Abstract
Background
With an increasing burden of stroke, it is essential to minimize the incidence of stroke and improve stroke care by emphasizing areas that bring out the maximum impact. The care situation remains unclear in the absence of a national stroke care registry and a lack of structured hospital-based data monitoring. We conducted this systematic review and meta-analysis to assess the status of stroke care in Nepal and identify areas that need dedicated improvement in stroke care.
Methods
A systematic literature review was conducted to identify all studies on stroke epidemiology or stroke care published between 2000 and 2020 in Nepal. Data analysis was done with Statistical Package for Social Sciences (SPSS) and Comprehensive Meta-analysis (CMA-3).
Results
We identified 2533 studies after database searching, and 55 were included in quantitative and narrative synthesis. All analyses were done in tertiary care settings in densely populated central parts of Nepal. Ischemic stroke was more frequent (70.87%) than hemorrhagic (26.79%), and the mean age of stroke patients was 62,9 years. Mortality occurred in 16.9% (13-21.7%), thrombolysis was performed in 2.39% of patients, and no studies described thrombectomy or stroke unit care.
Conclusion
The provision of stroke care in Nepal needs to catch up to international standards, and our systematic review demonstrated the need to improve access to quality stroke care. Dedicated studies on establishing stroke care units, prevention, rehabilitation, and studies on lower levels of care or remote regions are required.
Similar content being viewed by others
Explore related subjects
Find the latest articles, discoveries, and news in related topics.Background
Stroke has become a critical global public health challenge requiring prompt and effective intervention. In particular,12.2 million new cases, 101 million prevalent cases, and 6.55 million stroke-related deaths were reported [1]. The data show a remarkable increase in stroke incidence and mortality rates from 1990 to 2019, with a 70% rise in stroke incidence and a 43% rise in stroke-related deaths [1].
The situation of stroke in Asian countries is not different from the global scenario. The reported incidence of stroke in Asia ranges from 116 to 483 per 100,000 per year [2,3,4]. Furthermore, evidence suggests that South Asians have a twofold higher risk of getting a stroke than Europeans due to the higher prevalence of dyslipidemia, diabetes mellitus, and central obesity [5, 6]. Nepal, a South Asian country with a population of 29 million, has reported a relatively high crude and age-standardized prevalence of stroke in the southwestern region in 2018, with rates of 2368 and 2967 per 100,000 population, respectively [7]. However, this data only represents a specific region and may not be generalizable to the Nepalese context [2].
Improving stroke care demands reliable data on stroke epidemiology, risk factors, treatment, and outcomes. However, such data are not available for Nepal. Therefore, this systematic review aims to fill this knowledge gap by exploring stroke studies conducted in the Nepalese population regarding stroke epidemiology, risk factors, treatment, and outcomes. This review will help to identify the needs in stroke care in Nepal.
Methods
This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The study protocol was registered in PROSPERO [8] prior to the conduct of the review.
Selection of studies
Inclusion criteria
We included studies published in English between January 1, 2000, and January 1, 2021, reporting empirical data (quantitative, qualitative) obtained in Nepal. Studies were included if participants had a confirmed stroke diagnosis and were at least 18 years of age. (REF: Sacco L et al., Stroke, 2013) or TIA (REF: Easton et al., Stroke, 2009) and reported on incidence, epidemiology, risk factors, etiology, stroke outcome, or stroke treatment (e.g., diagnosis, acute and post-acute care, rehabilitation, financing of stroke care, complications of stroke).
Exclusion criteria
We excluded articles that could not be classified as empirical literature (e.g., commentaries, discussion papers, journalistic interviews, policy reports), reviews, studies on stroke mimics (e.g., migraine), and studies on mixed populations (e.g., South Asians) unless separate results for people with stroke in Nepal could be isolated. Studies reporting on adults < 18 years were excluded.
Search strategy
The study followed the “Cochrane Guidelines for Systematic Reviews of Health Promotion and Public Health Interventions” in designing the search strategy. PubMed, Ovid, Cochrane Library, Web of Science, and clinicaltrials.org were searched for English-language articles published between 2000 and 2020. Google and Google Scholar identified grey literature not indexed in academic databases was identified. The search terms and keywords related to stroke, knowledge, epidemiology, and treatment. The ‘Appendix 1 Search strategy’ contains the detailed search strategy. Additionally, the reference lists of included papers were screened.
