Let’s talk about the case of George Mabisa, a 39-year old male. On 22 June 2013, Mr Mabisa was spending time with friends, when in an attempt to go to the bathroom, he was astonished to find his left leg unable to take a step.  He felt it glued to the floor and noticed that he was sweating profusely. Feeling embarrassed in front of his wife and friends, he ignored what was happening and dragged himself to his bedroom where a friend came along to help, jokingly admitting that he might have had a couple of whisky’s too many.  

Still in denial the next morning, George assured his wife that ‘he is perfect’ and that she shouldn’t be worried over ‘nothing’.  He still couldn’t move his leg and couldn’t feel his left arm.  By the following morning, George finally relented and asked his wife to take him to the hospital where it was confirmed that he had suffered a stroke.  

“I couldn’t believe what I was hearing. I felt so embarrassed and disappointed at myself for two reasons; one, because I should have known better about lifestyle diseases as I work in the wellness industry, and secondly, that I didn’t act in time on the Saturday night to get help, solely because I didn’t know what was happening to me.”  

Like Mr Mabisa, many South Africans are unaware of the signs and symptoms of stroke and don’t get immediate treatment, yet every 6 minutes someone suffers a stroke and in 2014 stroke took the lives of over 23 000 South Africans.¹ Stroke devastates lives around the world and is the leading cause of disability and the second leading cause of death globally.² Global disparities do exist in stroke trends and burden between countries of different income levels. From 1990 to 2010 the absolute number of first strokes, stroke-related deaths and number of years of life lost due to disabilities or early death, have increased worldwide with most of the burden in low and middle-income countries.²  

Stroke can happen to anyone at any age

It affects everyone: survivors, family and friends, work colleagues and communities. Prof. Alan Bryer from the Division of Neurology at Groote Schuur Hospital explains: “Stroke happens when the blood supply to part of the brain is cut off. Without this life-giving blood that carries oxygen and other nutrients to the brain, brain cells can be damaged or die. Stroke survivors often report the different effects stroke had on their body, as it depends on where the blood supply to the brain was blocked off.  It can affect people’s body and movement, their speech, eyesight and even how they think and feel.”  

There are two types of stroke, ischaemic stroke and haemorrhagic stroke. An ischaemic stroke is the most common type where a small blood clot may form in a blood vessel and then block an artery in the brain. Sometimes this blood clot may develop in another part in the body, and then travel in the blood vessels to the brain and get stuck, blocking the blood vessel. Haemorrhagic strokes occur when a blood vessel bursts and causes bleeding into the brain, damaging it. Ischaemic strokes are much more common and whilst hemorrhagic strokes only make up 15% of cases, they are more likely to be fatal.

Stroke is treatable

Although stroke is a complex medical issue, there are ways to significantly reduce its impact. Prof. Pamela Naidoo, CEO of the HSFSA states that “Recognising the signs of a stroke early, treating it as a medical emergency and having access to the most appropriate professional health care, can substantially improve outcomes. These are key priorities that the HSFSA would like to highlight on World Stroke Day”. The key messages of the HSFSA and the WSO are embodied in the triple A’s: Awareness, Access and Action.

Awareness

Knowing how to recognise the signs of stroke, is a key first step in treating stroke. A useful acronym to remember and to share widely with family and friends, is FAST:

• Face: Is one side drooping?
• Arms: Raise both arms. Is one side weak?
• Speech: Is the person able to speak? Are words jumbled or slurred?
• Time: If even one of these signs are present, act quickly and call emergency services.

By asking these simple questions and being able to identify whether you, a friend or bystander is having a stroke, could save a life and improve chances of rehabilitation.  The sooner a stroke is recognised and care is sought, the higher the chances of survival and recovery.

Access

Having access to emergency medical care, medication and treatment when suffering a stroke, greatly increases the chances of a good outcome. Taking the suspected stroke victim to a hospital immediately ensures that treatment can start early.

In some instances, emergency medications or treatment is needed. Medications that can be administered include clot-busting drugs, which break up blood clots and increases the chances of a positive outcome by 30%.³ This treatment can be administered up to 4.5 hours of symptom onset in many patients with ischaemic stroke. The earlier it is given, the greater the effect. Clot retrieval treatment increases the chance of a good outcome by more than 50%.⁴ Clot retrieval treatment involves removing a blood clot and can improve survival rates and reduce disability for many people with ischaemic stroke caused by large artery blockage.

General treatment of a stroke patient includes careful management of hydration, nutrition and swallowing problems, as well as measures to prevent pneumonia and blood clots forming in the veins of the legs. High blood pressure and blood sugar levels may also require treatment.  After stabilising the stroke patient, the focus of management shifts to rehabilitation and preventing another stroke from occurring.

According to Prof Bryer “we still have a way to go in ensuring better access to emergency medication and treatment for stroke patients in South Africa.  These treatments are usually administered in specialised stroke units in hospitals.  We are currently working with government to identify ways to increase the number of stroke units in South Africa to ensure the best possible evidence-based treatments to all stroke patients.”

Action

The final step of the triple A’s, is to take action.  For stroke to be treatable, action is needed by government, health care professionals, individuals and survivors in order to drive awareness and advocate for better access to stroke treatments.

Governments: Governments and other health systems decision makers need to take a leadership role in stroke care by increasing access to stroke treatments, supporting the development of coordinated systems of care including specialised stroke units and stroke care teams, to support stroke awareness campaigns and support excellence in stroke research.

Healthcare professionals: Health professionals can have a big impact on stroke treatment even with limited resources by following best practices and providing evidence-based treatments.  All professionals should further strive for continuous improvement – a simple audit of available regional or local services to monitor and improve care delivery will play a vital role.

Individuals: Stroke can affect any one of us… Every South African should learn the signs of stroke in order to act FAST and share it with their family and friends.
One in four survivors will have another stroke, so it is imperative for survivors to be extra vigilant and work closely with their healthcare professional team. Knowing whether one is at risk for a stroke, plays a key role in its prevention – close monitoring of blood pressure, blood glucose and cholesterol can be a lifesaver and will highlight whether lifestyle changes are necessary.  Lifestyle changes can greatly reduce the risk of another stroke in survivors. Changes include:

• Eating well
• Being physically active
• Being tobacco-free
• Managing stress
• Limiting alcohol consumption    

Face the Facts, stroke is treatable.  Lives can improve with better awareness, access and action.

1. Mortality and causes of death in South Africa, 2014: Findings from death notification / Statistics South Africa. Pretoria: Statistics South Africa, 2015  
2. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, Moran AE, Sacco RL, Anderson L, Truelsen T, O’Donnell M, Venketasubramanian N, Barker-Collo S, Lawes CM, Wang W, Shinohara Y, Witt E, Ezzati M, Naghavi M, Murray C; Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) and the GBD Stroke Experts Group. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet. 2014 Jan 18;383(9913):245-54.
3. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials.
4. Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, Brott T, Cohen G, Davis S, Donnan G, Grotta J, Howard G, Kaste M, Koga M, von Kummer R, Lansberg M, Lindley RI, Murray G, Olivot JM, Parsons M, Tilley B, Toni D, Toyoda K, Wahlgren N, Wardlaw J, Whiteley W, del Zoppo GJ, Baigent C, Sandercock P, Hacke W; Stroke Thrombolysis Trialists’ Collaborative Group. Lancet. 2014 Nov 29;384(9958):1929-35. doi: 10.1016/S0140-6736(14)60584-5.
5. Prof Mayank Goyal, MD, Bijoy K Menon, MD, Wim H van Zwam, MD, Prof Diederik W J Dippel, MD, Prof Peter J Mitchell, MBBS, Prof Andrew M Demchuk, MD, Prof Antoni Dávalos, MD, Prof Charles B L M Majoie, MD, Prof Aad van der Lugt, MD, Maria A de Miquel, MD, Prof Geoffrey A Donnan, MD, Prof Yvo B W E M Roos, MD, Prof Alain Bonafe, MD, Reza Jahan, MD, Prof Hans-Christoph Diener, MD, Lucie A van den Berg, MD, Prof Elad I Levy, MD, Olvert A Berkhemer, MD, Vitor M Pereira, MD, Jeremy Rempel, MD, Mònica Millán, MD, Prof Stephen M Davis, MD, Prof Daniel Roy, MD, John Thornton, MD, Luis San Román, MD, Marc Ribó, MD, Debbie Beumer, MD, Prof Bruce Stouch, PhD, Scott Brown, PhD, Bruce C V Campbell, MD, Prof Robert J van Oostenbrugge, MD, Prof Jeffrey L Saver, MD, Prof Michael D Hill, MD, Dr Tudor G Jovin.  Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016 April 23;387(10029):1723-31. DOI: http://dx.doi.org/10.1016/S0140-6736(16)00163-X

• This release was first published in the HSFSA website

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