Y Investigation: Stroke cases on the rise in Oman

22 Nov 2017
POSTED BY Y Magazine

Stroke cases are on the rise across the age groups in Oman and patients include youngsters below 20. Team Y check out the good, bad and ugly truths about the leading cause of death in the world

Until our conversation with Minister of Health Dr Ahmed Mohammed Obaid al Saidi, little did we know about the biggest killer lurking around in our society. But when the experienced doctor firmly pointed out that it was our very own “lifestyle” that takes us to an early grave, there was no way out but to heed his words.

Dr Ahmed had more to tell us during our brief meeting at the signing of the agreement to assign new hospital projects in the country.

“In the Sultanate – like the rest of the region – unfortunately NCD (non-communicable diseases) like diabetes, cancer, heart disease and strokes have become the major causes of death.

“All these may be major causes of death, but more people are dying because of heart diseases at a younger age in Oman than what we see in Europe and North America,” the minister emphasised.

“Most of them (diseases) are related to our lifestyle. We can modify our lifestyle to prevent 40 per cent of these. When I say modifying lifestyle, I mean diet, exercise and stopping smoking and reduction of the consumption of alcohol. Health is ultimately the responsibility of the individual.”

However, this piece of advice may have come a bit too late for some people, like Indian expat Sanjeev who had been working in Oman for the last three decades.

Forty-eight-year-old Sanjeev had gone back to his hometown in India to help with the final touches of his cousin’s wedding. He had left his family back in Oman and promised to take them to India in time for the marriage.

But, a few weeks into the preparations, Sanjeev’s wife got a call from his family – a call that changed their life forever.

Sanjeev had suffered a hemorrhagic stroke and had been lying unconscious in the toilet for several hours. He was taken to hospital immediately but it was too late – much of his brain matter had already been rendered dead.

Recollecting the incident, Sanjeev’s son said with teary eyes: “Dad lay there in the toilet for around four hours and no one knew of his whereabouts. But one of my uncles suspected that something was wrong when he saw the bathroom door locked for such a long time, so he kicked down the door.

“That’s when he saw dad lying on the floor. Initially, he thought that dad had suffered from a heart attack – and that he may have already passed.

“But there was a pulse, and that’s when he called for the ambulance. In shock, he tried giving dad water but he wouldn’t swallow.

“We immediately took him to the nearby local hospital. The doctors diagnosed that he had just suffered a severe stroke but said that they couldn’t do anything to save his life.

“So the ambulance was called again and he was transferred to Lakeshore hospital in Kochi where he underwent surgery to drain the blood that had hemorrhaged around the brain. The procedure lasted for hours, but it felt like days to us.

“And then the doctor came out with the news: ‘Sanjeev has survived the ordeal but will be paralysed and will suffer from memory loss’.”

The recovery process took him a year-and-a-half but Sanjeev constantly suffered from short-term memory loss and was confined to a wheelchair.”

His son added: “The greatest part is that he survived. It doesn’t matter if he doesn’t remember that I’m out of school and have also finished my college. Sometimes he asks me how I did in school, and if I am studying well. The important part is that he remembers me.”

The son has completed college in Oman and is now working as an engineer in Muscat.

“We’re only glad that we have him by our side. It kills us when he forgets our names or loses track of what we talk but just seeing him on the wheelchair is motivating enough for me to educate everyone around me as to how one must take care of oneself to not be in this situation,” he told Y.

Sanjeev suffered a stroke at the age of 48. The average age for a patient suffering from stroke is 69.3 (as per the findings of livescience.com). This sheds light on one important matter: the average age of a patient suffering from stroke is dropping – and it’s falling fast.

The reason for the vein in his brain “bursting” was attributed to his lifestyle. Sanjeev was suffering from high cholesterol, diabetes and was diagnosed with hypertension. He was also a light smoker.

But what is it that causes strokes and, above all, what makes it one of the most leading killer of diseases among people today?

According to the World Health Organisation (WHO) data published in May 2014, deaths due to strokes reached 950, or 10.94 percent, of the total deaths in Oman. In our neighbouring country UAE, it was reported that annually 7,000 to 8,000 patients suffer stroke, which means every hour a person is hit by a stroke.)

To get to grips with the subject, we sat down with Dr Amal Al Hashmi, BSc, MD; FRCPc, senior consultant neurologist and head of the Central Stroke Unit in the Ministry of Health. She is also Oman’s first woman adult neurologist and an associate editor at the International Journal of Psychology and Neuroscience, a member of the Omani Human Rights Commission, and former vice president of the Oman Medical Association.

