A recent article in the Mail and Guardian described stroke as the third biggest killer in South Africa, after cancer and heart attack. However, a 1992 study cited strokes as the second commonest cause of death in South Africa (7.2.% of all deaths of persons aged 35 to 64 years), exceeded only by ischaemic heart disease (8.7% of all deaths and 9.6% of deaths of persons aged 35 to 64 years). Whichever way you look at it, stroke is an important cause of illness, disability and death in this country, and indeed worldwide.

What is a stroke?

In layman's terms a stroke is lack of blood to any area of the brain resulting in death or damage to that area and so neurological deficit to the rest of the body. The lack of blood flow may be caused by a decrease in the flow of blood to the brain, a blockage in one of the blood vessels of the brain, or bleeding into an area of the brain after a blood vessel has broken. Any one of these will result in damage to the brain which is shown by paralysis or weakness, either extensive or limited to one or more limbs, speech problems, memory deficits, loss of control of bowel and/or bladder, disturbance of vision and/or blindness and any number of disturbances in sensation. The most common deficit is hemiplegia, where one side of the body is either weak or paralysed. The specific deficits are determined by the part of the brain which is affected by the stroke.

Although strokes are more common in elderly persons, about 20% of strokes occur in people under 40.

Transient ischaemic attacks are mini-strokes. In these there are so-called focal neurological abnormalities, such as weakness or paralysis, speech disturbance etc. never lasting more than a few hours, and frequently only for minutes, which recover completely. These are usually caused by emboli, small particles, which briefly block the blood vessels, usually in the carotid or vertebral arteries in the neck. These are often recurrent and can be warning of an impending stroke.

What causes strokes?

'Stroke is a disease of lifestyle that can be prevented.' So write Vivian Fritz and Lewis Levin both of the University of the Witwaterstrand Medical School. The generalised vascular risk factors of smoking, hypertension, hypercholesterolaemia and diabetes are the major stroke risk factors. In developing countries, where more effort is being made to modify these risk factors, the incidence of stroke has been falling since the late sixties. This decline is not being seen in South Africa, partly because we have a developing population in which hypertension goes untreated and smoking is on the increase.

Hypertension or high blood pressure is regarded as the most important risk factor for stroke and treatment can reduce this risk by 42%.

A daily aspirin decreases the risk of further vascular events by 23% in those who have had either transient ischaemic attacks or a mild stroke.

There are obviously some rare conditions which will cause stroke regardless of lifestyle. These are more likely in the younger people who suffer strokes.

How are strokes treated?

This is all very well, but you didn't know about getting your blood pressure checked and you've never managed to give up smoking and now you are unlucky enough to have suffered a stroke. How should you be treated?

Stroke is a clinical diagnosis, meaning that a doctor should be able to make the diagnosis by examining you, without the aid of expensive and complicated investigations. These come only when there is some doubt as to the diagnosis and certain complications. Where the stroke has occurred in the brain should be obvious by the kind of neurological deficit you have suffered. Simple investigations such as blood lipids, blood count, ECG and chest X-ray can help to pinpoint the underlying cause of the stroke and are particularly important in a younger person with a stroke.

The most important part of treatment of a stroke is in determining care and rehabilitation after discharge from hospital. A supportive family and good financial support will obviously make all the difference. In the early stages in particular a heavy burden of care falls on family members, and their needs must not be neglected.

Regular physiotherapy, occupational therapy and speech therapy where needed are essential. The home may have to be modified. The occupational therapist will usually do a home visit to assess this.

Depression and loss of self esteem are common problems following stroke and the carers must watch for this and let the medical attendants know.

Degree of recovery is variable and depends on the patients age, the underlying cause of the stroke and the extent of the damage. Some people are unlucky enough to be left profoundly disabled, while others may regain full function. It will be very difficult to tell what is going to happen in the early stages, so don't be surprised by the doctors lack of willingness to commit themselves. Family and patient expectations are often too high and lead to anger and frustration with themselves and with the doctors.

Where do we go from here?

For the average person there have been no major breakthroughs in the treatment and prevention of stroke. It is, as with many other illnesses, a matter of simple measures to modify lifestyle which have made the difference in those countries where the incidence of stroke has fallen.

I found good information on strokes on The Virtual Medical Centre. The Mail and Guardian (August 22 to 28 1997) has a good article on strokes in young people.