A Neurosurgeon’s Guide to Strokes

Last updated on May 4, 2021.

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Stroke is the fourth leading cause of death in Hong Kong. Globally, it affects 15 million people every year and takes a life away every 6 seconds, according to the World Stroke Organization. What makes stroke a devastating disease is not only the possibility of death, but also its continuous impacts on patients and their family members.  

What is a Stroke?

Also known as cerebrovascular accidents or a brain attack, stroke is a life-threatening emergency condition. It happens when blood flow to the brain is cut off. Brain cells then cannot get oxygen and nutrients, resulting in injuries or even death of these cells. Stroke patients may not be able to carry out important brain functions permanently, such as reasoning, speech, vision, limb movement and regulation of other organs. 

There are two main types:

  • Ischaemic stroke: is caused by a blood clot in the brain blood vessels, or accumulation of plaque (blood clots & fatty substances) that narrows the blood vessels. Around 80% of the cases are ischaemic
  • Haemorrhagic stroke: is caused when a brain vessel bursts, which leads to bleeding in or around the brain. It can also be a result of uncontrolled high blood pressure or a brain aneurysm

Transient Ischaemic Attacks Are Not Strokes!

Transient ischaemic attacks (TIA) or mini-strokes are similar to strokes. They share the same signs and symptoms. In TIAs, blood supply to the brain is interrupted briefly, usually lasting for less than a few minutes but it can be up to an hour. You will get better quickly. TIAs do not bring lasting damages. 

DO NOT IGNORE TIAs. You should seek medical help promptly as they often signal a greater risk of developing a major stroke soon. About 10-15% of people who have a TIA will get a full stroke within 3 months. 

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Signs and Symptoms of a Stroke

The presentation and effects of strokes depend on the location of blood vessels in the brain and the extent of damage. All signs and symptoms often occur suddenly without warning. 

The acronym FAST will help you immediately recognize the main symptoms

  • Face: Uneven facial expression. One side of the face, especially the lips, may droop. The person may not be able to smile. Typically eyes are spared.
  • Arms: The person will lose strength to lift either side of arms or legs up due to weakness. For stroke, symptoms would usually like to one side.
  • Speech: Ask the person to repeat a simple sentence. He or she may have difficulties speaking or understanding you. Their speech is strange or slurred. 
  • Time: Dial 999 right away if you notice any of these signs or symptoms. Urgent medical care is critical in reducing brain damage and improving recovery chances. 

Other possible signs and symptoms

  • Trouble walking, dizziness, loss or balance or coordination. 
  • Unexplained sudden, severe headache.  
  • Vision problems in one or both eyes, e.g. seeing blurred or double images, or loss of vision in one eye.
  • Sudden confusion, disorientation, or loss of memory.
  • Numbness or poor coordination of one side of the body and/or limbs
  • Swallowing difficulties, drooling saliva.
  • Altered consciousness or coma.
  • Loss of control of the bladder which may lead to urine leakage. 
  • Vomiting. 

What To Do if Someone Has a Stroke? 

  1. Stay calm and call 999 immediately. 
  2. Record the time when symptoms first started and notify the ambulance staff. Medications only work within a limited period of time. 
  3. Lay the person on one side in case he/she vomits. 
  4. Loosen or remove any tight clothing, e.g. unbuttoning the shirt.  
  5. Accompany and reassure the person. 
  6. Perform CPR if the person is not breathing. 
  7. Do not give any medications, food or drinks. 
  8. Do not drive the person to the emergency room yourself. 
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Causes and Risk Factors of Strokes

Medical conditions:

  • High blood pressure: is the main risk factor.
  • Diabetes: can cause other risk factors of strokes, e.g. raised blood pressure. Diabetes also damages blood vessels.
  • Heart and blood vessel diseases: e.g. atrial fibrillation, tumor, aneurysm.
  • High blood lipid level: it promotes the buildup of plaque on the inside of the artery walls, which can restrict blood flow.
  • Sleep apnea: it has been shown that there is an association between sleep apnea and strokes.
  • Trauma: Damage to neck vessels can cause a stroke

Risk factors that can be controlled:

  • Smoking: can injure blood vessels and increase blood pressure.
  • Unhealthy diet
  • Lacking physical exercise or obesity
  • Alcohol abuse: can also raise risks for high blood pressure and make you gain weight.
  • Stress
  • Drugs: e.g. illegal drugs, birth control pills and hormone replacement therapy. 

