Three of the world's top 10 most populous countries are located in South Asia. The health-care problems of this region are different from those in the developed world, and the rapidly changing socioeconomic scenario, fast-increasing urbanization and longevity, changes in dietary patterns, and decrease in mortality from infectious diseases has made chronic illnesses of old age, such as coronary artery disease and stroke, an important area of focus. This article reviews stroke epidemiology and management issues in four South Asian countries: India, Pakistan, Sri Lanka and Bangladesh. The available literature is limited and mostly hospital-based, and differing study methodologies make direct comparisons difficult. The high prevalence of traditional risk factors, including hypertension, diabetes, dyslipidaemia and smoking, in these countries is alarming, and several nontraditional risk factors, such as water-pipe use, desi ghee, chewable tobacco, and infectious causes of stroke, are understudied. Access to tertiary stroke care is limited, and the use of tissue plasminogen activator is scarce. In addition, public and caregiver awareness of stroke risk factors and management is disappointing, and the interest of governments and policy makers in stroke is suboptimal. Interventions to reduce stroke burden and stroke-related mortality in South Asia should have a substantial impact at the global level.
At a glance
- The South Asian region, which includes India, Pakistan, Sri Lanka and Bangladesh, has a high prevalence of stroke, especially in younger individuals, and short-term mortality from stroke is also high
- In addition to traditional risk factors for stroke, nontraditional factors including chewing tobacco are widespread in this region
- South Asia accounts for the largest proportion of the global burden of stroke in pregnancy and cerebral venous thrombosis
- Acute stroke care, including thrombolysis and stroke units, is limited in South Asia, and stroke prevention strategies are nonexistent at the national level
- Cost-effective interventions are needed owing to financial constraints
- Important areas of intervention include public awareness and physician training, as well as strong advocacy efforts and implementation research
The South Asian Association for Regional Cooperation (SAARC) comprises eight countries: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka (Figure 1). South Asia constitutes 22% of the world's population (1.56 billion), with three countries—India, Pakistan and Bangladesh—among the top 10 most populous countries in the world, and the South Asian region makes up more than 40% of the developing world. According to WHO estimates in 2001, 86% of deaths related to stroke worldwide occurred in developing countries.1 South Asia is thought to be the highest contributor to stroke mortality in the world, probably accounting for more than 40% of global stroke deaths (Figure 2). In this region, stroke mortality rates might be as high as those for coronary artery disease,2 and both stroke and coronary heart disease occur about 10 years earlier, on average, than in the rest of the world.3
South Asian countries, on the one hand, have a very large stroke population and, on the other hand, are limited by human resources (neurologists and stroke specialists) and financial resources. National health-care authorities and health policy makers in this part of the world consider noncommunicable diseases to have low priority, yet global campaigns addressing stroke incidence and stroke-related morbidity and mortality cannot succeed without involvement from this region. In light of these problems, it is extremely important to study epidemiology, risk factors, region-specific issues, awareness, availability of care, management and outcome of stroke in South Asia. It is vital to understand the specifics of stroke in South Asia, so as to reduce the burden of stroke and improve outcome in this region. This Review not only focuses on the above areas, but also discusses the role of professional organizations, advocacy, current and future research, and implementation strategies.
Epidemiology and aetiology
Incidence and prevalence
Only a few well-designed, population-based studies relating to the incidence and prevalence of stroke are available from South Asia (mostly from India).4, 5, 6, 7, 8, 9 The data are summarized in Table 1. Estimates of the prevalence of stroke in India range from 44 to 843 per 100,000 population.10
Most of the data from Pakistan come from hospital-based case series.11 The estimated annual incidence of stroke in Pakistan is 250 per 100,000 population, which is projected to an estimate of 350,000 new cases every year.12 A recent study conducted in the urban slums of Karachi (the largest metropolitan city of Pakistan) estimated a 21.8% life-time prevalence of stroke and/or transient ischaemic attack (TIA) in individuals aged 35 years and older,13 although the case definition was rather liberal in this study. Another population-based study that used interviews with a selected ethnic group of northwestern Pakistan and Afghanistan found a stroke prevalence of 4.8%, with mean age of stroke onset of 45 years.14 In Pakistan, there is a female preponderance of stroke and TIA, and the age of onset of stroke is even younger in females than in males.3, 11, 13 The very high prevalence of stroke in these two population-based studies is alarming, and might be misleading owing to case ascertainment issues. The data need to be verified with proper case ascertainment by neuroimaging.
Sri Lanka, with its population of about 20 million, has an estimated stroke prevalence of 9 per 1,000 population.15 Limited data are available in relation to stroke prevalence in Bangladesh: one study reported an overall prevalence of 3 per 1,000 population, rising as high as 10 per 1,000 in people over 70 years of age.16
The estimated prevalence of stroke shows little variation across the countries of South Asia. No data are available from Afghanistan, Nepal, Bhutan and Maldives. The lack of authentic incidence and prevalence data from Pakistan, Bangladesh and Sri Lanka is a major limitation, and a pressing need exists for population-based studies in these countries. If data from India are generalized for South Asia, we can safely say that the incidence and prevalence of stroke in this region is higher than in the USA and China.
