The recent news stories about Liberia’s Archibishop Michael Kpakala Francis’ affliction with stroke, as well as reports from Liberia about patients (adults and children) who present themselves to local clinics and health centers with symptoms suggestive of strokes and are often told to go home because this is not a hospital treatable illness and remotely about Israel’s Ariel Sharon suffering the devastating consequences of a stroke should be a good point for us to educate ourselves and review some information about this often debilitating and deadly disease. Liberians from as far as the Bujumburam Refugee Camp in Ghana, SouthEast Asia, Grand Bassa County, Lofa County ,Guyana and Jamaica and different areas of the United States have expressed desire to know more about this subject. Hence, I will offer this brief summary.

First and foremost, a stroke is a neurologic emergency. In the absence of a functioning emergency medical service, most preventable strokes will be allowed to exert their often debilitating and deadly effects. Also, health belief modification is very important. The idea that this is caused by witchcraft or God’s will is without any basis whatsoever in logic, common sense or science. IN NEUROLOGY, TIME IS BRAIN. Every minute lost in a person with stroke is brain lost, period!!!!.

In general, if someone cannot raise their arms or legs upon command, or cannot speak, you must assume this person is having a stroke unless otherwise proven. It is then extremely urgent to call 911 (if such a system exists) or take the person to the nearest hospital ER or clinic where “stroke teams” and “stroke centers” have been especially formulated to handle such emergencies. If the person is presented to the health facility within three hours with clearly defined onset of symptoms and having met the inclusion criteria, the clot busting drug called tPA can be given and this can be lifesaving for quite a lot of people. This drug is not a cure-all for all strokes but it has made significant impact on strokes and is now recognized as a standard of care in most industrialized nations.

In most countries where stroke services and systems are organized, there has been a significant reduction in the mortality and morbidity from strokes. Hence, investing in local medical and emergency medical services, public education is very crucial. By the time, Archbishop Michael Francis was put on the plane to Ghana and then to the USA for treatment, the precious “window of opportunity of three hours” has since past and effective treatment then was out of reach for him.

In the United States, for example, stroke remains the third leading cause of death and a major cause of disability. Over 700,000 strokes occur every year (approximately one per minute) and more than 2/3 of these are first time strokes. Had they not invested in emergency medical services, patient education and established dedicated ‘stroke teams’ and “stroke centers”, these figures would have been much, much higher.
The financial burden created by stroke is high- no matter which country you live in; direct (eg. hospital and physician care) and indirect costs (lost productivity, family and societal burdens). In the USA, the financial burden was estimated to be $57 billion in 2005 alone.

A stroke occurs when the blood supply to the brain or the neural axis is suddenly interrupted by either a clot in the blood vessel supply that area of the brain or bleeding in the brain from rupture of the blood vessels supplying that territory. What we then see are the effects of the destroyed brain tissues on the structures that they control elsewhere in the body.

Strokes can be divided into two categories: ischemic strokes (80% of all strokes), including embolic and thrombotic strokes; and hemorrhagic strokes (20% of all strokes), such as primary intracerebral hemorrhage(bleeding; as in the case of Israel’s Ariel Sharon) and subarachnoid hemorrhage (usually from rupture of outpouching of brain blood vessels).

Most strokes are preventable (ie. primary prevention). The core of primary prevention is reduction of as many modifiable risk factors as possible and evaluation of potentially treatable/lesions, such as lowering high cholesterol in the blood with medications, surgically treating significant symptomatic carotid disease and treating irregular heart beats, especially atrial fibrillation- a very notorious risk factor of stroke.

Strokes can occur in the young child as well as the elderly without preference. The causes and risk factors are however different.

TIA, transient ischemic attack refers to a transient neurologic deficit lasting less than 24 hours with complete return to normal. This however is a herald for an impending stroke-ie. the big one. This is most true within one month of this transient ischemic event. For this very reason, TIA should be considered a medical emergency and immediate testing for preventable causes of stroke is a must. Treating strokes require an active, not a passive approach.

Risk factor modification is important in primary prevention of stroke. High blood pressure must be diagnosed and effectively treated as is checking and treating elevated blood cholesterol with diet and drug therapy. Also eliminate smoking and heavy alcohol use; engage in a sustained exercise program; detection and treatment of diabetes mellitus, heart disease including atrial fibrillation and daily use of aspirin as secondary prophylaxis. It has been shown in the literature that simple, effective management of high blood pressure (hypertension) alone can reduce stroke incidence by as much as 70% (1).

