Dubai: Brain strokes are one of the leading reasons of death and disability around the world. However, rapid diagnosis, imaging and administering of an enzyme (plasminogen activator) within the first three-four-and-a-half hours of the onset of symptoms can not just be a life saviour, but also completely reverse all symptoms in a majority of cases, according to guidelines issued by the American Stroke Association.
Neurologists in the UAE, who follow these guidelines at all stroke units, cannot emphasise this message enough on the occasion of World Stroke Day on October 29.
Providing a learned perspective on stroke incidence in the UAE, Dr Alaa Bou Ghannam, Medical Affairs Director, Johnson and Johnson Medical Devices Director, Middle East, said: “More than one stroke occurs every hour in the UAE, in other words, more than 10,000 every year."
According to the doctor, "Although stroke victims lose around two million brain cells or neurons every minute after a stroke, only 10 per cent of them reach a hospital on time to make a full recovery. Strokes are therefore the leading cause of disability and the third leading cause of death.”
Dr Sohail Al Rukn, President of the Emirates Neurology Society heading the stroke unit at Rashid Hospital, explained how quick intervention works in reversing symptoms.
“We say time is brain as in every single moment during a stroke is crucial to saving brain cells from dying. As per statistics, every minute of the time a person has a stroke, over two million brain cells are destroyed. Each hour in which treatment fails to occur, the brain loses as many neurons as it does in almost 3.6 years of normal ageing.”
The current treatment that can result in complete reversal of symptoms works effectively in case of thrombotic strokes (those that are caused due to clot or occlusion) of a brain artery. More than 88 per cent of the strokes that occur are thrombotic strokes.
Quick intervention is the key
So what exactly does the early treatment protocol with quick intervention do?
“The arteries going to the brain carry oxygen, glucose and other nutrients and when a patient has a clot or what we call an occlusion in an artery, blood supply to that area is cut off and the brain cells start dying within minutes."
Dr Arun Kumar Sharma, head of the neurology department at the Medeor Hospital, Dubai, said, "During the rapid evolution of stroke, the affected area is differentiated in terms of an already dead or umbra region at the core of brain tissue damage due to stroke, and the peripheral region where collateral arteries are still able to supply blood. The penumbra region is severely under-perfused, but amenable to recovery.”
What to do when you have a stroke?
Explaining the importance of time in the situation, Dr Sharma continued: “If an individual senses he is undergoing a stroke and comes to the nearest hospital, the emergency services are trained to carry out some basic tests. They perform a quick examination, determine the probable time of onset of symptoms, perform certain important blood tests and ECG, and promptly get a CT brain scan done to determine the episode is not a haemorrhage but resulting due to a clot. Once that is established and certain precluding conditions like a bleeding predisposition (haemophilia, ongoing treatment with anticoagulants) are excluded, an infusion of the recombinant Tissue Plasminogen Activator (rTPA) which is a clot-busting enzyme at the dose of 0.9 mg per kg of body weight is started.”
How does a clot buster work?
Elaborating on how the rTPA works, Dr Sharma said: “A clot is made up predominantly of red blood cells, platelets and a coalescing protein called fibrin. TPA converts plasminogen into plasmin. Plasmin, an enzyme, rapidly cleaves through the fibrous scaffolding of the clot made up of fibrin, leading to its dissolution. Usually, the golden window for administering this clot buster is 0-90 minutes. This window has recently been extended up to four hours by the American Stroke Association. The earlier the clot is broken up, the better it is. In many cases where there is a timely restoration of blood supply to brain, symptoms of stroke start reversing within 24 hours.”
How the brain recovers post stroke
Many stroke patients have reported complete resolution of symptoms within 48 hours which includes revival of power and sensation in the affected limbs and face, and regaining clarity of speech. Dr Sharma elaborated: “The brain cells (neurons) that have perished cannot be revived, but the cells in the penumbra region have a capacity of sprouting new synapses (connection points between neurons) and taking over some or most of the function of dead neurons. Clearly, a properly structured multimodal physical therapy regimen that includes occupational and speech training plays a hugely significant role in facilitating the process of neuroplasticity (laying down new synapses) and restoration of the lost neurologic function.”