Stroke types and subtypes
Population-based prevalence data of stroke subtypes is urgently needed to enable identification and implementation of interventions for stroke reduction in South Asia. Table 2 provides a comparison of stroke types and subtypes across the South Asia region, based largely on findings from hospital-based studies.17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 A higher percentage of haemorrhagic stroke (19–46%) has been reported in most of the South Asian studies compared with Western countries (Figure 3). This finding could be related to increased prevalence and poor control of hypertension in South Asia. The prevalence of intracerebral haemorrhage (ICH) is especially high in younger patients (15–45 years of age) with stroke (32–43%).34 The high frequency of ICH reported in Bangladesh31, 32, 33 could represent sampling bias related to hospital-based studies. Cardioembolic stroke is less prevalent in South Asia than in Western countries.20, 24, 26
Small-vessel disease plays a much greater part in ischaemic stroke in South Asia than in other regions. The very high prevalence of small-vessel disease (for example, 50% according to the INTERSTROKE data from India) is probably attributable to a similarly high prevalence of undiagnosed, untreated and poorly treated hypertension.35 One study that compared the frequency of various types of strokes in diabetic versus nondiabetic patients found a very high frequency of haemorrhagic stroke (42%) in nondiabetic patients compared with 12% in patients with diabetes.36
Both intracranial atherosclerosis and large-vessel extracranial disease have been reported in various studies, hence identifying the so-called South Asian pattern of vascular disease, with some regional variations. A comparison of data related to extracranial carotid disease and intracranial disease is provided in Table 2. Intracranial stenosis is considered to be the most common cause of stroke among Asians, and is associated with a poor prognosis and high rate of recurrence.37 Owing to financial constraints and lack of awareness in this part of the world, many patients with significant carotid artery disease do not undergo endarterectomy or stenting.27
Stroke in women, young people and children
Limited data obtained from hospital-based studies and extracted from stroke registries suggests that stroke is common at a relatively young age—especially in young women—in South Asia as compared with north America or Europe. Some of the earlier studies from India showed that about 10–15% of strokes occur in people below the age of 40 years.4, 38 In addition, data are available to suggest that the onset of stroke and ischaemic heart disease is almost 10 years earlier in this region than in the rest of the world.3, 11 According to a study from India published in 2007, the most common risk factors for stroke in the young are metabolic syndrome and premature atherosclerosis.39 A study of 118 young patients (aged 15–45 years) with stroke from Pakistan showed that hypertension and diabetes were the most frequent risk factors (45% and 30% of cases, respectively).40 Cerebral venous thrombosis (CVT) and rheumatic heart disease have also been shown to be important causes of stroke in younger individuals. Other reported risk factors among the young include coagulopathy, elevated lipoproteins, and elevated anticardiolipin antibodies.41, 42
Stroke in women is poorly reported in South Asia, despite being a leading cause of death in females above the age of 60 years in this region.43 Hospital-based studies have suggested a lower prevalence of stroke in women than in men, although this figure could be skewed by the fact that women with stroke or cardiac arrest in this part of the world are less likely to be taken to hospital than are men with these conditions.20 Two studies looking at arterial ischaemic stroke and CVT in young women aged 15–45 years from eight Asian countries found that large-vessel thrombosis (24%), CVT (21%) and cardioembolism (19%) were the most common mechanisms of stroke in this population. A high proportion of these strokes were pregnancy-related.44, 45 This region probably represents the area of highest prevalence for pregnancy-related and postpartum stroke.46
No population-based studies have been published on the incidence or prevalence of paediatric stroke in South Asia. In one hospital-based study from India, paediatric strokes constituted less than 1% of all paediatric admissions, and 5–10% of all instances of stroke in young individuals (under 40 years of age).47, 48, 49 Arterial ischaemic stroke formed the bulk (63%) of cases, followed by venous stroke (29%) and ICH (8%). Moyamoya disease, mitochondrial diseases, fibromuscular dysplasia, mitral valve prolapse, arteritis, homocystinuria and scorpion bite were some of the unusual causes of stroke in the paediatric population. In a single-centre study from Pakistan, a male:female ratio approaching 1:1 was reported, with 56% of cases related to infections (either meningitis or encephalitis).50
Age is an important non-modifiable risk factor for stroke. The mean age of stroke onset in the South Asian region (for example, 59 years in Pakistan and 63 years in India) is lower than in Western countries (for example, 68 years in the USA and 71 years in Italy). This phenomenon is probably related to both conventional and nontraditional risk factors. A comparison of epidemiological factors and conventional stroke risk factors among the countries of South Asia is provided in Table 3.16, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78 The population-based prevalence of hypertension, diabetes, cardiovascular diseases and dyslipidaemia is comparable among countries. This region is facing a double burden of tobacco exposure, with a 15–20% prevalence of smoking and up to 40% of people using chewing tobacco. A large number of the chewing tobacco users are women. The prevalence of obesity is alarmingly high, with the highest prevalence being observed in Sri Lanka. Data related to atrial fibrillation, carotid artery disease and intracranial disease are limited to India and Pakistan. Several nontraditional risk factors, such as use of water pipes, desi ghee (saturated fatty acids), chewable tobacco, and infectious causes might be factors that contribute to the high prevalence of stroke at a younger age.
