Brain Attack
May 2008
If a loved one was having a heart attack, you wouldn't hesitate to call an ambulance or to drive the person straight to the emergency room. When stroke occurs, it should be treated with the same urgency for the best chance at a positive outcome.
You are probably familiar with the saying, "Time Heals All Wounds." However for one neurological medical emergency, time is the undisputed archenemy: stroke. It is the nation's third leading cause of death. And for survivors, stroke is the number one cause of long-term disability.
Stroke does not isolate itself to the elderly who smoke and people who have diabetes or untreated high blood pressure. According to the American Stroke Association, about one-third of stroke survivors are under age 65, and women account for 3 of every 5 deaths from stroke.
Stroke occurs when a blood vessel bringing blood and oxygen to the brain gets blocked or ruptures, preventing brain cells from getting the flow of oxygen they need to operate and live. Time becomes the enemy because millions of cells die each minute from the immediate onset of stroke, and they are unable to regenerate once lost. When the cells die, the part of the body they control can't function either, explaining why disabled speech and paralysis are common consequences in survivors.
Could there possibly be good news among these daunting statistics? Believe it or not, the answer is a resounding yes! Most encouraging is that medical research shows stroke to be largely preventable. There are proven steps that reduce risk of stroke. Next, significant advances in drug treatment are dramatically reduce the potentially severe disabling outcomes from the most common types of stroke. But as with many medical scenarios today--and particularly in the case of stroke--it truly behooves the patient to be his or her own advocate and become educated about prevention, warning signs, and even diagnosis, especially as the patient ages or has other high risk factors.
"Treatment of stroke does not start at the hospital, it starts at home," explains Kimberly Elks, program coordinator for the nationally certified Primary Stroke Center at WakeMed Health & Hospitals Raleigh Campus. "At community education events, I tell participants that if a loved one was having a heart attack, there would be no hesitation to call an ambulance or to drive the person straight to the emergency room. When stroke occurs, it is a 'brain attack.' It is no different than a heart attack in terms of a medical emergency and should be treated in the same manner. Nationally, we are still working on this from an education perspective."
There is even good news if stroke has already affected you or a loved one. Quality stroke treatment now includes a comprehensive rehabilitation regimen, and there are other resources available such as national organizations and support groups that help in coping with the ongoing after-effects of stroke.
STEP ONE: KNOW YOUR RISK FACTORS
"Essentially, there are two categories of prevention," according to Dr. Keith Hull, Board certified neurologist, co-founder of Raleigh Neurology Associates and medical director at WakeMed's Primary Stroke Center. "There is primary stroke prevention and then there is secondary stroke prevention where we try to eliminate the possibility of a second stroke in an individual."
In both categories awareness of several key factors is essential, especially if there are hereditary conditions that may increase the chance of stroke. While genes are uncontrollable, there are some factors that are controllable.
- High blood pressure is the most important risk factor for stroke. Be your own advocate! Take advantage of stations at local retail pharmacy centers and regularly take your own recordings. If it's 140/90 or above on consecutive readings, talk to your doctor. "For every 10mm of mercury that a blood pressure reading is lowered, there is a 33 percent reduction in stroke risk," notes Dr. Hull in emphasizing the importance of addressing this risk factor.
- Smoking cigarettes or other forms of tobacco is another leading risk factor for stroke. Further, research has shown the use of oral contraceptives combined with cigarette smoking greatly increase stroke risk.
- Consumption of alcohol should be limited or eliminated. "In cases of secondary stroke prevention, I tell heavy drinkers that they must eliminate alcohol consumption for the best outcome," said Dr. Hull.
- Carotid arteries in your neck supply blood to the brain. Plaque build-up may cause a blockage. There are screening tools that can be used to evaluate carotid artery blockages before they present a problem.
- Atrial fibrillation is a heart rhythm disorder which can let the blood pool and clot in the heart's upper chambers. If a clot breaks off, it could lead to stroke.
- High cholesterol, poor diet, physical inactivity and obesity also top the list of risk factors for stroke.
"It is very helpful to have a reading of 100 or lower in the bad cholesterol reading," explains Dr. Hull. Also, aspirin therapy for women seems to show a significant benefit for some. "You should talk to your doctor to see if you are a candidate for this because there are some important considerations if you are on hormone replacement therapy," adds Dr. Hull.
He also points out that those baby boomers living in the southeastern United States, including North Carolina, should pay close attention to risk factors. "For still unknown reasons, strokes are much more common in the southeast states. It is the concept called the 'Stroke Belt' and has been studied for 40 years. We know that the incidence is high, but we are still determining the causes."
