Letters to the Editor
View(s):A plea to establish well-equipped ‘Stroke Units’ in the public sector
As far as minimising the morbidity and mortality of Non Communicable Disease (NCDs) on the island, cardiology units and cancer units have appeared in the Health sector hospitals. However, the other dominant NCD, i.e. Stroke care needs the public to agitate to move the powers that be, to man and equip the nascent units to become fully functional. The cost of rehabilitation for those affected by stroke, drains the purse of many a family, whether the patient is attended to by either system of health-care (indigenous or allopathic) as are operative in this country.
Having survived a catastrophic stroke some eight years ago, my message today to stroke patients and their caregivers is: ‘never give up hope – strive towards normalcy – yes you can!’ I felt it was binding on my part that I should make a contribution on this Universal Stroke Day – October 29.
What the public
should know
There are many natural causes for strokes. Diseased arteries (narrow – leading to reduced flow of blood) to the brain, clot from the heart reaching the brain and haemorrhage from a rupture of an abnormal artery inside the brain, constitute a large percentage of the natural causes. They present as Transient Ischaemic Attacks (TIAs) a stroke lasting less than a day, Reversible Ischaemic Neurologic Deficit (RIND) – a stroke which lasts more than 24 hours but settles within a week and is a full blown stroke.
People with High blood pressure, Diabetes and certain disorders of the heart are at risk of stroke.
Presentation and what
you should do
TIAs present with transient weakness or numbness of one side/part of the body (paralysis in the face, arm or leg, typically on one side of the body), slurred speech, seeing a shade coming down in your vision on one or both sides. RIND, typically show similar features but lasting up to a week. They are warning events of a full blown stroke to come, described as being 30-60% within a year or two.
Such persons must have a comprehensive evaluation and it should be done if possible within 24 hours by a Neurologist who will after a clinical assessment proceed with Imaging of the blood vessels in the head and neck (head CT, MRI with contrast angiography). Where indicated an ECHO Cardiogram of the heart is done as well. The lesion responsible for the TIA must be found and addressed to prevent recurrence, especially a full blown stroke.
Full blown Stroke –
where to go
This is a practical update on the facilities now available, giving location and the facility available, after interviewing the doctors concerned. It is necessary to take the person so affected to one of these centres, within 6 hours (4.5 hrs optimum), to gain maximum benefit.
In a full blown stroke, coming within 6 hours of the event without brain haemorrhage, as shown by CT Scans of the brain, done on admission to an emergency room, and are interpreted by a Neurologist or a competent doctor.
It is possible to use a Clot dissolution facility called intravenous thrombolysis (IVT)- with- Tissue Plasminogen Activator – Alteplase. This is available at: Emergency Rooms of all main Teaching Hospitals in Sri Lanka 24/7.
Results are good but time is of the essence, and avoids prolonged rehabilitation.
We need to develop Stroke units at least in each main Teaching Hospital, which will provide the next stage, if the ‘clot’ dissolution fails, but is in a larger artery of the brain. All over the developed world it can be removed mechanically by the procedure described below.
Mechanical Thrombectomy- Best within 4.5 hours – up to 6 hours
If the procedure to dissolve the ‘clot’ is ineffective, a mechanical method can be used to retrieve the clot, with a special catheter (‘Solitare’) introduced into an artery in the groin and then guided to the brain. This is done by using a special scanner called a Digital-Subtraction Angiographic (DSA) by experienced Consultant Specialists (called Interventional Radiologists). They can suck out (with a Penumbra Machine) the clot or entangle it (see diagram at left) on a meshed stent and retrieve it as the catheter is drawn out.
Where to go
This interventional facility for acute stroke, is at present available in the National Hospital (NHSL) Colombo 24/7 and the private hospital Asiri Central Colombo 24/7 as far as I know.
A 24/7 service for Stroke patients for Mechanical Thrombectomy is a must. Interventional Radiologists trained by the Post-Graduate Institute of Medicine are now deployed in all main Teaching Hospitals. These young enthusiastic Interventional Radiologists (IR), have developed their required skills further in Singapore. So the skilled manpower is in place. They are fighting a losing battle at present due to various factors, to keep their hand skills so acquired and serve the patients they were trained to help.
To mount a 24/7 Stroke facility requires immense cooperation by all levels of staff. I know the Neurologist at NHSL Dr. Padma Guneratne and the Interventional Radiologist at the time Dr. Lekamge tried their best to provide an islandwide service. They are now both retired.
The other centres with Interventional Radiologists are Kandy, Jaffna, Karapitiya, Batticoloa and Badulla. They are unable as yet to do Mechanical Thrombectomy on a regular basis because of; variously, shortages of sufficient nurses, radiographers, catheters, suction devices, penumbra machines, or are hampered also by breakdowns of these facilities.
Results, unfortunately have not yet been published, but I am a living example of a good result. It has revolutionised Stroke care in the developed world.
Carotid surgery
When the arteries to the brain outside the head (Internal Carotid artery- See Fig. above) are responsible, they are accessed from outside by an open procedure. This is currently performed by vascular units in NHSL Colombo, Peradeniya, Karapitiya, Anuradhapura, Polonnaruwa Teaching Hospitals as far as I can gather.
Dr. Channa Ratnatunga
More on Indo-Ceylon ferry
Apropos Cdr. E.L. Matthysz’s article on the Indo-Ceylon ferry in the Sunday Times of October 22- for the benefit of readers, I would like to add that the above ferry service was operated by the Shipping Corporation of India in conjunction with Southern Railways (India) and the Ceylon Government Railway (CGR).
Our family firm Narottam & Pereira (later renamed Asha Agencies) was and still is the local agents of SCI. They operated a ferry called T.S.S. “Irwin” and later there was T.S.S. “Ramunujam”. It was a tri-weekly service from Talaimannar to Rameswaram and vice versa. It catered mainly to the estate repatriates from here and there were lots of low budget travellers from the Indian side and some from Europe and the West.
A plus point was the ferry could accommodate a few vehicles.
A.J. Pereira Via email
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