Saturday 9 March 2019

2019 Stroke among war veterans


                                                  Eduardo C.Gerding

This article is based on various Argentine statistics (National Register of Stroke (Arenas 2018), British (State of the Nation, Stroke Statistics) and the Veterans Administration of the USA among others.

The Argentine war veterans´conscripts currently have an average age of 55 years. Argentine female war veterans range between 60/62 years. Many British war veterans were 19 years old at the time of the conflict. (Lucy Beck-Remembering the victims of the Falklands war-April 2007)

This is of an utmost importance  because the risk of suffering a stroke is doubled for each decade after age 55. 18
In the next 20 years (between now and 2035) episodes of first-time stroke in people over 45 years old will increase by 59% .15

 In 2016, stroke caused twice as many deaths as breast cancer. 15
In addition, people in deprived areas are usually more likely to suffer from severe stroke. 15

According to a study by Dr. Marlene Grenon of the University of California, San Francisco (USA) war veterans with PTSD  have their blood vessels damaged which would predispose them to heart attacks and stroke. These vessels dilate less than normal. It is possible that stress damages the internal lining of the vessels through hormonal changes or inflammation.17. This was also corroborated in a longitudinal study conducted by Mu-Hong Chen et al and published by The British Journal of Psychiatry.7

Currently, every 4 minutes an Argentine suffers a stroke. Out of this number, 18 thousand deaths per year are released.4
The profile of the Argentine who really has substantial  knowledge about stroke is: Adults over 50, university students, married and residents in the City of Buenos Aires. 9

Types of Strokes

A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts. Brain cells in the immediate area begin to die because they stop getting the oxygen and nutrients they need to function.18
·        A blockage of a blood vessel in the brain or neck, called an ischemic stroke, is the most frequent cause of stroke (85%) and is responsible for about 80 percent of strokes.
·       When a weakened blood vessel ruptures and spills into brain tissue, it’s called a hemorrhagic stroke (15%). The most common cause for the rupture is uncontrolled hypertension or high blood pressure.

·        Around 1 in 10 patients who have a haemorrhagic stroke die before reaching hospital. 15

·        Strokes caused by a bleed (haemorrhagic) are more common in children than in adults.


·        A TIA is a type of stroke where the stroke symptoms last only a few minutes and generally stop. A TIA is a serious medical event that needs prompt medical attention.
·        A transient ischemic attack is considered a “warning stroke.” Full strokes often happen after a mini-stroke. About half of all strokes that occur after a TIA, happen within 24 hours.15
·        1 in 12 people (8%) will have a full stroke within a week of having a TIA. 15

A study carried out in the Argentine Ramos Mejia hospital and published in the
 prestigious medical journal Stroke reveals that, in the population that goes to
 the Ramos Mejía hospital, 30% of patients with stroke present hemorrhages, 
when in the world such percentage does not exceed 20 percent.
This study also indicates that the subtype of stroke caused by the so-called 
penetrating vessel disease (the accident occurs in the smaller arteries that
 supply the brain) accounts for 42% of the cases, when in  Europe and the
 United States is about 20% 8

Mortality worldwide  15

·        Stroke is the second leading cause of death worldwide.
·        Every two seconds, someone in the world will have a stroke.
·        In 2016, there were almost 14 million incidences of first-time
  strokes worldwide.
·        Stroke causes around 6.2 million deaths each year, taking a life
  every five seconds.
·        Worldwide stroke-related illness, disability and early death is set
  to double in the next 15 years (by 2035).
·        Almost 1 in 8 (12%) deaths worldwide are caused by stroke.
·        1 in 3 Argentines do not know that stroke is a pathology with 
high mortality. 9


·        According to the National Institutes of Health, each year nearly 800,000 Americans experience a new or recurrent stroke. Approximately 610,000 of these are first attacks, and 185,000 are recurrent attacks. Stroke is the fifth leading cause of death in the US, killing nearly 133,000 people a year and accounting for one of every 19 deaths. Nearly three-quarters of all strokes occur in people over the age of 65 and the risk of having stroke more than doubles each decade after the age of 55. 18

UK 15
·        There are more than 100,000 strokes in the UK each year.
·        That is around one stroke every five minutes in the UK.
·        Between 1990 and 2010 the incidence of strokes fell by almost
          a quarter.
·        Around 1 in 6 men will have a stroke in their life.
·        Around 1 in 5 women will have a stroke in their life.
·        The rate of first time strokes in people aged 45 and over is
          expected to increase by 59% in the next 20 years (between now
          and 2035).
·        In the same period, it’s estimated that the number of stroke
          survivors, aged 45 and over, living in the UK is expected to rise
         by 123%.