Study selection
Study selection was performed by (1) independent screening of titles and abstracts (RP, CT), and (2) Independent screening of full texts of all hits judged suitable in the first step (RP, CT). Discrepant ratings were discussed and agreed upon in consensus meetings (AC, BPG, LT, and PJ). Specificity (proportion of suitable articles in all hits) and sensitivity (proportion of suitable articles in all correct positives) were calculated as quality criteria for the search strategy based on a predefined test set. Subsequently, studies on stroke awareness were excluded to keep the review topic specific to stroke care.
Data extraction, synthesis, and analysis
A data extraction form was designed, including author, year, study title, sample characteristics, stroke prevalence, incidence, etiology, risk factors, treatment (recanalization therapy, length of hospital stay), mortality, complications, outcome, and diagnostic findings. The included articles were extracted by AA, KB, SA, and PJ and checked by RP and CT. Given the significant heterogeneity of the included studies, a narrative data synthesis was performed. The heterogeneity of the studies was calculated using the I2 statistics; for I2 ≤ 50, a fixed effects model was used. For I2 > 50, the random effects model was used and represented using forest plots with CMA-3 for meta-analysis and SPSS 22 for descriptive analysis. The quality of the included studies was assessed using the Oxford Centre of Evidence-Based Medicine: Level of Evidence (March 2009) [9].
Results
Study selection
A total of 2533 studies were identified, and 141 duplicates were removed. The title and abstracts of 1250 studies were screened, and 1100 studies were excluded. Full texts of 150 studies were assessed, and 95 studies were excluded for definite reasons. A total of 55 studies were included in this systematic review (Fig. 1). Specificity was 3.9%, and sensitivity was 100%.
Study characteristics
Among the 55 included quantitative studies on stroke patients in Nepal, 19 were cross-sectional studies [10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28], 17 were retrospective [29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45], and 17 were prospective cohort studies [46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62]. Two case-control studies were present [63, 64], while no randomized trials were found. The sample size of quantitative studies ranged from nine to 1017 participants. Studies were mainly published in national journals (n = 48) [10,11,12,13,14,15,16,17,18,19,20,21, 23,24,25,26,27,28,29,30,31,32,33,34,35, 37, 39, 41,42,43, 45,46,47,48,49,50,51,52,53,54,55,56, 58,59,60, 63, 64], and only seven studies were published in international journals [22, 36, 40, 44, 57, 61, 62].
Study population
Thirty-four studies reported the mean age of the patient population [10, 12,13,14, 19,20,21,22,23, 26,27,28, 30, 31, 33, 36,37,38,39,40,41, 45, 48, 50,51,52,53, 56, 57, 59, 60, 62,63,64]. As indicated in Table 1, the pooled mean age was 62.4 years, ranging from 51.9 [38] to 70.5 years [18]. From 46 studies reporting data on sex distribution, 44 studies showed a higher percentage of stroke in males [10, 12,13,14, 16, 19,20,21, 23,24,25,26,27,28, 30,31,32,33, 35,36,37,38,39,40,41, 43,44,45, 47,48,49,50,51, 53,54,55,56,57,58,59, 61,62,63,64] (Table 1).
Study settings and location
All 55 studies were hospital-based and were conducted in the tertiary health sector. Of the 55 studies in stroke patients, majority (n = 26) were done in Kathmandu valley [12, 13, 15, 16, 19, 22, 27,28,29, 31, 33, 34, 41,42,43,44,45, 49,50,51,52, 54, 55, 59, 61, 64], followed by Sunsari (n = 7) [18, 30, 40, 53, 56, 60, 63], Chitwan (n = 6) [21, 25, 26, 47, 48, 57] and Morang (n = 6) [24, 32, 36, 46, 58, 62], which represent Central and Eastern region of Nepal. Only three studies were done in Nepalgunj, the Mid-western part of Nepal [11, 23, 39]. The location of each study within Nepal is presented in Table 2 and represented in Fig. 2.
Outcome parameters
The details of the outcome parameters are presented in Table 2 under the main focus area. Fifty studies reported on the types of strokes [10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62, 64], and 44 studies investigated risk factors in stroke patients [10, 12,13,14, 16, 18,19,20,21,22,23,24,25,26, 28, 30,31,32,33, 35,36,37, 39,40,41, 43,44,45, 47,48,49,50,51,52,53,54, 56,57,58,59, 61,62,63,64]. Six studies described using CT scan [10, 11, 18, 28, 47, 53]. Three studies described the use of carotid Doppler in ischemic stroke [58,59,60]. From 23 studies investigating aspects of acute care [13, 30, 40, 49], four studies consisted of data on length of hospital stay [13, 30, 40, 49], four studies highlighted complications [13, 16, 30, 48], and 19 studies reported mortality [11, 17, 21, 26, 29, 30, 32, 34, 36, 38, 40, 41, 45, 48, 51, 52, 56, 57, 62]. 12 studies included treatment modalities [21, 31, 32, 36, 38, 42,43,44,45, 48, 57, 61] [42, 44, 61].The outcome of stroke was described in 22 studies [11, 17, 21, 26, 29, 30, 32,33,34, 36, 38, 40, 41, 43,44,45, 48, 51, 52, 56, 57, 62], and the long-term outcome (3 months after stroke) was investigated only in seven studies [21, 38, 43,44,45, 51, 57]. The outcome parameters of the studies have been depicted in Fig. 3.
