STROKE SUPPORT PROGRAM (SSP)

Stroke which is also called as “Brain Attack” is one of the serious life threatening conditions. Stroke is becoming an important cause of premature death and disability in India. Majority of stroke survivors continue to live with disabilities in our country and the costs of rehabilitation impoverish their families. There are very few stroke centres in India and very less stroke rehabilitation centres.

WHAT IS STROKE?

Stroke which is also known as “Brain Attack” means sudden expiry of cells in a limited part of the brain triggered by a reduced flow of blood to the brain. It can be of two types,

  • Due to sudden blockage of blood flow to the brain which is known as ischemic stroke. Nearly 70 – 80% of strokes are ischemic strokes in our country.
  • It can also occur due to bleed into the brain known as haemorrhagic stroke or intra-cerebral haemorrhage which accounts for 15 to 30%.

WHO estimates suggested that by 2050, 80% stroke cases in the world would occur in low and middle income nationsespecially India and China.

Stroke is a major cause for loss of life, limbs and speech in India.The “Indian Council of Medical Research” estimated it in the year of 2004. There were 9.3 lakhs cases of stroke and 6.4 lakhs deaths due to stroke in India and most of the people were less than 45 years old. 

HOW FREQUENT IS STROKE IN INDIA?

  • The estimated adjusted prevalence rate of stroke range is between 84-262 out of 100,000 in rural and 334-424 out of 100,000 in urban areas. The incidence rate is 119-145 out of 100,000 based on the recent population studies.
  • Stroke usually affects the elderly people between 50 to 70 years. It is assumed that the average age of patients with stroke in developing nations is usually 15 years younger than those in developed countries. In India, nearly one-fifth of patients with first-ever stroke admitted to hospitals has been estimated to be aged 40 years or less which has been labelled as “Stroke in Young”.
  • It can affect both men and women but commonly men are affected. However, in a study published from Thiruvananthapuram, there is a higher incidence of stroke among women than in men.

BRIEF OVERVIEW OF OUR BRAIN

Brain has left and right Cerebral Hemispheres in the top, Cerebellum in the back and Brainstem in the centre.

  • The left half of brain exerts its control over the voluntary movements of the right half of body and the sensations. The speech centre is located on this side and hence known as “Dominant Hemisphere” or “Dominant Brain”. This part is also responsible for one’s verbal memory and our ability to calculate and write.
  • The right half of the brain or “Non- Dominant hemisphere” in addition to controlling the voluntary movements of the left half of body is responsible for appreciation of music, visual memory and spatial perception of our surroundings. But in fact both sides are absolutely essential for proper functioning of the human being.
  • Coordinated movements of our body and speech are controlled by cerebellar hemispheres which is located in the back of the brain.
  • Brainstem can be equated to the electrical power station and is responsible for maintaining our conscious level and it regulates our pulse, breathing and blood pressure.

WHAT ARE THE SYMPTOMS OF STROKE?

Stroke commonly is a “Sudden Onset”. It could strike you like a lightning or can progress over a span of 72 hours to cause paralysis of your functions. In few cases it can give you an early warning of causing transient loss of function of your body which recovers completely within a few hours known as “Transient Ischemic Attack [TIA]” which is almost similar to Angina of Heart Attack.

  • In majority of the cases of stroke, severe headache occurs prior to the onset of the dreadful event.
  • If the patient clearly is able to remember, “Time and date of onset of headache” and feels he/she has not experienced such severe headache ever in his lifetime, then it is likely that he has suffered a bleed into brain. This headache is known as “Sentinel Headache”.
  • In few cases of stroke, fits can be the presenting symptom.
  • Few patients may experience a transient loss of vision in one eye or blurring of vision or double vision just before major stroke.
  • Patients may get confused, they may have trouble in speaking and understanding.
  • The patients feel numbness in their face, arm or leg. This numbness will be particularly on one side of the body.
  • Patients have trouble with walking, dizziness and lack of co-ordination in their body.
  • Patients have trouble in controlling or expressing their emotions.
  • Some patients may also undergo into depression.

When Right brain [Cerebral hemisphere] is affected by Stroke it causes either,

  • Paralysis or loss of sensation of left hand or leg or both when the Motor or Sensory control areas of the brain are affected,
  • Can cause Memory deficits like inability to sing or appreciate music.
  • Impaired Visual Memory, inability to differentiate colours and its shades, difficulty in visualising objects in left half of our visual field and inability to recognize even faces of the relatives and which can be catastrophic when it occurs in an artist or a painter.

What happens when Left brain is affected?

  • Causes loss of voluntary function in right hand or leg or both.
  • Speech can be lost either partially or completely.
  • Memory deficits in the form of inability to do even simple addition, subtractions or even in writing a letter to your loved one.

When Cerebellum is damaged either due to lack of blood flow or bleed, it causes unsteadiness while walking which issimilar to a drunkard gait or slurred speech occurs.

The most dreadful thing to occur in stroke is when blood supply to brainstem is jeopardised. When Brainstem is affected, in mild cases it can cause severe giddiness with transient loss of consciousness. But in severe cases it can lead to comatose state and can be fatal. It is almost similar to complete shutdown of the electrical power station when the whole city plunges into darkness.

WHO ARE MORE PRONE TO DEVELOP STROKE?

