prevention and control of stroke

1. STROKE
Dr. Sumita Sharma
2nd year PG student
Dept of Community Medicine

2. OUTLINE
¢ Introduction
¢ Burden of stroke
¢ Types & Risk Factors of Stroke
¢ Pathophysiology of Stroke
¢ Signs & Symptoms of Stroke
¢ Stroke prevention
¢ Ongoing Trials on stroke
¢ Program related to stroke

3. v Term “stroke”: apoplexy - applied to acute severe manifestations of
cerebrovascular disease.
v WHO defined stroke as “ rapidly developed clinical signs of focal or global
disturbance of cerebral function; lasting more than 24 hours or leading to
death, with no apparent cause other than vascular origin”
v The 24 hours threshold in the definition excludes transient ischemic attacks(
TIA) which is defined to last less than 24 hours
INTRODUCTION

4. Morbidity-
• stroke is the 2nd leading cause of death and 3rd leading cause of disability
• 70% stroke and 87% both stroke related deaths and DALYs are seen in low and
middle income countries
Mortality-
• On a global level stroke has led to 6.5 million deaths yearly
Disability-
• In 2013, stroke led to around 113 million DALYs
BURDEN OF STROKE
GLOBAL SCENARIO
35%
46%
19%
life risk of stroke on
sociodemografic index
high SDI high- middle SDI low SDI
Source: Global, regional and national burden of stroke,1990-2016: a systematic analysis for the
global burden of disease study 2016;The Lancet

5. INDIAN SCENARIO
Ø Stroke emerged as the 5th leading cause of disease in 2016 according to reports from
Global Burden of Disease
Ø In North-Indian states Manipur and Tripura, Punjab and Himachal Pradesh
contributes maximum burden of stroke
Ø It is estimated that the overall prevalence of stroke is 1.54 per 1000 population of
India
Ø In India cerebrovascular accidents cause approximately 116.4 deaths per 1 lakh
population every year

6. TYPES OF STROKE
A.Ischemic stroke
sudden occlusion of arteries
supplying the brain
Intracerebral hemorrhage
Subarachnoid hemorrhage
Thrombotic ischemic stroke
Embolic ischemic stroke
occlusion may either be due to a
thrombus formed directly at the site
of occlusion
thrombus formed in another part of
the circulation, which follows the
blood stream until it obstructs arteries
in the brainB. Hemorrhagic stroke
bleeding from one of the brain’s arteries into the brain
tissue.
arterial bleeding in the space between the
two meninges pia mater and arachnoidea.

7. PATHOPHYSIOLOGY OF STROKE
¢ Brain requires constant supply of glucose & oxygen, delivered by
blood.
¢ Brain receives 15% of resting output & accounts for 20% of total body oxygen
consumption.
¢ Cerebral blood flow is maintained via auto regulation. Thus the brain is
highly aerobic tissue where oxygen is limiting factor.
¢ Blood flow
Ø If zero leads to death of brain tissue within 4-10 mins
Ø <16-18ml/100g tissue/min infarction with in an hour.
Ø <20ml/100gm tissue/min ischemia without infarction unless prolonged for
several hours or day.

8. Loss of cerebral autoregulation
Hypoperfusion mediated in ATP
Failure of Na-K ATPase
Glutamate release and Ca2+ entry
Liquefactive necrosis
ISCHEMIC STROKE
¢ Explosive entry of blood into
the brain parenchyma
structurally disrupts neurons.
¢ White matter fibre tracts are
split.
¢ Immediate cessation of
neuronal function.
HEMORRHAGIC STROKE

9. Modifiable Risk Factors :
•High blood pressure
•Arterial fibrillation
•Uncontrolled diabetes
•High cholesterol
•Smoking
•Excessive alcohol intake
•Obesity
•Coronary artery disease
Nonmodifiable Risk Factors :
•Age (>65)
•Gender (Men have more strokes, but
women have deadlier strokes)
•Race (African-Americans are at
increased risk)
•Family history of stroke
RISK FACTORS OF STROKE

10. EVIDENCE SHOWING RISKS
• According to the Global Burden of Disease 2016 Lifetime Risk of Stroke Collaborators, the mean
global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016,
• A mendelian randomization study among 500 000 Chinese individuals -causal evidence of high LDL
leads maximum chances of getting stroke.
• The largest multi-ethnic genome-wide association study of stroke conducted to date reported 32
genetic loci. Approximately half of the stroke genetic loci share genetic associations with BP.
• Among 81 714 females in the Women’s Health Initiative prospective cohort study, those who consumed
≥2 artificially sweetened beverages daily, on average, had an elevated risk of all stroke (adjusted HR,
1.23 [95% CI, 1.02–1.47]) and ischemic stroke (adjusted HR, 1.31 [95% CI 1.06–1.63]) compared with
those who consumed <1 artificially sweetened beverage weekly, after adjustment for demographics,
CVD history, risk factors, body mass index, health behaviours, and overall diet quality.

