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04 How often do Strokes occur?

05 What are the Signs & Symptoms of a Stroke?

07 Seek immediate Medical attention

07 Type of Strokes

08 What Are My Stroke Risk Factors?

09 How to Diagnose a Stroke?

11 Treatments

13 Stroke Rehabilitation

14 What Should I Do After I Leave the Hospital?

15 Some Complications After a Stroke

16 What Do I Do In Case…?

17 Keys to Recovery

19 Preventing another Stroke

20 Stroke and Sleep Disorders

23 Stroke and Vision Loss

25 All about Caregivers

26 10 Tips for Caregivers: How to cope

CONTENTS

Strokes are also referred to as “brain attacks” to remind you to take Stroke as seriously as you would a heart attack; the damage that can be caused is just as life threatening and serious. Remember, when dealing with stroke,

TIME is BRAIN.

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The most common warning signs of a stroke are:

In Mauritius, of the

3,206deathsdue to Diseases of the Circulatory System in 2017, 1,850 (57.7%) were due to Heart diseases.

Stroke and other Cerebrovascular diseases accounted for another

809 (25.2%) deaths

Acute Stroke is increasingly recognized as a Medical Emergency. Acute Stroke management in specialized wards (Stroke units) has been proven to be effective in acute Ischaemic Stroke. Although not available everywhere, Endovascular Therapy offers an additional treatment option.

(Source: Health Statistic Report 2017, Ministry of Health & Quality of Life).

Sudden severe headache with no known cause

Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body

Sudden confusion, trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

How often do

Strokes occur? Acute Stroke is one of the leading factorsof morbidity and mortality worldwide.

What are the Signs & Symptoms of a Stroke?

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A hemorrhagic Stroke occurs when a blood vessel in the brain breaks, leaking blood into the brain. This type of Stroke accounts for 13% of all Strokes, yet is responsible for 30% of all Stroke related deaths.

An ischeamic Stroke occurs as a result of a blood clot in an artery blocking the flow of blood to the brain. Often referred to as brain attack, Stroke is third leading cause of death behind coronary heart disease and cancer and is the leading cause of long term disability in Mauritius. Acute ischeamic Stroke can be a serious and devastating condition. Knowing all of the treatment options may help ensure the best possible outcomes.

What is Transient Ischemic Attack (TIA)?

TIA, or Transient Ischemic Attack, is a “mini Stroke” that occurs when a blood clot blocks an artery for a short time. The symptoms of a TIA are the warning signs of a stroke, but they usually last only a few minutes to several hours. About 10% of strokes are preceded by TIA’s. TIA’s are strong predictors of Stroke risk and the next attack almost always result in disabilities. Don’t ignore them. Call 118 immediately!

FAS

T

FACE:

ARMS:

SPEECH:

TIME:

Ask the person to smile. Does one side of the face droop?

Ask the person to raise both arms: Does one arm drift downward?

Ask the person to repeat a simple phrase. Is their speech slurred or strange?

If you observe any of these signs, call 118 immediately.

Use FAST to remember the warning signs

Seek immediate Medical attention

If you notice any signs or symptoms of Stroke, even if they seem to fluctuate or disappear, call your local Emergency Number right away. Every second counts. The longer Stroke goes untreated, the greater the potential for brain damage and disability. To maximise the effectiveness of evaluation and treatment, it is best that you get to the emergency room within 60 minutes of your first symptoms (Golden Hour).

Type of Strokes

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Risk Factors you CAN control:

• High Blood PressureShould be controlled and maintained at less than 140/90 mmHg.

• Heart DiseaseAtrial fibrillation (a rapid, irregular heartbeat) should be treated, talk with your Doctor about your options.

• Carotid Artery StenosisPuts you at higher risk for a Stroke and can be treated by surgery, stenting a clogged artery in the neck, or medical therapy.

• SmokingIf you smoke, you are putting yourself at a much higher risk for Stroke and many other dangerous health conditions. It is important that you quit smoking now.

• High CholesterolTotal cholesterol should be less than 200, bad cholesterol (LDL) should be less than 100.

• DietEat a diet low in saturated fat, cholesterol, and salt.

• DiabetesIncreases the risk for Stroke and should be controlled through diet, oral hypoglycemics (medications taken by mouth that lower blood sugar) or insulin.

