Abstract: HomeCirculationVol. 118, No. 25Stroke Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBStrokeIndian Scenario Shyamal Kumar Das, MD, DM and Tapas Kumar Banerjee, MD, FRCP Shyamal Kumar DasShyamal Kumar Das From the Department of Neurology, Bangur Institute of Neurosciences and Psychiatry (S.K.D.), and Department of Neurology, National Neurosciences Centre (T.K.B.), Kolkata, India. and Tapas Kumar BanerjeeTapas Kumar Banerjee From the Department of Neurology, Bangur Institute of Neurosciences and Psychiatry (S.K.D.), and Department of Neurology, National Neurosciences Centre (T.K.B.), Kolkata, India. Originally published16 Dec 2008https://doi.org/10.1161/CIRCULATIONAHA.107.743237Circulation. 2008;118:2719–2724In terms of population, India ranks second only to China. Recent rapid socioeconomic changes have led to a concomitant change in people's lifestyle, leading to work-related stress and altered food habits, raising the risk of hypertension. Those factors, coupled with an increase in the average life expectancy, are expected to have an impact on the occurrence of stroke disorder in India. Conducting an epidemiological survey in a developing and populated country like India with relatively few neurologists is a daunting task. As late as 2000, India was ranked among the countries lacking sufficient research data on stroke.1 In the last decade, however, some critical data on stroke disorder in India have become available. This article aims to provide an overview of stroke in India, with particular reference to epidemiological parameters, etiologic characteristics, and outcome profile. The present article also aims to address the lack of sufficient public awareness about the disease. Insufficient systematic data on the management of stroke preclude its inclusion in this review.Stroke PrevalenceThe first community-based study of stroke was carried out in and around the town of Vellore, South India, during 1968 to 1969.2 The next was in Rohtak, North India, during 1971 to 1974.3 The very low prevalence rates (PRs) of stroke in these studies (Table 1) led to the belief that stroke was less frequent in India than in the Western world. During the 1980s and 1990s, a spate of population-based surveys on stroke was conducted in various parts of the country in both urban and rural communities (Table 1).4–12 These surveys demonstrated that the crude PR generally ranged from 127 to 220 per 100 000 persons. However, 1 study found a significantly low PR,9 and another study of Parsis in Mumbai showed a substantially high PR.5 This divergence in rates could be due to the widely different age compositions of the populations studied. Age standardization with the US population as reference, used in some of these surveys, showed the PR to be 244 and 424 per 100 000. The somewhat higher PR among the Parsis could be attributed to the difference in ethnicity and demography, characterized by aging population. Table 1. PRs of Stroke From the Major Epidemiological Studies in IndiaPlaceRural or UrbanYearPopulation, nPR per 100 000*AA-PR per 100 000AA-PR indicates age-adjusted PR; WB, West Bengal.*Crude PR.†US population in 1960.‡US population in 1996.§World standard population.∥Not mentioned.North Rohtak, Haryana3Urban1971–7479 04644· · · Kuthar Valley, Kashmir4Rural198663 645143244†West Mumbai (Parsis)5Urban198514 010842424† Mumbai6Urban1997145 456220· · ·East Malda, WB7Rural1989–9037 286126· · · Baruipur, WB8Rural1992–9320 842147· · · Kolkata9Urban1998–9950 291147334‡ Kolkata10Urban2003–0452 377472545§South Vellore2Rural1968–69258 57657· · · Gowribidanur, Karnataka11Rural1982–8457 66052· · · Bangalore12Rural1993–9551 055165262∥ Bangalore12Urban1993–9551 502136The age-standardized PRs used in the above surveys (Table 1) are not strictly comparable because the standardized populations vary. Nevertheless, this helps us understand the PR of stroke in India compared with that of Western nations. Ideally, the standardization of epidemiological rates from non–North American and non-European populations should be calculated on the basis of the world standard population, which represents a population age structure of third-world countries.13 The most recent community study on stroke conducted in the metropolitan city of Kolkata (previously called Calcutta) during 2003 to 2004 showed the crude PR to be 471.58 per 100 000 (men, 495.91 per 100 000; women, 444.43 per 100 000) (95% CI, 414.99 to 533.83).10 When age was standardized to the world standard population, the PR was 545.10 per 100 000 (95% CI, 479.68 to 617.05), indicating proportionately less aged population among the studied sample compared with the reference population.Stroke Incidence and Case FatalityMost Indian surveys have been limited to determining the PRs of stroke.2–12 There are only a few surveys in India in which the annual incidence rates (AIRs) of stroke were determined. They are listed in Table 2. With the exception of the study conducted between 2003 and 2005,10 the others have included only stroke survivors, not stroke death cases.3,8,9 Additionally, the latter data included recurrent stroke cases and lack information about AIR of