Oye, H.,D.O.,Sanusi,M. M.D., Ugoji, U.,M.D., Adamu, Y., Edafe,E, M.D., Ocheli, E., M.D
ABSTRACT
IMPORTANCE: Stroke is the third leading cause of death the world. It is especially a devastating medical emergency in Nigeria where it affects a vast segment of the population. It has an usually higher morbidity and mortality in Nigeria because the rudimentary and fragmented healthcare system in Nigeria presents an unusual challenge for the effective treatment and rehabilitation of stroke patients.
OBJECTIVE: To transform the current fragmented and substandard stroke treatment
options in Nigeria to a more organized, rapid intervention platform that will minimize the morbidity and mortality. Using integrative medical technologies including telemedicine to enhance the survival of stroke victims in the urban and rural settings.
EVIDENCE REVIEW: Enhance the non-existent utilization of tissue plasminogen activator (tPA) in Nigeria for the management of ischemic stroke within the recommended therapeutically beneficial critical stroke intervention period of 1 to 4.5 hours.
CHALLENGES: The infrastructure challenges in Nigeria with traffic delays and denial of medical care to patients with lack of financial resources has caused many untimely deaths. Patients with stroke attacks must have improved healthcare access to receive
life saving treatment with the early critical time period if Stroke Units can become a reality.
CONCLUSION: The challenges of transforming the stroke management platform in Nigeria is a daunting task. The utilization of Telemedicine connectivity and strategically located Stroke units can help decrease the morbidity and mortality of Strokes in Nigeria. Continuing Medical Education of the Stroke team and healthcare providers will certainly be beneficial in the effort to improve Stroke care in Nigeria.
Stroke is the third leading cause of death in the world. Mortality from Strokes is higher in Blacks, than other racial groups. It is especially more debilitating in the African continent. Stroke is a major cause of morbidity and mortality globally, but the fragmented healthcare in Nigeria presents an unusual challenge for the effective treatment and rehabilitation of Stroke patients. It has been estimated at 1-14/ 1000 prevalence rate with a 30 day mortality as high as 40%.
Stroke or Cerebrovascular accident is a medical condition that can lead to rapid mental and physical dysfunction and even death. It does not discriminate on who gets affected on the basis of socioeconomic standing. It can occur suddenly and unannounced. There are various forms of Strokes that the public should be Know.
Transient Ischemia Attack (TIA) is generally considered a mini-stroke. It causes the patient to experience sudden loss of mental and physical symptoms due to partial blood flow interruption from blood clot or plaque. It lasts less than 24 hours and usually has full return to normal state. It is a warning sign that should be taken seriously because of the increased risk of impending stroke (CVA).
There are 2 types of major stroke. Ischemic versus hemorrhagic. The ischemic stroke is further divided into two: embolic versus thrombotic. Embolic stroke is usually from the heart or carotid arteries in the neck, where a blood clot or plaque is dislodged and escapes to the brain. If it lands at a specific location in the brain, it can cause malfunction or deterioration of that part of the brain. The net result of this malfunction is brain cell death and loss of critical functional capacity. Hypertension or high blood pressure is the most common cause of this type of stroke.
The other form of hemorrhagic stroke is called subarachnoid hemorrhage. It is usually caused by rupture of blood vessels near the surface of the brain and skull. It can put pressure on the surrounding arteries causing spasm and further reduction of blood flow to the brain and a resultant stroke. The most common cause is a ruptured aneurysm or bursted weak bulging artery.
Thrombotic stroke occurs when a blood clot or plaque develops locally in a specific blood vessel in the brain that causes the patient to experience loss of normal brain function pertinent to that area of the brain.
Hemorrhagic stroke occurs when there is a weakness of the wall of the brain use usually from an aneurysm or hypertension and the blood vessel ruptures and blood spills into and around the brain. There are two types of hemorrhagic stroke. Intracerebral versus Subarachnoid hemorrhage. Intracerebral stroke results from rupture or bursting of blood vessels in the brain and blood leaks into the brain tissue.
The devastating effects of stroke can be very real and sometimes permanent. If a stroke affects the left side of the brain, it can cause a problem with the patient controlling the right side of the body. The damage from stroke on the left brain can lead to difficulties in performing math and science problems, and understanding written or spoken language. On the other hand, the right side of the brain controls the left side of the body. These patients lose their ability to do creative things such as painting a picture, art or music appreciation, recognize the emotion in communication language, and spatial disorientation such as not being able to find where they plan to go.