·        Stroke is the fourth biggest killer in the UK.
·        Stroke is the fourth single leading cause of death in England
         and Wales, and the third biggest cause of death in Scotland and
        Northern Ireland.
·        In 2016, almost 38,000 people died of stroke in the UK. That’s a
         life lost every 13 minutes.
·        1 in 14 deaths are caused by stroke in the UK. This is equivalent
         to 6% of all deaths in men, and 7% of all deaths in women.
·        1 in 8 strokes are fatal within the first 30 days.
·        Stroke death rates in the UK fell by almost half in the period from
         1990 to 2010.
·        In 2016, stroke caused almost twice as many deaths in women
         as breast cancer.
·        In men, stroke causes 5,000 more deaths a year than prostate cancer

Social deprivation

·        In general, people from more deprived areas have an increased
          risk of stroke.
·        A study in Norfolk found that people living with the greatest
           levels of social deprivation were two and half times more likely
          to have a stroke.
·        In general, people from more deprived areas are likely to
           experience more severe strokes.
·        A study using data from England, Wales and Northern Ireland
          found that people with the greatest levels of social deprivation
          experienced strokes approximately five years earlier in their
         lives, compared to the least deprived.
·        On average, people from low and middle income countries
         have strokes at a younger age than people from higher income

Modifiable risk factors

High Blood Presure

·        Having high blood pressure can triple your risk of stroke and
 heart disease.
·        High blood pressure is a contributing factor in around half of
  strokes in England, Wales and Northern Ireland.
·        There are 9.5 million people in the UK diagnosed as having high
  blood pressure, also known as hypertension. That is 1 in 7
   people in the UK.
·        The number of people diagnosed as having high blood pressure
  has consistently increased since 2005.
·        For every 10 people diagnosed with high blood pressure, seven
  remain undiagnosed and untreated.
·        In England, 5.5 million people are living undiagnosed with high
blood pressure.
·        Treatment for high blood pressure significantly reduces the
  risk of stroke, heart attack and heart failure. Every 10 mmHg
  reduction in systolic blood pressure reduces the risk of stroke
   and heart attack by 20%.

High blood Cholesterol

·        As a general guide, ‘bad’ cholesterol (LDL) levels should be:
                   3mmol/L or less for healthy adults
                   2mmol/L or less for those at high risk.
·        Statins are medicines which limit the production of ‘bad’
 cholesterol in the liver. The use of statins in people at high risk
 of cardiovascular events reduces the risk of stroke by 25%.
·        Reducing cholesterol by 1mmol/L reduces stroke risk by 21%.
·        Daily consumption of oats and barley can help maintain healthy
  levels of cholesterol.
·        Consumption of ‘good fats’ (monosaturated and polysaturated)
  like the ones found in nuts, avocados, and fish contributes to
   healthy levels of cholesterol. Consumption of saturated fats,
   like the ones found in meat and dairy, can increase cholesterol
   levels in the blood. Foods containing trans fats, such as crisps,
    cookies, and fried foods, have the most impact on cholesterol

Diabetes type 2

·        Type 2 diabetes almost doubles the risk of stroke within the first
  five years of diagnosis, and is a contributing factor in up to 1 in 5
   strokes in England, Wales and Northern Ireland.
·        There are 3.6 million adults diagnosed as diabetic in the UK,
  which is about 5% of the population.
·        9 out of 10 (90%) diabetes cases are type 2.
·        It is estimated there are another one million people with
  undiagnosed diabetes in the UK. This includes both types of
·        Obese people are 80 times more likely to develop diabetes than
  a healthy person with a BMI under .
·        In Argentina, 22% of patients with stroke are diabetic and the
 disease extends to 12% of the population.4


·        Obese people are 80 times more likely to develop diabetes than healthy people with a low BMI.
·        35.4% of Argentines are overweight and 18% suffer from obesity. 4