11. SIGNS AND SYMPTOMS OF STROKE

12. LEFT AND RIGHT HEMISPHERE STROKE: COMMON PATTERNS
Left (Dominant)
Hemisphere Stroke:
Common Pattern
¢ Aphasia
¢ Right hemiparesis
¢ Right-sided sensory loss
¢ Right visual field defect
¢ Poor right conjugate gaze
¢ Dysarthria
¢ Difficulty reading, writing,
or calculating
Right (Non-
dominant)
Hemisphere Stroke:
Common Pattern
¢ Neglect of left visual
field
¢ Extinction of left-
sided stimuli
¢ Left hemiparesis
¢ Left-sided sensory loss
¢ Left visual field defect
¢ Poor left conjugate gaze
¢ Dysarthria
¢ Spatial disorientation

14. altered mental status syncope
hypertensive emergency systemic infection
suspected ACS other
30.9%
16.0%
12.8%
10.6%
9.6%
20.1%
Stroke chameleons
Dupree CM et al. J Stroke and Cardiovasc Dis 2014;23:374

15. Primary
prevention
Community
education
EMS response
Acute treatment
Continuous quality
improvement activities
Rehabilitation
Secondary
prevention
PREVENTION OF STROKE

16. Source : World stroke organisation
Control of high blood pressure
Exercise 5 times per week
Eat a healthy balanced diet
Reduce your cholesterol
Maintain a healthy weight
Stop smoking and avoid smoky
environment
Reduce your alcohol intake
Identify and treat atrial
fibrillation
Manage diabetes
Manage stress and depression

17. PRIMORDIAL PREVENTION
Ø Maternal malnutrition acts as a predisposing factor for intrauterine growth
retardation and in turn, metabolic disorders such as insulin resistance, diabetes,
hypertension, dyslipidemia and enhanced risk of atherosclerosis and
cardiovascular death in the offspring.
Ø Prevention efforts towards maternal nutrition can paveway for a healthy baby at
birth
Ø Educating the mothers on importance of breastfeeding and proper weaning
practices and developing healthy eating habits ; generate healthy life later
Ø Smoking cessation programs for pregnant women will influence maternal as well
as fetal health
Source; IAPSM BOOK

18. PRIMARY PREVENTION
• Tobacco cessation
• Regular physical activity
• Reduced salt consumption to < 5g per day
• 400 g per day of fruits and vegetables
• Those with a 10 year cardiovascular risk of >30%, aspirin, statins and
antihypertensives can be advised
• Antihypertensives for people with blood pressure > 160/100
• Antihypertensives for people with persistent blood pressure > 140/90 and
10-year
• cardiovascular risk > 20% unable to lower blood pressure through
lifestyle measures
• Health education to mass

19. SECONDARY PREVENTION
History taking & Physical examination
Investigations: blood tests
Platelet, PT-INR, blood sugar, electrolytes, lipid profile, computerized
tomography(CT) scan is done to look for a hemorrhage, tumor, stroke and other
conditions
MRI
Carotid ultrasound
Echocardiogram
Early diagnosis Treatment

22. WHO CRITERIA
FOR
DIFFERENTIATING
ISCHEMIC
STROKE
AND
HEMORRHAGIC
STROKE

23. Ischemic stroke
IV tPA should be administered to all eligible acute stroke patients within 3 hours
of the attack
Treatment:
Antiplatelets
Aspirin, Clopidogrel
Aspirin 300mg single dose to be given immediately following diagnosis.
if alteplase given it can be with held for 24 hrs
later aspirin at a dose of 75 mg in combination with clopidogrel 75 mg daily
for about one year duration.
Lipid lowering agents e.g. atorvastatin, rosuvastatin
Emergency endovascular procedures
Hemorrhagic stroke
Surgical blood vessel repair

24. TERTIARY PREVENTION
Rehabilitation
Improve quality of life
with motor aids
leg brace
toe spring
cane
walking stick

25. Leg exercise
Lift one foot until
your
knee is straight and
hold for a few
seconds. Return foot
to the starting
position
Abdominal
exercises
Squeeze your
abdominal
muscles while
raising both
your feet off the
ground. Hold for a
second and release
8-10 Exercises
5 days/week
Physical therapy

26. Arm raises
Holding light weights in
both hands and keeping a
bend in your elbows,
slowly lift both arms
until they are parallel to
the ground. Hold for a
second and slowly go
down to the starting
position
Triceps extensions
Holding a light weight, bend
your left elbow straight up
so it is pointing to the
ceiling. Slowly straighten
your arm. Hold for a
second, then lower to the
starting position.
6-8
Repetitions
Per
exercise/per
side

27. Leg stretches
To lengthen your
abductors;
Standing, bend your
left leg slightly and
lean your body left.
Hold for a few
seconds, then repeat
on the other side.
To stretch your legs:
Stand and put one.
Foot in front of the
other. Gently lean
forward, then repeat
on the other side.
Chest stretch
Clasp hands gently
behind your head.
Move your elbows
back to the wall
behind you. Hold for
a few seconds, then
repeat
Balance exercises
walk by placing the
heel of your right foot
directly in front of
your left foot. Switch
feet and repeat
2 days/
week
For 30
min

28. Speech therapy
• Breathing exercises
• Tongue strengthening exercises
• Practicing speech sounds
• Naming pictures
• Sentence practice

