Volume 10(3), Jul.-Sep. 2013

STROKE IS A BRAIN ATTACK

1

See Page 3

Contents :

Risk Factors of Stroke 1

From the Editor’s Desk 2

SFB Events 2

Readers Column 3

Measure of Obisity 3

Stroke Prevention 4

Carton of Stroke 5

1 in 6 people worldwide will have stroke in their Lifetime

ACT FASTF

A

S

T

Time is Brain.

ace Ask the person to smile, note drooping an one side.

rms Ask the person to raise both arms 90° in front.

Does one arm drift downward?

peech Ask the person to repeat a simple sentence

Does the speech seem slurred?

ime If a person develops any one of these stroke symptoms, then act urgently for his treatment as

Recognise STROKE...

Risk Factors of StrokeThere are certain conditions which make a person susceptible to a disease. These are

known as risk factors (RFs). Stroke also is associated with a number of known risk factors and even more of as yet unknown risk factors. Those risks that we are aware of are of the following types -

A. Nonmodifiable ( those that cannot be changed by any intervention)

1. Age – Increasing age is itself a risk factor for stroke- persons above 60 years are more vulnerable.

2. Gender- Incidence of stroke is higher in men but after menopause women are equally susceptible to stroke. In fact as longevity is higher in women stroke incidence increases in elderly female.

3. Family history - family history of stroke, HBP, Diabetes, peripheral vascular disease in first degree relatives is a risk for stroke. In these cases detection of risk factors should begin at an early date and appropriate management should be taken care of.

4. Race – Indians and people of east Asian and African countries are more vulnerable than Americans

5. Previous history of stroke or TIA

B. Modifiable (those that can be modified by interventions like lifestyle changes or medicines)

1. High blood pressure (HBP) known as hypertension – This is the most important treatable risk factor of stroke (details are discussed in the previous issue). Hypertension is the main cause of high incidence of stroke esp. hemorrhagic one in our country.

2. Smoking or tobacco use in any form (Oral e.g Jarda, Gutka, Khaini etc) – hemorrhagic stroke is commoner among tobacco users.

3. High blood cholesterol and other lipids in blood (Dyslipidemia) – Thrombotic Stroke (a type of Ischemic one)

4. Diabetes mellitus – Ischemic Stroke is commoner. Important fact about Diabetes is that a diabetic patient experiences a delayed recovery, as compared with a non-diabetic patient

5. Heart rhythm irregularities (commonest is Atrial fibrillation) – commonest cause of cerebral embolism (a form of Ischemic Stroke). In our country, young patients with rheumatic heart disease and the elderly with myocardial Infarction (or Ischemic Heart Disease), heart failure or implanted pacemaker are more vulnerable to this type of stroke.

6. Physical inactivity & excessive dietary intake esp. meats and sweets.

7. Obesity

8. Atherosclerosis (Thickening of blood vessels)

9. Certain heart diseases e.g. Congenital valvular disease and Cardio-myopathy.

10. Certain infections like tuberculosis, Syphilis and AIDS especially in countries like India.

11. Excessive alcohol and addiction of drug etc.

- it is the single most important risk factor for stroke. HBP leads to cardiac and renal failures also. It causes thickening and fat deposit in the blood vessels (atherosclerosis) which compromises blood flow to all the vital organs and in the brain causes an ischemic stroke or many silent strokes lead to loss of memory, inability to walk or imbalance during walking (Vascular cognitive impairment or multi infarct states). Often HBP may also damage the vessel wall leading to rupture of blood vessels in the brain

High blood pressure (HBP)

Dear readers,

The mid year is important for SFB as our foundation day falls on 24th June, marking the culmination of our year

long activities. We celebrated the seventh year of this organization this year with the joy and satisfaction of once

again bagging the “Honorable mention” for the World Stroke Campaign, 2012. This has reinforced our belief that

we are in the right track to combat stroke in our country. We need to consolidate our activities and for this, the active

involvement of all our members, readers and well wishers will add momentum to our mission. I appeal to all to

come and join us in large numbers this 29th October on the World Stroke Day. Looking forward to your comments.

Dr. A. Shobhana

From the editor's desk

2

The WHO Health 2002 policy identifies Hypertension as the world's most preventable disease.

