Health Checkup
1:00 am
Mon April 9, 2012

Stroke: Responding Quickly Reduces Lasting Effects

It’s the fourth leading cause of death in the country behind heart disease, chronic lung disease and cancer. Stroke occurs when blood flow to a part of the brain stops. It’s sometimes called a brain attack, but stroke is often preventable. In this KERA Health Checkup, Sam Baker talked about this with Dr. Dion Graybeal. He’s Medical Director of the Stroke Program at Baylor Medical Center.

Dr. Graybeal: Medically, a stroke is a disorder or problem of the blood vessels in the brain, whether a hemorrhage with a rupture of a blood vessel or a rupture of an aneurysm bleeding around the brain. The most common type of stroke is an ischemic, or lack of blood flow, stroke or a blood clot, or a blockage of an artery causes an interruption of blood flow to the brain, producing neurologic symptoms for a period of time. If that goes on permanently and causes a disability then that’s a stroke.

There are other types of lack of blood flow that are not permanent or that are more fleeting, less lasting, and those are called transient, ischemic attacks. Those are, at times, just as malignant as a completed stroke can be. Many strokes are preceded by a transient ischemic attack, probably at least 15 to 20 percent of the time. So that’s really an opportunity where patients need to know the warning signs and symptoms of stroke, what things they need to go to acute medical intervention to try to keep the process from continuing and  causing permanent disability or damage.

Sam: So you’re talking about an attack that may occur that may be an indication of a stroke or major stroke to come?

Dr. Graybeal: Correct. There are different risk factors for hemorrhagic or ischemic stroke. One of the more prevalent ones is hypertension, but also diabetes with problems of blood sugar, high cholesterol, obesity, physical inactivity. And there are other non-modifiable risk factors that we can’t treat, like your age, your sex, your family history, who your parents were. We all carry with us these difficulties but don’t have medical treatments to change those.

Sam: Which begs the question: Is stroke preventable?

Dr. Graybeal: Stroke is very preventable. We have, on average, over 700,000 strokes every year occurring in the United States. If you look at all strokes, both new and recurrent, that number goes up to almost 795,000. It’s the fourth leading cause of death in the country behind heart disease, chronic lung disease and cancer.

Sam: Why so many?

Dr. Graybeal: It goes back to a lack of preventative medicine for some patients. Risk factors that are not being modified well enough, and then some factors that are unforeseen and can’t be helped. For many patients, whether they come in with a transient ischemic attack – which may only last ten to twenty minutes – or a patient that acutely starts to have symptoms, we know that stroke in this day and age really is a medical emergency.

Just like a blockage in a heart vessel, a myocardial infarction, or a heart attack, stroke really is a brain attack. It’s a need when symptoms are identified to call 911, to go urgently to the emergency room – don’t wait to see your doctor, don’t wait to get in the car. The pre-hospital ambulance picks the patient up with the paramedics and immediately brings them. We’re fortunate in Dallas-Fort Worth to have a variety of stroke networks as well as stroke facilities where patients can be taken for appropriate care.

Sam: And the number of stroke facilities has increased over the years. Is there a reason?

Dr. Graybeal: There are several reasons. Starting in the mid-90s we had a variety of new medications that were actually enzymes the body normally produces that we give – one called tissue plasminogen activator (tPA) which is the clot-busting medication we can give to patients with blockages to try to restore the normal blood flow. If I look at all patients that we generally treat with the medication, the studies as well as our own experience, at least 12 to 13 percent of anyone we touch with the medication is made better -- having little or no symptoms of a stroke after maybe coming in with a disabling-appearing stroke at onset.

Sam: When a stroke occurs, how would you recognize it?

Dr. Graybeal: The common signs and symptoms of stroke are weakness or numbness involving the face or arm or leg, difficulty with speaking or confusion, difficulty understanding or expressing language, a lack of balance or gait, walking difficulty, a loss of vision that can occur in one or both eyes, as well as sometimes signaling more hemorrhagic stroke, the sudden onset of a very severe or explosive headache.

These five symptoms are what we think of as stroke warning signs or symptoms, and if patients have these, we recommend they call 911. Especially for those with the ischemic stroke, those patients having an infarction – all patients have up to three hours, for select patients, up to four and a half hours, to give this drug in the emergency room.

Things have to happen – be picked up by EMS, dropped at the emergency department, have a CAT scan, labs to make sure there’s not an extra bleeding risk. Then a specialist should be brought in, like a cardiologist, or a neurologist for stroke, to basically decide on giving the drug and proceeding forward.

Sam: But this all needs to happen within a window of about three hours or so?

