In two days’ time on World Stroke Day (October 29,) experts from around the world will gather to share their collective expertise on how they could effectively combat one of the commonest neurological diseases which in the absence of early and timely interventions, could transform a once active person to a helpless invalid for life.
Vice President, National Stroke Association and Consultant Neurologist, Sri Jayawardenepura Hospital, Dr Harsha Gunasekara explains to the Sunday Observer how to detect symptoms and more importantly prevent complications that accompany stroke by following the simple guidelines he gives readers in this article.
Excerpts…
Q. Although Stroke has been described as the commonest neurological emergency, not many of our readers are aware of how a stroke is caused, what symptoms they should look for. Could you enlighten them?
A. Stroke occurs as a result of the sudden disturbance of the blood supply to a particular area of the brain resulting in death or damage of the brain nerve cells. The mechanism is the same as with a heart attack. Thus stroke can be correctly termed a ‘brain attack.’ One in four is at risk of stroke in our lifetime. Fortunately today, technical advances have made it possible to prevent it with a few simple steps I will discuss later in this article.
Q. How is stroke caused?
A. The disturbance of the blood supply in most patients (85%) occur due to the blockage of a feeding artery (termed ischaemic stroke or infarction) and in others due to rupture of a feeding artery (termed haemorrhagic stroke).
Q. What is a Transient Stroke? Should patients who experience TIA take it seriously?
A. Around a quarter of patients with stroke may experience a Transient Ischaemic Attack (TIA or mini stroke). Here the symptoms of stroke last only a few minutes and then rapidly resolve. This condition should be given serious consideration and treatment initiated immediately as it may be the only warning one may get before developing a major stroke.
Q. Does stroke share the same risk factors as heart disease and other non communicable diseases?
A.Risk factors for stroke and other non-communicable diseases (NCDs) such as heart disease and cancer are quite similar.
Q. What are the top NCDs that could trigger a stroke?
A. They are heart disease, high blood pressure, diabetes, abnormal blood lipid levels and peripheral arterial disease affecting major feeding arteries of the brain.
Q. Early signs of a stroke? Have you an easy to follow guideline for laymen?
A. Knowing the “FAST” recognition of stroke is the best way to remember the commonest signs of stroke. ( see diagram) If any of the 3 signs are positive, the patient should be taken to the nearest major hospital immediately.
Q. Recovery outcomes if treated early? Is time an important factor?
A. Time to treatment is critical. It is estimated that an untreated stroke patient loses 1.9 million nerve cells every minute.According to the Sri Lanka Stroke clinical registry data, only 16 % of patients arrived at the hospital within 3 hours.
Hence anyone suspected to have developed a stroke should be taken immediately to the nearest major hospital.
Q. What is the usual treatment procedure on admission?
A. The patient will undergo a quick clinical assessment to confirm the stroke signs and then undergo a CT scan which helps to identify the type of stroke (a brain bleed or blockage of a blood vessel). Clot busting treatment will be given to eligible patients after assessment. All patients are assessed for any abnormalities in blood pressure, oxygen and glucose levels and corrected if necessary. These factors affect stroke of any type adversely. Needy patients will undergo rehabilitation by a stroke team within a stroke unit.
Q. Usually how long does a patient take to recover after a stroke? If the victim is young will he/she recover faster?
A. This is highly variable and depends on the severity of the stroke and other co-existing disease states. Most patients with mild to moderate severity can be expected to recover within two weeks of onset. As a general rule after a stroke one third of patients recover completely, another third would be left with a permanent disability and a third will die either in the acute stage or later from complications.
Q. Do you see a rising incidence of stroke victims in the past ten years?
A. Yes, this is particularly so in developing countries such as ours, and as a result of increasing aging population. The global lifetime risk of stroke has increased from 1 in 6 to 1 in 4.
Q. Is it true that the age of the victims is now increasingly getting younger? Why?
A. Sri Lanka Stroke clinical registry data shows that 33% of patients were less than 60 years of age, still in their working life. In a majority of these patients same risk factors that cause stroke in the elderly play a role, which means people are acquiring conditions like high blood pressure, diabetes, high cholesterol levels and heart disease at a relatively young age.
Q. How do you prevent a stroke?
A. The first step is to know your own personal stroke risk. This can be assessed using a simple risk assessment tool (now available as a mobile app). Once you know your risk, the next step is to identify which of the above mentioned risk factors are applicable to you and take corrective measures. Thereafter, carry on the advice given on how to control your risk factors which will essentially include adaptation of a healthy lifestyle and if necessary some medications. Easiest steps in maintaining a healthy lifestyle is to stay away from both active and passive smoking and take alcohol in moderation (2 units a day for men and 1 unit a day for women). Next is to maintain a normal body mass index (18.5 – 24.9) and healthy waist circumference (less than 40 inches for men and 35 inches for women). Regular moderate physical exercise (e.g. walking) for 30 minutes a day for at least 5 days a week is recommended. Regular exercise together with a healthy (in terms of both quality and quantity) balanced diet – rich in fibre, fruits and vegetables and low in saturated fats, salt and sugar helps to maintain a healthy weight. Get your blood pressure, blood glucose and cholesterol levels checked and take treatment if advised by your doctor. Controlling your risk factors before developing a stroke (also called primary prevention) reduces your lifetime stroke risk by 80%.
Q. Once you get a stroke is there a danger of another stroke?
A. Once you suffer a stroke, your risk of a second stroke increases significantly. Stroke clinical registry data shows 18% of patients had recurrent stroke. Therefore, one needs to carefully continue all medications prescribed and maintain a healthy lifestyle to prevent another stroke (this is called secondary prevention). Even after suffering a stroke or a TIA, if you adopt preventive measures, you can still bring down your risk of having another stroke by 40%.
Q. New interventions worldwide are now being tried out for stroke victims. I understand a new intravenous treatment called thrombolysis can reduce disability for stroke if the patient is brought to a stroke unit within 4 ½ hours. Is this available in Sri Lanka?
A. Yes, this (clot buster) treatment has been established in most major hospitals over the last few years. This is an expensive treatment, given free of charge at state hospitals. Unfortunately, despite awareness programs carried out by the Stroke Association, most patients miss the opportunity for treatment due to late presentation. In addition, clot retrieval treatment is being developed which can treat strokes in selected patients even up to 6 – 12 hours from onset.
Q. Stroke Units- how many are there in the country?
A. Most major hospitals now have either stroke units or dedicated beds in neurology units to care for stroke patients. Stroke units do not require high tech equipment but mostly a defined area to care and rehabilitate the patients through a dedicated multi-disciplinary team which includes doctors, nurses, physiotherapists, speech and language therapists, occupational therapists, psychologists, social workers and nutritionists. The Ministry of Health has also initiated the construction of fully equipped stroke units and improvement of existing stroke units in ten provincial and district general hospitals.
Q. Gaps you’d like to fill in stroke care?
A. Despite advances in treatment, stroke continues to be the leading cause of adult disability and 3rd leading cause of death in hospitalized patients. So prevention programs should be strengthened along with awareness raising and health education of the public. Basic investigations needed for assessment of stroke risk factors should be available at primary care level. The Essential Health Services Package to be launched by the Ministry of Health and WHO aims at universal health care which will bridge the gap in the current primary curative healthcare system.
Q. Your message to the public on stroke prevention?
A. Identify your own risk factors and follow the prevention guidelines detailed in this article. Caregivers must ensure that patients continue their medications and maintain healthy lifestyle practices even after recovery.