Factors you can't control include age, gender, and family history. Your stroke risk is many times greater if a parent, grandparent, sister or brother has had a stroke.
STEP TWO: LEARN TO RECOGNIZE STROKE AND REACT QUICKLY
"Fifty percent of those who die from stroke do so before they get to the hospital," says Elks. "I can't stress enough how education and awareness are the best first steps in treatment so the person at risk and their family know how to diagnose a stroke and then understand the importance of getting immediate medical help."
One of the strongest predictors of stroke is a TIA (transient ischemic attack), or "mini-stroke." It occurs when a blood clot blocks an artery for a short time. The symptoms are similar to stroke but only last for a few minutes. Think of a TIA as a warning signal. About 10 percent of strokes are preceded by TIAs.
Warning signs in TIA or stroke include:
- Sudden weakness or numbness of the face, arm or leg;
- Sudden confusion, trouble speaking or understanding;
- Sudden trouble seeing in one or both eyes;
- Sudden trouble walking, dizziness, loss of balance or coordination;
- Sudden, severe headaches with no known cause.
If these symptoms are visible, Dr. Hull explains the primary reason for treating them as a medical emergency. "When a person has a stroke, there are therapies we can apply, but if the patient ignores them and is too late in getting to the hospital, these therapies cannot be applied at all due to the nature of how tPA, the only drug approved to treat stroke, works."
Although it has been available for more than 10 years, a very low percent of stroke victims are unnecessarily unable to receive tPA because many do not seek medical care and are not diagnosed as having a stroke until after the three-hour window has passed.
"Do not wait to make a doctor's appointment if there is any question about diagnosing the warning signs as stroke. Call 9-1-1 immediately and get emergency medical professionals involved," Elks urges. "Again, I want people to be of the mindset that this is a 'brain attack' and treat it with the same urgency as if the patient was having a heart attack."
STEP THREE: REHABILITATION
There are nearly 5 million survivors of stroke today, and a lot has been learned about appropriately dealing with the aftermath of stroke. When the immediate crisis has passed, comprehensive rehabilitation therapy has become just as critical as using the emergency medical system during the onset of stroke.
"One of the elements that set apart a certified stroke program is that it treats patients and families along the entire continuum of care," said Elks. "This includes comprehensive post discharge services." Goals include increasing independence, improving physical functioning, helping regain quality of life and preventing another stroke. The rehabilitation team may include a physical therapist, occupational therapist, and nutritionist.
Other professionals who should play a major role in dealing with the emotional impact of stroke include a psychiatrist or psychologist and a speech therapist. These professionals can help entire families deal with common consequences of stroke.
For example, a little known, but serious consequence of stroke is aphasia. Aphasia is a partial or total loss of the ability to talk, to understand what people say, to read or to write usually resulting from damage to the left side of the brain. Some recover quickly, but for others it is a lifelong condition. About one million people in the United States have aphasia, ranking it above Parkinson's or muscular dystrophy.
"Communication is a social-emotional connection that binds us together," according to Maura Silverman, speech language pathologist and director of the Triangle Aphasia Project (TAP) at WakeMed Rehabilitation Services. "If we don't have communication, we don't have access. This is why 90 percent of aphasia sufferers feel socially isolated and tend to stop working, discontinue volunteer activities and drop out of social outings."
In an example of how quality programs move stroke rehabilitation from therapy to long-term support, Silverman spearheaded an effort to establish TAP in 2003. "Because aphasia doesn't just happen to an individual rather to a community of people, it made me look differently at the approach we need to take as professionals," she said. "So, I started TAP as an independent nonprofit organization to empower families and patients to return to successful interactions and life pursuits." (See Sidebar on Triangle Aphasia Project for more information.)
Dr. Hull sums it up best, "Thanks to education efforts by the American Heart and Stroke Associations and program certification like WakeMed's Primary Stroke Center where treatment and rehabilitation practices are constantly being evaluated and improved according to stringent national guidelines, the mortality rate of stroke has dropped 25 percent in the last 10 years. This makes a big difference to patients, families of stroke victims, and to the economy."
WakeMed Health & Hospitals is the first hospital in Wake County to earn The Joint Commission Gold Seal of Approval for stroke. WakeMed Raleigh Campus Primary Stroke Center earned the Gold Seal of Approval™ for stroke care following an on-site review in August 2006.
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