CEREBROVASCULAR STROKE

CEREBROVASCULAR STROKE Stroke (CVA) is a devastating disease. It cripples the active life leading to handicap and physical dependence. It leads to loss of productive years and burden to care givers. Except age, most of other stroke risk factors are preventable and controllable. It can affect any age group, thanks to lifestyles and food habits. Symptoms vary from loss of speech, loss of memory, walking difficulty to completely bed bound state or death.

DR MUKESH KUMAR Consultant in Neurosciences at Max Hospitals, Gurugram & Delhi

troke incidence and prevalence in India is variable over demographics and cultural differences. The estimated adjusted prevalence rate of stroke range is 84- 262/100,000 population in rural and 334-424/100,000 in urban areas. The incidence rate is 119-145/100,000 population based on the recent population based studies. It also varies city to city and different part of country. Kolkata has around 42% case fatality rate. Case fatality rate means chances of death due to stroke. Studies from India have shown a 2 to 3 time's high prevalence of hypertension, hyperlipidemia, obesity, diabetes mellitus, and smoking (in men) in urban compared to rural communities. Stroke is a treatable and preventable disorder. It should be identified early for better recovery. Brain cells dies fast as the time progresses. In each minute, 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers are destroyed. Stroke is a disease defined as a sudden neurological deficit (e.g. weakness, loss of sensation or other) due to a vascular cause. The deficit must last for longer than 24 hours and is of sudden onset. There are two main types: 1. Ischaemic (85%): can be due to a thrombus (a clot forming in one of the blood vessels supplying the brain); or due to an embolus – a clot which travels from another site (usually the heart) to block off one of the arteries in the brain. 2. Haemorrhagic (15%): this is due to rupture of one of the arteries in the brain – usually due to an aneurysm (an outpouching of an artery – causing a point of weakness) The onset of the stroke is usually sudden, although it can evolve in a step-wise manner over several hours in thrombotic stroke. After its development, the neurological deficit may improve gradually over the next few weeks to months, and sometimes it may completely improve, although most patients are left with a residual deficit. A TIA (or transient ischaemic attack) has the same symptoms as a stroke, but the symptoms last for less than 24 hours and associated with complete recovery. Haemorrhagic stroke also occurs suddenly, though it is usually accompanied by a severe headache. It is more CLINICAL FEATURES Stroke commonly presents with loss of sensory and/or motor function on one side of the body. The patient experiences a sudden inability to move a part or entire limb and/or have abnormal sensations over the affected limb. There might be difficulty or inability to speak and the patient as well as witness notice that there is a change in speech. There might be inability to understand spoken word leading to a confused look from the patient. Other symptoms include loss of vision, loss of consciousness, instability of gait, giddiness and vomiting. Early diagnosis of stroke is extremely important so all patients with symptoms suggesting stroke should be assessed in hospital. In general, any episode of acute onset loss of speech, gait difficulty, facial deviation or loss of consciousness should be considered a stroke and the person should be transferred to nearest hospital. In short term, it is mentioned as FAST (F-face deviation, A-arm drift, S-loss of speech or aphasia, T- time of onset). DIAGNOSIS A non contrast CT scan is invaluable in acute situation to rule out hemorrhagic stroke and guide further management course. CT scans may not detect an ischemic stroke, especially if it is small, of recent onset, or in the brainstem or cerebellum areas. A CT scan is more to rule out certain stroke mimics and detect bleeding. MRI brain is the modality of choice for lesions involving posterior fossa and provided much more detail as compared to NCCT. CT or MR angiography of neck and brain vessel is required to delineate the vascular structure and screen for vascular stenosis and dissection. ECG and 24 hour Holter monitoring help in diagnosing underlying arrhythmia which guide treatment modalities. TREATMENT There is radical change in management of stroke in last S

likely to cause coma than ischaemic stroke, due the increase in pressure in the brain.

