Ladies and gentlemen, our guest for today is Associate Professor Sidney Oparah, a Chief Consultant at the University of Calabar Teaching Hospital.
He has been a Medical Doctor for over 22 years and a Clinical Neurologist for 14 years. His hobbies are travelling, painting and drawing.
It is definitely a great a pleasure to listen to him share with us all we need to know about this very common illness in our environment, from his wealth of knowledge and experience. Let me share this fascinating interview with you. Enjoy
WHAT IS A STROKE?
Stroke is a health condition that occurs when the blood supply to a part of the brain is suddenly cut off. Especially, if the loss of blood supply lingers upto 24hrs. However, we don’t have to wait for 24hours to make the diagnosis of stroke.
What are the various descriptions of stroke in the population
Majorly, it has spiritual connotations. They believe it’s as a result of witchcraft attack, or an evil spirit has attacked. Infact the Ibo’s call it “MBA AGBARA” which means a spirit has evoked the person.
WHAT ARE THE NEUROLOGICAL DISEASES THAT ARE NOT STROKE?
There are quite some diseases that mimic stroke but are not Stroke. They include
conditions like a tumour in the brain
A fall especially in the elderly can lead to blood accumulation compressing that part of the brain.
Epilepsy especially in ‘Todd paresis’ in focal seizure. That part of the body that was involved in the convulsion becomes weak, and this weakness subsides completely after some minutes or hours.
Low blood sugar
Some forms of Migraine headache
Bacterial /Viral infections of the brain
All these manifestations will not be as sudden as it in stroke. So they’re not stroke
How does a stroke present?
The brain controls the rest of the body. So the manifestations depend on the part of the brain affected and the extent of brain injury.
It is always of sudden occurrence because it has to do with blood vessel. Generally they present with,
- Weakness on one side of the face. The face deviates to the good side
- The weakness of the hand, leg or both.
- Headache may or may not be present
- Problems of vision
- Difficulty with speaking. May understand you, but may not vocalise, or may not understand nor vocalise.
- Difficulty in movement of any part of the body
- Difficulty with balance
What causes a stroke with emphasis on the common causes in Nigeria?
The actual cause of stroke still remains “sudden” loss of blood supply to a part of the brain. Which could be as a result of
1.) obstruction to a blood vessel (Ischemic stroke)
2.) Rupture of a blood vessel (hemorrhagic stroke)
There are however RISK FACTORS. We usually classify them into NON-MODIFIABLE RISK FACTORS AND MODIFIABLE FACTORS.
The Non-modifiable factors are factors that are not within our control and they include
1) Increasing Age: The risk of stroke doubles for every 10 years after the age of 55 years. However, it doesn’t mean someone below 55 years can not have a stroke. This shows that increasing age doubles the risk of stroke. Unfortunately, we can not do anything about it.
2) Male gender : Stroke tends to occur more in males than females especially before menopause. This is believed to be as a result of some level of protection the female sex hormone oestrogen confers. However, after menopause, the risk is same
3) Black race: The risk is higher among the Negroes than the Caucassians.
4) Having a previous stroke is a risk factor for a repeat stroke.
5) Family history of stroke especially from first-degree family members like father, mother, brother or sister. It increases the chance and possibly due to genetic factors. These are all non-modifiable because we can not do anything about them.
The Modifiable risk factors are those factors which are within our control and they include
- Hypertension , which is the most common risk factor. Infact, hypertension should never be forgotten as the number one cause of stroke.
- Poorly controlled Diabetes Mellitus
- Cigarette smoking
- Obesity or overweight
- Sedentary lifestyle
- High cholesterol level especially the Low density cholesterol also known as ‘Bad cholesterol’
- Blood diseases like hemophilia
- Heart conditions like valvular heart disease, abnormal heart rhythm which can encourage clot formation
- Use of oral contraceptives pills, oestrogen supplementation after menopause in Hormone replacement therapy.
There is something called Stroke in the young.
A condition where stroke occurs in those less than 50yrs. The causes include
- Sickle Cell Disease which is common in the young and is a risk factor for stroke in the younger age group.
- HIV infection which is found more in persons of reproductive age (15-49years)
- Recreationsl Drugs like cocaine causes constriction of the vessels which can lead to loss of blood supply to the brain.
In what ways can we readily diagnose a stroke?
For a layman, look out for some of the symptoms of stroke, and the timing too. Was it of sudden onset? Which is characteristic of stroke. Check out for the symptoms earlier stated.
- Tell the person to look at you , then you look at the face and see if it’s shifted to one side. If it’s not obvious, you tell the person to smile. It will be more obvious.
- Raise the hand to see if there is any difficulty in doing so or if there is any weakness.
- Ask the person to talk (speech) and look out for any changes.
For the physician, he does an objective assessment to confirm the symptoms stated by the patient or the relative and examines the patient thoroughly. Then send for an urgent Brain CT scan which is the investigation of choice.
CT scan is an advanced form of Xray.
It shows if there’s a stroke, the location of the occlusion and the type of stroke. Other imaging like MRI can also be done.
The Physician will also look out for the likely cause of the stroke by asking the relevant questions and sending for some investigations depending on the likely cause.
How should stroke patients be optimally managed when they do occur?
The management of stroke is divided into four phases
Late Subacute phase
In the management, it should be a very fortunate thing to treat the stroke as early as possible in the Hospital especially in the acute and early Subacute phases
Once there’s “FAST” which stands for
F- FACE DEVIATION
A- Weakness of the ARM
S- Change in SPEECH
T- TIMING which are all of SUDDEN ONSET
You have to quickly bring the person to the nearest hospital. This is not the time for prayer house, traditional healers, Patent medicine dealers, pharmaceutical shops, native doctors, etc.
