The right food choices for those with diabetes

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Nutrition is the cornerstone of good health for everyone.

For those with diabetes, a common challenge is food – the type of food and the amount eaten. While eating well should be everyone’s objective, it is important to remember that food is crucial in diabetes management.

There is no “forbidden” food, but food choices are important. The easiest method to illustrate good choices is to create one’s own plate by drawing an imaginary line on the plate comprising the different food groups, with the objective of consuming large portions of non-starchy foods and a small portion of starchy foods.

New foods within each food category can then be tried without affecting the general objective.

General advice on food is available from the doctor, and specific information for the particular needs of an individual are available from a dietitian, to whom referrals should, ideally, be made at the initiation of treatment, and from time to time depending on the clinical situation.

Food groups

Food portions vary with individuals. Depending on a person’s requirements and nutritional goals such as weight loss, blood glucose control or fasting, advice on the amount of each food group will vary.

The food groups are fruits and vegetables; dairy products; proteins; starchy foods; and foods high in fat and/or sugar.

Fruits and vegetables are low in calories and fat, have large amounts of vitamins, minerals and fibre, and are useful in protecting against high blood pressure, heart disease, stroke and certain cancers.

The objective is to consume at least five portions daily – a portion being roughly what fits into the palm of the hand. Fresh fruits and vegetables are preferred. The choice of a variety of colours will provide a useful mix of vitamins.

Dairy products like milk and yoghurt contain calcium, which helps to keep the bones and teeth strong. They are also a good source of protein.

As some are high in fat, lower-fat alternatives have to be chosen, but it is important to be aware of any added sugar.

The objective is to consume three portions daily – a portion being roughly equivalent to 200ml of milk.

Meat, fish, eggs and beans are foods that are high in proteins. These are required for building and replacing muscle cells. They also contain iron needed for red blood cell production.

Omega-3 oils found in oily fish like sardines and mackeral can also help protect against heart disease. The alternatives for vegetarians are tofu, soya, beans, pulses and lentils.

The objective is to consume some proteins daily and two portions of oily fish weekly.

Starchy foods like rice, bread and pasta contain carbohydrates which are broken down into glucose, which is then used as an energy source.

Carbohydrates that are slowly absorbed in the gut are preferred as they will affect blood glucose less, and they also help keep one feeling full for a longer time. Starchy foods are low in fat. High-fibre ones like wholemeal and wholegrain also help in regular bowel action.

The objective is to consume some starchy foods daily, especially the wholegrain types.

Depending on the goals of treatment, some diabetes patients may be advised to estimate the amount of starchy foods consumed, spread the intake during the day and/or choose healthier foods.

Foods high in fat and sugar are not required by the body. However, they may be taken if controlled. Sugary drinks and food increases the blood glucose; so they should be substituted with low-calorie alternatives.

The intake of saturated fats can be reduced by replacing lard, butter and ghee with unsaturated fats like olive and sunflower oils. The objective is to avoid foods that are high in fat and sugar.

Excessive salt intake may contribute to high blood pressure, which leads to heart disease and stroke. It is also advisable to avoid or reduce the consumption of processed foods.

Fasting matters

The body enters into a fasting state about eight hours after the last meal.

Individuals may fast for a longer time for religious or cultural reasons. The bodily changes during fasting depend on the duration of the fast.

Initially, the body will use stored glucose as an energy source.

Later, stored body fat will be broken down to provide energy. Although the use of stored body fat will, in the long run, lead to weight loss, which in turn, can lead to better glucose control, it is not advisable to use fasting as a method of losing weight.

When fasting, eating patterns will vary. It is essential not to overeat and to stick to a balanced diet.

Fasting diabetics are advised to eat foods like rice, chapatti and dhal more slowly, together with fruits and vegetables, just before commencing the fast.

This will help keep one feeling full longer and keep blood glucose levels more stable during the fast.

Upon breaking fast, it is important to consume only small amounts of foods that are high in sugar and fat as excess will lead to weight gain.

