THE STAR, TUESDAY 29 OCTOBER 2019
STROKE AWARENESS
When the tangle
becomes dangerous
WHEN blood vessels get tangled up
into a mass, blood bypasses the
capillaries from the artery straight
into the veins. This occurrence is
called arteriovenous malformation
(AVM). Because pressure in the
artery is high while the vein has
low pressure, this surge of high
pressure into the vein can
perpetuate the risk of bleeding.
This causes a stroke.
Consultant neurosurgeon (brain
and spine surgery) at Ara
Damansara Medical Centre Dr
Ramesh Narenthiranathan, says
the exact cause of AVM is currently
uncertain, but lists several
possibilities.
“One possible cause is
congenital, when bleeding in the
brain is more commonly seen in
children. Another reason is that
angiogenetic factors in the brain
stimulate blood vessel growth,
which may lead to an AVM. Lastly,
minor trauma in the brain may
cause angiogenetic factors to be
released to repair the brain, thus
possibly forming an AVM,” he says.
Because the actual cause of an
AVM is not confirmed, risk factors
or particular patient groups cannot
be determined. Dr Ramesh has
seen children and elderly adults
alike with AVMs, and therefore
advocates for people to seek
treatment should they experience
AVM symptoms. These include
To the brain, time is of the essence
THE phrase “time is brain” often
arises in the context of a stroke
and emphasises that human
nervous tissues are rapidly lost as
more time passes after a stroke
has occurred. For each hour that
the patient is not treated, the
brain loses as many neurons as it
normally would in almost 3.6
years of ageing.
“Every second, every minute
counts,” says Dr Siva Seeta
Ramaiah, consultant physician
and neurologist at Subang Jaya
Medical Centre.
Stroke is the fifth most common
cause of death in Malaysia. When
a person suffers from a stroke, it
is essential that the patient
receives treatment as soon as
possible, as there is still time to
reverse the process and save the
brain cells.
If you see signs of a stroke in a
loved one or if you feel the
symptoms yourself, there are a
couple of things that you need to
do. First, note the time of the
stroke. Next, immediately get to a
hospital.
“Time is important,” says Dr
Siva. “You don’t want to waste
time by going to a clinic or
hospital that does not have the
services to treat a stroke patient.”
Once the patient arrives at the
hospital, a quick assessment is
Dr Ramesh Narenthiranathan.
headaches, seizures and, in worst-
case scenarios, haemorrhagic
stroke.
He adds, “There is also a rare
chance of intermittent ischaemic
stroke with an AVM. This occurs
with the steal phenomenon, where
blood supply is cut short in certain
areas of the brain because they are
bypassed. The stroke only occurs
when there is a lack of blood
supply in certain parts of the brain,
but when blood supply resumes
the patient can revert to normal
function. Such patients experience
intermittent neurological deficits.”
Treating it early
It is always recommended for
patients with AVM to have it
Dr Siva Seeta Ramaiah.
done, which includes assessing
the patient’s medical history
(which includes time of stroke)
and a full medical examination.
Next, to confirm that the patient
has indeed experienced a stroke,
the patient will undergo a CT scan
of the brain. Only once the stroke
has been confirmed can doctors
initiate necessary treatment.
However, not everyone is
aware that time is essential. “Even
in developed countries, only 10%
of stroke patients get to the
hospital in time,” says Dr Siva.
“Some of our patients wait a
while before coming in for
treatment. They may even wait
removed immediately upon
diagnosis. Dr Ramesh explains,
“Because we know the risk of a
haemorrhagic stroke is high, we
must treat the AVM the moment it
is diagnosed, even if a stroke has
not yet occurred.”
He mentions three kinds of
treatment – microsurgery,
stereotactic radiosurgery and
embolisation, which are carried
out depending on the presentation
and location of the AVM.
l Microsurgery is done by first
disconnecting the surrounding
blood supply from the tangled
mass (nidus) of blood vessels, and
then the draining vein before
removing the nidus.
l Stereotactic radiosurgery is
carried out with focused radiation
on the nidus of the AVM to destroy
these abnormal blood vessels.
When this is done, it also ablates
the angiogenetic factors (stimulates
blood vessel growth) that reside in
the walls of these blood vessels.
l Embolisation is a temporary
fix for an AVM where glue is
until their children have come
home from work before they come
in for treatment, even though the
stroke happened in the morning.
In those cases, there is not much
we can do.”
