Strokes in the military: Increased risks and effective measures

Physical and psychological overload, stress, lack of stable access to balanced nutrition, water, and medicines during combat operations - all this contribute to an increased likelihood of stroke in the military. This is despite the fact that combat injuries themselves can also be the cause of secondary strokes. How to recognize the first symptoms, what to do in case of suspicion of stroke, how to effectively treat strokes, and what are the ways to prevent repeated cases, read in an interview with Cherednychenko Yuriy - leading endovascular neurosurgeon of the Mechnikov Hospital in the city of Dnipro, a hospital that, along with its vast experience in treating strokes in civilians, has the greatest experience in the world in treating strokes in the military.

Yuriy Cherydnichenko

is a leading endovascular neurosurgeon at Mechnikov Hospital in Dnipro

Yuri Vitaliyovych, tell us what are the current statistics of strokes in the military and what are the causes?

Stroke in the military is a multifaceted issue. Let’s start with the fact that military personnel are the same people as civilians, with the same percentage of cardiovascular, cerebrovascular diseases, and other pathologies that can later be the cause of stroke. Ukrainians who went to the front voluntarily were not stopped at all, even by the presence of grave diseases known to them.

At the front, military personnel face factors such as stress, lack of stable access to water and balanced nutrition, excessive physical and psychological stress – all of which exacerbates the concomitant pathologies they have. Another problem is insufficient control over taking medications that a person took in civilian life. On the front line, this habit is often lost. That is, if a soldier, for example, has arterial hypertension, there he may not take antihypertensive drugs as required, or not take anticoagulant therapy for some forms of heart rhythm disorders that he is recommended to take. This increases the risk of strokes.

It is difficult to say how much this risk increases in percentage terms, but we are treating many soldiers now who are brought in with strokes, both ischemic and hemorrhagic.

It is also important to consider that explosive and gunshot wounds to areas such as the neck and head often lead to serious vascular damage. After an injury, an intraluminal blood clot can form in the damaged segment of the artery. These clots can block the artery or be washed away by the blood flow further, to the smaller arteries that supply blood to the brain, and lead to ischemic stroke.

Injuries to arteries directly within the cranial cavity can also lead to the formation of pseudoaneurysms. This is a kind of sac or capsule on an artery that has almost no wall and does not hold the blood inside the channel very reliably. Because of this, in these wounded people who already have a severe brain injury, secondary hemorrhage may occur, which will further complicate the situation. This is a special group of our patients, in whom secondary strokes occur as a result of explosive and gunshot wounds to the vessels of the head and neck. Here an entirely different approach to identifying symptoms is used and a different treatment tactic is applied. This is a more complex pathology. Such patients are put into a medically induced sleep – a medically induced coma – as soon as possible, and therefore it is often not possible to assess their neurological condition at the evacuation stage. Computed tomography with computed tomographic angiography is not enough for this group of patients due to artifacts from metal fragments that do not allow us to “see” the affected segment of the artery. Such patients are placed on the table in our angiographic operating room first for diagnostic angiography, which, in case of detection of dangerous vascular damage in the area of ​​injury and secondary thrombosis of the cerebral arteries, immediately proceeds to minimally invasive intravascular surgery. During operations, we can either “prosthetically repair” the affected segments with graft stents, or embolize pseudoaneurysms with spirals and compositions that harden upon contact with blood, or remove blood clots from the arteries of the brain. Furthermore, operations are typically performed in combination with each other. The operating algorithms were developed by us in cooperation with our American colleagues and friends, professors Rocco Armonda, Maxim Shapiro, who also help us together with the Razom for Ukraine Foundation and in providing such complex multi-component operations with disposable expensive instruments. As a rule, the next stage is “open” neurosurgical treatment of wounds, and further — complex work in neuroresuscitation, neurosurgery departments, rehabilitation, so that such a patient is discharged as recovered as possible.

How to detect a stroke in a soldier — hemorrhagic or ischemic, if it can be masked by another condition?

Ah, everything is elementary here. If there is a suspicion of a stroke, then it is correct to regard this situation as a stroke. The risk of a stroke is enormous, due to the very rapid rate of death of brain tissue, so it is critical not to waste time and to carry out diagnostic and therapeutic measures as soon as possible to save the brain tissue and the person.

Even if it later turns out that there was no stroke, such tactics are more than justified.

How to suspect that it may be a stroke?

Everything is like in civilians. There is the so-called “FAST” scale or the Ukrainian version of “Brain-Time”.

“FAST” stands for: Face – Arm – Speech – Time

The “Brain-Time” scale additionally assesses vision. If a person says: “I suddenly lost my vision”, or “something is double in my eyes”, or “I can’t see right”, this may indicate a stroke. Dizziness and a sudden loss of balance may also be a sign of a stroke. The patient should be taken as soon as possible to a stroke center or hospital, with the possibility of thrombolysis and endovascular operations.

In cases where a patient has become ill and is in a war zone, it is important to get the patient to the nearest hospital where doctors can examine him and perform a CT scan. Currently, such patients can usually be brought from the war zone to our hospital in about four hours. However, there are situations when the transport time can be extended due to the difficulties of evacuation.

