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Stroke

Stealth attack

Amanda Lyons

Stroke is an often underestimated but potentially devastating disease, and GPs are essential in its aftercare and possible prevention. 

Driving home with your wife after walking your puppy along the river. Few things sound quite so innocuous. But for 61-year-old Michael Shaw, it was during such a moment that his life changed irrevocably.

‘I just collapsed over the wheel,’ he told Good Practice. ‘I still don’t know to this day how we stopped the car.’

Michael had experienced a stroke.

Luckily, his wife Christina immediately recognised the signs of stroke and called paramedics, who got him to the hospital as quickly as possible.

‘I don’t remember anything from turning the corner in the car,’ Michael said. ‘I just remember waking up in hospital and seeing all these people looking at me, thinking, “What on earth’s going on here? Why are all these people looking at me?”’

Lazo Tancevski experienced a similarly cunning attack. His stroke at the age of 65 underlined the fact the disease often strikes without warning signs.

‘I’d seen my father the day before, he was perfectly fine,’ Lazo’s daughter Julie told Good Practice. ‘We had no idea this was about to happen.’

When people think about health risks, it could be said that stroke is often not at the top of their list. While this is somewhat understandable given its unexpected nature, alarming statistics paint a picture in which people should be more on guard.

‘Stroke kills more men than prostate cancer, more women than breast cancer and leaves thousands more with an ongoing disability,’1,2 Sharon McGowan, Chief Executive Officer of the Stroke Foundation, told Good Practice. ‘There is one stroke every nine minutes in Australia.’3

Stroke can also be an especially insidious disease when it comes to life after the fact. While Michael and Lazo were both able to access medical care in time to survive their strokes, the disease has had a lasting impact on the health of each man. Michael now walks with a limp and is unable to live the same active lifestyle he used to enjoy.

‘I can’t do a lot of things I used to without a second thought, mowing the grass and stuff like that,’ he said. ‘I just get so tired now that I can’t even contemplate it.’

Lazo was initially told he would be unable to walk again but, after months of occupational and physiotherapy, acupuncture and hydrotherapy, as well as an impressive amount of determination, he is walking with a stick and is able get up and down the stairs of his two-storey home with the aid of handrails.

‘He’s got some of his life back now and he can still enjoy his grandkids,’ Julie said.

‘I know of [stroke] patients who have got movement, but can’t have a conversation. So, no matter how hard it is, his life could have been a lot worse.’ 

A preventable disease

While stroke is a such a major and regular killer in Australia, the fact a majority of episodes are potentially avoidable may be a more shocking revelation.

‘More than 80% of strokes can be prevented,4 which is a staggering amount,’ McGowan said. ‘It is also treatable, but not enough Australians understand what a stroke is, that it can be prevented and it may be treated if people get to hospital quickly.’

Stroke is often caused by modifiable lifestyle factors, many of them the same as those on which doctors focus in order to prevent heart disease. This places stroke and its prevention firmly in the general practice wheelhouse.

‘The absolute cardiovascular risk guidelines recommend that everyone over the age of 45, or over 35 for Aboriginal and Torres Strait Islander peoples, has an integrated health check with the GP,’ McGowan said.

‘GPs can also educate their patients about atrial fibrillation [AF], an increasingly common irregular heartbeat. People with AF are more likely to have a stroke.

‘Finally, GPs also play a critical role in promoting lifestyle management programs, which help people quit smoking, lose weight, lower their cholesterol and live healthier lives.’

Michael makes sure to recommend these types of modifications to others as often as he can.

‘People need to know what their numbers are: blood pressure, waist measurement, pulse rate, cholesterol,’ he said. ‘I reckon people over 50 should have a medical every 12 months, because a lot can happen during that time.’

Michael proffered his own experience as a salient example – especially because his stroke was caused by genetic factors, rather than lifestyle, making his cholesterol levels one of the only potential indicators.

‘Within 12 months, my cholesterol had gone from five point something to eight. That’s how quickly it can creep up on you,’ he said.

Minor strokes and transient ischaemic attacks (TIAs) have also proven to be an important area of prevention for GPs. These occur when blood supply to the brain is interrupted for a shorter time than stroke, but with the same signs and symptoms. The signs may disappear in a few minutes and last no longer than 24 hours, but they should always be addressed as quickly as possible.

‘TIAs have quite a significant risk of going on to a completed stroke. Urgent medical management of TIAs and minor strokes is really important in preventing completed major strokes,’ Prof Parker Magin, GP and Director of the Research and Evaluation Unit for GP Synergy, told Good Practice.

‘Some people who have TIA symptoms don’t recognise them and don’t get to medical care. Of those who do get to medical care, the majority will go to a GP rather than to an accident and emergency department. Management of TIA is a major issue in stroke prevention and it’s a big issue for GPs.’

Prof Magin emphasised that, as with completed strokes, time is critical for the treatment of TIAs.

‘Strokes that occur after a TIA tend to happen pretty soon after the event; a fair proportion happen in the first two days after the TIA, so the risk is front-loaded,’ he said.