Common misconceptions
The ideal situation for a
suspected stroke patient is to seek
urgent medical attention. However,
Dr Siva explains that this is often
not the case, as many stroke
patients believe in alternative
treatments.
“I had a patient who, after
realising she was having a stroke,
took a needle and pricked her ear.
Don’t do that! Get to a hospital as
soon as possible,” stresses Dr Siva.
Another common misconception
is that once you have a stroke, your
life is over, because you would be
in a vegetative state. However, this
is not entirely true. Because of
medical advancements, we can
reverse the process if the patient
comes to the hospital on time.
Time is key in saving a stroke
patient’s brain from irreversible
damage. If you or your loved ones
suffer from a stroke, don’t wait,
and act fast!
n For more information call
03-5639 1212.
injected into the blood vessel
through a catheter. The glue stops
blood flow and risk of bleeding for
a period of time so doctors can
have more time to carry out more
definitive treatment.
Dr Ramesh says recovery rates
depend on the presentation of the
AVM at the time of treatment. “If
the patient is neurologically intact
at the time of treatment, the risk of
an adverse outcome from surgery
is less than 10%. However, if the
patient received treatment only
after having a stroke, the patient’s
recovery can only be determined
after undergoing intensive
rehabilitation.”
Consequences follow
ignorance
A brain AVM can present in
anyone. Therefore, Dr Ramesh
urges those who have frequent
headaches or migraines to undergo
neuroimaging of the brain,
Quick action saves lives
Time is of the essence when it comes to a stroke and knowing just
what to look out for can make all the difference. By knowing the
signs and symptoms, you can take quick action and possibly save a
life. Below are easy ways to remember what you need to look for.
Facial drooping
Does the face feel numb? Is it
drooping on one side? Ask the
person to smile, and see if their
smile is uneven.
Limb weakness
Is an arm weak or numb?
Ask the person to raise both
arms and see if an arm drifts
downwards.
Frequent headaches
must not be taken
lightly as it may be a
sign of arteriovenous
malformation.
preferably an MRI, to make sure
there are no structural lesions or
blood vessel abnormalities causing
the headaches.
He stresses that while headaches
are a common experience, it can be
disastrous if something more
sinister is missed out, saying, “It is
difficult to determine if the
headache is stress-related, a
migraine or another underlying
problem without a proper scan.”
If you experience headaches that
are quite persistent and increasing
in frequency, it is recommended
that you undergo an MRI.
Dr Ramesh also asserts that if
you have a sudden, severe
headache, it is best to rush into a
hospital that is well equipped with
neurosurgical and neurological
services. This is because sudden,
severe headaches are usually
suggestive of haemorrhages in
comparison with a chronic
insidious onset of a headache.
n For more information, call
03-5639 1212.
Slurred speech
Is their speech slurred? Ask
the person to repeat a simple
sentence, like “the sky is blue”.
Act fast
Time is brain, so react fast. Call
the ambulance or take the person
to the hospital immediately.
2 Stroke Awareness
By NGEH CHEE YEN
ACCORDING to the World Stroke
Organization, 14.5 million people
will have a stroke this year and 5.5
million people will die as a result.
In total, 80 million people have
survived stroke worldwide.
With these alarming figures in
mind, the theme for this year’s
World Stroke Day, “Don’t be the
one”, highlights the dire need for
people of all ages to take steps to
reduce their risk of getting a stroke.
World Stroke Day (WSD) was
established in 2006, shortly after
the merging of two global
organisations to form the World
Stroke Organization. Dr Deidre de
Silva, co-chair of the World Stroke
Campaign and neurologist, says the
driving force of this campaign was
a recognition that addressing the
individual and global impact of
stroke needed action from
everyone – including the public.
Dr de Silva says, “The purpose of
WSD was to create a focal point in
the year to get the world talking
about stroke.”
She adds that WSD aims to raise
public understanding of two areas
where awareness could have a
significant impact. First,
recognition of the signs of stroke
and the need to seek urgent
medical attention, and second, the
opportunity to take preventative
action to minimise one’s chances of
experiencing a stroke.
Understanding the
condition
Senior consultant neurologist
and physician Datin Dr Zariah
Abdul Aziz says 80% of stroke
occurrences are ischaemic in
nature, while the remaining 20%
Don’t become a statistic
Knowing the risk factors for stroke is the first step of prevention. That means knowing your blood pressure, blood glucose
and cholesterol levels, watching what you eat and quit smoking.
result from intracerebral
haemorrhaging (bleeding in the
brain).
