The Stroke Of Death And Disability
The World Health Organization (WHO) defines stroke as the manifestation of clinical signs of focal (or global) disturbance of cerebral function originating in the blood vessels, lasting for 24 hours or longer, sometimes leading to death and many times, disability.
The National Registry of Stroke identifies stroke to be the second leading cause of death in adults, two-thirds of which occurs in developing countries. A Global Burden of Disease study estimates that by 2030, 23 million will suffer from first-ever strokes, there will be 77 million stroke survivors, 61 million DALYs (Disability-adjusted life year) and 7.8 million deaths in low and middle income countries.
Between 1970-1979 and 2000-2008, there was more than 100% increase in incidence of stroke in low and middle income countries including India.
Stroke is amongst the most time critical conditions. From the time a patient starts having a stroke to the time the blood supply is restored, there is a very short time window as among all human tissues, brain is notorious for having a very short half-life.
“Brain death happens much more quickly, compared to a heart muscle or any other muscle. That’s why we need to act immediately,” stresses Dr Dhavapalani Alagappan, Emergency Medicine, Apollo Hospitals, Chennai.
Rapid Developments In Treatment
While that is bad news, the good news is that the medical outlook to how stroke is treated has changed radically. “Ten to fifteen years ago, what could be done was very limited. The emphasis was on stroke prevention for the future and managing the complications,” explains Dr Dhavapalani.
Management included inserting a nasogastric tube for nutritional needs and to keep the patient hydrated. Since the patient would be bed-ridden, prevention of pressure sores, providing rehabilitation and prevent aspiration of their secretions also was part of management.
In the last 15 years, however, the management of stroke has changed much. In fact, there is so much happening that what was being practiced the previous year is not applicable in the current year any more. It is dramatically changing so much that what was an acceptable outcome a year ago is being challenged this year.
In stroke, 80-85% are caused by blockages of the blood vessels and the remaining from blood vessels bursting or bleeding, called haemorrhage. Loss of blood supply, otherwise known as ischemic stroke, can be prevented and the blood vessels unblocked by administering a clot bursting drug if the patient present themselves early. The clot can also be sucked out mechanically. This is proven to have dramatic improvements in the patient’s outcomes.
Till a few years ago, a patient had only a window of 3 to 4.5 hours from the time of the onset of the stroke to be administered thrombolysis. From 2015, due to the introduction of advanced endovascular treatment approaches, the window has been significantly extended even up to 9 hours in selected cases. This is still short, though better than before, and makes timely intervention essential to save the patient from death or disability.
Because of the need to differentiate a block (ischemia) and haemorrhage, assessing the cause of the stroke is important, but it is not easy. With a heart attack, for instance, a simple tool like an ECG can help diagnose the condition and the patient can be subject to angioplasty immediately.
But in case of a stroke, the patient needs to be not only assessed clinically but also an imaging using CT or an MRI is essential to identify the cause – clot or bleed. Based on this, the course of treatment is decided. This takes time and skills.
From door-to-thrombolysis, it should take only 45 minutes and therefore requires a competent Emergency clinician, a radiologist for the CT scan and a neurologist to determine the treatment to be given. For strokes in the small brain, or posterior circulation strokes, treatment has a longer time window.
Patients do not perceive stroke as a dire emergency as they usually do not have pain and do not associate the condition with death like in the case of heart attack. This also prevents patients and their families from understanding the disabling and fatal nature of the disease and seeking immediate help.
Stroke has an impact on everyone around the patient. Depending on others for their personal hygiene needs, for feeding or even dressing is embarrassing and lowers the patient’s confidence. Many of the patients unsurprisingly become depressed. Dependence also puts burden on the family and turns the environment topsy-turvy. Patients may also display aberrations in behaviour, causing embarrassment to the family. Death from stroke is preventable with timely intervention.
Taking the patient to a hospital with a strong emergency department that has the right imaging facility, live reporting, a neurologist to take the decision on thrombolysis and an emergency department that executes it is a must.
For the bleed patients, controlling their blood pressure and preventing complications are a priority. Those with a massive bleed or with bleeding into the ventricles – the internal spaces in the brain – require surgical intervention. They need more aggressive treatments to prevent complications and to reduce morbidity.
Signs And Symptoms
To know when to rush to the hospital in case of a stroke, look for FAST – facial droop, arm or leg drifting/weakness where using the limbs becomes difficult, inability to speak or slurring, requiring time critical treatment. This is not foolproof though. Some of the other symptoms include loss of sensations, imbalance, behavioural changes and restlessness.
But even before the FAST stage, patients may also display certain warning signs called in brief as TIA – Transcend Ischemic Attack: momentary or time-bound neurological deficit.
The patient may be unable to speak or use their arm for certain number of minutes. They need a complete evaluation for stroke to check for narrowing of blood vessels in the neck and externally.
Tobacco, alcohol use, physical inactivity and unhealthy diet low in fruit and vegetables are metabolic risk factors that lead to obesity, high blood pressure; high blood cholesterol and high blood sugar increase the risk for strokes.
Genetics also plays a role. Lifestyle modification and keeping sugar and BP under check are very important preventive measures.
Good nutrition, exercising and avoiding tobacco and alcohol use along with periodic check-ups and timely presentation in case of any behavioural and physiological disabilities will help one lead a long and healthy lifestyle.