Types of strokes
Fifty-Four studies reported on the types of strokes [10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62, 64]. Pooled data showed ischemic stroke in 70.87% and hemorrhagic in 26.79%. The transient ischemic attack was reported only in 0.66% of patients (Table 1).
Risk factors
Of 44 studies reporting risk factors in stroke patients [10, 12,13,14, 16, 18,19,20,21,22,23,24,25,26, 28, 30,31,32,33, 35,36,37, 39,40,41, 43,44,45, 47,48,49,50,51,52,53,54, 56,57,58,59, 61,62,63,64], pooled data showed hypertension as the most prevalent comorbidity in 50.61% of patients, followed by history of smoking (38.65%), significant alcohol intake (27.31%), diabetes (17.39%), dyslipidemia (8.59%) and atrial fibrillation (5.87%) (refer to Table 2 for more details). Other socio-economic data of patients, like ethnicity and profession, is included in ‘Appendix 3 Education, ethnicity, and job of study participants’.
Carotid doppler findings
Three studies reported on carotid Doppler findings in ischemic stroke patients [58,59,60], where 70.78% of 178 patients were found to have plaque and 18.5% had 50–99% occlusion of the carotid artery.
Acute and post-acute care
Data on stroke care was reported in 12 studies [13, 29, 30, 40, 48, 49], and intravenous thrombolysis (IVT) was used in 2.39% of patients [42, 44, 61], and no studies reported on endovascular thrombectomy (EVT). While no study reported on stroke unit care, the mean length of hospital stay was 6.1 days [13, 30, 40, 49]. Five studies reported the use of Aspirin with the use of Aspirin in 83.30% of patients [21, 31, 48, 57, 61]. Surgery (for hemorrhagic stroke or malignant MCA infarct) was done in 14.38% of patients.
Disability/functional outcomes
From 13 studies reporting on the disability and functional outcome of stroke patients, ten studies used the modified Rankin scale (mRS) [13, 21, 35, 43,44,45, 50, 51, 56, 57], two studies used the Glasgow outcome scale [32, 36] and one used WHO disability assessment schedule [27]. Assessment time ranged from discharge to 6 months. Most patients had mRS 3 [21, 50], and the mean average mRS ranged from 2.66 to 3.48 [50, 51]. Table 3 presents the disability and functional outcomes of 13 studies.
Mortality
Mortality was reported in 19 studies [11, 17, 21, 26, 29, 30, 32, 34, 36, 38, 40, 41, 45, 48, 51, 52, 56, 57, 62]. Maximum mortality at three months was found in a study by Shrestha S et al. (28.57%), while at six months, mortality was high in a study by Nepal PR et al. (58.8%) [38, 57]. The meta-analysis showed mortality in 16.9% of patients (proportion 0.169, 95% CI: 0.130–0.217, I2: 88%) (see Fig. 4). Funnel plot examination and Egger’s test (P = 0.25) showed no publication bias (Fig. 5). Sensitivity analysis performed, excluding one study, did not show much change in the mortality rate. (Appendix 2 Sensitivity analysis)
Cost
No studies reported on the cost of stroke care or cost-effectiveness.
Complications
Four studies had data on the complications in stroke patients [13, 16, 30, 48] with the most common complication reported being pneumonia in 18.8% of patients (I2: 13.13), urinary tract infections (UTI) in 7% (I2: 9.24), seizures in 4.3%, and bedsores in 8% of patients. Falls, fever, and deep vein thrombosis were other reported complications (see Fig. 6).
Quality assessment
Of the 55 studies on stroke patients, 20 were classified as having a high level of evidence (LOE 2) [19, 21,22,23,24, 27, 29, 30, 32, 35, 36, 38, 40,41,42,43,44,45, 53, 61]. Only eight studies were rated as the highest level of evidence (LOE 1) [17, 26, 46, 51, 52, 55,56,57]. The vast majority of studies were found to have a low level of evidence (n = 27) [10,11,12,13,14,15,16, 18, 20, 25, 28, 31, 33, 34, 37, 39, 47,48,49,50, 54, 58,59,60, 62,63,64].
