Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Stroke in South Asian countries

Key Points

  • 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

Abstract

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.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1
Figure 2: Population and burden of stroke mortality in South Asia compared with the rest of the world.
Figure 3

Similar content being viewed by others

References

  1. Feigin, V. L., Lawes, C. M., Bennett, D. A., Barker-Collo, S. L. & Parag, V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol. 8, 355–369 (2009).

    Article  PubMed  Google Scholar 

  2. Kulshreshtha, A., Anderson, L. M., Goyal, A. & Keenan, N. L. Stroke in South Asia: a systematic review of epidemiologic literature from 1980 to 2010. Neuroepidemiology 38, 123–129 (2012).

    Article  PubMed  Google Scholar 

  3. Hashmi, M., Khan, M. & Wasay, M. Growing burden of stroke in Pakistan: a review of progress and limitations. Int. J. Stroke 8, 575–581 (2013).

    Article  PubMed  Google Scholar 

  4. Razdan, S., Kaul, R. L., Motta, A. & Kaul, S. Cerebrovascular disease in rural Kashmir, India. Stroke 20, 1691–1693 (1989).

    Article  CAS  PubMed  Google Scholar 

  5. Dhamija, R. K. Long term outcome of stroke in rural communities. J. Assoc. Physicians India 47, 39 (1999).

    Google Scholar 

  6. Banerjee, T. K., Mukherjee, C. S. & Sarkhel, A. Stroke in the urban population of Calcutta—an epidemiological study. Neuroepidemiology 20, 201–207 (2001).

    Article  CAS  PubMed  Google Scholar 

  7. Bhattacharya, S., Saha, S. P., Basu, A. & Das, S. K. 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).

    PubMed  Google Scholar 

  8. Das, S. K. et al. A prospective community-based study of stroke in Kolkata, India. Stroke 38, 906–910 (2007).

    Article  PubMed  Google Scholar 

  9. Dalal, P. M., Bhattacharjee, M., Vairale, J. & Bhat, P. Mumbai stroke registry (2005–2006)—surveillance using WHO steps stroke instrument—challenges and opportunities. J. Assoc. Physicians India 56, 675–680 (2008).

    CAS  PubMed  Google Scholar 

  10. Prasad, K., Vibha, D. & Meenakshi. Cerebrovascular disease in South Asia—Part I: a burning problem. JRSM Cardiovasc. Dis. 1, pii: cvd.2012.012025 (2012).

  11. Farooq, M. U., Majid, A., Reeves, M. J. & Birbeck, G. L. The epidemiology of stroke in Pakistan: past, present, and future. Int. J. Stroke 4, 381–389 (2009).

    Article  CAS  PubMed  Google Scholar 

  12. Khatri, I. A. & Wasay, M. Can we stop the stroke epidemic in Pakistan? J. Coll. Physicians Surg. Pak. 21, 195–196 (2011).

    PubMed  Google Scholar 

  13. Kamal, A. K. et al. The burden of stroke and transient ischemic attack in Pakistan: a community-based prevalence study. BMC Neurol. 9, 58 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  14. Jafar, T. H. 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).

    Article  CAS  PubMed  Google Scholar 

  15. Gunaratne, P. S., Fernando, A. & Sharma, V. K. Development of stroke care in Sri Lanka. Int. J. Stroke 4, 38–39 (2009).

    Article  PubMed  Google Scholar 

  16. Mohammad, Q. D. et al. Prevalence of stroke above forty years. Mymensingh Med. J. 20, 640–644 (2011).

    CAS  PubMed  Google Scholar 

  17. Das, S. K. et al. A prospective community-based study of stroke in Kolkata, India. Stroke 38, 906–910 (2007).

    Article  PubMed  Google Scholar 

  18. Dalal, P. M. et al. Population-based stroke survey in Mumbai, India: incidence and 28-day case fatality. Neuroepidemiology 31, 254–261 (2008).

    Article  CAS  PubMed  Google Scholar 

  19. Nagaraja, D. et al. Feasibility study of stroke surveillance: data from Bangalore, India. Indian J. Med. Res. 130, 396–403 (2009).

