World Stroke Day was on October 29 -:

A stroke in waiting

Urbanization, increase in the ageing population and poor socio-economic status all mean, more Sri Lankans are at risk of suffering a brain attack:

by Carol Aloysius

Stroke is perhaps one of the most debilitating diseases resulting in long term disability. However, its devastating impacts on the human body can be minimized if the patient is rushed to the nearest hospital in the shortest possible time, no sooner he/she gets a stroke (brain attack).

Here, Consultant Neurologist, Sri Jayewardenepura General Hospital, Dr Harsha Gunasekara, discusses the risk factors contributing to stroke, signs to look out for before a stroke and treatment available.

Excerpts…

Q: Stroke is a leading cause of illness and death worldwide and in Sri Lanka. Has there been a significant increase in the incidence in recent years? If so why?

A: Stroke is the 3rd leading cause of death and the leading cause of disability worldwide. In Sri Lanka, Stroke has taken 2nd or 3rd place for hospital deaths. However, national statistics on Stroke incidence are not available to date in Sri Lanka. Two community based studies done in Colombo and Gampaha Districts show that around 1% of the population develop stroke annually (approximately 200,000 stroke patients per year. As for why, three major causes in developing countries like ours include change in lifestyle associated with urbanization, increase in the ageing population and poor socio-economic status, which hinders successful strategies for prevention and treatment of stroke.

Q: Are these risk factors similar to those that have caused a surge in other non-communicable diseases (NCDs) in Sri Lanka?

A: Risk factors for stroke and other NCDs (heart disease, cancer etc.), are quite similar. The major risk factors for Stroke are smoking, high blood pressure, diabetes, atrial fibrillation (irregular heart rhythm which predisposes to stroke) and Carotid artery disease (narrowing of the major arteries which feed the brain). All these five major risk factors are modifiable, which means that if you correct them (for example quitting smoking, treating high blood pressure, diabetes and irregular heart beat etc.) you can prevent a stroke.

Other modifiable risk factors include obesity, physical inactivity, high blood cholesterol levels, some heart diseases, use of contraceptive pill and post-menopausal hormone replacement, diseases which predisposes to abnormal blood clotting, excessive alcohol consumption, and narcotic drug use.

Non-modifiable risk factors include advanced age, male gender, and family history of stroke, and low birth weight.

Q: Can Stroke be prevented?

A: Even with most modern treatment facilities, only a third of patients gain complete recovery from Stroke. Therefore, it’s best to prevent a Stroke before it develops. This can be done at two levels, namely ‘primordial prevention’ and ‘primary prevention’. In primordial prevention, life style modifications are practiced early to prevent development of Stroke Risk Factors stated above. Primary prevention is for people with established risk factors, yet not suffered a Stroke where treatment with medication in addition to life style modifications is started to prevent a stroke.

The third form of prevention called ‘Secondary Prevention’ is for patients who have suffered a Stroke or a TIA where anti-platelet (blood-thinning) treatment is started in addition to the measures used in primary prevention.

It’s best to adopt the two former methods of prevention and anyone can assess his or her Stroke risk using a simple scorecard (see the chart given elsewhere).

Q: How soon should a person be taken to hospital after a stroke?

A: When a person has symptoms of a heart attack, he is taken to the nearest hospital immediately. The same thing should be done when someone suffers from stroke. Just as heart attacks occur due to blockage of a blood vessel feeding the heart muscle, over 85% of Strokes occur due to blockage of a blood vessel feeding the brain (the rest due to ruptured blood vessel causing a brain bleed). Stroke is a ‘brain attack’. A person with symptoms of a suspected Stroke should be taken to the nearest hospital immediately. There are two main reasons for this. Firstly, to perform a CT scan to rule out or confirm a brain bleed and secondly to initiate treatment without delay.

Q: Early symptoms? How do we recognize them?

A: Stroke ‘strikes’ you suddenly, with a wide range of symptoms depending on the area of the brain affected. The common ones are numbness or weakness of one side of the body or one limb alone, disturbance of speech, impaired vision in one eye or double vision, impaired balance and co-ordination and impaired swallowing and bladder control. Sometimes headache, vomiting and impaired level of consciousness can occur especially in the case of a brain bleed.

As remembering all these symptoms is difficult, stroke organizations have put forward a simple test called FAST – Face, Arm, Speech, Time which is explained in the diagram.

If any of the 3 checks are positive, the patient should be taken to the nearest hospital immediately.

Q: Any other symptoms?

