New Delhi: Even as data on stroke-related deaths remains grim in India, experts say new trends show there has been an improvement in medical care and greater awareness about seeking urgent care for the life-threatening condition that claims one life every three minutes.
A stroke, also known as a brain attack, is almost always a medical emergency. It occurs when blood supply to a part of the brain gets blocked (ischemic stroke), or when a blood vessel in the brain bursts (haemorrhagic stroke). In either situation, parts of the brain become damaged or die, and this can result in lasting brain damage, long-term disability, or death.
According to the Global Burden of Diseases Report 2021, there are an estimated 18 lakh strokes in India every year, the highest globally. The disease also kills 7 lakh people every year, making it one of the leading causes of death in India after ischemic heart disease and respiratory conditions.
Strokes, directly or indirectly, cost the Indian economy over Rs 4 lakh crore every year.
Against this background, experts say that hope has emerged with the advent of newer treatment options. Some of these, such as endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT), are becoming more accessible to patients and leading to paradigm shifts in their outcomes.
“While the absolute number of stroke-related deaths is rising in India due to an ageing population and longer life expectancy, the mortality rate— or deaths per 100,000 people—has shown a slight decrease. This trend reflects improvements in medical care and awareness,” senior neurologist and stroke researcher Dr M.V. Padma Srivastava told ThePrint.
According to the Global Burden of Diseases Report 2021, for the 15–49 age group, for instance, the stroke death rate remained relatively stable, while the 50–69 age group showed a significant decrease in death rates, dropping from 207 in 1990 to 152 in 2021.
Similarly, the 70+ age group experienced a decrease in death rates from 806 in 1990 to 674 in 2021.
In India, high blood pressure, smoking, high cholesterol or dyslipidemia, diabetes, obesity, and a family history of stroke are considered risk factors for stroke. Also, while ischemic strokes comprise nearly 70-80 percent of stroke cases and are predominant in most parts, eastern and north eastern India see a comparatively larger chunk of hemorrhagic strokes, which are considered more fatal.
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New neuro-interventions ushering dramatic changes
Since the mid-1990s, a substance known as alteplase recombinant tissue plasminogen activator (rt-PA), among the most widely used drug for the lysis therapy, which can dismantle the underlying framework of the clot or thrombus and therefore break it down, have been the mainstay of acute stroke treatment.
It is estimated that nearly 50-60 percent of vascular occlusions or blockage of blood vessels can be broken down by the drug, thereby restoring the blood supply to the affected area of the brain.
However, lysis therapy is not suitable for every patient and must be administered within a 4.5-hour window after stroke onset.
Dr Vipul Gupta, mentor at the neuro interventional radiology with Sir H.N. Reliance Foundation Hospital in Mumbai, underlined that there has been a dramatic change in the management of stroke over the last decade or two. Among the new additions are the intra-arterial therapy (IAT) and EVT.
IAT, which is more targeted in approach and can deliver the drug directly to the blocked blood vessel, prevents further brain damage and can also reverse stroke features.
EVT, also known as mechanical thrombectomy, goes one step further, and a neurointerventionist guides catheters and other tools through the patient’s arteries, accessed through the leg or the arm, to the brain vessel. Then, the blockage is removed using a “stent retriever” (a basket-like wire mesh that travels inside the catheter) or a special aspiration catheter (a sort of tiny vacuum cleaner), causing decreased flow to the brain and brain damage. The entire procedure is monitored through X-ray.
Available in developed countries since 2008, the use of EVT, a minimally invasive procedure, in India began in 2015. The advantage of using this method is that doctors can actually revive parts of the brain and lead to dramatic improvement in patients’ deficits.
This technique gives doctors a window of 24 hours between the onset and treatment of stroke, and therefore more time than is the case with lysis therapy.
“One of the most impactful achievements (in stroke care in India) has been the wider availability of EVT. The inclusion of stroke care in India’s universal health coverage and clinical advancements, like the GRASSROOT trial led by the All India Institute of Medical Sciences (AIIMS), New Delhi, have further expanded access and strengthened acute stroke response,” Srivastava, who was previously with AIIMS, said.
As part of the GRASSROOT trial, 16 hospitals in various parts of the country have joined hands to test a next-generation stent-retriever—the first-ever device designed specifically to treat Indian patients for acute ischemic stroke.
Additionally, new generation thrombolytic agents such as tenecteplase—whose advantages include a longer half-life, allowing for the administration of a single bolus dose, and increased resistance to plasminogen activator inhibitor type 1, potentially reducing bleeding—have also emerged as key tools in treating strokes.
“Indian neurologists are among the pioneers in using tenecteplase for acute ischemic stroke,” said Dr Sudhir Kumar, a neurologist with Apollo Hospitals in Hyderabad.
Kumar also said, Sovateltide, a selective endothelin-B receptor agonist, first approved in India in May 2023 for treating acute ischemic stroke, has also aided the recovery for acute stroke patients. Sovateltide stimulates neural progenitor cells, a type of neural stem cell, and promotes neurovascular remodelling, contributing to brain repair.
However, reaching the centres in time to access the timely treatment is a crucial aspect, and while it is estimated that about 2,80,000 strokes in India would meet the criteria for thrombectomy in 24 hours, only a few thousand EVTs are carried out every year, as of now.
More centres, higher number of experts
Kumar underlined that there are a greater number of neurologists now who have sub-specialisations to provide better stroke treatments.
“Similarly, there are a greater number of trained doctors in the field of neuro-interventions who are experts in mechanical thrombectomy procedures. More hospitals, stroke units and Intensive Care Units (ICU) beds in the country are available now, which can provide the latest stroke treatments,” he said.
According to Manoj Khanal, the director of neurosciences, interventional neurology and neurology at Max Super Speciality Hospital, Delhi, there has been a lot of improvement in the stroke facilities and centres offering IVT and also EVT. Such facilities, he added, have also grown in number over the last five years.
“Around 25 to 50 percent of stroke centres also have facilities to offer EVT. Using the method [EVT] often leads to better outcomes, reduces mortality, improves speech, and the most important advantage of these devices (catheters and stent retriever) is that they can be used even after the time frame of intravenous thrombolysis,” Khanal said.
He also said that the availability of specialised stroke units and rehabilitation services has resulted in better outcomes in stroke and resulting in reduced mortality.
Stroke rehabilitation centres aid recovery, reintegration
Many stroke survivors are left with lasting disabilities, such as paralysis of the arms and legs, speech impairment, imbalance while walking, vision impairment and cognitive impairment. Rehabilitation centres play an important role in faster and more complete recovery, helping patients to go back to work earlier after proper post-stroke rehabilitation, said Kumar.
“While many hospitals are offering in-hospital rehabilitation, there are several stand-alone rehabilitation centres, too,” he said.
According to experts, such centres often provide multidisciplinary, individualised care, offering physical, occupational, and speech therapy to help survivors regain motor skills, communication, and daily functioning.
The inclusion of advanced rehabilitation tools such as robotics and virtual reality, along with caregiver education and long-term support, enables stroke survivors to achieve better recovery and reintegration into society, Srivastava said.
But, specialists also said, these centres are still largely located in larger cities and towns, meaning that people in rural areas and small towns do not have access to them. “There is an urgent need to start more rehabilitation centres in smaller cities,” Kumar stressed.
(Edited by Sanya Mathur)
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