Stroke is a major cause of death and disability globally and causes a significant burden in Asia. Stroke in Asia has unique epidemiological features which differ from other parts of the world, and this includes the younger stroke population [1, 2]. In addition, recent advances in endovascular therapy for acute stroke have changed the practice of stroke worldwide. There is concomitant rapid adoption of advanced multimodal imaging and interventional treatment particularly in major urban stroke centres [3, 4].
It is with this background that the preparation of this supplement was conceived, mainly to illustrate instructional points observed in the common and uncommon cases of stroke encountered in Asia. The collation of these cases was the result of the collective effort of stroke neurologists based in Asia who are members of the Asian Stroke Advisory Panel (ASAP). The key objectives of this group are to promote stroke education across Asia and to conduct international collaborative research. In the context of this journal supplement, an aphorism from generations of neurology educators comes to mind: ‘Strokes are best learnt case by case and stroke by stroke.’ It is our hope that the same spirit is captured in this body of work. These well-described cases have been presented and arranged according to presentation, diagnosis, aetiology and treatment modalities.
The first section consists of cases of acute ischaemic stroke and cerebral venous thrombosis, illustrated within the context of the new endovascular treatment and imaging paradigms in selected patients [3, 4]. The second section describes various cases of complications from external head and neck irradiation. These complications result in carotid and intracranial vasculopathy [5, 6] as well as optic neuropathy, responsive to anticoagulation. Management of these cases is common in Asia due to the high rates of nasopharyngeal carcinoma and radiotherapy.
The subsequent section describes the versatile role of transcranial Doppler ultrasound in well recognized clinical conditions such as monitoring arterial vasospasm after aneurysmal subarachnoid haemorrhage as well as in less common situations, i.e. vasculopathy in bacterial meningitis, cerebral haemodynamics in decompressive craniectomy and in evaluating cerebrovascular reserve in intracranial dissection. In cases related to subarachnoid haemorrhages, a ruptured spinal artery aneurysm proved to be a difficult diagnostic challenge for the clinician while issues of aneurysm size may be important but often underestimated in predicting the risk of rupture.
Moya-moya disease and its management is a more prevalent problem observed in Asia, particularly within the Far East region, while large vessel non-atherosclerotic arteriopathy including carotid dissection remains a diagnosis to consider in various clinical settings. Small vessel disease such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy can co-exist in the presence of conventional risk factors, while an unusual case of cerebral amyloid angiopathy and its long-term outcome have also been included. In Asia, herbal remedies often used as part of traditional and complementary medicine may have a role in enhancing recovery from intracerebral haemorrhage.
Unusual stroke cases involving the heart-brain axis with complications from adenocarcinoma of the cervix, cardiac myxoma with aneurysm formation and stroke related to chemotherapy complete our collection of submitted cases.
We hope that these case reports will provide valuable insights into stroke in Asia.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
This journal supplement was funded by an unrestricted educational grant from Moleac.
Author Contributions
K.S.T. completed the first draft of the paper and approved the final manuscript. N.V. reviewed the paper for content, provided critical feedback and approved the manuscript.
References
- 1.Venketasubramanian N, Yoon BW, Pandian J, Navarro JC. Stroke Epidemiology in South, East, and South-East Asia: A Review. J Stroke. 2017 Sep;19((3)):286–94. doi: 10.5853/jos.2017.00234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ekker MS, Boot EM, Singhal AB, Tan KS, Debette S, Tuladhar AM, et al. Epidemiology, aetiology, and management of ischaemic stroke in young adults. Lancet Neurol. 2018 Sep;17((9)):790–801. doi: 10.1016/S1474-4422(18)30233-3. [DOI] [PubMed] [Google Scholar]
- 3.Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. HERMES collaborators Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016 Apr;387((10029)):1723–31. doi: 10.1016/S0140-6736(16)00163-X. [DOI] [PubMed] [Google Scholar]
- 4.Lee SK, Mokin M, Hetts SW, Fifi JT, Bousser MG, Fraser JF, Society of NeuroInterventional Surgery Current endovascular strategies for cerebral venous thrombosis: report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg. 2018 Aug;10((8)):803–10. doi: 10.1136/neurintsurg-2018-013973. [DOI] [PubMed] [Google Scholar]
- 5.Liao W, Zheng Y, Bi S, Zhang B, Xiong Y, Li Y, et al. Carotid stenosis prevalence after radiotherapy in nasopharyngeal carcinoma: A meta-analysis. Radiother Oncol. 2019 Apr;133:167–75. doi: 10.1016/j.radonc.2018.11.013. [DOI] [PubMed] [Google Scholar]
- 6.Langendijk JA, Doornaert P, Verdonck-de Leeuw IM, Leemans CR, Aaronson NK, Slotman BJ. Impact of late treatment-related toxicity on quality of life among patients with head and neck cancer treated with radiotherapy. J Clin Oncol. 2008 Aug;26((22)):3770–6. doi: 10.1200/JCO.2007.14.6647. [DOI] [PubMed] [Google Scholar]