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Time is crucial when dealing with strokes

Jan. 10, 2005 — Time is the most important factor when dealing with stroke, the third leading cause of death in the U.S. But before a person can get a loved one crucial medical treatment in time, he or she must know what signs to heed. WUSM physicians and stroke experts Mark Goldberg and Maurizio Corbetta discuss stroke and its symptoms in the following St. Louis Post-Dispatch article.

The facts about stroke

(Republished with permission from the St. Louis Post-Dispatch. This article originally ran in the Health & Fitness section on Monday, January 10, 2005)

By Kathie Sutin

Special to the Post-Dispatch

Time lost is brain tissue lost.

That message is perhaps most important when dealing with a stroke, a potentially deadly condition, but one not well-recognized by the public.

Stroke is the No. 3 killer of Americans, behind heart disease and cancer, yet many people don't know its warning signs. Nor are they aware that immediate medical treatment is crucial, because in some strokes a medicine can save lives and prevent serious long-term effects - if it is administered within three hours of the onset of symptoms.

Thanks to several public awareness campaigns, Americans are fairly familiar with the warning signs of heart attack, yet medical professionals and the American Stroke Association are often dismayed at the average person's lack of knowledge about stroke.

In a recent survey, only 17 percent of respondents correctly recognized stroke symptoms and indicated they would call 911 if they thought someone was having a stroke, said Dr. Mark Goldberg, professor of neurology and director of the Hope Center for Neurological Disorders at Washington University School of Medicine.

The survey results are bad news, because knowing the signs of a stroke and seeking help immediately can sometimes mean the difference between life and death. It can also save you or someone you love from the severe disabilities that can result from a stroke.

"Public education is our only hope," Goldberg said.

When a stroke occurs, there is a brief period in which to save injured brain tissue, he said. To minimize disability, it is critical that stroke victims are evaluated and treated quickly.

A drug called tissue plasminogen activator (TPA) works only on ischemic strokes - the 80 percent of strokes that are caused by a blood-vessel blockage. The drug dissolves blood clots.

The choice of hospital in such instances is important, too. Only large hospitals are likely to have a rapid response stroke team, which is necessary to determine what type of stroke the person has had and whether the patient is a candidate for TPA. Physicians must be sure of the type of stroke involved, because the medication can cause bleeding in certain circumstances.

Other types of strokes

About 20 percent of strokes are caused by the rupture of an artery in or around the brain; they are known as hemorrhagic strokes.

Intracerebral hemorrhages occur when there is sudden rupture of an artery within the brain, most often because of high blood pressure, Goldman said. Blood then spills into the brain, compressing brain structures and mimicking ischemic stroke symptoms.

Subarachnoid hemorrhages happen when there is a rupture of the arteries that surround the brain. The walls of these arteries are weakened by small bulges called aneurysms. Subarachnoid hemorrhages can occur in younger patients.

Goldberg noted that the two types of hemorrhagic strokes are more often fatal than ischemic strokes, caused by blockages in a blood vessel.

"The effects may be catastrophic," Goldberg said. Hemorrhagic strokes can produce sudden, severe headache, neck pain, vomiting or loss of consciousness. Some patients die in the first few minutes after an aneurysm ruptures; others arrive at the hospital in time to receive urgent medical therapy and neurosurgical repair of the aneurysm.

Mini-strokes

Strokes can be so slight that people might not even realize they're having a stroke. These so-called mini-strokes or transient ischemic attacks (TIAs) are caused by temporary interruption of blood flow to a part of the brain or eye, Goldberg said.

TIA symptoms are the same as stroke but do not last as long, he said. While a TIA can persist up to 24 hours, it typically lasts about 5 to 10 minutes and almost always less than an hour.

People should be aware that symptoms of clots can come and go, said Dr. Maurizio Corbetta, associate professor of neurology, radiology, anatomy and neurobiology and head of the Stroke and Brain Injury Rehabilitation Section at Washington University School of Medicine.

"Maybe they come on for 10 minutes and then they go away," he said. "You're watching TV, you get up and now your leg is dragging. That might go away 10 minutes later."

That scenario is a warning sign that part of the brain is suffering, but the circulation has been restored naturally. Maybe there was a little clot that got cleared because the body protects itself. It's trying to keep those blood vessels open.

If such an experience occurs the person should be evaluated for evidence of an obstruction, Corbetta said.

If there is a blockage, the patient can be put on anti-platelet medication. Blood thinners such as warfarin may be appropriate if the patient has an irregular heartbeat. Or, if a major vessel is narrowed, surgery might be indicated.

That surgery includes carotid endarterectomy, a common surgical procedure in which the surgeon opens the carotid artery, removes the plaque and sews up the artery. Carotid endarterectomy is an effective way to prevent future strokes in some patients who have already had a stroke or TIA, Goldberg said.

Difficulties in screening

In the past few years, some companies have offered screenings to check for the likelihood of a stroke. While screenings to assess the risk of stroke may sound reasonable, some doctors warn that such tests may actually lead to harm.

"The screening tests themselves are safe, but all surgery has potential complications," Goldberg said. "Having carotid surgery when it's not absolutely necessary can endanger patients. If you operated on all otherwise healthy people who have narrowed carotid arteries, you might end up causing more strokes than you prevent."

The best course of action, experts say, is to check with your doctor to find out which tests are appropriate for you.

Being aware of and monitoring risk factors, then working with your doctor to control them, is the best way to reduce the risk of stroke, Corbetta said.

Avoiding stroke

Corbetta listed five things you can do to avoid stroke:

   1. Exercise. "It's really No. 1," he said. "Stroke and heart attacks are rare among people who have regular exercise. People who run marathons don't have heart attack and strokes." The recommendation is 30 minutes a day five days a week, or a variation, such as one hour three days a week.

   2. Take your medication.

   3. Monitor your blood pressure. "High blood pressure means high pressure in the pipes, so the pipes are more likely to break or to clog," Corbetta said.

   4. Don't smoke. Smoking makes arteries stiffer, which, in turn, makes them clot more easily.

   5. Watch your diet. Eat lots of fruits, vegetables and whole grains.

The statistics

   1. Stroke affects 730,000 Americans each year - causing 150,000 deaths - and is the leading cause of severe, long-term disability, according to the American Stroke Association. The estimated direct and indirect cost of stroke is $53.6 billion for 2004 alone.

   2. Although there are certain risk factors for stroke, no one is immune. And though the chance of having a stroke increases with age, people of all ages can suffer strokes, even infants.

   3. Ischemic strokes - those caused by a blocked blood vessel - are more common in older people.

   4. African-Americans have two to three times greater risk of ischemic stroke, and they are more likely to die of stroke.

   5. Hispanics also have a higher rate of stroke.

For more information on stroke, visit the American Stroke Association, a division of the American Heart Association, at strokeassociation.org. You can also call the Greater St. Louis Heart Association at 314-367-3383, or visit Washington University Medical School's stroke Web site at strokecenter.org.

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