ATTACKING BRAIN ATTACKS
Time is crucial in dealing with patients who suffer a stroke--and an acute-stroke unit is up for the job
By Arleen Leonore Cababa
Correspondent
A brain attack--this is how neurologists would like people to see a stroke as. It could strike as fast, and as fatally as a heart attack; it is the sudden loss of brain function, resulting from the blockage of an artery (ischemic stroke or infarction) or a rupture of a blood vessel to the brain (hemorrhagic).
As many as 5.5 million people from all over the world suffer a stroke every year, half of them in Asia. There are as yet no precise statistics on how massively brain attacks occur in the country, but the World Health Organization estimates that they occur at a rate of one out of every 20 Filipinos. Also, an estimated 400,000 Filipinos who have lived through a first stroke are fearfully anticipating a second one.
However, studies from all over the world are looking for ways to catch up with the speed of the onset of stroke and stroke-related damage--therapeutic agents and the establishment of acute-stroke units in hospitals have been showing great promise in meeting the challenge.
Drug therapy and the stroke unit
Since stroke is an emergency, possible patients and their relatives must know what to look for. A sudden onset of weakness or numbness of the face, arm or leg especially on one side, confusion, slurred speech, dizziness, loss of balance and coordination, trouble seeing in one or both eyes, severe headache of unknown cause are signs of an impending stroke.
Because time is crucial in stroke, evaluation and treatment often proceed simultaneously and the earlier a doctor sees a patient from onset of symptoms, the better his chances of qualifying within the six-hour golden period.
The introduction of intravenous tissue plasminogen activator (tPA) and intraarterial thrombolytic therapy has significantly raised the chances of survival of patients after the onset of stroke symptoms. Intravenous tPA, given within three hours of the onset of symptoms, was first approved for use after successful thrombolytic trials by the National Institute of Neurological Disorders and Stroke (NINDS) in 1996. However, running parallel with the therapeutic effect of tPA is a very serious risk of hemorrhage and greater damage to the already compromised patient. Hence, there must be strict adherence to study-based and approved guidelines.
Meanwhile, intraarterial thrombolytic therapy, which may be effective within six hours, has radically changed the treatment of ischemic stroke, which comprise 85 percent of all cases of strokes.
But the effectiveness of these emergency drugs still depends on the people administering them, and the setting in which the administration of these drugs, as well as other life-saving procedures, is performed. This is why many hospitals see the significance of establishing an acute-stroke unit. The bottom line is always the patient--saving his life, avoiding further disability, or preventing secondary aggravating complications.
An acute-stroke unit in action
One of the institutions with active acute-stroke units (ASU) is The Medical City (TMC)--in fact, it has eight beds that are an essential part of the neurology/intensive-care unit. Inaugurated on July 16, 2000, TMC's ASU not only takes charge of the highly critical first few hours of a stroke, but also during the next few days since intervention.
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Dr. Artemio Roxas Jr., head of TMC's ASU/Neuro-ICU, emphasized that an effective ASU needs "doctors who are very adept at this partICUlar disease and excellent nurses who know what to do." Essentially a multidisciplinary team, the people comprising the ASU perform specific roles in various levels of stroke management. A physical therapist (PT) or an occupational therapist (OT), for example, may be called in to initiate rehabilitation even while the patient is still at the ASU. The nurses, who play a significant role in the ASU, follow certain clinical pathways to ensure that critical items in the management strategy are not missed. Neurologists, meanwhile, are ready to provide immediate remedy and to correct any observed abnormal signs. Other members of the stroke team like the PT, physiatrist, speech therapist, nutritionist, and pharmacistall play a role in helping the patient achieve optimal recovery. The dictum is: The shorter hospital stay, the better.
Said Dr. Peter Rivera, neurosurgeon: "The trick for any disease of the blood vessels, brain, and spinal cord is to be able to detect really subtle signs. If there is a slight weakness on one side, when there's a slight facial droop, rising trend in BP or HR, these can be signs of impending doom. When signs like these occur unnoticed or observed but brushed aside the patient may lose a lot of functionality in the end. A stroke unit ensures that these signs are not missed or it would be significantly unfair to the patient and it ensures that [for] 24 hours seven days a week, patients are watched in the most ideal setting possible."
The role of stroke prevention
Roxas and Rivera are one in saying that more important than the acute-stroke treatment is prevention--and this, they said, is the patient's responsibility.
No amount of advances in revolutionary treatment can compensate for a reduction in deaths and disability. Said Rivera: "A doctor will only inform you but no one will eat right for you or no one will exercise for you. Because stroke is a bad disease it is always better NOT to have it at all." And this works not only with primary prevention, but secondary prevention as well.
Roxas and the rest of the TMC ASU team are concerned with educating patients and their families. The team uses a stroke-risk scorecard helps assess one's risk. They also encourage personal identification of risk factors.
Hypertension and smoking are proven risk factors. Fortunately both are modifiable. Increased risk plunges significantly within five years of smoking cessation. The Stroke Council of the American Heart Association (AHA) recommends that blood pressure be maintained at less than 140/90 mm Hg and hyperglycemia controlled to reduce the risk of microvascular complications. It further recommends that high-risk patients should be partICUlarly conscious in avoiding heavy alcohol consumption. Certainly, prevention involves aggressive reduction of risk factors and on a personal level, it means commitment to a healthier way of living.
Maintaining a stroke unit
The effectiveness of a stroke unit depends on the adherence to standard stroke-specific management practices. A stroke unit, with its high-tech equipment and a team of well-trained providers, markedly improves the condition of stroke patients and increases the appropriate use of stroke medication through established protocols. A general ward or a regular room may not prioritize a stroke patient, but a stroke unit will, subsequently reducing morbidity and mortality.
An ASU should be strongly connected to all the other units of the hospital. With an integrated system in place, each unit will be able to easily interact with one another for the benefit of the patient. A system with effective coordination and feedback mechanism leads to the rapid management of stroke and improves patient outcome--subsequently reducing cost resulting from longer hospital stay and complications.
The Stroke Society of the Philippines (SSP) advocates the establishment of stroke units in hospitals as one effective way to help reduce the burden of stroke in the country.
Roxas, secretary of the SSP, explained that a stroke unit is designed, aside from providing optimal care, to shorten a patient's hospital stay to not more than seven days. A stroke unit should have at least two beds in the ICU, a CT scan, a cardiac monitor, and a multidisciplinary team whose members constantly update and train themselves and work closely with each other. At the emergency room, it is important to have a brain-attack team. The SSP also recommends that hospitals adopt a stroke-care system, not necessarily the same as the ideal setup seen in developed countries but one that is applicable to local conditions.
The SSP acknowledges that these are formidable tasks. Cost and lack of appropriate equipment and trained medical staff are the major constraints. But Dr. Cristina San Jose, member of the SSP board, believes "it is doable." "The objective is to create and use innovative strategies to come up with stroke care applicable to the local setting," she said.
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