Pull the clot out, reverse the stroke: A call to all Sri Lankans

The 12th International Workshop and Conference on Stroke/Rehabilitation was hosted by the National Stroke Association of Sri Lanka and the Asia Pacific Stroke Organisation on 12 Sept.

From left: Dr. Harsha Gunersekera, Dr. Prasad de Silva, Dr. P.N. Sylaja, Dr. Dileep Yavagal Udaya Ranawaka and Dr. Manjula Caldera 

One of the world’s leading stroke champions Dr. Dileep R. Yavagal was up at 4 am in Florida, USA to keynote and rally top medical forces in Sri Lanka in a webinar to evangelise the possibilities to reverse strokes within 24 hours. Many a gripping story were told and challenges put forward. 

Ammi, age 56, had a tingling in her left hand, a little numbness, slurred speech and the worst headache of her life. We thought it would go away, but it continued overnight. Mobilising her quickly to a hospital to get treatment, from her home in the depths of the rubber plantation, was a challenge. Today Ammi is chair- and bed-bound, paralysed from the waist down with a gentle half smile and slurred speech. She is a constant reminder to us of the devastating impacts of stroke—a brain attack caused by blockage of blood (a clot) to the brain or a brain bleed.  She can’t cook or take care of her seven grandchildren. Think of our elders, how familiar is this image?

Dr. Prasad De Silva spoke about the first patient who received mechanical thrombectomy (a clot retrieval procedure) in Sri Lanka, which occurred in 2018.  Like Ammi, she was 56 years old; her stroke symptoms were recognised at 5:30 a.m., she came to the nearest hospital and was triaged for mechanical thrombectomy at 8:30 a.m., by 10:10 a.m. her clot was removed.  She regained full movement and speech and she walked home on day 3.  

“Spreading the message that stroke is now reversible up to 24 hours is key,” Said Yavagal.  “While that message appears so easy, it is the hardest to get out because we have had centuries of being not able to do anything for stroke and everybody just accepts it as a fate accompli.”

Yavagal is Chair of a global initiative, Mission Thrombectomy 2020+ (MT 2020+), which seeks to increase life-saving treatment for stroke across the world. He is an interventional neurologist of Indian descent who practices at the University of Miami Miller School of Medicine in Florida, USA.  

While the world wages the war against COVID, stroke advocates including our own— Dr. Harsha Gunesekera (neurologist), Dr. Udaya K. Ranawaka (neurologist) and Dr. Prasad De Silva (radiologist), in addition to being on the frontlines for COVID, have capitalised on the opportunity for virtual collaboration around the globe. 

The issue at hand: how to increase awareness around stroke and how to change the paradigm of stroke being a death or disability life sentence to one of resilience, where symptoms are recognised and acted upon early—time is brain. The longer the brain lacks oxygen and nutrients carried by blood, the more devastating the effects of a stroke. 

Since the early 2000s a clot busting medication has existed to dissolve brain clots; however, patients needed to be treated within a 4.5 hour window. In 2015 new guidelines supported the use of mechanical thrombectomy where a device is used to extract a clot from an artery and restore blood flow to the brain. This technology can be used up to 24 hours from when stroke symptoms start.  Though limited, we have capability to treat patients in Sri Lanka, yet recognition of stroke and triage to treatment is still a major issue and simply put, patients are not getting treated.

Ranawaka and his colleague Narayanaswamy Venketasubramanian, describe the toll that  stroke in Sri Lanka is taking as increasing—with an ageing elder population and a dearth of stroke neurologists and stroke units for treatment. In addition we lack rehabilitation facilities to help those impacted recover.

They also call for aggressive prevention strategies. These could include low cost medication to control blood pressure and diabetes underlying risk factors for stroke. They detail that the island has only 38 neurologists for 21.2 million people (as compared with 5.2 neurologists for every 100,000 people in the United States), that treatment with the clot busting drugs is only available in 14 hospitals and that mechanical thrombectomy is only available in one hospital.  

Stroke is among the leading causes of long term disability and death in Sri Lanka with nine out of every 1,000 persons affected.  This is higher than several high and middle income countries, who have increased awareness and focused on physician training. Sri Lanka is well positioned to be one of the leaders among countries similar to us.

Yavagal outlined several positives about Sri Lanka compared to other places worldwide: 1) the geography and small size of the country, lends itself to coordinated treatment if symptoms are recognised fast, 2) universal health care removes the barrier of patients having to pay for treatment or being denied treatment based on income, and 3) the highly educated population provides a great base for a successful stroke awareness campaign. 

Collaboration with MT2020+ allows Sri Lanka to take advantage of resources to assist with:

1. Physician training: remote proctorship so that neurologists in Sri Lanka can be trained in stroke treatment remotely.

2. Strengthening our triage systems: by educating our emergency medical services to recognize certain strokes in the field, and

3. Public Awareness: spreading the message that stroke is now reversible up to 24 hours and teaching people the signs, symptoms and response needed for stroke.  

Call to action

National Stroke Association of Sri Lanka President Dr. Harsha Gunesekera says: “Stroke awareness among the general public in Sri Lanka has improved over the past decade… the National Stroke Association has been striving hard to carry the message to the pubic urging the need for immediate hospital admission for successful treatment.”

Accelerating efforts for stroke treatment requires a coalition of efforts and with MT2020+ as a strong partner, there is great opportunity.  This is a direct call to the media, business, and philanthropists who can assist in kind or by finically supporting training and campaigns. 

Other countries have named fellowships to train more doctors; they have bus ad campaigns, billboards, education to school children and ads on TV. Each of us will either be affected directly by stroke or have a loved one who is.  Time is brain.

Parties interested in sponsoring a fellowship or assisting with any of the outlined collaboration points should reach out to Dr. Harsha Gunesekera ([email protected]) and/or Jennifer Potter-Vig, PhD ([email protected]).