Stroke remains to be an important cause for morbidity and mortality,
as it is the most common cause for disability and the second most common
cause of death. It is estimated that 50,000,000 people are affected with
stroke at any time globally. World Health Organization reports that more
than 20,000,000 people are affected with stroke every year worldwide and
5,000,000 of those die. The expected stroke mortality by the year 2025 is
7.5-10,000,000 deaths per year. The mortality of stroke is maximal in the
first month following stroke, accounting for about 40% of all mortalities in
one year. Globally, the crude incidence of first ever stroke is around
150-200/100,000/year. In the United State of America, more than 7,500,000
people are affected with a stroke every year. Stroke recurrence occurs in
one out of six patients over 5 years following the initial stroke.
The cost of stroke care is tremendous.
In UK, the yearly cost for stroke care is around £ 2.3 billions,
while in Australia it is around $ 1.1 billions. A major portion of this
money is spent on prolonged hospitalization and rehabilitation.
In Saudi Arabia, the crude incidence of first ever stroke is
29.8/100,000/year, however, the incidence rises to 126/100,000/year when
adjusted to the 1976 USA population. This reflects the well-known fact that
a large sector of the Saudi population is younger than 30 years. However, an
eventual rise of elderly is expected due to the expected increase in the
average age among the population due to the distinguished medical services
provided by the Saudi government and the increased rate of breading. This
would lead to an expected change in the horizontal and vertical age
distribution structure of the population with an accompanying increase of
the elderly population and thus, an increase in number of stroke victims.
There are no clear statistics about stroke care costs, but with simple
calculations (considering the adjusted incidence and that each patient costs
an average of SR 20.000), the amount of money spent on short-term stroke
care is expected to amount to around SR 500 millions/year. We should note
that a considerable number of admissions to hospitals are related to
cerebrovascular diseases, which might increase this number.
Among causes and risk factors that are strongly associated to stroke are
hypertension, diabetes mellitus, cardiac diseases, hyperlipidemia, blood
disorders, intracranial vascular malformations and smoking. The prevalence
of hypertension in Saudi Arabia is around 10-23%. The hypertensives that are
not well treated may reach up to more than 60%, a fact that increases the
risk for developing stroke. Diabetes mellitus (DM) is a major national
hazard, as the latest statistics show a marked increased incidence of DM
among Saudis above the age of 40 years (around 40%). Hyperlipidemia is also
a risk factor that is common among the Saudi nationals. Rheumatic heart
disease is still prevalent and is the a common cause for stroke in Saudis
below the age of 45 years. Arteriovenous malformations (AVM’s) are a
well-recognized cause for stroke among young Saudis. Smoking is another
major issue that is common among young Saudis. It was estimated in a study
that 40% of university male students are smokers.
In developed countries, attempts to reduce stroke impact were directed in 2
major lines. The first is towards improving prevention programs and second
is on the acute therapy and management.
In regards to the first line, national screening programs for risk factors
were carried out to accurately identify the incidence and prevalence of all
risk factors. These programs, unfortunately, are not conducted properly in
most of the developing countries; including Saudi Arabia. Also, health
related public education programs are another tool that were heavily
utilized in promoting the people information about stroke risk factors and
introducing best measures to be taken to reduce these risk factors. Again, a
huge failure is seen in the developing countries regarding this issue. Also,
new drugs and procedures for stroke prevention have been introduced
recently, including new antiplatelets, endarterectomy or carotid stinting
for internal carotid stenosis, cardiac procedures for patent foramen ovale (PFO),
embolizations for AVM’s, shunt and bypass surgery for
Moyamoya disease and sicklers, coil
insertion,
for aneurysms and many others. Such therapeutics modalities are
available in selected tertiary centers in the Kingdom of Saudi Arabia,
but, unfortunately, in a scattered manner and without clear protocols or
guidelines in most of these hospitals.
For the acute stroke therapy line, new modalities of treatment have
emerged over the last few years. The use of thrombolytic therapy with
intravenous rt-PA within 3 hours of ischemic stroke onset was found to
be a beneficial treatment that has been tested in different studies.
Also, the promising data with the use of neuroprotective agents in acute
ischemic stroke encourages the scientific investment in this therapy.
The use of intra-arterial thrombolysis is well recognized as a modality
of choice in treatment of ischemic stroke, and trials on this approach
are still on going. The latest optimistic findings seen with hypothermia
in the management of malignant middle cerebral artery infarction made it
possible to increase the choices of increased intracranial pressure
management treatments. Moreover, the proof that decompressive surgery in
patients with posterior fossa malignant infarction and malignant middle
cerebral artery (MCA) infarction, for life saving, is another
therapeutic option that is gaining a lot of attention recently. The use
of intraventricular rt-PA in cases of intraventricular hemorrhage is an
effective measure to reduce mortality of this morbid disease. Some of
theses therapeutic options have been implemented and carried out in a
limited scale in the major hospitals of the Kingdom of Saudi Arabia.
Also, New radiological techniques have made it possible to investigate
acute cerebrovascular events with a significant degree of confidence and
reliability in a very short time. These include the vast revolution in
magnetic resonance techniques and the rapidly developing Transcranial
Doppler techniques. Some of these advanced neuro-radiology tools are
available in the Kingdom hospitals.
Stroke units have shown, without any doubt, their effectiveness in changing
the out come of acute stroke patients. Mortality of patients who were
treated in stroke units was far less when compared to patients treated in
general medical words (20% reduction). Also, the disability improved by 29%
(reflected by active daily living measures) in patients treated in stroke
units. What make stroke units unique are the concentrated and well organized
management options given to patients with acute stroke. The other important
factor that make stroke units a necessity are the cost effectiveness.
Patients who are admitted to stroke units are mobilized and rehabilitated
earlier, making their hospital stay shorter. Also, the manpower, costs and
effort will be minimized if aforementioned acute stroke therapy modalities
were applied within a stroke unit setup. The patient care will be maximal
and to the excellence of clinical work if all stroke patients are managed in
a stroke unit. These units are not available in any medical facility within
the Kingdom, although of limited trials here and there.
We can conclude that, although stroke is a disease that is common in the
Saudi population and probably is expected to increase over the coming few
years, there are no single local group or body that deals with its issues.
This is true in spite of the fact that major hospitals provide distinguished
services for stroke, sadly lacking nationwide protocols and guidelines.
The need for an academic body that is concerned with the issues of
stroke in the Kingdom of Saudi Arabia becomes a necessity.
The Saudi Advisory Group Against Stroke is probably the first body
that is created to be concerned purely with issues regarding stroke. The
Group is acting under the umbrella of the Saudi Heart Association and its
objectives are mainly directed to accurately identify the burden of stroke
in Saudi Arabia. Also, to improve stroke prevention programs and try to
unify the protocols and guidelines in stroke prevention therapeutics and
acute stroke management. It is the goal and duty of this group to put Saudi
Arabia in the far front regarding stroke management. This will not happen
unless this group gets a lot of support and encouragement from different
medical services providers in the Kingdom of Saudi Arabia