STROKE RISK FACTORS:

Nonmodifiable:
Age: Advancing age; stroke doubles in each decade after age 55
Gender: More prevalent in men but stroke related case fatality higher in women
Race/Ethnicity: blacks and Hispanics have higher risk/mortality rates than whites
Hereditary: not clear cut but maternal and paternal history may increase risk

Modifiable risks:

Prior TIA/stroke; High blood pressure; Diabetes Mellitus, Cigarette smoking; High cholesterol levels; Heart Disease; Atrial fibrillation; Symptomatic carotid stenosis; sickle cell disease

Potentially modifiable:
Heavy Alcohol abuse; Drug abuse (eg. cocaine, heroine); Obesity; Oral contraceptives; Physical inactivity, etc.

EARLY WARNING SIGNS OF STROKE

1.Sudden numbness/weakness of face , arms or legs
2.Sudden confusion or trouble speaking
3.Sudden trouble seeing
4.Sudden trouble walking or dizziness
5.Sudden severe headache (eg. worse headache of your life)

In strokes, prevention is so much better than cure and modification of risk factors remains paramount in the prevention of a first stroke. After a stroke or TIA has occurred, secondary prevention should be started as soon as possible and this should include blood pressure medication, blood thinners (eg. anticoagulants or antiplatelet agents depending on the medical indication), cholesterol lowering medications, carotid endarterectomy/stenting in selected patients for carotid artery stenosis (“narrowing”) and continued modification of other know risk factors.

STROKES IN CHILDREN:

Strokes in children differs from that in adults primarily because of the predominance of congenital and genetic causes. There are also notable differences with regards to incidence, etiology, clinical presentation and clinical course. As is true in adults, disorders of the heart and great vessels are responsible for many strokes in children (2).

The presentation of stroke in children differs from that in adults in the following ways: a) seizures at the onset are more frequent in children whether the stroke in hemorrhagic or ischemic infarction; and b) stroke in the dominant hemisphere produces loss of expressive language, usually as mutism in younger children; fluent aphasia(“inability to use or understand spoken or written language”) is uncommon in childhood stroke.
Residual hemiparesis, epilepsy, mental impairment, and hyperactive behavior are common sequelae. Prognosis is least favorable when there are multiple seizures at the onset of the illness.

In children, cyanotic congenital heart disease is the most frequent cause of ischemic strokes, accounting for 26% . Other common causes of strokes are sickle cell disease, intracranial infection, intracranial hemorrhage, vascular malformations, and occlusive vascular disease(eg. moya-moya disease, fibromuscular dysplasia). Inborn errors of metabolism are a rare cause of stroke in children but not in adults. HIV/AIDS is becoming an increasingly important cause of stroke in children. Trauma to the neck may predispose to arterial dissection.

Evaluation of patients with stroke:

Triage;
ABCs( airway, breathing, circulation,etc);
Early consultation with a neurologist or stroke team;
Emergency CT scan head or MRI/MRA brain;
Thrombolytic therapy (after inclusion criteria are met).

This is not meant to be an exhaustive treatise on stroke but written as a summary for public health education and awareness purposes.

References:
1.Gorelick, PB. Stroke prevention. Arch Neurol. 1995; 52: 347-355
2.Young, R. Stroke in childhood, Neurology in clinical practice, 2000, eds: WG
Bradley et al

Dr. Lawrence A. Zumo, is a board certified neurologist with subspecialization in neuroinfectious diseases and autonomic nervous system disorders and is in private practice in Silver Spring, Maryland, USA. He is a diplomat of the American Board of Psychiatry and Neurology; Member, American Academy of Neurology; Neurology Teaching Service Attending of the Prince George’s Hospital Center Internal Medicine Program, Cheverly, Maryland as well as a consultative member of the Graduate Advisory Committee of the University Medical School, Debrecen, Hungary, European Union. He can be reached at zumoamos@aol.com.

A NEUROLOGIST IS A MEDICAL SPECIALIST WHO DEALS WITH STROKES IN CHILDREN AND ADULTS, BRAIN TUMORS, SEIZURES, BRAIN INFECTIONS, MULTIPLE SCLEROSIS, PARKINSON’S DISEASE, MYASTHENIA GRAVIS, HEADACHES, NEUROMUSCULAR DISEASES, NEUROPATHY, ALZHEIMER’S DEMENTIA, ETC.