first-ever-in-a-lifetime stroke. The recent Kolkata study10 captured both the stroke survivors and stroke-caused deaths. The AIR of first-ever stroke therein was 123.15 per 100 000 (men, 99.54 per 100 000; women, 149.49 per 100 000) persons per year (95% CI, 102.46 to 232.50; age-standardized rate to the world standard population, 145.30; 95% CI, 120.39 to 174.74). Incidentally, a recent prospective population-based stroke registry from Mumbai, Western India, has reported a similar AIR of 148 per 100 000 persons per year (95% CI, 120 to 170). This rate, when age standardized to the world standard population, is 154 per 100 000 per year.13 The AIR of stroke in India, as observed in the current studies, is higher than in United States (107 per 100 000 per year),14 European countries (61 to 111 per 100 000 per year),15–19 and Australia (99 per 100 000 per year)20 but similar to that reported from 1 Chinese city (Changasha).21Table 2. AIRs of Stroke in INDIAPlaceRural or UrbanYearPopulation, nAIR* per 100 000AA-AIR† per 100 000AA-AIR indicates age-adjusted AIR; WB, West Bengal.*US population in 1996.†US population in 1990.‡Age-adjusted to world standard population.§US population in 2002.Rohtak3Urban1971–7479,04633· · ·Kolkata9Urban1998–9950,29136105*Baruipur, WB8Rural1993–9820,842124262†Kolkata10Urban2003–200552,377123215.5§ (145.3‡)The overall 30-day case fatality noted in the Kolkata study10 is 41.08% (men, 38.18%; women, 43.24%), significantly higher than that seen in the Western industrialized countries (17% to 33%).15–18,20 Blacks in Manhattan (38%) and the inhabitants of Tbilisi in Georgia (35.7%) have shown similarly high stroke-related case fatality rates.19,22 Inadequacy of prompt medical care in the poor and lesion severity could be reasons for the high stroke-related case fatality.19,22 Genetic factors also might be responsible because there is greater susceptibility and higher mortality to stroke among UK residents of Indian descent.23 Hence, on the basis of the latest study,10 the stroke incidence and stroke-related case fatality rates in India are higher relative to Western industrialized nations. The rates are especially higher among women, perhaps because women outlive men (Census India, 2001) and exhibit higher prevalence of uncontrolled hypertension than men.24Stroke Subtypes and Etiologic FactorsBased on neuroimaging, recent studies have determined the stroke subtypes and the ratio of cerebral infarct to hemorrhage range as 1.86:1 to 2.21:1.9,10 Hence, cerebral hemorrhage is proportionately higher in the Eastern Indian community than in Western countries, where the ratio of infarct to hemorrhage is 5:1. Suitable neuroimaging data were available in only 50% to 60% of cases in these surveys. Incidentally, the high incidence of cerebral hemorrhage also has been noted among Chinese.24 The Kolkata study10 demonstrated that the basal ganglia-thalamic region was, by far, the commonest site (75%) of hemorrhage. In contrast, the subcortical region is the commonest site of infarction (75.6%). This predilection for subcortical infarct also is common in other Asian races. A study based on noninvasive tests to determine subtypes of ischemic stroke from a hospital-based registry of Southern India has attributed 41% of strokes to large-artery atherosclerosis, 18% to lacunar causes, 10% to cardioembolic causes, and 4% to such causes as hyperhomocystinemia, anticardiolipin antibody, Takayashu syndrome, carotid dissection, Moya Moya disease, and protein S deficiency. The remaining 27% of the cases were of undetermined origin.25 Among cardioembolic stroke, rheumatic disease (29%) and ischemic heart disease (27%) are predominant causes.25 In a clinicoradiological study among young strokes,26 the common site of arterial occlusion was the supraclinoid internal carotid artery, whereas narrowing or occlusion of major neck vessels occurred in only 10.8% of cases. Few other Indian studies trying to detect underlying vascular pathology have shown variable findings. A study from Western-Central India based on conventional angiograms has documented significant stenosis and occlusion in extracranial vessels comparable to a Western stroke registry.27 Two recent studies from large academic centers from Northern and Southern India have documented a high frequency of intracranial vessels affected on the basis of noninvasive vascular studies.25,28 This is consistent with findings in other Oriental countries. The Indian Collaborative Acute Stroke Study (ICASS), a recent multicenter study conducted among 2162 admitted stroke patients across Southern, Northern, and Western India, observed ischemic stroke in 77%, hemorrhagic stroke in 22%, and unspecified stroke in 1% of cases based on cerebral CT scans.29Stroke in the YoungPrevious hospital-based data from India indicated a high proportion of young stroke (first-ever stroke onset <40 years of age), ranging between 15% and 30%.30 However, this number was biased because of preferential admission policy. A population-based study from Southern India in the late 1960s found that 25% of stroke patients were <40 years of age, primarily young women with cerebral