Over the span of this course, I have had the ability to gain a greater perspective on the health care system and how it relates to my role as a Medical Radiation Technologist. In my journey of continuing to learn more about stroke, I will be exploring its prevalence in Canada, the gold standard for imaging to diagnose and treat patients experiencing stroke like symptoms, identifying the impact this disease has on women and the Indigenous community, as well as what advancements in technology there are to assist in diagnosis.
The definition of stroke is when the blood flow to the brain is stopped (John Hopkins Medicine, n.d.). The effects of stroke depends on the part of the brain affected and the extent of damage (Heart and Stroke, 2018). The different types of stroke can be identified as:
Ischemic Stroke: the most common type of stroke. It is the result of a major blood vessel being blocked. The blockage can be caused by a blood clot or a buildup of fatty deposit or cholesterol, also known as plague (John Hopkins Medicine, n.d.).
Hemorrhagic Stroke: the result of a burst blood vessel in the brain. The burst causes spilling of blood into nearby tissues and results in pressure build up in nearby brain tissue (John Hopkins Medicine, n.d.).
Transient Ischemic Attack (TIA): sometimes referred to as a “mini stroke”. It is caused by a small clot that briefly blocks an artery and stops blood flow. TIAs can be a warning that a more serious stroke may occur (Heart and Stroke, 2018).
Stroke is the leading cause of death and disability in Canada and worldwide (Kapral et al., 2020). One person dies in Canada every five minutes from heart conditions, stroke or vascular cognitive impairment (Heart and Stroke, n.d.). More than 62,000 strokes occur in Canada each year; over 30,200 of these happen to women (Heart and Stroke, 2018). Compared to other diseases Canadians suffer from, 13% more people die of heart conditions, stroke and vascular cognitive impairment than die from all cancers combined (Heart and Stroke, n.d.). After age 55, the risk of stroke doubles every 10 years. Males have a slightly higher prevalence of living with the effects of having a stroke than females in all age groups, however, 59% of stroke deaths occur in women, likely because women live longer, and men are more likely to die from other causes (Health Canada, 2006). The astonishingly high prevalence of stroke has significant impact on the Canadian economy - $3.6 billion a year in physician services, hospital costs, and lost wages (Heart and Stroke, n.d.). Unfortunately, once a stroke has occurred, there is no cure. With ongoing research and advances in medical and surgical treatments, the aim is to reduce one’s risk of experiencing another stroke (John Hopkins Medicine, n.d.).
The faster the signs of stroke are recognized and the person experiencing stroke gets to a hospital with acute stroke care services, the better their chances of survival and a good recovery (Heart and Stroke, 2018). One may ask, what does this have to do with diagnostic imaging? Both the diagnosis and treatment of stroke are a result of procedures performed in diagnostic imaging departments. A non-contrast CT is the primary imaging modality to evaluate those experiencing stroke like symptoms due to it’s availability in healthcare settings and speed in which the images can be processed (Birenbaum et al., 2011). This imaging procedure may identify the early signs of stroke, but most importantly, will exclude intracerebral hemorrhage and lesions that might mimic acute ischemic stroke (Birenbaum et al., 2011). Immediately after a non-contrast CT, a computed tomographic angiography (CTA) is often also performed, in which a rapid injection of intravenous contrast is administered to highlight the blood vessels in the brain. When the CTA reveals a blocking in a major blood vessel within a three hour time frame, then the decision to administer intravenous tissue plasminogen activator (TPA) is made as a stroke is more accurately identified (Birenbaum et al., 2011). Once TPA is administered, a patient can then be transferred to an Interventional Radiology suite, wherein an angiography would be performed. Angiography is a study that assists in visualizing slow blood flow through a constricted vessel and delayed filling of capillary vessels (Birenbaum et al., 2011). More specifically, an Endovascular thrombectomy (EVT) procedure is often performed, which uses a retrievable stent to physically remove large clots. EVT is highly recommended within six hours of stroke onset (and up to 24 hours).
