Treating Strokes

Published in Panorama


Timely Intervention in Treating Stroke

75 year old Abdul , within seconds of entering the wash room, felt his head reeling. Before he realized what was happening, he fainted and fell on the floor. Fortunately for him, his grandson who spotted him, rushed him to the hospital where he was diagnosed as having had a stroke.

Stroke or cerebrovascular attack or brain attack, is believed to be the third leading cause of death in the US and several other counties and it is also one of the principal causes of long term disability affecting individuals. A stroke is either a lack of blood supply to any part of the brain when an artery blocks off, or it is a bleed in the brain; this, it is either ischemic or haemorrhagic, explains Dr. Andre Wessels, Specialist Cardiothoracic Surgeon , Welcare Hospital, Dubai. Further, 85% of all brain attacks are ischemic, meaning, they are caused by diminished blood supply to the brain, resulting from an obstruction or constriction of blood vessels, supplying to the brain. Ischemic attacks may either be embolic or thrombolytic , explains Dr.Wessels. When a clot forms or originates in a region other than in the brain, (chiefly in the heart or neck region in the carotid arteries supplying blood to the brain) dislodges itself and travels to the brain, choking off blood supply to that region in the brain, it is an embolic stroke. Thrombolytic stroke, on the other hand, occur in the small blood vessels inside the brain, that is, the clot forms right there in the brain.

Haemorrhagic stroke, on the other hand, results from the rupture of a blood vessel in the brain itself. Although ischemic strokes occur more often than hemorrhagic strokes, the effects of a hemorrhagic stroke are much more devastating and more often fatal.

Who is at risk of stroke? High blood pressure is the most prominent risk factor for either type of stroke says Dr.Wessels. The other risk factors include heredity, age, gender, diabetes, elevated cholesterol levels, obesity, smoking, alcohol, heart diseases, carotid artery disease and diseases involving abnormal blood clotting. The risk for stroke generally increases with age, says Dr.Wessels. "Also, fewer women have stroke before menopause; then it's the same in both males and females. But even younger people may get stroke, especially in cases where individuals are born with an abnormality of blood supply to the brain; they have what is called an aneurysm of the blood vessels supplying the brain with blood and if they burst, there's a huge cerebral haemorrhage and then a stroke."

There are some people who suffer a certain disorder whereby they can clot blood spontaneously. These are young patients, who due to some deficiency in their blood, can clot anywhere; they are at risk of thrombolytic stroke.

A person who has had a stroke is at greater risk of a second stroke than someone who has not had a stroke.

What are the symptoms of a stroke? Are there any warning signals? Dr.Wessels explains, "Transient Ischemic Attack (TIA) are warnings of a stroke. This is a transient period where you have a stroke symptom for a short while because the blood supply to that part of the brain is cut of temporarily. It doesn't cause the brain cells to die since the blood supply, for some reason, gets re-established and the symptoms disappear."

Dr.K.R.Suresh, Vascular Surgeon, Mahaveer Jain Institute of Vascular Sciences, Bhagawan Mahaveer Jain Hospital Bangalore adds, "Most of the people who get an embolic stroke, will have TIA or preshocks or mini-strokes, which could last for few seconds to minutes. This is because a small clot gets dislodged from its origin, lodges in the brain in a particular area. These individuals will then manifest with any of a host of symptoms, ranging from weakness in the hands, speech or vision problem, have numbness in one or both sides of the body, dizziness, sudden severe headache. These symptoms may be gone in as little as 10 seconds! But the important hing to know is: they tell you that there is potential for major stroke."

Emphasizing the need for recognizing this potential threat and taking timely medical assistance, Dr.Suresh reveals, "Generally, people disregard these preshocks, attributing, for instance, the little numbness, to faulty posture."

