Strokes (or ‘cerebrovascular accidents’) occur when blood flow to an area in the brain is cut off. Brain cells, deprived of oxygen and glucose, die. If not treated early, this can result in permanent brain damage. While there are several types of brain strokes the ischemic stroke is the most common. It occurs when clots form in blood vessels, and the blockages lead to lack of oxygen to the brain.
Strokes are the leading cause of disability and the third leading cause of death. They are preventable by the control of risk factors. They are also treatable, but patients must seek immediate medical care.
Some of the earliest signs of stroke are: a) Sudden numbness or weakness in the face, arm, or leg; b) Sudden blurred vision in one or both eyes; c) Sudden inability to move part of the body; d) Sudden dizziness or headache with nausea and vomiting; e) Difficulty in speaking or understanding words or simple sentences; f) Difficulty in swallowing; g) Dizziness, loss of balance, or poor coordination; h) Brief loss of consciousness; and, i) Sudden confusion.
At times a stroke may present as a “mini-stroke” called transient ischemic attack (TIA). They are a warning of an impending stroke and typically consist of the same signs and symptoms of stroke, but the symptoms are transient.
The only approved treatment for acute ischemic (sudden onset) stroke is a thrombolytic agent or “clot buster” medication called tPA, which must be given within the first 3 to 4 hours of onset of stroke symptoms. There are several new and experimental drugs but their role is unproven.
In India, approximately 20 million per year suffer from stroke and, of those, 5 million will not survive. Studies project that total deaths from stroke in India will surpass established market economies by year 2020. Stroke is no longer a disease of the developed world. Indeed, low and middle-income countries account for 85 per cent of deaths worldwide.
Stroke is a life changing event with huge implications. It affects not only the person who is disabled but also the family and caregivers. It wreaks such havoc that it is viewed by more than half of those affected as being worse than death.
Up to 80 per cent of all strokes are preventable. Some controllable risk factors include: High blood pressure (greater than 140/90); Atrial fibrillation (an irregular heart rhythm); Uncontrolled diabetes; High cholesterol (greater than 200); Smoking; Alcohol (more than one drink per day); Being overweight.
The American Heart Association (AHA) has recently released detailed guidelines for primary stroke prevention but rightly emphasizes that a “one size fits all” treatment model may prove ineffective. In stroke prevention, personalized medicine with a “tailored” approach seems preferable. Here are some salient points of the vast document:-
High blood pressure should be treated to a goal blood pressure (BP) of less than 140/90 mm Hg. Achieving target blood pressure is, in itself, more important than the types of medications used to treat hypertension. Self-measured BP monitoring helps to reduce overall BP values and is recommended.
Statins, by lowering the “bad cholesterol”, should be first-line agents for stroke prevention among patients who are at a high risk. The drug niacin can raise favourably the “good cholesterol” but it is of unproven value in preventing stroke. Similarly, drugs like fibrates (used to decrease triglycerides) may not actually prevent stroke.
Exercise is important and the minimal amount of exercise recommended to prevent stroke is 40 min a day at 3 to 4 days a week. A reduction of sodium intake and increased intake of potassium to lower BP as well as the Mediterranean style diet is considered beneficial for stroke prevention.
Obesity increases the risk for stroke. Weight loss reduces BP and blood glucose levels and has been demonstrated to reduce the risk for stroke.
Aspirin at a dose of 81 mg per day or 100 mg every other day remains recommended for patients at high risk for stroke. Aspirin should not be used to prevent stroke among patients whose sole risk factor is diabetes or asymptomatic peripheral artery disease.
An important cause of stroke is a heart rhythm anomaly called “atrial fibrillation” where clots arise from the heart and clog the brain arteries. In an attempt to prevent clot formation, agents like warfarin are used. Newer, but more expensive substitutes, like dabigatran and others are being used to prevent bleeding in the brain which can occur as a side-effect of these drugs.
Few illnesses are as a disabling as a stroke. Here is what a sufferer had to say: “Before my stroke, I lived life in the fast lane. I was a party animal who loved to drink, dine and dance. Then the stroke hit me like a bolt from the blue – a devastating experience that left me demoralized.
Thank God I am now on the path of recovery. I have learned the hard way that our body and brain are God’s most precious gifts and we have to love and honor them”.
(Dr. Francisco Colaço is a seniormost consulting physician, pioneer of Echocardiography in Goa, column writer, singer/songwriter/music aficionado, Mando exponent, past president of the state IMA, social activist, popular orator and toastmaster, family man, with deep faith in God.)