While Ontario residents have universal access to hospital and physician services and diagnostic tests (Kapral et al., 2020), 95% of the Canadian population is currently within a six-hour drive of one of the 23 existing EVT stroke centres (Heart and Stroke, 2018). In a study performed by Kapral et al. (2019), rural residence was associated with an increased rate of stroke and mortality. Those living rurally have a 23% increase in stroke incidence and a 30% increase in stroke mortality, as compared to those living in an urban setting. The differences are mostly related to differences in cardiovascular risk factors, comorbid conditions, and access to care, as well as sociodemographic factors such as income, education, race, and ethnicity (Kapral et al., 2019).
In my previous blog post, the focus was on various modifiable risk factors which can contribute to one’s risk of suffering from a stroke. Some modifiable risk factors are hypertension, tobacco usage, alcohol consumption, and their socioeconomic status. There are, however, a number of non-modifiable risk factors that can also contribute to one’s chances of suffering from this disease. Specifically, they are related to age, gender, race, and whether they have experienced a prior stroke or TIA. It’s important to note that age is one of the single most important risk factors of stroke worldwide. Contrary to popular belief, however, stroke is not limited to the elderly, as one quarter of all stroke survivors are younger than 65 (Johns Hopkins Medicine, n.d.). A previous history of stroke or TIA significantly increases the risk for recurrent stroke; the risk is highest within the first 30 days after a stroke. Those suffering a TIA will present with the same symptoms as stroke, but the symptoms don’t last. If one has had one or more TIAs, they are almost 10 times more likely to have a stroke than someone of the same age and sex who has not had a TIA (Johns Hopkins Medicine, n.d.).
Stroke disproportionately affects women. More women die of stroke, women have worse outcomes after stroke, more women are living with the effects of stroke, and they face more challenges as they recover (Heart & Stroke, 2018). “Women have so many pressures on them with work and family that they do not take enough time to put their own health first. When signs of stroke appear in a younger female, they are more likely to down-play what they are experiencing and waste valuable time before seeking medical help, putting them at risk for a worse outcome,” says Dr. Patrice Lindsay, Director, Heart & Stroke. “We must improve stroke awareness and make sure women get access to life-saving care as fast as possible.” (Heart & Stroke, 2018). It is imperative that women take the necessary actions in getting treatment as soon as possible to ensure optimal levels of recovery can be achieved (Heart & Stroke, 2018).
Women of South Asian and African descent are at greater risk as are Indigenous women, who are also facing an increase in stroke rates and challenges to accessing adequate treatment and recovery support (Heart & Stroke, 2018). Specifically, Indigenous women are facing an increase in stroke rates and challenges in accessing treatment and recovery support (Heart and Stroke, 2018). Rates of hospital admission for stroke or TIA were higher among First Nations people than other people with diabetes in Ontario (Kapral et al., 2020). First Nations people were younger, more likely to be female, and more likely to live in rural areas (Kapral et al., 2020). Rates of cardiovascular disease among Indigenous women in Canada are rising and are nearing or surpassing those of non-Indigenous women. First Nations, Métis and Inuit peoples are more likely to have high blood pressure and diabetes – both risk factors for stroke – and are at greater risk of stroke than the general population, and twice as likely to die from it. Those living in remote and isolated communities face challenges accessing timely life-saving acute stroke treatment as well as recovery support. Social determinants of health such as poverty, education, access to affordable food and safe drinking water, and unsafe living conditions have created a widening health gap (Heart and Stroke, 2018). Generational trauma and stress created by the impacts of historical policies, such as the legacy of residential schools, has influenced a burden of risk factors, heart disease and stroke in Indigenous women (Heart and Stroke, 2018). Although western medicine has demonstrated benefits in treating members of the Indigenous community, many healthcare facilities do not offer traditional medicine options for healing. Spirituality is an integral part of Indigenous culture. Traditional medicine healing practices and beliefs are unique among First Nations, Métis and Inuit people. Health and wellness is based on a wholistic approach that embodies the physical, emotional, mental and spiritual self and treats the whole person (Heart and Stroke, 2018). Not having traditional medicine options available, may also deter those in the Indigenous community from being treated in a healthcare facility solely focused on Western medicine.
