By Doris Obinna
Adults who have not been personally touched by a stroke do not know what one really is and the fact that stroke is a somewhat complicated medical issue. However, each year, more women and men suffer from this disease.
The prevalence of stroke in Nigeria, according to National Library of Medicine, is 1.14 per 1,000, while the 30-day case fatality rate is as high as 40 per cent, stating: “Management of the disease is largely conservative while there is little or no funding for high-quality research.”
According to the World Health Organisation (WHO), 14 million people worldwide die from stroke each year and over 50 million survivors will live with permanent disability: “Stroke is the second leading cause of death for people above age of 60 years and fifth leading cause in people aged 15 to 59.
“Modifiable risk factor for stroke, such as dyslipidaemia, smoking, and hypertension are highly prevalent in the young stroke population. The list of potential stroke aetiologies among young adult is extensive.”
Chief medical director, God’s Goal Hospital, Lagos, Dr. Gabriel Omonaiye, said strokes or cerebrovascular accident (CVA) are a mixed group of disorders involving, sudden, focal interruption of blood flow in the brain, causing deficiency in neurological functions.
“It is a medical emergency and a leading cause of deaths in the Western world (the third most common).
“In the United State, it is the fifth cause of death, causing one death every five minutes. More than 100,000 cases are recorded yearly in Nigeria.
“Stroke, also known as brain attack, is a real medical emergency that needs immediate intervention by highly trained professionals, using the best medical knowledge, skills, drugs, interventions, equipment and technology for the afflicted to have the best possible outcomes. Unfortunately here, there is a conspiracy of unfavourable factors and beliefs, which works to cause the patient to hold the short end of the stick.
“Such issues as poverty, health illiteracy, superstitious beliefs and dearth of diagnostic machines and absence of the latest cutting-edge technology adversely hinder the prognosis of patients with stroke.
“Though strokes do occur in the two genders, all age groups and races, there are known risk factors that increase the probability of having CVA. Strokes are common in old people and this is related to the weakness of the cerebral blood vessels with advancing age, atherosclerosis.
“In Nigeria, hypertension is a major risk factor, especially when it is poorly controlled. Other risk factors are cigarette smoking, alcohol drinking, and diabetes mellitus, high cholesterol levels, family history of stroke, previous history of stroke in a person, sickle cell disease, the use of harmful recreational drugs such as cocaine and amphetamines, atrial fibrilslation (a form of heart disorder), intracranial aneurysm and the male sex.
Causes
The causes, according to Omonaiye, “When a portion of the brain is deprived of blood supply, the lack of oxygen and nutrients to that part of the brain will cause the death of the cells (neurons) in the particular area. The death of these neurons will cause the neurological deficit. Since different regions of the brain have different functions, the observed deficits will correspond with the affected area of the brain.
“Physicians use the knowledge of the neurological deficit to know the affected areas of the brain. The size of the affected part of brain (whether small or big) is directly proportional to the severity of the symptoms, signs and clinical presentation.
“Also, migraines are a form of headache. Usually severe, throbbing, and pounding are commoner in females than males (strokes tend to be more in men). There may be other symptoms such as abdominal pain, nausea, vomiting, and loss of appetite. In some people they have an aura.
“It has, however, been discovered that, in young women with migraine aura, there is a slightly increased occurrence of thrombotic stroke. The observation is, however, not causal. What is common to the two (migraine headache with aura and thrombotic stroke in some young ladies) is the presence of the risk factors of cigarette smoking and the use of contraceptive pills. This is a research area.”
He noted that some patients, while having stroke, may experience what looks like a migraine headache: “In migrainous aura, patient with aura symptoms lasting longer than one hour, may actually be having a brain infarction and should be evaluated for the same.”
Types of stroke
Omonaiye disclosed that there are two types of stroke; ischaemic stroke, from thrombosis and embolism (constituting 80 per cent) and haemorrhagic stroke: “Ischaemic stroke is due to the blockage of the blood vessels supplying a part of the brain from blood clot from a distant origin (embolism) such as the heart or deep vein thrombosis or clots formed in the cerebral blood vessels (thrombosis).
“Risk factors for the development of thrombosis include cerebral arthrosclerosis, plaque formation and hypercholesterolemia. Ischaemic stroke tend to have a better outcome. Haemorrhagic strokes are due to the rupture or tear or burst of cerebral blood vessels, cutting of blood supply to the territory of the brain supplied by the damaged artery or arteries.
“In addition there is an accumulation of blood in the cranial cavity leading to raised intracranial pressure and swelling of the brain. The raised pressure in the head, brain swelling and accumulation of blood except rapidly treated through drugs and sometimes neurosurgery, may cause death.
“Haemorrhagic strokes are of two types, intracerebral and subarachnoid haemorrhage. Subarachnoid haemorrhage is sudden bleed into the subarachnoid space, the most common cause being a ruptured aneurysm. This could be spontaneous, or due to head trauma, arteriovenous disorders, mycotic (fungi) aneurysms. The symptoms include sudden, severe headache, usually with loss or impairment of consciousness.
“Transient ischaemic attack (TIA) can be defined as stroke symptoms lasting less than one hour and usually does not damage brain tissue.”
He added that, with silent stroke patient, the symptoms are not easy to recognise (subtle) or did not remember having them, yet there is a permanent damage in the brain, which are recognised on brain scan. The patient will have thinking and memory problems:
“For ischaemic stroke, the symptoms and signs depend on the part of the brain affected. Deficits may become maximal within several minutes of onset, typically in embolic stroke. But the deficits may evolve slowly over 24 to 48 hours, commonly in thrombotic stroke. Embolic strokes tend to occur during the day, with headache preceding the neurological deficit.
“Thrombotic strokes tend to occur often in the night and are first noticed on awakening. Ischaemic strokes produce motor paresis (usually on one side of the body), speech defect, ataxia, weakness and deviation of the mouth to one side. Intracerebral haemorrhage tends to be sudden, often during activity. Sudden headache, nausea, vomiting delirium and focal or generalized seizures are common.
Treatment
“This is usually a multi-disciplinary in nature involving cardiologists, neurologists, nurses, interventionists, physiotherapists, radiologists and neurosurgeons. Clinical assessment and laboratory work up (full blood count, blood sugar, imaging studies
CT, MRI), drug therapy and round the clock nursing are part and parcel of the management.
“Residual problems will need rehabilitation, occupational therapy, speech therapy, technological aids and a loving family giving emotional support.”
Prevention
Omonaiye: “Diagnosis and adequate control of hypertension cannot be over emphasised.
Other measures include control of diabetes, low fat diet, reduction of high cholesterol, weigh reduction and regular exercise. Stop smoking; stop the abuse of cocaine and other harmful substances. Alcohol intake should be reduced and treatment of atrial fibrillation.”
Lifestyle and
recovery
“Lifestyle changes can help you recover from a stroke and may help prevent another one. Examples of these changes include quitting smoking, following a healthy diet, maintaining a healthy weight, and being physically active.
“You may experience changes in your relationships because of new limitations and challenges. Both your income and expenses may be impacted by stroke.
“There is still so much we don’t know about how the brain compensates for the damage caused by stroke. In some cases, the brain cells may be only temporarily damaged, not killed, and may resume functioning over time. In other cases, the brain can reorganize its own functioning.
Every once in a while, a region of the brain ‘takes over’ for a region damaged by the stroke. Stroke survivors sometimes experience remarkable and unanticipated recoveries that can’t be explained.”