It is treatable
HELD every Oct 29, World Stroke Day aims to raise awareness on both the incidence of stroke and the millions of survivors who are still working to improve their lives through treatment and rehabilitation.
According to the World Stroke Campaign under the World Stroke Organization, this condition affects 17 million people worldwide, with 5.5 million deaths and 26 million survivors between 2014 and last year.
Stroke is the third largest cause of death in Malaysia. According to Dr Loh Pei Kee, consultant neurologist at Ara Damansara Medical Centre, it is estimated that almost 40,000 Malaysians suffer from stroke every year and it affects men more than women.
Stroke itself is defined as the sudden and unpredictable result of tissue damage caused by a blood clot or haemorrhage in the brain.
This localised tissue damage occurs due to the loss of oxygen transported to brain cells. The brain itself uses 25% of all oxygen used in the body.
In line with this year’s World Stroke Day theme highlighting that stroke is a treatable disease, the perception about stroke treatment, rehabilitation as well as research and development is changing towards a more positive outlook.
Immediate action
Current conventional methods of treatment revolve around addressing the cause of the stroke, alleviating symptoms and rehabilitation. Going back to the core of stroke treatment, time is everything.
The faster a stroke patient has access to treatment, the higher the chance of saving the patient in terms of morbidity and mortality.
Stroke is usually categorised into two types, ischaemia stroke and haemorrhagic stroke. Ischaemia stroke occurs when there is a restriction of a blood vessel in the brain due to a blood clot and plaque build-up.
Haemorrhagic stroke, on the other hand, occurs when a weak blood vessel ruptures due to an increase in blood pressure.
Upon admission, doctors will come up with a strategy to reduce the effects of the stroke on the brain through medication and drugs before assessing the type of stroke the patient is having.
This would include a thorough medical history check as well as certain diagnostic tests that will inform the doctor on suitable treatment strategies.
“Evaluation of a patient with suspected stroke is performed after thorough history and clinical examination.
“It is divided into imaging, blood tests and other diagnostic tests such as computerised tomography, magnetic resonance imaging and magnetic resonance angiogram of the brain,” says Dr Loh.
“Other diagnostic tests that are commonly carried out are electrocardiogram, echocardiogram and transcranial Doppler study.”
Treatment strategies for both ischaemic and haemorrhagic conditions differ as doctors race to reduce the impact of stroke on the affected brain tissue.
“Acute treatment for ischaemic stroke such as blood-clot busting and endovascular treatment, if given or done early in carefully selected patients, can reverse the artery occlusion and reverse or minimise the severity of stroke,” says Dr Loh.
In the case of an ischaemic stroke, blood thinners and clot-dissolving medications will be administered to the patient to break down the clot of the restricted blood vessel in the brain.
One such strategy is to use a drug known as recombinant tissue plasminogen activator (tPA).
Ischaemic stroke occurs when fibrin, a structure in our blood, traps blood cells and platelets, forming a clot along an artery in the brain.
This usually occurs when there is an increased amount of plaque formation in the inner wall of a brain artery.
The tPA then aids in the generation of an enzyme known as plasmin, which dissolves the clot, thus restoring blood flow.
According to a 2014 meta-analytical study published in The Lancet, clot-busting drugs increase the chance of an effective treatment outcome by 30%.
“The drug can be injected into patients within 4.5 hours of symptom onset. The earlier the treatment is given, the greater the effect. This treatment can also be administered for medium to severe stroke attacks,” says Dr Mooi Chin Leong, neurologist from Mahkota Medical Centre.
Although this drug has significant impact in improving recovery outcomes, it is only available in selected hospitals due to its cost and scarcity.
In addition to this, the administration of tPA also comes with risks. Thus, it can only be administered by experienced physicians as it can cause excessive bleeding in higher doses.
Another advancement in the treatment of ischaemic stroke is through endovascular treatments.
This involves a procedure known as mechanical thrombectomy, where a discreet wire-caged device or stent is sent via a catheter to the site of the blocked blood vessel to widen it and allow for more blood flow.