SFB turns SEVEN ……..The seventh foundation day celebrations of the Stroke

Foundation of Bengal (SFB) was held at the Bidhannagar Municipality Auditorium, Salt Lake City, Kolkata on 24th June, 2013. The function began with the welcome address by Dr. A. Shobhana, secretary of SFB. She highlighted SFB's activities in the last one year. This year too SFB has bagged the “Honorable Mention” of the World Stroke Organization for the year 2012 for its continuing activities of Stroke awareness as part of the World Stroke campaign. The importance and usefulness of Tele medicine to prevent stroke was stressed upon. The program was inaugurated with lightning of the lamp by Prof. Salil Sen, President of Indian Medical Association, Salt Lake Branch, who in his inaugural speech appreciated the work of SFB in stroke prevention. He mentioned the relation of hypertension or high blood pressure with stroke, mentioned in this year's World Health Day's theme. Stroke can be easily prevented by controlling Hypertension.

Sri Malay Mukhopadhyay, SDO, Bidhannagar, who has been associated with SFB's programs in the past as well, released this year's Souvenir and voiced concern about the ignorance of the common man about the malady of stroke and its risk factors especially high blood pressure. He stressed upon the fact that change of lifestyle plays an important role in all non-communicable diseases (NCDs). He said that by changing the lifestyle people could easily lower the incidence of stroke, such as by restricting salt intake in our food, doing regular exercise, stopping smoking and controlling Diabetes.

Dr. Amitava Sarkar, WHO Medical Officer, National Polio Survelliance Project, India mentioned that Stroke is considered along with other cardiovascular diseases. He urged general people to join with SFB in spreading awareness about stroke more extensively throughout the country.

Dr. Anup Sandhu, Vice-president of SFB, high lighted the pattern of stroke in Kolkata and its difference from that of western countries. He talked about the survey of stroke pattern conducted by SFB from 2003 till date in Calcutta Medical College. His prospective CT Scan study (from 2003 till data) on 15000 acute stroke patients at Medical College, Kolkata revealed that majority of stroke patients were in the age group of 50-55yrs, 15 or more years earlier than acute stroke patients in

SFB Eventsthe western countries. He also observed that unlike western studies, majority of stroke are hemorrhagic. He said that hypertension is the single most treatable cause of stroke and how easily stroke can be prevented by measuring the blood pressure by a simple blood pressure instrument, available everywhere. He himself distributed Blood Pressure instruments and the DVD of the stroke documentary in Birbhum district and made people aware about stroke prevention. Dr. Sadhu also informed the audience about SFB's Stroke Support Group (SSG), which is the second one in India. He appealed to the general people to join SSG and share their views and experiences about stroke.

The President of SFB, Dr. Mandal thanked all who helped in the ongoing activities of SFB. Regarding the future activities he disclosed plans to set up a Stroke Rehabilitation Unit with the help of the local bodies and if financial support could be made available, a Comprehensive Stroke Unit would be established. He also stressed on Tele-stroke network that can link easily with hospitals of all parts of West Bengal, as only with the help of this modern Technology, rural stroke care service could be made available at an affordable cost. The help of the Government is the first precondition to make it successful. The recognition and encouragements received from leaders of World Stroke Organisation and of Indian Stroke Association were humbly acknowledged by the Stroke Foundation of Bengal (SFB). He ended on a hopeful note that this relatively unknown area of stroke devastation would receive attention from all sections of society, esp. the Government, and the sufferings of the afflicted patients would soon be reduced significantly by three proper important strategies – Prevention, Acute Care and subsequent Rehabilitation.

The program also included a lively interactive discussion on stroke, hypertension and life style diseases where the audience shared their experiences, and their queries were answered by a panel of experts featuring Prof. Arup Das Biswas HOD, Dept of Cardiology, NRS Medical College, Prof P. S. Badhyopadhyay, former HOD, Dept of Cardiology, R. G. Kar Medical College & Hospitals, Dr. P. S. Mondol, Consultant Diabetologist, Dr. Ashis Bhattacharya, Consultant Neurosurgeon, Dr. A. Shobhana, Dr. Anup Sadhu, Prof. D. K. Mandal. The audience placed queries about stroke risk factors, exercise regimes, stroke rehabilitation and post stroke spasticity. The day concluded with the vote of thanks by Sri. Asoke De, Treasurer of SFB.

3

Controlling High Blood Pressure and Stopping Addiction prevents more than 80% Stroke

Prof. D. K. Mandal was invited by Radio Mirchi to talk about stroke and tips to prevent stroke as part of their health information coverage. These would be aired regularly during their programs.

