Stroke and Cerebrovascular disease is the third leading
cause of death in India. As such, timely recognition and management of acute
ischemic stroke is paramount to reducing mortality and morbidity. Organization
of stroke services has been one of the key elements in the management of stroke
in many developed countries and has led to a reduction in DALYs (Disability
Adjusted Life Years) and YLL (Years of Life Lost due to premature death). The
various key components of the ‘acute stroke chain’ include recognition of
stroke symptoms, prompt communication with the stroke center which then
dispatches the team for pre-hospital stroke care, availability of imaging,
stroke neurologist and endovascular neurosurgeon at the hospital and the
infrastructure for appropriate treatment. Malfunctioning or inefficiency of any
component of the acute stroke chain may lead to adverse outcome and,
ultimately, increased morbidity and mortality.
Pre-hospital management of acute stroke forms an important
component of the acute stroke chain. The team should be available 24 x 7 and be
able to reach out to the patient as soon as possible, document the history and diagnose
stroke reliably, evaluate and manage airway, breathing, circulation and blood
pressure, perform and document stroke assessment using the NIHSS (National
Institute of Health Stroke Scale) and alert the hospital. Efficient
Pre-hospital service significantly reduces the time to treat a patient of
stroke and ultimately translates into better outcomes. Documenting the history
and evaluating the patient with regards to the severity of stroke significantly
reduces the time to formulate the appropriate treatment and helps the team at
the stroke center to be prepared for the patient. It is very concerning that
despite the availability of stroke neurologists and endovascular neurosurgeons
and the infrastructure in some of the hospitals in India, many patients with
stroke fail to reach the hospital in time so as to be eligible for acute stroke
therapy. Any patient with acute stroke should be treated in the same manner as
a patient with trauma and should receive the same level of priority.
The concept of telestroke is another important aspect in the
acute stroke chain. The capability of Pre-hospital stroke team to effectively
communicate with the acute stroke center significantly reduces delays in
imaging and treatment. Documenting the history, medications and NIHSS
eliminates the delay in imaging and decision making. With its widespread
availability, smart phone technology has a great potential for application in that
the on-field team can communicate with the stroke team at the hospital and send
essential data. The availability of telestroke services at the referring
hospitals is also important to diagnose, evaluate and initiate the treatment of
acute stroke. Despite the availability of teleradiology at many centers in
India, telestroke is still in its infancy and its potential for use needs to be
harnessed.
It is expected that, with increasing awareness among the
patients and general practitioners and availability of stroke specialists and
trained paramedical professionals, acute stroke services in India will improve
in the coming years. Unless a team approach is adopted and a systematic
protocol based therapy is instituted, it is not long that stroke and cerebrovascular
disease will become the most common cause of death in India.