RISK FACTORS Unavoidable risk factors Age greater than 60 (risk of stroke doubles every decade), male sex, family history of stroke, racial origin. Avoidable risk factors Hypertension, Diabetes, Smoking, Excess Alcohol consumption, Obesity, Lack of exercise. Age more than 65 years and male sex has higher preponderance compare to younger age and female sex. Hypertension contributes to 80-85% cases of stroke. Association of Diabetes with hypertension increases the stroke risk by three fold. The risk of stroke is two times higher in smokers. Alcohol consumption increases the risk of brain hemorrhage.

two decades. Stroke survival and disability free state are improving with general awareness and timely intervention and improved rehabilitation strategies. All ischemic strokes may receive thrombolytic therapy (clot buster) within 4.5 hours of stroke onset. The treatment of a patient with stroke is divided into immediate and long-term management. Immediate treatment is different for ischaemic and haemorrhagic strokes but general principles of management for both are listed: • Blood glucose monitoring • Blood pressure control • Cardiac monitor- ECG for ischemic changes or atrial fibrillation • Intravenous fluids • Oxygen- If hypoxic • Maintaining normal temperature. THROMBOLYSIS Thrombolysis, such as with recombinant tissue plasminogen activator (rtPA), in acute ischemic stroke, when given within three hours of symptom onset results in an overall benefit of 10% with respect to living without disability. It does not, however, improve chances of survival. Benefit is greater the earlier it is used. Between three and four and a half hours the effects are less clear. A 2014 review found a 5% increase in the number of people living without disability at three to six months; however, there was a 2% increased risk of death in the short term. After four and a half hours thrombolysis worsens outcomes. These benefits or lack of benefits occurred regardless of the age of the person treated. There is no reliable way to determine who will have an intracranial bleed post-treatment versus who will not. When administered within the first three hours thrombolysis improves functional outcome without affecting mortality. 6.4% of people with large strokes developed substantial brain bleeding as a complication from being given tPA thus part of the reason for increased short term mortality. Intra-arterial fibrinolysis, where a catheter is passed up an artery into the brain and the medication is injected at the site of thrombosis, has been found to improve outcomes in people with acute ischemic stroke. ISCHAEMIC STROKES The patient should be admitted into a dedicated stroke unit with multidisciplinary staff for rehabilitation. Aspirin (300mg) should be given. The patient’s swallowing ability should be tested (by a speech therapist) and a naso-gastric tube should be given if required to prevent aspiration. Long term medical management focuses on reduction of cerebrovascular risk to reduce recurrent stroke. Low dose aspirin (+/-clopidogrel) is typically prescribed to prevent formation of further clots. Other management of stroke includes changing lifestyle factors (increased exercise, healthy diet and smoking cessation), reduced blood pressure, lipid control (with statins) and strict blood glucose control. Thus additional management will depend on individual patient factors and concurrent disease. HAEMORRHAGIC STROKES Haemorrhagic strokes are managed differently acutely. The patient is not given Aspirin for fear of further bleeding, and if there are signs of increasing ICP (intra-cranial pressure) urgent neurosurgical treatment is sought. Hypertension should be controlled. SURGERY Surgical removal of the blood clot causing the ischemic stroke may improve outcomes if done within 7 hours of the start of symptoms in those with an anterior circulation large artery clot. It however does not change the risk of death. Significant complications occur in about 7%. Intravenous thrombolysis is generally used in eligible people even if they are being considered for mechanical thrombectomy. Certain cases may benefit from thrombectomy up to 24 hours after the onset of symptoms. Strokes affecting large portions of the brain can cause significant brain swelling with secondary brain injury in surrounding tissue. Relief of the pressure may be attempted with medication, but some require hemicraniectomy, the temporary surgical removal of the skull on one side of the head. This decreases the risk of death, although some more people survive with disability who would otherwise have died. HEMORRHAGIC STROKE People with intracerebral hemorrhage require supportive care, including blood pressure control if required. People are monitored for changes in the level of consciousness, and their blood sugar and oxygenation are kept at optimum levels. Anticoagulants and antithrombotics can make bleeding worse and are generally discontinued (and reversed if possible). A proportion may benefit from neurosurgical intervention to remove the blood and treat the underlying cause, but this depends on the location and the size of the hemorrhage. REHABILITATION Stroke rehabilitation is the process by which those with disabling strokes undergo treatment to help them return to normal life as much as possible by regaining and relearning the skills of everyday living. It also aims to help the survivor understand and adapt to difficulties, prevent secondary complications and educate family members to play a supporting role. A rehabilitation team is usually multidisciplinary as it involves staff with different skills working together to help the patient. These include physicians trained in rehabilitation medicine, clinical pharmacists, nursing staff, physiotherapists, occupational therapists, speech and language therapists, and orthotists. Some teams may also include psychologists and social workers, since at least one-third of affected people manifests post stroke depression. Good nursing care is fundamental in maintaining skin care, feeding, hydration, positioning, and monitoring vital signs such as temperature, pulse, and blood pressure. Stroke rehabilitation begins almost immediately.

