Awareness of risk factors and warning symptoms of stroke in general population

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1 Awareness of risk factors and warning symptoms of stroke in general population Monaliza,Meena Aggarwal,Achal Srivastava Abstract : Reduction in the risk of stroke and early admission to the hospital after the onset of stroke both depends on the knowledge of warning symptoms and risk factors of stroke in general public. The aim of the study was to assess the awareness of warning symptoms and risk factors of stroke among general population. A hospital based survey was conducted. The study subjects (N=467) were the general population who visited (neurology, cardiology, surgery and medicine) selected OPD's of AIIMS, New Delhi. The researcher interviewed the subjects using an interview schedule. Results indicate that 96.15% of study subjects had excellent knowledge of warning symptoms of stroke i.e. they knew the most common presentation of stroke (sudden numbness or weakness of the face, arm, or leg especially one side of the body) plus one other well established warning symptom of stroke. On the other hand, 52.87% subjects knew hypertension/ hypercholesterolemia or any other three well established risk factors of stroke. Subjects who were younger in age, more educated and belonged to higher income group had better knowledge of risk factors and warning symptoms of stroke. High risk group, who had the personal history of risk factors, had adequate knowledge of risk factors as well as warning symptoms of stroke. It is recommeded to develop health education programmes to improve the awareness of stroke at primary and secondary health care levels. Key words : Stroke, Warning symptoms, Risk factors Correspondence at : Monaliza, Clinical Instructor, NINE,PGIMER, Chandigarh Introduction Stroke is one of the most common neurological disorders in clinical practice. It is the leading cause of adult disability. According to WHO, it is the second commonest cause of death worldwide 1. In 2005, stroke deaths accounted for 87% of deaths in developing countries and an estimated 5.8 million people died from stroke worldwide 2. It is projected that deaths due to stroke will rise to 6.5 million by 2015 and by , stroke and coronary 149

2 artery disease together are expected to be the leading cause of lost healthy life years. 3 Surveys in different parts of India have shown that the prevalence of stroke varies in different regions of India and ranges from 40 to 270 per 100,000 population. 4-7 Framingham heart study and other international prospective epidemiological studies identified the major risk factors for stroke such as hypertension, diabetes mellitus, hyperlipidemia, and smoking. 8 In India a hospital based case control study in the west central region revealed that diabetes mellitus, hypertension, tobacco and low hemoglobin rather than the cholesterol are the most important risk factors of ischemic stroke. 9 Another community based cross sectional study showed that heart disease, hypertension, and smoking are significantly associated with stroke. 10 Other well established risk factors of stroke includes old age, history or family history of stroke, history or family history transient ischemic attack, heavy alcohol consumption,high fat/high sodium diet consumption and obesity. The population in India is now surviving beyond the peak years (age years) for the risk of stroke.11 With rising trends of hypertension, diabetes, smoking and stress in daily life among Indian population India 4, is likely to face enormous socioeconomic burden to meet the cost of rehabilitation of stroke victims. In India many centers have started recombinant tissue plasminogen activator therapy for treatment of ischemic stroke. The effectiveness and safety of this therapy depends on time of its application and it is generally accepted that patient should receive thrombolysis within 3 hours of the first symptoms 12 but, majority of stroke patients don t reach hospital in time because of inability of patients and by standers to recognize warning symptoms of stroke and to get an emergency room as quickly as possible after patients have had symptoms of stroke. Awareness and knowledge in general population, regarding risk factors and warning symptoms of stroke are essential for the prevention and initiation of immediate effective treatment of stroke. Besides that awareness of risk factors may also improve adherence to medical advice regarding lifestyle modifications. Systematic reviews have shown that one time advice from healthcare workers during routine patient interactions can have an appreciable impact on patient s behavior However, persons at risk often tend to misunderstand their own risk, underestimating their probability for stroke and assuming that adverse events will not happen to them 15.Sama et al.reported about one fourth of patients in their study,who recalled being informed of their increased risk by physician did not perceive themselves to be at risk for stroke. 16 The present study is aimed to evaluate general awareness of risk factors of stroke as well as warning symptoms in general public with a view to develop a heath teaching module for increasing awareness regarding stroke. 150