“To come to terms with the issue, everyone needs to have an understanding of what a stroke is,” said Dr Amal.

She went on to explain: “A stroke is a neurovascular disorder and is also the commonest form of acute neurological disorder. Stroke itself is considered to be the second leading cause of death worldwide – and the third leading cause of disability in the world.

“Of course, with an ageing society, increasing risk factors like hypertension, diabetes, atrial fibrillation, etc. the burden of the disease is even expected to increase. With changing lifestyle the numbers are expected to increase year by year. I think the Gulf (Middle East) area is not much different from the rest of the world because we are also inheriting this modernised lifestyle and are running on the same path.

“Our figures (of stroke cases) are not going to be any different from the figures in western countries, considering  the size of  our population. The Central Stroke Unit receives on average two cases per day which means a total of 14 cases per week and 56 cases per month and around 672 cases per year. These numbers exclude cases admitted at peripheral hospitals in all the governorates and regions. In addition, around 12-14 cases are seen per week in the
out-patient departments.”

The doctor then went on to explain strokes. “There are two different types of stroke: 1) Ischemic stroke, which is caused due to the cut of blood flow to certain parts of the brain; and 2) hemorrhagic stroke, which is a rupture of blood vessel within the brain.

“Ischemic stroke is a more common form of stroke and contributes to around 80 percent of cases we see here in Oman. I have done a study on stroke numbers in Oman and found out that our figures are similar to that of western countries. This study showed consistency with the trend seen in the western countries, the percentage of ischemic strokes always hovers around the 80 to 85 per cent range out of the total percentage of patients who have suffered from stroke. Whereas the hemorrhagic stroke only represents 10-15%.

The numbers vary from region to region. In the eastern countries (India, China, Japan, etc.), the figures for ischemic stroke are lower and hemorrhagic stroke contributes 30 percent of the total stroke cases.”

Dr Amal then made a startling revelation: “Strokes are on the rise among the younger audience globally. Stroke among youngsters has become a whole different category.”   

Those who are classified under this category fall below the age of 50 – which puts Sanjeev in the mix, too.

“Stroke is usually a disease associated with the older population, but that is not the case anymore.

“We are running a small study now. I can’t tell you the final results because we are still undertaking it. But we saw there has been an increase in the number of young patients who developed stroke. I have seen individuals in their 20s, 30s and 40s with stroke and my youngest patient was only 18 years of age.

Still, stroke in the younger audience is different from that of the older population.

“Age was considered to be the number one factor, originally. The older you are, the higher the risk of having a stroke,” Dr Amal said.

“That is only one factor. Others that we recognise today include hypertension, diabetes, dyslipidemia, cardiac disease, atrial fibrillation, etc.”

While these are diseases you likely contract as you age, it is also prevalent among today’s younger population, said Dr Amal.

“In addition to the risk factors that we have already talked about, there are other things like obesity, which is prevalent in the young population because fast food is part of one’s diet; and reduced mobility.”

Apart from that, these are some other reasons usually linked to causing health problems that can result in one suffering from a stroke:

1) Lack of exercise and eating food that has bad carbohydrates, sugar and other fatty foods.

2) Smoking cigarettes and shisha has been linked to complications that can result in a stroke.

3) Consumption of alcohol. “I am not sure how much this applies to this society, but it’s also a factor that can lead to this,” said Dr Amal.

4) Drug use. It has been proven that drugs like heroin and cocaine can lead to young addicts suffering from stroke.

“One thing that you should keep in mind is that these are not the only factors that contribute to a stroke at a young age; all of the aforementioned and everything that affects the older population can be risk factors,” Dr Amal explained.

“So when you look at it, their (younger population) plates are fuller,” she added.

This has come into the spotlight in another recent study published by the WHO. It stated that targeting risk factors like diet and tobacco that are closely related to cancers, heart disease and stroke, diabetes and chronic respiratory diseases is vital in Oman.

More than 50 percent of Omani men and women are overweight or obese, more than 40 percent have hypertension, and 12 percent have been diagnosed with diabetes.

One in five Omanis die before their 70th birthday, most from largely preventable cardiovascular diseases.

Strokes, in general, are classified, based on risk factors, into two: modifiable and non-modifiable.

“Modifiable risk factors are the ones that you can alter and fix. You can improve your ultimate outcome. For example, you can control your blood pressure and blood sugar levels. This will lead to a better control of chronic diseases like diabetes, hypertension, cardio diseases and dyslipidemia. You can also quit smoking, drinking and doing drugs, to alter the health of your heart.