Children’s Health Primary

DR SAGAR BHATTAD Paediatric Immunologist, ASTER CMI Hospital, Bangalore

Immunodeficiency In Children

IMMUNE SYSTEM IS OUR ARMY –WHAT IF, IT FAILS TO PROTECT US?

All living beings including humans have an efficient immune system that protects us from infections. The orchestra of the immune system is made up of players who defend the human body against pathogens like bacteria, virus, protozoans and many more. It is akin to an army that is made up of various levels of defense, each member coordinates with the other to defend the kingdom, the kingdom of human health. Unfortunately, nature fails to provide the necessary armamentarium to some children. These children, in the absence of one of these soldiers cannot effectively fight pathogens and thereby get repeatedly ill. The group of diseases in which children are prone to recurrent infections due to a defect in the immune system are called Primary Immune Deficiency Diseases. Unfortunately, physicians and pediatricians are not well versed with these diseases and this may result in undue delay in the diagnosis. MAGNITUDE OF THE PROBLEM Primary Immune Deficiency diseases are by no means ‘rare’. As per research conducted worldwide, 1 in 2000 children suffer from an immune deficiency. If these figures are extrapolated to the city of Bangalore, around 5000 children have immune deficiency disease. Unfortunately, majority of these children remain undiagnosed and suffer for years. There is an urgent need to increase awareness amongst doctors and public about these diseases. WHAT ARE THE SYMPTOMS? • Chest infection –children with problems in the immunity are prey to frequent chest infections. They may require hospitalisations for treatment of these ailments repeatedly. • Ear discharge –Recurrent episodes of ear-discharge can be a feature of underlying immune defect. • Loose motions –Repeated episodes of loose motions/diarrhea or diarrhea that takes unusually longer days to resolve, warrants evaluation by an immunologist. • Not gaining weight and height –Healthy children gain weight and height as per age norms. If a child fails to achieve his/her potential, a problem in the immune system must be sought for. • Death of children in the family –Some immune deficiencies are serious conditions and if untreated, such children die at young age. If you come across families who have lost children due to infections, one must advise them to meet an immunologist. HOW CAN THESE CHILDREN BE DIAGNOSED? If you come across children who remain unwell, kids who visit doctors very often, kids who are often hospitalised, ask them to contact an immunologist. By performing a few blood tests, the doctor would determine if there is any problem in the immune system of the child. Commonly asked immunological tests are serum immunoglobulins (IgG, IgA and IgM), however the battery of tests would vary based on the problems in a given child. TREATMENT FOR THESE CHILDREN? Children who have problems in immunity require special care and treatment. Injections that boost their immunity (immunoglobulins) can be given. For children with more serious defect in immunity, bone marrow transplant can be offered. If treated in time, these children lead a healthy and normal life.

• Children with frequent infections need appropriate evaluation. • Frequent episodes of ear discharge or lung infection and/or failure to grow normally warrants assessment of immune functions. In such settings, one must contact an immunologist. Simple blood tests can offer a solution to the ongoing problems. • Children with immune defect, if treated appropriately, grow out to become productive citizens.