Russell viper snake bite has been reported as a cause of stroke from both India and Sri Lanka.79, 80 Another interesting phenomenon that has been proposed as an aetiology of stroke is the squatting position during use of the toilet.81 Infections, acting directly or by causing vasculitis (especially in the case of tuberculous meningitis), are other notable nontraditional risk factors for stroke in South Asia.82
Data related to stroke genetics in South Asian patients is limited to a few studies. Epidemiological studies of families and twins have shown a distinct genetic component in the predisposition to stroke in South Asia.83 Three polymorphisms in the phosphodiesterase 4D (PDE4D) gene were evaluated in 200 patients with stroke compared with 250 controls from Pakistan.84 The study showed an association between the single nucleotide polymorphism (SNP) SNP83 and ischaemic stroke. Another study from India showed that SNP41, SNP56 and a novel SNP in the PDE4D gene were associated with various stroke subtypes.85 Other studies have shown positive associations between the E-selectin gene polymorphism Ser128Arg and ischaemic stroke, and between the ACE and AAD1 genes and extracranial and intracranial atherosclerosis in patients with ischaemic stroke.86, 87 A study from Chennai, India demonstrated a significant association between paraoxonase 1 (PON1) activity and PON1 Gln192Arg genotypes and ischaemic stroke in people from South India.88
Cerebral venous thrombosis
CVT is a frequent cause of stroke in South Asia. Initial studies from India indicated that CVT was essentially a postpartum disease,89, 90, 91 and one study that combined 109 patients from Pakistan and the Middle East found infection and the postpartum state to be the most common predisposing factors for CVT.92 However, the most recent and largest study from India, involving 428 patients, has shown that CVT affects both sexes almost equally.93 Risk factors for CVT, such as anaemia, hyperhomocysteinaemia, oral contraceptive pill use, alcoholism, and the procoagulant state, are being increasingly identified, whereas conventional risk factors such as the postpartum state are becoming more marginalized.
A study involving a large sample of young women with stroke from Asia reported that 20% of stroke cases in young women were related to CVT.44 This region probably represents the highest prevalence area for venous stroke in the world. Well-designed case–control studies are needed to identify the underlying causes of this high prevalence.
Stroke prevention and management
A vast gap in stroke knowledge, as well as in acute and long-term stroke care, exists between South Asian and Western countries. Stroke prevention is not a priority for health-care authorities in South Asia, and organized stroke care is nonexistent across most of this region. In addition, no national or regional stroke control programmes have been introduced by government authorities. Four cost-effective interventions (blood pressure control, low salt intake, daily exercise, and cessation of tobacco use) have been suggested by many authorities, but no implementation programme has been devised.94 Primary stroke prevention is the key to reducing the burden of stroke in South Asia, but unfortunately this is the most neglected area. Low public awareness of stroke, unavailability of cost-effective antihypertensive medications, and growing use of shisha (piped) and oral (chewing) tobacco add to the challenges of primary prevention in this region.
Effective acute stroke management depends on availability of an acute stroke service in the emergency room (especially urgent CT scan and tissue plasminogen activator [tPA]), and on access to dedicated stroke care units. tPA is very much underutilized in South Asia, and is still new to many places in this region. At present, approximately 50 stroke units in India and only two centres in Pakistan use tPA, and this agent is not available in Bangladesh and Sri Lanka. The barriers to stroke thrombolysis in this region include a lack of infrastructure, lack of awareness, and poor affordability. Most patients with stroke are treated by internists and family physicians in general medical wards, and only large tertiary care centres and university hospitals have dedicated stroke care units. The number of such centres in the whole region is probably fewer than 100.
South Asia also has a high burden of carotid disease, intracranial disease, hyperhomocysteinaemia and recurrent infections, all of which present extreme challenges for secondary stroke prevention. Lack of a complete diagnostic work-up in patients with acute stroke is also a major hindrance to secondary prevention. Many patients cannot afford MRI, magnetic resonance angiography or other expensive modalities such as echocardiography and carotid Doppler studies. Stroke work-up in young patients includes a battery of tests to evaluate coagulation function, which costs about 20,000 rupees (US$200) in Pakistan. The cost of care for patients with stroke, including the diagnostic work-up, hospital bed charges and pharmacy charges, can go up to $1,000 or more, which is higher than the average monthly income in Pakistan or India.95 Less than 10% of patients are covered by insurance in this region, so they have to rely on their own money or on government hospitals, which are limited in number and capacity. The stroke care is expensive and not affordable by most of the population, while the contribution of governments to stroke care is virtually nil. Availability of antihypertensive and lipid-lowering medications, diabetic control, and availability and affordability of carotid artery care are important factors in secondary stroke prevention.
Carotid ultrasound is used to aid secondary stroke prevention in most patients worldwide. Carotid artery disease is not uncommon in South Asia, but carotid endarterectomy (CEA) or stenting among patients with symptomatic carotid disease is extremely rare. One study from Pakistan found that only 12% of patients with surgically correctable lesions in carotid arteries underwent carotid revascularization at 6-month follow-up.27 A single-centre study from India showed that over a 10-year period, 49 patients underwent CEA under general anaesthesia. One patient died and four patients experienced mild reversible complications.96
Decompressive surgery in the management of acute stroke is gaining acceptability, particularly for young patients with malignant middle cerebral artery (MCA) strokes and massive cerebellar strokes. One series of five patients with malignant MCA infarcts from Pakistan reported zero mortality, with three patients being discharged with a modified Rankin Scale (mRS) score of 4 and two being discharged with an mRS score of 5.97 A study of 24 patients with malignant supratentorial infarcts from India showed 16.7% mortality (versus 25% in medically managed controls), and also showed improved functional outcome compared with a control group.98
An additional challenge for stroke management and prevention in South Asia is the practice of unproven or inappropriate treatment. Use of sublingual antihypertensives, steroids, and anticoagulation with heparin in the acute setting is still common.99 Substances such as citicoline, piracetam, gingko biloba and Neuroaid are also frequently used in patients with stroke.
