J S CHOPRA ORATION
|Year : 2006 | Volume
| Issue : 4 | Page : 193-198
Stroke care: Experiences and clinical research in stroke units in Chennai
President, Indian Stroke Association, Founder Member and Fellow, Indian Academy of Neurology, Prof. Emeritus. Dr. MGR Medical University, Chennai, Visiting Professor, Madras Institute of Neurology, Consultant Neurologist, Stroke Units, Vijaya/Mercury, Chennai, India
Stroke Unit, Mercury Hospital, 36, Pantheon Road, Chennai - 600 008
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: S troke is the second commonest cause of death in India with crude overall prevalence rate of 220 per 100,000. With an increasing aging population at risk, the stroke burden in India can be expected to reach epidemic proportions. Materials and Methods: The first protocol-based prospective studies, funded by private agencies was conducted in Madras Institute of Neurology in 1984-86. The results led to establishment of the first stroke unit in Tamil Nadu state, in the institute. The first all-India hospital-based studies in acute stroke was completed as INDIAN COOPERATIVE ACUTE STROKE STUDIES (ICASS I and ICASS II with WHO STEP ONE) by members of the Indian Stroke Association between 2000-2005. This has generated very useful data for our country. Results: Mortality in 1984-86 was 40%. Stroke unit in the institute dropped it to 12%. About 10 years later, ICASS studies showed a further fall of mortality to 8%, which is the current international figure in the west. Morbidity pattern showed about half return to their original activities. But about one third are left totally disabled needing prolonged care, for which fiscal, social and rehab provisions have to be done on a national basis. Conclusions: The progress and success of care of Stroke in the last three decades, from treatment in medical and neurology wards to specialized stroke units is presented. The main risk factors are hypertension, diabetes and ischemic heart disease across the country. Hypertension alone or with the other two diseases was present in 72% of cases. Prevention and treatment of these factors will reduce the stroke burden, mortality and morbidity of strokes. The Stroke-team concept can be extended to the smallest hospitals in our country.
Keywords: Clinical research, strokes, stroke units, stroke team
|How to cite this article:|
Gobindram A. Stroke care: Experiences and clinical research in stroke units in Chennai. Ann Indian Acad Neurol 2006;9:193-8
I feel honored to give this prestigious oration for my distinguished colleague Dr. J. S. Chopra. I thank my co-members in the Academy and the Executive Committee for bestowing up on me this privilege. Dr. J. S. Chopra is well known as a keen neuroscientist, an excellent teacher and an efficient organizer in India and in international neurology. I have valued his friendship and respect for the last four decades.
History of stroke care in our country and specifically in Chennai has changed remarkably. My interest in stroke commenced in 1951 when my mother suffered a right hemiplegia with total expressive aphasia. Treatment scenario then ranged from ice packs on the head for the presumed intra-cerebral hemorrhage in the acute stage to intravenous histamine drips in sub-acute stage of ischemic strokes to ipsilateral stellate ganglion block to ganglion blocking agents for hypertension management. International advances in the field of stroke, return of overseas-trained Indian neurologists and development of specialized neuroscience centers in India has changed this scene radically.
Stroke is the third leading cause of death in the USA after heart disease and cancer. In our country, stroke is perhaps the second commonest cause of death and probably the most common cause of disability. Despite being responsible for such high mortality and morbidity, regrettably, it is still to find a mention in the document drafted by the National Commission of Macroeconomics and Health in India.
There are few population-based studies that assess the prevalence of strokes in India. Studies in rural and urban population suggest an overall crude prevalence rate that ranges from 130 to 220 per 100,000 persons. In the age group of 40-60 years, the reported crude prevalence rate is 540 per 100,000, while in that of 55-65 years it is as high as 700 per 100,000 people.,,
With the life expectancy at birth crossing 65 years, in the next 10 years we can expect to see an increase in the ageing population that is at risk for strokes. More than 50% of stroke patients remain vocationally impaired and about 30% need full support for activities of daily living. With improved care saving more lives of stroke patients and secondary prevention measures prolonging survival in them, there are an increasing number of survivors needing provision for their prolonged care. This therefore warrants an urgent policy planning with appropriate fiscal allotments towards better primary prevention of strokes and rehabilitation of stroke survivors.
