Every year 15 million people around the globe suffer a stroke. According to the World Health Organisation, for five million of them the stroke is fatal and another five million suffer long lasting disability. On Wednesday, Malta joins other European countries in marking Stroke Awareness Day, urging people to maintain healthy lifestyles in a bid to avoid stroke. Cynthia Busuttil takes a look at the repercussions of this silent enemy and what we can do to avoid it.

The silent enemy

Stroke is the second most common cause of death after heart disease, with more people dying of stroke than of cancer. Last year, 334 people died of a stroke in Malta, bringing the total number of casualties from cerebrovascular diseases between 2001 and 2004 to 1,301, statistics from the Malta National Mortality Registry show.

Anthony Galea Debono, head of the Neurology Department, said that when a person has a stroke something happens that stops the regular and healthy circulation of blood in the brain - either a blood vessel gets blocked or it bursts. Although stroke can happen at any age, the older a person is the more likely that blood vessels get blocked.

A stroke can have severe implications for a sufferer, including the loss of use of one side of the body, balance problems and loss of eyesight. "The most common effect of stroke is the inability to move one side of the body," Dr Galea Debono said.

However, recovery is possible and the younger the victim is the higher the chances of cure. "Survival among older people tends to be less likely. An 80-year-old man is more likely to die if he suffers a stroke while a 40-year-old will probably go back to work, unless it is a massive stroke," he said.

Despite its severe repercussions, a stroke is easy to overlook and it is usually painless, creeping upon patients without much warning. In fact, the Stroke Awareness Day campaign - which is being organised by the International Stroke Society and supported by pharmaceutical companies Sanofi Aventis and Bristol-Myers Squibb Company - emphasises that stroke is a medical emergency that takes place suddenly. It thus makes it more important to recognise the symptoms early and seek medical help immediately.

"Patients will realise that something sinister is going on in their bodies because they will wake up in the morning and find out that they cannot move one side of their body or are unable to see from one eye. They might have a strange sensation in one side of the body, like pins and needles," Dr Galea Debono explained.

If the stroke is a haemorrhagic one, and a blood vessel bursts, the patient could suffer a headache.

Dr Galea Debono emphasised the importance of seeking help immediately, as soon as the patient realises that something is wrong. A patient undergoes a CT scan after general examination and this will show whether there was a haemorrhage, because a blocked blood vessel might not show before 24 - 48 hours. If the scan does not show anything on the first day, the person will be scanned again the next day. Those requiring in-patient rehabilitation will be sent to the Neuro-Rehabilitation Ward at Boffa Hospital and Dr Galea Debono said a good number of patients walk out of there after the programme. The elderly also receive rehabilitation at Zammit Clapp Hospital.

Although susceptibility to a stroke can be genetic, there are a number of conditions that exacerbate its potential. The worst threat is hypertension (high blood pressure) and Dr Galea Debono stressed the importance of people of all ages checking their blood pressure regularly so that if it is high they are given treatment immediately.

"A lot of patients we see who suffered a stroke are the ones who do not bother to check their blood pressure regularly or who do not take their medication to lower high blood pressure," he said. His recommendation is for people in their 20s to check their blood pressure once a year and the older ones to have it checked at every opportunity because it is "the singular most common cause of stroke".

"You would be amazed how many people come to hospital having suffered a stroke and they would not have seen their doctor for ages and who are found to have multiple conditions. Some people are very non-health conscious."

Smoking, diabetes and abnormal blood cholesterol can also be factors which lead to a stroke. As a guideline, the same factors that could lead to heart disease can also lead to cerebrovascular problems.

"The best treatment is to prevent rather than to cure," Dr Galea Debono emphasised. Rehabilitation can be slow and frustrating and, unfortunately, damage to the brain is many times irreversible.

The good news is that many times a stroke is a one off and the patient would probably not get another one.

Facts and figures

Between 2001 and 2004, 1,301 people died of cerebrovascular diseases, according to statistics by the Malta National Mortality Registry. These included 564 males and 737 females.

