Stroke

Everyone must have heard of strokes. Many of us – me included – have had a family member with a stroke, and as we get older friends with strokes too. Stroke is even used in ordinary conversation to express surprise or shock - “I nearly had a stroke!”. Stroke is common, sudden and surprising. But some people still think strokes are to do with the heart rather than the brain. To avoid this confusion many experts would like strokes rebadged as brain attacks, which would also give an appropriate sense of urgency and having to get on sorting them out fast – like heart attacks. But this term has never really caught on.

 

In the UK about 100 000 people have a stroke for the first time every year, thousands more have a recurrent stroke, and thousands more again have a very brief stroke lasting minutes maybe hours – a so-called transient ischaemic attack. In fact stroke is the fourth most common cause of death after heart attacks and all cancers put together, and the most common cause of serious physical disability.

So what causes strokes? They are very rare in children and become more common with ageing, but they are not an inevitable accompaniment of aging. We know this because they are more common in people who have raised blood pressure, who smoke, who have a common type of irregular heart beat called atrial fibrillation, in diabetics and to some extent in people who are overweight and don’t exercise, and those with a high level of cholesterol in their blood. Without one or more of these risk factors you are very unlikely to have a stroke however old you are. Contrary to common mythology strokes are not often if ever brought on by stress. There are several rare causes of stroke as well such as injury to the arteries in the neck or inflammation of the arteries in the brain.

 

Most strokes are due to a brain artery becoming obstructed by a blood clot – so-called ischaemic strokes, while some are due to bleeding in the brain – cerebral haemorrhage. In either event, an area of brain small or large is destroyed permanently or temporarily, and so stops working and it is that loss of brain function which causes the outward visible signs of a stroke – sudden loss of use of maybe one arm, an arm and a leg on one side, speech, or less commonly vision. In a really bad stroke the patient may lose consciousness immediately or within a day or two. About 2/3rds of stroke patients die of their stroke within days or weeks, while about one half of the stroke survivors are left with some sort of disability.

So what can we do to help strokes patients when the stroke occurs? Common sense, and indeed good evidence, tells us that in general common diseases are best looked after by experts in the disease in question. Stroke is no exception and these days stroke patients in the UK at least are or should be – and mostly are - admitted into a stroke unit where the doctors, nurses, physiotherapists and others are all well used to treating stroke patients quickly and effectively – right from the early hours through to rehabilitation in hospital and even at home, and with long term medical treatment to prevent recurrence.

 

A few ischaemic stroke patients should be and are treated with so-called clot busting drugs which reduce their chance of ending up dead or disabled but they do have to get to hospital very quickly – in maybe a couple of hours or so from their first symptoms, after that the harms of treatment outweigh the benefits. Most stroke patients are given aspirin, or if they have atrial fibrillation anticoagulant drugs like warfarin, to reduce the risk of recurrent stroke both in the short term and longer term. Occasionally surgery to remove a blood clot from the brain, or to relieve swelling of the brain, can be life saving.

 

Patients with mild strokes or transient ischaemic attacks don’t have to be admitted to hospital but they do need to be seen quickly – preferably at once. This is not because they need looking after in the sense of nursing, but partly because it is easier to make the diagnosis before the symptoms have gone, and mostly because the risk of having another stroke is so high in the first few days. We now know this risk can be reduced substantially. As well as aspirin or warfarin which I have mentioned, it is important to get good control of a patient’s blood pressure with one or more drugs (juggling them around to minimise side effects) and to use a statin to reduce the blood cholesterol (again watching out for side effects). Some will need their diabetes sorting out. A few patients can have their stroke risk substantially reduced by surgery on one of the neck arteries - carotid endarterectomy. As well as all this rather medical approach with a lifetime of drugs to prevent recurrence in the long term, it is crucial that stroke survivors stop smoking, get down to a reasonable weight and eat sensibly, and exercise appropriately.

In days past we all used to be very gloomy about what seemed to be an unstoppable epidemic of strokes which were regarded as untreatable. But, amazingly, there has been a remarkable fall in the incidence of stroke, at least in Oxfordshire which is the only place in the UK it has been reliably measured. Why? Probably because the medical system has become much better at detecting and treating high blood pressure, and the public health messages are getting through – about exercise, weight control, quitting smoking, less salt in food and so on.

 

Again amazingly, our treatments to prevent stroke recurrence are far more effective than they were – well, there weren’t really any in the 1960s when I qualified as a doctor. Certainly there were none mentioned in any of my student text books.

 

Of course, there are still thousands of people who are disabled by stroke but at least now we have far better rehabilitation services with well organised physiotherapists, occupational therapists, speech therapists and others working in hospitals and in the community – not enough, but more than there were. Depression and anxiety are better recognised, and better dealt with. And let’s not forget the role of the charities such as the Stroke Association who provide information and support for stroke survivors.

 

I don’t like to end on a negative note but although we are getting stroke prevention, treatment and care much better in the UK and indeed in other high income countries, the fact remains that most strokes in the world occur in low income countries, particularly in Africa where medical services are far, far more stretched than ours. And worse than that, the incidence of strokes may well rise if these countries take on the bad habits we have tried to avoid – such as obesity, smoking and lack of exercise. But still, we do know that if low income countries avoid these problems they will not have to face a stroke epidemic, and with resources the strokes that do occur will be better managed as effectively as they are these days in the UK.

 

I am sure there is plenty of room for improvement in stroke prevention and care, but now stroke in the UK is far higher up the priority list I certainly expect to see more improvements in the next ten years.