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The world of 35-year-old Aakash Batra* came to a screeching halt at 9.45am on the third Friday in February. He was reviewing today’s match with his tennis coach when he suddenly stumbled, lost his speech, and collapsed in a heap because he couldn’t move his right limbs. Within an hour, he was diagnosed with a stroke at a local hospital in Ahmedabad, given clot-busting drugs and rushed to a larger facility so as not to miss the golden hour of surviving. Today, he is learning to speak again with some help from a speech therapist and physical therapist. Akash can now form short sentences of three or four words although there is a problem with association at times. So he would end up saying “bottle” when he meant “water,” says his wife Prathana* who was the pillar he now relies on.
The words mean a lot to her, given the complexity of the stroke he suffered, which meant he could be immobilized forever. And although Akash and Prarthana both run their own healthcare company, they were unaware of strokes and had none. Whereas such strokes are caused by blood clots, in Akash the embolism was caused by fat or fat deposits. Since time is of the essence in treating the condition, the family took him to a local hospital where an MRI confirmed the presence of a clot. “He was treated within 30-45 minutes of his onset of symptoms. But in the absence of specialists, they gave him clot-busting drugs so that we could take him to CIMS Hospital, Ahmedabad,” Praratana says. Dr. Mukesh Sharma, Director of Neurointervention and Head of the Stroke Program at the hospital, was in for a surprise. It may have been the third time in his 15-year career that he had seen a fatty deposit blocking a brain artery. This is extremely rare, but possible. Fat builds up along our blood vessels, and with vigorous activity, the fat mass may break off, travel to the brain, and block an artery. In his case, the plaque could have ruptured from the aorta in his heart, float to the brain and get stuck there. Multiple factors, even viral infections, can damage and dislodge plaque. In the case of blood clots, the first line of treatment is to dissolve medications that must be given within an hour of the stroke. “Akash needed an intervention,” says Dr. Sharma. That was when he had a mechanical thrombectomy, in which specialists use endovascular devices to either break up the clot, dissolve it, or suck it out through a catheter-like vacuum.
Two days after the fat deposits were removed, Akash had to undergo a craniotomy, in which part of his skull was removed, to relieve swelling in his brain. Then he was transferred to the intensive care unit, where he spent almost 10 days, even having seizures. Six weeks later, Akash had to undergo a cranioplasty, during which the removed part of the skull was put back in place.
Dr. Sharma says he can save Akash because of the speed of the treatment. Once these patients arrive at the hospital, a “white code” is established, which means that the patient suspected of having a stroke is prioritized for investigation, early admission, imaging and treatment. The Stroke Team, which consists of a neurologist, neurointerventionist, radiologist and imaging technicians MRI and catheterization labs, collect and decide whether clot-breaking drugs are adequate or the patient needs to be transferred to the catheterization lab.
However, this protocol is rarely adopted in higher education systems in India, as there is also a shortage of skilled manpower and specialists. Delays in triage outside and within hospitals remain a challenge for saving stroke victims, who need intervention within four and a half hours of the onset of symptoms, known as the golden window. Less than one percent of stroke patients in India receive appropriate treatment during that period. According to the American Heart Association, for every minute a stroke is not treated, the average patient loses 1.9 million neurons. With every hour left untreated, the brain loses as many neurons as it does in approximately 3.6 years of normal aging. This means greater permanence of disability after stroke.
The 2021 ICMR study – the Indian Global Burden of Disease Study 1990-2019 – estimated that stroke was the largest cause of disability-adjusted life years (DALYs) and the leading cause of death in neurological disorders. In 2019, the estimated number of strokes in India was around 1.29 million with 699,000 deaths. An absolute increase in stroke deaths of 36.7 per cent was observed among younger adults in developing countries, compared to declining trends in developed countries. Approximately 30 percent of all strokes occur in people under the age of 50 and less than 10 percent in people under the age of 40. A Ludhiana-based study conducted between 2010 and 2013 calculated the incidence of stroke among young adults (aged 18-49) at 46 per thousand population.
Dr. Sharma lays out the cold facts. “Every minute a person in India has a stroke and every fourth minute a person dies because of it. While developed countries are seeing a decrease in the incidence of stroke, developing countries are seeing an increase. The motivating factors are our sedentary lifestyle, our poor food habits, lack of sleep and exercise, and addictions such as smoking.
But Akash did not know the risk factors. Prartana says, “He was very physically active, a tennis player since he was a teenager, and had no other comorbidities like high blood pressure, diabetes, cholesterol, or a family history of the disease. So far we don’t know why that happened.” Akash, who is still on the rehabilitation journey, can walk the day after he returns from the hospital. However, his hand movements and speech were so weak despite the quick intervention that he could not open his palms or hold objects. His memory was completely unaffected but he could not express his thoughts through speech. “He’s getting there. Apart from physiotherapy twice a day and speech therapy once a day, we constantly involve him as a family. We practice reading the newspaper, giving him instructions, and that has shown results. He tries hard but there are days when he feels weak. Then we call his friends home.” “He loved going out with his friends after work and playing with his kids. We take him to the office sometimes and attend meetings, just so he can still be spirited about his fight. Right now, he really wants to get back to driving his car and taking the kids outside on the bike,” says Prartana. But she knows that patience is synonymous with a miracle.
(*names have been changed)
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