In an effort to allow Ontarians to obtain equal access to stroke services, the province adopted the Ontario Stroke Strategy. This program aims to decrease the incidence of stroke and to improve patient care and outcomes for persons who experience stroke. By reorganizing stroke care delivery, the goal of the Ontario Stroke Strategy is to ensure that all Ontarians have access to appropriate, quality stroke care in a timely manner (Black et al., 2003). This initiative includes a Telestroke program to provide care in remote areas, which has resulted in improvements in acute stroke care, including elimination of a divide in the use of thrombolysis for rural versus urban residents (Kapral et al., 2019).
The field of diagnostic imaging is constantly advancing and improving with the development of new and innovative technologies. Over the past number of years, the introduction of Artificial Intelligence (AI) has taken over the industry across many modalities. AI refers to the ability of a machine to simulate human intelligence by thinking and acting like humans. This new technology is allowing faster, more accurate diagnosis of diseases than ever before. In an article released by Oren et al. (2020), AI often detects minor image alterations, more relevant outcome variables, include new diagnosis of advanced disease, disease requiring treatment, or conditions likely to affect long-term survival (Oren et al., 2020)
Although more research into the complexities of stroke are required, it is important for those who are at risk of stroke to be mindful of the modifiable risk factors needed in preventing the occurrence of stroke. It is important to highlight that stroke affects women throughout their lives and they are the constant: whether they personally experience a stroke, or are caregivers to loved ones who have had a stroke. Stroke disrupts women’s lives, affecting their roles at home, at work, and in the community, straining relationships and threatening their independence (Heart & Stroke, 2018). When living in a rural community, much like Indigenous Canadians, the risk of suffering from this disease drastically increases. With the programs that Ontario has made available as well as technologies being developed, the hope is that those most at risk for stroke would obtain the necessary life saving treatments available for optimal recovery.
References
Birenbaum, D., Bancroft, L. W., & Felsberg, G. J. (2011, February). Imaging in acute stroke. West J Emerg Med, 12(1), 67-76. Retrieved April 1, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088377/
Black, D., Lewis, M., Monaghan, B., & Trypuc, J. (2003, June). System Change in Healthcare: The Ontario Stroke Strategy. Hospital Quarterly, 6(4), 44-47. Retrieved March 31, 2022, from https://www.longwoods.com/content/16610/healthcare-quarterly/system-change-in-healthcare-the-ontario-stroke-strategy
Health Canada. (2006, June). Stroke. Public Health Agency of Canada. Retrieved March 31, 2022, from https://www.canada.ca/en/health-canada/services/healthy-living/your-health/diseases/stroke.html#ef
Heart and Stroke. (n.d.). Connected by the numbers. Heart and Stroke Foundation of Canada. Retrieved March 31, 2022, from https://www.heartandstroke.ca/articles/connected-by-the-numbers
Heart and Stroke. (2018). Lives disrupted: The impact of stroke on women. Stroke report. Retrieved April 1, 2022, from https://www.heartandstroke.ca/-/media/pdf-files/canada/stroke-report/strokereport2018.ashx
John Hopkins Medicine. (n.d.). Risk factors for stroke. The John Hopkins University. Retrieved March 30, 2022, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/risk-factors-for-stroke
Kapral, M. K., Shah, B. R., Green, M. E., Porter, J., Griffiths, R., Frymire, E., Slater, M., Jacklin, K., Sutherland, R., & Walker, J. D. (2020, January 1). Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: A population-based Cohort Study. CMAJ Open, 8(1), 156-162. Retrieved March 31, 2022, from https://www.cmajopen.ca/content/8/1/E156
Oren, O., Gersh, B. J., & Bhatt, D. L. (2020, August 24). Artificial Intelligence in medical imaging: Switching from radiographic pathological data to clinically meaningful endpoints. The Lancet Digital Health, 2(9), 486-488. Retrieved March 24, 2022, from https://www.sciencedirect.com/science/article/pii/S2589750020301606
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