• ObesityThe more overweight, the higher the risk for Stroke.

• Avoid Alcohol Intake

• Physical InactivityBeing inactive increases your risk. Speak with your Doctor about starting an exercise plan.

What Are My Stroke Risk Factors?

How to Diagnose a Stroke?

Risk Factors that you CANNOT control:

• AgeThe older you are, the higher the risk. The risk of having a Stroke doubles each decade after the age of 55.

• GenderMore men experience Stroke than women.

• HeredityAfricans, and Asians have higher risk than Caucasians.

• Family history of stroke or heart disease.

• A prior stroke: or TIA (Transient Ischemic Attack) or heart attack.

You may have any of the following tests to diagnose a stroke:

1. Use FAST to remember the warning signs • FACE: Ask the person to smile. Does one side of the face droop? • ARMS: Ask the person to raise both arms: Does one arm drift downward?• SPEECH: Ask the person to repeat a simple phrase. Is their speech slurred or strange? •TIME: If you observe any of these signs, call 118 immediately.

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2. Radiology Investigations:

A. Computerized Tomographic Scan (CT scan)Used to look at the skull, brain tissue, and blood vessels. You may be given dye before the Scan. The dye is usually given in your veins and may help your doctor see the scan better.

B. Magnetic Resonance Imaging Scanning (MRI)Using magnetic waves, this test, also called an MRI, provide very accurate images of the brain and is used to determine the presence, location and size of aneurysms and ischemic strokes.

C. Carotid Ultrasonography (Carotid Doppler)This test uses sound waves to show the blood flow in your carotid arteries. The carotid arteries are the blood vessels in your neck that carry blood to your brain. A carotid Doppler test will check if there is a narrowing or blockage of the carotid arteries that may lead to a Stroke.

3. Blood Investigations:

The following tests will advise us on the status of your blood glucose level, bleeding times, lipids profile, full blood count and electrolytes.

4. Electrical Activity Tests:

Electrocardiogram (ECG) - This test measures the electrical activity of your heart and takes about 5 to 10 minutes. It tells if you have had a past heart attack, have enlargement or are currently having a heart attack.

How is Stroke Treated?

Initial treatment consists of a complete patient evaluation. The Emergency Stroke Unit Team will document a full medical history, including physical and clinical neurological exams, as well as conduct an imaging evaluation.

Treatment of Stroke is dependent on the type of Stroke.For Haemorrhagic Stroke:1. Coiling 2. Flow diversion 3. Surgical clipping

Currently, Two Methods Exist for Treating Acute Ischaemic Stroke Patients: 1. Medical Management - Intravenous Thrombolysis 2. Advanced endovascular treatment - Clot Removal (Mechanical Thrombectomy)

Medical treatment involves medical supervision, monitoring and drug therapies. Physical treatment usually involves some type of activity that may be carried out by you, a healthcare professional or by both of you working together.

Additional medical care includes: • Range of motion exercises and physical therapy to avoid limb contracture and shoulder pain, blood vessel problems and pneumonia

• Frequent turning, good nutrition and skin care to avoid bedsores; sometimes use of a special mattress called an egg crate or air mattress may be put on your bed.

• Bladder training programs for incontinence

• Swallowing and respiratory therapy and deep breathing exercises, all of which help to decrease the risk of pneumonia

• Use of 4 prong cane or walker when walking may be needed to keep from falling; use of chairs with arms to ease getting up and down

Treatments

Psychological treatment can include counseling or supportive therapy for feelings that result from clinical depression.

Types of psychological treatment may include: • Antidepressant medication • Psychotherapy or a combination of both.

ENDOVASCULAR TREATMENT OF STROKE

Minimally invasive endovascular surgery - 2 tiny incisions in the groin with special set of catheters are used to reach through the veins in the brain and the clot is removed. The procedure is done through conscious sedation – Patient is awake but sedated, relaxed and does not feel pain.

This test provides detailed information about the condition of arteries in your head and neck that supply blood to your brain. A dye is injected into the blood vessels under the guidance of X-Ray. This provides a picture of the blood flow through these vessels and allows the size and location of the blockages or aneurysms to be evaluated.