    CAS  PubMed  Google Scholar 

  20. Kaul, S. 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).

    Google Scholar 

  21. Kaul, S. Stroke in India: are we different from the world? Pak. J. Neurol. Sci. 2, 158–164 (2007).

    Google Scholar 

  22. Dalal, P. M., Shah, P. M., Aiyar, R. R. & Kikani, B. J. Cerebrovascular diseases in west central India. A report on angiographic findings from a prospective study. Br. Med. J. 3, 769–774 (1968).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Padma, M. V., Gaikwad, S., Jain, S., Maheshwari, M. C. & Misra, N. K. Distribution of vascular lesions in ischaemic stroke: a magnetic resonance angiographic study. Natl Med. J. India 10, 217–220 (1997).

    CAS  PubMed  Google Scholar 

  24. Syed, N. A. et al. Ischemic stroke subtypes in Pakistan: the Aga Khan University Stroke Data Bank. J. Pak. Med. Assoc. 53, 584–588 (2003).

    CAS  PubMed  Google Scholar 

  25. Khealani, B. A. Hameed, B. & Mapari, U. U. Stroke in Pakistan. J. Pak. Med. Assoc. 58, 400–403 (2008).

    PubMed  Google Scholar 

  26. Aquil, N., Begum, I., Ahmed, A., Vohra, E. A. & Soomro, B. A. Risk factors in various subtypes of ischemic stroke according to TOAST criteria. J. Coll. Physicians Surg. Pak. 21, 280–283 (2011).

    PubMed  Google Scholar 

  27. Wasay, M. et al. Frequency and outcome of carotid atheromatous disease in patients with stroke in Pakistan. Stroke 40, 708–712 (2009).

    Article  PubMed  Google Scholar 

  28. Basharat, R. A., Yousuf, M., Iqbal, J. & Khan, M. M. 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).

    Google Scholar 

  29. Khan, M. et al. Stroke radiology and distinguishing characteristics of intracranial atherosclerotic disease in native South Asian Pakistanis. Int. J. Stroke 8 (Suppl. A100), 14–20 (2013).

    Article  PubMed  Google Scholar 

  30. Gunatilake, S. B., Jayasekera, B. A. & Premawardene, A. P. Stroke subtypes in Sri Lanka—a hospital based study. Ceylon Med. J. 46, 19–20 (2001).

    Article  CAS  PubMed  Google Scholar 

  31. Islam, M. N. et al. Burden of stroke in Bangladesh. Int. J. Stroke 8, 211–213 (2013).

    Article  PubMed  Google Scholar 

  32. Siddique, A. N., Nur, Z., Mahbub, S., Alam, B. & Miah, T. Clinical presentation and epidemiology of stroke: a study of 100 cases. J. Medicine 10, 86–89 (2009).

    Article  Google Scholar 

  33. Miah, A. H. et al. Seasonal variation in types of stroke and its common risk factors. Mymensingh Med. J. 21, 13–20 (2012).

    CAS  PubMed  Google Scholar 

  34. Khan, J. A. & Shah, M. A. Young stroke: clinical aspects. J. Coll. Physicians Surg. Pak. 10, 461–466 (2000).

    Google Scholar 

  35. Joshi, S. R. et al. 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).

    Article  PubMed  Google Scholar 

  36. Zafar, A., Shahid, S. K., Siddiqui, M. & Khan, F. S. Pattern of stroke in type 2 diabetic subjects versus non diabetic subjects. J. Ayub Med. Coll. Abbottabad 19, 64–67 (2007).

    PubMed  Google Scholar 

  37. Kamal, A. K. et al. 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).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Srinivasan, K. Ischemic cerebrovascular disease in the young. Two common causes in India. Stroke 15, 733–735 (1984).

    Article  CAS  PubMed  Google Scholar 

  39. Lipska, K. et al. Risk factors for acute ischemic stroke in young adults in South India. J. Neurol. Neurosurg. Psychiatry 78, 959–963 (2007).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Razzaq, A. A., Khan, B. A. & Baig, S. M. Ischemic stroke in young adults of South Asia. J. Pak. Med. Assoc. 52, 417–422 (2002).