Case study: Speech restored within 24 hours
Take the case of Nancy M, a 36-year-old Indian expatriate who realised one evening that she couldn’t speak at all. Describing her case, Dr Naseem Palakkuzhyill specialist neurologist at Aster Qusais, said: “The patient came to the emergency at 9pm and although she could comprehend what we were saying, she could not get words out of her mouth. A brain MRI revealed she had multiple infarcts (lesions due to dead tissues) in the left hemisphere of her brain that had impacted her speech. Luckily, she had come within the golden window time and we were able to carry out the clot busting procedure immediately and she spent a night in the Intensive Care Unit. Next day, she completely recovered her speech and was discharged on the third day. I would say up to 70 per cent patients with strokes are able to recover well with quick intervention, but there are few who might take up to 90 days to recover and others who may have poor recovery.
"Those with haemorrhage cannot be treated with this rTPA. But we advise patients to get to the nearest hospital as soon as possible.”
Advance technology also allows neurosurgeons to introduce a catheter through the femoral artery and completely remove the clot which is also a very effective method in management and treatment of strokes. The faster the clot is removed and blood supply restored, the higher are the chances of near total recovery.
What is a stroke?
Dr Charu Thadani, Director – Health Services at Aetna International, said: “A stroke occurs when a blood vessel bursts or becomes blocked by a clot. It is a life-threatening condition that requires medical attention, and the sooner the better. Use the acronym FAST to know when to take action:
• Face – Since stroke typically affects one side of the brain, half the victim’s face may droop or feel numb. If you suspect someone is having a stroke, ask them to smile and see if the smile is lopsided.
• Arms – One arm may feel weak or numb. Ask the person to raise both arms and see if one arm drifts downward.
• Speech – Slurred speech is another key sign, so ask the person to say a simple sentence.
• Time to Act – If you suspect stroke, call your local emergency response number immediately. Time saved equals brain saved.
Aside from the major symptoms, a stroke victim may experience numbness on one side of the body, be confused, experience sudden vision problems, have a severe headache, or have trouble walking.
Globally, strokes are more prevalent in the elderly population. However, around half of stroke patients in UAE are in the younger age group below 45. Part of the reasoning is that the population demographics has a greater component of younger age group people, but that’s not all. The prevalence of modifiable risk factors such as hypertension (high blood pressure), diabetes, obesity, smoking and hyperlipidemia (high cholesterol levels) increases the chances of developing a stroke.
According to Dr Al Rukn, hypertension is one major risk factor which is exacerbated by obesity and smoking habits in the UAE. “According to statistics from Ministry of Health and Prevention, 25 per cent of the adult population in the UAE suffers from hypertension. While one can look into managing the condition, what is more alarming is that in an additional 25 per cent of the adult population this condition is undiagnosed which means they are not even aware they have hypertension.”
Obesity is another high risk factor and more than one third of the UAE population suffers from it.
Tips to keep things under control
• Cut back on both salt and sugar intake. While excess sugar intake can result in impaired blood sugar and obesity, salt is equally bad. We consume hidden salt in processed and smoked meats, sauces, pickles, salad dressings which makes us consume over 3-4 tsp in a day. The recommended daily allowance for salt is 1.2 gm per day which amounts to ½ teaspoon in day. Salt causes the body to hold on to too much water in an attempt to flush out the excess salt, thereby increasing the blood volume and pressure.
• Smoke cessation is important as smoking leads to stiffening of arteries and hypertension that is the main trigger for strokes
• Incorporate a healthy diet rich in vegetables and fruits that can provide antioxidants which can prevent plaque formation
• Have a regular exercise routine. A study by Mayo Clinic in 2012 involved 2,013 adults from Germany who were examined in phases from 1997 through 2012. Cardiorespiratory fitness was measured using peak oxygen uptake and other standards. The results suggested that cardiorespiratory exercise may contribute to improved brain health and decelerate a decline in grey matter.