Discussion
Our study is the first systematic literature review to describe the overall picture of stroke patients and stroke care in Nepal and to analyze which aspects of stroke care have been scientifically investigated, what is known from these research results, and where there is an unmet need in research.
Despite a comprehensive search strategy, we identified only 55 studies conducted in Nepal within the last 20 years and analyzed stroke outcomes or aspects of care. The low quantity of studies weighs even more seriously because half of the studies are also of low quality, and there has yet to be a randomized controlled trial (RCT) on stroke care in Nepal. Therefore, the most urgent implication of our work is that more high-quality research is needed.
Most studies were conducted in densely populated areas in central Nepal, with better health infrastructures than in western regions. The studies were all done in tertiary care and teaching facilities and hence may not represent the situation for stroke patients in remote areas or at lower levels of care but rather overestimate the level of stroke care in Nepal. However, as with other diseases, patients from rural communities are referred to tertiary care centers for treatment, and the study population can be said to comprise patients from rural parts of the country. Hence, we need dedicated studies to get an accurate picture of the rural parts of the country. It is even more alarming that even in this setting, no stroke units are described, and the rate of thrombolysis is below 2.5%, so we must assume a thrombolysis rate of less than 1% for Nepal. As IVT, EVT, and stroke unit care are the mainstay of acute therapy in ischemic stroke [65], our systematic review emphasizes the need for dedicated and organized stroke care to improve the country’s overall picture of stroke care.
The mean age of stroke presentation varied from 68.6 years in men to 72.9 years in women [66]. The pooled results in our study showed a mean age of 62.4 years, which is younger than the global average; 63.1 in low-middle income country (LMIC) vs. 68.6 in high-income countries (HIC), which might be attributed to limited stroke care quality and accessibility [67]. Our study showed more men than women suffering from stroke. A systematic review done in 19 countries by Appelros et al. showed stroke incidence to be 30% higher in men than women and 41% more prevalent in men than women [66]. Further research is necessary to understand if this gender gap is caused by a reduced incidence of stroke in women or restricted access to care.
Our review highlighted a high prevalence of preventable risk factors in stroke patients, aligning with other studies’ findings [1, 68,69,70]. Policymakers should focus on preventing noncommunicable diseases through effective primordial, primary, and secondary prevention strategies [71] and adapt WHO strategies (e.g., Tobacco Control Convention) to meet the needs of Nepal.
The unavailability of stroke units is all the more detrimental because the long-term outcome of stroke can be significantly improved by preventing complications and recurrent stroke, which usually happens in a stroke unit. Pneumonia and UTI were common post-stroke infections (18.8 and 7% of patients) associated with more extended hospital stays. This data is similar to other studies showing UTI and pneumonia as the most common complications [72, 73]. As only four studies reported complications, our pooled data may not accurately portray the country’s real scenario, and more focused studies on post-stroke complications are required. Stroke recurrence is common, especially in large artery atherosclerosis and cardioembolic stroke. While we found a high rate of carotid plaque, only 3% of reported patients had atrial fibrillation, which might be due to insufficient detection methods. Studies on the prevention of complications, secondary prevention, and long-term functional outcome are scarce in Nepal [74].
The economic burden of stroke for an LMIC like Nepal cannot be overstated. The use of thrombolysis treatment ($1390) is expensive, especially under consideration of the annual per capita gross domestic product (GDP) of the country ($1208.22) [75, 76]. In addition, the loss of active earnings by stroke patients’ family members, costs of rehabilitation, and nursing care might even exceed the costs of acute treatment [77]. Hence, cost-effectiveness studies will be crucial to evaluating the direct and indirect costs of stroke care. Further, LMICs like Nepal need to focus more on preventing stroke and imparting knowledge to stroke patients’ families, which can assist significantly in minimizing overall stroke care costs.
Strengths and limitations
As the first study of its type, this is a milestone in stroke care in Nepal, especially in the absence of a population-based or hospital-based national stroke registry. However, our review has some limitations. We only included the articles in English and could not retrieve some full-text articles. We have also likely not identified all relevant articles published in non-indexed journals. Also, most of the studies included in our review were observational and were of low level of evidence as per Oxford grading. We, therefore, highlight the need to allocate more resources for research and access to publication in international journals for scientists from LMICs.
