General information about stroke which is of general interest - this information is not intended to subsitute for personal medical care or as a substitute for one's physician.
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What You Should Know About Stroke
There are two major kinds of strokes. Bleeding in the brain is called hemorrhagic stroke and accounts for 15 percent of strokes. The strokes described in the stories are called ischemic (iss-kee-mik) strokes, and these account for 85 percent of strokes. Ischemic strokes are caused by a blood clot blocking an artery in the brain, much like a clogged plumbing pipe. The arteries of the brain are carrying nutrients and oxygen to the brain cells. Once the artery is blocked the cells are starving. There is a very limited amount of time to unblock the artery before the brain cells die and cause permanent disability.
There are two ways to get rid of the blockage caused by the blood clot. The clot can be dissolved with a clot buster drug called tissue plasminogen activator (tPA) and/or the clot can be mechanically removed. The tPA functions like Drano in the pipe and the mechanical device is more like Rotor Rooter. The mechanical device described in the stories is the Merci Retriever®, the first device developed specifically for stroke treatment. It is a wire shaped like a corkscrew that can be “screwed” into the clot and extracted. In some of the stories it is referred to as the “corkscrew.”
But first, the patient has to arrive at the right place at the right time….
Time: The Chain of Survival
1. Recognition of symptoms
Because of paralysis, speech or visual impairment, confusion or other symptoms, it is usually someone other than the stroke victim who recognizes that something is wrong. It is important for everyone to know the warning signs of stroke:
Sudden weakness or numbness on one side of the body
Sudden loss of vision, especially if it is one eye
Sudden difficulty speaking or understanding speech
Sudden severe dizziness or headache
Note: Most ischemic strokes are NOT associated with headache so the absence of pain does not rule out a stroke.
A quick and easy way to assess the situation is to use the FAST system.
F See if the two sides of the face look the same
A Ask the person to hold their arms up. If one is weak,
something is wrong
S Ask the person to speak. If it is garbled or slurred, something
is wrong
T If any of the F, A, or S components are wrong, call 911. T is for
TIME. It is very important to note the TIME the
Symptoms started
2. Call 911—Get help as fast as possible
3. EMS (ambulance/helicopter emergency personnel)
Recognition of stroke symptoms is part of EMT training. In general, they are very knowledgeable about stroke and can play a major role in making a quick decision to get the patient to a “stroke ready hospital.” It some cases they may take the patient to the closest hospital unless the patient makes a specific request so it is important for everyone to know which hospitals are “stroke ready.”
4. Hospital arrival
In most cases the patient is transported to the closest hospital. Many small hospitals have a referral relationship with a larger hospital where acute stroke treatment can be given. In some instances the initial treatment is begun in the small hospital then the patient is transported by ambulance or helicopter to the larger stroke center hospital. Hospitals of any size can be “stroke ready.” This simply means that when a patient arrives, they have a plan to act quickly to treat the patient of transport to a place where treatment can be given.
5. CT Head Scan
A CT or CAT scan of the head is a specialized X ray that can visualize the brain in detail. This test has to be done in evaluating stroke symptoms to make sure there is no bleeding the in brain. If there is bleeding then it is hemorrhagic stroke and not an ischemic stroke. Hemorrhagic strokes cannot be treated with clot buster drug or mechanical devices. It is very important that the CT scan be done very quickly after arrival to the emergency room.
6. Stroke treatment
Clot buster treatment, tissue plasminogen activator (tPA) can be given two ways:
• Intravenous tPA (injection of the drug in the vein) is approved by the FDA and can be given IF the treatment can start within THREE HOURS after the start of the stroke.
• Intra-arterial tPA (injection of the drug into the brain artery that is clogged) is not approved by the FDA and has to be given with special consent from the patient or family. This method of treatment is done in the radiology department by an interventional neuroradiologist and a catheter is threaded up into the brain artery much the same way cardiac catheterization is done. This procedure can be done up to SIX HOURS after the start of the stroke.
The Merci Retriever® can be used to remove the clot mechanically up to EIGHT HOURS after the start of the stroke. The retriever is often used in combination with tPA. Some of the patients in the stories participated in the testing of the device.
In many of the stories, intravenous tPA is given at a local hospital and then the patient is transported to the Saint Luke’s Stroke Center by ambulance or helicopter for further treatment. The physicians and nurses in the emergency departments in and around Kansas City who are meeting this challenge make an essential contribution to the great outcomes for these patients.
Brain Arteries
Four major arteries supply the brain. The two arteries in front are the carotid arteries. Their pulse can be felt at the jaw line on both sides. The two arteries in the back are the vertebral arteries. They are called this because they run inside the bones of the neck and their pulse cannot be felt. The two vertebral arteries come together at the back of the brain to form the basilar artery. This artery is essential to life. The part of the brain it feeds controls breathing, heart rate and other vital functions. When the basilar artery is obstructed by a clot, life itself is threatened. The mortality rate for patients with basilar artery clots is 80-90 percent.
The carotid arteries on each side divide into the left and right middle cerebral arteries (MCA) and the left and right anterior cerebral arteries (ACA). MCA strokes are the most common. If the right MCA is occluded by a clot, the left side of the body is paralyzed. In addition, as the stories often recount, the patient has no understanding of what is happening. The patient frequently cannot even recognize his or her own limbs. This is called “neglect” and the stories report several examples of this problem. If the left MCA is occluded, then the right side of the body is paralyzed and the patient is often unable to speak since the left side of the brain controls speech in most people.
The Heart and Stroke
Approximately 30 percent of strokes are caused by conditions of the heart. Several of the stories mention atrial fibrillation. This is an irregular heartbeat that increases stroke risk substantially. Blood thinning with warfarin can reduce the risk of stroke in people who have atrial fibrillation. People who have congestive heart failure with low pumping strength in the heart are also at risk for stroke. Some of the people who are profiled in the stories have a patent foramen ovale (PFO). This is a hole between the upper chambers of the heart that should close at birth. Twenty percent of the time it doesn’t close completely. This is a potential way for clots to travel to the brain. PFOs can be detected by special ultrasound pictures of the heart called transesophageal echocardiograms (TEEcho or TEE).
Stroke Prevention
Many strokes are preventable. It is important to know how to decrease the risk of stroke. The following are general recommendations. Each person should consult with a physician to determine individual targets.
Blood pressure should be 120/80 or lower
Cholesterol should be 200 or lower and the bad cholesterol (LDL) should be lower than 100.
Optimal control of diabetes
Stop smoking
Atrial fibrillation should be treated with warfarin in most cases
Regular exercise
Ideal weight
Hypercoagualable states: some people have a strong tendency for the blood
to clot. These conditions have to be treated by a physician.
Age: Many of the stories are about people who are quite young. Although
age does increase the risk, strokes can strike at any age.
A Plan for You and Your Family
Stroke is a devastating event. The onset comes as a total surprise. The best way to assure the best possible outcome is to be prepared with a plan of action.
1. Assess and treat risk factors for stroke.
2. Find out what hospitals are “stroke ready” and how often stroke victims get reversal therapy.
3. Know the warning signs of stroke.
4. If a stroke occurs, direct the emergency responders to the “stroke ready” hospital you have identified.
5. If there is any delay in the emergency department, insist on immediate attention.
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