Mechanical Thrombectomy is the mechanical clot removal from the vessel with specially designed device.

Endovascular coils are mesh like devices that function by reducing the blood flow from the parent vessel into the aneurysm.

Flow diverters are mesh like stents for treatment of complex aneurysm by redirecting the blood flow from parent vessel into the aneurysm.

When the immediate crisis of a stroke has passed and you’ve been stabilized medically, it’s time to consider rehabilitation therapy. The effects of Stroke may mean that you must change or relearn how you live day-to-day. Rehabilitation may reverse some of these effects.

Your Rehabilitation Team May Include:

• Physical Therapist – A healthcare provider who specializes in maximizing a Stroke survivor’s mobility and independence to improve major motor and sensory impairments, such as walking, balance and coordination

• Occupational Therapist – A therapist who focuses on helping rebuild skills in daily living activities such as bathing, toileting and dressing

• Speech Therapist – A specialist who helps restore language skills and also treats swallowing disorders

• Neurologist

• Psychologist / Psychiatrist

What will I Do in Rehab?

• Daily living activities such as eating, bathing and dressing • Mobility skills such as transferring, walking or self-propelling a wheelchair • Communication skills in speech and language • Cognitive skills such as memory or problem solving• Socialization skills in interacting with other people • Psychological functioning to improve coping skills and treatment to overcome

depression if needed.

Stroke Rehabilitation

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What Should I Do After

I Leave the Hospital?

Medication Management

It is very important to take the medications prescribed for you when you leave the hospital. Here are some medication management tips for Stroke Survivors and Caregivers.

• Keep a current and accurate list of all medications (including vitamins, and over-the-counter meds) with you at all times for Doctor visits. • Do not miss your High blood pressure medicines. They are very important for Stroke survivors and anyone with high blood pressure. • Monitor for side effects of your medications. You can work with your Doctor to avoid the side effects. • Use just one pharmacy. It is easier to monitor drug interactions and usage. • Use a pill box to organize your medications for the coming week. It’s easier to remember if you have taken your medications. • Plan ahead and refill medications before they run out. Take your medications along if you travel. • Never change your dose or stop a medication without speaking with your Doctor first. • Never take any expired medications. • Never share medications that were not prescribed for you.

Your doctor’s highest priorities after a Stroke are to prevent complications from the present Stroke and to prevent another Stroke. Your doctor will determine that you are medically stable and able to resume some self-care activities. This means that all complications must be treated and are under control. Some complications happen as a direct result of injury to the brain due to Stroke, or because of a change in the patient’s abilities; for example, being unable to move freely can result in bedsores. Clinical depression can also occur with a Stroke.

The most common complications are:

• EdemaBrain swelling after injury

• SeizuresAbnormal electrical activity in the brain causing convulsions

• Clinical DepressionA treatable illness that often occurs with Stroke and causes unwanted emotional and physical reactions to changes and losses

• BedsoresPressure ulcers that result from decreased ability to move

Need for follow-up medical care after discharge

Your medications and treatments are most effective when they help you reach the goal of lowering each of your risk factors. Therefore, the doses of these medicines and the treatments you need will likely need to be adjusted in order for them to be effective. It is important that you receive regular medical care after you leave the hospital, since this is how the Doctor can measure the effectiveness of the treatments and make sure your medications are adjusted properly.

Some Complications

After a Stroke

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• Limb ContracturesShortened muscles in an arm or leg from reduced range of motion or lack of exercise

• Shoulder PainStems from lack of support or exercise of an arm

• Blood Vessel ProblemsBlood clots form in veins upon decreased mobility, most common in legs

• Urinary Tract Infection and Bladder ControlUrgency to pass urine and incontinence

• PneumoniaCauses breathing problems and is a complication of many major illnesses

1. I feel very weakLie down and check your pulse and blood pressure. Call your doctor. If the next dose of blood pressure medication is due; hold this dose until you get your Doctor’s advice.

2. Another doctor put me on a new medication Please notify your primary doctor and/or your neurologist within 24 hours of any medication change

3. I do not have a primary doctor or nurse: Choosing a doctor can be challenging. You may not want to just pick a name out of the phone book.

Encouraging independence is a key part of your role in your loved one’s recovery. The following tips may help survivors maintain their physical and mental health and regain control over their lives.

