STROKE MANUAL Guidelines for Prevention & Management of Stroke
What is Stroke?
Stroke (also called ‘brain attack’) is caused by problems in the blood circulation to the brain. They are either ‘blocks or bleeds ‘. Simply put, a clot of blood inside a blood vessel in the brain can block it. Or a weak spot in the wall of a blood vessel can leak, cause bleeding into the brain and formation of a blood clot outside the blood vessel. The bleeds are also called “brain haemorrhage”. In either event, the part of the brain served by the blocked or bleeding blood vessel is damaged or can die due to starvation. The disability that is left depends on the part of the brain involved and the extent of the damage.
In the first few hours, strokes can appear much more serious than they really are. It can look to relatives as if there is no hope for the patient who has suddenly gone in to coma. However, after a few days, if the person is going to recover, consciousness gradually returns. Movement and speech may improve rapidly in these early days.
This is because in the early stages, the whole brain is subjected to swelling and pressure. As the circulation recovers, the swelling lessens and the pressure falls, most of the brain returns to normal. Only a small area of permanent damage may be left.
The extent of recovery depends on how much initial damage is done, (which is difficult to assess in the first few hours) or, how quickly the person can be brought to expert help, and on the quality of long term after-care.
What does a stroke do?
Stroke hits peoples out of the blue. A common layman word for it is Lakwa, Adhrang, Pakshagat or Paralysis. In its common form, Stroke often becomes apparent on waking up from sleep. At other times, the victim suddenly becomes unable to move his limbs, or walk to the bathroom, or hold things in hands or speak. Many a times, stroke comes silently but suddenly while working, during the day with any of the above symptoms. This form of stroke without headache and vomiting or loss of consciousness is due to blockage of blood going to a part of the brain. In other form of stroke, the person gets severe headache and vomiting followed by weakness of limbs of one side with or without difficulty in speaking.
Many a times, the person rapidly progresses into unconsciousness. This is the usual form of “brain haemorrhage” – a haemorrhage in to the brain matter.
In some cases, stroke start with sudden severe headache of the type never experienced before, followed by vomiting and, in many cases, loss of consciousness. This is also due to type of brain haemorrhage on the surface of the brain, called subarachnoid haemorrhage. In some cases, particularly in women given child- birth, stroke may occur due to blockage of veins draining blood from the brain.
It used to taught that:
- A third of stroke victims die in their first attack.
- A third recovered, but with severe disabilities.
- And a third recovered to a near normal life.
Today the good news is that picture is changing. Fewer die from their stroke and more than half do very well. Those who are left with disabilities can be helped to make the best of what they have.
For effective treatment, patient should be brought to hospital at the earliest. If brought within 4.5 hours, a treatment to dissolve the blood clot may be given. Research is going on at a rapid pace to develop newer and better treatment to decrease the nervous system damage following stroke and help recovery of such patients to better level of function.
Who is likely to have a stroke?
Strokes can come out of the blue and even to people who don’t appear to be at a high risk. Some people are born, for example, with inborn weakness, an “aneurysm” in a brain artery that can leak, causing haemorrhage. This type of stroke can happen to young adults so it is not just disease of older ages. In older people, strokes are usually associated with clots in, or bleed from arteries.
We are higher than normal risk of strokes if we:
• Have uncontrolled high blood pressure.
• Have uncontrolled high blood sugar.
• Have a very high blood fat (cholesterol) level.
• Smoke cigarettes.
• Are overweight
• Take too little exercise.
• Have any heart disease.
Warning Symptoms
(a)Sudden unexpected weakness, numbness, blindness (usually one eye), speech problem, double vision etc, that improve within minutes to hours. But this is an emergency. Take any such symptom seriously, and see a neurologist (for blindness not only eye specialist, a common mistake) for further management.
To make it easy to remember, often people use an acronym FAST, which stands for:
F – Face (facial asymmetry, drooping of angle of mouth)
A – Arm (weakness, difficulty in using)
S – Speech difficulty (trouble speaking, inability to speak or slurring)
T – Time to act.
Message: if you have any symptom involving F-A-S-T. Then it’s Time to act immediately.