3 The objectives of the study were: 1. To assess the awareness of risk factors and warning symptoms of stroke in general population. 2. To associate the level of awareness with selected variables. MATERIALS AND METHODS The study was conducted using Quantitative, Cross sectional survey approach. study subjects were conveniently selected from general population visiting selected OPD s (medical, surgical, neurology, cardiology), AIIMS, New Delhi who were having Age = 18 years, willing to participate in the study, can understand Hindi or English.A total 467 subjects were interviewed from selected OPD s i.e.medical (N=124), surgical(n=111), neurology (N=143)and cardiology (N=89). An interview schedule was developed after extensive review of literature and discussion with the experts in neurosciences for collection of data from study subjects regarding their knowledge of stroke warning symptoms and risk factors of stroke. After developing the interview schedule, it was submitted to six experts in the field (four medical and two nursing experts) for content validity. Content validity index was 98.15%. Necessary modifications were made in interview schedule as per the suggestions received from experts. Try out of the interview schedule was done on 12 persons in selected OPD s (medical, surgical, neurology, cardiology) of AIIMS, New Delhi. It was found to be feasible for administration. Reliability of the interview schedule was established by test retest method with a time gap of 3 days on 5 study subjects. The reliability coefficient (Cronbach s Alpha) was found to be The interview schedule was translated into Hindi with the help of experts from Hindi section, AIIMS, New Delhi. Back translation was done to English and desired corrections were made in the Hindi version. The interview schedule consists of 3 components i.e. 1. Demographic data sheet having items dealing with demographic characteristics. 2. Interview schedule to assess knowledge related to warning symptoms and risk factors of stroke. It includes questions related to Risk factors of stroke, Warning symptoms of stroke and Personal history/history of illness of risk factors i.e History of tobacco use, alcoholism, hypertension, diabetes, heart disease, History of stroke/ transient ischemic attack (T.I.A),Family history of stroke/transient ischemic attack (T.I.A),History of hypercholesterolemia. Warning Symptoms refers to the subjective indications of stroke i.e.sudden numbness or weakness of face, arm or leg especially on one side of the body; Sudden confusion, trouble speaking or understanding; Sudden trouble in seeing from one or both eyes; Sudden trouble in walking, dizziness, loss of balance or coordination; Sudden, severe headache with no known cause. Risk factors refers to the established risk factors contributing to the development of stroke including Hypertension, Heart disease, TIA/previous stroke, Family history of stroke, Diabetes mellitus, Tobacco use, 151

4 Heavy alcohol consumption, Hypercholesterolemia Grading of Knowledge of risk factor was done as follows: Very good knowledge: refers to the knowledge of both hypertension and hypercholesterolemia as risk factors of stroke. Good knowledge: refers to the knowledge of either hypertension or hypercholesterolemia, or any other three well established risk factors of stroke. Fair knowledge: refers to the knowledge of any two risk factors of stroke other than hypertension and hypercholesterolemia and Poor knowledge: refers to the knowledge of any one/no risk factor of stroke other than hypertension and hypercholesterolemia. Grading of Knowledge of warning symptoms of stroke was done as follows: Very good knowledge: refers to the knowledge of sudden numbness or weakness of the face, arm or leg especially one side of the body plus any one other warning symptom of stroke. Good knowledge of warning symptoms of stroke: refers to the knowledge of sudden numbness or weakness of the face, arm or leg especially one side of the body as a warning symptom of stroke. Fair knowledge of warning symptoms of stroke: refers to the knowledge of any 2 of the well known warning symptoms except sudden numbness or weakness of the face, arm or leg especially one side of the body. Poor knowledge of warning symptoms of stroke: refers to the knowledge of one / no of the well known warning symptoms except sudden numbness or weakness of the face, arm or leg especially one side of the body. Ethical considerations: Written consent was obtained from study subjects. Ethical clearance was obtained from ethics committee of AIIMS, New Delhi. The confidentiality of every data collected was maintained. Study subjects were interviewed by the researcher. Data was collected for 6 month period.the subjects were enrolled on the bases of inclusion criteria (mentioned earlier).informed consent was taken from the patients or relatives after giving explanation about the study. An interview session took approximately 15 to 20 minutes to elicit the information from study participants. RESULTS Table 1 Depicts that half of study subjects were upto age of years (49.68%) while between age group of years were 41.11% of study subjects. Mean age was ± years and range was years % were males and 37.04% were females. Nearly half (45.82%) of study subjects were having their highest level of education as secondary or senior secondary, only 23.34% were graduates/postgraduates / higher level of education and 16.27% were illiterates. Nearly half( 47.75%)of study subjects were from middle income group i.e. had income between Rs and only % of study subjects were from high income group having income between Rs or above 152

