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Salunke et al.
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National Stroke Registry.4 Across the country, approximately
100 centers have the facility for EVT and are gradually
increasing.9,24 These are limited to large urban cities in
either tertiary referral public institutes or privately funded
corporate medical centers. In a recent survey by the mission
thrombectomy (MT) 2020 plus global network among 75
countries, global MT use was poor and LMIC had 88%
lower mechanical thrombectomy access when compared to
HICs.25 Infrastructural needs, limited trained manpower,
and significantly high cost will limit its implementation
across LMIC. Low-cost indigenously manufactured
devices, reducing device cost, and integration of hub and
spoke models could help overcome this limitation.24
Providing training to radiologists, neurologists, and neurosurgeons
will help increase the available manpower.26 The
National Board of Examination (NBE)-accredited fellowship
program in India is one step in this direction (https://
natboard.edu.in/fellowship.php; accessed 17 May 2023).
We found that 40% of hospitals cannot routinely perform
lifesaving surgeries like hematoma evacuation and decompressive
craniectomy. Timely surgical intervention can
reduce mortality in the case of intracerebral hemorrhage
(ICH) and malignant middle cerebral artery (MCA) infarction.27
In India, one neurosurgeon is available per one million
population. This unmatched need results in limited
access to surgical treatment with spontaneous intracerebral
hemorrhage (SICH).28 No well-described data are available
for such interventions from LMICs in previously published
literature.19-21
A multidisciplinary stroke team and admission to stroke
units improve outcomes.29 Availability of stroke units is
limited in LMIC with patients generally admitted in general
medical or neurology wards.16,19,21 Stroke unit admissions
were reported in 25% of patients admitted in Thailand, 12%
in Brazil, and 6% in Argentina.20 Presently, in India, stroke
units are limited and available predominantly in super specialty
tertiary care academic hospitals, private sector, and
metropolitan cities.9
Stroke subtyping is crucial for treatment and secondary
prevention due to variations in recurrence and mortality
rates. In South Asia (15.1%), a significantly lower percentage
of stroke patients undergo vascular imaging compared
to Western countries (84.3%).30 Limited availability of CT
angiography services during working hours hampers timely
diagnosis and subtyping. Stroke of undetermined etiology,
including cardioembolic that requires optimum evaluation,
was the second most common cause (27.3%) of ischemic
stroke in a registry study.31 In our study, only 59% of hospitals
were using the TOAST (Trial of ORG 10172 in Acute
Stroke Treatment Criteria) etiology classification at the
time of discharge.
Provision of optimal inpatient rehabilitation improves
the quality of life and motor function of stroke patients.32
Availability of rehabilitation expertise, although assessed
in our study, could be influenced by additional factors.
LMICs provide post-discharge rehabilitation services to a
smaller proportion (31%) of patients compared to HICs
(92%), leading to higher rates of functional disability.33 A
significant number of years lost due to stroke in rural India
occur in the age group of 30-70 years.34 There is a communication
gap in post-discharge rehabilitation needs, with
caregivers expressing a need for more information.34
LMICs have a shortage of skilled rehabilitation practitioners
(<10 per 1 million population), mainly concentrated in
tertiary care centers, necessitating innovative and accessible
stroke rehabilitation services, including tele-rehabilitation.35
The IMPETUS project aims to enhance rehabilitation
services and promote tele-rehabilitation for patients and
caregivers in hospitals and homes. Video modules and lowcost
assistive devices improve outcomes.
Strengthening caregiver knowledge and empowering
them to assist during inpatient care is extremely relevant to
LMICs due to shortage of nursing manpower.36 This is an
untapped strategy that leads to poor knowledge transfer that
may affect patient outcomes, especially once discharged to
home.34,35 One of the important components of the
IMPETUS project is to enhance caregiver knowledge using
training strategies for patient care.
Potential solutions to these limitations are possible and
various models can be explored to improve stroke services
in LMIC.16,37 The WSO Global Stroke Services Guidelines
and Action Plan framework proposes three tiers of stroke
services (minimal, essential, and advanced), depending on
the availability of multidisciplinary expertise, diagnostic
infrastructure, and capacity for acute reperfusion therapy
and should guide improvement of services in small steps
that can yield significant results as was observed from a
minimal stroke unit set up in Conakry, Guinea, Africa.38
The Brazilian Stroke Project initiative and National Stroke
Policy Act is an excellent example of implementing stroke
services, including pre-hospital notification, creation of
stroke centers, reimbursement of thrombolysis, rehabilitation.39
The line of stroke concept ensures each city or region
to comprehensively provide stroke services at all levels.
A simple smartphone-based tele-stroke model using was
a successful attempt to facilitate acute stroke care in the
state of Himachal Pradesh, India.40 In the ongoing National
NCD Programme (https://ncd.nhp.gov.in/) and Ayushman
Bharat Health and Wellness Centres (https://ab-hwc.nhp.
gov.in/) of India, screening and treatment is the strategy to
reduce disease burden. The Ayushman Bharat Pradhan
Mantri Jan Arogya Yojana (PMJAY) is a national public
health insurance scheme that supports treatment for low
income populations in India. Implementing NPCDCS
(National Programme for Prevention and Control of Cancer,
Diabetes, Cardiovascular Diseases & Stroke) program and
standardizing and homogenization of stroke care services
will be essential for optimal care.
Education and training for medical, nursing, and rehabilitation
graduates improve stroke patient management.
International Journal of Stroke, 19(1)
http://natboard.edu.in/fellowship.php http://natboard.edu.in/fellowship.php https://ncd.nhp.gov.in/ https://www.ab-hwc.nhp.gov.in/ https://www.ab-hwc.nhp.gov.in/
WSO - January 2024

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