• Get support Family and friends can help survivors adjust to everyday living, helping with tasks such as meal preparation, correspondence or transportation.

• Set measurable goals Survivors should set both long-and short-term goals based on their current capabilities. Take photos/video as reference for improvement. By assessing what they can reasonably accomplish, survivors will be better able to make decisions in their recovery process.

Here are some ideas to get you started:

• Personal referralPeople often ask their friends, families, and co-workers for referrals to Primary Care Doctor (General Practitioners). If someone you respect and trust has a positive experience with a doctor, it’s possible you may like that particular Doctor.

• Current physiciansIf you are moving to a new area, you could ask your current Doctor to help you find a Primary Care Doctor (General Practitioner) in your new neighborhood.

• HospitalsIt is common for hospitals to offer a referral service that can provide you with names of doctors who meet certain criteria you may be seeking, such as specialty, gender, experience, and location.

What Do I Do

In Case…? Keys to

Recovery

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• Communicate Speech and language may be affected when a person suffers a Stroke. Survivors should be encouraged to have conversations using fewer words and more gestures as necessary. Communication aids are also an option depending on the severity of the impairment.

• Get dressed Getting dressed is a way to be independent and maintain self-image. To make it easier, purchase comfortable, loose clothing; replace buttons and zippers with Velcro and lay out clothes before wearing.

• Stay activeMovement and exercise not only improve health, but may prevent a serious fall and injury if balance has been affected. For those who need a wheelchair, getting outside of the house should be encouraged for general well-being.

• Plan meals aheadEating healthy and in accordance with medication instructions is an essential part of stroke recovery but may take planning. Purchasing prewashed, precut fruits and vegetables and preparing meals that can be frozen will help keep things simple.

• Pursue interests Doing things that one enjoys creates balance and alleviates stress. Recreational activities can also help a survivor be active in the community. Remember, most activities can be modified to meet new needs.

• Be aware of stroke risk factors Stroke survivors should always follow the advice of healthcare professionals and make lifestyle changes that may lessen their risk for a second stroke.

For Stroke prevention, it is important to know that 90% of Strokes are linked to 10 modifiable risk factors including hypertension, smoking, obesity, physical inactivity, and unhealthy diet. The occurrence of an acute Stroke has to be considered a major emergency which needs a seamless chain of interventions until recovery.

As a caregiver, an important responsibility during the recovery process will be to help identify risk factors to avoid a second Stroke.

While there are some risk factors that you and your loved one cannot do anything about - such as gender, age, race and family history - there are others that you do have some control over.

• High blood pressure If blood pressure cannot be lowered by diet and exercise changes, seek advice from a healthcare professional.

• Atrial fibrillation This irregular heartbeat may lead to blood clots, and people with this condition are five times more likely to have a Stroke. Common symptoms are heart palpitations, sudden pounding or “fluttering” in the chest and dizziness.

• High cholesterol A build-up of cholesterol in the arteries may block blood flow to the brain, causing a Stroke. If cholesterol cannot be lowered naturally (through proper nutrition, exercise), certain medications may help.

• Smoking Smoking doubles the risk of Stroke. If your loved one is a smoker, help support their efforts to quit.

• Diabetes People with diabetes generally have other health problems that make them up to four times more likely to have a Stroke.

Preventing another

Stroke

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Strokeand Sleep Disorders

What is a sleep disorder?

Getting a good night’s sleep is an important part of Stroke recovery, yet sleep problems are common among Stroke survivors. When sleep problems go on for a long time, they are considered sleep disorders. If sleepiness is interfering with your daily routines or activities, you may have a sleep disorder.

There are a number of different kinds of sleep disorders, those associated with stroke include:

• Sleep-related breathing disorders or abnormal breathing patterns while asleep• Insomnia or difficulty falling and/or staying asleep • Hypersomnia or excessive sleepiness during the day • A “circadian” or sleep-wake schedule mismatch (both problems of insomnia during the night and sleepiness during the day)• Parasomnia or movement disorders occasionally with violent behaviors• Restless leg syndrome or periodic movements of the legs during sleep and/or unpleasant sensations in the legs usually at night

What is sleep apnea?

