Brain attack is an emergency

Stroke of brain attack is the No. 1 cause of disability in Southeast Asia and the rest of the world. Together with heart attack, it constitutes the No. 2 cause of death in the Philippines. Brain attack may either be due to a blockage (thrombosis) or a rupture of an artery (hemorrhage). When an artery is blocked, blood can no longer supply the necessary nutrients to the brain cells. A cascade of events then ensues which, when allowed to continue, causes the death of nerve cells. There is a great chance of salvaging brain tissue if the occlusion is relieved. This opportunity is time-bound. The time window is from three to six hours, after which treatment intervention may not be effective. In the case of the rupture of a blood vessel, sizable blood clots may injure the brain by sheer pressure, and timely removal of the blood clot is life-saving.

Time, therefore, is of the essence.

In the recent past, many advances to cope with brain attack have been proven to be effective. For example, clot-busters have been documented to improve the functional defects among stroke patients. However, for it to be effective, it has to be administered within three hours from the onset of symptoms.

But the frustration of stroke specialists is that in most instances, patients present themselves way past this golden period of opportunity, which we call the therapeutic window. It is, therefore, important to consider the reasons for these delays because only then can remediable measures be instituted to correct them.

In the St. Luke’s study, 26 percent of those who had symptoms did not consider their condition as an emergency.

There are quite a number of reasons for this delay so far identified in the local setting. Only 25 percent of the victims correctly identify the symptoms they’re suffering from as due to a brain attack. If the symptoms are mild, they consider these as trivial or attribute them to some other cause and procrastinate seeking medical consultation. Attributing the symptoms to some other condition, they often self-medicate or ignore them all together. If the symptoms wax and wane, they further delay seeking medical advice, hoping they will disappear. This is very frustrating because this is the best time to institute measures to reverse the symptoms. When the symptoms are mild at the outset, the time delay for consultation may be as long as 12 hours to several days. On the other hand, they lose no time going to the Emergency Room for consultation if there’s severe headache accompanied by vomiting, and if the victim rapidly loses consciousness.

It is, therefore, mandatory to formulate an effective and comprehensive community education program to increase public awareness in the recognition of stroke symptoms. The most reliable symptoms highly indicative of a brain attack include weakness of half of the body, slurring of speech, inability to express one’s thought, dizziness, incoordination or loss of balance, headache and vomiting, loss of vision especially if it involves one eye. These symptoms should prompt immediate consultation in a stroke center.

The other main reasons for the delay in the prompt management of brain attack are health care-related.

The correct diagnosis of a brain attack must necessarily differentiate an occlusion of a blood vessel producing brain infarction versus a rupture of a blood vessel producing a hemorrhage. The differentiation is absolutely necessary because treatment modalities differ. It is a disaster if one gives a clot buster to a patient who is bleeding inside the head. The only sure way is to do a Computerized Tomogram (CT) scan of the head. It is mandatory that this be done as quickly as possible. After a quick neurological evaluation and the institution of support measures, a CT scan should be done within the hour upon entry in the emergency room.

If no CT scan is available in the hospital where the patient was rushed, the transfer to a CT scan-equipped hospital can cause a marked delay. An important finding in the St. Luke’s study was that only 54 percent of the acute stroke patients had immediate access to a CT-equipped hospital, and transfer constituted a significant delay. The Stroke Society of the Philippines and the Department of Health are keeping a tab on the existing CT scan facilities in the whole country. The recommendation is quite clear at the 2nd Congress of Brain Attack in 2001 that patients who have symptoms of brain attack should seek admission in a hospital where a CT scan of the head can be done readily within the hour upon entry in the emergency room.

In the St. Luke’s study, the median time from presentation of cranial CT scan was two hours, compared to a median of 11.5 hours for those who were first seen in a clinic or hospital not equipped with a CT scan. In some instances, the delay may be as long as several days.

90 percent of patients were initially presented to a non-neurologist. This has tremendous implication because it is then extremely important for physicians to know the principles of stroke diagnosis and management. Much importance is given to physicians’ education to keep them up-to-date on these new trends. Unfortunately, some still continue to have a nihilistic attitude towards strokes. This must change.

The other health care-related issue that can cause delay in the diagnosis and management of brain attack is the lack of coordination in hospital services. The Stroke Society of the Philippines espouses the formulation of stroke teams and the creation of stroke centers with facilities for acute care, like acute stroke units.

A stroke team consists of neurologists, neurosurgeons, stroke nurses, cardiologists, rehabilitation experts and vascular specialists who keep abreast of the latest in the diagnosis and treatment of brain attack. Each hospital should formulate its own brain attack program.

Stroke units are special units which specialize in acute stroke care. It is demonstrated in many studies that patients taken care of in these units fare better – meaning there are less deaths, they have shorter hospital stay. Their functional outcome is much better and therefore, they are less disabled.

Currently, there are acute stroke units in only a few medical centers in the Philippines. Acute stroke units are found at St. Luke’s Medical Center, Philippine Heart Center, Jose Reyes Memorial Medical Center, Medical City, East Avenue Medical Center, San Juan de Dios Hospital, and recently at the Philippine General Hospital Diosdado Macapagal Stroke Center. In Metro-Cebu, the Chong Hua Hospital and the Cebu Doctors Hospital have established stroke teams with acute stroke units. The Stroke Society of the Philippines is encouraging its members to help initiate the creation of stroke centers in all the regional hospitals in the Philippines to serve stroke victims and promote prevention strategies to lessen the incidence of brain attack in the rest of the country.

The nihilistic attitude towards stroke must change. Effective diagnostic procedures are now available locally. Effective treatment strategies need to be operationalized across the country. We should all be advocates of these calls: Brain attack is an emergency! Brain attack is treatable! But we must use our head and act fast!