29. Occupational therapy
A Randomized Controlled Trial of Constraint-Induced Movement
Therapy After Stroke by K-C Lin et al. shows highly significant(p=
0.042) improvement in motor performance

30. Emotional support therapy
Promoting Psychosocial Well-Being Following
Stroke: Study Protocol for a Randomized,
Controlled Trial
Marit Kirkevold et al.
Effect of a Dialogue-Based Intervention on
Psychosocial Well-Being 6 Months After Stroke in
Norway: A Randomized Controlled Trial
Ellen G et al ;After controlling for the baseline values, no
significant benefit was found in the intervention group over the
control group (odds ratio (OR): 0.898: 95% confidence interval
(95% CI): 0.54-1.50, p = 0.680) 6 months post-stroke.

31. Ø In 2014, the American Heart Association issued its first guidelines for
preventing strokes in women
Ø In 2018, the American Heart Association and American College of Cardiology
issued new guidelines for clinicians on the management of cholesterol as a way
to reduce risk for heart attack and stroke.
Ø Newly included in the guidelines is a recommendation to use coronary artery
calcium score if healthcare providers are having difficulty deciding if a patient
could benefit from statin medications or should focus solely on lifestyle
modifications.
Recent activities of AHA regarding Stroke

32. Ongoing Trials in India
• Secondary Prevention by Structured Semi-Interactive Stroke Prevention
Package in India (SPRINT INDIA) Study Protocol hypothesize that a structured
semi-interactive stroke prevention package can reduce the risk of recurrent strokes,
acute coronary artery syndrome, and death in patients with sub-acute stroke at the
end of one year.
• Protocol for a Randomised Controlled Trial to Evaluate the Effectiveness of
the 'Care for Stroke' Intervention in India: A Smartphone-Enabled, Carer-
Supported, Educational Intervention for Management of Disabilities
Following Stroke
• ICMR has funded a new initiative for the first time, called Indian Stroke Clinical
Trial Network (INSTRuCT)
-A network of 27 stroke centres
-This is for the first time that 4,900 patients across the country will be examined
on one platform .

33. NATIONAL PROGRAM:NPCDCS
Ø Ministry of health and family welfare, government of India formulated NPCDCS program
Ø The NPCDCS focuses on health promotion and prevention, strengthening of
infrastructure including human resources, early diagnosis and management and
integration with the primary health care system through NCD cells at different levels
for providing optimal care.
Ø Build capacity at various levels for prevention, early diagnosis, treatment, IEC/BCC,
operational research and rehabilitation
Ø Provide support for diagnosis and cost effective treatment at primary, secondary and
tertiary levels of health care
Ø Provide support for development of database of NCDs through a robust surveillance
system and to monitor NCD morbidity, mortality and risk factors

34. NPCDCS
Ø Single center for Cancer, Diabetes, Cardiovascular disease, Stroke
Ø 100 districts in 21 states being covered in this program
Ø 20,000 subcenters and 700 community health centres (CHCs) covered
Ø Activities at sub-centres :
Ø Activities at CHCs:
Ø Activities at District hospital:
- Health promotion for behaviour and lifestyle change
- Opportunistic screening of BP, Blood glucose in age >30 years
- Referral to CHC of cases of cases of DM, HT
- diagnosis and management at NCD clinic
- Home visits by nurse for bedridden cases
- Referral to district hospital for complicated cases
- Activities at CHC + management of complicated cases
- Home-based palliative care for chronic, debilitating, progressive patient

35. National Stroke Registry Program
The national stroke registry was launched in 2012 by the ICMR- National Center for Disease
Information and Research(NCDIR).
The registry generates data on stroke incidence along with care given to stroke patients.
Two types of registry
• Collects information regarding stroke from
defined populations in IndiaPopulation Based Stroke
Registry(PBSR)
• Collects information from hospitals
Hospital Based Stroke
Registry(HBSR)

36. The WHO STEP wise approach to stroke surveillance
Population based
Nonfatal events in
community
Fatal events in
community
Events in hospital
Population based
Hospital
based

37. Population based
The optimal stroke surveillance system requires collection of data from all three steps.
STEP 1: Events in hospital (health facilities); estimate of the admission rate for stroke
Module 1- core data such as age, gender, identification of whether it is a
first-time or recurrent stroke, and vital status (dead or alive) at discharge from hospital.
Module 2-includes measures of functional
level, and medical treatment received during the stay in hospital and prescribed at
discharge.
module 3-advanced technical equipment to classify the stroke types
STEP 2:mortality rates
module 4-Fatal events in the community get information from death certificates or by using verbal
autopsies based on interviews with close relatives or care-takers,
A standardized verbal autopsy questionnaire is being developed but not ready
module 5-Data from autopsies represent the next level of complexity
STEP 3: Non fatal non hospitalized events; incidence and case fatality
module 6-Patients with stroke who are cared for entirely within the community are difficult to
identify but may constitute a large proportion of the total number of stroke patients. Thus
advancing to include this group of stroke patients represents the most complex level

39. 2019 theme of world stroke day

40. THANK
YOU