Conclusion
Without a national stroke registry, our systematic literature review will be highly relevant to Nepal’s medical community and policymakers. We observed the demographics of stroke patients to be similar to those from other regions, but the provision of stroke care needs to catch up to international standards. Based on the available literature, we highly recommend conducting more high-quality research in Nepal, especially in rural settings outside Kathmandu. Our systematic review emphasizes the absence of structured stroke care in Nepal and the urgent need to improve access to quality stroke care. Hence, with the collaboration of the medical fraternity, local bodies, and government, we must establish stroke care units, educate community members and caregivers, and adapt WHO-tested disease prevention models.
Data Availability
All data generated or analyzed during this study are included in this published article and its supplementary information files.
References
Feigin VL, Stark BA, Johnson CO, Roth GA, Bisignano C, Abady GG, Abbasifard M, Abbasi-Kangevari M, Abd-Allah F, Abedi V. Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the global burden of Disease Study 2019. Lancet Neurol. 2021;20:795–820.
Johnson W, Onuma O, Owolabi M, Sachdev S. Stroke: a global response is needed. Bull World Health Organ. 2016;94:634.
Abduboriyevna RK, Yusufjonovich NS. Stroke burden in Asia: to the epidemiology in Uzbekistan, Eur Sci Rev. (2018) 156–61.
Suwanwela NC, Poungvarin N. Stroke burden and stroke care system in Asia. Neurol India. 2016;64:46.
Venketasubramanian N, Yoon BW, Pandian J, Navarro JC. Stroke epidemiology in south, east, and south-east Asia: a review. J Stroke. 2017;19:286.
Kario K. Key points of the 2019 japanese society of hypertension guidelines for the management of hypertension. Korean Circ J. 2019;49:1123–35.
Thapa L, Shrestha S, Kandu R, Ghimire MR, Ghimire S, Chaudhary NK, Pahari B, Bhattarai S, Kharel G, Paudel R. Prevalence of stroke and stroke risk factors in a southwestern community of Nepal. J Stroke Cerebrovasc Dis. 2021;30:105716.
Schneider C, Paudel R, Gajurel BP, Pokharel BR. Christoph Gumbinger. Stroke and stroke care in Nepal: protocol for a systematic review and evidence mapping of empirical studies. PROSPERO 2021 CRD42021226389, (n.d.). https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021226389.
Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A. OCEBM levels of evidence, Centre for evidence-based medicine, Www Cebm Net (2009).
Acharya S, Tiwari A, Shakya RP. Clinico-radiological Profile of Stroke in Western Nepal. J Lumbini Med Coll. 2016;4:60–3.
Acharya S, Chaturvedi SK. Significance of computed tomography in the diagnosis of cerebrovascular accidents. J Lumbini Med Coll. 2014;2:18–20.
Bhatt VR, Parajuli N, Sigdel NRMS, Aryal M, Khanal NHS, Koirala S, Giri S. Risk factors of stroke, J Inst Med 31 (2009).
Dhungana K, Shakya D, Shrestha R, Bhatta S, Maharjan S. Medical complications during inpatient rehabilitation in patients with ischemic stroke in a tertiary care hospital in Nepal, J Kathmandu Med Coll. (2019) 162–6.
BasantaGautam MD, Shrestha TM, BikashShrestha MD. Distinguishing Non-Hemorrhagic From Hemorrhagic Stroke In Rural Nepal Setting Using The Besson Score, (n.d.).
Jha R, Shrestha T, Aacharya R. Association of Microalbuminuria with recent ischemic stroke. Nepal Med J. 2018;1:47–50. https://doi.org/10.37080/nmj.15.
Karn R, Tharu B, Basnet S, Subedi K. Determinants of Fever in Acute Stroke Patients. Nepal J Neurosci. 2015;12:20–5.
Keyal NK, Nepal PR, Tamrakar K, Bhattarai R, Thapa DK, Chaurasiya RK. A prospective study on the Outcome of Semi-Closed Neurointensive Care in a Tertiary Care Hospital located in a rural area of Eastern Nepal: a Lower-Income developing Country. East Green Neurosurg. 2020;2:7–13.
Kumari S, Rai BK, Bhandari R, Gupta SN, Ahmed K. Computerized tomography of the Brain for Elderly Patients presenting to the emergency room with Acute confusion state in Eastern Nepal. J BP Koirala Inst Health Sci. 2018;1:95–100.
Luitel R, Dhital S, Paudel SS, Bhattarai S. Socio-demographic characteristics of ischemic stroke patients in a tertiary care hospital of Nepal. J Brain Spine Foundation Nepal. 2020;1:16–9.
Maskey A, Parajuli M, Kohli SC. A study of risk factors of stroke in patients admitted in Manipal Teaching Hospital, Pokhara. Kathmandu Univ Med J. 2011;9:244–7.
