• Better stroke care for better brain health 

Stroke is a disease that affects the blood supply to and within the brain, leading to disabilities and even death of a person. According to global data, among the 240 causes of death, stroke is the second most common cause of death after ischaemic heart disease, and it is projected to be the same by 2030. Stroke survivors may suffer from disabilities, requiring temporary or lifelong assistance, and resulting in an enormous burden, both in human and economic costs. “World Stroke Organisation” is the only global agency focusing on Stroke.  Each year on 29 October, World Stroke Day is celebrated globally to raise awareness on the serious nature and high rates of stroke, discuss prevention and treatment of the disease, and ensure better care and support for stroke survivors. Featuring the slogan “Minutes can save lives”, World Stroke Day is celebrated today to educate the public that every second that goes by is crucial, when somebody gets a stroke.  This year, the ambassador of the global campaign is four-time Olympic Gold medalist and former world record breaker, Michael Johnson. In 2019, the once-fastest man in the world had a stroke, proving that it can happen to anyone. World Federation Neurology Chair – Public Awareness and Advocacy and University of Melbourne and Western Health Australia Encyclopedia Neurology (Elsevier – 2022 Edition) “Stroke and headache disorders” Section Editor Prof. Tissa Wijeratne shared his expertise via an email interview regarding stroke management and prevention.  He leads a successful stroke care program at Western Health where the team manages a large volume of stroke patients in western metropolitan Melbourne. Prof. Wijeratne is a world-renowned senior neurologist and a great asset for the Sri Lankan health system. Following are the excerpts of the interview: What is a stroke and what happens when a person gets a stroke? Let us consider the brain before we talk about stroke.  The brain is the most sophisticated biological computer around, and nothing is more complex than our brain. It consists of well over 100 biological wires packed together.  The length of these wires is equivalent to the distance of travel around the planet four times or more. These wires talk to each other through chemical connections known as synapses. There are well over 10 trillion such connections.  It is this electrical and chemical activity in the brain that lets us do everything we do. The brain needs a constant energy supply in the context of glucose through adequate blood supply for all these to occur.  There are only four tubes/arteries (two internal carotids and two vertebral arteries) to supply blood to the brain to ensure its constant functioning 24/7. These four tubes end up making a circle (circle of Willis) inside the brain with various branches to ensure that all parts of the brain get a constant supply of nutrients through the blood.   A stroke happens when blood cannot get to your brain because of a blocked or burst artery. As a result, your brain cells die due to a lack of oxygen and nutrients. There are two types of strokes. A stroke that is caused by a blood clot is called an ischaemic stroke. (Fig. 1) There are two ways an ischaemic stroke can occur: If a blood clot forms somewhere in the body (usually the heart) it can travel through the bloodstream to your brain. When the clot travels to a blood vessel that is too small for it to pass through, it gets stuck there and stops the flow of blood. These are called embolic strokes. As the blood flows through the arteries, it may leave behind cholesterol-laden “plaques” that stick to the inner wall of the artery. Over time, these plaques can increase in size and narrow or block the artery and stop blood getting through. In the case of strokes, the plaques most often affect the major arteries in the neck that take blood to the brain. Strokes caused in this way are called thrombotic strokes. Strokes caused by a break in the wall of a blood vessel in the brain are called hemorrhagic strokes. These cause blood to leak into the brain, stopping the delivery of oxygen and nutrients. (Fig. 2) Hemorrhagic strokes are described by their location in the brain. There are two types: Intracerebral haemorrhage occurs when an artery inside the brain bursts and bleeds into the brain. The most common cause is high blood pressure (hypertension). Subarachnoid haemorrhage (SAH) is bleeding on the surface of the brain. There are three layers of membrane (or meninges) that cover the brain. A subarachnoid haemorrhage is a bleed that happens between the layer closest to the brain and the second layer. Haemorrhagic stroke can be caused by a number of disorders that affect the blood vessels.  