Risk factors that cannot be controlled:

  • Age: stroke affects all people from children to elderly, especially those aged above 55 years.
  • Sex: while men are more likely to have strokes, strokes cause more death in women. It is the third leading cause of death for women. Pregnant women also have an increased risk.
  • Race: South Asian, African or Caribbean people are at a greater risk.
  • Family history
  • Prior strokes, transient ischaemic attacks, or heart attacks.

How is a Stroke Diagnosed?  

Your doctor will look at the symptoms, medications you have been taking and your medical history to determine the probable causes of your stroke. He or she will also measure blood pressure & glucose level, evaluate mental status, and check your balance and coordination, eyesight problems, weakness or numbness of muscles including in the face and limbs. 

Several tests can also be run. For instance:

  • A blood test to find out the lipid and sugar levels in your blood.
  • Diagnostic imaging tests like CT scans and MRI scans to confirm the type of stroke, to show the severity,  bleeding or damage and their location in the brain.
  • Heart and blood vessel tests, such as electrocardiogram to see if there are heart conditions related to the stroke, echocardiography to find sources of blood clot in the heart, carotid ultrasound to detect any narrowing or occlusion of blood vessels, and cerebral angiogram to review blood flow through the brain in details. 
  • A swallowing test to assess ability to swallow and the risk of aspiration. Swallowing difficulties are common after strokes, and can be silent clinically until chest infection occurs.

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How Are Strokes Treated?

Ischaemic stroke

  • Tissue Plasminogen Activator (tPA): they dissolve blood clots and are most effective within 4.5 hours of stroke onset through intravenous injection. Examples include Alteplase, Reteplase and Tenecteplase.
  • Thrombectomy: is a surgical procedure using a catheter and a small device to remove blood clots. It is recommended for patients with large vessel occlusion, to be performed as soon as possible up to 24 hours of symptoms onset in selected case.
  • Antiplatelets: they reduce blood clot formation by preventing platelets from sticking together. Examples include aspirin, dipyridamole and clopidogrel.
  • Anticoagulants: they reduce blood clot formation and thin the blood by changing the chemical composition of blood. It is particularly useful to prevent stroke related to atrial fibrillation. Examples include warfarin, dabigatran, apixaban and heparins.
  • Statins: they are lipid-lowering agents, which also help to stablize plagues and reduce the risk of recurrent stroke, for example atorvastatin and simvastatin

To avoid another stroke, endovascular stenting or carotid endarterectomy may be performed. It reduces the risk of another stroke caused by the plague within the vessel.

Stenting may also be considered for severely narrowed vessel or dissected (damaged) vessel to restore blood flow to the brain, 

Haemorrhagic stroke

  • Surgery: to relieve pressure within the skull by clearing the blood clot in the brain, releasing the cerebrospinal fluid, or to remove the skull bone to allow room for pressure to be relieved.
  • Embolization / clipping of aneurysm: if bleeding is related to rupturing of cerebral aneurysms, these surgeries have to be considered as soon as possible to prevent another devastating bleeding.
  • Stop medications that may increase bleeding risks

Your doctor may also prescribe blood pressure medications, such as hydrochlorothiazide, lisinopril and amlodipine

Stroke Recovery & Rehabilitation 

Strokes can impair a wide range of body functions and mental health greatly. The process of recovery often needs help from different medical professionals and some patients need long-term support. Below is a list of common problems encountered after strokes, and what to do to cope with them better. 

  1. Depression, anxiety, changed behavior or personality. You may need medications, or speak to a psychologist for counseling or cognitive behavioral therapy. Caregivers should also provide emotional support.  
  2. Reduced cognitive functions, for instance memory, attention, ability to make plans, problem-solving, orientation and reasoning, etc. Get help from your family members and friends if needed, and write down notes to remind yourself. Occupational therapist may help to consolidate training programs and seek ways to solve problems encountered during daily activities.
  3. Movement difficulties due to muscle weakness or one-side paralysis. Meet up with a physiotherapist so he or she can assess your condition, provide physiotherapy and teach you simple exercises to strengthen your muscles. You can also exercise based on your ability and use walking aids if needed.
  4. Aphasia (unable to understand and speak as a result of injuries in brain areas responsible for languages). See a speech therapist to help you understand the conversation, and improve your ability to speak correctly and clearly. Computerized apparatus may also help patients to communicate.
  5. Dysphagia (problems with swallowing), which can lead to aspiration and cause lung infections. Using a feeding tube may be needed but would deprive patients of the joy of eating. A speech therapist may help to coordinate training to allow patient to eat again. Liquid is usually the more risky type of food, a thickener may be required.
  6. Changes in vision, sensation and spatial relations judgment, etc. Acknowledge the deficit and pay attention to avoid bodily injury. For example if part of sensation is lost, patients need to be reminded to avoid unintentional burn injuries. If part of the visual field is affected, they need to pay extra cautions to the environment by turning the head to see.
  7. Difficulties controlling bladder and bowel movement, causing problems such as urine leakage, urinary tract infections, constipation and diarrhea, etc. Incontinence products and doing pelvic floor exercises may be useful. Do not refuse fluid intake.
  8. Returning to work. Evaluate your ability and challenges with your healthcare professionals to see if you can meet the demands and expectations of your work. It is common and often necessary to make adjustments at work with your employer.
  9. Spasticity, In general the muscle tone of the affected side would be raised. The increased muscle tone can lead to pain, deterred rehabilitation and caring problems. Frequent stretching, use of splints, and sometimes use of oral medications or Botox injections can help to reduce spasticity and improve quality of life.
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How to Best Prevent Strokes? 