Poudel RS, Thapa L, Shrestha S, Khatiwada D, Upadhyay N, Bhandari TR, Shrestha A. Efficacy of combined antithrombotic, Statins and anti-hypertensive agents in Acute ischemic stroke., J Nepal Med Association 53 (2015).
Shrestha GS, Upadhyaya S, Sharma AK, Gajurel BP. Ocular–visual defect and visual neglect in stroke patients–A report from Kathmandu, Nepal. J Optom. 2012;5:43–9.
Shrestha A, Shrestha R. Prevalence of hypertension in hemorrhagic stroke at NGMCTH, Kohalpur. J Nepalgunj Med Coll. 2018;16:11–4.
Thakur MK, Chhetri G, Shrestha R. Profile on ECG Changes in different types of stroke in patients at Tertiary Level Hospital in Eastern Nepal. J Nobel Med Coll. 2017;6:42–7.
Thapa L, Shrestha A, Pradhan M, Bhandari TR, Shrestha S, Poudel RS, Pokhrel B, Poudel R. Status of vitamin D and its association with stroke risk factors in patients with acute ischemic stroke in a tertiary care hospital. J Nepal Med Association. 2014;52:935–9.
Thapa LJ, Shrestha A, Pokhrel B, Poudel R, Rana PV. Stroke mortality in intensive care unit from tertiary care neurological center. Age (Omaha). 2013;64:15–31.
Shakya D, Chaudhary R, Shakya D, Shakya B. Quality of life and disability in stroke survivors. J Karnali Acad Health Sci. 2019;2:227–33.
Shrestha E, Thapa NB, Rajbhandari SBS. Pattern of computerized tomography findings of the brain in cerebrovascular accidents. Nepal J Med Sci. 2020;5:62–70.
Acharya SP, Bhattarai B, Bhattarai A, Pradhan S, Sharma MR. Profile of neurosurgical patients in a tertiary level intensive care unit in Nepal. J Nepal Health Res Counc. 2018;16:336–9.
Adhikari J, Neupane HS, Bartaula B, Shah BP, Paudel GR, Shah B. Post-stroke complications and its association with mortality of patients with stroke: a five-year experience at a tertiary care centre in Nepal: post-stroke complications, Stroke J. 4 (2019).
Aryal M, Niraula S, Shahukhal R, Mainali NR, Sigdel S, Giri S, Pandey S, Shakya YL. Management of stroke in emergency department in relation to blood pressure, blood sugar and use of anti-thrombotic agents. J Inst Med Nepal. 2010;32:11–4.
Cherian I, Amatya S, Burhan H. Intracerebral hemorrhage: epidemiology and surgical options from a tertiary care hospital in Eastern Nepal. J Nobel Med Coll. 2018;7:64–9.
Devkota KC, Thapamagar SB, Malla S. Retrospective analysis of stroke and its risk factors at Nepal Medical College Teaching Hospital. Nepal Med Coll J. 2006;8:269–75.
Gajurel BP, Parajuli P, Nepali R, Oli KK. Spectrum of neurological disorders admitted in Tribhuvan University teaching hospital Maharajgunj. J Inst Med Nepal. 2012;34:50–3.
Jwarchan B, Yogi N, Adhikari S, Bhandari P, Lalchan S. A study of prevalence and predictors of acute ischemic CVA patients admitted to manipal teaching hospital, Pokhara, Nepal, Eastern Green Neurosurgery. 2 (2020) 42–6.
Khattar NK, Sumardi F, Zemmar A, Liang Q, Li H, Xing Y, Andrade-Barazarte H, Fleming JL, Cherian I, Hernesniemi J. Cerebral venous thrombosis at high altitude: a retrospective cohort of twenty-one consecutive patients, Cureus 11 (2019).
Lamichhane BS, Thakuri SBH, Dhakal RM, Dhakal T, Khanal G. Profile of patients with stroke in Western Region of Nepal: A Hospital based Retrospective Study. Med J Pokhara Acad Health Sci. 2020;3:239–43.
Nepal PR, Rijal S. Outcome following decompressive surgery for malignant middle cerebral artery infarction. East Green Neurosurg. 2020;2:23–6.
Shah SK, Shah S, Shah SK, Shyam BK. Study of risk factors of stroke in patients admitted at Kohalpur Teaching Hospital. J Nepalgunj Med Coll. 2016;14:53–5.
Shah B, Bartaula B, Adhikari J, Neupane HS, Shah BP, Poudel G. Predictors of in-hospital mortality of acute ischemic stroke in adult population. J Neurosci Rural Pract. 2017;8:591–4.
