana Hrudayalaya, Bengaluru, Karnataka, India
2 Department of Critical Care, Narayana Hrudayalaya, Bengaluru, Karnataka, India
3 Department of Medicine, Hemraj Jain Hospital, New Delhi, India
|Date of Submission||12-Jan-2019|
|Date of Decision||04-Mar-2020|
|Date of Acceptance||25-Jun-2020|
|Date of Web Publication||7-Sep-2020|
Sachin Ajitkumar Adukia
Department of Neurology, Narayana Hrudayalaya, Plot - 258/A Bommasandra Industrial Area, Hosur Road, Anekal Taluk, Bengaluru - 560 099, Karnataka
Source of Support: None, Conflict of Interest: None
A recent trend of being a “stroke ready center” has been finding roots. But such centers are too far and few to reach many beneficiaries. And so, like all else, the burden of stroke preparedness also falls on the physician to brace and embrace. This review will address the physician's role in early assessment and management of acute stroke. Therapeutics such as thrombolysis with alteplase and tenecteplase will be appraised. Indian statistics on acute stroke management in comparison to Western standards will be discussed. Issues such as public education forums and cost considerations will be addressed. Government initiatives for the facelift of the Indian medical infrastructure will be mentioned wherever relevant. But an idea not coupled with action will never get any bigger than the brain cell it occupied. Therefore, we will conclude with actionable key points for physicians.
Keywords: FAST in stroke, stroke chain of survival, telestroke
|How to cite this article:|
Adukia SA, Ruhatiya RS, Jain GN. Is India ready to be “stroke ready”? An appraisal of our stroke preparedness. Med J DY Patil Vidyapeeth 2020;13:431-6
|How to cite this URL:|
Adukia SA, Ruhatiya RS, Jain GN. Is India ready to be “stroke ready”? An appraisal of our stroke preparedness. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Sep 26];13:431-6. Available from: http://www.mjdrdypv.org/text.asp?2020/13/5/431/294362
| Introduction|| |
“Stroke” was beautifully codified as a medical diagnosis in the 16th century. It meant that the victim suffered a “stroke by the hand of God.” Unfortunately, India suffers many such strokes by the hand of God year after year. The estimated adjusted prevalence rates of stroke in India are between 84 and 262 strokes per 100,000 persons in rural areas and between 334 and 424 strokes per 100,000 persons in urban areas. Incidence of stroke varies from 116 to 163/100,000 population. The last 15 years have seen an increase of 17.5% in the number of stroke cases in India. Stroke is a foremost cause of mortality. Of the estimated 6.5 million stroke-related deaths globally in 2013, more than 2/3rd occurred in developing countries. In India, it is the second leading cause of death as per the 2018 consensus statement of the Indian Stroke Association (ISA) and the fourth leading cause as per the 2016 report by the Indian Council for Medical Research (ICMR). In India, stroke-related mortality has increased by 7.8% from 1998 to 2004.
Consequently, India is bearing a burden of both communicable and non-communicable diseases. Due to increased exposure to risk factors, and inability to meet the high cost for stroke care, survivors living with stroke-related disability is rising. ICMR has reported it to be the fifth leading cause of disability adjusted life years in 2016. The economic impact of stroke remains to be quantified.
This is an appraisal of India's stroke preparedness. Therefore we will present an overview of the role of the general physician without mulling over scientific details. We are confident that our committed physicians have already updated themselves on the guidelines for stroke thrombolysis. The enthusiastic reader can always look up the detailed guidelines through the references we have listed below. We have restricted this discussion to thrombolysis in acute stroke because that's where the general physician can contribute substantially. We will refrain from commenting on endovascular treatment or its efficacy. That task is best left to the authorities of vascular neurology. Purpose of this communication is to convey the shortfall of acute stroke treatment in India and and help the physician in changing the same.
