Treating with strokes, brain cancer

BAVINA SOOKDEO

May is both Stroke Awareness Month and Brain Cancer Awareness Month, and Dr Avidesh Panday, a neurologist at Eric Williams Medical Sciences Complex, NCRHA, spoke to Newsday to shed some light on the topics of stroke and brain cancer as well provide insight on managing these locally.

Panday graduated from the faculty of medical sciences, University of the West Indies, St Augustine Campus and received his neurology training at the University of Calgary, Alberta, Canada. He is a fellow of the Royal College of Physicians (London) and the European Board of Neurology.

Understanding brain cancer and stroke

“Brain cancers can be divided into two subgroups – primary brain tumours and metastatic tumours,” Panday explained.

“Primary brain tumours arise directly from the brain and in some instances, the surrounding surface of the brain known as the meninges. Metastatic tumours are tumours that arise in other areas of the body such as the lungs and spread into the brain.”

Panday said a leading cause of brain cancer is genetics. “The predominant risk factor is that of genetic factors. Within each of our cells, there is a genetic code which programmes the way that our cells function.”

He explained that they are responsible for how fast our cells replicate and repair themselves when damaged or attacked.

“In some persons, there can be changes in this genetic code known as a mutation which can change the way our cells divide or respond to threats leading to tumour formation or growth. This explains why genetic testing is important in some patients with cancer as it assists us in guiding treatment regimens.” Other risk factors can include certain dietary products, such as cured meats and there is some evidence about repeated head trauma/traumatic brain injury as risk factors. While tobacco is a risk factor for most cancers, the doctor said it seems the risk of metastatic cancers from sources outside of the brain are more associated with tobacco smoking rather than primary brain tumours.

As for strokes, Panday explained, “A stroke is essentially a process where brain cells die due to a lack of blood supply (oxygen) either through blockage of an artery (termed ischemic stroke – roughly 85 per cent of cases or bleeding within an artery (termed haemorrhagic).” Pointing out that strokes can have multiple presentations he said, “In fact, it is possible for a patient to have a stroke and not know, for example, if the part of the brain responsible for vision is affected by a stroke, there would be visual loss. If the area for balance is affected, you can have impaired balance without loss of power.”

While brain cancer and stroke are medically distinct, he noted they can produce similar symptoms.

“They may produce similar symptoms but via different mechanisms. Also, the presentation of symptoms may differ in terms of timing.”

For example, he said, if a patient has a stroke affecting the power area then they may have symptoms of sudden onset weakness. If the patient has a tumour in the same area of the brain, the weakness may be slowly progressive or the patient could present with a first time seizure.

The local landscape: Steady numbers, persistent challenges

When asked whether stroke or brain cancer cases are on the rise in Trinidad and Tobago, the doctor said: “From my perspective, I think the numbers have been steady with no definite increase in rates of either.” He referenced a recent research project he participated in at a major local hospital, stating “We detected 546 patients with strokes during the period January 2023 to December 2023.” Panday also noted that there hasn’t been a significant change in age at diagnosis. He said in the above-mentioned study, the average age of patients with stroke was 65 years, and there was a male prevalence of 56 per cent.

As it regards brain tumours, he said, “Generally speaking, primary brain tumours are detected in younger patients, even in the paediatric and adolescent range and metastatic tumours, much later on in the mid 60s.”

Recognising symptoms and reducing risk

Symptoms of neurological conditions can be diverse. “Some patients may have a seizure whereas some can have loss of awareness.

“Some patients can present with loss of vision, impairments in balance and weakness. It is important that should you experience any neurological symptoms which are new to you, you seek urgent medical care.”

He highlighted the "Be Fast" acronym for stroke symptoms:

Balance

Eyes

Face drooping

Arm or leg weakness

Speech impairment

Time to seek treatment (if any of above)

To reduce stroke risk, Panday advised: “Eat healthily, exercise regularly, check in with your primary health care provider and get your routine blood tests depending on age or risk factor profile and avoid the typical risk factors for strokes.”

Treatment and technology: What’s available

Time is critical in stroke treatment. There is a "golden window" of 4.5 hours from the time of onset of symptoms where certain medications can be administered to dissolve the clots that cause the stroke and minimise and/or (in some instances either in short or long term) reverse the initial symptoms.

“This underscores the importance of not delaying treatment and why we say 'time is brain.' For every minute that treatment is delayed, brain cells are dying which translates into more neurological disability.”

Yet only “one per cent of all strokes worldwide are treated with this medication due to various factors such as time to access care and delays in accessing scans among other factors.”

In brain cancer treatment, patients are typically supported by a multi-disciplinary team consisting of the neurosurgeon and oncologist (cancer specialist).

“Some patients may be offered surgery where the surgeon tries to remove as much of the tumour as possible. This treatment may be in conjunction with medications (chemotherapy) and/or radiation treatment to the brain,” Panday said.

There have also been technological advancements. “Specifically in stroke care, there are newer imaging modalities such as perfusion imaging where we can look at the areas of the brain that have also incurred damage and see the surrounding tissue that is still viable. This can assist in administration of the appropriate type of treatment.” He said some hospitals are equipped with catheterisation labs where patients can even benefit from a procedure where the clot can be retrieved through retrieval devices inserted via the groin or hand.

Life after stroke or brain tumour: A long journey

Aftercare is critical to recovery, and Panday noted that different patients accrue differing degrees of disability. “One patient may have mild weakness of the right hand alone whereas another can have total loss of power affecting the right hand and leg. This can render the patient unable to walk or even meet basic self-care needs,” he explained.

“It is important (and in most cases), stroke patients have access to rehabilitation services such as physical therapy, speech and language therapy and occupational therapy.”

Some patients may be at very high fall risks or risks of infections from pressure ulcers to the lower back, shoulders as well as heel. “Such patients may need 24 hour or extended supervised home care” he advised.

When asked about access to care for the average citizen, Panday said, “All public major hospitals are capable of administering basic level stroke and after stroke care as well as investigations for stroke such as CT scans. The rate-limiting factor would be having an assessment, getting the CT scan and supporting tests done in a timely manner so that treatment can be administered within 4.5 hours. Presently this has been done at public tertiary care hospitals once the criteria for treatment has been met.

Highs and lows: A doctor’s perspective

Panday describes treating stroke and brain cancer patients as a journey with emotional peaks and valleys: “In some cases the outcomes are spectacular… and in some patients who were totally paralysed, (they) return to a good level of independent function at two to three months. However, some patients may have permanent deficits such as paralysis, loss of vision and mobility.”

He highlighted that in certain brain tumours, especially aggressive ones, some patients progressively deteriorate and may die within a few months. However, he said he recently saw a patient who was expected to live for no more than a few months, survive with a good quality of life for 14 years. “In most cases, you follow these patients for many years and you share the highs and lows with the patients and their families. You've got to be mentally strong in this speciality of medicine.”

A call for compassion and support

While praising local awareness efforts such as Ministry of Health awareness campaigns, Panday believes more can be done. “I would like to see better or more accessible social and medical (rehabilitation) services for post-stroke/tumour or really any patient affected with a neurological illness. As you can imagine, this places a huge burden on the patient and their family.”

His final message is one often heard: “Prevention is better than cure,” and he reiterated the importance of maintaining a healthy lifestyle through proper diet, regular exercise and routine medical check-ups.

“Be your brother's keeper – little things can go a long way for patients with neurological illness, little acts of kindness such as allowing them to go before you at the bank or grocery, occasionally touching base with a simple phone call to friend with a stroke may go a long way in that patient's psychological function."