Shrestha A, Shah DB, Adhikari SRKKR, Sapkota S, Regmi PR. Retrospective analysis of stroke and its risk factors at Bir Hospital., Post-Graduate Med J NAMS 11 (2011).
Shrestha R, Nakarmi R, Luitel R, Paudel SS. Patient profile of patients attending to emergency department of a tertiary neurological and neurosurgical hospital of Nepal: one year experience. J Brain Spine Foundation Nepal. 2020;1:20–4.
Shrestha R, Shrestha P, Rajbhandari P, Acharya S, Dhakal S, Limbu CP, Chandra A, Pant B. Technical notes and result of stereotactic evacuation of hematoma in spontaneous Supratentorial Intracerebral Hematoma. Nepal J Neurosci. 2018;15:27–31.
Thapa L, Shrestha S, Shrestha P, Bhattarai S, Gongal DN, Devkota UP. Feasibility and efficacy of thrombolysis in acute ischemic stroke: a study from National Institute of neurological and Allied Sciences, Kathmandu, Nepal. J Neurosci Rural Pract. 2016;7:55–60.
Thapa A, Bidur KC, Shakya B, Yadav DK, Lama K, Shrestha R. Changing epidemiology of stroke in nepalese population. Nepal J Neurosci. 2018;15:10–8.
Roka YB, Dhungana S, Shrestha M, Chaudhary A, Puri PR, Aryal S. Profile of admissions to neurosurgical intensive care unit: experience from the only centre in Eastern Nepal. Postgrad Med J NAMS. 2011;11:62–5.
Chhetri PK, Raut S. Computed tomography scan in the evaluation of patients with stroke. J Coll Med Sciences-Nepal. 2012;8:24–31.
Dewan KR, Rana PV. A study of seven day mortality in acute ischemic stroke in a teaching hospital in Chitwan. J Nepal Health Res Counc. 2014;12:33–8.
Dhungana K. Demographic characteristics of stroke in a tertiary care hospital in Nepal. Nepal J Neurosci. 2018;15:54–8.
Gajurel BP. A descriptive study on ischemic stroke., Nepal J Neurosci 11 (2014).
Karn R, Subedi K. Study of the Outcome differences among the ischemic stroke subtypes basedon TOAST classificationat Tribhuvan University Teaching Hospital, Nepal. Nepal J Neurosci. 2018;15:39–48.
Shrerstha A, Koirala SR. Early prognostic factors for ischemic stroke in a Tertiary Care Center. Post-Graduate Medical Journal of NAMS; 2016.
Naik M, Rauniyar RK, Sharma UK, Dwivedi S, Karki DB, Samuel JR. Clinico-radiological profile of stroke in eastern Nepal: a computed tomographic study. Kathmandu Univ Med J (KUMJ). 2006;4:161–6.
SK BMRP, Adhikari P. Lipid profile and carotid doppler findings in ischemic stroke in nepalese Population, Post-Graduate Med J NAMS 13 (2017).
Gaire D, AD PAR, Rana KJ, Karki L. Stroke Scoring??? Does it have role, Post-Graduate Med J NAMS 12 (2015).
Shah B, Subedi M, Bartaula B, Kattel V. Factors influencing mortality and functional outcomes among patients with stroke admitted to a tertiary hospital in Eastern Nepal: Mortality and functional outcomes in stroke, Stroke J 5 (2020).
Shrestha S, Poudel RS, Khatiwada D, Thapa L. Stroke subtype, age, and baseline NIHSS score predict ischemic stroke outcomes at 3 months: a preliminary study from Central Nepal. J Multidiscip Healthc. 2015;8:443.
Yadav AK, Dev B, Taparia S, Yadav N, Upadhyaya BB, Kumar P, Mandal R, Rajbanshi LK. Role of Color Doppler Ultrasonography in evaluation of Extracranial Carotid Artery in Stroke Patients: a prospective study. Birat J Health Sci. 2020;5:1091–8.
Tuladhar AS, Shrestha A, Adhikari P, Joshi LN, Sharma GR. Carotid doppler and lipid profile findings in ischemic stroke patients-a hospital based study. Nepal Med Coll J. 2013;15:98–101.
Thapa GB, Sundas A, Rauniyar RK. Morphological changes in carotid arteries in stroke cases. J Nepal Med Association. 2013;52:251–4.
Nepal G, Yadav JK, Basnet B, Shrestha TM, Kharel G, Ojha R. Status of prehospital delay and intravenous thrombolysis in the management of acute ischemic stroke in Nepal. BMC Neurol. 2019;19:1–9.
