Stroke the world’s second most common cause of death – Condition affects 16 million people each year – Benefits of treatment revolution felt differently worldwide – Prevention could add 100 million healthy life years
To mark World Stroke Day, held annually on 29 October, the World Stroke Organization is working, to increase awareness of stroke every year. Despite revolutionary advances in therapy, stroke is now the second most common cause of death in the over 60s and the second most common cause of disability. Experts are calling for improved prevention measures and better neurological care in all parts of the world.
Karachi, October 28th 2020 – “Stroke is the epidemic of the 21st century,” says Prof. M. Wasay, Ex-Head of World Federation of Neurology (WFN) Public Awareness Committee & President NARF Pakistan, of the explaining the World Stroke Organization theme of this year i.e. “#Join the MoveMent” as its motto Stroke is a brain attack on the occasion of World Stroke Day which will celebrate in partnership across the globe on October 29th every year. “We want to use this initiative to help reduce the number of deaths and disabilities caused by stroke in Pakistan,” Prof. Wasay says.
Stroke incident somewhere in the world every two seconds
16 to 17 million people worldwide suffer strokes each year, six million of whom do not survive. There are a greater number of stroke-related deaths each year than deaths linked to AIDS, tuberculosis and malaria put together. “More than one in ten deaths are attributable to stroke, making this cerebrovascular condition the second-largest cause of death in the world among people over 60. It is also a leading cause of disability,” Prof. Wasay concludes.
80 percent of sufferers live in developing countries
Worldwide, #1in4 adult could have a stroke, around a fifth of all women and a sixth of all men have a stroke at some point in their lives. While risk increases with age, young people are also affected: according to the WHO, stroke is the fifth most common cause of death for people in the 15 to 59 age bracket. However, the prevalence and effects of the disease vary greatly throughout the world: “Currently around 80 percent of those affected come from low and middle income countries,” Associate Prof. Abdul Malik (Vice President of Pakistan Stroke Society & General Secretary NARF-Pakistan) adds. “In the last decade the incidence of stroke in countries with low to middle incomes was around 20 percent higher than in high income nations. This shows that having a stroke is not inevitable, but very much depends on a person’s environment. This is something we can and must work on.”
Stroke classified as a neurological disease by the WHO
In light of the growing significance of stroke for the global disease burden, the World Health Organisation has also changed its stance and redefined stroke in the International Classification of Diseases (ICD). “The categorization of strokes in the ICD-10 was inconsistent and outdated”, Dr. Ravi Shunker, General Secretary Pakistan Stroke Society (PSS), explains. “While stroke was listed under the cardiovascular disease category, transient ischemic attacks were attributed to diseases of the nervous system and silent cerebrovascular diseases were included in the section of incidental imaging findings.” The newest version, ICD-11, expected to be approved by the World Health Assembly, reflected the recommendations of an expert advisory committee and create a single block of “cerebrovascular diseases” within the category of diseases of the nervous system which includes all relevant conditions.
“This latest development in the ICD-11 process correctly signals that stroke is a brain disease and contributes to improved clarity and clinical usefulness”, according to Dr. Bashir Soomro (Senior Neurologist at Ziauddin University). “Stroke is no longer in the shadow of other cardiovascular diseases and the position of stroke as one of the most important non-communicable disease, possible to prevent and treat, is strengthened.”
Stroke increasingly treatable thanks to breakthroughs
“There are few other diseases for which treatment options have improved so radically over the past decade and a half,” Dr. Abdul Malik, Vice President Pakistan Stroke Society, confirms. “Until recently we were largely powerless in the face of stroke and couldn’t do much more than alleviate some of the consequences – but today we can finally say that strokes are treatable.”
The first major breakthrough came 15 years ago when intravenous thrombolysis was first introduced. Under this procedure, stroke-causing blood clots in vessels of the brain are dissolved using medication. “Widespread use of this method has not only saved many lives, but also led to a huge expansion of neurological infrastructure and the introduction of stroke units in many countries. This alone can reduce mortality by about 20 percent in a single year,” Dr. Abdul Malik adds.
In around 10 percent of cases, the occlusions are so large that thrombolysis does not work. However, endovascular thrombectomy was introduced a few years ago to provide an option in precisely these kinds of cases. The procedure involves removing a clot from a blood vessel in the brain using a catheter inserted via the groin. Data have recently been made available which show that even blockages that are more than six hours old can be treated successfully. “Numerous international studies have shown that endovascular treatment represents a major advance compared with medication-only treatment,” Dr. Ravi notes.