“Non-modifiable risk factors are those that you can’t do much about. Age is one; everyone is growing older by the second. Then you have genetics; some people are more prone to develop certain genetic disorders because they have inherited it.

“There are certain things that run in the family; we don’t have explanations to them but they are risk factors,” she stressed.

The Ministry of Health has already included non-communicable diseases (NCD) prevention in the delivery of primary health care. An NCD screening programme for all adults aged 40 years and over is in place to augment the services addressing diabetes, hypertension, heart failure, asthma and stroke.

Dr Amal then walked us through to the next part: treating a stroke.

“How we manage a stroke patient is important. The treatments always must be tailored case by case; it’s never the same for every patient. We have to modify the mode of treatments based on the medical history of the patient, clinical presentation and what the investigation is going to tell us.

“Overall, however, the treatment depends on the type of the stroke a patient has suffered. For example, ischemic stroke is treated in the very acute phase and within the first 4.5 hours of the onset of symptoms with thrombolytic therapy in a simple ward. This is a special medication given intravenously to help dissolve and destroy the clot inside a blocked artery inside the brain. Other modes of intervention can also be taken when needed. Patients who suffered from ischemic stroke also will require close monitoring of their vital signs especially the blood pressure. Other modalities of treatment include using antiplatelet and antilipids medications. Not to forget the crucial role of early rehabilitation that helps stimulate the brain to restore the
affected functions.

“Treatment of hemorrhagic stroke is completely different from that of ischemic stroke, as in hemorrhagic stroke you should administer special medication to reduce the increased brain pressure and at times you might need to interfere surgically to remove the blood from inside the brain. Once these patients pass the hyper acute phase there will be a set of investigations done while the patient is admitted at the stroke unit, aiming to identify the direct case for developing a stroke.”

On the other hand, one cannot talk about stroke and avoid talking about the importance of stroke units. In short, stroke units are dedicated medical outlets – complete with the necessary equipment and trained staff – for patients suffering from strokes. These units are linked to hospitals but almost never share patients from general wards.

“A stroke unit is a defined geographical space for these patients. If you don’t have a stroke unit in the hospital it means that these patients will be admitted in scattered beds across the hospital.

“Also, these units are equipped with electronic beds with multiple functions. You cannot keep stroke patient on normal beds as most stroke patients are paralysed and can’t move around. The patients will also be hooked to monitors that will show all their vital signs.”

But the general idea of a stroke unit, according to the doctor, is not just to have a common geographical space but also to have a multi-disciplinary team dedicated to taking care of these patients.

“A stroke unit will have a strokologist, who is a consultant specialised in strokes; nurses who are trained to take care of these patients; a rehabilitation team to handle these cases; and staff from the intensive care unit (ICU) for the times you might need some urgent support.”

Sometimes the team also shares cardiologists and endocrinologists.

“But that’s not all,” said Dr Amal. “You also need to have the community nurses, a discharge planner and social workers. Everybody has to come together because we know these patients need emotional, as much as medical, support.”

“There is very strong evidence that patients who have been treated at a stroke unit have better outcomes when compared to patients who have been admitted in general
medical wards.”

Dr Amal presented her findings on stroke units to the American Academy of Neurology at the 68th annual meeting in Vancouver in 2016.

“We are currently working on a study on stroke cases in Oman. Hopefully it will be accepted in one of the journals,” she told Y.

We then asked her about the various challenges she faced on a day-to-day basis, working as a neurologist.

“Neurology itself is a very challenging field but stroke in particular is the most demanding per say, because you deal with acute cases.

“Here you’re dealing with brain matter, and if you don’t act very fast you could lose some valuable brain tissues, and then the consequences might not be what you want.

“At times, we get extreme cases where the patient has had massive bleeding or massive infarctions, which is when you have to stand on your toes to maximise the therapy that you can offer to these patients.

“The ultimate outcome may not reflect what you want at times, but we do not give up on patients – that’s something we’re trained to do.

“Another challenge is the time frame these patients reports to emergency. Some patients might arrive late to us which leaves us with very limited options of treatments. The earlier they report to ER, the better their chances of recovery.

“So, I would like to advise everyone to get periodical checkups and control their risk factors. Of course, if you’re feeling any of the symptoms of a stroke, immediately call the ambulance or report to the nearest emergency department.

“But, as a doctor who has worked on many cases, my final advice to everyone: Prevention is better than cure. As explained before, there are several risk factors, and if you’re prone to them, then you should tend to it. Also, take your medication correctly and always check with your practitioner before making a drastic change in your lifestyle.

As for those who have had a stroke, the doctor advises: “Do not give up easily. Fight with all your might, and we’re all here to support you.” 

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