Today Neurologists, Stroke Physicians, and all looking after the needs of stroke patients across the world will come together to observe World Stroke Day. In an interview with the Sunday Observer, President National Stroke Association of Sri Lanka, and Consultant Neurologist Sri Jayawardenepura Teaching Hospital, Dr. Harsha Gunesekara elaborates on the risk factors, preventive measures and treatments of stroke.
Q: I understand the theme this year is “Be Greater than Stroke”. To what extent does this global theme relate to the current needs of Stroke victims in Sri Lanka?
A. Stroke is the leading cause of adult-onset disability. One in four of us are at risk of developing a stroke in our lifetime. However, up to 90 percent of strokes are preventable. This year’s theme focuses on prevention of stroke, given its major economic and social impact especially in the low and low-middle income countries (LLMICs), like Sri Lanka. We can each take actionable steps to reduce our individual risk of stroke. And together we can lower the burden of stroke worldwide. Prevention is better than cure. And prevention is greater than stroke. The World Stroke campaign in 2023 showcases how together we are greater than stroke.
Q: How do you define Stroke?
Dr. Harsha Gunesekara
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).
Q: It has been said that stroke damages the brain as millions of neurons will die unless the patient is not treated immediately. What are neurons? How do they function in 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. A 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 stroke is left untreated. Therefore, treatment should be initiated immediately to prevent the damage.
Q: What are the causes and risk factors that make a person vulnerable to stroke according to your latest data?
A. The World Stroke Organization 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 (31percent), 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: How does a person know if he or she has had a stroke? What are the symptoms to watch out for?
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 ,what is the first thing that those nearby must do?
A. The patient should be rushed to the nearest major hospital – not to the general practitioner. 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. An updated map of hospitals equipped with clot buster treatment is maintained by the Association of Sri Lankan Neurologists at www.asn.lk
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: 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. According to Sri Lanka Stroke Clinical Registry data, haemorrhagic strokes are more common in men and ischaemic strokes are commoner in women.
Q: Stroke was once considered a disease of the elderly. However recent studies have reported that more young people are showing risk factors for strokes . What causes this and why?
A. Globally, stroke in the young (less than 45 years) accounts for 10-15 percent of all strokes. However, while in the past, stroke in the young was thought to occur as a result of rare risk factors, 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 ?
A. No. Stroke now is the 5th leading cause of death in hospitalised patients. Although stroke admissions to state hospitals have doubled from 30,000 to 60,000 over the past 10 years, this may be because the public is more aware that stroke is treatable and the hospitalisation is needed.
Q: What is a mini Stroke?
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: 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: The best place for patients with stroke to be treated ?
A. 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, North Central and Northern. Currently in Sri Lanka, only around 15 percent of patients have access to stroke unit treatment due to limited infrastructure facilities.
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 multi-disciplinary 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. All stroke units, Neurology units 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 ?
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 would a stroke patient have to be hospitalised?
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 Association regularly carries out massive island wide public awareness campaigns through Stroke walks, media programs, community awareness and education programs at public and private sector establishments, schools. In addition, training and programs 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;
1. Know your blood pressure and control it.
2. Do moderate exercise for 20 – 30 minutes at least 5 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
The NCD Unit of the Ministry of Health maintains over 800 healthy lifestyle centers (HLCs) in the country where free screening is offered for all above the age of 35 years. Advice on all of the above factors 1 -10 and free testing could be obtained through these. The closest HLC to you can be found at https://www.ncd.health.gov.lk
