| > | | | | detect the more usual kind of stroke, called an |
| Strokes are like Rodney Dangerfield--they just | | | | infarction, caused by a blocked blood-vessel. This |
| don't get any respect. Odd, considering that for | | | | is because, in the first 24 hours, damaged |
| the usual stroke victim, it's the most serious illness | | | | brain-tissue can look just like healthy tissue to the |
| of their life. | | | | scanner's x-ray beam. The CT scan also screens |
| Although stroke is the third-leading cause of death | | | | for other brain diseases, like brain tumors or |
| in the U.S. and the number one cause of disability, | | | | infections, that might mimic a stroke, but call for |
| this condition doesn't get the respect and | | | | completely different treatments. |
| attention it deserves. When people have sudden | | | | So far, the discussion has been all about testing. |
| chest pain, they know they might have a heart | | | | What about treatment? What can be done to |
| attack. They call 9-1-1 and seek help immediately. | | | | improve outcome, reduce the severity of the |
| But people who suddenly become weak or numb | | | | impairment and prevent death? |
| on one side of their body, or experience sudden | | | | A useful way to think of a brain infarction is as a |
| problems with speech or vision, often act | | | | central core of forever-lost brain cells that no |
| unhurried in seeking help. | | | | treatment can revive, surrounded by a larger |
| Why is this? One possibility is that heart attacks | | | | zone of sick brain-tissue that may or may not |
| are usually painful. Strokes are not necessarily | | | | recover. Early treatments focus on this |
| painful, and even when pain is present, it can be | | | | surrounding tissue that is "on the bubble," trying to |
| mild. Pain is a powerful motivator, and some | | | | influence it to survive rather than die. |
| people have the mistaken belief that all serious | | | | One dramatic but controversial treatment is to |
| medical conditions hurt, and the seriousness of the | | | | use an intravenous clot-busting drug called t-PA |
| problem is proportionate to the intensity of pain. | | | | (tissue plasminogen activator). The potential |
| Also, because the brain is a more complicated | | | | benefit of using this drug is to reduce the |
| organ than the heart, symptoms of strokes can | | | | eventual impairment of the patient caused by the |
| also be more complex, making them harder to | | | | stroke. However, the drug also increases the |
| identify. | | | | likelihood of brain-hemorrhage, and physicians are |
| In both strokes and heart attacks a portion of a | | | | not unanimous in believing that the benefits of this |
| body-organ has experienced a sudden disruption | | | | treatment outweigh its risks. However, one point |
| of its circulation. Increasingly, strokes are called | | | | of agreement is that if t-PA is going to be used, it |
| "brain attacks" to emphasize the parallel with | | | | has to be administered within 3 hours of the |
| heart attacks. As a neurologist, I sometimes | | | | stroke's onset. Arriving at the emergency room |
| describe a stroke as "a heart attack of the brain." | | | | after 2 hours and 59 minutes isn't good enough |
| Reflecting my bias as a brain specialist, I also | | | | because a clinical evaluation, CT scan and blood |
| describe a heart attack as "a stroke of the | | | | tests all need to be completed before the drug is |
| heart," but--what can I say?--this terminology | | | | infused. |
| hasn't caught on. | | | | Less dramatic treatments are every bit as |
| If you suspect stroke in another person, the | | | | important--and quite possibly more |
| American Stroke Association recommends a | | | | important--than use of a clot-busting drug. It's the |
| quick, 3-step, screening test to identify cases: | | | | simple things that often matter most, but |
| 1. Ask the person to raise their arms and keep | | | | because they're so simple, sometimes they are |
| them up. In many stroke victims one arm doesn't | | | | unappreciated or even forgotten. |
| go up or, once up, sags. | | | | One such treatment is to manage the |
| 2. Ask the person to smile. A lopsided or | | | | body-temperature. Fever increases the size of |
| one-sided smile can indicate trouble. | | | | the stroke, so when an elevated temperature is |
| 3. Ask the person to repeat a simple sentence. If | | | | present, it needs to be decreased right away. |
| it comes out garbled or unclear--or not at all--a | | | | Another little detail is to manage the blood-sugar. |
| stroke is likely. | | | | Oddly, an elevated blood-sugar is toxic to the |
| While it's better to have some system of | | | | oxygen-deprived but still-surviving brain cells. So |
| detection than no system, this screen misses | | | | the emergency team should aggressively treat |
| strokes affecting the parts of the brain involved | | | | elevated blood-sugars by administering insulin. |
| in sensation or vision which are just as serious as | | | | Yet another issue of crucial importance is to |
| strokes causing paralysis or loss of speech. | | | | urgently treat severe anemia (decreased red |
| So now that emergency help has been | | | | blood cells) by transfusing blood. Oxygen |
| summoned, what happens next? | | | | molecules are transported to the brain attached |
| The emergency squad, upon arrival, sizes up the | | | | to molecules of hemoglobin within red blood cells. |
| situation and measures vital signs, including rate | | | | So if there are fewer red blood-cells, less oxygen |
| and adequacy of breathing, pulse rate and blood | | | | is delivered to the sick brain-tissue. Providing more |
| pressure. They insert an IV line, check the | | | | red blood-cells increases oxygen-delivery. |
| blood-sugar level via a finger-stick method, apply | | | | Of course, if the patient's blood-pressure is |
| pads to the chest to monitor heartbeats, and | | | | severely elevated, it needs to be decreased, but |
| often administer oxygen as well. Then they | | | | mildly-to-moderately elevated blood-pressures |
| transport the patient to the nearest emergency | | | | might actually improve blood-flow to the damaged |
| department. | | | | tissue. If the patient's blood-pressure is |
| Upon the patient's arrival, the medical team | | | | excessively low, this is bad, too, and is treated by |
| obtains more history and examines the patient | | | | infusing salt-water or administering medication. |
| more thoroughly. They draw blood to measure | | | | Dangerous heart-rhythms also need to be |
| blood-sugar, blood-counts and blood-clotting | | | | treated, as does a concurrent heart attack, when |
| function, as well as other blood-chemicals, including | | | | present. |
| those showing the presence or absence of a | | | | The principal value of being in a hospital with a |
| concurrent heart attack. They perform an | | | | fresh stroke is to achieve clinical stability in a |
| electrocardiogram (EKG) and continue the process | | | | monitored environment where rapid interventions |
| of monitoring vital signs and heart-rhythms | | | | can be made when called for. The hospital also |
| initiated by the squad. | | | | provides a setting in which more extensive tests |
| A computed tomographic (CT) scan of the head | | | | can also be performed, though not necessarily in |
| is usually done soon after the patient's arrival. CT | | | | the first 24 hours, that seek to understand why |
| scans can detect the 1-in-6 kind of stroke | | | | the stroke occurred and what can be done to |
| involving bleeding within the brain, but often fail to | | | | prevent another brain attack. |