Dr. Graybeal: Yes. With any patient, if they identify symptoms at home, there’s going to be a lag time in terms of calling 911, the ambulance going to the house, stabilizing the patient, bringing them into the emergency room. So what we look at nationally as well as at Baylor Dallas is to try to optimize the treatment so the majority of our patients are receiving the tissue plasminogen activator in the appropriate format within an hour so that by the time they hit our emergency room door, to the time we have the I-V in – what we call door to needle time – is a goal of 60 minutes. That’s a national goal set up by American Heart Association, the American Stroke Association, and a variety of other national bodies. And at Baylor Dallas, we have continued to increase the proportion of patients that are meeting that goal of door to needle within an hour.

Sam: Can you have a stroke and not know it?

Dr. Graybeal: Oh, absolutely. That does happen at times. And what happens with many patients is, whether they’re afraid of what the symptoms might portend, whether they, with stroke, have cognitive difficulties -- we’re talking about the mind and the brain being involved. When one family member looks to the stroke victim and goes, “Are you okay?” Well, they may not be the right person to actually be making that decision impaired cognitively by having an acute stroke. And so the lack of knowledge within the patient population, within the community, of the urgency at times as well as the varied symptoms with stroke, really do hamper us in getting the patient quickly enough into the E-R for appropriate treatment.

Stroke as a brain attack is different than heat disease or heart attack because many times when someone is having a heart attack, it’s a more homogenous or simplified clinical spectrum, chest pain, pain may be riding up the jaw, down the air, feeling nauseous – more people are aware of that. There’s pain involved too. For a stroke, many strokes may occur upon awakening, so patients wake up from a nap or from sleeping the night before, and have a new onset of symptoms – did I sleep on my arm wrong? Is this a nerve problem? Or what does this really portend?’

Sam: So it could be easy to dismiss?

Dr. Graybeal: Sometimes it is very easy to dismiss.

Sam: Is there a profile of a typical stroke victim?

Dr. Graybeal: The patients at highest risk are those patients that are middle-aged to elderly, so your prevalence in the population, the percentage of patients that have an increased risk of stroke, while those percentages when you’re in your 20s and 30s are certainly much under five percent – the risk of a stroke as we look at every decade beyond the age of 45 actually doubles. What happens is you’ve had your chronic medical illnesses – chronic smoking, diabetes, difficulties with hypertension or high cholesterol, certain heart illnesses, then your chances are greater.

Sam: Which then begs a question: Do lifestyle choices have a great impact on whether or not you may have a stroke?

Dr. Graybeal: They actually do. When we look at what risk factors we can modify, many of those – diabetes and keeping your blood sugar under control, what you eat, how you manage your diet. Certainly uncontrolled diabetes portends a higher risk of stroke – whether its high blood pressure – are we dropping weight? Are we on a salt restricted diet? Exercising regularly to keep our blood pressure down? Are we appropriately taking our medications and following up to make sure our blood pressure is more adequately controlled? With cholesterol there are certain drugs as well as diet that make a great impact there.

So we see across the country, looking at this as a national health issue, that there is a stroke belt – there are certain states, the southeastern states, from North Carolina wrapping around the gulf states to Louisiana - that have a higher percentage, higher incidence, even higher mortality in stroke that other areas of the country.

Sam: Why is that?

Dr. Graybeal: Some of that may be lifestyle, may be diet. Some areas have a greater aging population as well. There are probably different public health factors all involved.

Sam: I suspect many people think of stroke and think of, afterwards, loss of speech, loss of motor skills. If you have a stroke, can you reasonably expect quality of life after?

Dr. Graybeal: Every stroke is different. When we look at stroke, we have different measures, we have different ways of examining the patient, to try to help prognosticate and tell which patients are going to be better able to come back from their disabilities. Obviously on a general average if you have a smaller stroke than a larger stroke because of less brain geog being involved, you’re less likely to have greater symptoms with a smaller stroke unless it happens in a very elegant area of the brain.

So every stroke is different and every stroke patient is different. Many stroke patients at the onset of their symptoms, whether they’re in the E-R or receiving tPA are generally at the worst within that first several days. As we stabilize the patient using different rehabilitation measures with physical, occupational and speech therapy, we then try to make inroads on reducing the disability. And recovery after a stroke is a lifelong process. There’s not a magic date that after you’ve had your stroke that you can expect that your recovery will stop. Most patients do make the majority of their inroads, the majority of their progress improvement early on. But again, recovery from a stroke really is a lifelong issue.

Dr. Dion Graybeal is Medical Director of Stroke Program at Baylor University Medical Center. You can hear and read more of this conversation and find links to more information about stroke at keranews.org. 

For more information:

http://www.strokeassociation.org/STROKEORG/

http://www.stroke.org/site/PageServer?pagename=prevent

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001740/

http://www.mayoclinic.com/health/stroke/DS00150

http://www.ninds.nih.gov/disorders/stroke/stroke_rehabilitation.htm