5 Table 1. Demographic distribution of study subjects. N=467 Demographic variables f (% ) Age in years (49.68) (41.11) 60 and above 43 (9.21) Gender Male 294 (62.96) Female 173(37.04) Education Illiterate 76 (16.27) Primary/middle 68 (14.56) Sec./senior sec. 214 (45.83) Grad/p.grad/higher 109 (23.34) Monthly family income in Rupees < (39.19) (47.75) and above 61 (13.06) Mean age ±SDS = ±12.86,.Range years Table 2 depicts the analysis of the sample distribution pertaining to the high risk group. It shows that majority (35.97%) of study subjects had hypertension, % had diabetes, 25.27% were tobacco users, 20.34% had history of Stroke/TIA, % had of Heart diseases, 14.35% had family history of Stroke/TIA, % were alcohol users and 8.78% had history of hypercholesterolemia. Table 2:Presence of risk factors of stroke among the subjects. N=467 Risk factors of stroke present f(%) Hypertension 168 (35.97) Diabetes 131 (28.05) Tobacco users 118 (25.27) History of Stroke/TIA 95 (20.34) Heart diseases 79 (16.92) Family history of Stroke/TIA 67 (14.35) Alcohol use 61 (13.06) History of Hypercholesterolemia 41 (8.78) Subjects had more than one risk factors Table 3 Depicts that hypertension (58.45%) was the most commonly reported risk factor followed by Alcohol consumption (48.82%), tobacco use (48.39%), diabetes mellitus 204 (43.68),family history of stroke (42.61%), TIA/previous stroke (26.98%). Hypercholesterolemia was reported by least (19.27%) study subjects. Other risk factors which were reported by 82.22% of study subjects were High fat, high sodium diet consumption, Obesity,Lack of exercise / sedentary life style, Old age,mental stress, Gender, Risk factors, Polycythemia (raised level of red blood cells in blood),use of contraceptive drugs, bite of snake, winter season, low blood pressure. 153

6 Table3: Knowledge of risk factors of stroke in study subjects. N=467 Risk factors f(%)* 1. Hypertension 273 (58.45) 2. Alcohol consumption 228 (48.82) 3. Tobacco use (smoking or any other form) 226 (48.39) 4. Diabetes mellitus 204 (43.68) 5. Family history of stroke 199 (42.61) 6. Transient ischemic attack(tia)/ previous Stroke 126 (26.98) 7. Heart disease 109 (23.34) 8. Hypercholesterolemia 90 (19.27) 9. Others (High fat/high sodium diet consumption,obesity,lack of exercise 384 (82.22) /sedentary life style, Old age, Mental stress, Gender, Risk factors, Polycythemia (raised level of red blood cells in blood),use of contraceptive drugs, bite of snake, winter season, low blood pressure.) *Multiple responses from study subjects. Table 4 depicts that sudden numbness or weakness of the face, arm or leg, especially on one side of the body was the most common warning sign reported by majority of the study subjects (98.28), followed by sudden confusion /sudden difficulty in speaking/ sudden difficulty in understanding written and spoken words(94.64%), sudden trouble in walking /Sudden dizziness/ Sudden loss of balance or coordination (88.22%),sudden trouble in seeing with one or both eyes(29.12%). Sudden severe headache of unknown cause was reported by least number of study subjects (4.9%) and another 57% reported other signs i.e. unconsciousness, pain in limbs, tremors, difficulty in breathing, difficulty in eating, fever, chest pain, incontinence. Table: 4 Knowledge of warning symptoms of stroke in study subjects. N=467 Risk warning symptoms of stroke f(%)* 1. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body 459(98.28) 2. Sudden confusion /Sudden difficulty in speaking/ Sudden difficulty in 442(94.64) understanding written and spoken words 3. Sudden trouble in walking /Sudden dizziness/ Sudden loss of balance or coordination 412(88.22) 4. Sudden trouble in seeing with one or both eyes 136(29.12) 5. Sudden severe headache with no known cause 23(4.90) 6. Others (Unconsciousness, pain in limbs, tremors, difficulty in breathing, 57(12.20) difficulty in eating, fever, chest pain, incontinence.) *Multiple responses from study subjects. 154

