Strokes – what’s new?

By Dr Channa Ratnatunga

Having been a victim of a disastrous stroke five years ago, I am reasonably well enough, that I can pen this ‘piece’ to you. Being a ‘medical man’, so to say, I probably have a better insight into the illness and the ‘road to recovery’ than most sufferers. I now would like to address stroke patients and their caregivers, to motivate them, in their time of need. I have found motivation, determination and self-reliance are the keys to a good result.

Formerly the brain was thought to be, when damaged, ‘damaged or good’. During the last decade, it was increasingly realized that this was not true. Let me expand on this concept. In the common type of stroke, the blood supply to an area of the brain gets blocked. Consequent to lack of oxygen to cells of the brain in the vicinity gets cut off. These cells then die. With the passage of time, the blood, finding it difficult to flow past the block, slows and eventually adds to the extent of the block, compromising the blood supply and the oxygen to the cells adjacent to the dead cells, making it worse. Time therefore, after the initial event, is of the essence and is crucial to prevent this progression. Over the many centuries of evolution, the brain has developed several protective ways to minimise this damage, but, in most cases, a time delay of more than four and a half hours is thought, at present, to be best avoided, as beyond this delay medical interventions may not yield gratifying results. However, in some areas of the brain, even a delay of 24 hours is now entertained.

During the first year of my rehabilitation, I had the opportunity to talk to many patients who had suffered strokes. This came to be, as we both attended the physiotherapy department of the hospital I had worked at. The conversations five years ago were most revealing. Many of them had come to hospital after strokes; one of them said that though investigated, no substantial treatment other than a nasogastric tube to feed had been done. The communication as regards his handicap had not been discussed with him or his relatives, who invariably sought ‘good ‘Ayurvedic practioners, who were usually recommended to them. The treatment was oils rubbed onto his paralysed limbs, and ‘arishtayas’. Most patients found the treatment difficult to afford, especially as the family income sources had dried up with their illness. They had come back, after a year or so, for physiotherapy, as they yet hoped that they could get over their residual handicaps.

When I tried to explain the modern Allopathic way now uniformly practised in the advanced societies in the West and informed them of early admission to hospitals with stroke services, the dissolution of the block by drugs and the removal of the same by a catheter as a last resort, they listened politely, but with little enthusiasm. I informed them that of late the drug enabling dissolution of the block was becoming available free (though very expensive) in major teaching hospitals with CT facilities. The practice of seeking Ayurvedic treatment will remain unless the availability of the new treatment is made known to the public. I observe that most tele-dramas aired on the electronic media, belittle ‘western’ treatment as being unsuccessful! The Suwasariya 1990, ambulance service provides an excellent service in bringing patients early, a boon for stroke care.

To update the public on the current scenario on stroke management in our state-run hospitals I interviewed, Neurologist Dr Manoji Pathiraja at the Peradeniya Teaching Hospital, She said, during the last two and a half years, 74 patients had been found suitable for block dissolution by the drug; 72 post dissolution went home after a week almost normal. The others (600 odd) were found unsuitable as either they came late (i. e. more than 24 hours later) or had suffered a very dense stroke. The most common reason given for the delay in seeking treatment was the belief that weakness or paralysis would go away and the patient might get better. As usual those at Peradeniya were very keen to mount a stroke care programme; they hoped they could start the interventional radiology programme necessary for catheter removal of block. But, unfortunately, the DSA machine they had worked so hard for was sent elsewhere!

What I gather from a discussion with Dr Padma Guneratne, the retired neurologist at the National Hospital, a pioneer in many aspects of stroke-care, is that there are at present, 16 centres doing drug dissolution all over the country. They are done mostly in Emergency rooms in the OPDs, after CT data are vetted by a Neurologist, who says it is ‘OK’ to do so. This, together with the results now being obtained for dissolution of block, augurs well for stroke care in the country.

Dr Padma Guneratne informs me that a Stroke Centre is at present being constructed at Mulleriyawa, a project that would make further inroads into this common disorder, which has a significant morbidity and mortality. To ensure a 24-hour service with trained staff of all categories, with the necessary drugs, catheters and expertise, requires commitment of a high order. Further, the ‘in-hospital delays, e. g. CT facility far away from the emergency room, service delays, equipment non-availability, etc., are all realities at present. Besides, the removal of the block by catheter (thrombectomy) for those not responding to the dissolution drug, requires further steps. Although the latter procedure is available at Asiri Central, (where I was successfully thrombectomised), it must be available at all state-run hospitals. It is costly but looking at the wasteful expenditure seen around us, it is an imminently mountable project by the government. Neurologists have an active role to play in it.