Prof Magin explained GPs can often administer treatment of TIA using drugs with which they are already familiar, such as aspirin, if specialist advice is not immediately available. That said, he would like to see all GPs have the support of rapid access to specialist opinion, as TIAs can be difficult to diagnose.

‘Telemedicine already has an established role in facilitating thrombolysis in stroke, and it’s not hard to imagine it could have a role in TIA,’ he said.

The importance of time in the event of a stroke cannot be overstated.

‘When a stroke occurs, brain cells die at a rate of 1.9 million a minute. Time-critical stroke treatments may be able to stop this damage,’ McGowan said.

Michael’s experience provides living proof of that frightening statistic.

‘I found out I lost 40% of my brain cells, and that’s with getting to hospital and being looked after within probably an hour of having the stroke,’ he said.

In light of this alarming fact, GPs can help to reduce risk by educating patients about stroke and how to react in the event they witness someone experience it. The ‘FAST’ (face, arms, speech, time) test provides an easy way for people to recognise and remember the signs of stroke.

‘The FAST campaign is the best means of patient education we have at the moment,’ Prof Magin said. ‘GPs have a role to be involved in patient education around FAST, whether it’s posters in the waiting room or some other means of getting that message across.’ 

Treatment after a stroke

As treatment and prevention of stroke have improved, so too have people’s chances of survival.

‘Stroke is no longer a death sentence for many,’ McGowan said. ‘It can be treated and it can be beaten due to major medical developments, including thrombolysis and endovascular clot retrieval.’

Many healthcare professionals become involved in a patient’s care after they have had a stroke. As the provider of day-to-day care, however, the GP often has the key role in terms of coordination and support.

‘A big part of the general practice care has really been as a support person and an interpreter, almost, between specialist and patient,’ Michael’s GP Dr Caroline Pattison told Good Practice.

‘It’s about being a negotiator and advocate for Michael. I can direct him to have ongoing rehabilitation, I can help him with his mental health, and spend a lot of time helping him to adjust to life after the stroke.

‘I also try to help him to understand as much as possible what’s actually happened, and why it’s happened.’

The Tancevski family’s long-time GP Dr Bernard Lee has played an integral part in Lazo’s ongoing post-stroke care.

‘Since Dad came home from the rehab facility, Dr Lee has pretty much called the shots,’ Julie said. ‘He helped organise ongoing physiotherapy and suggested cortisone injections, further investigation with his pain and more treatment in another rehab hospital.’

This type of role places GPs in an especially trusted position for the patient and their family, making them valuable supporters in dealing with life in the aftermath of a stroke.

‘It’s not uncommon [for patients] to have depression, anxiety or other psychological sequelae of a stroke,’ Prof Magin said. ‘The deficits that are involved for some patients make it particularly difficult to deal with depression. And often it’s the GP’s role to detect that depression, anxiety or other psychological distress and manage it.

‘That’s a big role and I look at it as part of the rehabilitation process.’

Michael, who had been extremely fit before his stroke, running 15–20km a day and playing touch football for the Queensland over-60 men’s team, has found it hard to adjust to a slower pace. Dr Pattison has been instrumental in helping him become accustomed to the new realities of life.

‘She has been my GP for 18 years and is someone with whom I feel completely at ease and comfortable,’ he said. ‘She was fantastic at explaining to me how hard it is to have something you love doing suddenly taken away from you. It has been difficult transition.

‘Dr Pattison has been a great support to me throughout all my medical issues and has been proactive in encouraging me to continue keeping myself physically fit. I believe this to be the major reason why I have come through some very serious health issues with great outcomes.’

Dr Pattison acknowledged that getting used to his new life has not been an easy process for Michael.

‘He has struggled over time, which is completely understandable,’ she said. ‘He oscillates between feeling like he’s lost an awful lot, which he has; his life is never going to be what it was before.

‘But he can also see what he’s still got, and how he can still have a productive and enjoyable life.’

Michael has managed to find other ways to be involved in the sports that he loves.

‘I now coach the National Touch Rugby Association Queensland Men’s over-65 representative touch football team. My team played New South Wales in State of Origin touch football at Coffs Harbour in June,’ he said. ‘So I am still involved.’

Julie confirmed that her father Lazo has also continued to improve, through a combination of his fitness before the stroke, help from healthcare professionals and his own considerable determination.

‘He’s gotten better and better,’ she said.

 

FAST signs of stroke

  • Face – Check their face. Has their mouth drooped?
  • Arms – Can they lift both arms?
  • Speech – Is their speech slurred? Do they understand you?
  • Time – Time is critical. If you see any of these symptoms, act fast and call 000.

 

References

  1. Australian Institute of Health and Welfare. Australia’s Health 2014. Cat no. AUS 178. Canberra: AIHW, 2014.
  2. Deloitte Access Economics. The economic impact of stroke in Australia, 2013. Canberra: Deloitte Access Economics, 2013.
  3. National Stroke Foundation. Stroke in Australia: No postcode untouched. Melbourne: National Stroke Foundation, 2014.
  4. O’Donnell M, Chin SL, Liu L, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): A case-control study. Lancet 2016;388:761–75.