A healthy lifestyle plays an important role in preventing a stroke from occurring. 

  1. Eat a balanced, low-fat and high-fiber diet with plenty of fruits and vegetables. Limit your salt consumption to 1 teaspoonful (6g) a day. Too much salt increases blood pressure. 
  2. Exercise regularly to stay at a healthy weight. You are encouraged to do at least 150 minutes of moderate-intensity aerobic exercise, for example swimming or brisk walk, weekly. 
  3. Quitting smoking can lower the risk of strokes and other serious diseases, for example lung cancer
  4. Avoid excessive alcohol intake. Men should only have up to 2 drinks and only one drink for women every day
  5. Treat and control underlying conditions, especially risk factors of strokes such as high blood pressure, high lipid level in blood, diabetes, and heart diseases. 
  6. Get regular checkups for early detection of any problems. 
  7. Proper stress management. 
  8. Take your preventive medications as prescribed if you have had a stroke. Second stroke risk is 15 times higher in stroke patients compared to others. 
  9. Know the warning signs of a stroke. 

How Much Does it Cost to be Treated for a Stroke in Hong Kong?

Cost of treatment in Hong Kong’s Public Sector:

For eligible persons with an HKID card, the cost for Accident & Emergency Departments (A&E) in public hospitals is $180 per attendance. The cost for inpatient (acute general beds) includes $75 admission fee and $120 hospital bed fee per day. Each attendance at Rehabilitation Day Hospital is $55. 

For non-eligible persons without an HKID card, the cost for A&E is $1,230 per attendance. Inpatient services in general hospitals are $5,100 per day. The cost for Rehabilitation Day Hospital is $1,320 per attendance. 

Beware of waiting times which can be very long in the public sector.

For details, call the Hospital Authority at 2300 6555.

Cost of treatment in Hong Kong’s Private Sector:

The cost of stroke treatment in the private sector varies in different private settings, and would be determined by doctor fees, medication fees, laboratory test and imaging test charges, and surgery charges, etc.

Generally, consultations with a doctor specialist neurosurgeon or neurologist in Hong Kong cost around $800 to $2,000, excluding medication fees. Diagnostic and assessment cost ranges from about $10,000 to over $25,000. Treatment packages offered in private hospitals for acute stroke cost roughly $70,000 – $90,000, excluding hospital charges and additional investigational test fees.

* All amounts are in HKD and were last updated in May 2021. No responsibility is accepted for any inaccuracies, errors, or omissions. It is always best to call ahead to make sure the information is still up-to-date.

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Does Insurance Cover Stroke Treatments in Hong Kong?

According to AD MediLink, consultations from a specialist neurosurgeon or neurologist are reimbursed under doctor specialist fees. Generally, high-end medical plans reimburse consultations and surgical fees in full without any sub-limit whereas local plans usually have surgical and doctor specialist limits. In regards to treatments and rehabilitation following a stroke, these are usually covered under outpatient benefits (eg. speech therapy, physiotherapy, etc.). It is important to check the extent of your outpatient benefits as well as any sub-limits. If you have any health insurance questions, contact an expert at AD MediLink at [email protected]

Useful Resources in Hong Kong

This article was reviewed by Dr. Wong Ping Hong Derek 黃秉康醫生. Currently, Dr. Derek Wong is a practicing neurosurgeon at the Hong Kong Neurosurgery Centre and an Honorary Consultant in Neurosurgery at Gleneagles Hospital Hong Kong. He has also been a Council member of the Hong Kong Stroke Society and the Hong Kong Society of Interventional & Therapeutic Neuroradiology since 2016.
This article was independently written by Healthy Matters and is not sponsored. It is informative only and not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be relied upon for specific medical advice.