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A step forward in stroke care in Sri Lanka

 

A recent lecture by Consultant Neurologist Dr. Padma S. Gunaratne at the inauguration of the second annual scientific sessions of the Association of Sri Lankan Neurologists and the International Stroke Conference on the theme: A step forward in stroke care in Sri Lanka.

"Stroke", the brain equivalent of heart attack, was first described by the father of medicine, Hippocrates more than 2400 years ago. It was called apoplexy because of the way it strikes people down.

Later Jacob Wepfer from Switzerland in 1600s found that patients who died with "apoplexy" had either bleeding into the brain or a blockage in one of the brain blood vessels. The research in the field of cardio vascular disease over the years, advanced the knowledge on stroke, and today, although the stroke is a catastrophe, it is preventable and treatable. There is a wealth of information available on causes, prevention, risk, and treatment of stroke. Most stroke victims now have a good chance for survival and recovery. What is important today, is to transfer already available evidence of research into action. It is important to develop and implement context specific and sustainable strategies at national level to narrow the treatment gaps that have already been identified out of research.

Every year, 15 million people world wide suffer a stroke. Stroke strikes making 60% of the affected dead or dependant for the rest of the life. The percentage of deaths caused by stroke is exceeded only by deaths caused by coronary heart disease and cancers. 80% of all deaths of stroke occur in this region or in low and middle income countries. Limited facilities for management and rehabilitation in developing countries result in poorer out come with higher mortality. Once faced with a stroke 10% die within 30 days, 50% remain disabled after 6 months and only 30% are functionally independent at one year. Stroke is the leading cause of adult disability. According to World Health Organization, loss of productivity caused by the disability and the cost involved with management of stroke could be significant enough to have an impact on the economy of a country.

The incidence of stroke is declining in many developed countries, largely as a result of better control of high BP and reduced level of smoking. However, absolute number of strokes continues to increase because of the ageing population.

The incidence of stroke in SL is 11 per 1000 population. It is the 5th leading cause of hospital deaths. As you would understand over the next few minutes, majority of stroke deaths occur out of hospital and if they are included, stroke is likely to be the third leading cause of deaths in Sri Lanka, like in any of the other countries.

According to Department of Census and Statistics, the aged population in Sri Lanka is on the rise. It is predicted that 20% of population by 2020 would be more than 65 years indicating that there will be a significant stroke burden to Sri Lanka by 2020. Are we geared up to face this burden?

Until recently the progress of stroke care was hindered by ignorance, nihilism, and negativity both within and outside the medical profession. This has all changed in the past few decades. Tremendous advances in understanding the pathogenesis, coupled with the advent of superb noninvasive diagnostic techniques, and evidence from randomized clinical trails of effective strategies to prevent and treat stroke, have seen stroke medicine establish itself as one of the frontiers of medicine and a multidisciplinary specialty in its own right.

Diagnosis of stroke.

It is known to medical profession that the accurate diagnosis of stroke could be made purely based on clinical history. Sudden onset neurological symptoms is the most important and characteristic feature useful in arriving the diagnosis. Nevertheless, the management decisions are made depending on whether the patient had a cerebral haemorrhage or an infarction. Infarctions are treated with thrombolytics given within three hours of onset of symptoms. A significant proportion of infarctions could be prevented by prescribing aspirin and, warfarin for cardiac source of thrmbo embolism. Endarterectomy of significant symptomatic carotid stenosis averts recurrent stroke in carotid territory. Certain venous infarcts need long term warfarinization.

The introduction of the magnificent radiological investigation in 1970s, CT scanning of brain, was a landmark in milestones in stroke care. CT brain is obligatory to differentiate cerebral haemorrhage from an infarction.

Could we afford to do CT brain for all stroke patients? I must mention that the first CT machine to Sri Lanka was introduced 2 decades ago. Since then the number of CT machines available have increased significantly. At present there are 19 CT machines available in hospitals in the ministry of Health. CT for brain is a basic investigation and it is the equivalent of ECG to diagnose myocardial infarction. Although it is clear that we need to have few more CT machines, Should we be arguing that whether we should do CT brain for all our stroke patients or Should we go all out get CT brain for all our stroke patients? In my opinion we are in an era where all clinicians should routinely request CT brain for all stroke patients.

Thrombolysis for acute stroke

In the event of a cerebral infarction there is ischemic penumbra that is dysfunctional but salvageable around the infracted tissue. Thrombolysis with Recombinant Tissue Plasminogen Activator given within first three hours, stays the specific form of treatment to salvage this ischemic tissue. Treating patients with thrombolytics is associated with a greater reduction in death or dependency, equivalent to 126 fewer dead or dependant patients per 1000 patients treated. The convincing effectiveness of thrombolyisis has lead in some of the developed countries to rule, not offering thrombolytics to the acute stroke amount to medical negligence.

The first programme of thrombolysis in the public sector hospitals was initiated in Sri Lanka in March 2007 at the National hospital of Sri Lanka. Since then all acute stroke admissions to National Hospital were screened and 19% of acute stroke were thrombolysed. The knowledge on the availability of a specific mode of treatment had lead some of the affected to reach hospital within 2 hours even from a distance of 20 kms away from hospital. Nevertheless, non availability of adequately allocated beds for stroke patients at the hospital hinders giving adequate publicity for this programme, depriving the treatment for a significant proportion of deserving patients.

As at present thrmbolysis is not available in any of the other public sector hospitals other than at National Hospital of Sri Lanka. Since thrmbolysis was proven to be effective, more and more studies confirmed safety of thrombolysis even in primary care settings with facilities for CT scanning.

When could we commence this useful form of treatment out of Colombo; At laeast at the other two large hospitals in Galle and Kandy by ?

Part II tomorrow

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