Let’s talk a bit about Stroke, what people to know about stroke and the signs that they should be aware of?
A stroke is the clinical manifestation of a disturbance in the blood supply to the brain, and this could be either due to a blockage in the blood vessel which prevents proper flow, or could be due to a rupture, causing a hemorrhage from the blood vessel. Around 85% of strokes are due to blockage, and around 15% are due to ruptured vessels.
We have a public awareness campaign which we started in 2009, to raise awareness about some of the stroke symptoms, so that when someone experiences such symptoms they would come to the hospital immediately. The awareness program is titled “Act F.A.S.T.”: ‘F’ is for ‘Face’ problems; if the person is asked to smile but one side of the face is loose, ‘A’ stands for ‘Arm’ problems; if they are asked to raise both their arms one of the arms drops down, ‘S’ stands for ‘Speech’ problems; if they were unable to speak properly, and ‘T’ means that if you experience any of these symptoms it’s ‘Time’ to call an ambulance and come in straight away. These are the most common 3 symptoms, and a lot of these public awareness campaigns started in the mid 1990’s when it came to our attention that most of the public didn’t know even one symptom of stroke, especially then in the mid 1990’s when we started having acute treatments that if given quickly could help limit brain damage, so we had to make the public aware of these symptoms so that they would come straight away to get the treatment. This “Act F.A.S.T.” program has been going around the world, and we introduced it in Abu Dhabi in 2009.
Other symptoms might include double vision, dizziness, vertigo, or sensory changes, like weakness or numbness in face, arm, or leg. If you get any of these symptoms, this might most probably be related to a blockage in the blood flow to the brain. If you’re having a severe headache or vomiting with these symptoms, then this might suggest there’s a hemorrhage; bleeding in the blood vessels to the brain. IF you experience any of these symptoms you should come to the hospital right away, and this is because there are new treatments available for blocked arteries; we can give a drug that would break down the clot and get the blood flowing to the brain again, and this would minimize brain cell damage during the stroke. We did this in 2009 when we introduced a 24-hour thrombolysis service in Mafraq, so that patients can come in whenever they experience any stroke symptoms and be treated right away.
If the patient arrived later than what is recommended?
For thrombolysis, for all patients treated within 4.5 hours, if you treat 9 people, you’ll save one from being severely disabled. If you treat all patients within 90 minutes, you only have to treat 3 to 4 patients to save one from being severely disabled. So that’s why the message needs to come through: “time” is brain for stroke.
What are the most common risk factors for stroke?
The five common risk factors for stroke are high blood pressure, diabetes, high cholesterol levels, smoking, family history and obesity. The less critical ones are things like stress, which is not directly related to stroke, but stress can cause high blood pressure, thus possibly indirectly leading to stroke.
What about the available medications in stroke management? How does time play an important role in using these medications?
The treatment we give to a typical blockage stroke is aspirin, which basically thins out the blood. For a haemorrhagic stroke we don’t give aspirin, because if we thin out the blood then there will be more bleeding. If the patient arrives within 4 to 5 hours we could give thrombolysis treatment where we give something that would actually break down the clot itself, which would be more powerful than aspirin. Generally we can give thrombolysis either through a catheter, and introduce it straight into the blocked vessel, or we can give it intravenously. If the patient arrives in the right time, we can give it intravenously because it’s quicker. There are some strokes where it might be better to do through angiography where there’s a higher risk of bleeding for example, or sometimes beyond 4 to 5 hours, we might be able to give the treatment through the catheter.
Occasionally, with larger blockages, in what we call the proximal part of the artery, where a big blockage appears before the artery branches into the brain, intravenous doesn’t work as well, so we use the catheter technology, it’s called intra-arterial thrombolysis. The majority would be getting intravenous, just a small number of selective cases would get intra-arterial thrombolysis, because time is critical, and it’s much easier to give it in the emergency room than to have to wait for the catheter suite to be ready.
It is known that ‘Time is Irreversible’ in Stroke, what does it mean practically for a patient?