·        Smoking doubles the risk of dying from a stroke.
·        Tobacco smoke contains over 7,000 toxic chemicals, including
  carbon monoxide, formaldehyde, arsenic and cyanide. These
   chemicals are transferred from your lungs into your blood
   stream, changing and damaging cells all around your body, and
    increasing your risk of stroke.
·        Cigarette smoke can affect cholesterol levels, reducing the
  amount of ‘good’ cholesterol (HDL) in your blood stream and
  increasing the amount of ‘bad’ cholesterol (LDL).
·        When you inhale cigarette smoke, carbon monoxide and
  nicotine enter your bloodstream. The carbon monoxide
  reduces the amount of oxygen in your blood. Nicotine
   makes your heart beat faster and raises your blood pressure,
   increasing your risk of a stroke. Smoking can also trigger an
   episode of atrial fibrillation.
·        The chemicals in cigarette smoke also make platelets in your
  blood more likely to stick together. This increases the chance of
   a clot forming.
·        1 in 6 (16%) people in the UK are active smokers104 105 106 107,
  however the number of smokers is rapidly declining.
·        There are about 1.9 million visits to UK hospitals a year for
  conditions related to smoking.99 100 101 102
·        Shisha smoking carries the same risks as cigarette smoking.
·        A study conducted in Sweden on healthy non-smokers showed
  that 30 minutes of e-cigarette smoking increased heart rate,
  arterial stiffness, and blood pressure. All of these are factors
  that can contribute to an increased risk of stroke.
Despite this, Public Health England has been encouraging
  switching from tobacco to e-cigarettes if people find it
  difficult to quit because other studies have found them to be
  less toxic.
·        27% of Argentines are smokers and 40% are exposed to cigarette smoke. 4


·        Regular consumption of large amounts of alcohol greatly
  increases the risk of having a stroke, as it can lead to high
   blood pressure, diabetes, obesity, and trigger atrial fibrillation.
·        Drinking too much alcohol can also damage the liver and
   stop it from making substances that help your blood to clot,
   increasing your risk of having a stroke caused by bleed.
·        When asked, 1 in 3 adults in the UK reported drinking more
  than recommended at least once a week. Drinking over the
  recommended weekly amount of alcohol was most common
  among adults aged 55 to 64
·        One study found that heavy drinking (considered as more than
  two drinks per day) was found to shorten the time to stroke by
  five years.
·        Another study found that drinking more than five drinks a day
  increases your risk of stroke by 1.6 times.


Drug use

·        Each type of illicit drug has a different effect on the brain and
  circulatory system, but all can have severe health repercussions
  which can cause both ischaemic and haemorrhagic strokes in
  young healthy people.
·        A recent study found that 6 out of 10 young adults were actively
  engaged in smoking, alcohol abuse or illegal drug use at the
  time of their stroke.
·        Marijuana use increases your risk of stroke. Some studies
  estimated it can increase your risk of heart disease by 30%.
·        Cocaine increases the risk of stroke in the 24 hours following
  use, as it can cause your blood to thicken and can drastically
  increase your blood pressure.
·        A study from 2012 found that 1 in 5 (20%) of those under 45
 who had a stroke had used illegal drugs.

The sedentary lifestyle

The sedentary lifestyle has increased notably in recent years.
 The usual aerobic exercise in the third age can diminish until 25%
 the risk of suffering an attack. 4

Non modifiable risk factors


·        In England, Wales and Northern Ireland the average age for
  someone to have a stroke is 72 for men and 78 for women.
·        In Scotland the average age to have a stroke is 71 for men and
  75 for women
·        Around one in four strokes happen to people of working age.
·        People are having strokes earlier in their lives.
·        In 1990 only a quarter of all strokes occurred in people aged
  20-64. In 2010, a third of all strokes happened to people in that
  age group.
·        People are most likely to have a stroke after the age of 55.


·        White people in the UK are more likely to have atrial fibrillation
  (a type of irregular heart beat), smoke and drink alcohol than
  other ethnicities.These are all factors that increase the risk
  of stroke.
·        Black people are almost twice as likely to have a stroke than
  white people.
·        On average, people of black African, black Caribbean and South
 Asian descent in the UK have strokes earlier on in their lives.36
·        Studies suggest that black and South Asian people tend to have
  strokes 10 years earlier than white people.
·        Research suggests this is because black people are more likely
  to have high blood pressure and diabetes than white people,
 both of which are stroke risk factors.
·        In the last 20 years, stroke incidence in London has decreased
  by 40% for white people, but has not decreased for black
·        Black people are also more likely to have sickle cell disease,
  which increases the risk of a stroke.
·        South Asian people are almost twice as likely to develop
 diabetes (a risk factor for stroke) as the rest of the UK
 population, and are likely to develop it at an earlier age.