Availability of rehabilitation services is important for stroke recovery. In South Asia, long-term stroke care and rehabilitation is only available to a limited number of patients with stroke, mostly in large cities. More than 150 rehabilitation clinics and centres are actively involved in long-term stroke care in India.100, 101, 102 An estimated 23 centres are providing physical medicine and rehablitation in Pakistan, most of them without a multidisciplinary approach.103 Most of the rehabilitation consultants in this country are concentrated in armed forces hospitals.
Neurorehabilitation is an emerging speciality in Sri Lanka, with growing interest among neurology trainees.104 Stroke rehabilitation has also begun to gain attention in Bangladesh in recent years. Two non-governmental organizations, BRAC and the Centre for the Rehabilitation of the Paralyzed, are actively involved in primary stroke prevention strategies and long-term stroke care, including rehabilitation.105, 106 The number of trained personnel including doctors and therapists, the availability of rehabilitation facilities, and awareness about rehabilitation benefits among patients and doctors, are major areas for intervention.
Stroke severity and outcome
The available data show high mortality and disability from stroke in South Asia. As in developed countries, age, decreased level of consciousness, and poorly controlled modifiable risk factors are likely to be contributory factors to high mortality in this region.107, 108 A younger population experiencing stroke and being left with substantial disability creates an enormous burden on society.
The WHO estimated that in 1990, out of 9.4 million deaths in India, 619,000 were due to stroke, giving a mortality rate of 73 per 100,000 population. In the same year, the number of deaths attributable to stroke was 22 times higher than those due to malaria, 1.4 times higher than those due to tuberculosis, and almost equal to those due to ischaemic heart disease.109 Stroke mortality rates among people of Indian ethnicity have been found to be two to three times higher than in the white population.110 A longitudinal population-based study from Kolkata reported very high early fatality of 33% and 42% at 7 days and 30 days respectively; however, long-term mortality was 59% at 7 years and 61% at 7 years, which is similar to findings from developed nations.111 Similarly high 1-month mortality has been reported from Mumbai (29.8%) and Trivandrum (27.2%).18, 53 Limited data suggest that stroke recurrence might be increased in India owing to poor compliance with treatment and control of risk factors.
In-hospital stroke mortality has been reported at between 7% and 32% in Pakistan.59 Poor functional outcome has been reported in the majority of stroke survivors both from India and Pakistan.5, 25 Old age, diabetes mellitus, and decreased consciousness at the time of presentation have been consistently reported as poor prognostic factors.25 A population-based case–control study of 1,250 deaths from Bangladesh reported population-attributable mortality of 25% in patients with stroke.112
Stroke awareness among the public and general practitioners is directly proportional to improved care and outcome. In India and Pakistan, level of awareness of the risk factors and the warning symptoms of stroke among the general population is very low.113, 114, 115 Improved socioeconomic status and higher education have been found to raise awareness of the risk factors and warning symptoms of stroke in both rural and urban populations. Poor recognition of early stroke symptoms and low perception of threat leads to delayed arrival of patients at hospitals. Other influences include distance from the hospital, education, socioeconomic status, family history of stroke, and advice of friends and local doctors.116
In one survey conducted among the general public in Pakistan, only 51% of the respondents identified the brain as the organ affected in stroke.115 Around 13% of the study respondents did not know of any risk factors for stroke, and 11.6% of the respondents were unaware of the signs of stroke. A survey of 588 family physicians from Pakistan showed that 88% of the physicians were aware of at least one of the five main symptoms of stroke—loss of vision, double vision, slurring of speech, weakness of arm and/or leg, and difficulty walking—but only 46% were able to correctly identify all five symptoms.117 This study also found that 63% of the physicians used a cut-off of 140/90 mmHg to start antihypertensive therapy in routine clinical practice; 75% did not routinely check cholesterol levels in their patients; and 57% used intravenous or sublingual antihypertensive medications in patients with acute stroke with blood pressure 160/100 mmHg. No published literature is available from Sri Lanka and Bangladesh regarding awareness among the general public and physicians regarding stroke diagnosis, prevention and management. Such data will be essential for planning of intervention studies to reduce stroke burden in South Asia.
Advocacy and professional societies
The Indian Stroke Association was formed in 2003, and has been organizing regular annual stroke meetings since 2006. This association has launched a massive initiative for stroke education at the grass-roots level through various educational programmes, and is also at the forefront of popularizing and endorsing stroke units across the country. The Indian Stroke Association and Indian Academy of Neurology have circulated guidelines for stroke management in India.118
The Pakistan Stroke Society was established more than 10 years ago, and works in collaboration with the Pakistan Society of Neurology. This society organizes public awareness programmes and Continuing Medical Education activities for internists and general practitioners, and provides small grants for stroke research in Pakistan. The society also organizes a biennial stroke conference and is actively involved in advocacy activities, including media campaigns and World Stroke Day activities. The Pakistan Society of Neurology has published and circulated guidelines for stroke prevention and management in Pakistan.119
The National Stroke Association of Sri Lanka (NSAS) was inaugurated in 2001 and has facilitated several activities, including organization of the International Stroke Conference in 2008.15 Sri Lanka was selected for the gold award of the World Stroke Association in 2009 for organizing the activities to mark World Stroke Day.120
Despite the limited academic infrastructure for research in South Asia, active research on many aspects of stroke is being carried out in some centres. The government-supported Indian Council of Medical Research and Department of Biotechnology have funded several projects to evaluate disease burden, risk factors, and also novel therapies such as stem cell treatment in stroke. Currently, several international and national research programmes in India are attempting to address stroke surveillance; these include INTERSTROKE and INSPIRE. Some collaborative projects between India and the USA are underway, mainly looking at the comparative demography of stroke and the possibility of telestroke programmes.