7 Table 5 Depicts the level of awareness of risk factors and warning symptoms of stroke as per the criteria mentioned.it shows that only 15.41% of study subjects had v.good knowledge, 52.89% had good knowledge, 3.63% had fair and 28.47% had poor knowledge regarding risk factors of stroke. It also shows that 96.15% of study subjects had very good, 2.35% had good knowledge and merely 0.64% subjects were having fair, and 0.86% subjects had poor knowledge of warning symptoms of stroke respectively. Table 5: Level of awareness regarding the risk factors and warning symptoms of stroke. N = 467 Knowledge of risk factors and warning signs Knowledge of risk factors f(%) V good 72 (15.41) Good 245 (52.89) fair 17 ( 3.63) poor 133 (28.47) Knowledge of warning symptoms V good 449 (96.15) Good 11 ( 2.35) fair 3 ( 0.64 ) poor 4 ( 0.86) Table 6 reveals the comparison of demographic characteristics and knowledge of risk factors of stroke. It depicts that nearly 50% of subjects in all the three age groups had good knowledge about risk factors of stroke and % of study subjects belonging to age group 60 and above had poor knowledge related to risk factors of stroke. No significant relationship was found between age and knowledge of risk factors of stroke (p=0.276, as per chi square). In comparison of knowledge of risk factors related to gender, it was found that nearly 50% of subjects in both the categories had adequate knowledge and it was not significant (p=0.338, as per chi square) Majority of subjects in each education category had good knowledge of risk factors of stroke but % of study subjects who were illiterate had poor knowledge on the contrary, only 16.51% of the study subjects who were graduates /post graduates/ or higher had poor knowledge of risk factors of stroke. The relationship was found to be significant (p=0.001, as per fisher s exact test) i.e. higher was the education level; better was the knowledge about risk factors of stroke. Majority of study subjects in all the three income groups had good knowledge of risk factors of stroke. The subjects (62.30%). in the high income group income group had more knowledge about risk factors of stroke.a significant relationship was observed (p=0.006,as per fisher s exact test) between monthly income and knowledge of risk factors of stroke i.e. higher the monthly income, better was the knowledge regarding risk factors of stroke. 155

8 Table 6: Comparison of Demographic variables and knowledge about risk factors among study subjects. N=467 Demographic variables Knowledge of Risk factors of stroke P value V.good f(%) Goodf(%) Fairf(%) Poorf(%) (+) chi square, (++) fisher s exact Age in years (13.36) 118 (50.86) 10(4.31) 73 (31.47) (18.75) 106 (55.21) 6(3.13) 44 (22.92) (+) 60 and above 5 (11.63) 21 (48.84) 1 (2.33) 16 (37.21) Gender Male 52 (17.69) 148 (50.34) 11 (3.74) 83 (28.23) female 20 (11.56) 97 (56.07) 6 (3.47) 50 (28.90) (+) Education Illiterate 2 (2.63) 25 (32.89) 3 (3.95) 46 (60.53) 0.001* Primary/middle 5 (7.35) 37 (54.41) 2 (2.94) 24 (35.29) (++) Sec./senior sec. 29 (13.55) 130 (60.75) 10 (4.67) 45 (21.03) Grad/p.grad/higher 36 (33.03) 53 (48.62) 2 (1.83) 18 (16.51) Monthly income in Rupees < (10.93) 92 (50.27) 9 (4.92) 62 (33.88) 0.006* (++) (17.04) 115 (51.57) 5 (2.24) 65 (29.15) and above 14 (22.95) 38 (62.30) 3 (4.92) 6 (9.84) *P value significant at p<0.05 Table 7 shows comparison of knowledge of warning symptoms of stroke according to demographic distribution of study sample. It depicts that that more than 95% study subjects in all the three age groups had excellent knowledge of warning symptoms of stroke so P value was not found to be significant( p=0.750, as per fisher s exact test) In comparison of knowledge about warning symptoms of stroke related to gender more than 95% of both the categories had very good knowledge of warning symptoms of stroke and P value was again not found to be significant (p=0.115,as per fisher s exact test) More than 95% in each education category had very good knowledge of warning symptoms of stroke. A statistically significant relationship was observed between education and knowledge of warning symptoms of stroke (p=0.003) i.e. higher was the education level better was the knowledge about warning symptoms of stroke. 156