·        Men are at a higher risk of having a stroke at a younger age than
  women. This is generally due to a combination of behavioural
  and medical factors.
·        Diabetes and heart disease, both risk factors for stroke, are
  more common amongst men.
·        In addition, on average, men consume more alcohol and are
 more likely to smoke.
·        More women than men die of stroke. This is because
 women tend to live longer than men, and the risk of stroke
  increases with age.
·        Women can experience increased stroke risk due to hormone
  changes, contraception, pregnancy and childbirth.
·        Hormonal contraception with oestrogen can increase the
  chance of blood clots. Studies have reported that taking the pill
  can increase your risk of heart attack and stroke by 1.6 times.28
   Although for healthy women who don’t have other risk factors,
   the risk is still extremely low.
·        Hormone replacement therapy (HRT) can slightly increase your
   risk of stroke. For every 1,000 women taking HRT, an extra six
   will have a stroke and an extra eight will develop a blood clot.29
·        Although the overall risk of younger women having a stroke is
  very low, pregnancy can increase your risk of stroke. In 100,000
   pregnancies, 30 soon-to-be mothers will have a pregnancyrelated
·        Women tend to experience worse psychological and physical
  repercussions from stroke. This may be because women tend
   to have strokes when they’re older and often living alone.

Atrial fibrillation

·        Atrial fibrillation (AF) is a heart condition that causes an
  irregular and often abnormally fast heartbeat.
·        There are about 1.2 million people with AF in the UK.
  It is estimated there could be another half a million people in
  the UK with undiagnosed AF.
·        People with AF are five times more likely to have a stroke.
·        AF is a contributing factor in up to 1 in 5 strokes in the UK.
·        Anticoagulant drugs, such as warfarin, can be given to people
  with AF to reduce the risk of blood clots forming.
·        Anticoagulants continue to be under-prescribed. In the UK,
  around a quarter of eligible patients with AF do not receive
  anticoagulant drugs. But, this is improving year on year. 81
·        Some studies suggest the reason for this is that people tend to
  be prescribed antiplatelet medicines such as aspirin, even though
   they have been found to be less effective in stroke prevention.
·        It is estimated that if AF were adequately treated, around 7,000
  strokes would be prevented and over 2,000 lives saved every
   year in England alone.
·        Anticoagulants have also been found to lower the risk of
 dementia by 26% in patients with AF.
·        Only half of all of the patients with known AF in England, Wales
  and Northern Ireland are on anticoagulant medication when
   they go to hospital with a stroke. In Scotland, less than one
   third of patients with AF are on anticoagulation when they are
    admitted with a stroke.
·        Almost all (97%) of the stroke survivors in England, Wales
  and Northern Ireland with AF are prescribed anticoagulant
   medication when they’re discharged from hospital. In Scotland,
    only 68% of stroke survivors

A hole in the heart (PFO)

·        A patent foramen ovale (PFO or hole in the heart) is an opening
 between the left and right upper chambers of the heart. This
  hole normally closes at birth, but in as many as one in four
  people it remains open.
·        A PFO is thought to increase stroke risk because it will allow a
 clot to travel through the heart and to the brain.
 However, it’s unclear whether a PFO increases the risk of
  stroke, as some studies have shown that someone with a PFO
  is at no higher risk of stroke than someone who does not have a

Sickle cell disease

·        Sickle cell disease is a disorder which affects the red blood cells.
 These are usually round and flexible to enable them to carry
 oxygen around the body.
·        In people with sickle cell disease, red blood cells become
  crescent (or sickle) shaped. This can lead them to clog up
  blood vessels, causing health problems and increasing the risk
  of stroke.
·        Sickle cell disease mainly affects people of African,
 African-Caribbean, South Asian and Mediterranean heritage.
·        A quarter of people with sickle cell disease will have a stroke
 before the age of 45.
·        Children with sickle cell disease are over 300 times more likely
 to have a stroke than children without it.


·        Stroke survivors are at greatest risk of having another stroke in
          the first 30 days following a stroke.
·        Around 1 in 4 stroke survivors will experience another stroke
           within five years.
·        In England, Wales and Northern Ireland, over a quarter of people
          who have a stroke have had a previous stroke or TIA.
·        In England, Wales and Northern Ireland 1 in 17 (6%) stroke
          patients have another stroke while still in hospital.
·        In Scotland the number of people having TIAs has increased by
           17% in the last decade (since 2006).


Across the globe, more people are surviving stroke than ever
    There are over 1.2 million stroke survivors in the UK.
Scotland has the largest percentage of the population who
     are stroke survivors, and the highest mortality rate of the UK
·        The percentage of people in Scotland surviving for more than
  30 days after their stroke has slightly improved in the last
  decade, from 81% in 2007, to 85% in 2016.
·        More than 8 out of 10 stroke patients in England, Wales and
 Northern Ireland survive their stay in hospital, and two thirds of
 stroke survivors are able to return home and live independently
 or with support in their own homes.
·        9 out of 10 stroke survivors in England, Wales and Northern
 Ireland have returned to living at home six months after their
·        A quarter of all stroke survivors in England, Wales and Northern
  Ireland live alone after their stroke.
·        Almost half (45%) of stroke survivors feel abandoned after they
 leave hospital.

