(Focus - India)
Stroke, often referred to as a "brain attack," is a critical medical condition that occurs when there is a disruption in the blood supply to the brain. According to WHO, stroke is the second leading cause of death and the third leading cause of disability. The consequences of a stroke can be severe and life-altering, often leading to disabilities such as paralysis, difficulty speaking, or cognitive impairments. Yet, through heightened awareness, preventive measures, and timely intervention, we hold the power to make a profound impact in mitigating its effects.
To learn more about it, we have interviewed Dr. Nirmal Surya, a renowned Neurologist from India who shared invaluable insights regarding stroke incidence and disparities. Dr. Surya also highlighted the pivotal role of age, which significantly magnifies the risk of stroke, especially when compounded by factors like hypertension, diabetes, and atherosclerosis over time.
Dr. Nirmal Surya is a Neurologist and Chairman at Surya Neuro Center, Mumbai, Maharashtra, India.
The risk of stroke is more prevalent in men than women. Importantly, certain risk factors are more prevalent in men, such as smoking and obesity. But now, the prevalence of female gender-specific risk factors for stroke is increasing, such as oral contraceptives, predisposing women to an increased risk of stroke. Hence, women aged 35-44 years or >85 years have a similar risk of stroke compared to the males in the corresponding age group.
WHO states that the risk of stroke generally increases with age, and individuals are more susceptible to stroke as they grow older [1]. What are the underlying factors or mechanisms that contribute to the observed increase in stroke incidence with advancing age?
Dr. Nirmal - The risk factors such as hypertension, diabetes, hyperlipidemia, and atherosclerosis are associated with increased risk and increased prevalence with advancing age. Further, the smoking population in older people would have accumulated sufficient risk for stroke due to the dose-response relationship of smoking with stroke. The presence of any of the above risk factors increases the likelihood of getting a stroke, and the risk is further augmented if two or more risk factors are present. Hypertension is the single most important risk factor for stroke that can be treated.
According to the WHO there are gender disparities in stroke incidence. Are there any gender differences in stroke incidence? What do you see in your clinical practice?
Dr. Nirmal - The risk of stroke is more prevalent in men than women. Importantly, certain risk factors are more prevalent in men, such as smoking and obesity. But now, the prevalence of female gender-specific risk factors for stroke is increasing, such as oral contraceptives, predisposing women to an increased risk of stroke. Hence, women aged 35-44 years or >85 years have a similar risk of stroke compared to the males in the corresponding age group.
The data is clear, suggesting that black is more affected than white. The data from Asia and India indicate that the mean age of patients affected by stroke is ~10 years less compared to their Western counterparts. And therefore, it is another serious issue, particularly in India, that we must worry about. It may probably be genetic.
Doctor, we understand that timely recognition of stroke symptoms is crucial for optimizing treatment outcomes and reducing the risk of disability and mortality associated with stroke [1]. What are the typical warning signs and symptoms that commonly indicate the occurrence of a stroke?
Dr. Nirmal - We advocate BE-FAST, Balance issues, Eyesight loss, Facial drooping, Arm weakness, Speech difficulties, and Time to call the ambulance. It can be a transient weakness involving the face, hand, and speech or an established stroke if the symptoms persist. If the above-mentioned alarming symptoms occur, one should immediately consult a neurologist or a doctor for emergent intervention in stroke.
Do racial or ethnic disparities exist in stroke incidence or outcomes, and if they do, what are the underlying factors that contribute to these disparities?
Dr. Nirmal - The data is clear, suggesting that black is more affected than white. The data from Asia and India indicate that the mean age of patients affected by stroke is ~10 years less compared to their Western counterparts. And therefore, it is another serious issue, particularly in India, that we must worry about. It may probably be genetic. The increased prevalence of hypertension and being unrecognized also contribute to it.