venous thrombosis (CVT) occurring in the postpartum stage.2 CVT was found to be 12 times more common in India than in Western countries. In the late 1970s, a hospital-based study from Northern India documented a frequency of up to 4.5 per 1000 obstetric admissions.31 An angiographically proven study reported that 50% of the total cases of stroke in young women were related to pregnancy and puerperium, 95% of which were due to CVT.31 The important predisposing factors for CVT were thought to be poor socioeconomic status and consumption of illicit liquor.32 In a recent well-designed population-based study,10 8.8% of stroke subjects were young, which is similar to that seen in Western countries.30 Interestingly, the incidence of postpartum CVT was not high in this study. This variance in observations might be related to regional and temporal differences across studies.Moya Moya disease, a disorder with predominantly intracranial inflammatory vascular pathology, is much more common among the Orientals than among whites. This disorder is also reported in India, but there is no epidemiological data or large clinical series.33 Takayasu's arteritis is another vasoocclusive inflammatory disease of unknown origin. Takayasu's arteritis involves extracranial vessels such as aorta and its branches and commonly affects young women.34 Among Indians, the genders were almost equally affected. Stroke occurred in 40% of children and adolescents (4 to 15 years of age) with Takayasu's arteritis. The subclavian arteries were occluded more often than the carotids, leading to posterior circulation stroke.35Although tuberculosis is endemic in India, only 8% of subjects were affected by the disease in a prospective study of young stroke.36Stroke-Related Mortality in IndiaHospital-based studies have documented a reduction in mortality from 33% in 1984 to 1986 to 12% in the mid-1990s among patients with ischemic strokes, possibly related to improvements in stroke management.37 The mortality of patients with intracerebral hematoma was very high (48%), mainly because of delayed hospitalization.37 However, a community-based stroke study has documented a very high rate of overall case fatality, indicating that a large number of stroke victims may die before reaching a hospital because of either stroke severity or an inability to be admitted to the hospital as a result of no transport and/or economic constraints. Recently, a mortality study has confirmed epidemiological transition of the disease pattern in India characterized by more deaths resulting from noncommunicable diseases. This report was generated from a rural community in South India on the basis of verbal autopsy and has documented a crude death rate of 7.5 per 1000 (95% CI, 7.1 to 7.9), with circulatory compromise being the leading cause of death (32%).38 An almost similar proportion of deaths was attributable to ischemic heart disease (14%) and stroke (13%). Overall data on stroke-related mortality in India are limited. Although medical certification of the cause of death is a legal requirement, only 13.5% of all deaths in India were medically certified in 1994.39 Therefore, ascertainment of the cause of death is inadequate in India. It has been estimated that stroke represented 1.2% of the total deaths in the country when all ages were included.40 The proportion of stroke death increased with age, and in the oldest group (>70 years of age), stroke contributed to 2.4% of all deaths.Risk FactorsRisk factor assessment is an important step toward understanding the origin of a disease and helps in formulating preventive strategy. Several studies have attempted to identify the risk factors of stroke and other noncommunicable diseases. A multicentric, hospital-based case-control study revealed that diabetes mellitus, hypertension, tobacco use, and low hemoglobin, rather than cholesterol level, were the most important risk factors of ischemic stroke.6 Other community- and hospital-based studies have identified hypertension as the most important risk factor.6,9,41–43 A recent community-based study from North India among urban, rural, and semiurban people has documented higher levels of biochemical risk factors such as fasting blood glucose, cholesterol, triglycerides, and low high-density lipoprotein.44 A case-control study from the same region has produced similar results and documented low consumption of fruits and vegetables, sedentary lifestyles, and psychological stress as contributory factors.45 Another study from South India reported ≥3 components of the metabolic syndrome among young stroke subjects between 20 and 40 years of age.46 The affected subjects have a higher prevalence of hypertension (particularly systolic pressure), diabetes mellitus, lower high-density lipoprotein, and smoking. All these studies indicate the importance of controlling hypertension and biochemical risk factors and avoiding smoking. The pattern of tobacco consumption is commoner among less educated persons by ≈2.69 times and prevalent among families with lower socioeconomic stratum.47Among women of advanced age, the high incidence and case fatality of stroke had a strong