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Spring 2008 - Stroke Sense

Chances are you know someone who has suffered a stroke. The third leading cause of death among Americans, stroke is responsible for more adult disability than any other disease, injury or medical issue. The majority of people who survive a stroke will have some type of disability.

These are sobering facts, but there is good news. The majority of strokes can be prevented. Prevention guidelines that involve healthy lifestyle and personal health awareness can help to significantly reduce the likelihood of stroke.

It’s also important to understand how strokes are treated. Today, there are advanced technology and medication that actually help decrease the likelihood of disability after stroke. For many stroke patients, rehabilitation is also an important part of recovery.

Stroke prevention and treatment can be confusing, but knowing the basics can save lives.

What Is a Stroke?
“Strokes are, in some ways, similar to heart attacks,” explains Ravish Sachar, MD, a cardiologist with Wake Heart & Vascular Associates. “A heart attack involves lack of blood flow to the heart; most strokes result from lack of blood flow to the brain. Both are very serious cardiovascular issues that require immediate treatment.”

Act F.A.S.T. to Detect a Stroke

The National Stroke Association offers this simple test you can administer when you suspect someone is having a stroke.

F = Face — Ask the person to smile. Does one side of the face droop?

A = Arm — Ask the person to raise both arms. Does one drift down?

S = Speech — Ask the person to repeat a simple sentence. Does the speech sound slurred or strange?

T = Time — See any of these signs? If so, it’s time to call 911 or get to the nearest hospital where acute stroke treatment is available. The more time that elapses, the more brain cells are lost.

There are Two Types of Stroke:

Ischemic Stroke — Arteries are blood vessels that carry blood from the heart throughout the body. When blood cannot reach the brain due to a clot or a buildup of plaque in the artery, an ischemic stroke occurs. About 85 percent of strokes are ischemic.

Hemorrhagic Stroke — When a blood vessel in the brain breaks and releases blood into the brain, a hemorrhagic stroke occurs. Fewer people suffer hemorrhagic strokes than ischemic, yet the chance of survival after hemorrhagic stroke is lower.

Why Does Stroke Cause Disability?
When blood flow to the brain is interrupted, brain cells begin to die, and brain damage occurs. The ability to move, speak and remember things are controlled in different centers of the brain. For example, when a stroke occurs that cuts off the flow of blood to the area of the brain that controls speech, the person affected may experience speech problems. “The amount of brain damage a person experiences during a stroke determines how moderate or severe the person’s disability will be and if it has the potential to be reversed,” says Sachar.

What Are the Symptoms of Stroke?
“Everyone needs to know how to recognize stroke symptoms and how to get effective, immediate help,” says Keith Hull, MD, a neurologist with Raleigh Neurology Associates and medical director of the WakeMed Stroke Program. “Prompt and effective treatment can minimize stroke damage and improve outcomes.” The National Stroke Association offers the following information.

Common Stroke Symptoms

  • Sudden numbness or weakness of the face, an arm or a leg, particularly on one side of the body
  • Sudden confusion, trouble speaking or understanding
  • Sudden trouble seeing or loss of vision in one eye
  • Sudden loss of balance or coordination, trouble walking, dizziness
  • Sudden severe headache with no known cause

How Do I Know if I am at Risk for Stroke?
Like heart disease, some stroke risk factors are controllable; others are not. In general, people over age 55, males and African-Americans are at a higher risk for stroke. “Identification and treatment of some common risk factors can substantially reduce your chance of having a stroke,” says Dr. Hull. Some of these include:

  • A previous stroke
  • High cholesterol
  • High blood pressure
  • Heart disease
  • Diabetes
  • Atrial fibrillation
  • Carotid artery disease

How Can I Prevent Stroke?
As previously mentioned most strokes are preventable. “Stroke prevention takes personal commitment, particularly if you have risk factors that cannot be controlled,” says Dr. Sachar. If you are dedicated to stroke prevention, adopting and maintaining a healthy lifestyle is mandatory. Talk to your doctor about how to incorporate the following guidelines into your life.

  • Blood Pressure — Know it, lower it and have it checked often.
  • Atrial Fibrillation — This is a heart rhythm problem. About 15 percent of strokes occur in people who have atrial fibrillation. You may need blood thinners. Ask your doctor about it.
  • Stop Smoking
  • Limit or Eliminate Alcohol Consumption
  • Cut the Salt — Stick with fresh foods and packaged foods with less than 100 mg of salt per serving.
  • Cholesterol — Know it, lower it and have it checked often.
  • Exercise at Least 30 Minutes a Day
  • Diabetes — If you have diabetes, keep it under control.
  • How’s your Blood Circulation? — If you have problems, talk to your doctor.
  • Stroke Symptoms — Knowing them can save lives.

Advanced Stroke Diagnosis and Treatment
“Time is brain,” says Dr. Hull. “By calling 911 immediately for emergency transportation to WakeMed, or the closest hospital that offers acute stroke treatment, you can improve the chances for a stroke victim to preserve as much normal brain as possible. This can improve recovery in most cases and can save some lives.” At WakeMed, a dedicated Stroke Team of neurologists, endovascular neurosurgeons, radiologists, interventional cardiologists, emergency medicine physicians, nurses and therapists work together to provide advanced, timely stroke diagnosis and treatment.