According to American Stroke Association’s International Stroke Conference 2023, the neuroprotectant ApTOLL, a medication that may shield the brain from tissue damage, was linked to reduced death and disability among people treated for stroke when used with standard treatments to restore blood flow [2]. Considering its potential as a neuroprotectant, do the findings suggest that ApTOLL could emerge as a promising therapeutic option for mitigating brain tissue damage in treating stroke patients? What are your thoughts on this?
Dr. Nirmal - The experience of using ApTOLL in India is limited. The data of the trials using the drug are promising, but more evidence is required before widespread use and recommendation can be advocated. However, with the fast-paced advances in stroke treatment, emerging treatment can potentially create a paradigm shift in stroke management. If the patient presents within the first 3-4 ½ hours or 24 hours, thrombolysis or thrombectomy can be performed if the patient fulfills the criteria for the above treatment strategies.
It is a wonderful way of exercising in a virtual world or environment. I mentioned neuromodulation like rTMS and TCDS, which can be performed with conventional rehabilitation. Similarly, virtual reality that can be paired with treadmill gait training when combined with conventional rehabilitation is very useful.
A recent study in the Stroke Journal found that, when coupled with physical rehabilitation, a new kind of treatment called vagus nerve stimulation could more than double the recovery rate for patients with impaired upper limbs [3]. Could you explain the key differentiating factors of vagus nerve stimulation compared to conventional treatments for upper limb impairments and what makes it a promising avenue for significantly improving patient recovery?
Dr. Nirmal - Well, the neuromodulation strategies in stroke recovery have been very promising. Vagus nerve stimulation, a type of neuromodulation, has been more suitably adapted for use in refractory epilepsy in children and adults who fit the criteria for pharmacoresistant epilepsy. There is emerging evidence from a few case reports and other research data that it might help in upper limb recovery. But, other modalities such as repetitive magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are far more effective and can be game changers, especially rTMS, in the recovery of acute and chronic stroke.
A research study in the Journal of NeuroEngineering and Rehabilitation found that some Virtual Reality systems showed significant impact on upper-limb recovery compared to standard therapy [4]. How does VR technology specifically benefit stroke patients, and what are some key mechanisms through which VR systems contribute to the recovery of their upper limbs?
Dr. Nirmal - It is a wonderful way of exercising in a virtual world or environment. I mentioned neuromodulation like rTMS and TCDS, which can be performed with conventional rehabilitation. Similarly, virtual reality that can be paired with treadmill gait training when combined with conventional rehabilitation is very useful. A person is immersed in a 3D environment where one can interact, exercise and work his way to recovery.
Research published in the Journal of Stem Cells Translational Medicine found that a single infusion of umbilical cord blood was both safe and helpful in the treatment of ischemic strokes [5]. What are your thoughts on this? How will it help in the effective management of stroke?
Dr. Nirmal - We have been hearing about stem cells going to change stroke recovery for the last ten years and has ever been stirring the hype. Yet, I've not seen any clinically translated evidence with a positive outcome in these ten years. And therefore, I feel that stem cells might have great potential, but it is only in the research where it belongs at present. The effectiveness is very much doubtful and requires more evidence before.
To conclude our session, what are the takeaway messages and actions can patients and caregivers implement to effectively manage and support stroke recovery, ensuring the best possible outcomes and quality of life?
Dr. Nirmal - I would say that stroke should be treated early. Therefore, any person who gets early warning signs should take early warning signs seriously. If you have already developed a stroke, try and reach within three hours to the best possible stroke center so that you can get the thrombolysis or mechanical thrombectomy, whichever is appropriate.
But if you are not lucky and still are left with a deficit despite all the treatment modalities, you don't have to be disheartened. Systematic rehabilitation can make a great recovery, and you need to start early rehabilitation and follow it regularly as per the supervision. A multidisciplinary scheme is what will be required. Many new gadgets are available, technologies are coming, and they will evolve over the next few years. And hence stroke rehabilitation has many new avenues opening in the years to come.
Thank you for your time!
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