Doctors proceed with this treatment only after the patient has received tPA and the blood clot has been cleared.
Treatment for haemorrhagic stroke is a lot more different compared to ischaemic stroke.
The aim of the treatment is to stop the bleeding from the ruptured vessel as fast as possible to reduce blood loss and a dip in oxygen concentration in the brain.
According to the American Stroke Association, there are two main treatment strategies for haemorrhagic stroke – an endovascular procedure or a surgical procedure.
Similar to ischaemic stroke, a catheter is inserted through an artery and travels to the site of vessel rupture to deposit a mechanical agent like a coil to prevent further damage and reduce blood loss.
Endovascular procedures for haemorrhagic stroke has made great strides in terms of minimally invasive procedures. This decreases patients’ recovery time and allows them to proceed with rehabilitation therapy as soon as possible.
Surgical procedures are prescribed for haemorrhagic stroked cause by an abnormal tangle of blood vessels or a severe aneurysm.
Road to recovery
Rehabilitation is a process. The long-term goal is to facilitate a stroke survivor in becoming as independent as possible.
Survivors will be encouraged to relearn basic skills such as eating, bathing, dressing, walking and communicating. Rehabilitation therapy starts in the hospital itself once the patient’s vitals have stabilised.
“Once the patient is stable, rehabilitation will commence, even while he is in the intensive care unit. The type and level of rehabilitation will be increased according to the patient’s disability, tolerance and improvement,” says Dr Loh.
Rehabilitation helps stroke patients relearn skills that are lost due to a damage at a specific position in the brain.
Rehabilitation therapies help the brain create new neural connections in the damaged area, thus restoring function to the brain and improving physical function.
Like the treatment process, rehabilitation is personalised and based on the severity of the stroke.
Physiotherapy, occupational therapy, counselling, recreational activities and light sports are some of the therapy modules in the rehabilitation process.
However, rehabilitation therapy can be costly and time consuming. Survivors and their family have to assess available options and where they can get the best service possible. This is where associations and non-government organisations come in.
“We know that hospitals generally charge RM100 to RM150 per hour for rehabilitation therapy. However, the queue is long and, often, patients may only be able to get two appointments in a month,” says Sylvia Chong, general manager of the National Stroke Association of Malaysia (Nasam)
“At Nasam, our one-to-one rehabilitation therapy costs less and for group therapy, we seek a contribution of only RM300 per month at our Petaling Jaya centre and lower at our other centres.
“Survivors who sign up for group therapy come to Nasam for rehabilitation for two hours every day. This works out to be a very minimal sum per hour,” she adds.
Beyond convention
Some doctors believe that if complementary medicine does not cause excessive harm and does not interfere with an ongoing medical regime, patients can explore these options to reduce symptoms.
“Complementary medicine such as acupuncture is suitable to relieve pain for some patients and it is being practised as a professional medical treatment in some countries. In addition, some patients are allergic to certain medications. Hence, complementary medicine offers them an alternative,” says Dr Mooi.
Dr Mooi adds that there should be transparent communication between the doctor and survivor if they are pursuing alternative medicine so that doctors can advise on the risks of a certain complementary medicine treatment or modify their current treatment.
There is a great deal of research and development that is being conducted to find new treatment and rehabilitation options for stroke survivors.
Last June, a clinical trial conducted by Stanford University of Medicine, the United States, showed that modified stem cells injected into the brain of chronic stroke patients have the ability to restore motor functions. Although the trial produced promising pilot results, the true efficacy and safety of this therapy option will only be concluded at the end of the trial.
Although stroke is treatable, it does not mean we are allowed to be complacent. Prevention is always better than cure and by maintaining a healthy lifestyle, we can reduce the risks of getting a stroke.
On the flip side, the fact that stroke is treatable should be regarded as a moral boost for survivors to be more confident in regaining their physical functions and improving their quality of life. In future, stroke treatment will cost less yet be highly accessible with a spectrum of available treatment options.