Stroke research in Pakistan is limited to few universities. The Aga Khan University has an NIH grant to train stroke specialists and researchers in Pakistan. Most of the research is limited to stroke epidemiology and hospital-based studies. An increasing number of centres are becoming involved in collaborative research both within and outside Pakistan. The recently completed Asian young women stroke registry and the Asian CVT registry will generate more information related to these specialized stroke groups in Asia.
The Bangladesh Stroke Registry was started in 2011 with plans to enrol 1,200 patients with confirmed stroke. This large database of patients will provide useful information related to stroke in Bangladesh.
Conclusions and future directions
Despite advances in the understanding and management of stroke around the world, South Asia still faces many challenges relating to this disease. These challenges include a lack of trained neurologists and stroke specialists, a lack of stroke diagnostic facilities (especially CT scan) and treatment facilities (stroke unit, rehabilitation); poor public and physician awareness, and very low priority for governments.
In its current 5-year plan, the Government of India has allocated funds on a priority basis for stroke prevention by launching risk factor awareness programmes, and to support stroke care pathways at a district level, including early treatment incorporating thrombolytic therapy, and rehabilitation. These measures, coupled with the expected rise in educational and economic standards, are bound to improve stroke care in the coming years.
Stroke risk factors need recognition in mass media campaigns, and require repeated promotions. Healthy eating, exercise, smoking cessation, and diagnosis and effective management of hypertension and diabetes, are essential components of such awareness programmes. Local official guidelines should be adopted for each country and implemented at all levels of care. All large hospitals must establish special units for the management of patients with stroke. Such stroke units are not expensive and should be part of any comprehensive stroke strategy for the region. Scaling up of interventions such as low salt intake, smoking cessation, physician activity and cost-effective pharmacotherapy is expected to avert more than 10 million deaths in the next 8–10 years.94
National task forces for stroke prevention with involvement and participation of all stakeholders, including government, physicians, professional organizations, non-governmental organizations, patient support groups and media, are urgently needed for all the countries in South Asia. These task forces should be commissioned to design stroke prevention strategies, and must work with medical colleges, district hospitals and other governmental and private sector teaching institutes to improve education and training for stroke care at graduate and postgraduate levels. All district hospitals should be equipped with stroke units and stroke rehabilitation programmes. Research for innovative, cost-effective strategies to control the stroke epidemic should be a major area of focus for these task forces. Diagnosis of high blood pressure and its effective control, use of antiplatelet therapy, and strategies to control smokeless tobacco (chewing tobacco) and smoking, are the most important areas of intervention. Finally, multilevel collaboration among South Asian countries in the field of research, guideline development and implementation, and advocacy will be extremely fruitful, leading to new interventions to target stroke in this region.
We searched MEDLINE and WHO databases using search terms related to stroke (for example, “cerebrovascular diseases”, “ischaemic stroke”, “intracerebral haemorrhage”, “haemorrhagic stroke” and “cerebral infarction”) from 1980–2012 in South Asia. We also combined stroke terms with country names, including “India”, “Bangladesh”, “Pakistan” and “Sri Lanka”. We screened more than 400 abstracts related to stroke in South Asia. We selected more than 195 manuscripts for full-text review, a large number of which were included in the bibliography. These included population-based studies, hospital-based studies, reviews and commentaries. Although a formal systematic analysis was not done due to high variability in reporting methods, the available data were summarized and, where possible, categorized according to country.
- Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol. 8, 355–369 (2009). , , , &
- Stroke in South Asia: a systematic review of epidemiologic literature from 1980 to 2010. Neuroepidemiology 38, 123–129 (2012). , , &
- Growing burden of stroke in Pakistan: a review of progress and limitations. Int. J. Stroke 8, 575–581 (2013). , &
- Cerebrovascular disease in rural Kashmir, India. Stroke 20, 1691–1693 (1989). , , &
- Long term outcome of stroke in rural communities. J. Assoc. Physicians India 47, 39 (1999).
- Stroke in the urban population of Calcutta—an epidemiological study. Neuroepidemiology 20, 201–207 (2001). , &
- A 5 years prospective study of incidence, morbidity and mortality profile of stroke in a rural community of eastern India. J. Indian Med. Assoc. 103, 655–659 (2005). , , &
- A prospective community-based study of stroke in Kolkata, India. Stroke 38, 906–910 (2007). et al.