Statistics from St Luke's Hospital show that in the last five years 395 people were admitted suffering from a stroke. These included 216 males and 179 females of ages varying from 20 to over 90.

People in their 70s and 80s seem most likely to suffer from a stroke, with 138 people between 70 and 79 and 102 people between 80 and 89 being admitted to St Luke's Hospital suffering from cerebrovascular accident.

Although there were slightly more males than females who were admitted to St Luke's Hospital suffering from cerebrovascular accident in the past five years, males seem more likely to recover. In fact, the mortality for females who suffer a stroke is higher, 737 between 2001 and 2004 as opposed to 564 males.

Deaths caused by cerebrovascular diseases

Year Male Deaths Female Deaths Total
2001 128 178 306
2002 149 179 328
2003 149 184 333
2004 138 196 334
Total 564 737 1,301

Source: The Malta National Mortality Registry, Health Information Department.

Prevention is better than cure

Although a person can be genetically predisposed to stroke, there are a number of lifestyle changes that can help reduce the risk of a stroke:

¤ Stop smoking.

¤ Regular physical exercise which helps maintain a healthy blood circulation.

¤ A healthy diet - including limiting salt, fat and sugar in the diet - and maintaining the proper weight.

¤ Avoid excessive alcohol intake.

¤ Regular blood pressure checks, which should increase the older you are.

¤ Seeking medical advice as soon as you feel changes in heartbeat.

What is a stroke?

There are two major types of stroke, the most common of which is ischaemic stroke. This takes place when an artery in the brain is blocked by a blood clot, thus interrupting the brain's blood supply. This can be caused either by a blood clot which forms in the heart and then travels to the brain or by a blood clot that forms on a hardened fatty build-up in one of the larger blood vessels going to the brain.

The second type of stroke is haemorrhagic stroke, which takes place when a blood vessel in and around the brain bursts and causes bleeding. This could be caused by a weakened section of a brain artery that balloons out and bursts. It could also be the cause of a brain vascular malformation, high blood pressure that raptures a tiny artery, drugs that cause acute blood pressure changes or direct brain injury.

In both cases of stroke, the blood supply is disrupted and a part of the brain remains without oxygen for a period of time, thus leaving the brain cells deprived of oxygen and other nutrients. This leads to the part of the brain controlled by these cells to stop functioning properly. The effects can be permanent.

A person could also get a transient ischaemic attack (TIA), or a mini-stroke. This is not a big problem in itself and alerts the person that there are problems which need to be tackled. The symptoms - which are like those of a stroke - usually last from a few seconds to minutes and there is usually no permanent brain damage but a TIA is often the sign that a major stroke is about to take place.

Damage caused by stroke

The damage caused by a stroke varies depending on the size of the blood vessel and the amount of tissue destroyed during the stroke. The area where the stroke takes place in the brain also has an impact on the effects of the stroke.

Dr Galea Debono explained that if the left hemisphere of the brain is damaged, problems could include the inability to move the right side of the body, loss of speech and calculation and loss of eyesight.

"A stroke in the left hemisphere is far more devastating because it makes rehabilitation more difficult - if people cannot understand you, it is more difficult to help them get better," he said.

If the stroke happens in the right hemisphere, the left side of the body would be affected.

A stroke can also happen in the brain stem, the back part of the brain. Such strokes tend to lead to the patient having balance problems and also language problems. However, in the second case, instead of not being able to find the right words, the patient is more likely to slur his words.

Strokes act fast: could you?

The Stroke Awareness Day emphasises the importance of recognising the first signs of stroke because the longer the delay for evaluation and treatment the more likely the damage will be irreversible and the higher the chances that the patient will die or experience severe disability. With strokes, time lost is brain lost. A leaflet which will be distributed to mark the day says that the most common symptoms are the sudden onset of:

¤ Weakness or numbness of the face arms or legs, most often on one side of the body.

¤ Difficulty speaking or understanding speech.

¤ Difficulty seeing with one or both eyes.

¤ Difficulty walking, dizziness, loss of balance or coordination.

¤ Severe headache with no known cause.

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