On Guard: Protecting against a stroke’s blow

By Dr Poonam Khetrapal Singh WHO Regional Director for South-East Asia

How to prevent, detect and respond to brain strokes

The human brain is uniquely complex. The billions of neurons it contains provide the substance of reason and thought, while the functions it controls define our every move.

But when the brain is deprived of blood and the oxygen it carries, or when bleeding inundates surrounding tissue and causes the brain to swell, its effective operation becomes compromised. Both incidents can cause lasting vision problems, seizures, fatigue, loss of speech, memory loss, and paralysis among other adverse effects. If severe enough, they can also cause death.

To suffer such an event is to undergo a ‘brain stroke’, also known as a ‘brain attack’. It is an event and condition that too many of us know too little about, but which – for the most part – each one of us has the capacity to prevent and detect.

Given the numbers, learning to do so should be a priority. In low-and middle-income countries, which include those of the WHO South-East Asia Region, over 11 million strokes occur every year. This causes the deaths of more than 4 million people annually, and leaves approximately 30% of survivors seriously disabled. For the 70% of survivors who recover, the likelihood of suffering further strokes is greatly increased: ‘Recurrent’ stroke accounts for around one in every four episodes of the life-threatening condition.

Some are more disposed to the problem than others. This includes people with high blood pressure, high cholesterol, heart disease, diabetes or a high blood-sugar level. It includes people that are obese, smoke or consume alcohol in large volumes. And it also includes people that are physically inactive. In addition, the risk of stroke increases with age, while males are more likely to suffer a stroke than females. Though demographic factors cannot be helped, there is much that can be done to reduce lifestyle-related risks.

First, people who smoke should quit, and those who drink heavily should cease. These two factors alone significantly multiply the likelihood of stroke, meaning avoiding them is vital to preventive efforts. Second, a diet high in vegetables and fruit and low in salt should be consumed. Doing so will decrease fatty deposits in the arteries that can cause blockages, as well as diminish the prospect of burst vessels that high blood pressure brings. Third, regular exercise should be undertaken. This means getting at least 30 minutes of moderate-intensity aerobic activity at least five times a week. And fourth, blood pressure, blood-sugar and cholesterol levels should be checked regularly, with associated conditions managed in consultation with a health care provider.

As each of us adopts these simple but effective habits, which also help prevent against other noncommunicable diseases such as heart disease and diabetes, it remains important to be able to identify a stroke’s early warning signs. One of the reasons why people delay seeking immediate treatment is due to a lag in recognizing that a stroke is occurring.

There are three key questions and signs related to the face, arm and speech that can help to identify a stroke: Is the face drooping on one side? Is there weakness in one arm? Is the speech slurred? If the answer is yes to one or all of the above, the person may be having a stroke, meaning there is just one thing to do: get medical help, and get it fast.

Health systems must be in a position to act decisively to prevent stroke-related disability or death. National treatment protocols and guidelines should be robust and clear. Emergency referral systems should be well-honed and efficient. And health care staff should be given the skills to support emergency care and management and act in accordance with protocol. Though even the most advanced health systems are unable to provide cutting-edge technology at every facility, good health system planning can nonetheless maximize the reach and quality of services offered.

Importantly, as a means of diminishing the likelihood of a stroke occurring in the first place, treatment and counselling to manage stroke-related conditions such as diabetes and hypertension should be available at the primary health care level. Increasing access to these services will not only decrease the number of strokes occurring, but will also help limit other complications these underlying conditions can cause. With the recent adoption of the Colombo Declaration, which calls for a Region-wide primary health care approach to tackling noncommunicable diseases, commitment across the Region is encouraging.

In acknowledging the serious, life-threatening nature of stroke, the condition’s name – derived from an ancient Greek term meaning ‘struck down by violence’ – is perhaps more fatalistic than it needs to be. Through avoiding tobacco and alcohol, consuming a nutritious diet, getting regular exercise, and managing underlying conditions, most brain strokes can be prevented. And through knowing the symptoms, seeking immediate care, and having a well-prepared health system, most complications can be averted. To ensure this is the case, individuals and the health systems they rely on must adapt accordingly.