Stroke Literary Review
Stroke is currently the second leading cause of death and the third leading cause of disability in the world (Johnson et al 2016). Although we now know quite a lot about the physiology of a stroke in order to treat it effectively, it was initially identified about 2,400 years by Hippocrates in a time when there was little to no knowledge on brain anatomy (Bogousslavsky and Maurizio 2008). It was originally known as apoplexy, a Greek term defined as being “struck down by violence” (Bogousslavsky and Maurizio 2008). Due to the lack of anatomical knowledge, the symptoms of apoplexy (sudden numbness, paralysis, etc.) were attributed to the four humors (Bogousslavsky and Maurizio 2008). They believed that a buildup of black bile in the brain was the culprit behind the strange symptoms (Bogousslavsky and Maurizio 2008).
Moving forward now to more than two millennia later, medical knowledge of stroke and brain anatomy is at its very peak. There are three different ways to classify a stroke: ischemic, hemorrhagic, or as a transient ischemic attack (Mayo Clinic 2018). An ischemic stroke makes up almost 80%, of all strokes and occurs due to a blockage in the brain’s arteries which causes reduced blood flow to the brain (Mayo Clinic 2018). A hemorrhagic stroke, on the other hand, occurs due to a rupture in the blood vessels of the brain (Mayo Clinic 2018). Finally, a transient ischemic attack (TIA) is known as a “ministroke” because of the short time period over which stroke-like symptoms present themselves (Mayo Clinic 2018). This usually occurs due to a temporary decrease in the brain’s blood supply but does not usually lead to permanent damage or long-term problems (Mayo Clinic 2018).
Stroke is important to global health not only due to the large impact it has on mortality and disability globally but also due the lifestyle risk factors which can increase its incidence, meaning these are areas which public health policies can work on. An unhealthy lifestyle involving obesity, physical inactivity, heavy drinking, or illicit drug use can increase the likelihood of stroke (Mayo Clinic 2018). In addition to this, having prior chronic health conditions such as hypertension, diabetes, and cardiovascular disease can increase this likelihood even more (Mayo Clinic 2018). Both preventative medications like anti-platelet drugs and anticoagulants and treatments such as tPA (clot-busting drug for ischemic stroke) or surgical repair/intervention are available for stroke (Mayo Clinic 2018).
Prevalence of stroke is especially significant because of its long-lasting impacts in terms of chronic disability, dementia, depression and death (Nguyen-Huyn and Ovbiagele 2011; Johnson et al 2016). These impacts seem to be even more pronounced when socioeconomic disparities are factored in with 70% of strokes and 87% of stroke-related deaths and DALYs lost occurring in low- and middle-income countries (Johnson et al 2016). This indicates how a lack of resources and education may be at play in preventing and treating this condition as on the other hand, stroke incidence has actually declined by 42% in high-income countries (Johnson et al 2016). It becomes even more difficult to monitor this condition in low- and middle-income countries as most of the research done on this condition is performed in high-income countries. However, with statistics such as 84% of stroke patients dying within three years of being diagnosed, it is evident that low-income countries require greater attention and resources in order to improvement stroke management (Johnson et al 2016). Not only do these disparities exist between low-income and high-income countries, but also within low-income populations in high-income countries. It has been shown that those with lower socioeconomic status are less likely to be properly diagnosed and receive quality acute care in the event of a stroke, thus increasing likelihood of long-term disability or even death (Marshall et al 2015).
Incidence of stroke has also been shown to vary within ethnic groups. Minority ethnic groups seem to have an increased risk of the condition in comparison to majority white populations (Marshall et al 2015). Although there are only a limited number of studies analyzing the correlation of ethnic groups on stroke incidence and mortality, it has been found that black populations tend to be on the higher end of the spectrum in both aspects with almost double the mortality from stroke compared to other ethnic groups (Marshall et al 2015; Morgenstern and Trimble 2009). Incidents of stroke have also found to be consistently higher in Hispanic and Native American populations in comparison to majority white populations (Morgenstern and Trimble 2009). Although the ethnic background itself may present as a risk factor, as in the case of sickle cell anemia (prevalent in African American populations) being a risk factor for stroke, most minority ethnic groups tend to carry a greater burden of stroke because of other overlying factors such as educational differences, lifestyle risk factors, income, and low healthcare access (Morgenstern and Trimble 2009). Because ethnicity often coincides with socioeconomic status, the incidental trends of stroke or any other chronic health condition tend to be similar in both.
Age is another significant risk factor in the incidence of stroke as incidence doubles with each decade after age 45 and >70% of all strokes occur after age 65 (Kelly-Hayes 2011). Because women tend to live longer than men, they tend to have higher rates of stroke at older ages while men have higher rates in younger ages (Kelly-Hayes 2011). This increase in incidence with age is likely correlated with higher risk of other risk factors with age such as hypertension, diabetes, and inactivity. In fact, recent trends have shown that due to increasing prevalence of diabetes and obesity in younger populations, prevalence of stroke in those populations could also be expected (Kissela et al 2012). Again, coinciding lifestyle risk factors tend to put populations at greater risk rather than just age on its own.