It is important to avoid dehydration by drinking plenty of water and sugar-free drinks. If one has diabetes and a sweet tooth, sweeteners should be used instead of sugar.

If the fast is broken for any reason, the normal meals should be continued for the rest of the day. The fast can be made up at a later date.

Blood glucose levels need to be checked more frequently as they may drop too low (“hypoglycaemia”), especially if one is on diabetic medications and/or there is illness.

If there are symptoms of hypoglycaemia, e.g. sweats, shaking and disorientation, the fast has to be broken immediately and treatment (glucose tablets, sugary drinks, followed by a snack) commenced.

With fasting, the risk of high blood glucose levels (“hyperglycaemia”) may increase due to the change in eating patterns. This may lead to a serious complication called ketoacidosis.

The symptoms of hyperglycaemia include increased thirst, passing large amounts of urine and/or marked tiredness. Immediate medical attention should be sought whenever such symptoms arise.

Prior to the commencement of fasting, it is advisable to discuss with the doctor about medications and the maintenance of good blood glucose control.

The time, type or dose of medication may have to be altered, e.g. insulin users will require less insulin before commencing fasting and the insulin type may need to be changed.

The risk of aggravating diabetic complications such as poor vision or heart or kidney disease is increased by fasting and consideration needs to be given whether fasting is advisable.


Dr Milton Lum is a member of the board of Medical Defence Malaysia. The views expressed do not represent that of organisations that the writer is associated with.

What is Metformin

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Metformin is usually the first medicine prescribed for type 2 diabetes. It reduces blood glucose by decreasing the production of glucose by the liver and making the body’s cells more responsive to insulin.

It is generally well tolerated, with mild side effects of nausea, anorexia and diarrhoea.

Unlike other oral medicines, metformin does not cause weight gain. It also has a beneficial effect on outcomes in diabetics with heart disease.

It is usually not prescribed if there is impaired kidney function, liver cirrhosis, heart failure, chronic respiratory disease, vascular disease, severe infection, terminal ileum disease or previous gastrectomy.

If you are on Metformin and still not able to manage your diabetes, perhaps you should consult a Physician for other options available.

 

There is no cure for diabetes

For diabetics who can’t control glucose levels with lifestyle measures, drugs are required. sugar-973899_640THERE is no cure for diabetes. The objective of its management is to maintain blood glucose levels within normal limits to prevent the development of health problems, for example, heart disease, kidney disease or stroke, in later life. The initial treatment of mild type 2 diabetes is lifestyle measures, which is all that is necessary sometimes. However, medicines to control blood glucose levels are necessary when lifestyle measures are no longer effective in mild diabetes and in moderate to severe diabetes. The initial medicines will be tablets. Later, it may include insulin, which is injected, and/or other medicines as well.

If you are suffering from Type 1 & 2 diabetes, please consult a Physician for the available options.

Cholesterol Lowering Drugs – Does it mean I can eat anything?

You often hear people saying that once you have taken a cholesterol lowering drug, you can practically eat anything as you are safe. This statement is not true. Cholesterol in the bloodstream comes from certain foods while your liver makes some. Statins (class of drugs used to lower cholesterol levels) reduce the amount of cholesterol made by the liver but it does not reduce the cholesterol from the food we eat.

Doctors would always prescribed cholesterol lowering medication along with careful diet selection and lifestyle changes. Doctors would also suggest a nutritionist to assist you in the careful selection of meals that are high in cholesterol. Taking doctor prescribed medications with proper diet and lifestyle changes proves to be most effective in controlling cholesterol and reducing heart related problems.

 

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a disorder of the hand caused by pressure of the nerve that run through the wrist. Symptoms include numbness, pins and needles, and pain around the fingers. These sensations are often more pronounced at night and can awaken people from sleep.

Chronic carpal tunnel syndrome can also lead to wasting (atrophy) of the hand muscles and frequent dropping of objects from the hand due to reduced in grip strength.