In the management
For acute phase,
The clot causing an iscaemic type of stroke can be dissolved in hospitals where they have facilities for such a treatment, if there are no contraindications.
If this is done within the first 3 to 4 and a half hours, the outcome is encouraging. Thrombolysis (the breakdown of the clot) within first 4 and half hours can be quickly done with a certain drug.
However, the drawback is our patients normally present late, beyond this window period (3 to 4 and a half hours) and the drug which dissolves the clot is not readily available in this part of the world.
But you have to also handle other issues like blood pressure control, blood sugar control, adequate hydration, etc
Other forms of rehabilitation including occupational rehabilitation would be needed. Even after the stroke survivor is discharged from the hospital , physiotherapy should be continued for some time.
Are there alternatives to hospital care of stroke patients?
Stroke management must be in the hospital. So there are no alternatives to hospital care.
Is having a stroke the end of one’s normal activity, like his job, sexual activity and social activities?
No. There is a 1/3rd rule in stroke. It shows the outcome of stroke
I/3rd of stroke patients die from the stroke.
Another 1/3rd recover with little or no deficit
And the remaining 1/3rd are left with moderate to severe deficit
The ones with little or no deficit go back to their normal life.
Those with moderate to severe deficit will need rehabilitation.
Sexual activity is not affected.
People should understand that stroke is an illness, a disease. No one calls for that. There’s something called Post-stroke depression.
It can be a bit challenging, but it is beneficial to be well motivated.
In fact, the recovery in motivated persons is much better. It’s not the end of life
What are the challenges to diagnosis and management of stroke in Nigeria?
It could be from the Society, Physician or the Authority.
- Level of society
Inability to recognize a stroke
Coming to the hospital late
Ignorance and unhelpful beliefs, and attitudes toward stroke
- Level of the Physicians
Though not common, there can be misdiagnosis. Mostly as a result of the patient/Doctor ratio here, which is very abysmal.
You see one Doctor attending to so many patients, and some of them may have some tendencies to inadvertently gloss over some issues. However, this should not be an excuse for negligence.
- Level of government
Most of the imaging facilities are expensive, and require constant power supply. We all know what the power supply is like in this country.
Some of the facilities needed are not readily available in this part of the world like CT scan, MR1 machines etc
Even when they are available , they’re not very affordable. The reality is that people pay out of their pocket for health care in our setting. For example to do an MRI in Calabar, costs #70,000, while the cost of CT-scan ranges from #40-50,000
Then what’s the minimum wage? #30,000!
And what solutions can you offer towards these challenges?
There’s need to create more health awareness on stroke like you’re doing with your blog and I must applaud you for that. Also, the government should pay more attention to the Health care system and provide the necessary facilities needed to better the healthcare of her citizens.
What can Nigerians do to prevent having a stroke?
Anyone that wants to prevent stroke must do this
-Know your blood pressure
Hypertension does not give signs. That’s why it’s called a silent killer. And it still remains the commonest cause of Stroke
And once the blood pressure is up to 140/90mmHg, you must work with your doctors to keep it under control.
It is important to check your blood pressure at least once a year if you’re not Hypertensive.
More often if there’s a history of high blood pressure,
And even more also if there’s a history of high blood pressure in the family.
-Know your blood sugar especially for diabetic patients
-Cholesterol level both for High density cholesterol (good cholesterol) and Low density cholesterol (bad cholesterol)
-No smoking. Smoking doubles the risk for stroke.
If someone quits smoking, over time, the risk for stroke reduces.
-No excessive alcohol.
Alcohol should be in moderate amount.
However, studies have shown that there is no benefit of alcohol. No amount is harmless
It affects the brain (stroke), liver, kidney.
It has has been implicated in some cancers like colonic cancer and breast cancer.
Especially avoid saturated fat
Eat more of unsaturated fat
Rule of the thumb is, if the oil congeals under room temperature is likely to be saturated fat. Avoid such oil. Omega3 & 6 are good.
-Eat more of vegetables and fruits, nuts high in potassium.
-No added salt, it doesn’t mean you should not use salt. It simply mean after cooking, no extra salt.
Avoid refined sugars especially for those who have diabetes.
30mins in a day up to 5 days in a week is highly recommended
It decreases the risk of progression of heart conditions
Beneficial to having good blood pressure readings, losing weight and maintaining a healthy weight, and carbohydrate metabolism.
Helps in optimizing insulin sensitivity. Insulin is a hormone that helps in metabolism of sugar.
It is advisable to perform activities you’re likely to continue. Consistency is key. It must not be jogging up and down.
One can adopt other activities like climbing up and down the staircase several times every morning, briskly walking around your house, deliberately parking your car at an appreciable distance from your office etc. For me, I love to wash my cars every morning.
For overweight and obese patients, weight loss can help in increasing the good cholesterol, while reducing the bad one. It also helps to reduce blood sugar in diabetic patients.
Apart from this, it is important for people to know the symptoms of stroke and take appropriate actions like rushing the person to the hospital
If you have any medical conditions that can cause stroke, you should cooperate with your doctor to manage such conditions like hypertension, diabetes, SCD, etc
In conclusion, what in essence should anyone do if he sees someone suspected to have suffered a stroke?
Always remember “FAST“
Quickly rush the person to the hospital.
The burden is higher in this part of the world, with hypertension as the number one risk factor.
Stroke is something we can manage and the best place to manage it, is in the hospital.
Once again, if you suspect someone has had a stroke, quickly rush the person to the hospital. It is not the time to deliberate on prayer houses, patent medicine dealers, money, native doctors etc.
Comply with the instructions from the doctors and other health care providers, and put in some of the measures that aid in prevention of stroke.