Stroke is a global health crisis, ranking as the second leading cause of death worldwide, trailing only cardiac diseases, and the third most common cause of disability. Studies suggest that one in four individuals, or 25 per cent of the population, will experience a stroke during their lifetime. In India, it stands as the second most frequent cause of death. According to the Global Burden of Diseases (GBD), India bears a significant burden of stroke, accounting for 68.6 per cent of stroke incidence, 70.9 per cent of stroke-related deaths, and 77.7 per cent of disability-adjusted life years (DALYs) lost.

Approximately 185,000 strokes occur annually in India, translating to nearly one stroke every 40 seconds and one death every four minutes. Stroke is a non-communicable disease resulting from the rupture of a brain blood vessel or a blockage in the blood supply to the brain, leading to brain damage. Common symptoms include sudden numbness or weakness on one side of the body, trouble speaking, and loss of balance.

The burden of stroke is expected to rise due to increasing life expectancy and an ageing population in India. In urban and rural areas, stroke prevalence ranges from 45 to 487 and 55 to 388.4 per 100,000 population, respectively. India faces the challenge of combating stroke alongside existing high burdens of communicable diseases and lifestyle-related issues like diabetes, obesity and stroke, especially among the younger population.

Risk factors

Stroke risk factors can be categorised into modifiable and non-modifiable factors. Non-modifiable factors include increasing age, genetics, male gender, and low socio-economic status. Modifiable risk factors include hypertension, obesity, tobacco and alcohol consumption, unhealthy diets, diabetes, heart disease, stress, poor socio-economic status, and air pollution. Hypertension is the most significant modifiable risk factor for stroke, contributing to 55.5 per cent of the stroke burden in low- and middle-income countries like India. Elevated blood pressure control can substantially reduce stroke incidence.

Primordial prevention, aimed at preventing the emergence of risk factors, is an ideal strategy. India has taken steps to reduce tobacco consumption by introducing warning labels and advertising bans. Increasing tobacco taxes and raising the legal age for tobacco sales are additional strategies. Taxing junk foods and sugary beverages and reducing pollution levels in major cities are also part of primordial prevention efforts.

The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) was launched in 2010 to strengthen infrastructure, human resources, health promotion, early diagnosis, management, and referral. However, the focus on secondary and tertiary healthcare left a gap in managing diseases like stroke at the grassroots level, which was addressed by the introduction of Ayushman Bharat in 2018. Health and wellness centres promote healthy lifestyles and provide screening for hypertension and diabetes.

Other primary prevention strategies include identifying high-risk individuals, using aspirin in high-risk cases, reducing salt consumption, improving medication compliance, and using behavioural change messaging.

Secondary prevention emphasises early diagnosis and treatment to improve prognosis and quality of life. Early treatment is crucial, as brain cells die every 15 minutes during a stroke. Delayed treatment leads to disability and mortality. As per the studies, in some cases, up to 80 per cent of brain stroke patients reach the hospital late. CT scans are essential for distinguishing between ischemic and hemorrhagic strokes, but their availability is limited in many district hospitals and community health centres (CHCs). Expanding IT-based teleradiology solutions can help bridge this gap. Treatment options for ischemic stroke include intravenous thrombolysis and endovascular intervention.

Shortage of care units

The shortage of Cardiac and Stroke Care Units (CSCUs) in district hospitals is a critical issue, with only 25 per cent of districts in India having such units as of April 2022. Expanding CSCUs is vital for reducing stroke mortality and morbidity. Initiatives like the ‘hub and spoke’ model have been successful in managing stroke, such as Karnataka’s Brain Health Initiative and Himachal Pradesh and West Bengal’s tele-stroke model. They provide modern stroke care to the patients at the periphery.

They enable the neuro-expert at the hub to guide the medical officer at the peripheral spokes on treatment and referral by using information technology platforms. These health centres have fundamental equipment like a CT scan, ECG and blood sugar testing. The neuro-expert then generates an e-prescription for the spoke and guides the medical officer accordingly.

Tertiary prevention focuses on limiting disability and rehabilitating stroke patients. Stroke affects millions globally, leading to death or permanent disability for many. Around 15 million people worldwide suffer a stroke annually. Of those, five million die and another five million are left permanently disabled. Physical therapy is crucial in rehabilitation, but the recommended patient-to-therapist ratio of 1:6 is far from being met. Establishing peer support groups can provide emotional support and education.

Stroke care comes with a significant financial burden, with households often facing catastrophic health expenditures. The effective implementation of the Ayushman Bharat scheme can help alleviate this burden, especially for marginalised populations.

In conclusion, stroke is a major global health challenge, and India faces unique challenges in combating it due to its diverse population and existing health burdens. A multi-pronged approach that includes primordial prevention, expanding healthcare infrastructure, improving early diagnosis and treatment, and focusing on rehabilitation is essential to reduce the impact of stroke on individuals and society. It requires concerted efforts from individuals, families, communities, and the government to effectively address this complex and multifactorial disease.

Surbhi a Neurology resident at NIMHANS, Bengaluru, and Ravi is District Collector, Jashpur

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