For more information about other hand conditions, please refer to www.alphahandcentre.com or visit our Consultant Orthopaedic & Trauma Surgeon, Dr. Terence Tay at

Alpha Hand Surgery Centre
25 Jalan PJU 5/6, Kota Damansara,
47810 Petaling Jaya,
Selangor, Malaysia

Tel: +60 3-6142 1087 /+60 3-6141 8533

Breast Lumps

1. What are breast lumps?
Breast lumps are swellings felt within the breasts. They may be single or multiple.

2. How are breast lumps detected?
Breast lumps are usually discovered by the patient herself. This may be on self-examination or during unrelated activity e.g. during a shower. They can also be detected by a doctor during a health check-up. Breast lumps are reliably detected on screening by breast imaging, either with ultrasound or mammogram.

3. What are the related symptoms?
Most breast lumps are painless. Pain is found in a rapidly growing lump or if there is infection (abscess). Pain is not a feature in breast cancer.

Your doctor will ask relevant questions when you present with a breast lump. These include whether you had a previous history, how long it was there, fluid discharge from the nipple, the number of children you have, taking oral contraceptives (the ‘Pill’), whether you still have periods or if you are menopausal, and whether you have a family history of breast cancer. These questions aid in diagnosing the nature of the breast lump.

4. What are the types of breast lump?
Breast lumps are either cystic (liquid-filled) or solid. Cysts are almost entirely benign. Solid lumps can be either benign or malignant (cancerous). Benign lumps are mostly fibroadenomas (firm white lumps containing the protein collagen). Other benign lumps include haematoma (old blood clots), galactocoele (collection of breast milk), mastitis (inflammation), abscess (infection) and granuloma (chronic infections including tuberculosis).

5. What are the tests required?
The ultrsound scan will distinguish between cystic and solid masses. Mammography (‘Mammo’) is useful in detecting changes in the breast pattern (architecture) on plain x-ray films; some of these changes may indicate early cancer even before a ump is detected. Mammograms are usually recommended after the age of 40. Because these tests provide different kinds of information, a combination of both is often used. In cystic swellings, the fluid may be aspirated (drawn out) and sent for cytology, which is a microscope test to look for cancer cells. Solid lumps can also be studied by this method, namely fine needle aspiration cytology (FNAC). The accuracy of this test is over 90%.

6. What is the treatment?
Cysts should mostly be left alone. They can be aspirated if large and/or cause symptoms, such as discomfort. Should a solid lump be left alone of removed? Based on the history, physical examination, and ultrasound and/or mammogram, your surgeon will advise on the best treatment plan for you. If there is any suspicion of cancer, urgent FNAC and/or excision is vital.

7. Surgery for breast lumps
Excision is done under general anaesthesia. This is not a major surgery and can be performed in a day-care setting; i.e. you do not require overnight hospital stay. It is a short procedure (about 30 minutes). The scar will match the size of the lump. If absorbable sub-cuticular (under the skin) sutures are used, they do not have to removed and scarring is much less. All excised lumps are sent to the laboratory for histological examination (HPE)to determine their exact nature. Needless to say, early surgery offers the best chance of cure in breast cancer.


 

Disclaimer: Nothing on this blog should be considered or used as a substitute for medical advice, diagnosis or treatment. Blog visitors with personal health or medical questions should consult their health care provider.

Heartburn or acid reflux

Acid reflux is also known as heartburn or acid indigestion. It creates a burning pain in the lower chest area and often after eating. Acid reflux is often associated with our lifestyle and eating habits.  Eating frequent but smaller meals can help reduce your risk of heartburn and acid reflux diseases. Reduced consumption of carbonated drinks and alcohol along with exercise may help to reduce the symptoms.

Symptoms to note:

  • Hard to swallow food down your throat
  • Indigestion for 3 weeks or more
  • Sudden weight loss
  • Frequent burping or trapped wind
  • Nausea or vomiting
  • Pain in the upper stomach area

 

People who suffer from persistent heartburn for more than 3 weeks should seek help from doctor or a Gastroenterologist as it may lead to stomach and oesophageal cancers or other medical conditions.

