A. General Considerations

A stroke is a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off.

Stroke is a medical emergency and urgent treatment is essential.

The sooner a person receives treatment for a stroke, the less damage is likely to happen.

If you suspect that you or someone else is having a stroke, call 999 immediately and ask for an ambulance.

A stroke causes damage to the brain. A common cause of stroke is a blood clot that forms in a brain blood vessel (artery). Immediate treatment may include a clot-busting medicine to dissolve the blood clot. Other treatments include medication to reduce risk factors for further strokes. Rehabilitation is a major part of treatment. Disability following a stroke depends on factors such as the part of the brain affected, how quickly treatment was given and the extent of the damage to the brain.

Stroke has already reached epidemic proportions. Globally 1 in 4 adults over the age of 25 will have a stroke in their lifetime. 13.7 million people worldwide will have their first stroke this year and five and a half million will die as a result. Current trends suggest that the number of annual deaths will climb to 6.7 million annually without appropriate action.

Stroke is one of the leading causes of morbidity and mortality worldwide. WHO statistics indicate that all types of stroke ranked cause of death (13-15%) as the third and surpassed only by heart disease and cancer. Each year 15.000.000 persons suffer from stroke worldwide out of which 5.000.000 and up with mortality and the remaining 10.000.000 have been deeply disabled.

Within the Arab world, stroke disease burden varies greatly. For example, the percentage of disability-adjusted life-years (DALYs) due to stroke is over 4% in Egypt, United Arab Emirates, and Tunisia in 2016, but less than 2% in Bahrain, Djibouti, and Qatar. In 2019, there were 7.3 million prevalent cases of stroke in the MENA region leading to over 312.000 deaths in the same period.

A retrospective hospital based study in 2000 by Al-Jishet al. at the Salmaniya Medical Complex, Bahrain, reports a stroke incidence of 57/100,000. The incidence is higher in males as compared to females in all age groups. Hypertension, dyslipidemia, diabetes mellitus, ischemic heart disease and smoking were commonly identified risk factors. In a retrospective study of 872,288 individuals in 2015, Al Bannaet al. reported a crude stroke incidence of 60/100,000, with diabetes, hypertension and dyslipidemia being the most common risk factors for stroke.

Types of Stroke

An ischemic stroke is the most common type of stroke. This happens when a blood vessel in the brain is blocked, stopping blood flow and causing brain tissue death. This blockage may be from a blood clot that formed somewhere in the body and traveled to the brain, or it may be from a blockage that starts in one of the brain’s arteries. There are two different types of ischemic strokes:

• An embolic stroke is when plaque (fat deposits) or a blood clot travels from the heart or blood vessels leading to the brain and blocks blood flow to the brain tissue.
• A thrombotic stroke is when plaque or a blood clot forms inside the arteries in the brain, blocking blood flow to the brain tissue.

A cryptogenic stroke is a stroke that happened without a known cause. Cryptogenic strokes may account for more than 25 percent of all strokes.

Although a transient ischemic attack (TIA) is not a stroke, it is serious. It happens when blood flow to the brain suddenly stops for a short period of time and is then restored without any tissue death. During this time, the brain cannot function properly. This is often a warning sign that a stroke may happen in the near future.

A hemorrhagic stroke is less common, but more deadly. It happens when a blood vessel in the brain bursts and blood spills into or around the brain. There are two different types of hemorrhagic strokes:

• An intracerebral hemorrhage happens when a weakened blood vessel (also called an aneurysm) leaks or bursts and bleeds into the brain tissue, causing the tissue to die. The most common cause of an intracerebral hemorrhage is high blood pressure.
• A subarachnoid hemorrhage happens when an aneurysm leaks or bursts, causing blood to enter the space between the skull and the brain (called the subarachnoid space). This blood can irritate other blood vessels, causing them to spasm and reduce blood flow to the brain, resulting in a stroke.

B. Symptoms of a stroke

The main symptoms of stroke can be remembered with the sentence BE FAST:

B. Balance: sudden loss of balance;

E. Eyes: sudden loss of vision in both eyes;

F. Face: the face looks uneven; the face may have dropped on 1 side, the person may not be able to smile, or their mouth or eye may have dropped;

A. Arms: the person with suspected stroke may not be able to lift both arms and keep them there because of weakness or numbness in 1 arm.

S. Speech: their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake; they may also have problems understanding what you’re saying to them.

T. Time: it’s time to dial 999 immediately if you see any of these signs or symptoms.

The BE FAST checklist does not cover every possible symptom of stroke or transient ischemic attack. However, it is easy to remember and it is estimated that about 8 or 9 in 10 people with a stroke or TIA will have one or more FAST symptoms.

Do not ignore these warning signs.