Major variances in quality of care provision worldwide
There is still a long way to go before these breakthroughs benefit all patients worldwide. “Unfortunately there are still a lot of countries that simply do not have the infrastructure and specialists in neurology,” says Prof. M. Wasay. “While wealthy countries have three neurologists per 100,000 inhabitants, the total for low income nations drops to just 0.03. The fact that the chances of surviving a stroke depend greatly on where someone lives is unacceptable and something that the WSO and its partners must tackle with all of the resources available to them,” says Prof. Wasay, issuing a call for international solidarity on the issue.
“Stroke, its treatment and prevention must be given the highest priority in healthcare policy in every country,” NARF Secretary General Dr. Abdul Malik confirms. “As advocates for stroke patients, we will not tire of calling for and promoting fair distribution of treatment opportunities for stroke patients. But for this to happen, all hospitals need to be equipped with specialist stroke units, and medicine for basic thrombolysis treatment needs to be made available – but that’s not all. It is of great importance to raise awareness in the general population for the most common risk factors, in particular hypertension, for early detection and for the need for adequate care, not only in the acute stage, but also on the long term. As the prevalence of stroke sufferers left with permanent disability is still high, efforts towards permanent care facilities need to be a task of national neurological and stroke societies.”
Ten risk factors responsible for 90 percent of all strokes
A large proportion of all strokes are avoidable, according to data from the INTERSTROKE study. “Ten influenceable risk factors are responsible for 91 percent of all strokes worldwide,” Dr. Bashir Soomro, highlights. “These are high blood pressure, physical inactivity, an unfavourable situation of blood lipids, poor diet, a high waist-to-hip ratio, psychosocial factors, smoking, a high alcohol intake, cardiac disease and diabetes.” An analysis of the results of stroke-related data generated by the 188-country Global Burden of Disease Study came to a similar conclusion, but like other current studies also highlighted air pollution as an additional risk factor.
High blood pressure is the single largest risk factor for stroke. “Hypertension is behind almost 50 percent of all strokes and also increases the risk of intracerebral haemorrhage, which often leads to particularly severe disabilities,” Dr. Soomro warns. “There is potential to add 100 million healthy years worldwide solely from effective strategies designed to reduce strokes.” In addition to focusing on the effective treatment of diabetes, increased blood lipids and atrial fibrillation, as well as preventing obesity and promoting physical activity, experts are also pushing for the speedy introduction of a global smoking ban.
Early detection saves lives
“Alongside prevention, we also have to promote awareness of how to detect and respond correctly in an emergency,” Prof Mohammad Wasay, President NARF, confirms. Experts believe that almost 70 percent of patients fail to identify transitory ischemic attacks – a temporary interruption to the brain’s blood supply – and even mild strokes. Even when symptoms are identifiable, almost one in three people do not seek immediate help. “Reducing the amount of time that elapses between the emergence of the initial symptoms and the patient receiving care is a central factor in improving treatment outcomes, and can save many sufferers from a lifetime of severe disability,” Prof Wasay says.
To help people with a non-medical background identify the wide range of different – and often unclear – symptoms, the WSO draw attention to some simple guidelines to provide clarity in the event of a suspected stroke incident. The only thing that non-experts have to remember is the “FAST” mnemonic:
- F for face drooping: Ask the person to smile. Does one side of their face droop?
- A for arm weakness: Ask the person to raise both arms. Is one arm numb and does it drift downward?
- S for speech difficulty: Ask the person to repeat a simple sentence. Is their speech slurred? Are they able to correctly repeat the words, or are they hard to understand?
- T for time to call an ambulance: If someone shows any of these symptoms, time is crucial. Call an ambulance or help get the person to hospital immediately.
We as representatives of the national stroke body, the largest doctors & social welfare organizations demands:
- A National Stroke Prevention Program should be established. We have a TB Control Program, AIDS control program, Malaria control program, Mental Health Program and why we cannot have a Stroke prevention program that would really affect the mortality and disability related to stroke, which is a huge economic and social burden in our society.
- Govt. should establish Stroke Units in all DHQ of the country and specifically across Sind Govt. Hospitals, we can facilitate provincial governments health ministry in this regards.
- Shall designate one hospital in Karachi as dedicated Stroke Center with all diagnostics, inpatients and rehabilitative facilities.
- Availability of tPa and thrombectomy in stroke centers.
- Mandatory Stroke specific “Training for nurses and paramedics”.