Preventing strokes

Primary prevention to reduce the incidence of stroke should be targeted at the whole population and groups that are at increased risk by increasing awareness and promoting healthy lifestyles that reduce the risk factors for stroke.

THE brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage, and possibly death of the brain cells.

A stroke, which is also called a cerebrovascular accident (CVA), is a condition in which the blood supply to a part of the brain is cut off. It is a medical emergency and the earlier treatment is provided, the less likely will be the damage.

Strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum (i.e. every hour, six people experience a stroke).

The risk for recurrent vascular events after a stroke or transient ischaemic attack (TIA) is about 5% per year for stroke, 3% per year for heart attack, and 7% per year for any one of stroke, heart attack or vascular death. The risks are higher in patients who are at an increased risk of CVA or who have carotid stenosis.

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA.

As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes.

Risk factors

A risk factor increases the chances of getting or having a certain health condition. Some risk factors for stroke cannot be changed, but others can be prevented. Changing risk factors over which a person has control will assist in achieving a longer and healthier life.

Strokes are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

  • Age – The risks are increased in the older person, although about a quarter of strokes occur in the young. The risk doubles in each successive decade after 55 years of age.
  • Gender – The risks are increased in males (except in older adults, when it evens out).
  • Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.
  • Medical history – The risks are increased if one has had a heart attack, stroke or TIA. The risks are also increased in pregnancy, abnormal heart beats, chronic renal disease, cancer, some types of arthritis, and in those with abnormal blood vessels or weakness in the wall of an artery.
  • Family history – The risks are increased if a close relative has had a stroke.

Primary prevention is vital in any programme to reduce the incidence of stroke. This should be targeted at the whole population and groups that are at increased risk by increasing awareness and promoting healthy lifestyles that reduce the risk factors for stroke.

Secondary prevention are measures used to prevent recurrence of a stroke. They are individualised depending on the person’s pathogenesis based on neuroimaging and other investigations.

The prevention of stroke is similar to the prevention of coronary heart disease.

High blood pressure

High blood pressure (hypertension) is a major risk factor for stroke. The incidence increases in proportion to both the systolic and diastolic blood pressures. Isolated systolic hypertension (systolic blood pressure of more than 160mm Hg and diastolic blood pressure of less than 90mm Hg) is an important risk factor for senior citizens.

A reduction in blood pressure reduces the incidence of stroke. A reduction of the systolic blood pressure by 10mm Hg is associated with a reduction in risk of stroke by about a third, regardless of the baseline blood pressure levels.

Hypertension is controlled by diet, exercise and medicines.

Hyperlipidaemia

There is an association between raised blood lipids and risk of ischaemic stroke. Hyperlipidaemia is controlled by diet, exercise and medicines.

The use of statins in those at increased risk, e.g. those with cardiovascular disease, diabetes, reduces the incidence of coronary events and ischaemic strokes even in individuals whose blood cholesterol levels are normal (less than 5.0mmol/L).

Diabetes

Diabetes increases the risk of ischaemic stroke by 1.8 to 6 times. The incidence of stroke is significantly reduced by stringent control of hypertension in diabetics.

Scientific studies have indicated that strict control of the blood glucose (Hb A1c less than 6%) is critical.

Diabetes is controlled by diet, exercise and medicines.

Diet

Foods rich in fat lead to fatty deposits in the artery walls. The overweight are at risk of hypertension. A low-fat, high-fibre diet, which includes abundant fruits and vegetables (at least five servings daily), is recommended.

Unsaturated fats which increase the blood cholesterol, e.g. meat, ghee, lard, should be avoided. However, a balanced diet has to include some unsaturated fat like fish, olive and vegetable oils.

The daily intake of salt should not be more than 6gm (0.2 oz), which is about one teaspoonful.

