An estimated 85 percent of deaths and 87 percent of disabilities due to stroke are from low and middle income countries such as Sri Lanka with more young people showing risk factors for stroke. - Study
 Dr. Harsha Gunasekara |
Once regarded as a disease of the elderly, the risk factors for stroke are now being diagnosed among younger patients, some in their early 40s and 50s globally and in Sri Lanka.
What is Stroke? What are the risk factors that drive this disturbing trend?
Unhealthy diets? Poor lifestyles? Lack of exercise? Delay in seeking medical advice when there are suspicious symptoms? How can we prevent these risk factors?
The Sunday Observer sought the help of Consultant Neurologist and President of the National Stroke Association of Sri Lanka Dr, Harsha Gunasekara for answers and to give readers simple guidelines they can follow to prevent risks leading to strokes.
Q: Today as Neurologists, Stroke Physicians, and many others looking after the needs of stroke patients across the world will come together to observe World Stroke Day. I understand the theme this year is Save Precious time as Minutes can save lives . To what extent does this global theme relate to the current needs of stroke victims in Sri Lanka?
A. Following a stroke, there is rapid loss of brain cells (neurons) to the tune of 1.9 million per minute. Therefore, every minute counts and treatment initiated immediately can prevent this loss. This year’s theme is based on this fact to promote awareness of rapid recognition of stroke symptoms and the need for immediate treatment. It also communicates what can be saved; a life, but also from being disabled for life and precious memories.
Q: Define stroke in simple language for the benefit of readers.
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 (neurons). Over 85 percent of strokes are due to a blockage of a blood vessel (ischaemic stroke) and the balance 15 percent due to rupture of a blood vessel (haemorrhagic stroke). Stroke is the third leading cause of hospital deaths and the leading cause of adult-onset disability worldwide. One in four of us are at risk of developing a stroke in our lifetime.
Q: It has been said that when somebody has a stroke, every second that goes by is crucial. As brain tissues and millions of neurons begin to fade away, time could not be more precious. Can you explain this further to our readers? What are neurons and how do they affect the brain ?
A. Neurons are basic cellular functional units of the brain and act by transmitting electrical impulses and chemical signals within the brain and rest of the nervous system through multiple connections called synapses. Normal healthy adult brain has approximately 100 billion neurons and 100 trillion synapses.
Following a stroke, 1.9 million neurons are lost every minute and on average 1.2 billion neurons die if the stroke is left untreated. Therefore, treatment should be initiated immediately to prevent the damage.
Q: I understand there are several causes that drive this disease. What are they? Are there any new causes?
A. The underlying causes are termed risk factors. One or more risk factors will make a person susceptible for stroke. Risk factors for stroke and other non-communicable diseases (NCDs) such as coronary heart disease are quite similar. The world stroke organisation has updated the top 10 stroke risk factors for stroke together with the frequency of their association with stroke. They are; high blood pressure (56 percent), unhealthy (which means high in sugar, salt and saturated fats) diet (31 percent), high body mass index (24 percent), high fasting glucose (20 percent), air pollution (20 percent), smoking (18 percent), high LDL cholesterol (10 percent), kidney dysfunction (8 percent), alcohol use (6 percent) and low physical activity (2 percent).
Q: Drastic changes in unhealthy lifestyle among both young and old alike are said to be among the major contributory causes for the stroke figures continuing at their unacceptable levels e.g. increase in cigarette smoking, alcohol, ingesting fast foods high in carbs and unsaturated fats , eating salty spicy bites . Do you agree ?
A. Yes, these risk factors related to lifestyle habits which not only increases your risk of stroke but also other non-communicable diseases such as heart disease and cancer are well recognized in all age groups.
Q: How does a person know if he or she has had a stroke? What are the symptoms that the victim or an onlooker must watch out for? Are there some simple steps to follow ?
A. The best method is to use the FAST stroke scale which is a simple, quick and a reliable assessment. Here is the way to remember it; F - stands for FACE drooping, A - stands for ARM weakness, S - stands for SPEECH difficulty and T - stands for TIME to to take immediate action, even if the symptoms resolve. Presence of any one of the symptoms suggest a possible stroke.
Q: If a person has symptoms that resemble a stroke at home or at work ,what is the first thing that those nearby must do?
A. The patient should be rushed to the nearest major hospital – not to the family doctor. The patient should be treated in a hospital equipped with a CT scanner as this helps to identify the type of stroke and initiate treatment promptly. All Provincial and almost all District General Hospitals in the country have CT scanners.
Q: How soon should he/she be taken to hospital after the first symptoms?
A. As urgently as possible. Treatment time windows in stroke are narrow and treatment should be started immediately to minimise the damage.
Q: What happens if there is a delay?
A. Delays can lead to missed opportunities for treatment or poor outcomes from treatment resulting in death or permanent disability. Annually, 60,000 stroke patients are admitted to state hospitals, but the majority of them arrive late.
Q: Age-wise and gender wise, who are most at risk of getting a stroke? Why?
A. Globally, 60 percent of strokes occur in people under 70 years and 8 percent are under 44 years. Both types of strokes are commoner in men.
Q: A study abroad has said that over half of stroke deaths occur in women and that more men have strokes, but more women die with strokes. Where does Sri Lanka stand in this scenario? Your comments.
A. Globally, stroke is commoner in men (52 percent) but deaths from ischaemic stroke is commoner in women. Deaths from haemorrhagic strokes are commoner in men. We don’t have any incidence data on the Sri Lankan situation. However, research has shown that 85 percent of deaths and 87 percent disability due to stroke occurs in low and low-middle income countries like ours.