Sleep apnea is a type of sleep-related breathing disorder. If you are sleeping and you stop breathing for 10 seconds or more, then you may have sleep apnea. People with sleep apnea may stop breathing hundreds of times a night without even being aware of it. It is estimated up to 80% of sleep apnea patients are undiagnosed.

The most common type of sleep apnea is obstructive sleep apnea (OSA). OSA happens when your airway is blocked by soft tissues of the upper airway while relaxing. Those tissues then collapse and block the airway stopping the air from getting into the lungs.

Most people with sleep apnea do not have breathing problems during the day.

Sleep apnea is most common in middle age men between the ages of 35 and 70. More than half of sleep apnea patients are also overweight. More than half of the people who have Stroke also suffer from sleep apnea.

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What are the symptoms of sleep apnea?

• Loud snoring• Insomnia• Disrupted sleep (occasionally due to gasping and/or nightmares)• Excessive daytime sleepiness• Morning headaches• Short attention spans• Memory loss

How is sleep apnea related to stroke?

Sleep apnea can be an after effect of Stroke, but can also be the cause of a first time or recurrent Stroke. The condition causes low oxygen levels and high blood pressure, both of which can increase the risk of a future Stroke.

How is sleep apnea diagnosed?

Often sleep apnea symptoms are recognized by a spouse or another person who observes (and is often disturbed by) the sleeper’s snoring. It is important when possible to have the patient’s sleep partner or family member describe the snoring or breathing practices to the patient’s healthcare team. Once sleep apnea is suspected, a referral can be made to a sleep specialist who can perform a sleep study to determine if you have sleep apnea. For more information, call us on 601 2300.

How is sleep apnea treated?

The most common treatment for sleep apnea is Continuous Positive Airway Pressure (CPAP). With this type of treatment, a bedside device gently delivers pressurized air through a small mask or nasal pillow system.

This pressure acts like an “air splint” to keep your upper airways open and help prevent apneas. In severe cases, if a CPAP cannot be tolerated, surgical alternatives are available.

For mild cases of sleep apnea, the following lifestyle changes may also be helpful:

• Weight loss• Avoidance of alcohol• Avoidance of sleeping or sedating medications

How does vision loss relate to Stroke?

Vision loss can be both a symptom and result of a Stroke. Temporary vision loss can be a sign of impending Stroke and requires immediate medical attention.

Vision complications due to a Stroke depend on where the Stroke occurs. The majority of visual processing occurs in the occipital lobe, in the back of the brain. Most Strokes affect one side of the brain. If the right occipital lobe is injured, the left field of vision in each eye may be affected. A Stroke that affects the left occipital lobe may disturb the right field of vision in each eye. Rarely, both sides of the brain are affected, which can result in blindness.

Up to a quarter of Stroke survivors may have vision loss. While most Stroke patients with vision loss do not fully recover their vision, partial recovery or natural vision improvement is possible, usually in the first months after a Stroke. Proper diagnosis and a vision rehabilitation plan can help improve most daily activities, self-esteem and feelings of independence.

Good sleep hygiene helps to maintain regular wake and sleep cycles. Good sleep hygiene includes:

• Avoid napping during the day• Avoid stimulants such as caffeine and alcohol too close to bedtime• Exercise can promote good sleep• Avoid large meals before bedtime• Get adequate amounts of natural light during the day• Establish a regular and relaxing bedtime routine• Make your bedroom quiet, dark, restful, and a little bit cool

Strokeand Vision Loss

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What are the types of vision loss?

The most common type of vision loss with a Stroke is loss of half of the visual field in each eye (homonymous hemianopia). Other types include loss of a quarter of the vision field (homonymous quadrantanopia) and an island-like area of blindness (scotoma). An automated visual field test provides proper diagnosis.

What are other possible vision problems following a Stroke?

The brain stem is the starting point for three pairs of nerves that control eye movements. A Stroke in this area can result in only one eye moving correctly. This can cause double vision or the inability of both eyes to look in a particular direction.

Also originating in the brain stem is the sensation that objects at which one is looking are moving. A Stroke in this area may lead to reading difficulties because the normal sense of stability is affected.

Loss of feeling may occur on the eye’s surface, making blinking difficult, not allowing an eyelid to properly close or causing a droopy lid or blurry vision.