Exercise

A combination of a healthy diet with regular exercise is the best method to maintain a healthy weight, which reduces the risk of developing hypertension.

Regular exercise ensures that the heart and circulation are efficient, keeps the blood pressure normal, and lowers the blood cholesterol.

The recommendation is that there be at least 150 minutes of exercise of moderate intensity, e.g. fast walking, per week (about 30 minutes daily).

A person who has had a stroke should discuss with his healthcare provider about possible exercise plans. It may not be possible to have regular exercise immediately after a stroke, but exercise should begin when there has been progress with stroke rehabilitation.

It is essential that weight be maintained at healthy levels. Many people go on weight reduction programmes only to find that they gain back the kilogrammes they lost. It would be better to accept a steady rate of weight loss instead of overnight success.

Programmes that promise an ideal weight within a short period of time do not usually work out in the long term. The key to keeping the weight loss is to make changes to diet and lifestyle that one can live with. One has to adhere to these changes for life; they have to be part and parcel of everyday life.

Smoking

Both active and passive smoking increase the risk of stroke. Smoking doubles the risk as it leads to narrowing of the arteries and increases the likelihood of the blood clotting.

Smoking cessation can reduce the risk of a stroke by up to half. In addition, it will also improve general health and reduce the risk of developing other serious conditions like heart disease and lung cancer.

Smokers who have stopped for more than five years have the same risk of stroke as non-smokers.

Alcohol consumption

Heavy alcohol consumption increases the risk of stroke by three times as it can lead to high blood pressure and irregular heart beats, which are both major risk factors for stroke. In addition, alcohol causes weight gain because they are high-calorie compounds.

Consumption of more than three units a day (one unit = one glass of wine = a peg of hard liquor) increases the risk while light or moderate alcohol intake protects against all strokes.

Aspirin

Aspirin has been reported to be of benefit to women aged 65 years or more in the primary prevention of stroke due to its blood thinning effects.

There is substantial evidence of the benefits of aspirin in secondary prevention of recurrent strokes, with a 25% reduction in risk in all patients with strokes who have received aspirin.

When given within 48 hours of a stroke, it has also been beneficial in reducing recurrent strokes and death.

Other anti-platelet medicines

Alternative antiplatelet medicines are prescribed in patients intolerant or allergic to aspirin, have contraindications to aspirin, or when aspirin has failed. The medicines include ticlopidine and clopidogrel.

It is essential to take aspirin or other anti-platelet medicines under the supervision of a doctor. In addition, one should take measures to avoid falls or tripping when taking these blood-thinning medicines.

In a nutshell

There are several measures that can be taken to prevent a stroke or a recurrent stroke, if one has had a stroke. The following will reduce the likelihood of a stroke or recurrent stroke:

  • Control high blood pressure through diet, exercise, and medicines, when necessary.
  • Control diabetes through diet, exercise, and medicines, when necessary.
  • Control raised cholesterol through diet, exercise, and medicines, when necessary.
  • Exercise at least 30 minutes a day.
  • Maintain a healthy weight by eating healthy foods, eating less, and joining a weight reduction programme, if necessary.
  • Do not smoke, or stop smoking.
  • Limit alcohol consumption to one drink a day for women and two a day for men.
  • Avoid illicit drugs.
  • Have regular medical checks and consultations with the family doctor or physician.

 

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

A cautionary sign

Transient ischaemic attack is a warning sign that a stroke may just be around the corner.

A TRANSIENT ischaemic attack (TIA) is due to a temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. Its features are similar to that of a stroke, but the duration is about a few minutes. The TIA is usually resolved within 24 hours.

TIAs provide a warning that further TIAs or a stroke is on the way. Its incidence is not well known as many people who have TIA do not seek medical attention. However, strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum, i.e. strokes occur in six persons every hour.

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA. As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes. Its early investigation and treatment will markedly reduce the risk of another TIA or stroke.

Anatomy of a TIA

The brain receives its blood supply primarily from the carotid arteries in the front of the neck and secondarily from the vertebral arteries in front of the backbone. These arteries branch into smaller vessels that supply blood to all parts of the brain.