    CAS  PubMed  Google Scholar 

  41. Christopher, R., Kailasanatha, K. M., Nagaraja, D. & Tripathi, M. 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).

    Article  CAS  PubMed  Google Scholar 

  42. Nagaraja, D., Christopher, R. & Manjari, T. Anticardiolipin antibodies in ischemic stroke in the young: Indian experience. J. Neurol. Sci. 150, 137–142 (1997).

    Article  CAS  PubMed  Google Scholar 

  43. Vibha & Laskar, A. R. Women's health: beyond reproductive years. Indian J. Public Health 55, 247–251 (2011).

    Article  Google Scholar 

  44. Wasay, M. et al. Ischemic stroke in young Asian women: risk factors, subtypes and outcome. Cerebrovasc. Dis. 30, 418–422 (2010).

    Article  PubMed  Google Scholar 

  45. Wasay, M. et al. Predictors of cerebral venous thrombosis and arterial ischemic stroke in young Asian women. J. Stroke Cerebrovasc. Dis. 21, 689–694 (2012).

    Article  PubMed  Google Scholar 

  46. Khan, M. et al. Pregnancy and puerperium-related strokes in Asian women. J. Stroke Cerebrovasc. Dis. 22, 1393–1398 (2013).

    Article  PubMed  Google Scholar 

  47. Mehndiratta, M. M., Aggarwal, P., Gupta, M., Puri, V. & Aggarwal, S. Stroke in 127 young people. Presented at the Lancet Stroke Conference, Montreal, 1998.

  48. Kaul, S. Cerebrovascular disease in children. Indian Pediatr. 37, 159–171 (2000).

    CAS  PubMed  Google Scholar 

  49. Murty, A. et al. 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.

  50. Siddiqui, T. S., Rehman, A. & Ahmed, B. Etiology of strokes and hemiplegia in children presenting at Ayub Teaching Hospital, Abbottabad. J. Ayub Med. Coll. Abbottabad 18, 60–63 (2006).

    PubMed  Google Scholar 

  51. Gupta, R. Trends in hypertension epidemiology in India. J. Hum. Hypertens. 18, 73–78 (2004).

    Article  CAS  PubMed  Google Scholar 

  52. Bhagyalaxmi, A., Atul, T. & Shikha, J. Prevalence of risk factors of non-communicable diseases in a District of Gujarat, India. J. Health Popul. Nutr. 31, 78–85 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  53. Sridharan, S. E. et al. Incidence, types, risk factors, and outcome of stroke in a developing country the Trivandrum stroke registry. Stroke 40, 1212–1218 (2009).

    Article  PubMed  Google Scholar 

  54. Thakur, J. S., Garg, R., Narain, J. P. & Menabde, N. Tobacco use: a major risk factor for non communicable diseases in South-East Asia region. Indian J. Public Health 55, 155–160 (2011).

    Article  CAS  PubMed  Google Scholar 

  55. Sinha, D. N., Gupta, P. C., Ray, C. & Singh, P. K. Prevalence of smokeless tobacco use among adults in WHO South-East Asia. Indian J. Cancer 49, 342–346 (2012).

    Article  CAS  PubMed  Google Scholar 

  56. Mohan, V., Sandeep, S., Deepa, R., Shah, B. & Varghese, C. Epidemiology of type 2 diabetes: Indian scenario. Indian J. Med. Res. 125, 217–230 (2007).

    CAS  PubMed  Google Scholar 

  57. Sharma, U. et al. Dyslipidemia and associated risk factors in a resettlement colony of Delhi. J. Clin. Lipidol. 7, 653–660 (2013).

    Article  PubMed  Google Scholar 

  58. Krishnan, M. N. Coronary heart disease and risk factors in India—on the brink of an epidemic? Indian Heart J. 64, 364–367 (2012).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  59. Khealani, B. A. & Wasay, M. Burden of stroke in Pakistan. Int. J. Stroke 3, 293–296 (2008).

