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|THE EDITORIAL DEBATE: PROS AND CONS
|Year : 2016 | Volume
| Issue : 7 | Page : 6-7
Management of stroke: The triumphs and the travails
MV Padma Srivastava
Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||3-Mar-2016|
M V Padma Srivastava
Department of Neurology, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Padma Srivastava M V. Management of stroke: The triumphs and the travails. Neurol India 2016;64, Suppl S1:6-7
Cerebrovascular diseases impose an overwhelming requirement for astute perception of the complexities of anatamo-physio-pathological array of actions of the intricate and extremely complex vascular-neural-endothelial-glial networks. For anyone who wishes to foray into an all encompassing and complete understanding of "stroke", the field throws open continuous challenges.
Stroke is the second commonest cause of death in India. According to ICMR statistics, 1,65,000 strokes occur each year, with nearly one stroke every 40 seconds and one stroke death every 4 minutes. Amongst the stroke survivors, many are afflicted with serious long-term disability. ,,,
Many Indian hospitals lack the necessary infrastructure and organization required to triage and treat patients with stroke quickly and efficiently. The clinical stroke services across the country need to be optimized for the delivery of adequate stroke care. The existing treatment gaps in stroke care include a dismal rate (0.5%) of thrombolysis for stroke; and, non-availability of 24x7 stroke physicians, stroke interventionalists, stroke area maps, stroke care pathways, stroke units, stroke teams, sufficient community awareness programs, and efficient public emergency ambulance systems, which are all essential elements necessary to provide optimal stroke care to the community. It is imperative and immediately necessary that adequate measures are implemented to meet the stroke epidemic in India. ,,,,,,
There have been amazing advances in the understanding of management and outcomes of stroke in the last decade. There is a palpable paradigm shift in approach to a stroke patient from one of nihilism to the current era of hope, aggression and optimism. Central to this change are the enormous advances in neuroimaging technology, which has transformed the way we assess a stroke patient. In minutes, we can obtain information on the type of stroke, the cause, vessels involved, subtype, best treatment protocols, prognosis and recurrence risk.
Endovascular treatment of acute ischemic stroke (AIS) is a therapy with a visible effect. With prompt and effective reperfusion, our stroke patients with hemiplegia and aphasia can walk back into their lives and integrate as normal members of the society. All the recent trials, MR CLEAN, EXTEND-1A, SWIFT-PRIME, REVASCAT, THRACE, THERAPY ,,,,,, have given unequivocal results in favour of endovascular intervention in selected patients. We have now entered a new era of stroke therapy for major acute ischemic stroke, aneurysmal bleed, and revascularization for major artery occlusions. Better devices, better techniques and better expertise have all increasingly improved outcomes after stroke. Endovascular treatment has become a new standard of care for large vessel AIS.
We will need to evolve triage rules, systems and processes, and train new and existing emergency personnel. We will need to assess the medical aspects of care including the thrombolytic drugs in combination with endovascular thrombectomy, anaesthesia use, adjuvant antithrombotic therapy, and medical management of blood pressure. We will need to identify the best and most appropriate imaging selection techniques for implementing optimal, time-sensitive management strategies for stroke treatment.
The new mantra is "time" and the single unifying theme is "speed". Onset-to-reperfusion time is the new bottom line process metric and remains the fundamental principle for AIS.
As with intravenous recombinant tissue palsminogen activator, only a small percentage of patients with stroke will require endovascular therapy but this small percentage will drive the reorganization of systems of stroke care.
It is imperative that the focus remains "Indiacentric". It is pertinent to design and enact the mandate of National Programs for Non-Communicable Diseases of Government of India to address issues such as stroke burden in India, what is unique to India with regard to stroke in the young, the risk factors, stroke in pregnancy, the atherosclerotic pattern, stroke mortality and recurrence risk and most importantly, the management strategies including treatment and prevention best suited to Indian infrastructure and economy; to design protocols and blue prints for ensuring best management to most patients, regardless of the socioeconomic and geographic barriers across the country.
Telestroke services in our country can amalgamate the tertiary with the secondary and primary stroke care services and reach out to the remote and underprivileged sections of our society. Using low cost smart phone technology and "whattsapp" social networking sites, the state of Himachal Pradesh has successfully implemented the "Telestroke" services in the entire state with 12 district hospitals and just 4 neurologists. They have successfully established acute stroke care pathways and thrombolysed patients with AIS at the district level with trained emergency doctors, free of cost to the patients. This enormous success of the stroke program in Himachal Pradesh should be the way forward for rest of the country.
