Stroke, one of the commonest neurological diseases is also undeniably one of the most disabling conditions that can afflict a once active person reducing him to a helpless invalid for life in the absence of timely interventions.
“That is why every minute counts. Rapid recognition of symptoms and need for immediate treatment saves lives and prevents lifelong disabilities,” said Consultant Neurologist, Sri Jayewardenepura Teaching Hospital and President, National Stroke Association of Sri Lanka, Dr Harsha Gunesekara.
In an interview with the Sunday Observer, Dr Gunesekara explained how early symptoms of stroke can be detected, and most importantly early onset of stroke can be prevented by following some simple golden rules.
Excerpts
Q: Two days ago, on World Stroke Day, Neurologists, Stroke Physicians, and others looking after Stroke patients shared their resources to highlight the urgent need to help save lives of stroke victims with timely intervention and treatment. This year’s global theme is Minutes can save lives. How does it relate to the 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. 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.
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). One in four people are at risk of developing a stroke in their life time.
Q: You mentioned neurons. What are they?
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 call synapses. A healthy adult’s brain has around 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 stroke is left untreated. Treatment should be initiated immediately to prevent the damage.
Q: It is said that stroke is usually caused by several underlying causes. What are they?
A: The underlying causes are termed risk factors. The five major risk factors are high blood pressure, smoking, diabetes, raised blood cholesterol levels and irregular heart beat (atrial fibrillation).
Q: Are there simple rules an onlooker can look out for in a patient showing symptoms of stroke?
A: The best method is to use the FAST stroke scale which is 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 take immediate action, even if the symptoms resolve. Presence any one of the symptoms suggests a possible stroke.
Q: If a person shows symptoms resembling a stroke, what is the first thing that should be done?
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 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. 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 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 a half of stroke deaths occur in women and that more men have strokes, but more women die from strokes. Where does Sri Lanka stand in this scenario?
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
Q: A study in 2014 said that more young people are showing risk factors for strokes. How far is this true today and why?
A: 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 young and older-onset stroke as a result of acquiring these risk factors early in life from unhealthy lifestyle habits.
Q: In 2001, stroke was ranked as the leading cause for disability and mortality in Sri Lanka and in 2004, it was the third leading cause of in-hospital deaths. Do these figures still hold today?
A: Stroke, now, is the seventh leading cause of death in hospitalised patients. Stroke admissions to state hospitals have doubled over the past 10 years. This is because the public is more aware that stroke is treatable and the hospitalisation is needed.
Q: What is a mini-stroke? Is it a prelude or warning to a stroke? What is the difference?
A: 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 is 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 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? Why?
A: Stroke units provide the ideal care through a multi-professional stroke team committed to caring of stroke patients with evidence of improved outcomes, enhanced recovery and shorter hospital stay. The multidisciplinary team (MDT) consists of doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, nutritionist, psychologist and a social worker.
Q: How many such units are there in Sri Lanka? Where?
A: There are nine stroke units in the country, distributed over five provinces: Western, Southern, Central, Sabaragamuwa and Northern. The Ministry of Health will be developing 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 a Neurologist or a Physician even in the absence of a stroke unit.
Q: Is the treatment 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: How long should a patient with stroke remain in hospital after a stroke?
A: It 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 the onset. As a general rule, after a stroke, one third of patients recovers 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 recent interventions for stroke victims and how you obtain funding for them?
A: The National Stroke Association of Sri Lanka (NSASL) was established in 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 islandwide public awareness campaigns through stroke walks, media programs, community awareness and education programs at public and private sector establishments and schools. Training programs for healthcare professionals on stroke care are held throughout the country. Funding for these activities are 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 for stroke victims is a priority. 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: Golden rules on preventing strokes?
A: Almost 90 percent of strokes can be prevented by following 10 simple steps to control the risk factors. They are; 1) Know your blood pressure and control it. 2) Do moderate exercise for 20 – 30 minutes at least five times a week. 3) Eat a healthy balanced diet rich in fresh vegetables and fruit and low in processed foods. 4) Know your blood cholesterol level and control it. 5) Maintain a healthy weight with a normal body mass index and waist circumference. 6) Stop smoking and avoid smoky environments. 7) Reduce alcohol intake. 8) Know your blood glucose level and control diabetes. 9) Identify and treat irregular heart rhythm known as atrial fibrillation. 10) Manage stress and depression.