 Symptoms of a stroke 18

Some of the effects of stroke are:

·        Weakness in arms and legs
·        Problems with speaking, understanding, reading and writing
·        Swallowing problems
·        Vision problems
·        Losing bowel and bladder control
·        Pain and headaches
·        Fatigue , tiredness that does not go away with rest
·        Problems with memory and thinking
·        Eyesight problems
·        Numb skin, pins and needles.

Living with the physical impact of stroke 15

·        In a survey of over 1,000 stroke survivors conducted in 2015,
  4 in 10 people told us the physical impact of stroke was the
  hardest to deal with.
·        It is estimated that 60% of stroke survivors have vision
 problems immediately after their stroke. This reduces to about
 20% by three months after stroke.
·        Limb weakness is common after stroke
·        More than three quarters of stroke survivors report arm
  weakness, which can make it difficult for people to carry out
  daily living activities, such as washing and dressing.
·        Almost three quarters of stroke survivors report leg
 weakness, which can make walking and balancing more
·        Today, around one million stroke survivors across England,
  Wales and Northern Ireland require further care after being
  discharged from hospital.
·        In Scotland, more than half of stroke survivors need the
  assistance of another person to be able to walk.
·        Loss of bladder and bowel control (incontinence) is a common
  problem for stroke survivors. Around half of stroke survivors                 
  experience problems with bladder control.

·        Around a third of stroke survivors experience some level of
  aphasia, which affects their ability to speak, write, read or
  understand what others say.
  Aphasia is a language and communication disorder caused by
  damage to the language centres of the brain.
·        Stroke can also cause dysarthria, a weakness in the facial
 muscles which makes it difficult to speak clearly; and apraxia,
  a condition which makes it difficult to move or coordinate the
  face, mouth and throat muscles needed for speech.
·        Communication problems tend to improve quite quickly, usually
 within the first three to six months.
 However, between 30-40% of those affected will remain
 severely affected in the long term.
·        Around half of all stroke survivors in England, Wales and
 Northern Ireland require speech and language therapy after a
  stroke. However, only half of the people who need this therapy
   to aid their recovery actually receive it. This means that more than half of the     stroke survivors who need  help to communicate have to go without the    support they need.
·        A recent study found that 44% of stroke survivors experiences severe anxiety as a result of their aphasia.

Swallowing and breathing

·        Swallowing is a complicated task, which needs your brain to
  coordinate lots of different muscles. If a stroke damages the parts
  of your brain needed to do this, it can affect your ability to         
 Doctors use the term dysphagia to describe problems with
·        If you can’t swallow safely then food and drink may be getting
 into your airways and lungs. This is called aspiration. It can lead
 to infections and pneumonia, so it’s extremely important that
  swallowing problems are identified early.
·        Everyone who has a stroke should be checked to see whether they
  can swallow safely. This should happen within the first few hours
  after arriving at the hospital.
·        Around half of all stroke survivors have problems swallowing.
 This can make eating and drinking difficult. Delays in hospital
  assessments for swallowing are associated with a higher risk of
·        In England, Wales and Northern Ireland, 1 in 3 patients are
  not assessed to see if they can swallow properly within the
   recommended time window of four hours. 1 in 5 patients is not
   assessed at all.

 ·        In Scotland, 1 in 3 patients is not assessed to see if they can
       swallow properly, however this is improving every year.
·        In England, Wales and Northern Ireland, 8% of stroke survivors
 contract pneumonia within seven days of being discharged from        

Emotional impact
·        Emotionalism, or difficulty controlling emotional responses
  such as crying or laughing, is common after stroke.
·        Emotionalism affects about 1 in 5 stroke survivors in the first six
  months after stroke.
·        In a 2015 Stroke Association survey of over 1000 stroke
  survivors, 1 in 5 told us the emotional impact of stroke was hard
  to deal with.
·        42% of people report a negative change in their relationship
 with their partner after a stroke.
·        A quarter of people report that stroke had a negative impact ontheir family.

Cognitive impairment and psychological impact of stroke

·        Fatigue is common after a stroke: half of stroke survivors
  report fatigue. It can affect many aspects of daily life. It can be a
   serious problem for people returning to work and is associated
   with depression after stroke.
·        Stroke can affect your mood, and cause changes in the way you
  feel. Around a third of stroke survivors experience depression
  after their stroke.
·        Over half of stroke survivors experience symptoms of anxiety
  at some point within the ten years of their stroke.
·        Cognitive impairments include problems with thinking,
  memory, concentration and practice such as basic arithmetic,
   and can make simple tasks very difficult.