H2H Spring 2008 stroke Docs

Targeted Treatment
Several effective treatment options are now available for stroke patients. The Stroke Team determines the most appropriate treatment.

“Clot Busters” — Our bodies produce tissue plasminogen activator (t-PA), an enzyme that changes the plasminogen in our bodies into another enzyme, which dissolves blood clots. T-PA has been genetically engineered so that it can also be administered intravenously to dissolve the very serious clots associated with stroke. It is available in most hospital emergency departments throughout the United States and is approved for qualifying patients who arrive at the hospital within three hours of symptom onset. Many patients who receive t-PA within the three-hour window recover with few or no disabilities. However, t-PA does carry a risk of brain hemorrhage. That is why it is only approved for patients who meet specific criteria.

Interventional Stroke Treatment — Interventional cardiologists Ravish Sachar, MD, and Matthew Hook, MD, and endovascular neurosurgeon Kimberly Livingston, MD, offer advanced procedures to prevent strokes and stop them in their tracks.

Special devices are used to remove clots from blocked blood vessels. These devices — the Merci® Retrieval System and the Penumbra System — are often used when stroke patients cannot tolerate t-PA or simply do not respond to it. The Merci retriever is a coil on a catheter that is threaded to the clot in the blood vessel of the brain. The interventionist then advances the coil so that it wraps around the clot. The interventionist can then remove the clot from the body. The Penumbra System uses suction to remove the clot and restore blood flow to the brain.

Technology to Diagnose Stroke
Computed tomography (CT) perfusion imaging, now used at WakeMed, continues to prove its value as a fast and effective way to diagnose stroke and determine the appropriate type of treatment. “MRI offers precise diagnosis but takes much longer than CT and presents some logistical obstacles that can be cumbersome in the setting of acute stroke, where every minute counts,” explains Philip R. Saba, MD, a neuroradiologist with Wake Radiology and member of the WakeMed Stroke Team.

“We can also use angioplasty to stop strokes, much like we use it to stop heart attacks,” explains Dr. Hook, Wake Heart & Vascular Associates. Using a catheter, the interventionist threads a balloon through the artery to the blockage. The balloon is then inflated to open the artery. Sometimes, the interventionist will also place a stent, a small device made of metal mesh, at the site of the blockage to help prevent future strokes.

According to the National Stroke Association, 40 percent of stroke patients experience moderate to severe disability that requires specialized rehabilitation. Stroke can affect speech, mobility, dexterity and memory. “The impact that stroke has on the brain causes the body to ‘forget’ how to do certain things,” says Skip Roy, PT, a manager with WakeMed Rehabilitation Services. “Specially trained physical, occupational and speech therapists help patients ‘relearn’ how to walk, talk, and do the other daily activities that their bodies have forgotten how to do.”

Rehabilitation is most effective for individuals who experience minor disability. For those who suffer more debilitating effects from stroke, inpatient or outpatient rehabilitation can mean the difference between returning home and admission to a nursing care facility.

“The earlier rehab can begin the better,” says Roy. Other factors that contribute to the success of rehabilitation include the extent of the injury to the brain, effectiveness of timely medical interventions, the skill and experience of therapists, the patient’s attitude and motivation, and the cooperation and support of family and loved ones.

Stroke rehabilitation typically begins while the patient is in the hospital. Large health systems like WakeMed offer comprehensive inpatient, in-home and outpatient rehabilitation options and have the capacity to provide them in convenient locations. Different types of rehabilitation services exist.

  • Rehabilitation while in the acute care hospital
  • Rehabilitation hospital
  • Home health therapy
  • Outpatient treatment, including day treatment programs
  • Therapies in long-term care facilities

WakeMed Health & Hospitals provides all these options for post-stroke rehabilitative care. Rehabilitation facilities are chosen based on the patient’s needs and desires. At WakeMed, a stroke case manager works directly with patients and family members to ensure they are aware of their options.

“As specially trained therapists, our goal is to help stroke patients regain as much of their independence as possible and lead productive lives,” says Roy. “Stroke rehabilitation may take weeks or even many months. Regardless of how long, we are here to help patients progress to their highest possible level of functional independence.”


H2H Spring 2008 stroke Xray

Technology Can Buy Time, but Don’t Count on It

When t-PA is administered within the three-hour window after symptom onset, it can significantly reduce the chances of long-term disabilities from stroke. Penumbra and Merci technology can actually broaden that recovery window to eight hours. But Dr. Hook offers some important advice.

“Yes, our procedures and technology can increase a patient’s chances of a full recovery even when they have been experiencing symptoms for more than three hours. This doesn’t mean you can take your time getting to the hospital. Time is brain. If you think you or a loved one is having a stroke, call 911 and get to the hospital as soon as possible.”

H2H Spring 2008 Rehab



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