Development of specialized stroke care in India
A few visionaries and neuroscientists, through their sheer hard work and perseverance and despite limited availability of drugs and overcrowding in our hospitals, have been responsible in bringing down the mortality and morbidity rates of strokes in India to levels comparable to international standards. Dr. Praful M. Dalal, who is acknowledged as the man initiating the specialized stroke management concept in India, managed in an overcrowded municipal hospital, with limited resources to reduce the mortality from 33 to 12% in ischemic infarctions. Prof. Jagjit Singh Chopra, who returned from the UK to head the Neurology Department at the Post Graduate Institute (PGI) in Chandigarh, along with the brilliant neuropathologist, Dr. Banerji, initiated autopsy studies on strokes. Their reports of the alarming incidence of strokes in the young and their pioneering work in cerebral venous sinus thrombosis are often referred to in literature. Many of us also know Prof. Chopra as the chief architect in the formation of the Indian Academy of Neurology. Two individuals, who were not neurologists, played a vital role in initiation of specialized stroke care in South India. Late Sri Nagi Reddy, the famous film producer, used his wealth to form a trust to open a huge complex of medical facilities, known as Vijaya group of hospitals with special stress on low- costing and free beds and the stroke ward was his pet specialty. The other was late Dr. T. J. Cherian (TJC), who pioneered bypass and open-heart surgeries at a service-oriented hospital in Southern Railway long before our academic Medical Colleges could start it. Interested in acute care he realized that acute strokes can be saved better with a dedicated care service and started the first stroke unit in India in private sector in 1985, after retirement. In south and many other parts of India, TJC's name is synonymous with stroke care. And yet when a young neurologist seeking neurological base to work, in 1988, met Sri Nagi Reddy and was directed to TJC, he in his usual magnanimous way told him "come and work with me; from today onwards , you will be in charge of stroke unit".
This youngman has followed the tradition of workoholic TJC and has nurtured this stroke care unit further. He has created the most suitable concept for our country, stroke teams concept, who with suitable training can work in hospitals without stroke units.
He has organised a thrombolysis team with Dr. Shivkumar who has performed over 80 thrombolyses, the largest number in india; and Carotid endarterectomy with Dr. Balaji was started 5 yeas ago.
I have been a member of his team in a small hospital with 30 beds but i have had the pleasure and unique opportunity of chronicling the routine and clinical research work in these stroke units.
Here I present some aspects of my work in stroke care development and clinical research.
| Stroke Care at the Institute of Neurology|| |
The generous funding by the pharmaceutical company, Merck, under the directorship of Dr. Chico Vaz and later Dr. Gupte, helped us at the Institute of Neurology, under the stewardship of Prof. V. Natarajan, to study acute stroke between 1984 and 1986. The Madras Institute of Neurology encephabol stroke study was done after CT scan became available in 1979, even before the stroke unit was formed. The results presented at World Federation of Neurology Congress in Delhi in 1989 and at the 7th Asian and Oceanian Congress of Neurology at Bali in 1987 are summarized below.