 ·        Some stroke survivors experience apraxia (sometimes called
        dyspraxia), which affects their ability to plan tasks and order
        the steps they need to take in their heads, making it difficult to
        complete daily tasks such as making a cup of tea.
·        Neglect is another cognitive impairment which can occur after
  stroke. Neglect occurs when your brain has difficulty processing
   information from your body. If your stroke has caused loss of
   movement in one arm or leg it might feel like this is not part of    
   your body.

Vascular dementia

·        Cognitive impairments after a stroke may improve in some
 patients, but in others it may worsen and develop into dementia.
·        Vascular dementia has similar symptoms to other types of
  dementia, including difficulties with understanding and        
   responding to things quickly; struggling to remember things; and   
   problems  concentrating. The main difference is that vascular   
   dementia is caused by a loss of blood supply to the brain, which
   often happens over a long period of time.
·        Vascular dementia can happen through a single stroke or a series
  of strokes, and is linked to small vessel disease. Small vessel
  disease is caused by the narrowing of small blood vessels deep
   inside the brain. At the moment relatively little is known about    
   how to diagnose, treat or prevent vascular dementia.
·        20% of all people with dementia in the UK have vascular
  dementia. Another 10% of people are diagnosed with mixed
   dementia, which could consist of a combination of dementia
   types like Alzheimer’s disease and vascular dementia.
·        It is estimated that around 7 out of 10 65-year-olds and almost
  all 90-year-olds show signs of small vessel disease in the
   brain. This is thought to be a contributing factor in 4 out of
   10 dementias.
·        Stroke and vascular dementia are both consequences of small
 vessel disease of the brain.
·        A recent study has found that up to 1 in 3 stroke survivors are at
 risk of developing [vascular] dementia within five years.
·        Three quarters (75%) of dementia cases in stroke survivors are
  thought to be caused by vascular dementia.
·        Vascular dementia is a condition strongly linked to stroke, and
  there is currently no proven treatment.
·        People live an average of five years after being diagnosed with
 vascular dementia.
·        People with vascular dementia are most likely to die from a stroke or a heart attack.

Important elements of diagnosis

·        Almost a third of people who went to hospital with a stroke in
 England, Wales and Northern Ireland in 2016–17 did not know
 what time their symptoms started.
·        An estimated 1.9 million neurons are lost every minute a stroke
  is untreated.
·        80% of people having a stroke in England, Wales and Northern
  Ireland arrived at hospital by ambulance.
·        In England, Wales and Northern Ireland, about half of patients
  who go to hospital while having a stroke receive a brain scan
   within an hour of arriving, and almost 9 out of 10 of stroke
   patients receive a brain scan within 12 hours.
·        In Scotland, 9 in 10 patients receive a brain scan within 24 hours
  of admission.
·        It takes an average of seven and half hours from the onset
  of symptoms to be admitted to a stroke unit across England,
  Wales, and Northern Ireland.
·        In Scotland, 8 out of 10 people are admitted to a stroke unit
  within 24 hours.
·        In Scotland, less than 70% of stroke patients receive the
  complete stroke care bundle (a group of intervention
   processes, which together can significantly improve the
   patient’s outcomes).

Transfer of the stroke patient
• The Brain Rescue Mobile Units represent an opportunity for patients
 suffering from this event. These are ambulances specially equipped with 
technology and professionals for the diagnosis and immediate treatment of
 stroke. Two recent studies of the Society of NeuroInterventional Surgery (SNS)
 of the United States show how these mobile devices significantly reduce the 
time that elapses from the time the LCA is unleashed until the treatment is
 implemented and that would improve the survival rates and the probability 
of recovery of the patient. 2
• The "downtimes" that occur throughout care were also reduced compared to 
control groups, accelerating the entrance to the health center from 31 to 19
 minutes; from admission to computed tomography, from 32 to 12 minutes,
 and from tomography to intra-arterial intervention, from 165 to 82 minutes. 2
• If the diagnosis of ischemic stroke is confirmed, treatment begins in the same
 ambulance, by administering a thrombolytic drug.

Stroke Unit

·        A stroke unit is a specialist hospital ward where stroke patients
  are cared for by a team of professionals who specialise in stroke
·        Stroke patients who are cared for on stroke units are more
 likely to be alive and living independently one year after having a
 stroke than those cared for on other wards.110
·        In England, Wales and Northern Ireland, 9 out of 10 (96%) stroke
  patients are cared for on a stroke unit.
  In 2016, 82% of patients in Scotland were cared for at a stroke
   unit; this is a significant improvement from 2015, when only
   78% of patients were cared for on a stroke unit.
·        According to NICE (National Institute for Health and Clinical
  Excellence), 1 in 20 strokes in Wales, England and Northern
  Ireland are treated in hospital facilities which are not adequate.
·        Stroke care is improving in England, Wales and Northern Ireland.