| the Indian Scenario|| |
Stroke is characterized as a neurological deficit attributed to an acute focal injury of the central nervous system by a vascular cause, including cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage. In India over 1.5 million strokes occur every year, of which 70%–80% are ischemic., This highlights the physician's burden in assessing and managing ischemic stroke. The past decade has produced numerous studies on stroke in India, encompassing social and clinical parameters. We have focused on authoritative Indian studies from indexed journals from the last 5 years. The “stroke chain of survival” as per the American Heart Association (AHA) is shown in [Table 1]. It will serve as scaffolding for our discussion. Relevant comparisons and statistics will be explored as one moves further along the 8 D's in this chain. Along each “D,” we must reflect on the availability of resources and accept one's therapeutic limitations on a case-to-case basis.
| Stroke Chain of Survival|| |
A recent study from Bangalore showed that 73% of the patients neglected initial stroke symptoms leading to delay in treatment initiation. Untreated stroke damages 1.9 million neurons per minute. The ischemic brain ages at the rate of 3.6 years each hour without definitive treatment. For every 15-minute reduction of the door-to-needle time (arrival to emergency room to thrombolysis), in-hospital mortality reduces by 5%. Each 15-minute decrease in treatment delay can provide an average equivalent of 1 month of additional disability-free life. So how can the physician contribute to the early detection of stroke symptoms? By raising public awareness. One has to firmly advocate the motto “time is brain” and “time loss is brain loss.” Mnemonics for stroke detection like FAST (F-Face drooping, A– Arm numb/weak, S– Speech slurred, T– Time not to be wasted) have to be propagated through mass stroke awareness campaigns. In Hindi, “Dekhna, dikhna, hath, paer, bol, chaal”– is an easy mnemonic. Any sudden onset disturbance in dekhna, dikhana, hath, pair, bol or chaal should raise suspicion of cerebrovascular event, and need for prompt medical attention. The population needs to be sensitized to keywords like stroke, facial droop, weakness/fall, or communication problem. Such words help in accurate stroke detection by emergency medical services (EMS) personnel in 80% cases.
The physician's role in dispatching a stroke patient during the prehospital phase is limited. However, we can promote prenotification systems and train the paramedics in stroke recognition. Government services like “dial 108” are being expanded in a phased manner. Free ambulance services have been made available by the government in states like Odisha, Punjab to name a few. Indeed, only 13% of stroke cases arrived at a tertiary center in Kerala via ambulance. A Chinese review estimates that only 15% of stroke cases use EMS in India and China. Whether education and time to detection of symptoms are to be blamed is yet unclear. By comparison, EMS usage in developed nations like the United States, Sweden, Germany, and England stands at 51%, 53%, 72% and 78% respectively.
Cultural influences such as opting for alternative medicines like oil massages, ayurvedic medicines, homeopathy, or faith healing, witchcraft lead to significant delay in delivery of the patient to a doctor. But let us consider that the bystander has detected a possible stroke and has arranged transport. What should be his destination? His choices broadly include a local quack, a primary health center, a district hospital, a privately owned nursing home or clinic, a tertiary care institute like a teaching hospital or a specialized stroke ready center.
The AHA/American Stroke Association (ASA) guidelines of 2018 and the ISA consensus statement of 2018 both recommend admission to stroke units for better outcomes. The guidelines for Prevention and Management of Stroke issued by the Government of India in 2019 also favours setting up a stroke unit which includes physicians trained in stroke care. Additionally, this team comprises of nursing, physiotherapy, occupational therapy, speech therapy, and social workers.,
Interestingly, none of the guidelines insist that a neurologist or neurosurgeon should head such a unit. And besides, dependency on a neurologist for acute stroke care is not feasible. India has approximately 1200 neurologists, which means there is only one neurologist per ten lakh population. India has about 35 dedicated stroke units, predominantly in private hospitals. Approximately 100 centers provide intravenous (IV) alteplase treatment and only 55 centers are capable of performing intra-arterial or mechanical thrombolysis. In 2010, a “stroke program for India” was proposed which would provide an add-on certification to medical graduates, residents of general medicine, physicians, and neurologists. But it was never flagged off and therefore currently, no such certification exists in India.