The ultimate aim of any therapeutic strategy is maximum restoration possible and eventual return to normalcy of function. The non-regenerative capability of an injured adult brain has been recently challenged and neural plasticity has been documented in both experimental and clinical global and focal brain ischemia. Considering the fact that the neuronal circuitry is a complex array of neurons and connections, the possibility of enhancing reconstruction of damaged neuronal network by means of drugs, devices and robotics is becoming increasingly feasible and possible, much to the delight of scientists working in the field of restorative medicine.
Needless to say, we are at the threshold of exciting times; of changing landscapes and receding horizons; of what is possible in preventing stroke, treating stroke, and rehabilitating a stroke victim. Pathways of stroke care and stroke recovery cannot be expected to be smooth. But triumphs can only be achieved after travails! And it is worth it!
| » References|| |
Dalal PM, Malik S, Bhattacharjee M, Trivedi ND, Vairale J, Bhat P, et al.
Population-based stroke survey in Mumbai, India: Incidence and 28-day case fatality. Neuroepidemiology 2008;31:254-61.
Sridharan SE, Unnikrishnan JP, Sukumaran S, Sylaja PN, Nayak SD, Sarma PS, et al.
Incidence, types, risk factors, and outcome of stroke in a developing country: The Trivandrum Stroke Registry. Stroke 2009;40:1212-18.
Das SK, Banerjee TK, Biswas A, Roy T, Raut DK, Mukherjee CS, et al.
A prospective community-based study of stroke in Kolkata, India. Stroke 2007;38:906-10.
Nagaraja D, Gururaj G, Girish N, Panda S, Roy AK, Sarma GR, et al.
Feasibility study of stroke surveillance: Data from Bangalore, India. Indian Journal of Medical Research 2009;130:396-403.
Pandian JD, Sudhan P. Stroke Epidemiology and Stroke Care Services in India. Journal of Stroke 2013;15:128-34.
Pandian JD, Srikanth V, Read SJ, Thrift AG. Poverty and stroke in India: A time to act. Stroke 2007;38:3063-9.
Pandian JD, Kalra G, Jaison A, Deepak SS, Shamsher S, Padala S, Singh Y, Abraham G. Factors delaying admission to a hospital-based stroke unit in India. Journal of Stroke and Cerebrovascular Disease 2006;15:81-7.
Pandian JD, Jaison A, Deepak SS, Kalra G, Shamsher S, Lincoln DJ, Abraham G. Public awareness of warning symptoms, risk factors, and treatment of stroke in northwest India. Stroke 2005;36:644-8.
Langhorne P, Pollock A, in conjunction with the Stroke Unit Trialists' Collaboration. What are the components of effective stroke unit care? Age Ageing 2002;31:365-71.
Langhorne P, Villiers LD, Pandian JD. Applicability of stroke-unit care to low-income and middle-income countries. Lancet Neurol 2012;11:341-48.
Pandian JD, Joy SA, Justin M, Premkumar AJ, John J, George AD, Paul P. Impact of stroke unit care: An Indian perspective. International Journal of Stroke 2011;6:372-3.
A Radiology Today staff report, Endovascular Stroke Treatment: 'MR CLEAN' Data Supports Within-the-Artery Approach to Treating Ischemic Stroke. Radiology Today 2015;16:26.
Campbell B, Mitchell J, Kleinig TJ, Helen M, Desmond PM, Geoffrey AD, and Davis SM, for the EXTEND-IA Investigators. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. The New England Journal of Medicine 2015;372:1009-18.
Jeffrey L, Goyal M, Bonafe A, Vivek K. Reddy, Rochemont RDM, Singer OC, Jahan R, for the SWIFT PRIME Investigators. Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. The New England Journal of Medicine 2015;372:2285-95.
Smith WS. REVASCAT Trial: Further Advancement in Endovascular Stroke Therapy. Stroke 2015;46:3012-13.
Ding Dale Endovascular Mechanical Thrombectomy for Acute Ischemic Stroke: A New Standard of Care. Journal of Stroke 2015;17:123-6.
Bracard S, Ducrocq X. THRACE: Trial and cost effectiveness evaluation of intra-arterial thrombectomy in acute ischemic stroke; In: European stroke organisation (ESO) conference; 2015. Abstract 180.
Balasubramaian A, Mitchell P, Dowling R, Yan B. Evolution of Endovascular Therapy in Acute Stroke: Implications of Device Development. Stroke 2015;17:127-37.