In this study, 159 consecutive cases were studied with detailed assessment of physical and cognitive measurements. There were 130 infarctions and 29 hematomas that were treated as would be by a stroke team with one neurologist. Guy s hospital score was used to differentiate clinically between infarction and hemorrhage and correlated with brain scans. The maximum frequency of stroke (73%) was in those aged 51 years and above [Table - 1] and 14% of strokes occurred under in those aged 40 years. This was in contrast to the data two decades ago from hospital-based studies, which had shown a high incidence of strokes in the younger age group. Most cases of hematomas were brought in the late stages and mortality was high (48%). One hundred and thirty five cases of intra-cerebral hematomas were analyzed in the Institute of Neurology in 1989. Maximum frequency (63%) was seen in the 51 to 70 year age group and 11% occurred in the below 40 years age group. Most cases had uncontrolled hypertension due to lapses in treatment. Final outcome showed a mortality of 24% in the non-operated group and surgical results were worse because of delay in admission [Table - 2].
| Stroke unit in Madras Institute of Neurology|| |
In view of high mortality in strokes, a stroke unit with four beds was created in 1993 at the Madras Institute of Neurology, under direct care of neurologist Dr. Dhanraj who provided dedicated care in the intensive care unit where these beds were placed.
In the first prospective study mortality in this stroke unit in 100 consecutive cases dropped to 12% [Table - 3]. The decrease in case-fatality rates in strokes across the world may be due to improved stroke care or decreased disease severity or early admissions.
Clinical Research and Indian Stroke Association. The All India Cooperative Acute Stroke Studies (ICASS).
Much work regarding strokes has been reported in India in the past 50 years. Few of it was done on an all India multi-centric basis using common standard international scales. Drs. Dalal, Hastak and Katrak pioneered the Indian cooperative acute stroke study, Step I (ICASS-I). This included 10 centers spread from north to south of India and included a multiethnic population with varied lifestyles. Ethnic disparities have been studied in many countries. A common protocol was used that excluded TIAs, subarachnoid hemorrhages and non-stroke events and events over 48h old. On 3rd May 2001 after a review of the results ICASS-I, it was decided to plan ICASS-II study with special details, as per international norms, to the risk factors seen in ICASS-I. WHO STEP-1 study was added to ICASS-II. The ICASS-II was conducted at six centers and part of that study has been reported in the recent First National Congress of Stroke Association and Regional Asian Stroke congress held in Chennai.
We are aware that ICASS-II would miss the TIAs and the silent infarctions. Miller et al from Cincinnati assessed that 51% of TIA and mild strokes are never admitted to hospitals while Vermeer et al from Rotterdam reported 11% of asymptomatic population showed ischemic changes on MRI brain. Some results from ICASS studies are summarized below.
ICASS-I had 1354 cases reported from 10 centers in India. Hypertension alone or in combination with Diabetes Mellitus or Ischemic Heart Disease was present in 62%. Among the clinical predictors of stroke, an NIH scale score on admission of less than seven, predicted no mortality and good prognosis with 82% near- independent at follow-up. A NIH score of over 14 predicted an 18% mortality, 63% were severely disabled and only 9% became independent at follow-up [Table - 4]. Best results with thrombolysis with tPA are seen in those who are given intravenous thrombolysis within first 3h after stroke.,, However, in the ICASS only 20% of cases arrived within 3h, 14% came between 3 and 6h and 50% came between 12 and 48h [Figure - 1].
This shows a greater need for public and primary doctor education for early referral of strokes to stroke units. The final outcome at 12 weeks is shown in [Figure - 2]. The average mortality was 8%, 38% remained totally dependent and 40% were independent. These results suggest that the cost of care and secondary prevention in the national context is likely to be enormous in the years to come, unless Herculean efforts are made towards primary prevention and early admissions in stroke care units.
| Vijaya Hospital Stroke Unit in Chennai|| |
At our stroke unit, Vijaya Hospital, we admit about 700 strokes per year. One unit is dedicated to thrombolysis and carotid surgery. What follows is the data on 402 cases seen between 2003 and 2004 in our stroke unit.
