When clinicians came together to observe National Stroke Day on February 28 , this year, they focussed on a new emerging health issue that has up to now received scant attention: namely the rise in the number of younger persons and also those without high risk profiles being admitted to hospitals with stroke.
What has caused this new disturbing health trend? How do we identify its symptoms? Most importantly, how can it be prevented?
These questions posed by the Sunday Observer were fielded by the President of the National Stroke Association of Sri Lanka and Consultant Neurologist, Sri Jayewardenepura Teaching Hospital, Dr Harsha Gunasekara.
Following are excerpts
Q. While Stroke is one of the most debilitating conditions that affect human beings, not many people still know what exactly a Stroke is. For our readers benefit define Stroke in easy layman language.
A. Stroke occurs as a result of 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”. It is estimated that 1.9 million nerve cells are destroyed every minute after a stroke and permanent damage could occur within a few hours.
Q. In the not too distant past, Stroke was considered a disease of the elderly. Is this still true today? Or do you see a new trend with younger patients now being admitted for stroke?
A. Yes. This alarming trend has been highlighted in the latest global stroke fact sheet published by the World Stroke Organization in the latest issue of the International Journal of Stroke (February 2022). The latest global data suggests that 16 percent of all stroke types and 23 percent of haemorrhagic strokes (“brain bleeds”) occur in the age group 15-49 years. Overall, 63 percent of all strokes occur in people less than 70 years of age. Only 37 percent of all strokes and 32 % of brain bleeds occur in the age group over the 70 years.
In a majority of these patients the same risk factors that cause stroke in the elderly play a role, which means people are acquiring risk factors like high blood pressure, diabetes, high cholesterol levels and heart disease at a relatively younger age. Sri Lanka Stroke clinical registry data in 2017 also showed that 33 percent of patients admitted after a stroke were less than 60 years of age, still in their working life.
Q. What has caused this disturbing trend?
A. The major contributory factor is the lifestyle changes with unhealthy dietary habits (consumption of fast and processed foods) and lack of exercise leading to a higher incidence of hypertension and diabetes at younger ages. Stress and unmanaged depression also play a role.
Q. What are the most important risk factors that lead to Stroke?
A. Almost 90% of all strokes are linked to 10 key risk factors globally and therefore preventable. The most important out of these is uncontrolled high blood pressure which accounts for 56 percent of all strokes. In the order of frequency of occurrence, the other risk factors are unhealthy diet (31 percent), high body mass index (24%), high fasting blood glucose levels (20 percent), air pollution (20 percent), smoking (18 percent), high LDL cholesterol levels (10 percent), kidney disease (8 percent), alcohol use (6 percent) and low physical activity (2 percent).
Q. Any recent contributory factors?
A. Air pollution and kidney disease appear to be new and emerging risk factors compared to the previous reports of other traditional risk factors common to other non-communicable diseases, especially heart disease, cancer and dementia.
Q. Today a large number of people both young and old, living in villages, towns and urban areas have switched to convenience foods such as takeaways and junk foods which are high in fat, salt, oil and carbohydrates. Do you agree this is one reason why more people are getting strokes at an earlier age?
A. Yes, 31% of all strokes are linked to poor and unhealthy diet rich in salt, saturated fats and sugar. Fast foods and processed foods are rich in salt and saturated fats. It is best to replace this with a diet rich in vegetables, fruits and low content of carbohydrates and fats.
Q. Are those with low immune systems like diabetics and those with hypertension, cancer and heart problems more vulnerable to Stroke?
A. Vulnerability to develop a stroke depends on your individual risk of cardiovascular disease. Diabetes, hypertension and some types of heart diseases increase the risk of stroke. There is no direct link between stroke and low immunity and cancer. Another striking feature that current global stroke data reveals, is that up to 80% of strokes and heart attacks occur in people with a low or moderate absolute risk of cardiovascular disease. This underlines the need for everyone, irrespective of their risk status to strictly adhere to the preventive measures.
Q. Are there different types of Stroke?
A. The disturbance of the blood supply in most patients (85%) occur as a result of blockage of a feeding artery (termed ischaemic stroke or infarction) and in others due to rupture of a feeding artery (termed haemorrhagic stroke). 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.
