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The Tsunami and Stroke: Two Killer Waves

It will soon be a year since the tsunami devastated the coast of many South-East Asian countries (Indonesia, Sri Lanka, Thailand, Maldives Republic, India and Myanmar), affected East Africa and changed the water level worldwide. On December 26, 2004, the day after Christmas was calm: people were carrying on with their normal lives, many enjoying their vacation at paradise-like resorts. Suddenly, and without warning, the forces of nature broke loose. In a matter of minutes, tens of thousands of lives were taken. Aside from our natural empathetic concern as humans, is there any relationship between the tsunami and cerebrovascular disease that could teach us – stroke neurologists – a specific lesson? First, there is the obvious. An enormous number of human beings were affected by the flood and many either died or suffered severe ischemic sequelae from different forms of cerebral hypoxia. Others may have sustained trauma causing cervicocephalic arterial dissections. Direct cranial injury likely caused different types of cerebral haemorrhage in many. The immediate loss of medications, and difficulties in reintroducing them in a timely way, probably contributed to the loss of therapeutic levels of anticoagulation, development of uncontrolled hypertension or arrhythmias with consequent cerebrovascular complications. There may be another important message from this natural catastrophe. While the toll was dramatic, sudden, hitting the young and old, men and women alike, it could have been prevented, and therefore, the number of casualties could have been minimized. Just like stroke, the tsunami was caused by the second strongest earthquake in the world’s history. Likewise, stroke is the second leading cause of death. There is little doubt that most people suffered a greater shock when reading about a tsunami than when they learn (through the media) about a movie star, politician or more directly of someone in their own family who has suffered a stroke. Is this disproportionate reaction justified? We know that approximately 200 000 people died within a few hours because of the tsunami (the total number of lives lost was about 300 000). Images in the newspapers and on TV and the Internet were terrifying. Families physically divided, others completely gone, lost children, orphans, entire villages erased forever from the face of the earth. For most people, the loss of life at this level of magnitude would be the worst imaginable nightmare. As stroke physicians we, fortunately or unfortunately, have access to even more frightening statistics every day. We ought to use this sad, natural catastrophe to help lay people understand the magnitude of cerebrovascular disease. Out of the 15 million people that annually suffer a stroke worldwide, 5.5 million die. This is equivalent to the deaths caused by a tsunami occurring every 2 weeks. What measures and efforts would be initiated toward stroke prevention if such a huge wave of deaths occurred in different areas of the world twice a month? We would all be petrified with horror, wondering when our turn would come. Public awareness would immediately increase, most people would become stroke experts, and technological and economic resources would pour into stroke prevention. Indeed, if the problems faced by the victims of stroke attracted the same kind of attention as those of the tsunami, the harnessing of a similar level of presently available medical knowledge and pharmacological resources would save more than a million lives per year worldwide. But this is not the case. There are critical attitudinal differences between the tsunami and stroke. (1) A follow-up seismic activity on March 28 caused terror in those that had recently suffered the unleashed power of nature. However, communities become accustomed to the all too frequent occurrence of stroke around them. (2) According to seismologists, predicting earth movements that can generate a new tsunami is a difficult task. However, blood pressure machines, blood analyses for lipids and other risk factor identification procedures are readily available. (3) The water calmly retiring from the beaches was the only, and brief, warning preceding the killer wave that followed. Stroke, on the other hand, is often preceded by days, weeks and even years of heralding vascular risk factors. (4) The tsunami is an accident of nature. Stroke is not a cerebrovascular accident. As stroke physicians, we are failing in transmitting the real magnitude of the stroke wave toll to the general community. The alarm is going off but there is no answer to this wake-up call. Primary prevention is needed as much as care of the acutely and chronically affected. Blood pressure measurement, laboratory analyses, drugs for prevention and treatment of risk factors, thrombolytics for acute stroke and other measures are all available. Cerebrovascular disease does not come in the form of water, but as a constant wave, and has been with us all along while the world mostly watches. While we must be concerned about the ‘first 3 h’ after stroke, we cannot lose sight of the next 10 years to plan for prevention and improved acute management strategies. If ‘time is brain’ let us not waste another second. Let the tsunami analogy inspire us to increase our efforts to fight stroke back. Correspondence: Conrado J. Estol, Associate Editor, International Journal of Stroke. Email: cjestol@infovia.com.ar