These are things that the public and patients should be aware and informed about preventing stroke.
1. Control Hypertension ( high blood pressure).
2. Avoid Atrial Fibrillation (irregular heart beats that can generate blood clots in the
heart Chamber which can escape to the brain and cause a brain attack).
3. Avoid smoking. Smoking doubles the risk for stroke.
4. Drink alcohol in moderation. Heavy or excessive drinking increase the risk of
stroke.
5. Lower total cholesterol in the blood to less than 200.
6. Manage Diabetes Mellitus due to increased risk for stroke.
7. Exercise daily. (Walking, bicycling, or swimming).
8. Lower salt and fatty food intake.
Some signs of stroke that we should not take lightly include:
. Sudden numbness or weakness of the face, arm, or leg, especially unilaterally
( on one side ).
. Sudden confusion, trouble speaking or understanding (garbled speech).
. Sudden loss of vision in one or both eyes.
. Sudden trouble walking, dizziness, or loss of balance.
. Sudden severe headache with no known cause.
. ACT FAST.
. F Face : Drooping on one side of the face.
. A Arms: Drifting of one arm.
. S Speech: Garbled or slurred speech.
. T Time: Call for Emergency Help.
The over riding objective of this proposal is to transform the the Stroke Care challenges currently seen in Nigeria. To begin such a project, it will be imperative to understand some of the complex issues healthcare providers face in the Nigerian context. First, the country is experiencing serious economic difficulties from dwindling oil revenues. The Federal and State Governments have serious financial challenges in balancing their budgets and providing salaries for Civil Servants, and the ripple effect has spilled over to the private sector. The Government run hospitals ,therefore, are experiencing significant budget short falls. The current transportation infrastructure in the urban cities are inefficient and chaotic and can pose significant delays that can make meeting the therapeutic window for thrombolytic therapy impractical in some cases. The development of an efficient air evacuation by helicopter can potentially solve this problem, but will also increase the cost of treatment significantly. The alternative will be a governmental control of traffic lanes to make medical transport by land ambulance more efficient and safer. Collaboration with the State Governments to make land ambulance travel accessible during traffic jams will prove quite beneficial. A public service announcement to sensitize lawless road drivers and punitive fines for impeding ambulance travel will be imperative.
To optimize therapeutic benefit for stroke victims, it may be prudent to have regional Mobile Stroke Units In the North, South, East, and Western parts of the country. This will allow quicker initialize interventions to stabilize the patients and plan eventual suitable rehabilitation options. The private sector will be more efficient in managing the Mobile Stroke units with appropriately trained stroke team members that will work in concert with referring physicians, nurses, or institutions. We will provide continuing medical education training to the Stroke team and all healthcare providers seeking advanced training in stroke care.
In addition to making tissue plasminogen activator (tPA) readily available at the MSU for ischemic stroke management, it will necessary to have functioning CT scan for the initial brain scan to accurately differentiate the ischemic from hemorrhagic stroke. The availability of an Endovascular Cath Lab or Hybrid Operating theatre will be beneficial for the management of complex stroke cases. This will involve the training and retraining of essential personnel once the system is fully established. In the interim, stroke victims can be treated in both the urban and rural settings using our available Telemedicine connectivity with our USA based Stroke team. We will have to sort out the logistics associated with the regional internet availability to enhance the telemedicine experience. The benefit of the telemedicine option will be the availability of the the Endovascular & Vascular Surgeons, Neurologists, and Neuro-Radiologist consultants based in the USA to provide appropriate electronic consultation recommendations.
After the initial stabilization phase of therapeutic intervention of the stroke victim, and the reduction of the high morbidity and mortality currently observed in the country, it will be imperative for these patients to undergo aggressive in-patient rehabilitation with the full complement of physical therapy, occupational, and speech therapy. Alternative medical options such as acupuncture, osteopathic manipulative therapy, massage therapy by native Doctors can be incorporated into the program to demystify certain stroke superstitions and encourage timely referrals. The ultimate goal is to maximize their recovery in the shortest time possible so they can return to improved functional capacity to enhance their work or life style.
Though the financial implication for a successfully managed Stroke Unit will be significant, it can still become a reality in the Nigerian context if it is private sector driven and financial burden is tailored to meet available resources.
To optimize therapeutic benefit for stroke victims, it may be prudent to have regional Mobile Stroke Units In the North, South, East, and Western parts of the country. This will allow quicker initialize interventions to stabilize the patients and plan eventual suitable rehabilitation options.
