That stroke-like attack is an emergency — Anyanwo, stroke expert

Dr Benjamin Anyanwu is a stroke and critical care specialist at the Regions Stroke and Neuroscience Hospital, located in Owerri, Imo State. In this interview with SADE OGUNTOLA, he says many people have “stroke-like attacks”, which are overlooked although it is a harbinger of an impending major stroke.

I S transient ischemic attack (TIA) the same as a stroke?

TIA, the shortened form of transient ischemic attack by simple definition is a stroke-like attack or a neurological deficit that resolves within 24 hours without any evidence of this attack in the brain when assessed using a CT or MRI scan. However, with a lot of new technology, we have also discovered that a lot of people assumed to be having TIA had a stroke even though their symptoms resolved completely within 24 hours. In such individuals, when a CT scan or brain MRI is done to take a picture of their brain, there will be signs that the person has had a stroke.

Now, TIA can be caused by many things, including problems with the blood vessels. It can also be caused by a complicated migraine or a seizure. However, stroke occurs only when there is complete cessation in the flow of blood in blood vessels within the brain, unlike seizures which occur due to problems with the electrical activities in the brain. When it is due to the blood vessel bursting open, it is termed a bleeding stroke or haemorrhagic stroke. But if there’s a blockage in the blood vessel, it is termed ischemic stroke.

TIA could indicate many things but it’s most likely a harbinger of stroke; it is an emergency. I tell my patients when they come and say it is just a simple TIA that “it is God knocking on your door telling you stroke is coming soon, do something about it”. It is just a medical emergency as a real stroke.

How soon will the stroke happen?

If you don’t try to find out what caused the TIA and address it, you are most likely going to have a major stroke within the first two weeks to 3 months. Of course, no one knows if the type of stroke that will result afterwards is that which will disable or kill the individual. Individuals that experience a TIA must go to see the doctor and I also teach doctors that when a patient comes with a TIA, they must find out why it occurred – whether it is because of a blood vessel problem like a stroke or other problems like migraine or seizures. Problems like migraine or seizures are easier to treat but stroke can be disabling and can kill the patient.

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At the doctor’s clinic, at least a CT scan or MRI of the brain needs to be done to determine whether it is a TIA or stroke. Second, they need to do some blood work, including checking on the kidney, blood sugar and blood pressure levels, as well as studies to look at the blood vessels entering their brain and those within to ensure that they are open. In addition, there may be a need for a referral to a cardiologist to look at the heart in more detail. But the most important thing is that at end of the visit, appropriate advice will be given on interventions to prevent a big stroke.

What are some of these interventions? For instance, where there is high blood sugar, which is suggestive of diabetes, they put the person on medication. If the cholesterol level is high, exercise, dietary change or medications may be recommended to reduce it.

As they say, high blood pressure is a silent killer. Therefore, some people might not know that they have high blood pressure. During the evaluation, if the doctor finds out that the individual has high blood pressure, they will be put on medication to control their blood pressure. So, the interventions that will be prescribed will be based on what they find and of course to reduce the chances of having a major stroke.

What are the common signs and symptoms suggestive of TIA?

The signs and symptoms of a TIA resemble those found early in a stroke and may include sudden onset of weakness, numbness or paralysis in the face, arm or leg, typically on one side of the body. Others include sudden headache, confusion, slurred or garbled speech or difficulty understanding others. These signs and symptoms will be transient.

Sometimes, the clinical presentation can vary widely. For instance, a person waking up in the morning, and noticing on one side of the body, that the hand or leg is weak and only becomes okay a few hours after flipping it. Or difficulty in holding a spoon or pencil, and such items are falling and only to regain the ability maybe 3 or 5 hours later. Some of these or similar transient difficulties in performing tasks could be a sign of TIA.

It could be that as you are driving or as you wake up, you suddenly find that you are not seeing very well from one corner of the eye. But before the next day, everything is completely normal and then wouldn’t go to the hospital. It could be a sign of TIA.