People who are more prone to develop stroke have certain risk factors like

  • High Blood Pressure – Uncontrolled or poorly controlled – systolic BP > 140- 150, diastolic BP [lower one] > 95 -100. [Risk factor is around 60 to 80%]
  • Grossly elevated cholesterol levels [Total Blood Cholesterol: 240mg/dl and above],
  • Smoking
  • Poorly controlled Diabetes
  • Atherosclerosis [High risk]
  • Obesity [Modifiable factor]
  • Previous heart disease, like who have valvular heart problem or heart attack with an irregular pulse.
  • Low haemoglobin less then 12g [Treatable condition]
  • Kidney disease, mainly end stage renal failure which usually leads to uncontrolled hypertension and bleed into the brain.
  • Increased salt intake [Can be easily prevented]
  • Among women before menopause, the use of oral contraceptives has also been associated with a small increase in the risk for stroke. Risk is higher among women who have migraine or who smoke.
  • In post-menopausal women, hormone replacement therapy [HRT] a combination of estrogen and potent progestin can lead to increased incidence of stroke.
  • Women who had a stroke should not be started on hormonal therapy.

HOW STROKE IS DIAGNOSED?

Stroke is diagnosed after clinical suspicion like taking a CT [Computed Tomography] scan or MRI scan [Magnetic Resonance Imaging] of brain by the treating doctor.

  • CT scan can be done in few minutes and helps to differentiate between ischemic infarct [lack of blood flow to the brain] and brain haemorrhage [bleed into the brain].
  • In a few cases especially when CT scan taken within 6 hours of a minor stroke [like Transient Ischemic Attack] it can be normal even though there is definite clinical evidence of stroke. In these cases, MRI scan of brain is most useful when it is combined with Diffusion imaging studies which evaluate the blood flow to that particular part of the brain.
  • Physical examination can also have been done. The patients may ask to check blood pressure, carotid arteries in the neck and examine the blood vessels at the back of the eyes.
  • Blood test can be performed in order to check how quickly the patient’s blood clots, and also to check whether the patient has any infections.
  • Carotid Ultrasound scan is recommended by the doctor to check blood flows of the carotid arteries and to check any plaque are present.
  • Echocardiogram, a detailed image of the heart is created to check for the source of clots that could have travelled to the brain to cause a stroke.
  • If haemorrhagic stroke is suspected, then cerebral angiogram is done to exclude aneurysm. In the past few years, cerebral angiogram [similar to coronary angiogram performed for heart attack] is being done even in ischemic strokes, if the patient reaches the hospital within 4 ½ hours of onset of the stroke.

HOW STROKE IS TREATED?

IN ISCHEMIC STROKES:

Patient reaching the hospital within 4 ½ hours: In ischemic strokes, blood clot dissolving agents like TPA [Tissue Plasminogen Activator] can be given. Very good results have been reported with patients having good functional outcome. But there is a definite risk of patient developing bleed into the brain which can be even fatal.

  • With further advancements in technology, in a few patients where TPA is contraindicated, then these blood clots could be mechanically retrieved or dissolved using small catheters pass through the blood vessels which are going to the brain.
  • The most important factor in the above line of management is the TIME FACTOR of 4 ½ hours. If the above treatment is instituted after the above window period, in majority of cases catastrophic bleed into the brain occurs.

Patients reaching the hospital after 4 ½ hours: In ischemic strokes either Heparin or Low Molecular Weight Heparin or even Aspirin will start.

In certain massive ischemic strokes which cause severe brain swelling will lead to comatose stage and death. Decompressive Craniotomy surgery which is removal of the skull bone flap on the side of the ischemic stroke is performed to save the life of the patient. 

In Strokes which are caused due to the bleed into the brain:

Strokes caused due to bleed into the brain can be due to

  • Abnormal enlargement of the blood vessel known as Aneurysm which ruptures causing subarachnoid haemorrhage. These are treated after confirming the diagnosis by cerebral angiogram. Various treatment options like surgery are available where Clipping of the Aneurysm is performed by Neuro-radiological intervention using the method of Coiling of Aneurysm.
  • Hypertension causing brain haemorrhage, depending upon the location and size of bleed in the brain, surgery is contemplated.

CAN STROKE BE PREVENTED?

Yes, seek advice from your doctor to eliminate or control the predisposing risk factors. Prevention is always better than cure.

  • Daily brisk walking for 30 minutes. Avoid sedentary lifestyle.
  • Reduce your weight if you are obese or overweight. Try to achieve optimal height – weight ratio. Consult your dietician.
  • Stop smoking.
  • Stop alcohol consumption.
  • Strict control of Hypertension and Diabetes.
  • Take your drugs regularly if you have medical illness.
  • Women should avoid self-medication with oestrogen pills or hormone replacement therapy without medical supervision.
  • If there is a family history of stoke, you should have a regular follow up with your physician.
  • If you had stroke or heart attack, do not stop taking blood thinners like Aspirin without consulting your doctor.
  • Avoid taking food thatare rich in fat like ghee items, sweets and high intake of mutton.
  • Your diet should also include vegetables, fruits and lean meats such as chicken, fish and low-fat dairy products.
  • Add fibre to the diet, such as whole grain bread, cereal products or dried beans that may also help to reduce cholesterol.
  • Change cooking habits to baking, broiling, steaming or grilling instead of frying which would help to reduce cholesterol if you have high a cholesterol level.

Things to be remembered

A healthy and active lifestyle can prevent you from stoke. Try to get a control over your taste buds. If you suspect with the symptoms of stroke first consult a doctor and follow their advice. Do not try to do self-medication that may put you into trouble. If you follow all these general habits, then stroke can be prevented.