    Article  PubMed  Google Scholar 

  60. Jafar, T. H. et al. Ethnic subgroup differences in hypertension in Pakistan. J. Hypertens. 21, 905–912 (2003).

    Article  CAS  PubMed  Google Scholar 

  61. Alam, S. E. Prevalence and pattern of smoking in Pakistan. J. Pak. Med. Assoc. 48, 64–66 (1998).

    CAS  PubMed  Google Scholar 

  62. Ahmad, K. et al. Prevalence and predictors of smoking in Pakistan: results of the National Health Survey of Pakistan. Eur. J. Cardiovasc. Prev. Rehabil. 12, 203–208 (2005).

    Article  PubMed  Google Scholar 

  63. Gilani, S. I. & Leon, D. A. 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).

    Article  PubMed  PubMed Central  Google Scholar 

  64. Jafar, T. H. et al. Ethnic differences and determinants of diabetes and central obesity among South Asians of Pakistan. Diabet. Med. 21, 716–723 (2004).

    Article  CAS  PubMed  Google Scholar 

  65. Jafar, T. H., Jafary, F. H., Jessani, S. & Chaturvedi, N. Heart disease epidemic in Pakistan: women and men at equal risk. Am. Heart J. 150, 221–226 (2005).

    Article  PubMed  Google Scholar 

  66. Jafar, T. H., Chaturvedi, N. & Pappas, G. Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo-Asian population. CMAJ 175, 1071–1077 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  67. Islam, A. K. & Majumder, A. A. Hypertension in Bangladesh: a review. Indian Heart J. 64, 319–323 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  68. Hossain, A. M. et al. Analysis of sociodemographic and clinical factors associated with hospitalized stroke patients of Bangladesh. Faridpur Med. Coll. J. 6, 19–23 (2011).

    Article  Google Scholar 

  69. Badiuzzaman, M. 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).

    Google Scholar 

  70. Global Tobacco Surveillance System. Global adult tobacco survey: Bangladesh report 2009. WHO [online], (2009).

  71. Akhter, A. et al. Prevalence of diabetes mellitus and its associated risk indicators in a rural Bangladeshi population. The Open Diabetes Journal 4, 6–13 (2011).

    Article  CAS  Google Scholar 

  72. Mostafa Zaman, M. et al. Plasma lipids in a rural population of Bangladesh. Eur. J. Cardiovasc. Prev. Rehabil. 13, 444–448 (2006).

    Article  CAS  PubMed  Google Scholar 

  73. Zaman, M. M. et al. Cardiovascular risk factors: distribution and prevalence in a rural population of Bangladesh. J. Cardiovasc. Risk 8, 103–108 (2001).

    Article  CAS  PubMed  Google Scholar 

  74. Wijewardene, K. 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).

    Article  CAS  PubMed  Google Scholar 

  75. Mendis, S. & Ekanayake, E. M. 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).

    Article  CAS  PubMed  Google Scholar 

  76. Somatunga, L. C. et al. Smokeless tobacco use in Sri Lanka. Indian J. Cancer 49, 357–363 (2012).

    Article  CAS  PubMed  Google Scholar 

  77. Katulanda, P., Jayawardena, M. A., Sheriff, M. H., Constantine, G. R. & Matthews, D. R. Prevalence of overweight and obesity in Sri Lankan adults. Obes. Rev. 11, 751–756 (2010).

    Article  CAS  PubMed  Google Scholar 

  78. Tennakoon, S. U., Kumar, B. N., Selmer, R., Mikram, M. J. & Meyer, H. E. 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).

    Article  PubMed  Google Scholar 

  79. Panicker, J. N. & Madhusudanan, S. Cerebral infarction in a young male following viper envenomation. J. Assoc. Physicians India 48, 744–745 (2000).

    CAS  PubMed  Google Scholar 

  80. Gawarammana, I., Mendis, S. & Jeganathan, K. Acute ischemic strokes due to bites by Daboia russelii in Sri Lanka—first authenticated case series. Toxicon 54, 421–428 (2009).

    Article  CAS  PubMed  Google Scholar 

  81. Chakrabarti, S. D., Ganguly, R., Chatterjee, S. K. & Chakravarty, A. Is squatting a triggering factor for stroke in Indians? Acta Neurol. Scand. 105, 124–127 (2002).

