Organization of Pre-hospital stroke services in India

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.