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| Sunday, 29 February 2004 |
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Features |  |
| News Business Features Editorial
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Compiled by Carol Aloysius Today is National Stroke Day : Can stroke be prevented? by Dr. Jagath C. Wijesekera (President, National Stroke Association of Sri Lanka) Stroke is a major health problem throughout the world. It is the second commonest cause of death worldwide, and is the third leading cause of in-hospital deaths in Sri Lanka. The major impact of stroke on society, however, is due to the large number of disabled and dependent survivors left behind. Stroke is also the most important cause of adult disability. Stroke cerebrovascular accident is one of the most devastating illnesses that can affect man. There have been new developments in the treatment of individuals who have already suffered a stroke, such as drugs used to dissolve the blood clot in the brain (thrombolytic agents). These drugs though promising have to be given within a few hours of the onset of the stroke. Furthermore, they are available only in a few countries such as the USA and will be too costly for routines use in a developing country like Sri Lanka. Hence, prevention of stroke is the main strategy used worldwide to lessen the burden of stroke. This is not only true to developing countries but is also applicable to developed countries. Risk factors for stroke There are well-documented risk factors, which are modifiable and treatable. These include. * High blood pressure (Hypertension) * Heart disease * Smoking * Previous stroke or transient ischaemic attacks (TIAs) also referred to as mini strokes High Blood Pressure High blood pressure is the most important of the risk factors, which is modifiable. It has been shown that adequate control of high blood pressure can significantly reduce the incidence of stroke in the community. Recent studies have also shown that reduction of blood pressure even when in the average range will result in reduction of stroke incidence. Hence, the importance of regularly checking the blood pressure and taking suitable medication on a long term basis, once high blood pressure is detected under medical supervision. Heart Disease Proper treatment of those individuals who suffer from heart disease can pevent the occurrence of stroke. In the Sri Lankan perspective, Rheumatic Heart Disease which results from inadequate treatment of Rheumatic Fever, is of particular importance as it is imminently preventable and treatable. Heart disease which result from insufficient blood supply to the heart muscle (Ischaemic Heart Disease - HID) and those resulting from irregularities of heart rhythm (e.g. Atrial Fibrillation - AF) could also result in stroke, and hence their early detection and treatment is of utmost importance. Cigarette Smoking The association between smoking and stroke has been clearly demonstrated by large clinical trials. There is a direct relationship between the number of cigarettes smoked and stroke incidence. It has also been shown that will cessation of smoking the incidence of stroke is progressively lessened. In fact after 5 years of cessation of smoking the liability of having a stroke in one who has smoked previously will be the same as a non-smoke. Mini Strokes Transient neurological symptoms (transient weakness, numbers, visual loss or blurring, double vision, slurred speech, etc) which last for a few minutes or hours are termed transient ischaemic attacks (TIAs). Patients who have TIAs and mini strokes are at a higher risk of having a major stroke within the next five year period, the maximum risk being during the period soon after the mini stroke. Identifying the cause of the TIA/stroke and treating appropriately with medication or surgical procedures will significantly reduce the subsequent occurrence of a major stroke. Other risk factors which are known to be important in the aetiology of stroke but which are less well documented than those mentioned above include. * Diabetes mellitus * Elevated cholesterol and lipid levels * Heart disease other than IHD, AF and valvular disease * Obesity (excessive body weight) * Lack of exercise * Excessive alcohol intake * Use of oral contraceptive pill The control of above factors are also important in prevention of stroke. Recent studies have also shown that use of Vitamins such as Folic acid, Pyridoxine (Vitamin B6) and Vitamin B12 in patients who have had strokes will reduce the possibility of having a subsequent stroke. It has been shown that diets rich in Potassium which is abundantly present in fruits is beneficial for stroke prevention. Thus, it would seem that the most important aspects of stroke prevention would be to educate the public to have regular blood pressure checks and take medication if they are suffering from high blood pressure under the supervision of a physician, early detection and treatment of heart disease, refraining from smoking and be able to detect symptoms of a mini stocks and seek early medical attention. Furthermore, a lifestyle with a suitable diet in order to maintain optimum weight, control of blood cholesterol and lipids, consumption of fruits in inadequate amounts, control of alcohol intake and regular physical activity/exercise will also be of help. Stroke is commoner with increasing age, and Sri Lanka has one of the fastest aging populations in the world. The population of over 60 years will increase from 10 per cent to 20 per cent by 2025. Factors that increase the risk of having a stroke such as high blood pressure, diabetes and smoking are increasing with the changes in dietary habits and lifestyles. We are likely to see a large increase in the number of dependent stroke survivors in the near future. Our experience of treating over 200 stroke patients at the stroke unit of the Institute of Neurology at the National Hospital of Sri Lanka, Colombo has shown that these risk factors are common and sometimes undetected. Of these patients, 48 per cent had high blood pressure and 26 per cent had diabetes. 