- Mumbai stroke registry (2005–2006)—surveillance using WHO steps stroke instrument—challenges and opportunities. J. Assoc. Physicians India 56, 675–680 (2008). , , &
- & Meenakshi. Cerebrovascular disease in South Asia—Part I: a burning problem. JRSM Cardiovasc. Dis. 1, pii: cvd.2012.012025 (2012). ,
- The epidemiology of stroke in Pakistan: past, present, and future. Int. J. Stroke 4, 381–389 (2009). , , &
- Can we stop the stroke epidemic in Pakistan? J. Coll. Physicians Surg. Pak. 21, 195–196 (2011). &
- The burden of stroke and transient ischemic attack in Pakistan: a community-based prevalence study. BMC Neurol. 9, 58 (2009). et al.
- Blood pressure, diabetes, and increased dietary salt associated with stroke—results from a community-based study in Pakistan. J. Hum. Hypertens. 20, 83–85 (2006).
- Development of stroke care in Sri Lanka. Int. J. Stroke 4, 38–39 (2009). , &
- Prevalence of stroke above forty years. Mymensingh Med. J. 20, 640–644 (2011). et al.
- A prospective community-based study of stroke in Kolkata, India. Stroke 38, 906–910 (2007). et al.
- Population-based stroke survey in Mumbai, India: incidence and 28-day case fatality. Neuroepidemiology 31, 254–261 (2008). et al.
- Feasibility study of stroke surveillance: data from Bangalore, India. Indian J. Med. Res. 130, 396–403 (2009). et al.
- Subtypes of ischemic stroke in a metropolitan city of South India (one year data from a hospital based stroke registry). Neurol. India 50 (Suppl.), S8–S14 (2002). et al.
- Stroke in India: are we different from the world? Pak. J. Neurol. Sci. 2, 158–164 (2007).
- Cerebrovascular diseases in west central India. A report on angiographic findings from a prospective study. Br. Med. J. 3, 769–774 (1968). , , &
- Distribution of vascular lesions in ischaemic stroke: a magnetic resonance angiographic study. Natl Med. J. India 10, 217–220 (1997). , , , &
- Ischemic stroke subtypes in Pakistan: the Aga Khan University Stroke Data Bank. J. Pak. Med. Assoc. 53, 584–588 (2003). et al.
- Stroke in Pakistan. J. Pak. Med. Assoc. 58, 400–403 (2008). &
- Risk factors in various subtypes of ischemic stroke according to TOAST criteria. J. Coll. Physicians Surg. Pak. 21, 280–283 (2011). , , , &
- Frequency and outcome of carotid atheromatous disease in patients with stroke in Pakistan. Stroke 40, 708–712 (2009). et al.
- Frequency of known risk factors for stroke in poor patients admitted to Lahore general hospital in 2000. Pak. J. Med. Sci. 18, 280–283 (2000). , , &
- Stroke radiology and distinguishing characteristics of intracranial atherosclerotic disease in native South Asian Pakistanis. Int. J. Stroke 8 (Suppl. A100), 14–20 (2013). et al.
- Stroke subtypes in Sri Lanka—a hospital based study. Ceylon Med. J. 46, 19–20 (2001). , &
- Burden of stroke in Bangladesh. Int. J. Stroke 8, 211–213 (2013). et al.
- Clinical presentation and epidemiology of stroke: a study of 100 cases. J. Medicine 10, 86–89 (2009). , , , &
- Seasonal variation in types of stroke and its common risk factors. Mymensingh Med. J. 21, 13–20 (2012). et al.
- Young stroke: clinical aspects. J. Coll. Physicians Surg. Pak. 10, 461–466 (2000). &
- Prevalence of diagnosed and undiagnosed diabetes and hypertension in India—results from the Screening India's Twin Epidemic (SITE) study. Diabetes Technol. Ther. 14, 8–15 (2012). et al.
- Pattern of stroke in type 2 diabetic subjects versus non diabetic subjects. J. Ayub Med. Coll. Abbottabad 19, 64–67 (2007). , , &
- The Karachi intracranial stenosis study (KISS) Protocol: an urban multicenter case–control investigation reporting the clinical, radiologic and biochemical associations of intracranial stenosis in Pakistan. BMC Neurol. 9, 31 (2009). et al.
- Ischemic cerebrovascular disease in the young. Two common causes in India. Stroke 15, 733–735 (1984).
- Risk factors for acute ischemic stroke in young adults in South India. J. Neurol. Neurosurg. Psychiatry 78, 959–963 (2007). et al.
- Ischemic stroke in young adults of South Asia. J. Pak. Med. Assoc. 52, 417–422 (2002). , &
- Case–control study of serum lipoprotein(a) and apolipoproteins A-I and B in stroke in the young. Acta Neurol. Scand. 94, 127–130 (1996). , , &
- Anticardiolipin antibodies in ischemic stroke in the young: Indian experience. J. Neurol. Sci. 150, 137–142 (1997). , &
- Women's health: beyond reproductive years. Indian J. Public Health 55, 247–251 (2011). &
- Ischemic stroke in young Asian women: risk factors, subtypes and outcome. Cerebrovasc. Dis. 30, 418–422 (2010). et al.
- Predictors of cerebral venous thrombosis and arterial ischemic stroke in young Asian women. J. Stroke Cerebrovasc. Dis. 21, 689–694 (2012). et al.
- Pregnancy and puerperium-related strokes in Asian women. J. Stroke Cerebrovasc. Dis. 22, 1393–1398 (2013). et al.