In general, stroke tends to impact women more than men due to the fact that stroke events increase with age and women have higher longevity (Reeves et al 2009). Additionally, women tend to face worse outcomes post-stroke in terms of quality of life. This might be due to the fact that elderly women are more likely to live alone and be more socially isolated and thus lack the support needed to recover but there is not enough extensive research done on this topic (Reeves et al 2009). It is important to note that below age 45, stroke mortality between men and women is similar and between ages 45-74, women actually have a lower risk of mortality from stroke than men (Reeves et al 2009). Mortality jumps significantly post-stroke in elderly women (Reeves et al 2009). Sex steroid hormone differences have been researched as a cause behind the differing mortality rates due to their effects on blood flow and circulation in term of ischemic stroke (Reeves et al 2009). In human trials testing the effects of hormone therapy, providing postmenopausal women who had significant cardiac or stroke histories with exogenous estrogen and progesterone did not reduce the risk of coronary events (Reeves et al 2009). Thus, the accuracy behind hormones and their relation to stroke events is still inconclusive. Additionally, based on a Japanese study, it was found that higher psychological demands due to having to balance both home and work life may be a risk factor for stroke in women (Toivanen 2012).
From what current research shows, it seems that the occurrence of stroke and its management afterwards affect the most vulnerable populations simply because they lack the resources and knowledge to manage it. Poorer populations either do not know how to recognize stroke symptoms and seek acute care when they present themselves or just do not have the access to acquire that acute care. Especially in the developing world, strokes are often not diagnosed in time to prevent long term disabilities later, causing for even more DALYs lost in a person’s lifetime. Additionally, stroke prevention is not commonly discussed in these parts of the world as much bigger issues over day-to-day survival take priority. Also, in regions of the world where alternative medicine and healers may be more trusted, the symptoms of a stroke may not receive the correct medical care which is required. More so, the fact that risk of stroke increases with age may seem less significant in developing populations where life expectancy is somewhat low to begin with. Greater incidences of the condition in women in developing countries may also go unnoticed or untreated since the cultures tend to prioritize males. Household air pollution and poor filtration, which women are more exposed to, have also been seen as a risk factor (Kalkonde 2018). Finally, common stroke treatment such as anticoagulants are very expensive and also become difficult to administer in populations which are already prone to rheumatic heart disease (Poungvarin 1998). The biggest problem at hand seems to be of helping these vulnerable populations recognize their symptoms and seek care in time.
Responding effectively to stroke begins with teaching the community effective prevention measures. Prevention tends to be the most cost-effective strategy in terms of almost all chronic health conditions. Creating policy to emphasize and reward reducing blood pressure and cholesterol in the population with both medications and lifestyle changes could be of use (Kalkonde 2018). The developing world might require a different approach in which education over regular blood pressure checkups and maintenance may be needed. A population-based strategy has been discussed in which cardiovascular risk is attempted to be reduced in a large context. This requires complete restructuring and mobilization of healthcare systems as done in Mauritius where mass media and health education in day-to-day environments (school, work, community) have been used to promote healthy lifestyles (Kalkonde 2018). The fact that this has been effective in a developing country such as Mauritius reflects the impact such methods can have if the entire community is willing to make a change. Current measures such as the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke developed in India are paving the path for the kinds of programs which may help promote changes in lifestyles (Kalkonde 2018). Although plans such as these are effective, the likelihood of convincing an entire population to change their lifestyles remains low. This is why controlling hypertension remains a high priority in stroke prevention as of now.
Proper diagnosis and treatment of stroke is also extremely important in controlling mortality and disability rates. Due to the acute nature of the condition, it is very important for the community to be aware of the symptoms and know when and how quickly to take action. Educational programs and mass media may once again be helpful in raising awareness on the condition. Additionally, acute care has to become more accessible to more vulnerable communities. Either medical professionals have to become better trained in diagnosing strokes without expensive CT scans and lab tests or these resources have to become more available in some sort of portable manner. The cost of tPA, the anti-clotting stroke medication, is extremely high and thus very inaccessible in the developing world. Efforts must be made to provide these resources to those living in developing areas either through funding from more developed countries or through cheaper but effective pharmaceutical alternatives. Community health centers which specialize in acute care and do not cause patients the worry of how they will pay for this care should also be developed. It is difficult to raise money for these efforts and thus improving diagnosis/treatment for these conditions remains a struggle, which may be why prevention if often seen as a more favorable approach.
Finally, the long-term disabilities resulting from a stroke can often be prevented or lessened from proper rehabilitation care. In the US, such long term care is very expensive and can often be inaccessible to those without the money or time to invest in getting back to proper health. Programs to ensure proper care for these individuals post-stroke may be effective in lowering the burden of this condition. In developing countries, programs to teach family members how to assist their loved ones after a stroke when rehabilitation care is not available may be of importance as well. With this condition presenting as the third leading cause of disability in the world, proper care afterwards is vital to ensure the least amounts of DALYs lost.
Overall, although the risk of stroke is present in all populations in the world, it has become even greater in those with less access to education and resources. As predictions for even higher incidences of the condition are made, it is important to move our attention to those populations and create programs and policies to decrease the burden as much as possible.