·        Four years ago, 20% of stroke patients were treated in general
  wards rather than a stroke unit. Now, 17% of patients are
  treated in facilities other than stroke units.
·        4 out of 10 hospitals in England, Wales and Northern Ireland
  have a shortage of stroke consultants.
·        In England, Wales and Northern Ireland, only 51% of hospitals
 have adequate.

Hyper-acute stroke units (HASU)

·        HASUs are a type of stroke unit that exist in some hospitals
  in the UK.
·        HASUs bring experts and specialist equipment for the
  emergency treatment of stroke under one roof to provide
  world-class treatment, 24 hours a day, seven days a week.
·        This model was first adopted in London and then in Greater
·        In London, the HASU model saves about 96 extra lives a year;
  and in Greater Manchester, they have reduced the length of
  hospital stays by two days. Other areas across the UK are
  centralising their acute stroke care and introducing the HASU

Clot-busting treatment 6,15

·        Thrombolysis is a treatment that uses drugs to break down and
  disperse a clot for people who have had an ischaemic stroke. It is
  licensed to be used up to four and a half hours from the onset of
  stroke symptoms.
·        In 2016-2017, more than half of the patients who received the
  clot-busting treatment, thrombolysis, in the UK received it
  within an hour of arriving in hospital. If the time when symptoms
   started is unknown, or it is more than four and a half hours after
   symptoms started, the treatment cannot be provided.
·        Clot-busting drugs increase the chance of a good outcome by
·        12% of stroke cases in England, Wales and Northern Ireland are
 eligible to receive thrombolysis5, equivalent to around 10,000
 people. Of these, 85% received thrombolysis treatment in 2016.
·        In Scotland eight years ago, only 3% of all stroke patients
  received thrombolysis; today 10% receive it. Half of these
  received thrombolysis within one hour of their arrival in hospital.
·        6 out of 10 patients in England, Wales and Northern Ireland
  arrived at hospital after the four and a half hour time window,
   or had a stroke during their sleep so the time could not be
·        The average door-to-needle time (the time gap between
  the patient’s arrival at the emergency department and being
  administered anaesthetic) in the UK is around 55 minutes.
·        The number of patients who survive a stroke and are able to
  return to their lives without any added assistance increases by
  2% when thrombolysis is given within three hours.

Mechanical clot retrieval

·        Thrombectomy is a procedure used to mechanically pull a blood
  clot out of the brain. It can be performed up to six hours after a
·        Although a relatively small number of patients are eligible
  for thrombectomy, it is shown to provide significant benefits
  and NICE guidance says it is safe and effective.
·        There are a few centres where thrombectomy is available
 in the UK, but there are currently not enough trained
 professionals for the service to be rolled out across the UK:
·        Almost a third of hospitals have no access to
 thrombectomy either on site or by referring to another
·        In order to have full UK coverage 150 trained consultants
 are required. However, in 2016 only 83 consultants
 across England, Wales, and Northern Ireland could
 undertake the procedure.”
·        The adoption of thrombectomy treatment has been slow in
  the UK compared to Germany, France and the US. However
  over 400 patients received thrombectomy in England, Wales
  and Northern Ireland in 2015–16.
·        In Scotland, fewer than 10 thrombectomies took place 2015
  and 2016.
·        Clot retrieval treatment increases the chance of a good
  outcome by more than 50%.

·        Other major advances are represented in the second generation of devices for the extraction of thrombi.like intracranial stents. 1,4

                              (Infobae-July 2nd, 2016)



·        Patients receive post-acute treatment after their stay in
  hospital. This happens when patients are considered clinically
  stable and the focus moves to their ongoing rehabilitation,
  or which occurs in rehabilitation units where patients are
 transferred following their treatment in a stroke unit.
·        One million stroke survivors in England, Wales and Northern
  Ireland need post-acute care.
·        Although the biggest steps in recovery are usually in the first
  few weeks after a stroke, the brain’s ability to ‘re-wire’ itself,
  known as neuroplasticity, means it is possible to continue to
  improve for months or years.
·        In England, Wales and Northern Ireland, over a third of stroke
   survivors are discharged to an Early Supported Discharge
   (ESD) or community rehabilitation team. The majority of stroke
   survivors discharged via these routes are cared for by stroke or
   neurology specialist teams.
·        2 out of 10 hospitals in England, Wales and Northern Ireland do
  not offer ESD services.
·        Only approximately half of the stroke survivors in England,
  Wales, and Northern Ireland are discharged from hospital having
   been assessed for all appropriate therapies and with agreed
   goals for their rehabilitation.