The functions of the different parts of the body are controlled by different parts of the brain. So, the symptoms vary depending on which part of the brain is affected and on the size of the damaged area. Symptoms develop suddenly and usually include one or more of the following:

• Weakness of an arm, leg, or both. This may range from total paralysis of one side of the body to mild clumsiness of one hand.
• Weakness and twisting of one side of the face. This may cause you to drool saliva, or cause slurred speech.
• Problems with balance, co-ordination, vision, speech, communication or swallowing.
• Dizziness or unsteadiness.
• Numbness in a part of the body.
• Loss of consciousness (occurs in severe cases).

Who is affected by stroke?

One of the main disease processes leading to stroke is atherosclerosis. The incidence of stroke increases significantly with age. There are many other risk factors, including tobacco use, physical inactivity, unhealthy diet, harmful use of alcohol, hypertension, atrial fibrillation, raised blood lipid levels, obesity, male gender, genetic disposition and psychological factors.

Most cases of Stroke occur in people aged over 65 years. Each year about 1 in 100 people over the age of 75 years will have a stroke. But a stroke can occur at any age – even in babies. The impact of stroke can be short- and long-term, depending on which part of the brain is affected and how quickly it is treated. Stroke survivors can experience wide-ranging disabilities including difficulties with mobility and speech, as well as how they think and feel. Half of these people depend on others for help with everyday activities.

Fast access to treatment saves lives and improves recovery.

Evidence is growing that COVID 19 infection increases an individual’s risk of stroke. This is the case even for younger people and those with no other stroke risk factors.

C. DIAGNOSTIC OF STROKE

Like all organs, the brain needs the oxygen and nutrients provided by blood to function properly.

If the supply of blood is restricted or stopped, brain cells begin to die. This can lead to brain injury, disability and possibly death.

There are 2 main causes of strokes:

• ischaemic – where the blood supply is stopped because of a blood clot, accounting for 85% of all cases
• haemorrhagic – where a weakened blood vessel supplying the brain bursts

There’s also a related condition called a transient ischaemic attack (TIA), where the blood supply to the brain is temporarily interrupted. This causes what’s known as a mini-stroke. It can last a few minutes or persist up to 24 hours.

Certain conditions increase the risk of having a stroke, including:

• high blood pressure (hypertension)
• high cholesterol
• irregular heart beats (atrial fibrillation)
• diabetes

A doctor can usually diagnose a stroke by the typical symptoms and signs which develop suddenly. Tests which are commonly done include:

• A brain scan (CT scan or MRI scan). This can determine the type of stroke (ischaemic or haemorrhagic) and may detect rarer conditions which may have caused the stroke or which may mimic a stroke.
• Blood tests to check on such things as blood sugar level and cholesterol level. High levels can increase the risk of a further stroke.
• Chest X-ray and a heart tracing (electrocardiogram, or ECG) to check for heart or lung conditions which may be a cause of stroke (for example, atrial fibrillation).
• Ultrasound scan of the carotid blood vessels (arteries) in the neck to check if there are large patches of atheroma in these arteries.

D. STROKE TREATMENT

Treatment depends on the type of stroke affecting the patient, including which part of the brain was affected and what caused it.

Strokes are usually treated with medication. This includes medicines to prevent and dissolve blood clots, reduce blood pressure and reduce cholesterol levels.

In some cases, procedures may be required to remove blood clots. Surgery may also be required to treat brain swelling and reduce the risk of further bleeding if this was the cause of your stroke.

Immediate care (emergency admission to hospital)

Ideally, the patient will be assessed quickly by a doctor. Commonly, a scan of the brain is organized as soon as possible. The aim of the scan is to confirm the diagnosis and to tell whether the stroke is an ischemic or hemorrhagic stroke. This is very important to know, as the initial treatment of the two is very different.

Thrombolysis (clot-busting) – If an ischemic stroke is diagnosed and it has been less than four and half hours since symptoms started, the patient will be treated intravenously with clot busting medicine which aims to dissolve the blood clod and restore circulation (thrombolysis). If the blood clot that caused the stoke can be dissolved shortly after symptoms begin, it can improve the eventual outcome.

Clot removal – Sometimes an ischemic stroke affects the front part of the brain (called the proximal anterior circulation). If you have a severe stroke affecting this region and it has been less than six hours since symptoms started, you may be offered thrombectomy – a surgical procedure to remove the clot. This is given alongside thrombolysis. The sooner this treatment is given, the more successful it is likely to be. In some circumstances, clot removal may be offered if the stroke symptoms started 6-24 hours ago.

Further early treatment – The treatment plan can depend on factors such as the severity of the stroke, the effects it has, the cause of the stroke, and other diseases that may be present. Treatments that may be considered include the following:

• Antiplatelet medication which reduces the stickiness of platelets. This helps to prevent blood clots forming inside arteries, which helps to prevent a further stroke. Aspirin (low-dose) is the most commonly used antiplatelet medicine. Another antiplatelet medicine called clopidogrel is usually given long-term after the initial treatment.
• Blood Pressure Control: Raised blood pressure is a major risk factor for stroke. In case of a bleed into the brain, the medical team will consider medication to bring the blood pressure down rapidly and keep it low for at least seven days. In case of an ischemic stroke, the blood pressure should be controlled in the longer term. However, in the short term, blood pressure-lowering medication is not usually recommended.

