Ischemic Stroke: A Growing Concern in Pakistan and How to Manage

Introduction

Ischemic stroke is the most common type of stroke, accounting for approximately 85% of all cases worldwide. In Pakistan, with its rapidly growing population and rising incidences of cardiovascular diseases, ischemic stroke is becoming a significant public health issue. Stroke is one of the leading causes of disability and mortality in the country, which is compounded by late diagnosis, inadequate access to healthcare facilities, and a lack of public awareness.

This article will focus on understanding ischemic stroke, its causes, and management protocols, including hospital care and treatment options available in Pakistan.

What Is an Ischemic Stroke?

An ischemic stroke occurs when a blood clot obstructs the blood flow to a part of the brain, depriving brain tissue of essential oxygen and nutrients. If blood flow is not restored quickly, brain cells begin to die, leading to neurological damage, disability, or death.

The primary risk factors include:

• Hypertension
• Diabetes
• Smoking
• Hyperlipidemia
• Sedentary lifestyle
• Obesity

Steps to Manage Ischemic Stroke

Timely intervention is critical for minimizing the long-term impact of a stroke. Here are the recommended steps in managing ischemic stroke:

1. Recognizing the Symptoms In Pakistan, awareness campaigns should emphasize recognizing stroke symptoms, which can be remembered by the acronym “FAST”:
   • Face drooping on one side
   • Arm weakness or numbness
   • Speech difficulty
   • Time to call emergency services
2. Immediate Action Time is critical. The faster a patient receives medical attention, the better their chance of survival and recovery. In urban areas of Pakistan, reaching a stroke-ready hospital can take time due to traffic or inadequate access to emergency services. Efforts should be made to reduce these barriers.
3. Pre-Hospital Care While awaiting an ambulance or transport, basic life support measures should be applied:
   • Ensure the patient is breathing and check their pulse.
   • If trained, perform cardiopulmonary resuscitation (CPR) if necessary.
   • Avoid giving food or water, as swallowing ability may be impaired.

Hospital Care Management

Once the patient arrives at the hospital, the first 60 minutes, often referred to as the “golden hour,” are crucial. Stroke-ready hospitals in Pakistan should have a stroke protocol that is followed rigorously:

1. Initial Assessment
   • CT or MRI: The primary step is to confirm whether the stroke is ischemic or hemorrhagic. A brain scan (CT or MRI) is performed to rule out bleeding in the brain.
   • Blood tests: These are done to assess clotting factors, glucose levels, and electrolytes.
   • Vital signs: Blood pressure, oxygen levels, and heart rate are closely monitored.
2. Acute Management
   • Thrombolytic Therapy: If the ischemic stroke is confirmed, thrombolytic agents like tissue plasminogen activator (tPA) can be administered within 4.5 hours of symptom onset. However, access to tPA in many regions of Pakistan is limited due to cost and availability.
   • Endovascular Thrombectomy: In cases where large artery occlusion is present, mechanical thrombectomy may be performed. This procedure is often available in tertiary care hospitals in major cities such as Islamabad, Lahore, and Karachi but remains limited in smaller cities and rural areas.
   • Antiplatelet and Anticoagulant Therapy: Patients may be started on aspirin or other antiplatelet agents to prevent further clot formation.
3. Monitoring and Secondary Prevention After the acute phase, patients are closely monitored for complications such as swelling of the brain, infections, or worsening of neurological symptoms. Long-term care strategies focus on preventing another stroke:
   • Blood pressure control: Aggressive management of hypertension is key.
   • Glucose management: Diabetes is closely monitored and treated.
   • Cholesterol management: Statins are prescribed to reduce cholesterol levels.
   • Lifestyle modifications: Smoking cessation, weight control, and regular exercise are strongly recommended.
   • Antithrombotic therapy: Long-term use of anticoagulants, such as warfarin, may be necessary for patients with atrial fibrillation or other clotting disorders.

Rehabilitation and Long-Term Care

Stroke rehabilitation is essential for improving outcomes and restoring as much function as possible. However, in Pakistan, the availability of structured rehabilitation programs remains limited, especially outside major urban centers.

1. Physical Therapy: Helps regain mobility and strength in affected limbs.
2. Occupational Therapy: Assists with daily living tasks.
3. Speech Therapy: For patients with speech and swallowing difficulties.
4. Psychological Support: Many stroke survivors suffer from depression and anxiety, requiring psychological counseling and community support.

Treatment Options Available in Pakistan

While the treatment for ischemic stroke aligns with international standards, several barriers exist in Pakistan, such as high costs, lack of infrastructure, and delays in treatment. However, the government and private sector are making efforts to improve stroke care:

1. Public Health Initiatives: Stroke awareness campaigns have been initiated in major cities to educate the public on recognizing symptoms and seeking timely medical care.
2. Advanced Treatment Centers: Tertiary care hospitals in major cities are equipped with state-of-the-art facilities for managing ischemic stroke. Examples include Aga Khan University Hospital in Karachi, Shifa International in Islamabad, and Mayo Hospital in Lahore.
3. Telemedicine: Telemedicine can potentially improve access to stroke care, especially in rural areas. Some hospitals in Pakistan are adopting telemedicine platforms to provide remote stroke consultations.

Conclusion

Ischemic stroke is a leading cause of disability and death in Pakistan. By increasing awareness, improving access to timely medical interventions, and enhancing hospital care, the burden of this disease can be significantly reduced. Prevention strategies, including managing risk factors like hypertension and diabetes, are key to lowering the incidence of stroke. Expanding access to rehabilitation services and promoting long-term care can improve the quality of life for stroke survivors.

The government, healthcare providers, and the public must work together to reduce the impact of ischemic stroke across the nation.