A: Around a quarter of patients with Stroke may experience a Transient Ischemic Attack (TIA or mini Stroke). Here the symptoms of Stroke last only for a few minutes and then rapidly resolve. This condition should be given serious consideration and treatment initiated as it may be the only warning one may get before developing a major stroke.

Q: What is the first line of treatment?

A: Doctors will first assess the patient to confirm a Stroke and determine the risk factors, then do investigations including a CT scan. Initial treatment involves monitoring and controlling the blood pressure (which should not be too high or too low in the early stages after a Stroke), blood glucose level, oxygen level, and if needed measures to reduce brain swelling. Once a brain bleed is ruled out, blood thinning (anti-platelet) treatment is initiated. Patients will also be given cholesterol lowering drugs. If the patient is brought to the hospital and a brain bleed is ruled out within 3 hours, clot buster treatment is given in a few hospitals where it’s available. In the near this treatment will be available in most major government hospitals in the island.

All patients with Stroke should also be assessed and treated for possible complications such as infections (of the lungs and the urinary passage), DVT (clots in the leg veins), pressure ulcers and depression. Stroke patients should be managed with the aim of preventing these complications which would otherwise adversely affect recovery from stroke.

Q: What is the next step towards rehabilitating victims?

A: Rehabilitation of a stroke victim requires multidisciplinary support and is best undertaken in the setting of a Stroke Unit. A Stroke Unit is a hospital unit (may be separate or part of a ward) that cares for stroke patients exclusively or almost exclusively, with specially trained staff and a multidisciplinary approach to treatment and care. The multidisciplinary team consists of doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, psychologists/counsellors and a social worker. It has been proven that treatment in a Stroke unit improves chances of survival and reduces both disability and length of hospital stay.

Q: Where are these Units?

A: At the National Hospital Sri Lanka, which was the first of our Units, in Kurunegala, Kalutara, Ragama Sri Jayewardenepura, Badulla, Ratnapura, and Anuradhapura hospitals Six more units are being set up this year.

Q: Any dietary guidelines?

A: The diet should be rich in fruits and vegetables and low-fat dairy products and reduced saturated and total fat, sugar and salt. Cessation of smoking and limitation of alcohol intake are essential to prevent another stroke attack.

Q: Exercise?

A: Guidelines for exercise recommend increased moderate aerobic physical activity for 150 minutes a week (i.e. 30 minutes a day for 5 days). There is no limitation of the type of aerobic physical activity as long as the patient can cope with it safely (especially with the aim of avoiding falls). Supervision and guidance by a physiotherapist or carer may be needed in the initial period, while close medical supervision may be required for patients with heart and lung diseases.

Q: How long does it take for a patient to recover?

A: On average after a stroke, one third of patients fully recovers or will have only minor disability. Another third will be disabled for life. One third of patients will die, either directly as result of the stroke or due to one of its complications. Duration of recovery is variable depending on the severity of stroke, age of the patient, presence of complications and the setting of post-stroke care.

Majority of patients who do recover usually regain physical functions and activities of daily living over a period of approximately 2 – 4 weeks. Stroke victims carry a higher risk of developing a second stroke, irrespective of their level of recovery. Patients should strictly adhere to advice on lifestyle modifications and take treatment prescribed to prevent another stroke.

I am a woman; Stroke affects me

Giving their views on the subject at a media discussion at the Health Education Bureau Friday October 29, two Consultant Neurologists, Dr. Udaya Ranawaka, President of the National Stroke Association of Sri Lanka and former President Stroke Association and Consultant Neurologist, National Hospital Sri Lanka, Dr Padma Gunerathne, said the theme of this year’s World Stroke Day, was ‘I am a woman; Stroke affects me, stroke affects everyone’. It had been especially chosen due to escalation of risk factors, which make women more vulnerable to stroke than men, they noted, a fact proved statistically. Out of ten stroke deaths six were likely to be women.

The reasons? Because they live longer than men, and have age related diseases more frequently than men e.g. hypertension, diabetes, migraines with visual aura, atrial fibrillation, depression and are more prone to obesity than men. They also suffer from sex specific risk factors such as pregnancy, pre-eclampsia, take birth control pills, hormone replacement therapy, and develop gestational diabetes, cerebral venous thrombosis.

The doctors also noted that women do not receive the same care that men with stroke receive, and less rehabilitation than men, although they responded equally well to the treatment given. The fact that most women delay going for treatment due to their multiple roles as housewives and mothers, even after they were alerted to the symptoms, make their situation worse.

“These gender gaps between men and women with stroke require more awareness raising and education. There are many gaps which we hope to fill once our new Centre for stroke activities at the National Stroke Hospital at Mulleriyawa gets underway soon,” Dr Ranawaka said.