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Time is of the essence in treating strokes
By James Grotta, M.D. | June 21, 2012 | Updated: June 21, 2012 7:01pm
Stroke is a disease that everyone fears because it is so common (in Houston, almost 100 people suffer a new stroke each day) and because it is one of the leading causes of severe disability leading to the need for chronic care. No one wants to be a burden to their family or to live out their days bedridden in a nursing home. While the chances of stroke rapidly increase as we age above 65, stroke also can occur in children and young adults, particularly African-Americans with hypertension. Stroke also disproportionately affects women, since elderly women outnumber men and are less likely to have a spouse available as a caregiver if they suffer a stroke. Twice as many women die of stroke as from breast cancer.
The most important way to avoid the ravages of a stroke is to prevent it. A stroke is due to a blocked or ruptured artery in the brain, and recent studies have shown that aggressive medical management of its well known risk factors is much more effective than surgery or invasive treatments. These measures include cessation of smoking, weight loss, exercise, control of blood pressure, diabetes and high cholesterol, blood thinners for certain cardiac conditions (especially atrial fibrillation), and in some cases surgery or stenting of narrowed carotid arteries. But most patients are not compliant with these measures, even though we have new and affordable medications that have few if any side effects. A new era of stroke prevention is upon us - we know that if patients take their medications, keep their blood pressure and cholesterol low, maintain the proper level of blood thinning, and lead reasonably healthy life styles, their chance of being disabled by a stroke is markedly reduced.
But what if a stroke occurs? The first step is to recognize that a stroke is happening and not to ignore the signs. Most patients are not aware of the gravity of the situation, and it is up to a spouse, family member, co-worker or bystander to do the right thing. But fewer than one in four Houstonians knows the symptoms of a stroke. If you remember only one thing from this article, remember the acronym word FAST, for face, arm, speech and time. It is one of those things that should be on your refrigerator door. Look at the person; is one side of the face drooping? Have him hold out his arms; does one drop down faster than the other? Get the person to talk; is his speech slurred or does he have trouble getting his words out? If any of these conditions are present, you must call 911 immediately. Don't call your doctor, don't call your son or daughter or spouse, and don't just drive to the clinic or hospital. Call 911.
Why is it so important to call 911? Because time is brain. Brain cells cannot live without the oxygen and glucose that is delivered by the blocked artery. It is estimated that 2 million nerve cells die every minute after a stroke begins. That means that someone having a stroke when you began reading this has already lost more than 10 million nerve cells. We have therapies that can help reverse the damage caused by stroke but they are only effective if given quickly. The most effective and well-established treatment is intravenous tissue plasminogen activator, or TPA. This is a natural clot busting substance that we all have coating our arteries. After a quick CT scan to be certain the stroke is not caused by bleeding, TPA is injected into the vein, circulates through the bloodstream, hones in on the clot and begins to dissolve its components. The treatment has risk, but all studies, including one just completed in Europe with more than 3,000 patients, confirms its benefit if given within three hours of symptom onset. Fifty percent of patients treated within two hours of onset will recover with no disability.
The other reason to call 911 is that only some emergency departments in Houston can deliver TPA quickly and predictably. Houston fortunately has a highly trained paramedic force with the Houston Fire Department-Emergency Medical Services (HFD-EMS). HFD-EMS will answer your 911 call and will be able to recognize if the person is having a stroke and will know where to take them. That decision requires balancing the importance of time and the availability of expertise. It doesn't do any good to go to the closest hospital or the one where your doctor works, if they are not prepared to treat you. Severe trauma patients go to one of Houston's excellent Level 1 trauma centers. Similarly, a stroke patient should go to one of Houston's outstanding stroke centers. The Stroke Team at UT Medical School and Memorial Hermann Hospital at the Texas Medical Center (MHH-TMC), in collaboration with HFD-EMS, were one of the first in the world to test TPA when it was first developed in the 1980s. Since then, several other hospitals, but not all, have become stroke centers where you can be assured to receive TPA if you arrive within the three-hour time window and meet other treatment criteria. Currently, 25 hospitals are certified by our local emergency care agency as primary (Level 2) or comprehensive (Level 1) stroke centers. Together, they treated with TPA roughly 10 percent of the stroke patients taken to one of their emergency rooms last year, more than twice the national average.
This fall, some of these hospitals will receive national certification as comprehensive stroke centers, which will identify their expertise in delivering more complex stroke therapies and conducting research to find better therapies. After all, a treatment that is used in only 10 percent of stroke patients and that only works up to 50 percent of the time is not good enough. At MHH-TMC, we are testing newer treatments (more powerful clot-busting drug combinations, ultrasonic energy, catheters, brain cooling, to name just a few) that might improve on the benefit of TPA, but all have to be given quickly. We are also testing exciting new approaches to helping patients recover from their strokes. But for the most part, the battle for complete recovery from stroke is won or lost in the emergency department in those first few hours.
Not all stroke care is equal. Take ownership of all aspects of your health. In particular, Houstonians need to be informed and active participants in decisions about both stroke treatment and prevention.
For any questions or further resource information about stroke, there are a number of excellent online resources:
* www.strokeassociation.org/STROKEORG/General/Patient-Infor mation-Sheets_UCM_310731_Article.jsp
Grotta is professor and chairman of the Department of Neurology, University of Texas Medical School, and chief of neurology and co-director of the Mischer Neuroscience Institute, Memorial Hermann Hospital-Texas Medical Center. These opinions are the author's and do not necessarily reflect those of the UT Medical School or Memorial Hermann Hospital.