One of these smaller blood vessels gets blocked off during a TIA. This blockage is temporary, lasting a few minutes, and the blood supply is restored soon after, unlike a stroke, in which the blockage lasts a longer period of time. The lack of a constant supply of oxygen-rich blood leads to damage, and later, death of the brain cells.

The blockage is due either to a narrowing of the arteries or as a result of a blood clot formed elsewhere in the body getting into the brain’s arteries to reach a blood vessel small enough to block its passage.

The brain’s arteries are narrowed or blocked by cholesterol deposits (plaques) on its inner lining due to atherosclerosis. Everyone’s arteries get narrower with age, but the process is hastened by factors like high blood pressure, poorly controlled diabetes, raised blood cholesterol, obesity, smoking, excessive alcohol intake, obesity, and a family history of diabetes or heart disease.

TIAs can also result from blood conditions like leukaemia, abnormally thickened blood (polycythaemia), or overproduction of platelets (thrombocythemia).

A TIA can result from blood clots formed in an artery (from elsewhere in the body), which gets “thrown” off (emboli) and eventually blocks the brain’s blood supply. This may be due to irregular heartbeats, the causes of which include high blood pressure, coronary artery disease, disease of the heart’s mitral valve, overactive thyroid gland and excessive alcohol intake.

It is rare that a brain haemorrhage causes a TIA.

TIAs, like strokes, are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

  • Age – The risks are increased in the older person, although TIAs can occur at any age, including the young.
  • Gender – Men are more likely to have TIAs than pre-menopausal women. However, the likelihood of TIA and stroke increases in postmenopausal women. Although the reason for this is not well elucidated, it is believed that the female hormones, oestrogen and progesterone, affect the elasticity of the body’s ateries.
  • Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.
  • Medical history – The risks are increased if one has had a heart attack, stroke or TIA.
  • Family history – The risks are increased if a close relative has had a TIA or stroke.

There are several other factors (preventable) that increase the risks of TIAs and strokes. They include:

  • High blood pressure (hypertension) is the single most important risk factor. The hypertension leads to extra strain on the arteries, causing them to narrow or be easily blocked.
  • Diet – Atherosclerosis is more likely to develop with a diet high in saturated fats and excessive salt intake.
  • Diabetes increases the likelihood of TIA because of the increased risk of atherosclerosis.
  • Smoking doubles the likelihood of TIA or stroke because the chemicals in the cigarette smoke cause thickening of the arteries, thereby increasing the likelihood of clotting.

Features of TIA

The features vary depending on the part of the brain that is affected and the extent to which it is affected.

The common features of TIAs and strokes are:

  • Face – There may be an inability to smile, open the mouth or the face or eye may hang downwards.
  • Arms – There may be an inability to lift one or both arms due to numbness or weakness.
  • Legs – There may be an inability to move one or both legs due to numbness or weakness.
  • Speech – There may be slurring of speech or an inability to talk at all although awake.

Other features may include sudden vision loss, dizziness, difficulty talking and understanding what others say, difficulty swallowing, balancing problems, sudden headache, and blacking out.

Diagnosis

Immediate medical attention should be sought if one has or knows another person who has features of a TIA. This will reduce the likelihood of another TIA or stroke.

The diagnosis of a TIA is made by history taking and physical examination even if one thinks that the symptoms have gone. The objective is to check the patient’s neurological status and to rule out other conditions which may have caused the symptoms.

If a TIA is suspected, a referral will be made to a physician, geriatrician or neurologist for further evaluation. This should be done within a week of the occurrence of a TIA and immediately if there is more than one TIA in a period of seven days.

There are several investigations that are carried out after a TIA to check for the underlying conditions that may have caused it. They include:

  • Blood tests like clotting factors, glucose, cholesterol
  • Electrocardiogram to detect any abnormal heart rhythms
  • Chest x-ray may be done to exclude other medical conditions
  • Imaging

The common methods of brain imaging are computerised tomography (CT) scan and magnetic resonance imaging (MRI).

