Do outcomes differ between ischemic and hemorrhagic stroke survivors?

Stroke is the fourth leading cause of death and the fifth leading cause of disability in India.^[1] The prevalence of stroke in India ranges from 44 to 459/100,000 population.^[2]This may be an underestimate of total stroke burden due to limited national stroke registries and underreporting of many cases. In India, approximately 10–14% of strokes occur in individuals under the age of 40 years.^[3] Compared to Western countries, Indians develop stroke 10–15 years earlier on average, making it a major cause of disability in the economically productive population.

Outcome measures used to assess recovery and disability in stroke include the modified Rankin scale (mRS), the Barthel index (BI), and the stroke-specific quality of life scale. Mini-Mental State Examination and Montreal Cognitive Assessment are used for testing cognition and psychological outcomes. The mRS is a simple and widely accepted tool; however, it has several disadvantages, such as interobserver variability, broad categories, and a primary focus on physical disability. The BI is limited in that it measures only basic physical functions and ignores cognitive function, fine motor skills, nd speech problems.^[4,5]

In this context, the study by Varghese et al.,^[6] published in the current issue of The Journal of Neurosciences in Rural Practice used the stroke impact assessment questionnaire (SIAQ) as an outcome scale. The authors included stroke survivors from a tertiary care hospital and found that outcomes measured by mRS and SIAQ were similar in both ischemic stroke and hemorrhagic stroke patients. The SIAQ consists of eight domains: cognition, communication, sensory, motor, behavioral, emotional, social, and economic. It is a comprehensive tool that not only measures motor disability but also considers family and community support, cognition, and economic factors. It includes items appropriate to the sociocultural context of South Asian countries. Although it has been validated by Sasikumar et al.,^[7] it has not been tested in stroke survivors over the age of 65 years.

In the study by Varghese et al., the mean age of patients was 60.37 (standard deviation 11.28), and 62.5% of ischemic stroke patients were ≥60 years.^[6] The use of SIAQ in patients above 65 years is therefore a limitation of this study. In addition, as a comprehensive tool, SIAQ takes more time to administer, which may limit its use in routine clinical settings.

Second, the majority of patients had ischemic stroke (86.2%), while only 13.8% had hemorrhagic stroke. Although the authors used analysis of covariance and non-parametric tests to minimize bias from unequal group sizes, this remains an important limitation of the study.

In hemorrhagic stroke, there is higher early mortality due to mass effect and raised intracranial pressure. However, patients who survive the acute phase may have functional outcomes comparable to or sometimes better than ischemic stroke survivors.^[8] In ischemic stroke, there is lower early mortality compared to hemorrhagic stroke; however, long-term disability varies widely and depends on several factors such as infarct characteristics, collateral circulation, and timely reperfusion therapy (thrombolysis or thrombectomy).^[8] Thrombolysis and endovascular therapy have revolutionized the management of ischemic stroke, and outcomes depend heavily on whether patients receive these interventions. In this study, such data were unavailable, limiting the comparison between ischemic and hemorrhagic stroke survivors.

Despite these limitations, the results reflect real-world scenarios and may serve as a basis for further hypothesis generation. The lack of significant association observed could be due to the limitations alluded to by the authors in the study. Separate analysis of ischemic stroke and hemorrhagic stroke survivors may be useful to account for differences in pathophysiology and treatment inherent to the stroke type.