Radio Mirchi joins SFB inspreading awareness

How risk factors were ignored

Reader’s Coloumn

See Page 4

causing a hemorrhagic stroke. This Is more common in eastern India. Incidence of HBP increases with age. HBP is also common among blacks and post menopausal women. Most women are unaware of their blood pressure levels. Even in the United States 30% were unaware that they had HBP 11% were aware but untreated.24%were treated but inadequately & 35% had BP<140/90 (JNC VII). Treating HBP with proper medications will bring down stroke incidence and mortality by 30%.

The most import thing about high blood pressure is that sudden withdrawal of anti- hypertensive drugs result in severe form of hemorrhagic stroke with high incidence of fatality and severe disability.

Atherosclerosis (deposition of fat in inner wall of blood vessels leading to their stiffening and narrowing thereby compromising blood flow to organs can affect the heart also. This leads to heart attacks or ischemic heart disease. The risk for ischemic heart and stroke are more or less common. Ischemic heart disease itself can be a risk factor for stroke. Apart from this there are few heart diseases like rheumatic heart disease, disorders of heart rhythm (atrial fibrillation being the commonest) can cause stroke. All these heart ailments must be sought and treated. For detecting irregular heart beats sometimes prolonged monitoring of ECG (Holter monitor) is essential.

Smoking and tobacco intake in all forms is harmful. It increase atherosclerosis, increases bad cholesterol in blood (raised LDL) and leads to stroke both ischemic and hemorrhagic. Of concern in India is consumption of non smoke tobacco especially in rural areas and among women.

Alcohol increase chances of hemorrhagic stroke. Addiction to certain drugs (amphetamines, cocaine etc) may also cause hemorrhagic stroke .

Diabetes is harbinger of heart attack as well as stroke as it is commonly associated with HBP and increased blood cholesterol. The number of diabetic patients in India more than doubled from 19 million in 1995 to 40.9 million in 2007. It is projected to increase to 69.9 million by 2025.

Rise of blood cholesterol is usually associated with heart attacks but the LDL, TG and LP(a) fraction increase risk of stroke. Cholesterol lowering drugs have been shown to decrease risk of stroke as well as heart attack. These medicines also repair the inner wall (remodeling) of the blood vessel thereby improving blood flow. High Tryglyceride level often cause large artery diseases.

Stroke is uncommon in women of child bearing age but those who take oral contraceptive pills may have risk of thrombosis (formation of blood clots in the blood vessels) especially if they have other associated risk factors of stroke. A common but often “missed stroke” in young women immediately after child birth is the cerebral venous sinus thrombosis (CVT). So any patient at this time presenting with headache, visual problems, abnormal behaviours or progressive drowsiness or convulsion should receive immediate attention as this type of stroke is easily diagnosed and treated successfully.

Obesity and lack of physical exercise is spreading with the spread of mechanization and urbanization. This with the alterd

Cardiac Disorders

Cont. on Page 1Risk Factors of Stroke

Measures of obesity

?

?

?

Waist circumference (WC) measurement and body mass index (BMI) are the recommended ways to estimate body fat. Waist circumference is the distance around your natural waist (just above the navel).

The body mass index formula assesses body weight relative to height. It's a useful, indirect measure of body composition, because in most people it correlates highly with body fat. Weight in kilograms is divided by height in meters squared (kg/m2).

BMI values less than 18.5 are considered underweight.

BMI values from 18.5 to 24.9 are normal.

Over weight is defined as a body mass index of 25.0 to less

than 30.0 (consistent with U.S. Dietary Guidelines for Americans). A BMI of about 25 kg/m2 corresponds to about 10 percent over ideal body weight.

Case 1

SH a 50 year old Government employee had a mild ischemic stroke last year which left her with minimal right sided weakness. She is diabetic hypertensive and has high cholesterol levels. Although she was taking her medicines regularly she never went to her doctor for a check up nor did she measure her blood pressure or blood sugars regularly. She was admitted with a major stroke in June this year. She was found to have uncontrolled blood sugar levels and blood pressure.

Case 2

SM, a 35 year old, the sole bread earner for a family of four used smoke and drink heavily. His wife’s entreaties fell on deaf ears. In September this year he suffered a cerebral hemorrhage. His blood pressure at that time was 210/110 mmHg. hitherto unchecked. He requires four types of medicines to control his blood pressure now.

