Population-based stroke survey in Mumbai, India: incidence and 28-day case fatality.

OBJECTIVES: The aims of this study were (1) to establish a prospective community-based stroke registry in Mumbai of subjects having 'first-ever stroke' (FES) and (2) to collect standardized data on annual incidence, stroke subtypes, and case fatality rate at 28 days during the years 2005 and 2006. BACKGROUND: An estimated 5.8 million people died from stroke (cerebrovascular disease) in 2005, two thirds of them were from low-/middle-income countries but reliable population-based studies are scarce. METHODS: The manual on WHO STEPwise approach to stroke surveillance (STEPS Stroke; http://www.who.int/chp/steps/Manual pdf) was the operational protocol. We selected a well-defined community (H-district) having verifiable census data and being representative of the population structure of Mumbai (Bombay). Of 337,391 permanent residents, 156,861 persons between the age of 25 and 94+ years who were eligible for survey were screened. The responses to a predefined questionnaire (version 2.0) were entered in coded data sheets for analysis. RESULTS: During the 2-year study period (January 2005 to December 2006), 456 (238 males and 218 females) had FES, indicating an annual incidence in subjects of 25 years and above of 145/100,000 persons (CI 95%: 120-170); for males it is 149/100,000 persons (CI 95%: 120-170) and for females it is 141/100,000 persons (CI 95%: 120-160). The age-standardized rate for study population (both sexes) by the direct method using Segi's 1996 world population is 152/100,000/year (CI 95%: 132-172). Stroke diagnosis was supported by computed tomography in 407 (89.2%) of 456 FES cases: 366 (80.2%) had ischemic stroke, 81 (17.7%) had hemorrhagic stroke and 9 (1.9%) were in the unspecified category. The mean age was 66 +/- (SD) 13.60 years, women were older as compared to men (mean age 68.9 +/- 13.12 years vs. 63.4 +/- 13.53 years). Case fatality: at 28 days, 320 (70%) of 456 FES cases were still alive and 136 (29.8%) had died. Of the 320 surviving patients 38.5% had moderate to severe disability by the modified Rankin scale. CONCLUSIONS: The results of Mumbai stroke study, using uniform definitions and methodologies, show that the annual standardized incidence rates, stroke subtypes and case fatality rate are very similar to those reported from developed nations. To plan effective intervention and prevention strategies, standardized data in representative samples of regional populations are urgently needed.

Mumbai stroke registry (2005-2006)--surveillance using WHO steps stroke instrument--challenges and opportunities.

BACKGROUND: India will face enormous socioeconomic burden because life expectancy is increasing placing larger numbers of older people at risk of stroke and other chronic diseases. In order to plan prevention strategies, reliable information on stroke epidemiology is required. For uniform data collection (population based), WHO recommends use of STEPS Stroke instrument. STUDY: A well-defined community (H-ward) with verifiable census data, and representative of population structure of Mumbai (Bombay), was selected. The manual on WHO STEPwise approach to stroke surveillance (STEPS; http://www.who.int/chp/steps/Manual.pdf) was the operational protocol. RESULTS: During the two year study period (Jan 2005 to Dec 2006), 521 new stroke (CVD) cases (males--275 and females--246) were identified; of which 456 (238 males and 218 females) had "first ever stroke"(FES) indicating an annual incidence of 145 per 100,000 persons (CI 95%: 120-170); age adjusted Segi rate: 152/100,000/year (CI 95% 132-172). Two thirds of the FES cases were admitted to health care facilities (Step I: "in-hospital" cases), the remaining 150 (32.8%) either died outside of hospital or were treated at home or nursing homes (Step II: Fatal events in community and Step III: Non-fatal events in community). CVD Diagnosis was supported by CT (Computed Tomography) in 407 (89%) of 456 FES cases: 366 (80.2%) had Ischaemic CVD, 81 (17.7%) had hemorrhagic CVD and 9 (1%) were of unspecified category. The mean age was 66 yrs SD +/- 13.60 and women were older compared with men (mean age 68.9 yrs SD +/- 13.12 versus 63.4 yrs SD +/- 13.53). Hypertension (BP more than 140/90 mm Hg) alone or in various combinations was present in 378 ( 82.8%) cases. Case fatality at 28 days after the FES stroke was 29.8%. Of 320 surviving patients 38.5% had moderate to severe disability. CONCLUSIONS: WHO STEPs stroke surveillance Instrument is simple to use and, practical for community surveys. The data are useful for planning stroke prevention campaigns on public awareness and education with regard to diet, exercise, blood pressure control and early symptoms of minor strokes.

Antithrombotic agents in cerebral ischaemia.

The current evidence suggests that aspirin is treatment of choice when compared to anticoagulants for patients with non-cardioembolic stroke. The usefulness of combination therapy (aspirin vs. with or without warfarin) is still debated. Likewise the combination of Aspirin with clopidogrel has no added advantage (MATCH Trial). However anticoagulant therapy significantly benefits high-risk patients with atrial fibrillation in the elderly subjects whereas aspirin may still be the drug of choice in stroke prevention in low risk group in the younger age. There is dire need for well planned randomized double blind controlled studies to define the role of Antithrombotic agents in "cryptogenic stroke" (PFO/ASD related) antiphospholipid antibody syndrome, arterial dissections and intraluminal clot syndromes. Evaluation and treatment of associated risk factors in all categories needs greater emphasis.

Strokes in the elderly: prevalence, risk factors & the strategies for prevention.

Current demographic trends suggest that the Indian population will survive through the peak years of occurrence of stroke (age 55-65 yr) and stroke-survivors in the elderly with varying degree of residual disability, will be a major medical problem. The available data from community surveys from different regions of India for 'hemiplegia' presumed to be of vascular origin indicate a crude prevalence rate in the range of 200 per 100,000 persons. Thus, the anticipated costs of rehabilitation of stroke-victims will pose enormous socio-economic burden on our meagre health-care resources, similar to what is now faced by industrialised nations in the West. Therefore, prevention of strokes at any age should be our main strategy in national health planning. Among all risk factors for strokes, hypertension is one of the most important and treatable factor. Community screening surveys, by well defined WHO protocol, have shown that nearly 15 per cent of the urban population is 'hypertensive' (160/95 mm Hg or more). Though high blood pressure has the highest attributable risk for stroke, there are many reasons such as patient's compliance in taking medicines and poor follow up in clinical practice that may lead to failure in reducing stroke mortality. In subjects who have transient ischaemic attacks (TIAs), regular use of antiplatelet agents like aspirin in prevention of stroke is well established. It is also mandatory to prohibit tobacco use and adjust dietary habits to control body weight, and associated conditions like diabetes mellitus etc., should be treated. It is advisable to initiate community screening surveys on well defined populations for early detection of hypertension and TIAs. Primary health care centres should be the base-stations for these surveys because data gathered from urban hospitals will not truly reflect the crude prevalence rates for the community to design practical prevention programmes.

Ischaemic strokes: management in first six hours.

Cerebrovascular disease (CVD) or stroke is one of the foremost causes of high morbidity and mortality for many nations of the world, posing a major socio-economic challenge in the occupational and neuro-rehabilitational programmes of the 'stroke-survivors'. For example, in USA alone it has been estimated that a sum of 3261 million dollars is spent as direct cost for treatment, in addition to 4104 million dollars as indirect costs, consequent on economic losses of 'stroke victims'. Thus, the new concept in stroke pathophysiology and strategies for stroke prevention have assumed global importance. Among all risk factors for strokes, hypertension is one of the most important and treatable factor. Community screening surveys, by well defined WHO protocol, have shown that nearly 15% of urban population is hypertensive (160/95 mm Hg or more). Though high blood pressure has the highest attributable risk for stroke, there are many other reasons such as patient's compliance in taking medicine and poor followup in clinical practice that may lead to failure in reducing stroke mortality. In subjects, who have transient ischaemic attacks (TIAs), regular use of antiplatelet agents like aspirin is well established in prevention of stroke. It is also mandatory to prohibit tobacco use and adjust dietary habits to control body weight. Associated conditions like diabetes mellitus etc. should also be treated. It is advisable to initiate community screening surveys on well defined populations for early detection of hypertension and TIAs. Primary health care centres should be the base stations for these surveys, because data gathered from urban hospitals will not truly reflect the crude prevalence rates for the community to design practical prevention programmes.

Cerebrovascular disease in type 2 diabetes mellitus.

Incidence of CVD in diabetic men was reported to be twice as that of non-diabetics and almost three times greater in diabetic women in the Framingham Study. It is postulated that excessive glycation and oxidation, endothelial dysfunction and increased platelet aggregation may be responsible for endothelial proliferation and thickening of plasmatic membrane in small blood vessels ('lipohyalinosis') leading to lacunar infarction. Prothrombotic state may precipitate a stroke, however, platelet aggregability, elevated fibrinopeptide A (FPA) and D-dimer were not significantly related to stroke in diabetic mellitus (DM), whereas suppressed fibrinolytic activity was a common finding. Of many unknown factors in pathogenesis, the deficient insulin secretion, resistance to action of insulin at level of 'insulin receptors', changes in counter regulatory hormones (e.g. glucagon, pancreatic polypetides, growth hormone, catecholamines, etc.) and decrease in the hepatic sensitivity to insulin action in suppressing glucose output have received more attention. Hyperosmolar state can simulate stroke syndromes. Early recognition and treatment of risk factors such as hypertension or better glycemic control, correction of hyperlipidemia or obesity in diabetic population are important. In diabetic subjects already showing recurrent transient cerebral ischemic attacks (TIAs) or minor strokes, the benefit of antiplatelet agents or antithrombotic therapy in prevention of major strokes is well established. Ramipril has been found to be effective in reducing stroke risk by 33% in diabetic patinets in HOPE study.

Use of calcium channel blockers in acute ischemic cerebrovascular disease.

Many studies have shown that increased intracellular concentration of calcium ions is an important factor influencing neuronal damage in acute ischemic cerebrovascular disease (ICVD) and administration of calcium-channel blockers during the "open therapeutic window" have beneficial cytoprotective effects. In a prospective ICVD study we administered dihydropyridine compound "nimodipine" (1.5 to 2.0 mg/kg/day) either orally or as continuous intravenous drip round the clock for the first three days followed by oral therapy along with standard treatment after the diagnosis of a stroke was confirmed by CT Scan. The "ICVD" control cases received best medical care (BMC). The degree of functional neuronal recovery (using modified Mathew's scale) was assessed after three weeks of therapy. Our study shows significant improvement in the quality of neurologic recovery though there was no change in mortality rate in both the groups.