The only solution is to involve more physicians in acute stroke care by providing them with precise and concise education, and easily implementable protocols. The National Institute of Health Stroke Scale (NIHSS) certification is a free online certification. It can be accessed at https://secure.trainingcampus.net/uas/modules/trees/windex.aspx?rx=nihssenglish.trainingcamps.net. NIHSS score is rapid, reproducible and universally accepted, and it does not require any special equipment other than a pin. Written protocols in the emergency department are always recommended.
In 2018, “Save the brain initiative” proposed the “spoke and hub” model for management of acute stroke and IV thrombolysis in urban India. It comprised of one hub (a tertiary center) along with six other primary/secondary health care centers as spokes of the wheel. The programme stressed on community awareness, sensitization programmes, and strengthening of stroke pathways within the hospital. Indeed it yielded positive results on rate of stroke detection, early arrival and IV thrombolysis.
Regarding the population behavior, the ISA reports that the local doctor or the community doctor is the first medical contact for around 51% stroke cases in India. Thus, the general physician will find himself facing acute strokes more often than not.
The trick lies in treating every stroke case as urgent. The EMS personnel have to be trained by the physician to have a high suspicion and low threshold for detecting a possible stroke signs. If they have wrongly informed you, they should be dealt with tactfully to not jeopardize future notifications from them. After triage, the case may be forwarded to the stroke unit or elsewhere as per the physician's preference. The ABC of the emergency department (airway, breathing, circulation) must never be overlooked in haste. In 2019, the All India Institute of Medical Sciences in New Delhi conducted a study to educate the EMS personnel. It showed improvement of all acute stroke quality matrices like door-to-imaging time and number of cases receiving reperfusion therapy. Such practices can be replicated by the physician in his practice as well.
This is the physician's first contact with the possible stroke case. From this phase onwards, the physician should know the time targets recommended by the ISA as shown in [Table 2].
The physician reaches the case on a priority basis, administers an NIHSS score, obtains relevant history like “time when the patient was last seen normal,” previous medical history and medication history. The objective is to rule out stroke mimics thereby reducing the strain on the system and the patient. Stroke mimics include seizures, hypoglycemia, hypertensive encephalopathy, Wernicke's encephalopathy, migraine with aura, brain abscess, brain tumor, drug toxicity and psychogenic causes. NIHSS can be easily calculated at bedside using smartphone applications like “NIHSSapp.” Finally, the physician urgently mobilizes the case for brain imaging and relevant laboratory investigations. Of course, the time targets have to be tailored as per patient stability and availability of resources. In the case of nonavailability of neuroimaging, the wise physician would have already identified the nearest 24 × 7 neuroimaging center and ambulance services, thus avoiding last-minute chaos.
A noncontrast computerized tomography of the head along with a radiologist's opinion is a minimum requirement before thrombolysis. The other relevant test is blood glucose level to rule out hypoglycemia. Tests like platelet count, prothrombin time, activated partial thromboplastin time are applicable in scenarios like liver dysfunction, ongoing anticoagulation therapy, suspected thrombocytopenia, etc., They are not required routinely and must not delay the plan to administer thrombolysis.
You have diagnosed an ischemic stroke. Now what? This is the stage to decide the most appropriate treatment for your patient. Consider a scenario where you are planning thrombolysis. A quick check through the list of indications and contraindications is warranted. Spend some time reviewing this list before offering the option of thrombolysis. Smartphone applications like “IV Thrombolysis” are quick and comprehensive in identifying contraindications to IV thrombolysis. A detailed discussion on the scientific rationale for the indications and contraindications of stroke thrombolysis is beyond the scope of this article. A reassuring Australian study concluded that there was no difference in terms of door-to-needle time, symptomatic hemorrhage, hemorrhagic transformation, mortality or discharge while comparing thrombolysis carried out by stroke neurologist versus a nonneurologist physician who has been trained in stroke care. But if doubt still exists, it is advisable to recruit technology to assist you. Telestroke provides expert opinions to centers without fulltime neurological consultation services. In teleradiology brain images are transmitted to a radiologist for urgent opinion, and if possible, diagnosis. The use of smartphone applications like WhatsApp in Himachal Pradesh is an example of the success of telestroke. It has proven that a substantial increase in stroke thrombolysis can be achieved without extra resources or additional manpower.
The importance of discussing the risk and benefits with the family, informed consent, and robust documentation cannot be stressed enough.
The reason for this appraisal is that only 0.5% of acute stroke cases in India receive thrombolysis. Compare this to 7.3% in the United States or 20.6%, 19.6%, 18.4%, 17.5%, 15% and 11.7% in Netherlands, Denmark, Austria, Germany, Sweden, and United Kingdom respectively. These last few years have seen a steady increase in number of stroke thrombolysis in India. A tertiary center study from North India between 2011 and 2015 supports this claim. Unpublished data on the nationwide use of alteplase states that 9,000 patients were thrombolysed in 2015, 10,800 patients in 2016, 12,600 patients in 2017 and 15,000 patients in 2018. Assuming these figures to be accurate, only 1% of all acute stroke cases in India received thrombolysis. This data does not include the use of tenecteplase for stroke thrombolysis. Endovascular intervention also pinches away a proportion of cases who would have received alteplase in previous years.
Hurdles in delivery of thrombolytic medication in India in descending order include failure to recognize stroke, lack of neuroimaging facility nonaffordability,, failure of the primary care physician to recognize stroke, and transport problems. Only 2% are aware of thrombolysis as a treatment modality for stroke. The high cost of thrombolytics has limited its use to certain private institutes. As many as 56% eligible cases visiting a teaching hospital did not consent for thrombolysis due to its high cost, while 18% refused it in another. However, a Neurosciences institute in West Bengal convinced the state government to provide alteplase free of cost after proving its success. One hopes that other states follow soon.
A cheaper alternative is on the horizon. A meta-analysis showed no significant difference between any dose of tenecteplase and alteplase for either efficacy or safety endpoints. Tenecteplase costs nearly half of alteplase and is given as an IV bolus. It has been approved by the Government of India for use in acute stroke in the first 3 h of symptom onset. The ISA has reserved its opinion on the matter as it waits for more trials.
To encourage physicians for thrombolysis, reliable statistics about the increasing number of stroke thrombolysis should be dispersed periodically. Success rate and adverse events must be presented statistically to dispel any myths. Neurologists can form groups on WhatsApp which incorporates few physicians in their respective locality. Easy access will encourage physicians toward thrombolysis. We reiterate the importance of informed consent, and proper documentation before, during and after thrombolysis.
In this last stage, treated patients are immediately transferred and monitored in an intensive care unit or a stroke unit. However, if the physician has precious little to offer due to whichever limitation, he must urgently refer the patient to the nearest stroke ready center. After all, time is brain!
| Action Plan for Physicians|| |
We urge the reader to look up the AHA/ASA 2018 Guidelines for the early management of patients with acute ischemic stroke, ISA 2018 consensus statement for the early management of acute ischemic stroke and the Government of India 2019 guidelines on prevention and management of stroke. This review has not provided flowcharts or protocols or indications and contraindications for stroke thrombolysis as it is beyond its scope [Table 3].
|Table 3: Summary of the role of the general physician in the stroke chain of survival|
Click here to view
| Future Direction|| |
Mobile stroke units have been successfully deployed in Germany. India can only see this as a futuristic dream due to the sloppy infrastructure. Instead, we should set realistic targets such as doubling the beneficiaries of acute stroke treatment by 2030. Vascular neurology is advancing in leaps and bounds, and is sure to create its niche in acute stroke treatment. Telestroke has the potential to integrate all the links of the stroke survival chain and save those precious extra minutes. One hopes for early government intervention and funding in the matter. Indeed, a comparison of the national registries for stroke thrombolysis in India and China concluded that overall, rate of thrombolysis was higher in India. We have to ensure that these trends are maintained and improved.
| Conclusion|| |
Repeated awareness programmes at the community level, and with local doctors can improve the detection, dispatch, delivery, and door phases of the stroke chain of survival. Simple steps like NIHSS certification, smartphone applications like NIHSSapp and IV Thrombolysis, and a Whatsapp network amongst local doctors will go a long way in improving resource utilization and rate of IV thrombolysis. We sincerely hope that more and more physicians take on the task of thrombolysis with greater confidence.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]