The CT scan involves multiple x-ray imaging to produce detailed three dimensional images of the brain and will provide information about factors that may have caused the TIA, e.g. haemorrhage or tumour. The MRI involves use of magnetic and radio waves to produce detailed images of the brain.

Both the CT scan and MRI are used to take images of the brain’s blood vessels as well the blood vessels in the neck that connect the heart and the brain’s blood vessels. This procedure, called a CT or MR angiogram, involves injecting a dye into a vein in the arm.

The brain imaging modality used depends on the availability of CT scan and/or MRI.

Other investigations of the cardiovascular system will be carried out to determine the cause of the TIA. It includes ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan). It can also include injecting dye into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

The management of TIA will be discussed in a subsequent article.


 

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with

Brain attacks

When blood supply to the brain is compromised, it can lead to damage, and possibly death, of the brain cells, a condition called stroke.

THE human brain has been compared to a supercomputer. But the brain is much more complicated than that, a fact that is confirmed with each new discovery about its capabilities, which is still largely unknown.

This single organ controls all the body’s functions, which include heartbeat, breathing, sexual function, thinking, speech, memory, emotions, movement, and sleep. It influences the immune system’s response to ill health, and determines, to some extent, how a person responds to medical treatment.

In short, the brain makes us human and separates us from other living creatures on planet Earth.

The brain, which is encased in the bony skull, is divided into two sides (hemispheres), each controlling the opposite side of the body.

Different parts of the brain have different functions. The frontal lobe is responsible for the highest intellectual functions like thinking and problem-solving. The parietal lobe is responsible for sensory and motor function. The hippocampus is involved in memory. The thalamus is the relay station for almost all of the information coming into the brain, and the hypothalamus, the relay stations for the systems regulating the body’s functions.

The midbrain has cells that relay specific sensory information from the sense organs to the brain. The hindbrain comprises the pons and medulla oblongata, which control breathing and heart functions, and the cerebellum, which controls movement and cognitive processes that require precise timing.

The brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage, and possibly death, of the brain cells. This is called a stroke.

A stroke, also called a cerebrovascular accident (CVA), is a condition whereby the blood supply to a part of the brain is cut off. It is a medical emergency, and the earlier treatment is provided, the less severe it will be.

Strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum, i.e. strokes occur in six persons every hour.

Different types

There are two main types of strokes.

Ischaemic strokes, which comprise the majority of stroke cases, occur when the blood supply to the brain stops because the vessel is blocked by a blood clot. This may be due to thrombosis, in which a blood clot forms in one of the brain’s arteries, or to an embolism, in which a blood clot formed elsewhere in the body gets into the brain’s arteries to reach a blood vessel small enough to block its passage.

Haemorrhagic strokes occur when bleeding results from a burst blood vessel supplying the brain because of weakness in its wall. The blood collection compresses the brain, causing damage and loss of function.

A related condition is transient ischaemic attack (TIA) in which there is temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. As TIAs provide a warning that a stroke is on the way, they should be treated seriously.

Causes of stroke

Strokes are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

·Age – The risks are increased in the older person, although about a quarter of strokes occur in the young.

·Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.

·Medical history – The risks are increased if one has had a heart attack, stroke, or TIA.

·Family history – The risks are increased if a close relative has had a stroke.

Ischaemic strokes occur when the brain’s blood supply is blocked by clots formed where the arteries are narrowed or blocked by cholesterol deposits due to atherosclerosis.

Everyone’s arteries get narrower with age, but the process is hastened by factors like high blood pressure, poorly controlled diabetes, raised blood cholesterol, smoking, excessive alcohol intake, obesity and a family history of diabetes or heart disease.

An irregular heartbeat leads to blood clots being thrown off to block the brain’s blood supply. The causes of irregular heartbeats include high blood pressure, coronary artery disease, disease of the heart’s mitral valve, overactive thyroid gland and excessive alcohol intake.