correlation with the high prevalence of hypertension.10,24 This indicates that less attention is paid to women's health in this country with insufficient control of hypertension.9Stroke and Socioeconomic FactorsThere are hardly any comprehensive data in India about the implication of socioeconomic factors on stroke. Over the last few decades, a rise in noncommunicable diseases has been considered to be related primarily to lifestyle changes and stress.48 Rapid urbanization and increasing employment opportunity has resulted in large-scale migration of people from rural areas to cities, resulting in a burgeoning of the cities' slum population, which, as of 2001, constituted 30% to 40% of the cities' population (Census India, 2001). The slum population acquires the maladies of an unhygienic environment because of overcrowding, poor sanitation, and intercurrent infection; in addition, it is a victim of lifestyle-related diseases. A survey among slum dwellers in the metropolitan city of Delhi has shown significant levels of vascular risk factors such as generalized and regional obesity, dyslipidemia, and diabetes mellitus, particularly among women.49 Thus, it is expected that the incidence of vascular disease will be similar to that of non–slum-dwelling people who are socioeconomically well off. In a recent survey, no difference was found in the incidence and case fatality rates of stroke between the slum dwellers and non–slum dwellers despite a substantial socioeconomic difference.10 However, the observation was not sufficiently empowered for definite conclusions. Population-based surveys from South India conducted concurrently in rural and urban populations showed a higher prevalence of stroke in the rural area.12 There are no published data on the prevalence of vascular risk factors separately among those below the poverty line (mean annual income, less than US $1 per day).48 The vascular risk factors of poor rural people might be different from those of the urban elite. Infectious diseases such as tuberculosis and cerebral malaria may be important risk factors in the former. CVT, a common cause of young stroke, has been found to be associated with poverty and certain dietary factors.31–32,50Outcome of StrokeIt has been estimated that by 2021 the stroke-related disability-adjusted life-years would be 61 million, 52 million of which would be in developing nations.51 According to recent studies, 55% to 70% of stroke survivors become fully independent by 1 year and 7% to 15.7% remained completely disabled.10,41 Prominent residual spasticity was noted in 46% of cases; it was severe in one third.41 The physical outcome of stroke is similar to that in a developed country.52 Among those who had speech dysfunction, complete recovery was reported in 47% of cases, and there was no improvement in 12%.33 Dysarthria was commoner than dysphasia. Poststroke seizure was observed in ≈2% of cases.10 The low incidence of poststroke seizure may be related to predominantly subcortical involvement. A similar observation has been made in a group of cases with vascular dementia, the pathology of which is largely small-vessel subcortical ischemic lesions.53Public Awareness Regarding StrokeWarning Symptoms of StrokeIn India, awareness of the warning symptoms of stroke among the general population is far from satisfactory. This lack of awareness leads to a delay in receiving medical advice from local doctors and a delay in hospitalization, which are setbacks for providing the necessary treatment. Warning symptoms of stroke such as affected unilateral motor and sensory abilities were readily recognized by both urban and rural populations, but other symptoms such as headache, dizziness, difficulty in speaking or understanding speech, and altered sensorium were less commonly identified.54,55 About one fourth of the unaffected urban respondents had no knowledge of any warning symptoms compared with one third of the unaffected rural population. Only 55% of the urban population were aware of 1 warning symptom of stroke; 16.2% were aware of 2 symptoms; and only 6.2% could identify 3 symptoms. Analysis has shown that improved socioeconomic status and higher education raise awareness of the warning symptoms of stroke for both rural and urban subjects.54,55Risk Factors of StrokeLack of awareness about risk factors leads to increasing stroke morbidity and mortality and to difficulty in implementing prevention strategies. A study among stroke subjects with a predominantly rural background showed awareness of risk factors in about one fourth of subject.55 Two studies on healthy subjects from rural and urban backgrounds documented knowledge of hypertension as a risk factor in 25% and 45%, respectively.53,54 Stress as a risk factor of stroke was perceived among 41% of urban subjects only. The role of other risk factors such as diabetes, smoking, hyperlipidemia, and heart disease was recognized by rural people in ≈19%, 24%, 15%, and 6% compared with 10.7%, 1.2%, 6.7%, and 2% among urban population. Only 51.2% of the unaffected urban respondents could name 1 risk factor; 18.5% could name 2 risk factors; and 9.7% could identify 