Q. What are the early warning signs to look for prior to someone getting a stroke?
A. The most important feature is the sudden onset. A wide range of symptoms and signs may be seen depending on the area of the brain affected. Knowing the “FAST” stroke scale is the best way to remember the commonest signs of stroke. If any one or more of the 3 signs are positive, the patient has very likely developed a stroke.
Q. What is it? How can it be used?
A. This scale checks for 3 most common signs of stroke, they are;
F – Face : Look for facial drooping when the patient talks or smiles
A – Arms : Does the arm drop when asked to raise both arms
S – Speech : Is the speech slurred when talking
T – Time : If any one of these signs are present, take action immediately
Q. If we see these signs appearing in someone what is the first thing we should do? Who should we contact and where can we get the quickest response?
A. The patient should be taken to the nearest major hospital with a CT scanner, not the family doctor, even if the symptoms appear to be resolving. All Teaching, Provincial, District General and most Base Hospitals have the facility. 1990 Suwa Sariya Ambulance service is available free to transfer the patient. Calling through 1990 mobile App will help quick identification of the location (available for free download).
Q. What is the first thing to do when a patient shows signs of a stroke?
A. The first step in the treatment is to identify the type of stroke by a CT scan. Therefore, the patient should be taken directly to a hospital with this facility.
Q. There are advanced techniques now being used for emergency management of a stroke such as clot busting. Tell us about this technique?
A. This is done by administering an injection to dissolve the clot after careful evaluation of the patient.
Q. What category of patients are eligible for this treatment?
A. Patients with a blocked artery or ischaemic stroke, once all contra-indications are excluded
Q. How long does this particular procedure take usually?
A. There are strict time windows for clot busting treatment for eligible patients which is 4.5 hours currently.
Q. What happens next?
A. Once the emergency management is done, the patients are admitted early to a stroke unit, a Neurology unit with dedicated stroke beds or a rehabilitation ward. A multidisciplinary team comprising doctors, nurses, physiotherapists, speech and language therapists, occupational therapists and a social worker will be managing the patient to minimise complications and disability and improve the patient’s functional capacity.
Q. Once a person gets a stroke will he/she be vulnerable to another stroke ?
A. One in four stroke survivors are at risk of developing another stroke. Hence all prescribed medications and lifestyle modifications should be meticulously continued.
Q. Simple guidelines to follow?
A. Controlling the risk factors mentioned above will prevent 90% of all strokes. Adopt healthy lifestyle habits which include diets rich in fresh fruits and vegetables, low in processed foods, and avoid high saturated fats, free carbohydrates and salt. Thirty minutes of physical exercise at least 5 times a week following your doctor’s instructions, avoiding smoking and keeping alcohol use within safe limits, will also help.. Those who have NCDs should seek medical advice and control them.
Q. Is obesity a risk factor for early stroke?
A. Yes, a body mass index of over 24.9 and increased waist circumference (over 40 inches for men and 35 inches for women) significantly increase the risk of stroke.
Q. We are now in the post Covid era. How vulnerable are Stroke patients to this highly infectious disease ?
A. Pre-existing NCDs, especially chronic lung and heart disease can increase the risk of infection. Preliminary data from countries with heavy burden of Covid-19 shows increased risk of stroke and heart attacks due to increased risk of thrombosis. My most important advice to patients is to continue all prescribed medications even if they are unable to attend clinics as we see a significant number of recurrent strokes due to non-adherence to preventive treatment. In the event of new stroke symptoms, getting to a hospital immediately is essential in order to obtain treatment on time.
Q.The Stroke Association of Sri Lanka celebrated its 20th anniversary last year. What are some of the interventions your Association has put in place to help improve the quality of life of Lankan stroke victims?
A. Currently, we are improving public awareness of stroke, carrying the messages to the public that stroke is treatable if action is taken immediately and stroke can be easily prevented by adopting lifestyle changes.
Q. Your plans for this year and the future?
A. Due to the Covid-19 mass public awareness campaigns like stroke walks will not be held. An awareness campaign through print, electronic and social media will be carried out instead. The Association is also liaising with the Ministry of Health to establish more stroke units in provincial hospitals and a state-of-the art National Stroke Hospital which will be set up in Colombo East.
Q. Your message to our readers on how to reduce their risks of stroke
A. Adopt healthy lifestyles, even if your risk is low. Seek medical attention early when necessary to prevent a stroke. Learn how to recognise a stroke easily to be able to prevent adverse outcomes.