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Sunday, 28 February 2016





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Today is National Stroke Day:

Preventing a brain attack

With over 200,000 Lankans struck down by debilitating paralysis every year, stroke is the 2nd leading cause of hospital deaths in Sri Lanka, but paying attention to your body can help avert both death and debilitation, says Dr Harsha Gunasekara

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Strokes have claimed more lives than HIV, Tuberculosis and Malaria combined. It has disabled more adults than any other cause in the world - in Colombo alone, 1 in every 100 has been a victim. In a developing country like Sri Lanka, the 80% of strokes that hit individuals below the age of 70 continues to contribute to loss of workforce and inhibit economic progress. The tragedy however, is that simple awareness and change that could prevent this leading trigger of Sri Lankan deaths - is all too often regrettably ignored.

Here, Consultant Neurologist, Sri Jayewardenepura Hospital, Dr Harsha Gunasekara explains why it is important to pay attention to the smallest signs and symptoms that indicate the onset of a stroke, which is now the second leading cause for hospital deaths.


Q: Has the incidence of strokes risen in the recent past?

A: There has been a serious increase in stroke and resultant death in Sri Lanka. At present strokes are responsible for the second largest number of hospital deaths after heart attacks. Although complete statistics on stroke incidence in Sri Lanka are not available, two studies carried out suggest that every year more than 1% of our population develop stroke - that means 200,000 stroke victims annually!

Q: What are the main reasons for this increase?

A: Three major developments are considered the primary causes for the increase:

1) Lifestyle changes that is associated with urbanisation including less healthy diets;

2) Higher levels of stress, less exercise and obesity;

3) The rapid ageing of our population, and poor socio-economic status that continues to be a barrier to access to stroke treatment and prevention strategies.

That said, poor lifestyle choices could seriously aggravate dangerous stroke risk factors such as high blood pressure, diabetes and high cholesterol, especially if strict treatment is not obtained.

Q: You mentioned pressure, diabetes and cholesterol. Can these non communicable diseases lead to stroke?

Recognising a stroke

Q:What are the early symptoms of stroke? How do you recognise them?

A: As the name implies, symptoms of stroke 'strike' you very suddenly; there is a wide range of symptoms depending on the area of the brain affected. It is essential that you are able to recognise the following warning signs of a stroke:

*Paralysis of one side of the body - severity could range from a feeling of numbness or an 'anaesthetic' state to complete paralysis of one side of the body. The area affected is often, but not limited to, an arm, leg or half of the face.

*Difficulty in swallowing

*Ataxia - lack of voluntary coordination of muscle movements (unbalanced, difficulty in walking)

*Loss of balance

*Vertigo - spinning feeling and dizziness

*Slurred speech - inability to vocally communicate. Recognition is possible and behaviour otherwise appropriate, yet the victim may not be able to understand words or speak. If questioned, a response may not be given.

*Sudden, severe headaches with no apparent cause

*Abnormal eye movements

*Reduction in field of vision from 180 to 90 degrees. Only objects directly in front of the field of view may be seen, vision of the corners of the surroundings is reduced when looking straight ahead.

*Loss of vision completely from one eye

*Double vision

*Loss of bladder control

Sometimes a sudden severe headache with no apparent cause, vomiting and an impaired level of consciousness can occur, especially in the case of a brain bleed.

A: Risk factors for stroke and other non-communicable diseases such as heart disease and cancer are quite similar. There are two types of risk factors:

1) Unmodifiable risk factors. These cannot be controlled and include increasing age, being male in gender, being Asian, and having a family history of strokes.

2) Modifiable risk factors are treatable or changeable and can be controlled. They include 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 if you correct them (by quitting smoking, obtaining treatment for high blood pressure, diabetes and irregular heart beat) you can prevent a stroke.

Other modifiable risk factors include obesity, physical inactivity, high cholesterol levels, certain heart diseases, excessive consumption of alcohol, use of narcotics, use of contraceptive pills, post-menopausal hormone replacement, and certain blood diseases.

Q: A common misconception is to confuse a stroke with a heart attack. Is stroke the cause of heart attacks or vice versa?

A: Stroke is a 'brain attack' and occurs due to either the clogging of a blood vessel to prevent blood from reaching the brain, or due to rupture of a blood vessel in or near the brain. A heart attack is when blood flow to the heart is interrupted causing damage to the heart muscle.

