Paralytic Stroke: A global problem on the rise

Paralytic Stroke is a catastrophe. It leads to loss of many bodily abilities. These abilities could include difficulties in speech, movement and memory.

One of the common presentations is loss of movement of one part of the body (hemi-paresis). Stroke is a common cause of death after heart attacks and cancers in the general population.

Every year 15 million people worldwide suffer a stroke and out of which 5 million die and another 5 million suffer permanent severe disability.

The prevalence of stroke in India based upon an epidemiological study conducted in 4 cities (Mumbai, Trivandrum, Ludhiana and Kolkata) state of Punjab and 12 villages of West Bengal published in 2021 by Stephanie Jones and others in International Journal of Stroke has been reported the crude prevalence to be 26-757 100,000 of population and a crude incidence to be 108-172/100,000.

They reported a one-month mortality of 18-42%. These figures match the figures of crude prevalence 143/100,00 reported by Sushil Razdan, carried out in Kuthar Valley in District Anantnag in 1989. The study was published in the Journal Stroke. With the increase in the ageing population the numbers of strokes are steadily increasing. It is estimated that 1 in 4 persons at present is destined to have a stroke in his/her lifetime.

There have been significant developments in the very early management of an acute stroke by administering clot buster medicines after a CT Brain to rule out bleeding as the cause has shown very good results and near complete recovery but unfortunately very few patients reach hospitals in this time window.

We need to understand and acknowledge that ‘time is brain’ and plug the gaps such as lack of awareness, delay in arrival, and lack of centers offering thrombolysis.

The result is that most major strokes lead to permanent disability and afflicted patients become a burden on the family with little hope of significant recovery. It is therefore imperative that the answer is prevention of a stroke. The good news is that according to epidemiological data more than 80% strokes can be prevented.

These measures are simple but need a sustained long- term approach. The key is to recognize at least 4 major risk factors and control them

High Blood Pressure (hypertension):

According to all the studies on stroke, this is the most common cause of stroke.  All the studies from the valley also point towards it. As per the published study of 2019 by Hakim Mohammad Shafi and Aijaz Ahmad Hakeem from Govt Medical College Srinagar, it was present in 78% patients at presentation. The figures were 58.8% in Sushil Razdan’s study from Kuthar valley in Anantnag district. In the recent data from Srinagar hemorrhage inside the brain was present in 78% cases making them  not eligible for clot buster treatment.

Hypertension is highly prevalent in the valley and according to one of our recently published studies uncontrolled hypertensives was seen in 64% of the rural population who had been prescribed medicines for treatment.

Effective medical treatment is very important to minimise the chance of getting a stroke. It should be emphasised that non drug treatment with better life style is always a necessary accompaniment to drugs. The ideal BP should be around 130/80 mms Hg.

Cigarette Smoking:

It is a very important risk factor in the causation of stroke especially in persons who already have risk factors like hypertension and a family history of stroke. It has been shown that quitting smoking reduces the stroke risk substantially. In several patients with stroke smoking is the only identifiable risk factor. In the recent study for govt Medical College Srinagar, it was present in more than half of the population (53%).

Diabetes Mellitus:

It nearly doubles the chance of getting a stroke. This coupled with obesity and high BP which is a frequent association leads to a very high incidence of stroke. India is also called the diabetic capital of the world with around 70 million patients with this disease. Its prevalence in the city of Srinagar has been recently reported as 9.8% by Mohd Saleem Sheikh and associates from Govt Medical College Srinagar. in tribal communities as reported recently by Dr Dr Mohd Abdul Ganie and colleagues the prevalence was low (1.26%) but pre-diabetes based upon HbA1c levels was alarmingly high at 11.64%. High BP and high cholesterol levels were common associations.

Early detection and good treatment always help. New drugs for treating diabetes help in reducing strokes. These agents belong to the groups of GLP1 analogues and are available as once a day/ weekly injection (Liraglutide and dulaglutide) especially in preventing a second stroke. Recently an oral agent semaglutide (Rybelsus) which avoids an injection has also been marketed.

No doubt life style management, weight reduction and treating other risk factors like high BP and high cholesterol levels assume immense importance.

Atrial Fibrillation (AF) and risk of Stroke:

AF is an abnormality of heart beat which increases the risk of stroke by at least 5 times. As age advances the risk also increases exponentially. The hallmark of this arrhythmia is rapid and irregular heart beat and pulse. It can come as episodes with intervening periods being normal. High BP is an important risk factor.

The upper chambers of the heart (atria) beat chaotically and red blood clot can form because of stagnation of blood. A portion of these clots can get dislodged and enter the blood circulation of brain and produce a stroke suddenly. ECG diagnoses this arrhythmia and most patients with AF need anti-coagulants. Aspirin intake does not prevent it because it is not an anti-coagulant.  Warfarin and drugs like dabigatran, rivaroxaban and apixaban are the agents. These agents need to be given under medical supervision.

Miscellaneous Risk factors:

The 4 risk factors discussed above are the most important ones and need extreme attention to prevent the paralytic strokes. Besides this attention needs also to be given to high cholesterol levels, excessive weight and a healthy life style consisting of regular exercise and a diet rich in fruits and vegetables. 

Take Home Message:

Stroke is a devastating event and makes the life of the individual and his family miserable. Once it occurs prompt attention is needed and getting proper medical attention is extremely important. Once fully evolved treatment is only palliative.

It is best to adopt measures to prevent it, which is highly possible by treating the risk factors like high BP, cessation of smoking, diabetes and early detection of atrial fibrillation. Public campaigns to educate our population are of utmost importance.

DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.

The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.