But this acronym misses other symptoms like changes in sensation, eye symptom, and leg symptom. I have therefore changed it to FASTEST, i.e.
E – Eye (vision related symptom, blindness in one or both eyes, or double vision)
S – Sensation loss (numbness)
T – Trouble walking
It may sound better to use the first T to mean ‘trouble walking’ and second T to mean ‘Time to act’. (F - Face, A - Arm, S - Speech difficulty, T - Trouble walking, E - Eye (vision problem), S - Sensations loss, T - Time to act)
(b) Sudden severe headache of the type never experienced before in life: this is a warning for ‘leakage’ type of stroke i.e. brain haemorrhage. Must get a CT scan of head done to rule out brain haemorrhage.
How is stroke treated?
Stroke occurs at any time, and you may be the only help available. The aim should be to take the victim to an emergency room of a nearby hospital as early as possible. If the patient becomes unconscious, make him lie down on one of his sides. This prevents sucking of saliva in to lungs, arrange to transport him to a nearby hospital. If available and possible, call an ambulance (helpline number 900 900 1050).
In emergency, the first things, which are paid attention to, are the air- pipes (airways) and breathing and heart (ECG). After taking care of these, the treatment is devoted to saving as much as of the brain as possible. For this, in blockage (ischemic) type of strokes, the culprit ‘clot’ in either dissolved or taken out from the blockage artery. Dissolving or removal of the clot is time-sensitive. Clot dissolving medicine has to be started within 4.5hrs of start of first symptom and removal of clot, if a large artery is blocked, has to be started within six to nine hours (in some cases up to 24hrs). This is why a patient must reach at the earliest, earlier clot-dissolving medicine or clot removal is accomplished, and better is the outcome after emergency treatment. The aim is to prevent recurrence of stroke. This is done by lowering the blood pressure (if high), lowering the pressure inside the head, operation to clip or clotting the weak portion of artery (for subarachnoid haemorrhage) and by treating the heart condition. Many patients have to be on lifelong medications to decrease the chances of recurrence.
Can I lower my own chances of stroke?
The risk of stroke rises from age of 40 years onwards, but the underlying causes are often laid down much earlier. We recommend that precautions should be taken from the age of 20 years.
It is estimated that 15 to 16 lakhs persons get brain attack/or strokes every year in our country. The number is likely to increase year by year unless all of us take steps to prevent it.
High blood pressure and high blood cholesterol level rarely cause symptoms. The first sign of them, in fact, can be the onset of stroke. If you have high blood pressure, control them by healthier eating, exercise and medicines, if required. The modern treatment for high blood pressure is not only more effective than before, it is much likely to cause unwanted and unpleasant side effects.
One of the surest ways to lower your stroke risk is NOT to smoke. Smoking raise the chances of stroke and heart attack. You should stop smoking; just cutting down is not enough. Nicotine, tar and carbon monoxide in the smoke are the poisons that cause the clotting and bleeding.
Another good habit is to exercise regularly. A brisk walk is as good as any, but choose an exercise that suits you best, and won’t bore you after a few days. Swimming, cycling, running will all help. Try to do enough to make yourself slightly out of breath at least twice a week. Exercise lower blood fat levels, so it gives a double extra benefit for stroke as making you feel better.
Warning: Start your exercise slowly and build it up gradually. If your eventual aim is to enjoy, start with walking. Don’t take on an ‘Explosive’ exercise, like weight lifting, in middle life. That may drive up blood pressure and invite a problem.
Don’t exercise: -
(i) If your blood pressure is 200mm systolic (upper one) or 110 mm diastolic (lower one) or more : first control your blood pressure.
(ii) If your blood glucose is high (more than 250 mg%), first control your blood sugar.
(iii) If you have severe eye disease (diabetic eye).
Common misconceptions
- Stroke is caused by “witchcraft or God’s anger”.
No, Stroke (brain attack) is usually caused by blockage of a blood vessel to brain just as heart attack is caused by a blockage of blood vessel going to the heart. However, a form of stroke called “brain haemorrhage” is caused by rupture of a blood vessel leading to leakage of blood within the brain or on the surface of brain.
b. Stroke is always fatal.
No, almost 40%-50% of persons getting stroke can recover and rejoin their previous work.