9 Table 7: Comparison of Demographic variables and level of knowledge of warning symptom of stroke among study subjects. N=467 Demographic variables Knowledge Warning symptoms of stroke P value V.good f(%) Good f(%) Fair f(%) Poor f(%) (+) chi square, (++) fisher s exact Age in years (96.98) 4 (1.73) 1 (0.43) 2 (0.86) (++) (95.31) 6 (3.13) 1 (0.52) 2 (1.04) 60 and above 41 (95.34) 1 (2.33) 1 (2.33) 0 (0.00) Gender Male 281 (95.58) 9 (3.06) 3 (1.02) 1 (0.34) (++) female 168 (97.11) 2 (1.16) - 3 (1.73) 0.003* (++) Education Illiterate 72 (94.74) (5.26) Primary/middle 64 (94.12) 3 (4.41) 1 (1.47) - Sec/senior sec 208 (97.20) 5 (2.33) 1 (0.47) (++) Grad/p.grad/higher 105 (96.33) 3 (2.75) 1 (0.92) - Monthly income in Rupees < (95.08) 6 (3.28) 1 (0.55) 2 (1.09) (96.86) 3 (1.34) 2 (0.90) 2 (0.90) and above 59 (96.72) 2 (3.28) - - *P value significant at p<0.05 Table 8 Depicts the level of awareness of risk factors in study subjects who had history of any risk factor of stroke,as per the criteria mentioned.it shows that majority of the study subjects who were at high risk (history of tobacco use, alcohol use, hypertension, heart diseases, hypercholesterolemia, history of stroke /TIA, diabetes, family history of stroke /TIA) of getting stroke had adequate knowledge of risk factors of stroke. The study subjects who had hypertension, diabetes, History of stroke / TIA, heart diseases, hypercholes-terolemia, family history of stroke/ TIA had better knowledge of risk factors of stroke and the relationship was found to be significant with p values specified.(chi square test and fisher s exact test) 157

10 Table 8: Comparison of Personal history of risk factors and level knowledge about risk factors of stroke among study subjects. N=467 variables Knowledge of risk factors of stroke P value V. Good f(%) Good f(%) Fair f(%) Poorf(%) (+) chi square, (++) fisher s exact Tobacco use Yes 21 (17.80) 54 (45.76 ) 7 (5.93 ) 36 (30.51) 0.218(+) No 51(14.61) 191(54.73) 10 (2.87 ) 97 (27.79 ) Alcohol use Yes 11 (18.03) 36 (59.02) 3 (4.92) 11 (18.03) 0.274(++) No 61 (15.02) 209 (51.48) 14 (3.45) 122 (30.05) Hypertension Yes 32 (19.05) 94 (55.95) 2 (1.19) 40 (23.81) 0.027*(++) No 40 (13.38) 151(50.50) 15 (5.02) 93(31.10) Diabetes Yes 28 (21.37) 79 (60.31) 4 (3.05) 20 (15.27) 0.001*(++) No 44 (13.10) 166 (49.40) 13 (3.87) 113 (33.63) History of Stroke/TIA Yes 18(18.95) 61 (64.21) 2 (2.11) 14 (14.74) 0.005* (++) No 54(14.52) 184 (49.46) 15 (4.03) 119 (31.99) History of Heart diseases Yes 20(25.32) 42 (53.16) 1 (1.27) 16(20.25) 0.020* (++) No 52 (13.40) 203 (52.32) 16 (4.12) 117 (30.15) History of Hypercholesterolemia Yes 13 (31.71) 21 (51.22) 0( 0.00) 7 (17.07) 0.010* (++) No 59 (13.85) 224 (52.58) 17 (3.99) 126 (29.58) Family history of Stroke/TIA Yes 13 (19.40) 45 (67.16) 0 (0.00) 9 (13.43) 0.004* (++) No 59 (14.75) 200 (50.00) 17 (4.25) 124 (31.00) *p significant at p<0.5 DISCUSSION Stroke continues to be a leading cause of death and long term disability in adults worldwide. In India and other developing countries, an alarming increase in the incidence of stroke has been observed owing to an increase in life span with rising trends of hypertension, diabetes, smoking and stress in daily life 17. Previous studies have shown a poor knowledge of stroke among patients 158