Q: Stroke was once considered a disease afflicting elderly persons over 60 years . However, a study in 2014 said that more young people are showing risk factors for such strokes. Judging by hospital admissions, how far is this true today and why?
A. Globally, strokes in the young (less than 45 years) accounts for 10-15 percent of all strokes. Traditionally, stroke in the young was thought to occur as a result of rare risk factors. However recent studies have shown that similar risk factors account for both young and older-onset stroke as a result of acquiring these risk factors early in life.
Q: In 2001 stroke was ranked as the leading cause for disability and mortality in Sri Lanka and in 2004 it was ranked as the third leading cause of in-hospital deaths in Sri Lanka. Do these figures still hold today considering the many preventive interventions that have been made since then?
A. It’s pleasing to note that stroke now is the 7th leading cause of death in hospitalised patients. Stroke admissions to state hospitals have doubled from 30,000 to 60,000 over the past 10 years. This is because the public is more aware that stroke is treatable and hospitalization is needed.
Q: What is a mini Stroke? Many people are confused when they are told they have suffered a mini stroke but are still able to function normally. Is it a prelude or warning to a stroke? What is the difference?
A. Mini stroke or TIA (transient ischaemic attack) refers to rapid improvement of stroke symptoms, usually within minutes. This has to be given serious consideration as it’s a warning of an impending stroke. It’s your best opportunity to prevent a major stroke by seeking immediate medical attention.
Q: Treatment- No sooner a patient is rushed to a hospital what is the first line of treatment?
A. This depends on the type of stroke. A CT scan is performed urgently to determine this after initial assessment of the patient. Clot busting treatment will be given to eligible patients. All patients will benefit from urgent treatment at hospital which will prevent further worsening of stroke itself or by its complications. Needy patients will undergo rehabilitation by a stroke team within a stroke unit.
Q: What is the best place for patients with stroke to be treated ? The Stroke Unit? Why?
A. Yes, stroke units provide the ideal care through a multi-professional stroke team committed to caring for stroke patients with evidence of improved outcomes, enhanced recovery and shorter hospital stay.
Q: How many such Units are there in Sri Lanka? Where?
A. There are 9 established stroke units in the country distributed over 5 provinces, namely Western, Southern, Central, Sabaragamuwa and Northern. Currently in Sri Lanka, only around 15 percent of patients have access to stroke unit treatment due to limited infrastructure facilities. The Ministry of Health is planning to develop more stroke units to cover the other provinces.
Q: What if there is no such Stroke Unit in the nearest hospital to where the patient has been sent?
A. Emergency stroke care will be provided at all hospitals equipped with a CT scanner and also having a Neurologist or a Physician even in the absence of a stroke unit.
Q: I understand there is a multi disciplinary team that looks after the needs of Stroke patients . Who comprises this team?
A. The multidisciplinary team (MDT) consists of doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, nutritionist, psychologist and a social worker.
Q: Once the patient recovers I understand he goes through a rehabilitative process. What is this process?
A. Rehabilitation is the process that involves assessment of the rehabilitation needs of the patient and interventions to optimise function and reduce disability to enable a person to engage in basic and instrumental activities of daily living.
Q: Where can an underprivileged person have access to these facilities for rehabilitation?
A. All stroke units, Neurology wards and Medical wards in state hospitals and in ward and out-patient rehabilitation services of rehabilitation hospitals are offered free to all patients but need to be through a referral by a doctor.
Q: Is the treatment a blanket one or is it customised for each patient depending on the severity of the attack?
A. Treatment is specific to the type of stroke initially and thereafter the rehabilitation process depends on the severity of the stroke. Patients with higher degrees of disability will need longer periods of rehabilitation by the MDT.
Q: For how long should a patient with a stroke remain in the hospital?
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 will be left with a permanent disability and a third will die either in the acute stage or later from complications.
Q: As President of the National Stroke Association of Sri Lanka, briefly outline the recent interventions for stroke victims in the past few years.
A. The National Stroke Association of Sri Lanka (NSASL) was established in the year 2001 by its Founder President Dr Jagath Wijesekera and has completed two decades of service to the country. A National Stroke Day was declared by the Association long before the World Stroke Day was established. The Association regularly carried out massive island wide public awareness campaigns through Stroke walks, media programs, community awareness and education programs at public and private sector establishments and schools. In addition, training programmes for healthcare professionals on Stroke care are held throughout the country. Funding of these activities are entirely through public and corporate sector donations.
Q: Gaps you like to fill to ensure optimal care for stroke patients?
A. Establishment of more stroke units to optimise the care of stroke victims is a priority. In addition, the association is also working on expanding the new clot retrieval treatment which is available only in Colombo to other parts of the country.
Q: Your message to the public on preventing strokes?
A. Almost 90 percent of strokes can be prevented by following 10 simple steps to control the risk factors. They are;
*Know your blood pressure and control it.
*Do moderate exercise for 20 – 30 minutes at least 5 times a week
*Eat a healthy, balanced diet rich in fresh vegetables and fruit and low in processed foods.
*Know your blood cholesterol level and control it.
*Maintain a healthy weight with a normal body mass index and waist circumference
*Stop smoking and avoid smoky environments.
*Reduce alcohol intake
*Know your blood glucose level and control diabetes.
*Identify and treat irregular heart rhythm known as atrial fibrillation
*Manage stress and depression