As for wounds, the situation is similar, but more complicated. A person with head or neck injuries should be taken as soon as possible to a hospital with a CT scan, and then to us.

Why is this significant? Our experience shows that patients in this category need to undergo invasive angiography in a specialized operating room. This allows us to assess all the nuances, including the presence of metal fragments and arterial lesions that can cause a stroke. In such cases, CT angiography does not always give a clear picture, and invasive angiography reveals more details.

The main advantage of this method is the ability to operate on the patient immediately during the examination in the angiographic operating room. This allows us to immediately eliminate the cause that could have led to a stroke or to external bleeding, or bleeding into the soft tissues or into the mediastinum.

Today, we have the greatest experience in the world in treating such patients. It is sad, but good that there is knowledge and opportunities to save them. Mostly, patients are delivered on time, which allows us to prevent the development of a stroke.

Regarding secondary strokes in the wounded, we have developed a treatment strategy almost from scratch. Previously, there was nothing to rely on. However, there is a problem that we have only been able to solve partially so far. It consists in the fact that many tools necessary for the treatment of such patients are not physically available in Ukraine. There are no others in the nomenclature of purchases under centralized budget programs. Thanks to cooperation with foreign volunteer organizations, we are currently solving this issue. Now a regional program has also joined, which is great news. However, we do not receive much centrally for this category of patients, due to the above reasons. We have already raised this issue and hope that it will be resolved in the near future.

What about the algorithm of actions of combat medics? Are there any specifics to consider when evacuating military personnel with suspected stroke?

Yes, combat medics should make a note that it is a stroke, and such a patient should be taken as soon as possible to a hospital that has the capabilities to treat strokes. But if there is no such hospital nearby, but there is a hospital with a computer tomography — then there. Then all the doctors: neurosurgeons, neurologists who work there, have a connection with us and can transfer this patient to us.

The main condition is to ensure airway patency, and in case of violation of vital functions — to stabilize them. There is another nuance that is important to consider for doctors evacuating a soldier with suspected stroke (in the absence of gunshot and explosive wounds). If the systolic pressure does not exceed 220 mm Hg, then before the patient is examined on a computer tomography and the subtype of stroke is determined, there is no need to lower the pressure.

In patients with stroke, increased pressure can provide additional perfusion through small collateral arteries, that is, supply blood to an area that could die if the pressure were lower. In fact, the pressure “pushes” blood around the blocked artery. If you start fighting to normalize blood pressure in such a patient, then everything will be lost long before he gets to us.

In wounded patients, the algorithm is entirely different and more relevant to the medical profession. If there is a wound to a large arterial vessel in the neck, for example, the carotid artery, and there is external bleeding, then there are few options to save the patient. One of them is the use of a Foley catheter.

The Foley catheter is inserted into the wound and inflated until the bleeding stops. If the balloon is fully inflated and the bleeding does not stop, the combat medic must reposition the balloon and inflate it again. If this is successful, it is a giant success and a chance for the patient to survive.

How often do military personnel have recurrent strokes? What do you think can help reduce the number of recurrent strokes?

Yes, we have several cases where military personnel had recurrent strokes. But this is nonsense because a person should not be on the frontline after a stroke. If he has fully recovered and is on secondary prevention (the risk of recurrent stroke is maximally reduced), then the person can return to service and perform, for example, logistical tasks. But this definitely should not be a frequent practice.

As for the prevention of a second stroke, it all depends on the cause and type of stroke that has already occurred. If the patient has had a hemorrhagic stroke due to a ruptured aneurysm, then prevention consists in surgical treatment of the aneurysm. Now, such operations are more often performed endovascularly — in fact, the aneurysm is “sealed” with special instruments through a small hole in the femoral or radial artery.

If we are talking about an ischemic stroke, for example, the cardioembolic subtype, when a person has a heart rhythm disorder and because of this a blood clot forms in the heart cavity, which then blocks the arteries of the brain, we remove the blood clot endovascularly. Next, the patient needs to change his lifestyle and take medications that:

1. Reduce the risk of rhythm disturbance.
2. Reduce the risk of blood clots forming in the heart cavity.

If we are talking about significant stenosis of the main arteries of the head, then endovascular or surgical restoration of their patency, subsequent administration of antiplatelet drugs, and statins is the prevention of recurrent stroke.

In addition to medical prevention, lifestyle correction also reduces the risks of recurrent stroke: normalization of sleep, normal physical activity, reduction of stress levels, blood pressure control, a diet with restrictions on animal fats, and timely medical examinations. This applies to both military and civilian personnel.

It is also worth giving up bad habits, such as smoking. This is a very dangerous habit that can cancel out all the efforts of doctors. I think that it is not worth risking your health for the sake of this habit.

And in general, we owe it to the military that we can live in Ukraine, see how our children grow up. Therefore, we must create the best system of medical care for people who went to the hell of war to protect the country, our lives, and future. We have already done a lot to bring this goal closer, but we continue to work and do even more.