- Stroke in 127 young people. Presented at the Lancet Stroke Conference, Montreal, 1998. , , , &
- Cerebrovascular disease in children. Indian Pediatr. 37, 159–171 (2000).
- Etiological spectrum and outcome of pediatric stroke at a tertiary referral center in South India. Presented at the Annual Conference of the Indian Academy of Neurology, Trichy, 2010. et al.
- Etiology of strokes and hemiplegia in children presenting at Ayub Teaching Hospital, Abbottabad. J. Ayub Med. Coll. Abbottabad 18, 60–63 (2006). , &
- Trends in hypertension epidemiology in India. J. Hum. Hypertens. 18, 73–78 (2004).
- Prevalence of risk factors of non-communicable diseases in a District of Gujarat, India. J. Health Popul. Nutr. 31, 78–85 (2013). , &
- Incidence, types, risk factors, and outcome of stroke in a developing country the Trivandrum stroke registry. Stroke 40, 1212–1218 (2009). et al.
- Tobacco use: a major risk factor for non communicable diseases in South-East Asia region. Indian J. Public Health 55, 155–160 (2011). , , &
- Prevalence of smokeless tobacco use among adults in WHO South-East Asia. Indian J. Cancer 49, 342–346 (2012). , , &
- Epidemiology of type 2 diabetes: Indian scenario. Indian J. Med. Res. 125, 217–230 (2007). , , , &
- Dyslipidemia and associated risk factors in a resettlement colony of Delhi. J. Clin. Lipidol. 7, 653–660 (2013). et al.
- Coronary heart disease and risk factors in India—on the brink of an epidemic? Indian Heart J. 64, 364–367 (2012).
- Burden of stroke in Pakistan. Int. J. Stroke 3, 293–296 (2008). &
- Ethnic subgroup differences in hypertension in Pakistan. J. Hypertens. 21, 905–912 (2003). et al.
- Prevalence and pattern of smoking in Pakistan. J. Pak. Med. Assoc. 48, 64–66 (1998).
- Prevalence and predictors of smoking in Pakistan: results of the National Health Survey of Pakistan. Eur. J. Cardiovasc. Prev. Rehabil. 12, 203–208 (2005). et al.
- Prevalence and sociodemographic determinants of tobacco use among adults in Pakistan: findings of a nationwide survey conducted in 2012. Popul. Health Metr. 11, 16 (2013). &
- Ethnic differences and determinants of diabetes and central obesity among South Asians of Pakistan. Diabet. Med. 21, 716–723 (2004). et al.
- Heart disease epidemic in Pakistan: women and men at equal risk. Am. Heart J. 150, 221–226 (2005). , , &
- Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo-Asian population. CMAJ 175, 1071–1077 (2006). , &
- Hypertension in Bangladesh: a review. Indian Heart J. 64, 319–323 (2012). &
- Analysis of sociodemographic and clinical factors associated with hospitalized stroke patients of Bangladesh. Faridpur Med. Coll. J. 6, 19–23 (2011). et al.
- Prevalence of modifiable risk factors among stroke patients in a tertiary care hospital in Dhaka. J. Med. 10 (Suppl. 1), S18–S21 (2009). et al.
- Global Tobacco Surveillance System. Global adult tobacco survey: Bangladesh report 2009. WHO [online], (2009).
- Prevalence of diabetes mellitus and its associated risk indicators in a rural Bangladeshi population. The Open Diabetes Journal 4, 6–13 (2011). et al.
- Plasma lipids in a rural population of Bangladesh. Eur. J. Cardiovasc. Prev. Rehabil. 13, 444–448 (2006). et al.
- Cardiovascular risk factors: distribution and prevalence in a rural population of Bangladesh. J. Cardiovasc. Risk 8, 103–108 (2001). et al.
- Prevalence of hypertension, diabetes and obesity: baseline findings of a population based survey in four provinces in Sri Lanka. Ceylon Med. J. 50, 62–70 (2005). et al.
- Prevalence of coronary heart disease and cardiovascular risk factors in middle aged males in a defined population in central Sri Lanka. Int. J. Cardiol. 46, 135–142 (1994). &
- Smokeless tobacco use in Sri Lanka. Indian J. Cancer 49, 357–363 (2012). et al.
- Prevalence of overweight and obesity in Sri Lankan adults. Obes. Rev. 11, 751–756 (2010). , , , &
- Differences in predicted cardiovascular risk in Sinhalese and Tamils in Sri Lanka compared with Sri Lankans in Norway. Asia Pac. J. Public Health 25, 452–462 (2013). , , , &
- Cerebral infarction in a young male following viper envenomation. J. Assoc. Physicians India 48, 744–745 (2000). &
- Acute ischemic strokes due to bites by Daboia russelii in Sri Lanka—first authenticated case series. Toxicon 54, 421–428 (2009). , &
- Is squatting a triggering factor for stroke in Indians? Acta Neurol. Scand. 105, 124–127 (2002). , , &
- Cerebral infarction in tuberculous meningitis. Pak. J. Neurol. Sci. 6, 25–29 (2011). &
- Genetics of ischemic stroke: Indian perspective. Neurol. India 60, 498–503 (2012). &
- Association of phosphodiesterase 4D gene with ischemic stroke in a Pakistani population. Stroke 36, 2275–2277 (2005). et al.
- Association of SNP41, SNP56 and a novel SNP in PDE4D gene with stroke and its subtypes. Gene 506, 31–35 (2012). et al.