Dr.Wessels also stresses, "TIA is the most prominent warning signal of an imminent stroke. You're paralysed, for instance, on one side of your face or arm, and within minutes or half an hour, you're okay. But even if this lasts only for a few minutes, it is quite dramatic for you not to notice it. TIA is not just a little momentary second of dizziness; it is more than that, a definite entity which you should not ignore."

Symptoms of ischemic stroke may therefore include numbness on one or both sides of the body, impaired speech and vision, vertigo, weakness in the face, arms or legs, severe headache, nausea and vomiting. Symptoms of haemorrhagic stroke include loss of consciousness, either total or partial, nausea and vomiting, stiff neck, inability to tolerate light, one-sided paralysis of the body, numbness and weakness in the face or extremities and fainting.

How is stroke diagnosed? Any type of stroke is a medical emergency requiring immediate medical attention since it can make the difference between life and death. Timely diagnosis and intervention with necessary treatment are vital in the overall outcome of a stroke. While symptoms are the first indications for diagnosis, CT Scan of the head is in order to identify the type of stroke since this is important for treatment of the condition, explains Dr.Wessels. Further, an MRI is ordered to determine the presence, size and location of aneurysm. Also, the carotid arteries may be checked using Doppler ultrasound to check for narrowings. Even angiography may be indicated in certain instances.

Treatment modality following confirmation of stroke, depends upon whether the stroke is haemorrhagic or ischemic, explains Dr.Wessels. "There is no specific cure for haemorrhagic stroke; it can at best be prevented by controlling the risk factors, mainly controlling blood pressure. A big haemorrhagic stroke can even be fatal and surgery may be called for to evaculate the blood in the brain and repair the ruptured blood vessels."

If the stroke is ischemic, clot-busting medication is used; Aspirin and heparin are generally used.

Dr.Suresh adds, "Where there is carotid artery narrowing to the extent of more than 70% and the patients are showing up stroke symptoms, surgery and angioplasty with stenting are the treatment modalities. But, ironically, the main problem with these methods is STROKE! That is, you are causing what you are trying to prevent! But the heartening fact is that, if you look at someone with over 70% block or with a TIA, the risk of stroke per year is 25-30%. But the risk of stroke from surgery or angioplasty is only 2% - 5%. Angioplasty is becoming more popular these days because of the use of newer protection devices. Earlier, when you did an angioplasty, you could dislodge the clots; now, we have cerebro-protection devices like an umbrella, which can catch these dislodged clots during the procedure, and thus prevent the stroke."

Are there any contra-indications to the surgery? Dr.Suresh explains: "In people who have had radiation for the treatment of cancer, in the neck region, getting the arteries, and healing, are problems. Secondly, in patients who have already had surgery once for narrowing of the carotids, there is chance of re-narrowing in 6%-8% of cases. Going back for re-surgery in these cases, is technically more challenging. Thirdly, sometimes, the blood vessel blockage is very high near the skull. In these areas, it is not easy to reach or even impossible to reach, to perform surgery. So apart from these three instances, there is no real contra-indication to surgery for the treatment of stroke."

What is the damage that stroke can cause? Dr.Wessels explains, "The effects of a stroke can be devastating, ranging from mild and temporary, to severe and permanently debilitating. The worst scenario from a stroke is that the patient may die. The next stage is that, one could have a severe stroke and lose the function of one half of the body and not recover from it at all. It all depends on the locality in the brain which is affected, that determines the disability the patient is going to suffer. Recovery of functions depend on the extent of the stroke and the damage caused to reform. The area of the brain affected and magnitude of damage, determine the neurological deficits following a stroke."

On the recovery aspect, Dr.Wessels elucidates, "If a person has had a stroke and is paralysed on the face, or on one side, for instance, it is very difficult to say how much he will recover. But if he is going to recover, he will get maximum recovery within two years. The quicker he recovers, the better the outcome and ultimate prognosis. Effective rehabilitation with physiotherapy, speech and occupational therapy is very important to enable the patients to regain as much functional independence as possible."

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