Stroke is a common neurological health problem globally and in Sri Lanka. It is also one of the most preventable diseases, with recent studies confirming that almost 90 percent of strokes can be prevented with 10 easy- to- follow simple steps to control the risk factors that cause it.
Unfortunately not many people know about these risk factors, while pockets of the community are also unaware of the urgency of admitting a patient showing symptoms of stroke to the nearest hospital preferably with a stroke unit as soon as possible to ensure he/she receives optimal treatment with successful outcomes. Hence educating the public on these issues is thus the need of the hour, and the reason why the National Stroke Week was launched recently, President of the National Stroke Association of Sri Lanka (NSASL), Dr. Harsha Gunesekara told the Sunday Observer in a recent discussion on the objectives of this special week.
Following are excerpts.
 Dr. Harsha Gunesekara |
Q. Recently the National Stroke Association of Sri Lanka (NSASL) of which you are the President observed a National Stroke Awareness Week. Why was it necessary to devote a whole week just to raise awareness on this particular subject ?
A. Because stroke, which is a global neurological problem, is also a preventable health issue. Thus raising public awareness on how to prevent and minimise its risk factors is extremely important.
Q. What were the key messages which this special week focused on?
A. 1). Be aware of stroke and its causes.
2) Up to 90 percent of strokes are preventable
(3) Stroke is treatable, especially if the patient is hospitalised immediately.
Q. When was the first National Stroke Day held?
A. The National Stroke Association of Sri Lanka declared a National Stroke Day way back in 2004
Q. How does it spread the key messages you just mentioned?
A. Through stroke walks, educational meetings at work places, schools, clubs and the media. This year’s effort promoted awareness of the above key messages, mainly through media. In addition, the Association will be holding an International Stroke Conference in collaboration with the Asia Pacific Stroke Organization, with the participation of global experts in Stroke from Australia, South Korea, India, and USA. There will be a Training Workshop on novel stroke treatment called “thrombectomy” or clot retrieval. Furthermore, through its Stroke Bed Project, the NSASL will be donating equipment to establish a stroke unit in the Teaching Hospital, Anuradhapura on March 30. It will be one of many projects to equip stroke units for the needy hospitals of the country.
Q. But aren’t the units already existing sufficient? What is the urgency for setting up so many stroke units countrywide considering our cash strapped- economy?
A. Because in Sri Lanka there are only 9 stroke units which are mainly concentrated in the Western, Central, Sabaragamuwa, North Western and Southern provinces. Thus only 15 percent of our stroke patients have access to a stroke unit. It is well established that stroke patients managed in stroke units have better chances of recovery. So, if we can establish more stroke units in hospitals, especially in provinces without stroke units, this will help more stroke patients to be treated in stroke units where the outcomes are more successful.
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 tissue 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 disability. Name five leading causes that lead to a Stroke?
A. The underlying causes are termed risk factors, and the 5 major causes are high blood pressure, smoking, diabetes, high cholesterol level and atrial fibrillation (irregular heart beat). Recently, chronic kidney disease has also been added as a risk factor. The lifestyle factors closely linked to increased stroke risk are unhealthy diet (see below), lack of regular exercise, obesity, excessive alcohol use, stress and depression.
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?
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 someone presents the above symptoms,what is the first thing that those nearby must do and how soon?
A. Initiate treatment in the nearest hospital as soon as possible. Treatment time windows in stroke are narrow and treatment should be started immediately to minimise the damage. The patient should be rushed to the nearest major hospital – not to the family doctor and 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. 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% of deaths and 87% disability due to stroke occurs in low and low-middle income countries like ours.
Q. A study in 2014 said that more young people are now showing risk factors for such strokes. Judging by our hospital admissions is this correct?
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?
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. 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, nutritionists, psychologists 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. Which hospitals currently offer persons with limited budgets access to the facilities for rehabilitation which you just mentioned?
A. 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. However they need to be through a referral by a doctor.
Q. As President of the National Stroke Association of Sri Lanka what are the 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. Let me reiterate what I mentioned earlier when I said that almost 90 percent of strokes can be prevented by following 10 simple steps to control the risk factors. These steps are as follows:
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 (18.5 – 23) and waist circumference (below 36 cm for men and 32cm for women)
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