- Association of E-selectin gene polymorphism (S128R) with ischemic stroke and stroke subtypes. Inflammation http://dx.doi.org/10.1007/s10753-013-9774–0. et al.
- ACE and ADD1 gene in extra and intracranial atherosclerosis in ischaemic stroke. Neurol. Res. 35, 429–434 (2013). et al.
- Paroxenase activity and PON1(Q/R192) gene polymorphism in ischemic stroke patient. IJLPR 2, 169–176 (2012). , , &
- Decompressive surgery for severe cerebral venous sinus thrombosis. Neurol. India 58, 392–397 (2010). et al.
- Treatment of cerebral sinus/venous thrombosis. Neurol. India 50, 114–116 (2002). &
- Cerebral venous sinus thrombosis in a tertiary care setting in India. QJM 99, 491–492 (2006). , , &
- Cerebral venous thrombosis: a descriptive multicenter study of patients in Pakistan and Middle East. Stroke 39, 2707–2711 (2008). et al.
- Risk factors, clinical profile, and long-term outcome of 428 patients of cerebral sinus venous thrombosis: insights from Nizam's Institute Venous Stroke Registry, Hyderabad (India). Neurol. India 60, 19–24 (2012). et al.
- Fight against chronic diseases (high blood pressure, stroke, diabetes and cancer) in Pakistan; cost-effective interventions. J. Pak. Med. Assoc. 59, 196–197 (2009). &
- Cost of acute stroke care at a tertiary care hospital in Karachi, Pakistan. J. Pak. Med. Assoc. 53, 552–555 (2003). , , , &
- Carotid endarterectomy: results and long-term follow-up of a single institution. Neurol. India 59, 390–396 (2011). , , &
- Salvage decompressive craniectomy in malignant MCA infarcts—results of local experience at Shifa International Hospital, Islamabad, Pakistan. J. Pak. Med. Assoc. 58, 404–408 (2008). , , , &
- Decompressive hemicraniectomy in supra-tentorial malignant infarcts. Surg. Neurol. Int. 3, 29 (2012). et al.
- Alternative therapies for stroke treatment in Asia. Int. J. Stroke 6, 541–543 (2011). , , &
- Physiotherapy practice in stroke rehabilitation: a cross-sectional survey of physiotherapists in the state of Kerala, India. Top. Stroke Rehabil. 19, 405–410 (2012). et al.
- Neurological disorders and barriers for neurological rehabilitation in rural areas in Uttar Pradesh: a cross-sectional study. J. Neurosci. Rural Pract. 3, 12–16 (2012). &
- Community based rehabilitation in India—an emerging trend. Indian J. Pediatr. 59, 401–406 (1992).
- A report on disability and rehabilitation medicine in Pakistan: past, present, and future directions. Arch. Phys. Med. Rehabil. 92, 161–166 (2011). , &
- Neurorehabilitation in Sri Lanka: an emerging sub-specialty for neurology trainees. Int. J. Stroke 7, 163–164 (2012).
- Burden of stroke in Bangladesh. Int. J. Stroke 8, 211–213 (2013). et al.
- Perceptions of disability among mothers of children with disability in Bangladesh: implications for rehabilitation service delivery. Disabil. Rehabil. 32, 845–854 (2010). et al.
- Five-year survival after first-ever stroke and related prognostic factors in the Perth Community Stroke Study. Stroke 31, 2080–2086 (2000). et al.
- The frequency, causes and timing of death within 30 days of a first stroke: the Oxfordshire Community Stroke Project. J. Neurol. Neurosurg. Psychiatry 53, 824–829 (1990). , , , &
- 1994). & Global Comparative Assessments in the Health Sector: Disease Burden, Expenditures and Intervention Packages (WHO,
- Etiology and risk factors of ischemic stroke in Indian-American patients from a hospital-based registry in New Jersey. Neurol. Asia 14, 81–86 (2009). , &
- Early and delayed fatality of stroke in Kolkata, India: results from a 7-year longitudinal population-based study. J. Stroke Cerebrovasc. Dis. 22, 281–289 (2013). et al.
- A population-based case–control study of 1250 stroke deaths in rural Bangladesh. Eur. J. Neurol. 19, 999–1006 (2012). , , , &
- Awareness of warning symptoms and risk factors of stroke in the general population and in survivors of stroke. J. Neurosci. 14, 12–16 (2007). , , , &
- Public awareness of warning symptoms, risk factors, and treatment of stroke in North West India. Stroke 36, 644–648 (2005). et al.
- Awareness of stroke risk factors, signs and treatment in a Pakistani population. J. Pak. Med. Assoc. 59, 495–499 (2009). et al.
- A study of factors delaying hospital arrival of patients with acute stroke. Neurol. India 49, 272–276 (2001). &
- Knowledge gaps in stroke care: results of a survey of family physicians in Pakistan. J. Stroke Cerebrovasc. Dis. 20, 282–286 (2011). et al.
- Stroke management. Ann. Indian Acad. Neurol. 14 (Suppl. 1), S82–S96 (2011). et al.
- Ischemic stroke care—official guidelines from the Pakistan Society of Neurology. Pak. J. Neurol. Sci. 5, 38–43 (2010). et al.
- World Stroke Day 2009, gold award winner. Int. J. Stroke 5, 323–324 (2010). &