Haemorrhagic strokes occur when a blood vessel of the brain bursts, resulting in bleeding into the brain itself (intracerebral haemorrhage). Sometimes, the bleeding is on the brain surface (subarachnoid haemorrhage).

The primary cause of haemorrhagic stroke is high blood pressure, the risk factors of which include smoking, overweight or obesity, lack of exercise, excessive alcohol intake and stress.

Blood-thinning medicines can also cause haemorrhagic strokes, which can also occur from blood vessel malformations in the brain or an aneurysm, which is a balloon-like swelling of a blood vessel.

Trauma can also cause bleeding in the brain. Although the cause is usually apparent, bleeding into the brain’s lining (subdural haematoma) may occur without signs of trauma.

A rare cause of stroke is blood clot formation in the brain’s veins, which is usually due to clotting abnormalities.

Signs and symptoms

The features vary depending on the part of the brain that is affected and the extent to which it is affected. Strokes usually occur suddenly.

The common features are:

·Face – There may be an inability to smile, open the mouth or the face or eye may hang downwards.

·Arms – There may be an inability to lift one or both arms due to numbness or weakness.

·Legs – There may be an inability to move one or both legs due to numbness or weakness.

·Speech – There may be slurring of speech or an inability to talk at all.

Other features may include sudden vision loss, dizziness, difficulty talking and understanding what others say, difficulty swallowing, balancing problems, sudden and severe headache, and blacking out.

Awareness of the above features is crucial, particularly for those at increased risk of a stroke, and their caregivers.

The complications of stroke include swallowing problems (dysphagia), which affect about a third of stroke patients. This leads to small food particles entering the respiratory tract causing lung infection (pneumonia).

Stroke can also lead to excess cerebrospinal fluid (CSF) in the brain’s ventricles (hydrocephalus) in about 10% of haemorrhagic strokes. CSF, which is produced by the brain, is continuously drained away and absorbed by the body. When its drainage is stopped following a haemorrhagic stroke, the excess CSF causes headaches, loss of balance, nausea and vomiting.

A small percentage of stroke victims who have lost some or all movement in their legs will have blood clot formation in their legs. The features of this deep vein thrombosis (DVT) include swelling, pain, tenderness, warmth and redness, especially in the calf. Urgent diagnosis and treatment is necessary to avoid the clot moving to the lungs, causing pulmonary embolism, which is potentially fatal.

Diagnosing stroke

The diagnosis of a stroke is made by history taking and physical examination. However, imaging of the brain is essential to determine if it is an ischaemic or haemorrhagic stroke, the part of the brain that is affected, and the severity of the stroke.

As the treatments of the different types of stroke vary, a speedy diagnosis will facilitate its management.

The common methods of brain imaging are computerised tomography (CT) scans and magnetic resonance imaging (MRI).

The CT scan involves multiple x-ray imaging to produce detailed three-dimensional images of the brain. MRI involves the use of magnetic and radio waves to produce detailed images of the brain.

Both the CT scan and MRI are used to take images of the brain’s blood vessels, as well as the blood vessels in the neck that connect the heart and the brain’s blood vessels. This procedure, called a CT or MR angiogram. involves injecting a dye into a vein in the arm.

The brain imaging modality used depends on the availability of a CT scan and/or MRI. A CT scan provides enough information if the suspected stroke is major. The MRI is useful if there are complex symptoms, the extent or location of the affected area is unknown, and in patients who have recovered from a TIA.

Brain imaging should be done early; in some patients, within an hour of admission.

A swallow test is usually done for all stroke patients because of the risk of aspiration pneumonia due to dysphagia. This involves giving a few teaspoons of water to the patient and if there is no choking or coughing, to be followed by half a glass of water.

Other investigations of the cardiovascular system will be carried out to determine the cause of the stroke.

It includes ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan). It can also include injecting dye into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

The management of stroke will be discussed in a subsequent article.


 

Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.