Circadian rhythm and stroke onset
It is now well recorded that circadian rhythm is a definite risk factor in stroke due to changes in BP, coagulability of blood and hypoxia when sleep disorders are superadded in elderly populations.,,, Many strokes occur overnight and the exact time is often not clear. However, with effort one can narrow it down to hours by taking a history of toilet awakenings. In our data in 158 cases the time of onset was clear [Table - 5] and the maximum incidence was between 4 am and 12 pm (48% of cases), similar to what is reported in the literature. There was also a second peak between 4 pm and 8 pm in our series. Both the sympathetic and renin secretions increase after evening hours and peak around midnight and could perhaps explain our second peak. Several stroke patients give a history of breathing disorders in sleep, like sleep apnea and snoring. Stroke incidence has been reported to be higher in these conditions.
Risk factors: We evaluated five risk factors in detail- hypertension, diabetes, ischemic heart disease, cholesterols and tobacco. The prevalence of these risk factors matched that of what has been seen across India [Figure - 3]. Hypertension alone or with other risk factors like diabetes or ischemic heart disease was present in 72% of the patients, similar to figures reported in world literature., Diabetes mellitus (DM) was seen in 8%. Although this figure is low, DM is a very important factor in India where it is expected to reach epidemic proportions in the years to come. DM makes the prognosis worse when occurring with hypertension or ischemic heart disease., Ischemic heart disease alone in form of ECG changes or echocardiographic abnormality was present in 2% of cases. It was present with hypertension and DM in a third of cases. Although it is well-established that chronic hyperlipedemia predisposes to premature atherosclerosis leading to cardiovascular and cerebrovascular events, values of lipids in acute stroke are not correlative. A high cholesterol and low-density lipoprotein (LDL) and low high-density lipoprotein are essential predisposing factors. Very low LDL may be a marker for intra-cerebral hematoma. Statin therapy, although not proved to be useful statistically, may be offered to elderly with major risk factors. In India, tobacco is chewed and smoked as cigarettes and bidis (Indian version of the cigarette), across urban and rural areas. It is well- established as a causative agent in peripheral vascular and coronary artery disease. Nagaraja et al showed smoking, alcohol and tobacco abuse were more prevalent in younger strokes (relative risk 1.2, 1.9 and 1.5 respectively). In our study there was no statistical significance for smoking as a risk factor. Dalal, added case control studies for risk factors including alcohol and showed that hypertension ( P =0.001) and ischemic heart disease ( P =0.008) followed by alcohol ( P =0.05), were the most statistically significant risk factors.
Stroke unit care in India
Among the advances for treatment of stroke, imaging techniques and stroke unit care have contributed immensely in reduction of mortality and morbidity., Addition of thrombolysis in the golden hours has further improved the outlook. In our experience the most important advance has been inclusion of family members in physiotherapy from very early stages and they have produced gratifying results. In smaller hospitals, Stroke team concept works equally well under a stroke-trained neurologist or physician. Thankfully several stroke centers have started all over India.
| Conclusions|| |
This presentation shows the change in care of stroke patients in India over the last four decades. Strokes treated by physicians initially in 1960s, were helped by neurology consults in 1970s until the stroke unit care concepts were proven by Dalal. Increased availability of intensive care units enabled to drop mortality from 40 to 12% in 1990s. Further advances in treatment in the last 15 years have reduced it further to 8%.
Unfortunately all patients saved do not achieve independence and about 38% remain totally dependent. The future lies in (1) prevention of primary risk factors, hypertension being the commonest; (2) early detection; (3) pre empting the disease of risk factors (4) secondary prevention of recurrence; (5) recommendations of change in life style of population at risk regards salt and sugar intake and (6) strict avoidance of tobacco and alcohol in this population. Public awareness programs should take this up on a national basis. We should probably ask how many children the stroke patient has rather than ask if his peers had strokes; and teach those children at risk all the preventive methods possible. Any discussion on stroke care is incomplete without a grateful tribute to the caretakers of these unfortunate people, who have willingly learnt and imparted rehabilitation therapy at home to produce astounding results in many cases. Introduction of trained and interested neurologists in stroke and working in small teams can be implemented in any part of our country at the smallest hospitals to minimize mortality and morbidity due to strokes.
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[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]