The symptoms of stroke are very different to the commonly understood symptoms of heart attack. It is essential to be aware of both and respond immediately.

Stroke does not cause heart attacks, but due to the similarity of causative risk factors, a person with a stroke has a higher risk of developing a heart attack. Heart attacks can give rise to stroke, especially in the early stages, due to the development of blood clots within the diseased heart that can become mobile and clog a blood vessel leading to the brain.

Q: Any other factors to keep in mind?

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 for 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. Action must be taken early - rush to the nearest base hospital - not the general practitioner next door. Stroke Units are available at the hospitals of Colombo (the National Hospital), Kurunegala, Kalutara, Ragama, Sri Jayewardenepura, Badulla, Ratnapura, Jaffna and Anuradhapura.

Q: What should NOT be done till help arrives?

A: The brain is very sensitive to the lack of oxygen and glucose and can only survive between 3 to 5 minutes without them; brain health is time - so act fast. Do not put food or water into the mouth of the patient, and do not sit them up as this could increase the risk of choking. Instead turn them on their side and tilt the head back to open the airway and prevent them choking on their tongue, especially if they are unconscious. When the patient attempts to communicate and if they have difficulty in talking, make suggestions to allow easier communication. The severity of the stroke can vary, so symptoms may settle and improve after a while. However, a stroke has still been experienced - so rush to hospital.

Q: How can stroke be prevented?

A: Even with the most modern treatment facilities, only a third of patients completely recover from stroke; it is the far better option to prevent a stroke before it develops. This can be done at two levels, 'primordial prevention' and 'primary prevention'. In primordial prevention, lifestyle changes that are commenced early to prevent the development of modifiable stroke risk factors (which have been outlined in a previous question above). Primary prevention is for people with established risk factors who have not yet suffered a stroke; it involves medication in addition to lifestyle changes to prevent the risk factors causing a stroke. A third form of prevention, called secondary prevention, exists for patients who have already suffered a stroke or a TIA. Here anti-platelet (blood-thinning) treatment is started in addition to the measures used in primary prevention, to prevent a further often more severe stroke. It is possible for anyone to assess their stroke risk using a simple scorecard.

The symptoms

Q. Is there a quick easy way to recognise these symptoms?

A. The Stroke Association with the Ministry of Health has put forward a poster for this purpose. If any of the following 3 checks listed below are positive, the patient should be taken to the nearest hospital immediately:

*If the patient is requested to stretch out both hands in a sleepwalking motion, one hand will drift downwards, indicating paralysis of muscles. The same process applies to the legs.

*If asked to bare their teeth in an "ee" grin (clench the teeth), the mouth is pushed to one side. This is due to the pull exerted by the muscles that are properly functioning on the paralyzed muscles, forcing them towards the healthy side of the face.

*If the patient is spoken to or asked simple questions, they may be unable to respond. Difficulty in movement of the tongue may also be observed - if asked to put their tongue out, this may prove arduous.

However, even they are capable of this, speech is often impossible; they may not be able to state their name and address. This is not confusion or a psychiatric disorder; this is a stroke. Acting fast is vital again, as the inability to communicate vocally leaves the patient under conditions of incredibly high stress.

Q: At the hospital, what is the first line of treatment?

A: All patients with stroke will 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, which would adversely affect recovery.

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 in a hospital may be a separate section or part of a ward that cares for stroke patients exclusively. The stroke unit is composed of: Doctors specially skilled in treating patients, Nurses who oversee nutrition and care for patients at all times, Physiotherapists who oversee breathing and chest movements, help in regaining motion of limbs and breathing., Speech and language therapists - provide speech exercises, helping communication skills gradually resurface again. It has been proven that treatment in a Stroke Unit improves chances of survival and reduces both disability and length of hospital stay.

Q: The golden rules to follow after a stroke?

A: Avoid foods such as egg yolks, fatty meats, butter and cream, which are high in fat and cholesterol. Eat moderate amounts of food and cut down on saturated fat, sugar and salt. Avoid fried food and take baked or boiled food. Avoid fast food. Eat more fruits, vegetables, cereals, fish and lean meats.

Q: What about 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 to the type of aerobic physical activity as long as the patient can cope with it safely (especially with the aim of avoiding falls).


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