However the main cause of hemorrhagic stroke is high blood pressure (hypertension). What are the symptoms of a stroke? A stroke attacks the brain – changing lives in an instant. Injury to an area of your brain can impact how you think, behave, use words, swallow, see, feel, touch, and move your body. Stroke can happen to anyone of any age. Signs and symptoms of a stroke depend on the part of the brain that lost its function due to the stroke. Signs and symptoms often appear soon after the stroke has occurred. If symptoms last less than one or two hours (as per old WHO definition less than 24 hours), the stroke is a transient ischemic attack (TIA), also called a mini-stroke, the signs and symptoms of which are the same as stroke. How do you know if someone is having a stroke?  Think…BE FAST. B – Balance: Watch for a sudden loss of balance. Is the person leaning to one side or staggering when walking? E – Eyes: Is there a sudden loss of vision in one or both eyes? Double vision that doesn't go away when you blink your eyes. No side vision or vision above midline? F – Face: Ask the person to smile or stick out their tongue. Is the smile uneven, the tongue deviated to one side, or one side of the face droop? A bit of drooling out of that side of the face may be present. A – Arms: Ask the person to raise both arms. Does one arm drift downward? Is there sudden loss of co-ordination, numbness, weakness of that arm? For example, is the person suddenly unable to pick up a coffee cup or get it to his or her mouth? Does the arm or leg feel numb, or do they want to shake it all the time to wake it up like it's asleep? S – Speech: Sudden difficulty in speaking or understanding. Can the person repeat a simple phrase? Does the speech sound slurred/strange/garbled? Does the person say he or she has a thick tongue or have difficulty swallowing? T – Time: What do you do if you observe any of these signs in yourself or in someone you are with? Call 1990; do not drive the person to the local emergency room. By contacting Suwaseriya, assessment and treatment can be started prior to arrival to the Emergency Department and time (brain) is saved. If known, note the time the patient was last seen well and give this information to emergency personnel, along with any information you may have regarding the person’s current medications. This will help determine what treatment the person is eligible for. What are the risk factors to develop a stroke? There are some risk factors you cannot do anything about, like: age; the older you get the greater your risk of stroke, gender; stroke is more common in men, having a parent or sibling who has had a previous stroke, if you’ve had a previous stroke or transient Ischaemic attack (TIA). Modifiable risk factors such as smoking, excess use of alcohol, unhealthy diet habits and sedentary lifestyle can increase the risk of Stroke.  “It is worth remembering that nearly all strokes can be prevented. Despite this, as we write this, there are well over 100 million stroke sufferers worldwide. This is because we failed to act on well known 10 stroke preventive measures globally.” Time is so precious when a person gets a stroke.  Why is it important to go to a hospital as soon as possible? Every second of delay in treatment leads to loss of a day from a stroke affected person. Let me put this in a different angle. Suppose you are 45 years today and get a large vessel stroke and admitted to the National Hospital of Sri Lanka Colombo, treatment delay will let you leave the hospital as a 90 year old person, even if you may survive the acute stroke as you will continue to lose the biological electrical wires at a much faster rate than normal ageing process.  Therefore, time matters. Remember – Save a minute. Save a day.  What are the treatment options available for the patients affected with stroke? These are the proven therapies for stroke.

