A stroke in time


  • Health
  • Sunday, 06 Apr 2003

By Dr NG WAI KEONG

STROKE is usually an age-related disease. Unfortunate, but true, a reflection of the many things that start going wrong as the numbers add up in the column of life marked “age”. Otherwise called a brain attack, strokes are often devastating and leave the victim with considerable disability and handicap.  

It is perhaps the third most common cause of death in Malaysia. However, it is the leading cause of disability in most countries. The economic burden of stroke is large. In the United States, the cost of stroke is US$2bil (RM7.6bil) per year. In that country alone, there are 500,000 new strokes per year.  

In Malaysia, there is no reliable data on the incidence of stroke. However, the incidence rate is quite substantial. 

Strokes are due to the interruption of blood supply to a part of the brain. It may take the form of a blockage (infarct) or bleeding (haemorrhage). 

The mean age of the population is increasing, and this inevitably will mean that the incidence of stroke will rise. Debilitating as it may be, strokes are potentially preventable. Prevention either before a stroke occurs (primary prevention) or after it has occurred (secondary prevention) are key to lowering the incidence of stroke. 

The most common cause of strokes is due to artherosclerosis. This is a degenerative process that starts with deposition of cholesterol plaques in the walls of the arteries, leading to damage of the arterial walls. There are multiple risk factors that will accelerate artherosclerosis leading to strokes. 

The most common presentation of stroke is weakness of one half of the body (hemiparesis) associated with speech difficulty. Others included sudden onset of dizziness associated with nausea and vomiting. There is often slurred speech and visual problems. These symptoms may be transient, lasting minutes. It is important to recognise these mini strokes or Transient Ischaemic Attacks (TIA) as it is a warning sign that a major (and permanent) stroke may occur in the future. 

No two strokes are the same. The area of the brain involved is different and the mechanism of stroke differs. The stroke pattern in Asians is different from Caucasians. In 1994, data from the University Hospital Stroke Registry showed that stroke that involve the small blood vessels are more common compared to large blood vessels in Asians compared to Caucasians. The downside – these strokes often leave the patient disabled. 

It must be stressed that public education of stroke is important to reduce the arrival time of patients to hospitals. Patients are educated regarding the warning signs of a stroke. Brain cells will die within minutes after a stroke has occurred. However, it is possible to break up the fresh clot that has lodged in the blood vessel of the brain with ‘clot busters’. This is called thrombolytic therapy. The use of these drugs, namely recombinant tissue plasminogen activator (r-TPA) within three hours of the onset of stroke improves disability at three months. 

The main risk of such drugs is internal bleeding. In carefully selected patients who fulfil the criteria for thrombolytic therapy, the drug makes a large difference between being independent or dependent with activities of daily living. 

The aim is to reduce a minor stroke to one of full recovery and a major stroke to a minor one. Patients who survive the first stroke are often worried about the second stroke. Most patients will alter their lifestyle and take medications to prevent recurrent strokes.  

The use of antiplatelet drugs such as asprin, ticlodipine and clopidogrel has reduced the risk of recurrent strokes after a TIA by about 23% per annum. However, this risk reduction is still small. Therefore, every effort should be used to stratify other potential modifiable risk factors of artherosclerosis.  

Smoking increases the risk of stroke of an individual to three times normal. Cessation of smoking is important in preventing strokes. The control of hypertension should be optimum. Dietary intake with high fat content food will inevitably lead to strokes. Cholesterol levels should be reduced to target values. Diabetes should be controlled well. 

In the last few months, the use of a drug perindopil, an ACE Inhibitor at a dose of 4mg daily can reduce the risk of recurrent strokes by 35%. This recent finding is important as a means of stroke prevention. 

There are other specific risk factors that may need specific intervention. For one, atrial fibrillation. This is a medical term given to describe an irregular heart beat. It leads to turbulence of blood flow leading to clot formation within the chambers of the heart. The wandering clot can travel and lodge in the arteries of the brain causing a stroke. The use of asprin and warfarin is recommended to prevent the first stroke as well as preventing recurrent strokes. Atrial fibrillation is more common in the elderly and one out of ten elderly patients over the age of 75 years will have atrial fibrillation. 

Another specific risk factor is carotid stenosis. This is a medical term used to describe significant narrowing of the large artery supplying blood to one half of the brain. When the narrowing is more that 70%, it is recommended that the patient undergo an operation to remove the potential cholesterol plaque that occludes the blood vessel. This procedure is called a Carotid Endarterectomy. 

The risk of the procedure is 2.5% of death or suffering a stroke during the procedure. But the risk of recurrent strokes is more that 15% per annum.  

Rehabilitation is an essential part of stroke recovery. It should start early and the combined effort of physiotherapy, occupational therapy, speech therapy and support groups are vital to maximise the functional ability of a patient. 

The elderly are at the highest risk of suffering a stroke. Recovery is usually slow and minimal in older age groups. Early recognition of the warning signs of a stroke is the cornerstone of treating acute strokes. As effective treatment is available, although not ideal, stroke prevention will remain the best way to reduce the global burden of stroke. 

  • This article is a contribution of The Star Health & Ageing Panel, a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. 

    This group of specialist doctors and members of the academia are committed to public education, and the weeks ahead will see numerous articles on aspects of healthy ageing and the prevention of disability in men and women. 

    The members of the panel include: Datuk Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; A/Prof Sarinah Low, psychologist; Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Guna Sittampalam, consultant obstetrician and gynaecologist; Dr Ting Hoon Chin, consultant dermatologist; Dr Ng Wai Keong, consultant neurologist. 

    The Star Health & Ageing Advisory Panel provides this information for educational purposes only and it should not be construed as personal medical advice. Information published in this article is not meant to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. 

    Doing well

    CHAN Swee Cheong was still working at the age of 78. He was a healthy 78, with no serious medical problems. The only niggly thing he would occasionally complain of was numbness in his legs. He also had a slight heart condition, where his heart rate would fluctuate at times. Apart from that, he was well.  

    Then one day at work during his tea-break, he just fainted. His son recalls: “The people at the office rushed him to the clinic. After treatment at the clinic, he seemed to look fine. But as the GP told us to take him to the hospital, we did just that,” said his son. 

    It had turned out that Chan had a stroke. 

    “On the way to the hospital, his legs started to become numb and started to get weaker. He also started to slur. It was good that we managed to get him in quickly and got immediate treatment at the hospital. 

    “He was there for a week before he was discharged, and hr recovered steadily. We were told that it was a good thing we got him in within three hours to the hospital, as the doctors were able to give him appropriate treatment to reduce the effects of his stroke. 

    “There are no serious after-effects now and my father seems to be doing fine. The numbness in his legs and the slur has gone. But he still has to take his medications and go for a check-up every two months,” he says. 

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