    Article  CAS  PubMed  Google Scholar 

  82. Taqui, A. M. & Wasay, M. Cerebral infarction in tuberculous meningitis. Pak. J. Neurol. Sci. 6, 25–29 (2011).

    Google Scholar 

  83. Kaul, S. & Munshi, A. Genetics of ischemic stroke: Indian perspective. Neurol. India 60, 498–503 (2012).

    Article  PubMed  Google Scholar 

  84. Saleheen, D. et al. Association of phosphodiesterase 4D gene with ischemic stroke in a Pakistani population. Stroke 36, 2275–2277 (2005).

    Article  CAS  PubMed  Google Scholar 

  85. Munshi, A. et al. Association of SNP41, SNP56 and a novel SNP in PDE4D gene with stroke and its subtypes. Gene 506, 31–35 (2012).

    Article  CAS  PubMed  Google Scholar 

  86. Roy, S. 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.

  87. Kalita, J. et al. ACE and ADD1 gene in extra and intracranial atherosclerosis in ischaemic stroke. Neurol. Res. 35, 429–434 (2013).

    Article  CAS  PubMed  Google Scholar 

  88. Marugan, M. M., Alagirisamy, R., Manokaran, S. & Balkrishnan, A. Paroxenase activity and PON1(Q/R192) gene polymorphism in ischemic stroke patient. IJLPR 2, 169–176 (2012).

    Google Scholar 

  89. Lath, R. et al. Decompressive surgery for severe cerebral venous sinus thrombosis. Neurol. India 58, 392–397 (2010).

    Article  PubMed  Google Scholar 

  90. Nagaraja, D. & Sarma, G. R. Treatment of cerebral sinus/venous thrombosis. Neurol. India 50, 114–116 (2002).

    CAS  PubMed  Google Scholar 

  91. Kalita, J., Bandal, V., Misra, U. K. & Phadke, R. V. Cerebral venous sinus thrombosis in a tertiary care setting in India. QJM 99, 491–492 (2006).

    Article  CAS  PubMed  Google Scholar 

  92. Khealani, B. A. et al. Cerebral venous thrombosis: a descriptive multicenter study of patients in Pakistan and Middle East. Stroke 39, 2707–2711 (2008).

    Article  PubMed  Google Scholar 

  93. Narayan, D. 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).

    Google Scholar 

  94. Wasay, M. & Jabbar, A. Fight against chronic diseases (high blood pressure, stroke, diabetes and cancer) in Pakistan; cost-effective interventions. J. Pak. Med. Assoc. 59, 196–197 (2009).

    PubMed  Google Scholar 

  95. Khealani, B. A., Javed, Z. F., Syed, N. A., Shafqat, S. & Wasay, M. Cost of acute stroke care at a tertiary care hospital in Karachi, Pakistan. J. Pak. Med. Assoc. 53, 552–555 (2003).

    CAS  PubMed  Google Scholar 

  96. Misra, B. K., Purandare, H. R., Ved, R. & Ashok, P. P. Carotid endarterectomy: results and long-term follow-up of a single institution. Neurol. India 59, 390–396 (2011).

    Article  PubMed  Google Scholar 

  97. Khatri, I. A., Siddiqui, M., Khan, I., Nadeem, M. & Ahmad, A. 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).

    PubMed  Google Scholar 

  98. Nizami, F. A. et al. Decompressive hemicraniectomy in supra-tentorial malignant infarcts. Surg. Neurol. Int. 3, 29 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  99. Pandian, J. D., Liu, M., Misbach, J. & Venketasubramanian, N. Alternative therapies for stroke treatment in Asia. Int. J. Stroke 6, 541–543 (2011).

    Article  PubMed  Google Scholar 

  100. Khan, F. R. et al. Physiotherapy practice in stroke rehabilitation: a cross-sectional survey of physiotherapists in the state of Kerala, India. Top. Stroke Rehabil. 19, 405–410 (2012).