3 risk factors.55Hospitalization and TransportationPoor recognition of early stroke symptoms and low perception of threat lead to delayed arrival of stroke subjects at hospitals; only one fourth arrived within 6 hours. In a major urban center, the median time to casualty arrival was 7.66 hours, with 25% of cases arriving within 3 hours and 49% of cases arriving within 6 hours. In this study, distance from hospital, contact with a local doctor, and low threat perceptions of symptoms were independent factors for delay in arrival.56 A rural-based study documented that the mean arrival time of stroke patients was 34±6 hours.54 The arrival time differed substantially from that in an urban study and was influenced by distance from the hospital, education, socioeconomic status, family history of stroke, and advice of friends and local doctor. Thus, transportation of stroke subjects is an important issue in management. Poor availability of transport in rural areas and congestion in urban areas also are considered constraints or barriers to immediate hospitalization and initiation of treatment.57,58 A hospital-based study from Northwest India has documented that only 12% of patients came by ambulance.59TreatmentA hospital-based study assessed the awareness of stroke treatment among the relatives of nonstroke patients. More than two thirds of the respondents preferred hospitalization in cases of stroke among their kith and kin. More than half of the subjects were not aware of the available treatment strategies.54 Low awareness of potential treatment availability is an important factor for the lack of motivation to obtain hospitalization. A study has documented that local-language periodicals covering important health-related topics are an important source of awareness generation. No handout in vernacular language is provided at the time of discharge from the hospital. Thus, a great lacuna in doctors' overall involvement persists.A hypertension detection program from Western India revealed that 50% of the hypertensive subjects could be detected and that only half took medicine regularly.60 Another survey from Eastern India documented very poor drug compliance (3%).24 All this points out poor public awareness regarding hypertension and its proper management. One encouraging report has emerged from a mass screening program for the detection of hypertension and the prevention of stroke. A repeat survey showed involvement of two thirds of the original sample population in a hypertension intervention strategy. Hence, this program has demonstrated the phenomenon of positive reinforcement.61ConclusionsAlthough earlier population-based studies did not determine the actual incidence rate of stroke, the data accumulated so far are sufficient for us to declare that stroke in India is very much on the rise. Management of hypertension, the most important risk factor in the community, is far from satisfactory. A high prevalence of cerebral hemorrhage has been documented in Eastern India. Similar studies need to be conducted in different parts of India to develop a national stroke registry using a common methodology that would define criteria, dietary, and risk factors because India is a multiethnic and multicultural country. It is essential to compile data regarding the long-term outcome of stroke to provide rehabilitation benefits, to identify the influence of socioeconomic factors on the occurrence of stroke, and to assess the pharmacoeconomic burden on the individual and family for determining the allocation of resources by health planners. More important, there is now an urgent need for undertaking health education measures about the awareness of risk factors and early warning signs of stroke in the community so that people in general and affected subjects specifically can receive early and effective therapy through modern means. A holistic approach to contain the challenge of stroke disorder in India is absolutely essential because the illness is now poised to become a major threat to life in this country.We are grateful to Biman Kanti Roy, MD, DM, and Jaynata Roy, MD, DM, stroke neurologists, and Ashish Dutta, MD, for useful suggestions. We are thankful to Dr Debasish Bhattacharya, MD, DM, and Surma Das (Ghosh) for literary support.DisclosuresNone.FootnotesCorrespondence to Dr Shyamal Kumar Das, Professor and Head, Department of Neurology, Bangur Institute of Neurosciences and Psychiatry, 52/1 Shambhu Nath Pandit St, Kolkata-700025, India, E-mail [email protected] References 1 Asian acute stroke advisory panel: stroke epidemiological data of nine Asian countries. J Med Assoc Thai. 2000; 83: 1–7.MedlineGoogle Scholar2 Abraham J, Rao PSS, Inbaraj SG, Shetty G, Jose CJ. An epidemiological study of hemiplegia due to stroke in South India. Stroke. 1970; 1: 477–481.CrossrefMedlineGoogle Scholar3 Bansal BC, Parkash C, Jain AC, Brahmanandan KRV. Cerebrovascular disease in young individuals below the age of 40 years. Neurol India. 1973; 21: 11–18.MedlineGoogle Scholar4 Razdan S, Kaul RL, Motta A, Kaul S. Cerebrovascular disease in rural Kashmir, India. 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