Ischaemic stroke occurs when
the artery nourishing the brain
with oxygen gets cut off either by a
clot originating from the heart or
other parts of blood vessels, or
because of fatty buildup within
the blood vessel itself. Sometimes,
this clogging is temporary and is
called a “mini” stroke or transient
ischaemic attack (TIA). TIAs are
treated with the same urgency
as they can lead to a full-blown
stroke.
On the other hand,
haemorrhagic stroke occurs
when there is a leaky or
ruptured blood vessels in the
brain. This is commonly related
to uncontrolled blood pressure.
Dr Zariah explains that the
No.1 stroke risk factor, both in
Malaysia and globally, is related
to high blood pressure. “Our
database shows that 75% of our
stroke-afflicted population were
hypertensive. Having diabetes
mellitus, coronary artery disease
and high cholesterol levels also
puts you at risk of getting stroke.”
Need for transformative
change
As risk factors for stroke
become more common globally,
especially in low- and middle-
income countries such as
Malaysia, it is crucial that
precautionary measures are
taken for the health of individuals
and the nation.
On an individual level, knowing
your risk factors for stroke is the
first step in preventing a stroke.
Then, by undergoing regular
THE STAR, TUESDAY 29 OCTOBER 2019
medical checkups, you can focus
on what you can control or change
to lower your stroke risk.
Dr Zariah advises, “Know your
blood pressure, check your blood
glucose and cholesterol levels, be
active and stop being a couch
potato, watch what you eat, watch
your weight, and please, stop
smoking.”
Dr de Silva agrees that 90% of all
stroke cases are associated with 10
main risk factors, which include
smoking, an unhealthy diet, lack of
exercise and excessive alcohol
consumption – factors we can all
manage to lower our individual
stroke risks.
However, she believes the
nation will see much faster
progress if the Government
commits to implementing public
health policies that support its
citizens in making changes to
reduce their risk of stroke and a
host of other diseases. Some
examples include stricter tobacco
control, the removal of trans fats in
foods and taxation of alcohol and
sugary beverages.
She says, “Improving universal
access to healthcare also plays a
role when it comes to diagnosis,
screening and treatment of clinical
risk factors for myriad diseases,
including high blood pressure,
diabetes, cholesterol and atrial
fibrillation, all of which are linked
to increased stroke risk. Preventing
stroke is a massive challenge and
we can prevent many occurrences
if we all work together.”
> TURN TO PAGE 4
THE STAR, TUESDAY 29 OCTOBER 2019 3
4 Stroke Awareness
Oat bran for a healthy heart
ACCORDING to the National Health and
Morbidity Survey 2015, non-communicable
diseases such as cardiovascular disease,
including heart attack and stroke, contribute
to an estimated 73% of deaths in Malaysia.
The biggest contributor is
hypercholesterolemia, which is a risk factor
for heart disease and stroke. It involves the
formation of plaque in the arteries that
results from high levels of blood cholesterol,
restricting oxygenated blood flow to the
brain and consequently causing stroke.
However, the risk factors for heart disease
and stroke can be managed by adopting a
healthy lifestyle, including:
l Adopting a high-fibre diet – Increase
your fibre intake by eating more fruits,
vegetables, whole grains and other cereal
products that are high in soluble fibre (such
as oat beta glucan)
l Practising a low-fat diet – Eat foods
that are low in saturated fat, trans fat and
cholesterol
l Limiting your salt (sodium) intake
l Being physically active – Engage in
physical activity for at least 30 minutes on
most days of the week
l Avoiding alcohol or drink in
moderation
l Avoiding smoking
Towards a healthier lifestyle
Products made from oat bran such as
Biogrow Oat BG22 Oat Bran Powder consist
of high amounts of soluble dietary fibre, also
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oat beta glucan, especially its cholesterol-
lowering effect and how it may reduce the
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have been extensively studied. In addition,
oat beta glucan helps prevent spikes and
dramatic dips in blood glucose levels.
Taking active measures to combat stroke
> FROM PAGE 2
Because Malaysian society comprises
people from different socio-economic
backgrounds, mindsets and cultural
beliefs, spreading awareness of stroke to
the whole community proves a challenge.
Dr Zariah says, “In my years of practice,
I have come across people who sought
alternative therapy rather than go to the
hospital when they experience stroke
symptoms. Where stroke is concerned,
these are the people who need to be
educated and informed.”