    Article  CAS  PubMed  Google Scholar 

  101. Kumar, H. & Gupta, N. 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).

    Article  PubMed  PubMed Central  Google Scholar 

  102. Thomas, M. Community based rehabilitation in India—an emerging trend. Indian J. Pediatr. 59, 401–406 (1992).

    Article  CAS  PubMed  Google Scholar 

  103. Rathore, F. A., New, P. W. & Iftikhar, A. A report on disability and rehabilitation medicine in Pakistan: past, present, and future directions. Arch. Phys. Med. Rehabil. 92, 161–166 (2011).

    Article  PubMed  Google Scholar 

  104. Wijeratne, T. Neurorehabilitation in Sri Lanka: an emerging sub-specialty for neurology trainees. Int. J. Stroke 7, 163–164 (2012).

    Article  PubMed  Google Scholar 

  105. Islam, M. N. et al. Burden of stroke in Bangladesh. Int. J. Stroke 8, 211–213 (2013).

    Article  PubMed  Google Scholar 

  106. Maloni, P. K. et al. Perceptions of disability among mothers of children with disability in Bangladesh: implications for rehabilitation service delivery. Disabil. Rehabil. 32, 845–854 (2010).

    Article  PubMed  Google Scholar 

  107. Hankey, G. J. et al. Five-year survival after first-ever stroke and related prognostic factors in the Perth Community Stroke Study. Stroke 31, 2080–2086 (2000).

    Article  CAS  PubMed  Google Scholar 

  108. Bamford, J., Dennis, M., Sandercock, P., Burn, J. & Warlow, C. 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).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  109. Murray, C. J. & Lopez, A. D. Global Comparative Assessments in the Health Sector: Disease Burden, Expenditures and Intervention Packages (WHO, 1994).

    Google Scholar 

  110. Biswas, M., Sen, S. & Simmons, J. 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).

    Google Scholar 

  111. Ray, B. K. et al. 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).

    Article  PubMed  Google Scholar 

  112. Mateen, F. J., Carone, M., Alam, N., Streatfield, P. K. & Black, R. E. A population-based case–control study of 1250 stroke deaths in rural Bangladesh. Eur. J. Neurol. 19, 999–1006 (2012).

    Article  CAS  PubMed  Google Scholar 

  113. Das, K., Mandal, G. P., Dutta, A. K., Mukherjee, B. & Mukherjee, B. B. Awareness of warning symptoms and risk factors of stroke in the general population and in survivors of stroke. J. Neurosci. 14, 12–16 (2007).

    Google Scholar 

  114. Pandian, J. D. et al. Public awareness of warning symptoms, risk factors, and treatment of stroke in North West India. Stroke 36, 644–648 (2005).

    Article  PubMed  Google Scholar 

  115. Aly, Z. et al. Awareness of stroke risk factors, signs and treatment in a Pakistani population. J. Pak. Med. Assoc. 59, 495–499 (2009).

    PubMed  Google Scholar 

  116. Srivastab, A. K. & Prasad, K. A study of factors delaying hospital arrival of patients with acute stroke. Neurol. India 49, 272–276 (2001).

    Google Scholar 

  117. Wasay, M. et al. Knowledge gaps in stroke care: results of a survey of family physicians in Pakistan. J. Stroke Cerebrovasc. Dis. 20, 282–286 (2011).

    Article  PubMed  Google Scholar 

  118. Prasad, K. et al. Stroke management. Ann. Indian Acad. Neurol. 14 (Suppl. 1), S82–S96 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  119. Kamal, A. K. et al. Ischemic stroke care—official guidelines from the Pakistan Society of Neurology. Pak. J. Neurol. Sci. 5, 38–43 (2010).

    Google Scholar 

  120. Gunaratne, P. S. & Jeevatharan, H. World Stroke Day 2009, gold award winner. Int. J. Stroke 5, 323–324 (2010).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Contributions

All three authors researched the data for the article, provided substantial contributions to discussions of the content, and wrote the article. M.W. reviewed and edited the manuscript before submission.

Corresponding author

Correspondence to Mohammad Wasay.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

PowerPoint slides

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wasay, M., Khatri, I. & Kaul, S. Stroke in South Asian countries. Nat Rev Neurol 10, 135–143 (2014). https://doi.org/10.1038/nrneurol.2014.13

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrneurol.2014.13

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing