October 29 is marked as the World Stroke Day. In India as in developing countries, an alarming increase in the incidence of stroke, a highly preventable condition, has been observed owing to rising trends of hypertension, diabetes, smoking and stress in daily life. The mortality rate in stroke patients is 20%, while 50% of the patients continue to suffer with a minor or major disability, doctors tell THE HEALTH PIONEER
Stroke is one of the leading causes of death and disability in India. An estimated 18 lakh stroke cases are reported every year in India, exerting a huge economic impact on the patients, their families and society in general. Dr Anand Alurkar, president Indian Stroke Association (ISA), the apex body for stroke prevention and treatment said that the cases have almost doubled in the past decade. “Earlier, stroke was mostly affecting the elderly, but now 15-20% of the patients are under the age of 40. The challenge in stroke cases is identifying the symptoms and ensuring timely treatment.” He was speaking at the National Stroke Conclave 2023 in Ahmedabad recently.
ISA Secretary Dr Arvind Sharma added, “we want uniformity and quality in stroke care across India. The ISA initiative of Stroke Accreditation with Quality and Accreditation Institute (QAI) has made India only the third country after the US and Canada to have accreditation standards for stroke. As of now, 65 hospitals have applied for the accreditation and ten have received it.”
A report published in the Lancet Neurology journal early this month sounded alarm as it said that stroke could lead to nearly 10 million deaths annually by 2050, primarily affecting low- and middle-income countries (LMICs) including India.
Dr. Sanjay Pandey, HoD, Department of Neurology, Amrita Hospital, Faridabad echoed similar sentiments as he talked about the long-term effects of stroke, which he said, can be multifaceted – ranging from movement disorders like tremor, dystonia, parkinsonism, and epilepsy to depression and cognitive challenges and a third of all stroke patients fall prey to these health issues.
Studies show that stroke reigns as the third-most common cause of death in developed countries and remains one of the leading factors behind fatality among developing nations too when it comes to deaths and disabilities owing to non-communicable diseases. While most healthcare providers focus on the gravity of acute strokes, they often fall short to turn an eye towards the long-term health implications of such strokes.
In this regard, Dr. Sanjay Pandey said, “Most stroke patients undergo epilepsy, yet it is the formidable post-stroke movement disorders that emerge as the true giants, with a staggering morbidity rate of 10-15%. Post-stroke epilepsy follows closely behind at 10-12%, while post-stroke depression, though significant, stands at 5-9%. Regrettably, 50% of stroke survivors go undiagnosed of such post-stroke complications.”
“Long-term consequences, including post-stroke epilepsy, movement disorders, chronic pain, and paralysis, significantly erode one's quality of life. Joint deformities, facial asymmetry, contractures, and bedsores are also common. Stroke can have its impact on a patient’s mental health too in the form of anxiety, depression, memory lapses, and concentration difficulties. In some cases, individuals may develop vascular dementia, which can present itself like Alzheimer's disease. Cognitive challenges arising out of stroke can impair fundamental tasks such as eating, bathing, and everyday activities for which an individual then has to rely on caregivers. The lingering effects of a stroke can lead to an enduring state of dependence and, in many instances, a loss of employment,” added Dr. Pandey.
However, there still remains hope for stroke patients as the long-term implications can be treated with early mobilization, physiotherapy, and occupational therapy. For instance, Botulinum toxin injection has helped patients having post-stroke spasticity and dystonia. They can improve the overall functional outcome of the patients. Furthermore, there are prevention strategies for recurrent stroke which can help reduce the long-term impact of a stroke.
Even children under the age of 20, as approximately 5.2 million strokes have been reported in this age group. As life expectancy in India steadily rises, the impact of stroke on young adults is particularly concerning, as it often leads to physical disability, depression, cognitive impairment, and a significant loss of productivity, all of which carry personal, social, and economic implications.
Speaking about India, Dr. Rajiv Bahl, Director General, Indian Council of Medical Research (ICMR), has stressed the importance of implementing evidence-based stroke care to mitigate disability and prevent new strokes.
TWO MAIN TYPES OF STROKE
There are two main types of stroke, ischemic and hemorrhagic as well as several subtypes of strokes that fall under these two categories. Medical treatment will depend on the type of stroke you are experiencing.
Ischemic Stroke
Ischemic stroke is the most common type of stroke, accounting for approximately 87% of all cases. It occurs when a blood vessel supplying the brain becomes blocked or narrowed by blood clots. This blockage prevents oxygen-rich blood from reaching the brain, leading to cell damage. Common causes of ischemic stroke include atherosclerosis (build-up of plaque in the arteries), heart disease, and blood clots originating from other parts of the body.
Ischemic stroke is divided into two types, thrombotic and embolic.
Thrombotic = From blood clot formed within the brain. A thrombotic stroke is the most common of the two and occurs when a blood clot forms within a blood vessel in the brain and blocks blood flow. It is often due to a buildup of fat and lipids inside the walls of blood vessels called atherosclerosis.
Embolic = From blood clot that formed in another part of the body and traveled to the brain. An embolic stroke, on the other hand occurs when an embolus (clot or other particle) forms elsewhere in the body, travels through the bloodstream to the brain, then lodges itself blocking the flow of blood. The embolism could be from a piece of clot or atherosclerotic plaque that broke off or due to blood clots that form in people with atrial fibrillation, a condition in which the upper chambers of the heart do not beat effectively.
Symptoms of ischemic stroke (both thrombotic and embolic) include sudden weakness or numbness on one side of the body, difficulty speaking or understanding speech, severe headache, and vision problems. Treatments often involve administering clot-busting medications like tissue plasminogen activator (tPA) or performing mechanical thrombectomy to remove the clot.
Hemorrhagic Stroke
Hemorrhagic stroke occurs when a blood vessel in the brain ruptures, causing bleeding into the surrounding brain tissue. This type of stroke accounts for around 13% of all cases and can result from conditions such as high blood pressure, aneurysms (weakened blood vessels), or arteriovenous malformations (AVMs) - abnormal connections between arteries and veins in the brain.
The symptoms of hemorrhagic stroke may include a sudden, severe headache, nausea, vomiting, seizures, and loss of consciousness. Treatment for this type of stroke focuses on controlling bleeding, relieving pressure on the brain, and repairing the damaged blood vessel. Surgical interventions or endovascular coiling techniques may be used to repair the ruptured vessel and prevent further bleeding.
Transient Ischemic Attack (TIA)
Often referred to as a "mini-stroke," a transient ischemic attack (TIA) is a temporary interruption of blood flow to the brain. Although TIAs usually resolve within a few minutes to a few hours, they should not be ignored. TIAs are considered warning signs for a potential major stroke, and their occurrence should prompt immediate medical attention. The symptoms of TIA are similar to those of an ischemic stroke
Cryptogenic Stroke
Cryptogenic strokes are a subtype of ischemic stroke in which the cause remains unknown despite a thorough investigation. Despite extensive diagnostic testing, including imaging studies and blood tests, the underlying cause of cryptogenic strokes remains elusive. These strokes pose a challenge in terms of treatment and prevention, as identifying the cause is vital for preventing future occurrences.