Rehabilitation is a process. The long-term goal is to facilitate a stroke survivor in becoming as independent as possible. Survivors will be encouraged to relearn basic skills such as eating, bathing, dressing, walking and communicating.
WITH fast treatment and the right rehabilitation, stroke survivors can live a fairly healthy life.
Leong Yee Khiam
On Feb 19 this year, Leong Yee Khiam was wheeled into the National Stroke Association of Malaysia (Nasam), Petaling Jaya, for the first day of therapy by his wife and business partner.
It was four weeks after his stroke due to a brain aneurysm and it affected the mobility on his left side. His rehabilitation programme at Nasam consisted of 12 one-on-one sessions, three times a week.
After six sessions into the third week, he was able to stand and walk independently. This achievement came six weeks after his stroke.
On April 1, he joined the advanced group for daily rehabilitation and on April 3, Leong bravely ventured into the shallow end of the kid’s swimming pool. He tried to float but balancing was an issue.
“Leong was healthy and exercised regularly as he loved sports. He comes from a family with a history of high blood pressure. He was taking medication but irregularly. We were shocked when he had the stroke. When the neurosurgeon told me his condition was very bad, I didn’t know what to think or what to ask,” says Poh Chan, Leong’s caregiver.
“It is a great relief now that he is recovering well from the stroke and happily getting back to what he used to enjoy before. Generally, he is a cheerful, jovial and flamboyant gentleman. Much of his good nature has returned as he continues to work hard at recovery,” she adds.
Leong now spends four hours every week in a swimming pool. According to Leong, getting into the water gives him a power boost.
The natural buoyancy of water allows a person with weak muscles on one side of the body to stand and walk with much less effort than on dry land.
“Working out is more fun when you are splashing around. It’s so relaxing that you don’t notice how hard you are working,” says Leong.
Leong’s twice-a-week routine in the water consists of walking and jogging, which he does in a forward and backward direction as well as a few laps of breast stroke.
After that, he enjoys a welldeserved cup of coffee while resting by the pool.
Now that his swimming has picked up pace, he is getting back into the swing of golf and hopes to start tennis soon.
Lai Seng
Lai Seng is no stranger to having a good time in the pool. As a child growing up by a river in Teluk Sisek, Kuantan, Lai’s main sports activity was swimming.
He fondly remembers the fun long hours spent diving into the water with his childhood buddies.
On Jan 20 this year, his left leg felt odd when he was busy working. He called his family and was taken to a hospital.
He was diagnosed with a right haemorrhagic stroke with a weakness on the left side.
There was no surgery and he was discharged after two days of monitoring and conservative treatment.
“My initial reaction was that I could not give up on life. All that ran through my mind was I had to find a way to recover. Moreover, since I was able to move my hands and legs, I considered myself blessed with a second chance at life.
“My main issue after the stroke was balance and coordination. Due to this weakness I did not think I could swim, but I was pleasantly surprised when I went into the pool during Nasam’s hydrotherapy session. My body just took over and, with the help of my therapists, I was able to swim,” says Lai.
Just seven weeks after his stroke, Lai returned to his favourite sport. He practises swimming once a month during Nasam’s hydrotherapy session but his goal is to swim for one hour a week.
“I like this sport as it enables me to move all my limbs effortlessly and it is less tiring than exercising on land. It is also a lot more cooling and provides a good cardio workout.
“Since I began swimming, my hand and leg coordination as well as gait, which was affected by the stroke, have improved tremendously.
“The water therapy helped me reduce my dependency on a walking aid. It has also increased my stamina and now I am able to finish my regular walk of almost 500m with less effort,” says Lai.
Lai encourages stroke survivors to keep themselves motivated through recovery by finding a sport that they enjoy and incorporating it into their rehabilitation.
“Find a sport you enjoy and you can practise regularly. Start slow and gradually increase your sessions. Never give up and stay positive.” – Case studies courtesy of Nasam.
"Working out is more fun when you are splashing around. It’s so relaxing that you don’t notice how hard you are working.' Leong Yee Khiam