1. Stroke unit care

This should not be anything fancy. Stroke unit care means co-ordinated care for stroke in a geographically localised area. This can be done in every hospital in Sri Lanka easily, as we have tested this in Sri Lanka in the past with great success. 

2. Clot buster therapy and clot removal (ischemic Stroke only) 

Our group in Melbourne is among some of the pioneers in these treatments with potential to “cure” some of the ischemic stroke patients. Hundreds of disabling strokes were treated with these therapies, with hardly any disability by our group over the years.

3. Antiplatelet therapy (Ischemic stroke only) 

Number of medications available to reduce the stickiness of the platelets in these patients. This is a proven therapy for stroke as well.

4. Temporary removal of part of the skull to accommodate the swelling in a small subset of highly selected patients 

This is also known as hemi-craniectomy – only suitable for a small subset of highly selected stroke patients that will be decided by your stroke neurologist based on the individual circumstances.  What is the prognosis for stroke? Acute prognosis is excellent with almost “cure” for some patients. Long term prognosis is not great as a lot more science is yet to be sorted. Many patients continue to live with a plethora of post-stroke complications such as dementia, pain, depression, anxiety, epilepsy, and fatigue, to name a few.  This is why the best stroke is the one that you never had and do our very best to prevent strokes.  What can be done to reduce the risk of stroke?  These are the steps to a healthy life that will help you reduce your stroke risk well over 90%;  Make time for a health check – Particularly once you turn 45. High blood pressure is the top risk factor for stroke. It’s a hidden risk, as high blood pressure has no immediate symptoms. Hence the only way you know you have it is to get checked by a doctor. Optimal blood pressure to maintain is around 120/80, so if your blood pressure is regularly over 140/90, you may have high blood pressure. Check your cholesterol levels – The main cause of high cholesterol is a diet high in saturated fats (fats from animal foods).  Stay on top of type 2 diabetes – maintain blood glucose levels through diet, regular exercise and monitoring. Get to the heart of it – Atrial fibrillation (AF or an irregular heartbeat) can cause clots to form in the heart, which can move to the brain, leading to a stroke. Ask your doctor for an AF check, especially if you feel your heart beating irregularly, either in your chest or by taking your own pulse. Eat well – Having a poor diet can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease, and stroke. Balance your diet – Mix it up with vegetables, fruit and grain, lean meats, poultry and fish, reduced fat milk, and yoghurt. Reduce saturated fats like butter or fried foods. Drop the salt – Cut out salt and check the sodium content on packaged foods. Substitute your sugar – Swap sweet snacks for nuts or fresh fruit. Steer clear of sugary drinks – drink water. Go fresh – Buy from markets or shop around the outside aisles of the supermarket. Stay active - Raise your heart rate through exercise at least 2.5-5 hours a week. Being inactive, overweight, or carrying too much body fat can contribute to high blood pressure and high cholesterol. It can also lead to heart disease and type 2 diabetes. Regular physical activity can reduce your risk of stroke. Think before you drink – Drinking large amounts of alcohol increases your risk of both types of stroke (bleed and clot). Be smoke free – It increases stroke risk by increasing blood pressure and reducing the oxygen to the brain. Within a month of quitting, blood pressure can return to its normal range. The risk of heart attack and stroke starts to drop immediately, and can drop by up to half after a year. What is your ‘World Stroke Day’ message to the public?    Stroke is a preventable and treatable disease. Get involved and join our global campaigns to stop stroke and treat appropriately when they do occur. Let us make stroke a thing of the past by working together. Let us prevent stroke and dementia together. When you prevent strokes, you prevent nearly 40-50% of dementia as well. National Hospital Sri Lanka Consultant Neurologist and Association of Sri Lankan Neurologists (ASN) President Dr. Gamini Pathirana also shared his expertise in relation to the country’s situation: In comparison to the Western world, do you see any difference in the prevalence of stroke in Sri Lanka?  Based on the limited information available, the prevalence of Stroke in Sri Lanka is 10 per 1,000. The burden of stroke is much more in the low and middle income countries including Sri Lanka. So we think incidence and prevalence of stroke burden is more in Sri Lanka than in the Western world.   How can we minimise the burden felt from stroke in Sri Lanka?  Deficiencies can be there in any healthcare system, and the quality depends on the availability of resources. Within the resources available, I think we are delivering an excellent service for stroke patients in Sri Lanka.  It is true that stroke gives an immense burden to the society since it causes disability. We can minimise this burden by reducing the incidence of stroke in the community. To reduce stroke incidence, good lifestyle measures are of paramount importance.  Furthermore, it should be noted that quick recognition of stroke at home, immediate transport to hospital, delivering acute treatment to all those who qualify, take all measures to salvage ischaemic penumbra, early and sustained scientific rehabilitation, delivering therapy in a stroke unit, recognition of TIAs, quick evaluation of TIA patient evaluation, and social service contribution to those who are affected with stroke are the most important aspects in reducing long term stroke disabilities.  Establishing acute stroke units is underway by the Ministry of Health, amounting to one stroke unit per province. Making the stroke care teams in each hospital updated on acute stroke care is necessary considering the fact that stroke management keeps changing as new evidence is coming in.  The National Stroke Association of Sri Lanka, led by Dr. Harsh Gunasekara at present, and others in the past, have delivered an immense service in meeting the improved stroke care in the country.  I believe that planning for the future establishment of TIA clinics in hospitals would further help minimise the stroke burden in Sri Lanka. (The writer is a Medical Officer at the Directorate of Healthcare Quality and Safety of the Ministry of Health)