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April 2012
Stroke Time Is Critical
Dr Sudhir Kumar
Brain stroke, the medical emergency rooted in the occlusion of blood supply to a part of brain, commonly leads to paralysis and is one of the three leading causes of death and disability - the other two being heart attack and cancer.

Risk Factors For Brain Stroke
A number of factors put a person at risk of brain stroke. Some of these factors are genetically acquired, while others are the direct result of the person’s lifestyle.

Non-modifiable Risk Factors
  • Age: The prevalence of stroke increases with advancing age.
  • Gender: Men face a higher risk of stroke when compared to women. The risk facedby postmenopausal women may however be similar to men.
  • Family history: previous cases or instances of stroke in a family member, parents or siblings or children.
Modifiable Risk Factors
  • Diabetes mellitus
  • Hypertension
  • Dyslipidemia (elevated LDL cholesterol & triglycerides; low HDL cholesterol)
  • Smoking
  • Obesity
  • Elevated serum homocysteine (homocysteine is an amino acid, normally present in the blood and its higher concentrations can lead to atherosclerosis)
  • Cardiac disease (such as valvular heart disease, atrial fibrillation, prosthetic heart valves, etc). Clots can form in the heart and they can reach the brain via the bloodstream leading to stroke.
  • Prothrombotic states such as deficiency of Protein C, Protein S and Antithrombin III. These proteins prevent clotting of blood, and if they are deficient, clotting can occur in the brain arteries, leading to stroke.
  • Stress is known to increase the prevalence of diabetes and hypertension leading to stroke.
  • Unhealthy diet may also be responsible for several of these risk factors.
Clinical Presentation Of Brain Stroke
The common presentations of stroke can be remembered by the acronym FAST:
F= Face: Drooping or weakness of one side of the face.
A= Arms: One arm is weak and cannot be raised as much or as high as the other one.
S= Speech: Speech may be slurred or confusing.
T= Time: Time is critical.

Symptoms of stroke develop all of a sudden. For example, a person may go normally for a morning walk. After coming back, he starts to read a newspaper while having tea. Suddenly, he slumps to one side and falls down, is unable to hold the newspaper in his hand, and is unable to call for help in a clear voice. These symptoms develop over a few minutes and require immediate attention.

Striking The Young
Though stroke occurs more commonly in older people, its prevalence is increasing in the younger generation too. This is true in India and other Asian countries. We now commonly see very young people (in their 30s) coming to the emergency room with acute brain stroke. This is because of risk factors such as
  • High cholesterol
  • High homocysteine
  • High BP
These are more common in youngsters these days and are compounded by their hectic and stressful lifestyle. The symptoms of stroke are similar in younger and older people. However, recovery from stroke is better in younger people.

The best and most effective treatment for brain stroke is “clotbusting therapy”. In this treatment, a medicine – tissue plasminogen activator – is injected in the patient’s arm vein or brain artery within the first few hours (4.5- 6 hours of symptom onset). It issolves the clot and improves the condition of the patient. It should be emphasized here that the medicine cannot be given after the above-mentioned window period. So, time is critical and patient should be immediately rushed to a specialized stroke care centre.

Mortality And Morbidity In Stroke
Stroke is associated with high mortality and morbidity. A significant number – 30 to 40 per cent – of stroke patients die within a month of stroke onset. In the best stroke centres, the mortality rate is 8-10 per cent.
Stroke survivors have multiple disabilities. These may include:
  • Weakness of arm and leg
  • Difficulty in walking and doing household chores
  • Difficulty in speaking
  • Stiffness of arm or leg
  • Imbalance while walking
  • Difficulty in swallowing food
  • Impaired vision
  • Memory impairment
  • Seizures
  • Depression
When they receive proper care, stroke survivors mark a significant improvement in their functional status. About 20-30 per cent of stroke survivors continue to be partly or fully dependent on others to go about the activities of daily living. However, several patients are able to lead a near-normal life. Many even go back to their jobs.

Care For Stroke Survivors
  • Regular medications: Patients are required to take several medications to keep the blood sugar, BP and cholesterol under control. In addition, they are prescribed blood thinners such as aspirin. These medications should be taken regularly in consultation with the doctor, and they are often required to be continued for life.
  • Physiotherapy and speech therapy: A stroke survivor has residual weakness of arm or leg and also has speech disturbances. These functional deficits can be greatly improved with proper physiotherapy, occupational therapy and speech therapy.
  • Proper nutrition: Patients may have difficulty in swallowing and chewing. They may require tube feeding too. They also have co-morbid conditions such as diabetes, high BP and cholesterol that require dietary modifications. A dietician’s opinion is valuable in such cases.
  • Good nursing care: The patient’s position on the bed should be frequently changed to prevent pressure sores. Bowel, bladder and back care are also important.
  • Prevention of deep vein thrombosis (DVT): Stroke survivors have a higher risk of DVT due to paralysis or immobilization. DVT stockings and passive limb movements are useful in preventing DVT.
  • Cognitive stimulation: Patients have memory impairment and need to be stimulated by talking, reading newspaper, listening to songs, etc.
Dr Sudhir Kumar is Senior Consultant Neurologist Apollo Health City Hyderabad

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