Sometimes it looks as if the person is about to fall or walk and staggering a little bit, like a drunkard but after some time, they are fine and are back to business, it could be a sign of TIA. These are all the signs that could suggest they are having a TIA.

How can people with TIA be helped?

TIA is a harbinger or a warning sign of a stroke. It is like armed robbers are coming to your house and they shoot outside the gate into the air and you do nothing. You cannot remain there. That’s what happens with TIA when you do nothing. A major disabling stroke may happen. The chances of dying from a stroke in Nigeria is unacceptably very high, compared to the rest of the world. It is the number one cause of disability in adults, too. Helping people with TIA stem the burden of stroke is the reason members of the African Stroke Organisation gathered in Ibadan to develop a “roadmap for stroke care in Africa”.

Nigeria has lost a lot of manpower to stroke. Therefore, we need to find a way to reduce the burden of stroke. And in this case, find a way to reduce the burden of TIA because we know that it is going to lead us to a stroke. So, we have to educate the public to understand what TIA is, know that it is dangerous, and know what to do.

The government needs to set up programmes to be able to attend to these people. Therefore, when they go to emergency rooms, they should be attended to.  One of the things that we’re doing here today is to encourage hospitals, including private hospitals, to build stroke teams. These are people who respond to strokes and are skilled in the treatment of patients with stroke.

So, when these people come to the hospital, like we have in America, they were asked simple questions that help the clinician determine if they are having a stroke and therefore get them help very quickly. Those in the stroke team are now the ones going to figure out whether it is a TIA or stroke and send them for appropriate treatment.

Politics is central to so many things; how can we ensure politicians buy into improved quality care for stroke management?

It starts with understanding who a politician in Nigeria is; a politician in Nigeria is always rich and influential and what counts to them is what would affect their ability to retain their positions. What will affect their ability to retain their position? It is people’s votes. If we have some major determinants for public and private hospitals to work, including those to treat stroke, what will happen is that individuals will begin to patronise such hospitals.

Now, if in a state, there is no such state-of-the-art hospital that meets the quality to treat stroke and now people within the state are going to access stroke care in another state, then people will start asking and demanding from the politicians in the area for such facilities. The politicians will react because they also want to keep their jobs. That’s how it happens.

But for that to happen, we, first of all, have to develop those quality matrixes and disseminate the information to the public so that the public will know the hospitals that can offer quality stroke care. And that’s what the African Stroke Organisation is working on to ensure that a roadmap is drawn on how we can change stroke care and TIA in Africa.

By designating hospitals that meet the quality matrixes both in the public and private as hospitals, like those to treat stroke, will such stand the test of time considering the sorry state of some federal health centres?

The question is who was monitoring these designated centres; that is the problem. That is where the African Stoke Organisation comes in – for monitoring and evaluation. Such designated stroke hospitals, after some form of certification, will also be expected to report every year how many stroke patients they treat and how they were treated, including those that died. It is when we push everything to the government that we have problems.  That is the difference between what we did before, where the government just gave money to all these places designated as the centre of excellence for such things as open-heart surgery and other specialised care, without anybody monitoring them continuously or serious questions asked about their outcome.

How do we get the buy-in of the private sector to move stroke care forward?

The private sector has a role to play and the part where we get it wrong is that once you bring the private sector in, they are only there for the money and to take over the hospital. That is not the truth. In some cases, it could be taken over, but in some cases, it could be a partnership. But nothing stops a private sector participant from partnering to educate the public, and to build the capacity of doctors, nurses and other health workers who run the stroke unit. Nobody is making money from this. The private sector can also go on to help run the stroke unit in government hospitals. At the end of the day, our patients will win.

I’ll tell you the hospital where I used to work in the USA, our endoscopy and cardiac intervention units were not owned by the hospital. It is the private group that put it there. You would never know because it serves everybody and everybody gets treatment. That’s where the private sector also comes in. It is vibrant in America.