Review of acute ischaemic stroke in Pakistan: progress in management and future perspectives

Abstract

Ischaemic stroke is a major cause of neurological morbidity and mortality. The objective of this review article is to summarise facts pertaining to acute ischaemic stroke and its various aspects in a developing country like Pakistan, where resources are limited and the healthcare system is underdeveloped. No large-scale epidemiological studies are available to determine the true incidence of stroke in Pakistan. We reviewed the available literature on stroke from Pakistan and through this article we primarily aim to present the current acute ischaemic stroke management in Pakistan in juxtaposition to that of the developed world. We also intend to highlight areas for future development and improvement in management. The routine practice in Pakistan is that of using stat dose of aspirin in emergency (ER) at large with only a handful of centres offering thrombolytic therapy with recombinant tissue plasminogen activator for acute ischaemic stroke. This too is faced with the problem of long window periods before the patient reaches a proper stroke care centre. The facilities of interventional therapies like arterial thrombolysis and endovascular surgery are non-existent and rehabilitation facilities limited. The opportunities for training physicians in acute stroke are also scarce. Stroke in children is underdiagnosed and that in women not availing facilities at stroke care centres. While basic research has gained pace regarding local demographic data, advanced research and genetic studies are extremely limited. The field of stroke neurology needs to grow at a substantial pace in Pakistan to be at par with the developed world.

Keywords: Cerebrovascular accident; Pakistan stroke management.; acute ischemic stroke; recombinant tissue Plasminogen Activator; window period.

Figure 1

Risk factors for ischaemic stroke. An algorithm showing the risk factors for ischaemic stroke. SAH, subsarachnoid hemorrhage.

Figure 2

Bedside clinical signs to be noted in stroke; (A) a patient who has not suffered a stroke can generally hold the arms in an extended position with eyes closed. (B) A patient with stroke will often display ‘arm drift’ (pronator drift)—one arm will remain extended when held outwards with eyes closed, but the other arm will drift or drop downwards and pronate (palm turned downwards).

Figure 3

Graphical representation of patients within and outside window period for IV thrombolysis in a study conducted by Ali and colleagues in 2015–2016 (adapted from ref. 28). Out of the cohort of 100 patients, 29% had presented within the window period for IV thrombolysis. IV, intravenous.

Figure 4

Process of tissue damage and time intervals for possible salvage in acute ischaemic stroke.