Nepal R, Choudhary MK, Dhungana S, Katwal S, Khanal SB, Bista M, Monib AK, Kafle DR. Prevalence and major cardiac causes of cardio-embolic stroke and in-hospital mortality in Eastern Nepal. J Clin Prev Cardiol. 2020;9:19.
Deo RK, Karki P, Sharma SK, Acharya P. Association of cardiovascular events with glycosylated haemoglobin in diabetic patients. Kathmandu Univ Med J. 2008;6:476–85.
Ghimire RK, Oli KK, Pradhan S, Agrawal JP. Carotid Intimomedia Complex Thickening in patients with stroke: a Case Control Study. Nepal J Neurosci. 2005;2:117–21.
Gajurel BP. Nepal: the pain of stroke treatment. Pract Neurol. 2021;21:81–6.
Appelros P, Stegmayr B, Terént A. Sex differences in stroke epidemiology: a systematic review. Stroke. 2009;40:1082–90. https://doi.org/10.1161/STROKEAHA.108.540781.
Rahbar MH, Medrano M, Diaz-Garelli F, Gonzalez Villaman C, Saroukhani S, Kim S, Tahanan A, Franco Y, Castro‐Tejada G, Diaz SA. Younger age of stroke in low‐middle income countries is related to healthcare access and quality. Ann Clin Transl Neurol. 2022;9:415–27.
Sarikaya H, Ferro J, Arnold M. Stroke Prevention - Medical and Lifestyle Measures. Eur Neurol. 2015;73:150–7. https://doi.org/10.1159/000367652.
Abdu H, Tadese F, Seyoum G. Clinical profiles, comorbidities, and treatment outcomes of stroke in the medical ward of Dessie comprehensive specialized hospital, Northeast Ethiopia; a retrospective study. BMC Neurol. 2022;22:399.
Tu W-J, Wang L-D. China stroke surveillance report 2021. Mil Med Res. 2023;10:1–26.
Pandian JD, Gall SL, Kate MP, Silva GS, Akinyemi RO, Ovbiagele BI, Lavados PM, Gandhi DBC, Thrift AG. Prevention of stroke: a global perspective. The Lancet. 2018;392:1269–78.
Smith C, Almallouhi E, Feng W. Urinary tract infection after stroke: a narrative review. J Neurol Sci. 2019;403:146–52. https://doi.org/10.1016/j.jns.2019.06.005.
Westendorp WF, Nederkoorn PJ, Vermeij J-D, Dijkgraaf MG, van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMC Neurol. 2011;11:110. https://doi.org/10.1186/1471-2377-11-110.
Lin B, Zhang Z, Mei Y, Wang C, Xu H, Liu L, Wang W. Cumulative risk of stroke recurrence over the last 10 years: a systematic review and meta-analysis. Neurol Sci. 2021;42:61–71. https://doi.org/10.1007/s10072-020-04797-5.
Worlddata.info. Indicators of economy in Nepal. (2022). https://www.worlddata.info/asia/nepal/economy.php (accessed January 7, 2023).
Si L, Chen X, Ouyang M, Wang X, Chen G, Cao Y, Wu G, Zhang J, Zhang J, Liu Y. Cost-effectiveness of low-dose compared to Standard-Dose Alteplase for Acute ischemic stroke in China: a Within-Trial Economic evaluation of the ENCHANTED Study, Cerebrovasc Dis. (2022) 1–8.
Rajsic S, Gothe H, Borba HH, Sroczynski G, Vujicic J, Toell T, Siebert U. Economic burden of stroke: a systematic review on post-stroke care. Eur J Health Econ. 2019;20:107–34.
Acknowledgements
None.
Funding
None.
Author information
Authors and Affiliations
Contributions
Study concept and design, prepared protocol for the study and performed initial studies extraction and screening: RP, CT, BPG, BRP and CG. Data collection and screening of studies: RP, CT, BPG, AC, GK, PJ, LT, SP, BRP and CG. Data extraction and entry, analysis with tables and figures preparation: SS, RCS, AA, SA, KB, PJ and NK. Preparation of the draft and appropriate editing: RP, CT, SS, RCS, and AA. All the authors have read and approved the manuscript.
Corresponding author
Ethics declarations
Competing interests
None of the authors has any conflict of interest to disclose. We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
About this article
Cite this article
Paudel, R., Tunkl, C., Shrestha, S. et al. Stroke epidemiology and outcomes of stroke patients in Nepal: a systematic review and meta-analysis. BMC Neurol 23, 337 (2023). https://doi.org/10.1186/s12883-023-03382-5
Received:
Accepted:
Published:
DOI: https://doi.org/10.1186/s12883-023-03382-5