11 with established risk factors for stroke and in community at large Most of the patients and caregivers did not recognize the onset of stroke and their knowledge of risk factors was poor 21. Awareness of risk factors and warning symptoms of stroke in general population is essential for prevention and initiation of prompt treatment. The major findings of the present study revealed that majority of study subjects had very good knowledge of warning symptoms of stroke (>95%) and nearly 50% were well informed of risk factors of stroke. These findings from present study were similar to the findings from Pandian JD et al. (2005) 22 who, in a hospital based survey among relatives of outpatients found better knowledge about risk factors and warning symptoms of stroke. These findings from the present study may be biased because the survey was conducted among the subjects who visited hospital, as they come to hospital they gain some knowledge about disease entity and hence were well informed The findings of the present study showed that younger age and higher level of education were associated with better knowledge about risk factors and warning symptoms of stroke. This finding is similar to the findings from few western studies by Pancioli AM et al.(1998) 18 and Yoon SS et al.(2001) 19 in which it was found that knowledge about stroke varies positively with education and age. Under the present study in relation to gender the knowledge about risk factors and warning symptoms of stroke was found to be equally distributed among both the genders. This finding is in contrast with the finding by Pancoili AM et al.(1998) 18 and Yoons SS et al.(2001) 19 who found lower knowledge among men than women. In the present study, it was found that higher was the economic status better was the knowledge of subjects related to risk factors and warning symptoms of stroke. This finding could be because the higher socioeconomic status subjects often have better education background hence were well informed about risk factors and warning symptoms of stroke. This finding is consistent with the findings from Pandian JD et al. (2005) 22 who also found better awareness of risk factors (65.1%) and warning symptoms (81.3%) of stroke among higher income group respondents. In this survey majority of (98.28%) study subjects mentioned weakness and paralysis of one side of body as most common presentation of stroke. Similarly, Pandian JD et al. (2005) 22 found the most common (62.2%) symptom identified by respondents was weakness of one side of body. Kothari et al.(1997) 23 in a study of patients with acute stroke also reported that most commonly documented stroke warning sign was weakness of one side of body. In the present study, other well known symptoms were less frequently recognized by the subjects. This finding is consistent with the finding of other studies conducted in India 22, Australia 19, and US

12 Hypertension(58.20%) is recognized as the most common risk factor in this study This finding is similar to the observation made in other studies from India(45.1%) 22, Michigan (32.3%) 24, Australia (31.8%) 19 and Ohio (49%) 18. On the contrary, in this study the proportion of subject, who mentioned other established risk factors such as diabetes mellitus,heart disease, increased cholesterol were higher as compared to the other community based studies 22,19 Yoon SS et al.(2001) 19 and Pandian JD et al.(2005) 22 reported that the awareness of risk factors in high risk individuals was poor and did not differ significantly from those who had no risk factors. But in the present study 52.89% of study subjects have good knowledge regarding risk factors of stroke and 28.49% of study subjects have poor knowledge of risk factors and the knowledge of risk factors in high risk group was found to be adequate in this study and this finding is consistent with Gupta et al. (2000) 25 who reported that 65% of elderly patients who comprises high risk group for stroke, in their study correctly identified at least one risk factor for stroke. The survey reveals good knowledge of stroke risk factors and warning symptoms of stroke among majority of study subjects. Younger persons with higher levels of education and higher income group subjects have more knowledge about risk factors and warning symptoms of stroke. High risk group, who has the personal history of risk factors, has good knowledge of risk factors as well as warning symptoms of stroke. There is a need to develop health education modules, programs to improve the awareness of stroke both at primary and secondary health care levels. It is recommended that a similar study on larger sample can be replicated so that the findings can be generalized and future studies are needed which focus on community surveys including rural and urban population especially focusing on indigenous treatment and myths about stroke and its potential complications. References 1 Bonita R,Mendis S,Truesen T.The global stroke initiative.lancet Neurol 2004;3: Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the world. Lancet Neurol 2007;6: WHO.The world health report 2000: health system improving performance.geneva: WHO, Anand K,Chowdhury D, Singh KB, Pandav CS,Kapoor SK.Estimation of mortality and morbidity due to stroke in India.Neuroepidemiology 200l;20: Dhamija RK, Dhamija SB. Prevalence of stroke in rural community: an overview of Indian experience. J Assoc Physicians India1998;46: Banerjee TK, Mukerjee CS, Sarkhel A. Stroke in the urban population of calcutta an epidemiological study. Neuroepidemiology 2001;20: Razdan S, Koul RL, Motta A, Kaul S. Cerebrovascular disease in rural Kashmir, India. Stroke 1989;20: Wolf PA. MohrJP, Choi DW,Grotta JC, Weir B, Wolf PA, Epidemiology of stroke:stroke Pathophysiology,Diagnosis, and management. Philadelphia: Churchill Livingstone 2004;

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