Life after a stroke

·        In England, Wales and Northern Ireland, only 3 out of 10 stroke
 survivors who need a six month assessment receive one.
·        A six month review monitors how well stroke survivors are
  recovering and identifies additional, tailored support that may
  be needed to prevent unnecessary readmissions to hospital
  and care homes.
·        1 in 5 stroke survivors in England Wales and Northern Ireland
 ask for psychological support at their six month review.
 However, stroke survivors wait an average of 10 weeks after
 referral to receive psychological treatment.
·        Only 15% of post-acute services in England, Wales and
  Northern Ireland have the resources to help people return to
  work after their stroke.
·        1 in 3 areas in England, Wales and Northern Ireland do not
 provide support to the carers and families of stroke survivors.
 1 in 5 commissioning areas in England, Wales and Northern
 Ireland do not offer Access.

Guideline for six month reviews

The new National Clinical Guideline for Stroke published in 2016
recommends that stroke survivors, including those living in a
care home, should be offered a structured health and social
care review at six months and one year after the stroke, and
then annually. The review should consider whether further
interventions are needed, and the person should be referred for
further specialist assessment if:
·        New problems are present
·        The person’s physical or psychological condition, or social
  environment has changed.

The economic burden 14

·        The economic burden of stroke falls on different sectors of
  society. Every new case of stroke represents significant costs
  to the NHS, social care services, the stroke survivor and their
   family, and may signify a loss of productivity for the economy
   (when stroke survivors or their carers can no longer work).
   These costs are borne by different people throughout the
   stroke pathway.
·        The estimated cost of stroke to UK society is £26 billion a year.
·        The total cost to UK society for all new cases of stroke is £5.3
  billion a year.9 Around 30% of this sum will be costs to the   
·        The estimates for Argentina establish a total of 52,155 hospitalizations per stroke and a total of 277,408 hospital days for this cause. 5
·        The informal care sector (relatives and friends providing care)
  contributes a total of £15.8 billion a year to look after someone
   who’s had a stroke.
·        The older you are when you have a stroke, the more expensive
  the care.
·        The NHS could save £4,100 over five years for each stroke
  patient given thrombolysis, and £1,600 over five years for each
  patient discharged with Early Supported
·        It is difficult to estimate the financial burden of stroke to the
  family, as each case is unique.
·        One report estimates the average cost of stroke to a family in
 the UK is £22,377.
·        The report claims the costs may vary between £5,000 and
  £100,000, depending on how severe the impacts of the
 stroke are.
·        People of working age who have had a stroke are two to three
 times more likely to be unemployed 8 years after their stroke.
·        Around 1 in 6 stroke survivors experience a loss of income after
·        Almost a third of stroke survivors say they have to spend more
  on daily living costs.

 In 2012, government and charities spent £56 million on stroke
  research in the UK. This figure is dwarfed when compared to the
  amount spent on cancer research (£544 million). Stroke also
 receives considerably less funding from the government and
  charities than coronary heart disease (£166 million) and dementia
  research (£90 million).
·        £48 is spent on stroke research for each person in the UK who
 had a stroke. This is a one fifth of the amount spent on cancer
 research (£241) and less than half of that spent on dementia
 research (£118).

·         Primordial and Primary Prevention -
·         Community education
·         Notification and response of emergency medical services
·         Acute stroke treatment, including the hyperacute and emergency department phases
·         Subacute stroke treatment and Secondary Prevention
·         Rehabilitation
·         Continuous quality improvement (CQI) activities



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12-Rodriguez, Gabriel E y col-Atención del stroke audo en una unidad de stroke y una sala general-Neurología Argentina-Vol. 2. Núm. 1.Enero - Marzo 2010.
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14-Singh, SN- The burden and management of TIA and stroke in the Veterans Administration and Department of Defense.Am J Manag Care. 2009 Jun;15(6 Suppl):S185-92.

15-State of the nation-Stroke Statistics-Stroke Association.

16-Unidad de Ataque Cerebral del Hospital Italiano de La Plata-El Día-1 de diciembre de 2015.


17- Vets with PTSD may also face greater risk of heart attacks and strokes


18-Wright Patterson Air Force Base-Stroke Prevention Awareness-Preventing Stroke. Air Force Materiel Command Wellness Support Center