We share the views Tan Sri Dr Ismail Merican expressed in his letter “Don’t ignore other needy patients” (The Star, April 28, 2020). Urgent treatment and emergency services should not be compromised during the Covid-19 outbreak.
One of these medical emergencies is a “brain attack”, or stroke. As one of the leading causes of death in Malaysia, stroke has claimed many lives and incapacitates thousands of victims each year.
Most people would be aware that a heart attack is caused by a blockage in one or more arteries supplying oxygen and nutrients to the heart muscle. Similarly, a stroke, or brain attack, occurs when brain cells are deprived of the oxygen and nutrients required to function optimally. In both circumstances, restoring the blood flow as soon as possible is crucial to prevent or reduce permanent damage to these organs. To achieve this, the patient needs to be sent to a hospital equipped with facilities that can identify the mechanism of a stroke and manage it immediately.
There are many mechanisms of stroke: a blocked artery, bleeding, infection or inflammation. The vast majority of strokes occur when an artery in the brain is blocked by a blood clot. The manifestation of symptoms in stroke victims depends on which arteries are affected. Smaller vessels cause milder strokes while bigger vessels cause a more severe stroke. Mild stroke means the chances of recovery is higher with a shorter duration of disability. A severe stroke often results in permanent brain damage, long-term physical disabilities, behavioral changes, emotional stress or even death.
"Time is Brain" is a concept used to impress the importance of starting treatment early in a stroke caused by an arterial block. Studies have proven that immediate treatment with a clot-dissolving medication (thrombolysis) within 4.5 hours can restore blood flow before major brain damage sets in. However, in unsuitable patients – eg, in delayed presentation – these thrombolytic drugs are hazardous and may cause serious bleeding in the brain that can be deadly. Thus, this treatment should only be given to selected patients who understand the risks and benefits, and are in a hospital with full back-up support.
An acronym for a life-saving act in stroke is "FAST", which stands for “Face” (does the face look uneven?), “Arms” (is one arm weak or numb?), “Speech” (does the speech sound strange?), and "Time" (4.5 hours before brain damage). If you spot these symptoms, call for an ambulance urgently from a hospital with thrombolysis therapy. Do not delay because "time loss equals brain tissue loss" and every minute counts.
Many patients miss the golden treatment period of 4.5 hours because they fail to recognise the three major symptoms, ie droopy face, limb weakness and slurred speech. In social media, there are many irresponsible and unscientific pieces of information suggesting alternative treatments for stroke, including performing traditional massage even when the patient is already semiconscious. This will only delay the appropriate treatment in a hospital and miss the golden hour of thrombolysis therapy.
Many people are sceptical of modern medicine because of potential side effects or previous unpleasant experiences. However, with medical advancement, the benefit of thrombolysis therapy has been proven at the level of evidence categorised as 1A. This means the treatment has the highest level of evidence to support its use. The number of stroke patients who recovered after receiving this treatment is high. Every medical treatment has drawbacks and risks but strong and reproducible scientific evidence in this case has shown that the benefits outweigh the risks – but also that time is absolutely of the essence here.
In Malaysia, thrombolysis therapy is available in a few tertiary centres within the Health Ministry, private hospitals and university hospitals. These centres not only have the appropriate expertise but are supported by other facilities such as the relevant laboratory tests and brain imaging. Government hospitals offering thrombolysis therapy include Hospital Kuala Lumpur, Hospital Raja Permaisuri Bainun Ipoh, Hospital Seberang Jaya (Penang), Hospital Sungai Buloh (Selangor), Hospital Taiping (Perak), Hospital Umum Sarawak and, the latest, Hospital Sultan Abdul Halim (Kedah). During the movement control order period, emergency services such as stroke thrombolysis are still ongoing in these hospitals. These hospitals are taking the necessary precautions to minimise the risk of the spread of Covid-19 to patients and healthcare workers without compromising on urgent medical treatments that patients desperately need.
If you encounter family or friends with "FAST" symptoms, remember it’s "Time" to call an ambulance immediately. Acting FAST can help stroke patients get the treatment they need to avoid brain damage. The treatment works best only if the stroke is recognised and diagnosed within 4.5 hours of the first symptoms. A CT (computed tomography) scan of the brain will be required to identify the type and size of the stroke.
Stroke is one of the top three causes of mortality and morbidity in Malaysia. Help us to spread the word and educate our families and friends about FAST so that, hopefully, fewer people will be incapacitated by stroke.
Dr ZAINURA CHE ISA & Dr LIM JO ANNE
Sungai Petani, Kedah
Note: Dr Zainura is a consultant physician in acute medicine and Dr Lim is a medical officer at Hospital Sultan Abdul Halim
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