From a global standpoint, Dr de Silva
observes that many developing countries
and rural communities do not have the
resources to develop and distribute quality
Prevent and take action
Dr Deidre de Silva, co-chair of the
World Stroke Campaign, believes that
awareness of stroke needs to be
improved globally. She says, “It is the
largest cause of disability and the
second largest cause of death in the
world, but still, too few people are
aware of the signs of stroke or know it
that can be prevented.”
She asserts it is critically important to
address these gaps in awareness. Action
on prevention will mean that fewer
people face the trauma and long-term
challenges of stroke, while public
awareness of stroke symptoms and the
need for urgent medical care has the
potential to save lives and improve
recovery.
Creating stroke awareness is a
universal challenge. Senior consultant
neurologist and physician Datin Dr
Zariah Abdul Aziz says it is especially
worrying when research indicates that
older people have lower awareness of
stroke warning signs and risk factors
when this chunk of the population are
Biogrow Oat BG22 Oat Bran Powder consists of high amounts of soluble dietary fibre that can help reduce the risk of developing
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l Lab-tested and proven to be low on the
patient information. While mobile
technologies have the potential to improve
access, the costs may still be too high for
some. Lower levels of health literacy – and
literacy in general – may mean that
additional support is needed for
individuals to understand and act on the
information provided.
She also notes that if we want to
improve awareness, we need to match that
effort with efforts to improve access to
preventative treatment and acute care for
stroke. She says, “There is little point in
knowing that you are at higher risk of
stroke because of hypertension or atrial
fibrillation if you have no access to
treatment that can reduce that risk.
“Similarly, knowing the signs of stroke is
the ones particularly vulnerable to
stroke.
“Stroke symptoms that most people
are familiar with are those that cause
numbness and weakness, but there are
symptoms that can be subtle, such as
acute confusion, memory loss, changes
in vision or loss of balance. These
symptoms are perhaps unfamiliar to
most members of the public,” she says.
She notes that many also fail to realise
that deficits may be reversed if stroke
treatment is started early (within a 4.5-
hour window) using clot-busting or
thrombolytic therapy. Therefore, it is
important for everyone to recognise
stroke symptoms and act fast.
BEFAST is the acronym used for
symptom recognition:
l B stands for balance
l E refers to eyes or visual changes
l F is for facial asymmetry
l A is for arm (or any limb) weakness
l S is for slurred speech
l T is time (get to the hospital as
soon as possible)
Glycemic Index (<55)
l Suitable for people with diabetes
l Proven to lower cholesterol and regulate
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l Able to dissolve well in cold or
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cholesterol-lowering effects
only really helpful if you have access to
quality stroke care. This is why the World
Stroke Organization continues to call on
governments to deliver on three As –
awareness, access and action.”
An effort on all fronts
In her experience, Dr Zariah says the
medical community is seeing a generally
increasing trend of stroke cases in our
country. Therefore, to combat stroke, both
patients and doctors have important roles
to play.
Dr Zariah says, “We need to empower
patients to keep track of their own health.
Doctors have their own key performance
indicators (KPIs) to achieve the standard
In Bahasa Malaysia, the acronym
MASA (Bahasa Malaysia for time) can be
used instead:
l M is for muka (look for facial
drooping and asymmetry)
l A for angkat tangan (raise your arms
to look for weakness)
l S for suara (listen for slurred speech)
THE STAR, TUESDAY 29 OCTOBER 2019
Start your preventative strategy
today by adopting a healthy lifestyle
and incorporating oat beta glucan into
your diet.
This article is brought to you by Legosan
Company (Malaysia) Sdn Bhd.
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care for stroke. Rehabilitation measures
must also be in place during and after a
patient is discharged.
“However, patients and caregivers
should set their own KPIs to ensure
optimised control of their stroke risk
factors. They must be compliant with their
medication plans, undergo regular
checkups and follow-ups with their
doctors and watch their diets.”
When all parties work together to
prevent stroke and improve rehabilitation
processes, this will eventually lead to
lower incidences of stroke and better
recovery rates.
Therefore, don’t be the one. It is time
for all of us to start taking active measures
in the fight against stroke.
l A for ambulans (call emergency services
immediately)
Using these simple acronyms can make it
easier for the public to educate one another
on stroke symptoms, leading to faster
treatment times and better recovery for all
stroke patients in Malaysia.