15 per cent with high blood pressure and 15 per cent with diabetes were previously undiagnosed. Stroke Management We need to improve the quality of stroke care if we are to minimise the burden of stroke. This could be achieved by improving acute management of patients with stroke, improving the rehabilitation services to overcome the functional impairment, and initiating measures aimed at stroke prevention. Stroke prevention is the most cost effective way of reducing the burden of stroke. Public education plays a very important role in this regard. Healthy life styles should be encouraged. People must be educated on the importance of control of the factors that increase the risk of stroke such as high blood pressure, diabetes and smoking. In Sri Lanka, there is no organised structure for stroke care, and multidisciplinary approaches to stroke rehabilitation are virtually non-existent. Lack of physiotherapists, occupational therapists and speech therapists is a major factor responsible for this. Sri Lanka's first stroke unit was established at the Institute of Neurology of the National Hospital of Sri Lanka (NHSL) in June 1998, aimed at improving the quality of stroke care at the NHSL. How to improve the stroke services? A comprehensive stroke service should be developed, aimed at improving all aspects of stroke care. This can evolve around a stroke unit, which can serve as a hospital based focal point of services and expertise. If a stroke unit can be established in each province, a stroke service can be developed to serve the entire province. The services should not remain hospital bound, but must reach the community it serves. This is essential if preventive strategies such as educational programmes are to be successful. Community participation is vital in this regard. Why a Stroke Association? A stroke association will bring together medical and non medical people committed to improving stroke care. The managerial skills of the non medical professionals can be harnessed to take the stroke service to the community to ensure community participation, and to develop educational campaigns. Creating and improving awareness on stroke, and dispelling the myths regarding stroke are important objectives. The association will also be a meeting point for stroke victims, their families and caregivers, and health care professionals. **** Early medical attention will prevent deaths and ensure better recovery. Early warning signs 1. Weakness or numbness of one side of the body 2. Difficulty in speaking 3. Sudden change in vision 4. Dizziness, loss of balance 5. Difficulty in swallowing 6. Sudden severe headache To prevent strokes, Have a healthy diet: Stop smoking, Be physically active Control - high blood pressure - diabetes - high cholesterol - heart disease **** Strokes - the Lankan scenario 1. Stroke is the 3rd leading cause for death. 2. Disability in elderly people is mostly due to stroke. 3. 85% of strokes are caused by the blocking of blood vessels. 4. 15% of strokes are caused by burst blood vessels connected to the brain. 5. 65% of stroke victims become paralysed. 6. 35% lose their speech. 7. 25% of strokes are caused by smoking. 8. 25% of strokes are caused by excessive drinking. ###### Brain attack Dr. Udaya Ranawaka, Secretary, National Stroke Association of Sri Lanka answers some frequently asked questions about stroke .... Q. What is a stroke? A. Stroke is a sudden disturbance of brain function due to a disturbance to its blood supply. It is also known as a 'Brain Attack'. Q. What causes a stroke? A. The blood supply to the brain may be distributed in two main ways. Firstly, a blood vessel carrying blood may become blocked resulting in inadequate blood flow. Strokes that occur as a result of this type of disturbance to the blood flow are the commoner variety, and are known as ischaemic strokes or cerebral infarcts. Sometimes spontaneous bleeding may occur into the brain tissue due to a rupture of (or bursting of) a blood vessel. Strokes resulting from this are less common, and are called haemorrhagic strokes or intracerebral haemorrhages. Certain factors may increase the risk of an individual having a stroke, these are known as stroke risk factors. The risk of developing a stroke can be reduced by modifying these risk factors. The most important modifiable stroke risk factors are: High blood pressure, Heart diseases of various types, Diabetes, High cholesterol, Smoking, Excessive alcohol consumption, Lack of exercise, sedentary lifestyle and obesity. Q. What are the effects of a stroke? A. The effects of the stroke depends on the area of brain that is damaged, functions normally controlled by this area will be affected for some time. The commoner effects are: . Weakness or paralysis of one side of the body . Numbness or loss of feeling of one side of the body . Loss of ability to speak, or to understand speech . Alteration of, or loss of, consciousness . Changes in vision . Headache, vomiting, giddiness and falls Sometimes, stroke can lead to sudden death. Q. How long do the effects of a stroke last? A. The effects of a completed stroke last more than 24 hours, usually from a few days to a few weeks. Sometimes the effects due to an interruption to the brain blood flow may last only a few minutes or a few hours, resolving completely within 24 hours. These are due to 'mini-strokes' and are known as 'Transient Ischaemic Attacks' (TIA). It is important to recognize these symptoms and to seek medical attention, as these are warning symptoms that a stroke may soon follow. Q. How can a stroke be diagnosed? A. A stroke is usually diagnosed by the collection of symptoms that the patient (or relatives) complain of, and the signs that are noted on examining the patient. A procedure called CT (computed tomography) scanning, which is a mechanism of taking a series of X-ray like pictures of the brain, is very helpful in finding out the type of stroke (ischaemic or haemorrhagic). Q. How can a stroke be treated? Treatment of a patient with stroke includes; 1. Early management 2. Rehabilitation 3. Prevention of another stroke Early management consists of; General care: This includes attention to the basic needs of the patient which are commonly affected in stroke, such as intake of fluids, nutrition, swallowing, bladder and bowel control etc. Careful control of blood pressure, blood sugar and body temperature are vital. Drug treatment Drugs can be given to reduce the brain swelling of the area of brain damage in certain countries, a new class of drugs, known as 'clot busters', are now used to dissolve a blood clot that may be responsible for the blockage to the blood supply producing an ischaemic stroke. Drug treatment such as these must be given very early after a stroke if they are to be effective. Therefore stroke must be considered an emergency, and medical attention must be sought as soon as possible, ideally in a stroke unit. A stroke unit is a separate area dedicated to the care of stroke patients, manned by a 'stroke team'. A stroke team is a group of health care professionals, which includes doctors, nurses, physiotherapists, speech therapists, occupational therapists and social workers. Rehabilitation is the process by which patients after a stroke are restored to their previous functional, mental and social capacity. This is carried out by the stroke team, with the active participation of patients and the caregivers who look after them. Q. How can strokes be prevented? A. Stroke prevention includes: Prevention of the first stroke in persons who have not had a previous stroke (Primary Prevention); Prevention of a recurrence of stroke in persons to have had a previous stroke (secondary prevention) The approach to stroke prevention is same in both these groups. The main areas of attention are: Modifying lifestyles: i.e. Healthy eating habits, Regular exercises, Stopping smoking, Reducing alcohol consumption. Attention to risk factors such as high blood pressure, heart disease, diabetes, high cholesterol etc. Drugs can be used in certain situations to minimize the risk of stroke. eg: aspirin. ##### Most heart attacks and strokes occur early morning - says Dr. D. P. Atukorale It is common knowledge among doctors, especially, those working in the medical wards and intensive care units, that majority of heart attacks and strokes (brain attacks) occur in early hours of the morning. An analysis of a large number of patients hospitalized with myocardial infarction (heart attacks) studied as a part of the Multicenter Investigation of Infarct Size (MILIS) has revealed a prominent circadian periodicity for the time of onset of acute myocardial infarction. The researchers found that peak incidence heart attacks is at about 9 am. This has been confirmed by other researchers. The early morning occurrence of majority of heart attacks and brain attacks has been confirmed by World Health Organization (WHO) report. The early morning peak of heart attacks parallels the onset of other related phenomena including sudden cardiac deaths thrombotic strokes and transient myocardial ischaemia. Circadian rhythm affects many physiological and bio-chemical parameters and the early morning hours are associated with rises of hormones such as catachollamines and cortisol in plasma. Platelet stickiness also increases in the early morning hours. The blunting of morning peak of heart attacks by both betablockers and aspirin emphasizes the contribution of both the sympathetic nervous system and the coagulation (blood clotting) pathways to circadian rhythm. The heart rate is usually high in the early morning hours and ischaemic ST segment changes in ischaemic heart disease patients too occur in early morning hours. There is a similar blood pressure rise during the early morning hours. The metabolic demand of the heart also increases during the early morning hours. It has also being found that there is an increase in heart attacks on Mondays. It is common knowledge among doctors who have worked in Coronary Care Units in the Western countries that there is an increase in heart attacks in the winter especially in the months of January, February and March. It has been my experience that there was an increase in the number of heart attack patients admitted to Coronary Care Unit (CCU) during the last week of December and early part of January during the period I served the Institute of Cardiology, National Hospital of Sri Lanka. |
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