Medication may be advised to reduce any risk factors for having a further stroke as for example medication to lower a raised sugar level or cholesterol level.

In case of atrial fibrillation which have an increased risk of a blood clot forming in a heart chamber and travelling to the brain to cause a stroke an anticoagulant medicine (such as warfarin, dabigatran, apixaban or rivaroxaban) may be prescribed. Anticoagulant medicines help to prevent blood clots forming.

Carotid stenosis is another condition with increased risk of having a stroke. Carotid stenosis means a narrowing of one of your carotid arteries, due to atheroma. If the narrowing is severe, the doctor will advise if the surgery to strip out the atheroma is recommended.

In case of a hemorrhagic stroke to a patient already taking an anticoagulant medicine, treatment to reverse the effect of the anticoagulation is given.

Other operations are occasionally done. For example, sometimes surgery is considered to ease the pressure within the skull if the pressure becomes high following certain types of stroke.

Early mobilization to reduce the risk of complications such as blood clots on the leg which can travel to the lungs. This is to start the process of rehabilitation as soon as possible and it may also help reduce the risk of long-term disability. Also, this reduces the risk of having a deep vein thrombosis (DVT) in a leg vein, which is a risk if you are inactive in bed for long periods

Rehabilitation

The aim of rehabilitation is to maximize activity and quality of life following a stroke. Hospitals which deal with stroke patients have various specialists who help in rehabilitation. These include physiotherapists, occupational therapists, speech therapists, dieticians, psychologists, specialist nurses and doctors. One or more of these may be required, depending on how the stroke has affected you. Good-quality rehabilitation is vital following a stroke and can make a big difference to your eventual outcome.

Long-term effects of stroke can include:

• Paralysis (an inability to move) or weakness on one side of the body • Problems using or understanding language
• Changes in vision
• Numbness or tingling sensations
• Trouble with chewing or swallowing foods or liquids
• Problems controlling emotions
• Depression
• Difficulty with thinking, including attention, memory and problem solving

Fortunately, research shows that recovery never stops. Stroke recovery is hard work. Even if your improvement may seem to slow down at times, the effort you put into your recovery will result in a better quality of life. Some stroke survivors will continue to see improvement years after their event.

Stroke prevention

There are a number of risk factors that increase the chances of having a stroke: Some you cannot change, but most you can. Up to 80 percent of strokes can be prevented through managing and lowering risk factors.

Risk Factors You Cannot Change

You cannot change or reverse the following risk factors for stroke. It is important that you know how these risk factors apply to you:

• Age – As you get older, your risk of having a stroke increases.
• Gender – Women are at higher risk of having a stroke.
• Past stroke – If you have already had a stroke, your risk of having another stroke is higher.
• Family history – If someone in your family has had a stroke, your risk of having a stroke is higher.

Risk Factors You Can Change

A common reason why a blood clot forms is because it develops over a patch of atheroma on the lining of a blood vessel (artery). Certain risk factors increase the chance of atheroma forming – which increase your risk of having a stroke (and heart attack). You can reduce the risk of having a stroke (or a further stroke) if you reduce your risk factors. Briefly, risk factors that can be modified are:

Smoking. Stopping smoking can greatly cut your risk of having a stroke.

High blood pressure usually causes no symptoms but can be damaging to the arteries. If you have high blood pressure, treatment of the blood pressure is likely to have the greatest effect on reducing your risk of having a stroke.

Weight (Obesity). In case of overweight patients, losing some weight is advised.

High cholesterol level. This can be treated if it is high.

Inactivity. It is recommended, if possible, some moderate physical activity on most days of the week for at least 30 minutes. For example, brisk walking, swimming, cycling, dancing, gardening, etc.

Diet. The patient at risk should aim for a healthy diet. Briefly, a healthy diet means:

• Fruit and vegetables every day;
• Avoidance of fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc.;
• Fish consumption every week;
• Less red meat;
• Avoid alcohol;
• Limit salt usage;

Diabetes is a risk factor and it should be controlled in order to keep the blood sugar level as near normal as possible.

Cardiovascular disease control.

Atrial Fibrillation have an increase risk of stroke. This increased risk can also be reduced by following recommended treatment by the cardiologist.

REMEMBER!

If you, or someone around you experience any of the symptoms described as “BE FAST” set of symptoms:

B. Balance

E. Eyes

F. Face

A. Arms

S. Speech

T. Time

Dial 999 immediately! Time is critical!

If you have had a stroke, you are at a higher risk of having another one.

Follow the advice of your cardiologist, internal medicine specialist, diabetologist, nutrition specialist, general physician. Check your health status with required frequency and follow your medical treatment and recommended lifestyle and diet.

Contact a specialty consultation or advice from a neurology specialist: