What factors have led to heart disease claiming most fatalities in the world?

An introduction of stroke, its causes and consequences, by Dr Manio von Maravic, neurologist at German Neuroscience Center

With more than 25 years of professional experience in treating neurological diseases such as headaches, vertigo, back pain, sleep disorder, dementia, stroke, epilepsy, MS and others, neurologist Dr Maravic discusses the disease that has been causing the highest number of fatalities around the globe.

A stroke is a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off. Strokes are always a medical emergency and urgent treatment is essential. 

The sooner a person receives treatment for a stroke, the less damage is likely to occur.

Our brain, like all other organs, depends on oxygen and a perfect blood supply to maintain its functions. The interruption of blood flow to the brain cells causes progressive cell deaths and leads to a definite injury of brain tissues, resulting in disability or death.

About 85% of strokes are ischemic, meaning the stroke is caused by a blood clot that blocks blood flow to an area of the brain. Starved of blood and oxygen, brain cells begin dying.

15% of strokes are haemorrhagic – where a weakened blood vessel supplying the brain bursts causes a bleeding into the brain tissue.

Transient ischaemic attacks (TIA) are short episodes that can last minutes to a few hours where blood supply to the brain is temporarily interrupted, but the blood flow recovers completely as does the patient and symptoms disappear. However, TIA an absolute emergency and requires immediate hospital treatment.

Blood clots can originate in our heart or the arteries connecting the heart with the brain, and are brought by the blood stream to the brain.

The risk factors of stroke are responsible for the formation of arteriosclerosis of our arteries leading to narrowing and obliteration of small arteries in the brain resulting in stroke.

Major risk factor for stroke (identic for heart attacks):

High blood pressure that is untreated increases the stroke risk 10-15x.

High cholesterol, irregular heartbeat (atrial fibrillation); diabetes, smoking, obesity – principally our lifestyle dominated by stress, work conditions, unhealthy diet and being overweight are all factors. In other words, an unhealthy lifestyle increases risk. The only non-modifiable risk is aging, as stroke risk increases with every decade lived.

Why is the younger generation in the region is becoming more susceptible to stroke? As you said, “It’s not the disease of the old”.

Stroke occurrence increases exponentially with age. Stroke at a young age covers the range from newborns to 45 years of age.

Annual incidence rates of ischaemic stroke in infants and children range from 0.6 to 7.9/100,000 children per year. In adults younger than 45 years old, incidence ranges from 3.4 to 11.3/100,000 people per year in white populations. However, the stroke risk in young black adults is double at 22.8/100,000 people per year. The numbers of young stroke patients has been rising since the 1980s.

Possible reasons for this increase are better stroke awareness and revolutionary improvements of diagnostic stroke detection and acute treatment tools, but also the increasing prevalence of lifestyle related risk factors like the extreme obesity rates in children (especially in US, South European and Arabic countries), and the increasing use of illicit drugs such as cocaine, heroin and ecstasy as party drugs.

Several studies have found that paediatric ischemic stroke is more common in boys than in girls (estimated 60:40). The male predominance was present regardless of age, stroke subtype, or a history of trauma. The explanation for the apparent male predominance is unknown.

Rehabilitation process: You mentioned multiple side effects such as memory, mobility and speech impairments. Besides physiotherapy and medications, what are the other patient’s options in the form of complementary therapy and diet to improve their physical as well as cognitive recovery?

Major sequels of stroke requiring long term and intensive rehabilitation are the loss of muscle function in one part of the body (hemiplegia), the loss of coordination affecting the use of hands and affecting walking with instability,; loss of speech – aphasia, which could affect the formation of words and phrases, in general the production of speech with preserved understanding (motor aphasia), or it affects the comprehension alone (sensorial aphasia), or the entire speech function (global aphasia); other deficits could be the loss of half of the visual fields, double vision or slurred unintelligible speech. And it could affect the memory function, but not as primary or usual symptoms.

All these symptoms require rehabilitation, and whatever the rehab technique is, it trains the brain and activates non-damaged neurons to take over functions – the so called neuroplasticity.

What are the options of therapy and the facilities dedicated exclusively to this medical field?

Rehabilitation must be a combination of stroke specialised physiotherapists (using the Bobath therapy concept, which is to promote motor learning for efficient motor (movement) control in various environments, thereby improving the participation and functioning of the patient in general).

Ergotherapists (occupational therapists) focus on maintaining and using personal abilities necessary for casual daily work. Speech therapists (logopaedic training) is therapy lasting for many months focused on the re-education of all language skills.

However, the stroke survivors themselves must contribute to their improvement and especially preventing the re-occurrence of strokes. These are some of the most relevant rules stroke survivors should integrate into their daily life:

  • Eating a healthy, balanced diet – a low-fat, reduced-salt, high-fibre diet is usually recommended, including plenty of fresh fruit and vegetables. This is known as the Mediterranean diet, which is known for stroke and dementia prevention
  • Exercising regularly – for most people, at least 150 minutes of moderate-intensity activity, such as cycling or fast walking, plus strength exercises on two days of every week is recommended 
  • Stopping smoking – if you smoke, stopping may significantly reduce your risk of having a stroke in the future 
  • Cutting down on alcohol – men and women are advised to limit alcohol intake to 14 units per week

After suffering a stroke, patients must learn to relax, calm down and reduce their daily psycho-physiological tension. They have to learn copying strategies to overcome the stroke experience:

Biofeedback, cognitive behavioural treatment and simple meditation techniques might be helpful and could be selected by psychologists or psychotherapists.

Physiotherapy, an Ergotherapy, can be supported by yoga, as yoga has a positive effect on problems with balance and coordination which are common after a stroke.

Massage therapy can enhance a person’s health and well-being. It can improve daily function, mood, sleep patterns, and pain in individuals who have suffered a stroke

What is mirror therapy? How useful is it to restore hand mobility? Could there be other options that help improve hand mobility?

Paralysis of the arm or leg is common after stroke and frequently causes problems with the activities of daily living such as walking, dressing, or eating. Mirror therapy (MT) is a rehabilitation therapy in which a mirror is placed between the arms or legs so that the image of a moving non-affected limb gives the illusion of normal movement in the affected limb. Through this setup, different brain regions for movement, sensation, and pain are stimulated. However, the precise working mechanisms of mirror therapy are still unclear. 

A 2018 study about MT showed that it moderately improved movement of the affected upper and lower limb and the ability to carry out daily activities for people within and also beyond six months after the stroke. Mirror therapy reduced pain after stroke. The beneficial effects on movement were maintained for six months. No adverse effects were reported.

What is music therapy? Can it facilitate any of the processes involved in the rehabilitation process?

Listening to music has a positive effect, but it is even better to become an active musician – singing, dancing in groups, using rhythm instruments, playing the piano, even as a beginner, and independent of age, enhance brain function, and simultaneously stimulates various brain areas with different functions such as speech, motor function control, memory, coordination of movements.

Music therapy has been shown to improve language skills in stroke survivors. This effect is intuitive, as music and language both involve the auditory cortex, that means that music and language are using identical brain structure. Techniques such as therapeutic singing and melodic intonation therapy (a method of inducing speech using musical tones or rhythm) have resulted in significant improvements in aphasia.

Recovery of deficient motor functions (muscle paralysis, walking deficitis) are responding well to music therapy. A number of studies have shown positive outcomes for patients passively listening to music or singing and playing rhythm and percussion instruments. Even learning to play piano helps the recovery of hand functions.

Music therapy is a young therapeutic discipline for rehabilitation, but it is very promising. Unfortunately, professional and experienced music therapists are still rare.

Which of the complimentary therapies you mentioned are available in the UAE? Do you recommend your patients to try those out?

Alternative treatments are offered in many places in UAE as this is a multicultural place. Therefore, all treatment techniques are brought to this country by the different nationalities.

As long as complimentary treatments are not doing harm all therapy options are allowed, but everybody must be aware that complimentary treatments are not scientifically approved and never may substitute the standard acute and poststroke treatments.

Could stroke reoccur? How can one ensure sustained wellness?

Survivors of stroke or mini-stroke who do not experience early complications are usually discharged from secondary stroke prevention services. However, new research shows that these people remain at a long-term increased risk of stroke, heart attack, and death for at least 5 years after the initial stroke.

The risk of recurrent stroke accumulates early after an initial stroke or mini-stroke, or transient ischemic attack (TIA), and this is typically within the first 90 days.

The estimated risk of recurrent strokes and death remain elevated in the long-term, with 18% percent after 5 years and 44 % after 10 years. Therefore secondary stroke prevention is an obligation: a combination of blood thinners like Aspirin, Clopidrogel or a modern new anticoagulant – the type of drug depends on the cause of the stroke. Strict control and improvement of all lifestyle risk factors, healthy diet, physical activity and treatment of accompanying disease like heart condition causing strokes are absolutely essential.

Symptoms of stroke everybody should know – the FAST rule
  • Face

    The face may have dropped on one side, the person may not be able to smile, or their mouth or eye may have dropped.

  • Arms

    The person with suspected stroke may not be able to lift both arms and keep them there due to weakness or numbness in one arm.

  • Speech

    Their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake; they may also have problems understanding what you're saying to them.

  • Time

    It's time to dial the local emergency number if you see any of these signs or symptoms.

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