Salt restriction in diet is the most cost effective way of reducing blood pressure

4

food habits of consuming fast food has lead to a spurt of non communicable diseases. Abdominal obesity is associated with high level of bad cholesterol in the blood, HBP, diabetes and prone to atherosclerosis. The youth in modern India are falling prey to lifestyle diseases. At least 30 mins of brisk walking for most of the days of the week is recommended. Along with this, reducing stress and tension needs no elaboration.

Optimal healthy blood pressure is a systolic blood pressure

of £120 mmHg and a diastolic blood pressure of 80 mmHg.

There may be several factors that may predispose to HBP :

1. Genetic factors : family history of HBP

2. Advancing age

3. Coexistence of diabetes, high blood cholesterol, kidney diseases

4. Being overweight

5. Consuming excess salt in diet, fast & rich food in fat.

6. Lack of exercise

7. Tobacco, Alcohol and other addiction

8. Stressful life

9. Those who snore while sleeping

What is the normal blood pressure?

What are the factors that help high BP to develop?

£

Cont. on Page 3Risk Factors of Stroke

Stroke and other noncommunicable diseases have already risen to epidemic proportions in India. The prevalence rate of stroke in India is about 545 per 100,000 and annual incidence rate of first ever stroke at 145,overall 30 day case fatality was 41% (Dalal et, JAPI Oct 2013:Vol 61). Modification of risk factors itself will decrease stroke mortality by 2%. Prevention of stroke is much easier than treating stroke and dealing with post stroke disabilities. Moreover, this will have palpable effect on the health and economics of our nation. We need to identify the risk factors, modify or treat them in time through different stroke prevention clinics. Most of these risk factors lead to multiple health problems and diseases affecting the brain (cerebrovascular disorders), heart (cardiovascular disorders), kidney problems and eye problems. Hence by reducing the risk factors so many diseases could be prevented. Prevention could be Primordial - preventing risk factors from appearing in the individual. This can easily be achieved by targeting the younger population like school students through health check ups and lifestyle modification. Next Primary prevention to prevent strokes in those who have never had a stroke. It is when risk factors like high blood pressure (HBP) have already set in but still not caused organ damage due to diseases like stroke. For primary prevention widespread public education about stroke and other vascular diseases, ways to treat risk factors, go for regular check ups, taking the appropriate medicines, and understand the signs or symptoms of stroke is of prime importance. Secondary Stroke Prevention means prevention of subsequent stroke after the first stroke. This is very important to understand that chance of stroke is much higher in the stroke or TIA (mini-stroke) affected individuals. It has been observed that 25% of patients admitted in hospital emergency had a previous stroke. Second or subsequent stroke are more serious and the outcome in terms

Stroke Prevention

of death and disability is relatively worse. This is best appreciated by stroke patients, their family members and stroke care givers. Accordingly they are much more concerned about stroke de-vastation than general people. Their concern is being reflected in the WSD Campaign 2012-13 Because I care... along with 1 in 6.

Preventing stroke recurrence in those who have already had a brain attack is equally important to save lives and limit disability. What is important is to identify the mechanism of stroke, get down to the risk factors, treat them (Like HBP, blood sugar, cholesterol, stopping smoking, addictions). In ischemic strokes blood thinners (antiplatelets and sometimes anticoagulants in atrial fibrillation etc) need to be taken regularly. Sometimes the blood vessels supplying the brain suffer narrowing when they traverse the neck. Sometimes a carotid surgery or stenting is recommended in selected cases. Secondary prevention begins in the hospital itself to be continued at home for lifelong along with rehabilitation. Regular exercise and stopping smoking along with prescribed medicines are the best ways to prevent secondary prevention.

Of foremost importance is spread of health awareness and education about risk factors of NCDs. Effective and adequate health care measures need to be adopted at the government level. This should include proper financing of health care sector, spread of health check ups, establish prevention clinics like Hypertension clinic, legislation to curb addictions, proper dietary supply, availability of drugs at subsidized rates so that essential medications like blood pressure medicines etc can be afforded even by the poor people. Life style modification should start at the school education level itself. Its also necessary to educate the common man about stroke symptoms, how to recognize stroke and what to do if stroke strikes. All these will ensure disability limitation and better quality of life.