A Stroke may also interfere with visually comprehending, understanding or recognizing objects. Visual agnosia is the inability to recognize or interpret objects by sight and often causes an inability to recognize familiar faces or objects.

How can vision loss be treated?

An Ophthalmologist or optometrist can diagnose and recommend a vision rehabilitation plan. Vision rehabilitation includes different types of therapies.

Compensatory vision therapy

Compensatory vision therapy includes prisms, visual field awareness systems and scanning.

Prism and visual field awareness systems typically compensate for vision loss by shifting images from the non-seeing to the seeing visual field.

The Caregiver’s RoleAs the primary caregiver for a Stroke survivor, you are a very important part of the recovery process. While this role can be very rewarding, it can also be challenging. As you adjust to these life changes, you will have many questions and concerns. This brochure will help you during the recovery journey, with tips on how to improve well-being for both your loved one and you.

Once your loved one leaves the hospital, the primary responsibility for his or her everyday care switches from healthcare professionals to you. It is normal to feel unsure or anxious - developing a new routine and adjusting to the changes brought about by Stroke may seem overwhelming.

While the role of a caregiver varies, you may be doing some of the following throughout the recovery process:

• Taking part in informed decision making and treatment planning

• Coordinating appointments with healthcare professionals; helping ensure that medications are refilled and taken properly

• Assisting with walking and transportation

• Helping with everyday tasks such as meal preparation, bathing and toileting

• Monitoring survivor health; being aware of pain, dietary instructions, depression or risk factors that may lead to a second Stroke

• Managing financial or legal and end-of-life matters

• Providing encouragement and support for your loved one and family members

• Supporting survivor independence

All about

Caregivers

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Caring for the Caregiver

Caregivers may feel more stress than the general population, are twice as likely to become depressed and frequently experience sleep deprivation. However, they are less likely to seek treatment for these conditions.

Keep this in mind: Caring for yourself is just as important as caring for your loved one.

• Stress causes increased blood pressure and heart rate. • Excessive stress puts you at increased risk of heart disease, sleep problems and depression. • Depression and sleep deprivation interfere with overall quality of life.

Feeling exceptionally tired, irritable or down in the dumps is not “just part of” caregiving. Notice how you are feeling, get regular check-ups and seek counseling for feelings that are overwhelming or draining. Making the time to care for yourself will benefit both you and your loved one.

1. Accept that you cannot do this alone Do not feel guilty enlisting the help of friends and family. Assign them specific tasks if they offer to help.

2. Educate yourself Learn about your loved one’s condition and how to effectively communicate with healthcare professionals.

3. Allow yourself to grieve It takes time to accept the loss of your former lifestyle/relationship, but remember that time will also bring about new goals and dreams for you and your loved one.

4. Learn to relax There are many techniques that you can use, from walking or writing to enrolling in a yoga class or practicing meditation.

5. Eat well A diet rich in fruits and vegetables will keep you healthy and energized.

6. Stay active At least 30 minutes of daily exercise can greatly reduce stress, help you maintain a healthy weight and improve your mood.

7. Have fun! Take some time to do activities you enjoy. Maintaining your own identity is crucial and will help “recharge” your energy for better care for your loved one.

8. Stay social Make an effort to interact with people. Meet up and laugh with your friends.

9. Find a caregiver support groupBeing around others who are going through similar experiences provides an outlet for sharing ideas, venting frustrations and supporting each other through hardships.

10. Take things one day at a timeThe future is uncertain not just for Stroke survivors, but for everyone. Focus on the accomplishments of each day, and don’t get carried away with the “what ifs” of the future.

Developments in Neurovascular Radiology has made Stroke and dementia preventable, treatable and increasingly reversible, thus reducing the burden on patients, families and our society. Our aim is to increase awareness, make available quality acute stroke treatment, primary and secondary prevention and rehabilitation.

10 Tips for Caregivers: How to cope

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THE MEDICAL & SURGICAL CENTRE LIMITEDHEAD OFFICE: Georges Guibert Street, Floréal 74111, Mauritius

Tel: (230) 601 2300 Fax: (230) 696 3612 (Administration) / (230) 696 1209 (Medical)

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Grand Bay, MauritiusTel: (230) 601 2500 | Fax: (230) 269 6224

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