Be Aware of F.A.S.T: Understanding and Managing strokes

5 July 2025

KOTA KINABALU: The public should remember the simple F.A.S.T. acronym as signs of a Stroke, it means (F) face drooping, (A) arm weakness, (S) speech difficulty, and time (T) to call emergency services immediately.

Prompt action is essential because during a stroke, every minute counts. The phrase "time is brain" encapsulates the urgency, the longer treatment is delayed, the greater the loss of brain tissue, leading to more severe disability or death.

This is shared by Dr. Ananda Arumugam a Resident Consultant Neurosurgeon at KPJ Sabah Specialist Hospital. His specialist interests include skull base and neurovascular surgery, encompassing the treatment of brain and spinal conditions such as traumatic brain injuries, aneurysms, paediatric neurosurgery, and spinal tumours.

During Nabalu News recent visit, the friendly doctor shared that, understanding strokes is a vital area of neurological medicine, and as a consultant neurosurgeon, he has witnessed firsthand how crucial prompt diagnosis and treatment are in improving patient outcomes.

“Strokes remain one of the most urgent and complex neurological emergencies, and their management requires a precise understanding of the different types and the best approaches to care.”

He shared that his role in stroke management varies depending on the specific type and severity of the condition. Strokes primarily affect the brain and spinal cord and are broadly classified as either ischaemic, caused by a blockage of blood flow, or haemorrhagic, resulting from bleeding within the brain.

“Initially, a thorough clinical assessment is essential, involving detailed history-taking and a comprehensive neurological examination to gauge the extent of neurological deficits. Following this, imaging studies are crucial. A CT brain scan is the first-line imaging modality used to detect bleeding in the brain, which is vital for diagnosing haemorrhagic strokes. An MRI provides a more sensitive assessment, especially in identifying early ischaemic infarctions.”

“Additionally, CT angiography helps identify vascular abnormalities such as aneurysms, arteriovenous malformations, or stenosis, which can influence treatment decisions.”

Based on imaging findings, he determines the appropriate course of action. Ischaemic strokes are usually managed medically with thrombolytic therapy unless complications necessitate further intervention. In contrast, haemorrhagic strokes require a more nuanced approach, depending on the size of the bleed.

“Small bleeds may be managed conservatively with strict blood pressure control and medications such as Tranexamic acid (TXA), which I have researched extensively. Larger bleeds that cause increased intracranial pressure often require surgical intervention, such as evacuation of the blood clot to relieve pressure and prevent further brain damage.”

“My research on Tranexamic acid has shown promising results in controlling bleeding in haemorrhagic stroke. I have conducted clinical trials published in the Malaysian Medical Journal, starting with a Phase 1 study in 2015 involving 30 patients, followed by a Phase 2 trial in 2023 with 60 patients, and a Phase 3 trial involving 200 patients is currently pending publication. These studies suggest that TXA can help reduce the expansion of blood clots, offering new hope for better management of haemorrhagic strokes and potentially improving patient outcomes,” he shared.

In Malaysia, stroke remains a significant health burden, with public hospitals seeing approximately 400,000 admissions annually, averaging around 110 patients each day. The majority of these cases involve haemorrhagic strokes, although ischaemic strokes are also prevalent. Recognising the warning signs early can make a profound difference.

According to him, diagnosis is confirmed through a combination of clinical examination, patient history, and urgent brain imaging. Surgical intervention becomes necessary in specific circumstances, such as when there are large blood clots exceeding 25cc accompanied by significant midline brain shift or worsening consciousness.

In cases of large territorial ischaemic strokes with substantial brain swelling, decompressive hemicraniectomy may be performed to reduce intracranial pressure. The surgical procedures typically employed include craniotomy to evacuate blood in haemorrhagic strokes and decompressive craniectomy for large ischaemic strokes.

“However, surgery is not always the best option, it depends on the patient’s overall health, the size and location of the clot or infarction, and the brain’s response to initial treatment.”

Recovery after stroke varies widely. Many patients recover well, especially with early intervention, physiotherapy, and emotional support. Full recovery is possible, although it depends on individual circumstances, the severity of the stroke, and how quickly treatment was administered.  Rehabilitation is a critical component of stroke care, with neurologists working closely alongside physiotherapists, speech therapists, and psychologists to help patients regain mobility, speech, and independence.

“Prevention plays a pivotal role in reducing the risk of stroke. Lifestyle modifications and medical management can significantly lower the chances of occurrence. Maintaining blood pressure below 130/80 mmHg, controlling blood sugar levels in diabetics, quitting smoking, limiting alcohol intake, and staying physically active are all vital measures.”

“While strokes are more common among older adults over 60, increasing cases are now observed among those aged 40-59, largely driven by lifestyle factors such as hypertension, diabetes, smoking, and obesity. Although less common, strokes can also occur in individuals under 40, often related to genetic predispositions or risky behaviours.”

For individuals who have experienced a mini-stroke or transient ischemic attack (TIA), the risk of a full stroke is higher. However, up to 80% of recurrent strokes can be prevented with appropriate treatment, lifestyle adjustments, and regular medical follow-up.

“Recent advances in stroke treatment include the use of TXA for bleeding control, minimally invasive procedures such as balloon catheter-assisted clot removal, and improved imaging technology like high-resolution microscopes and fluorescence-guided surgery, which allow for more precise interventions.”

 It is heartening to hear Dr. Ananda say that the future of stroke care is promising, with technological progress enabling them to perform surgeries with greater accuracy and safety. Image-guided surgery and advanced visualisation tools are reducing risks and improving outcomes for patients. It is essential to remember that stroke is a medical emergency. Recognising symptoms early and seeking immediate medical attention can be life-saving. Prevention through lifestyle changes remains equally vital, and public awareness is crucial in reducing the devastating impact of strokes.

Neurosurgeons primary aim is to restore function and preserve life, he shared adding, the profession is demanding, but the opportunity to help individuals regain their independence makes it profoundly rewarding.

“Ultimately, strokes are serious but largely preventable. Increased awareness, early recognition, and prompt treatment are the most effective tools we have to save lives and improve the quality of life for stroke survivors.”