TIA (Transient ischemic attack), as the name goes, is a temporary lack of blood supply to the brain with symptoms of stroke appearing and disappearing in a few minutes. By the classical terminology symptoms should last less than 24 hours. However it has been found that on MRI scanning of brain many patients do have ischemic features. TIA just warns that an atherosclerotic narrowing of blood vessel to the brain is present which may close completely in the future cutting blood supply to that part of the brain. In fact most people who experience a TIA suffer a major stroke in the first month itself and the rest in the next three months if neglected. So this warning must be taken seriously. A patient with TIA must be hospitalized and investigated thoroughly to find out the predisposing risks and treated accordingly.

In India low hemoglobin in blood (anemia) has been pointed as a modifiable risk factor of stroke. Few infections of the brain like tuberculosis can cause stroke. Few diseases of the blood that lead to alteration of the clotting – anticlotting mechanisms (prothrombotic disorders) must be tested for in suspected cases.

Diet

Avoiding junk food and consuming a diet with less salt and sugar, plenty of fresh fruits and vegetables is the mantra for all lifestyle diseases.

Secondary Prevention

How to have effective preventive measures

Observe “World Stroke Day” on 29th October, 2013

5

DO YOU KNOW1. About 20 lakh Indians are afflicted by stroke (Brain Attack), each year with more than 6 lakh death and many

more persons disabled mildly to severely, resulting tremendous loss of human and economic resources.

2. Majority patients are in the age group of 50-55 yrs. about (man 15 years earlier than in any developed country) due to lack of preventive strategies.

3. Reduction of High Blood Pressure (Hypertention) and cessation of addiction (smoking, oral tobacco and drugs e.g. Cocaine) can easily reduce stroke incidence by our 80% cases in our country.

4. Management of Stroke and proper post stroke care reduce death and disability remarkably.

So Rabi, its two months thatyou have had a stroke. Now how do you feel ?

Much better Doc. But my righthand and leg fail to work

normally as before.Please give me medicines so

that they become normal

My friend, you have not understood your diseaseproperly. I’m afraid there is no medicine that will makeyour arm and leg to work properly after a stroke. Youcan improve your limb power only by a good andeffective physiotherapy. If you put in sincere efforts youare bound to improve further. By the way, are now takingyou blood pressure and other medications regularly?

Oh yes Doc, I dare notforget my medicinesnow.

And what aboutyour life style?

Oh Doctor, he doesn’t listento us. He refuses to takemorning walk everyday inspite of such a fine weatherand he continues to smoke asbefore. He gets angry if wedon’t allow him to and askshis friends to bring cigarettesfor him. Doctor is it not harmful?

I must say Mrs Sen that Rabi’s friends are not doing any goodto him. Smoking itself can cause another stroke.

Smoking can affect the heart and can cause cancers.Regular exercise and walking will help him to stay healthy

Rabi realizes his blunder of missing his medicines

3

1

4

2

Rabi’s wife ‘s woes

Rabi is dismayed.

Mr. Rabi Sen goes to the doctor for Check up

Published by : Stroke Foundation of Bengal, Editor Dr. A. Shobhana and Printed by : Saha Enterprise, Subhaspally, Khalisani, Chandannagar, Hooghly - 712 138, Ph. : 98300 20996

Published by :

THE STROKE FOUNDATION OF BENGAL(Regd. No. 37041 of 2006-2007)

FE-1A, Flat - 7, Salt Lake City, Kolkata 700 106, West Bengal, India

Ph. (033) 2359 8230 / 29, (M) : 9433911937,

email : strokefnd_dkm@yahoo.co.in

Founder President, Prof. Dipes Kumar Mandal

Price : Rs. 8.00Our next issue Volume 10 (4) in Oct. to Dec. 2013WORLD STROKE DAY

6

<www.strokefoundation.in>

Secretary SFB & Hony. Editor, Stroke Bulletin : Dr. A. Shobhana, Ph : 94330 83894

MANAGEMENT OF STROKE RISK FACTORS

l

l

l

l

l l

l

Keep blood pressure < 130/80

Keep blood sugar levels controlled HbA1c<7.0% and FBS <120mg.

Keep blood cholesterol levels low ( LDL < 100mg/ dl & < 70mg/dl in who already have had a stroke

Say no to tobacco in any form

Avoid alcohol, Consume less dietary salt

Do regular daily exercise, morning walk