Stroke in Asia

Abstract

Background: There is a significant burden of stroke in Asia. Asia has the largest population in the world in 2023, estimated at 4.7 billion. Approximately 9.5-10.6 million strokes will be anticipated annually in the backdrop of a diverse group of well-developed and less developed countries with large disparities in stroke care resources. In addition, Asian countries are in varying phases of epidemiological transition.

Summary: In this review, we examined recent epidemiological features of ischaemic stroke and intracerebral haemorrhage in Asia with recent developments in hyperacute stroke reperfusion therapy and technical improvements in intracerebral haemorrhage. The article also discussed the spectrum of cerebrovascular diseases in Asia, which include intracranial atherosclerosis, intracerebral haemorrhage, infective aetiologies of stroke, moyamoya disease, vascular dissection, radiation vasculopathy, and cerebral venous thrombosis.

Key messages: The review of selected literature and recent updates calls for attention to the different requirements for resources within Asia and highlights the breadth of cerebrovascular diseases still requiring further research and more effective therapies.

Keywords: Aetiology; Asian stroke pattern; Classification; Epidemiology; Stroke intervention; Stroke systems of care.

Fig. 1.

Radiological findings of a 76-year-old male with atherosclerotic stenosis of the horizontal portion of the left middle cerebral artery (MCA). MRA (a, b) clearly demonstrates severe stenosis of the horizontal portion of the left MCA (arrows). High-resolution MRI shows eccentric plaque in the horizontal portion of the left MCA. c T1-weighted image, coronal view. d T2-weighted image, sagittal view.

Fig. 2.

MRA (a) and 3-dimensional constructive interference in steady state (3D-CISS) (b) of a 44-year-old female with unilateral moyamoya disease (MMD). Note that the outer diameter of the horizontal portion of the middle cerebral artery (M1) is markedly reduced on the left side (1.3 mm), compared with the right side (2.9 mm). c A column graph demonstrates the outer diameter of the M1 portion is smaller in patients with MMD than in those with atherosclerosis and controls. d A scatter graph shows that the arterial shrinkage in the M1 portion well correlates with the Suzuki’s disease stage in MMD.

Fig. 3.

Pre- and post-operative findings on cerebral angiography in an 8-year-old boy with MMD. Before surgery, left internal carotid angiography demonstrates a marked stenosis of the carotid fork associated with the development of moyamoya vessels. Note that the moyamoya vessels originating from the anterior choroidal artery are markedly dilated (arrow). On follow-up, left internal carotid angiography was performed 4 months later after STA-MCA anastomosis combined with EDMAPS (see the text); the extent and diameter of the moyamoya vessels markedly diminished (arrow). On external carotid angiography, the surgical collaterals through direct and indirect bypass are well developed and widely supply the blood flow of the operated hemisphere.

Fig. 4.

Pre- and post-operative findings on 123 I-IMP single photon emission computer tomography (SPECT) in an 8-year-old boy with MMD. Before surgery, cerebral blood flow is markedly reduced in the territory of the internal carotid artery on both sides. Note the disappearance of hyperfrontality. Bilateral STA-MCA anastomosis combined with EDMAPS markedly improved cerebral haemodynamics in the bilateral hemispheres.