An average brain has 22 billion neurons, and for each minute of a typical stroke, we’re losing 1.9 million brain cells, i.e. each hour you’re basically losing around 120 million brain cells. And if nothing is done, by the time a stroke is complete you could have lost around 1.2 billion brain cells. In the normal ageing process, you lose around 1 neuron per second, so, after completion of a stroke compared to normal ageing, it’s equivalent to 36 years of ageing. That’s why it’s critical to arrive in time and receive the thrombolysis treatment and get the blood flowing before losing a large number of brain cells. And unlike other cells like muscle or liver for example, once you’ve lost brain cells, they’re gone, they do not grow back, and there’s no treatment for that nowadays. The hope is in the advancement in stem cell technology in the future, not just for stroke, but for many other neurological diseases as well.
The public know that time is an important factor in managing critical cases in general, how far that is of importance in handling Stroke?
The thrombolysis treatment mentioned, you need to have the agent given within 4 to 5 hours, so, you can imagine the patient coming in, form the time they arrive in the emergency room, it takes about an hour for us to do all the tests to confirm that it is a stroke, so this leaves us 3 to 4 hours . What we notice in the trials is that even within that 3 to 4 hour time frame, patients to better with the drug the quicker you give them the medication, so, if you get the medication within an hour, you do better than within 2 hours, and in 2 better than 3, so, time is really critical in treatment, and that’s why we’ve coined the phrase “time is brain” for stroke.
Critical care is one of the main Healthcare concerns in the region, what does an advanced stroke center mean?
You need to have a full thrombolysis service, and by “full” I mean 24/7, so that anytime a patient arrives with a stroke they would receive the treatment right away, any time of the day, any day of the week. There also needs to be a good ICU, because after thrombolysis the patient needs to be monitored for 24 hours, because there might e a risk of a haemorrhage. Also you need to have good neurosurgical access, because if a haemorrhage does occur after thrombolysis treatment, sometimes it needs to be evacuated by a surgeon, so, you need to have all the backup facilities in case anything goes wrong with the treatment. Also sometimes there’s a lot of swelling in the brain following a stroke, and in this case we need the surgeon to do a decompression, where they open up the skull to allow the brain to swell, then when the swelling goes down they put things back in place, because sometimes if you don’t do this decompression with swelling it might lead to death.
Mafraq is actually in a good position in this aspect, we’ve good neurosurgeons, a good number of critical care beds, a well-equipped ED and the physicians there are trained to deal with stroke.
Can a stroke patient be managed in a hospital that is not equipped by a stroke unit?
Yes, absolutely. Actually most stroke patients would be admitted to a hospital where they do not have acute stroke service, and this is where you can do a brain scan and make sure there’s no bleeding, but you can still get the aspirin treatment. If the blood pressure or blood sugar level is really high, any hospital can bring it down and save brain cells. The most important thing is for the patient to come in to any hospital straight away, the quicker they come in the better the possibilities for treatment.
What other challenges a stroke patient might face to receive good care?
One of the issues at the moment is good rehabilitation after the stroke, and this is where the new rehabilitation hospitals should help. Because the first few weeks after the stroke, following up with a qualified therapist is extremely important for proper recovery. Right management of Stroke patient might not be concluded only by saving his/her life; but it might affect the patient’s whole life afterwards. Tell us more about that stroke management is more than a lifesaving process.
We actually give patients a discharge leaflet about stroke to take home with them, to inform them what stroke is, and what lifestyle changes are needed to decrease the chance of stroke, and help in getting more information about strokes generally.
Some people believe that they should start considering such health risk after 50’s. What do you advise them? I would advise considering such risks at the time you’re an adult! Strokes are common as you get older, but you can have strokes when you’re young, I’ve seen strokes in teenagers, and in people in their twenties and thirties. Life style change considerations for prevention of stroke are important at any age.
What are the first measures a person should take if they faced a situation where somebody had a stroke attack?
They should take them directly to the nearest hospital if they recognized any of the F.A.S.T. symptoms, and not do anything else. They shouldn’t even give aspirin, because back in the 80’s some people were suggesting that you should give aspirin before going to the hospital, but, like I said, 85% are blockages, but 15% might be due to bleeding, and aspirin would actually increase the bleeding, and a brain CT scan has to be made before giving treatment.