Last week, staff at a Maryland emergency room sprang into action when a new patient arrived by ambulance, clearly in the throes of a stroke. The middle-aged man had weakness in his left arm and the left side of his face, he couldn’t feel the entire left side of his body and his speech was impaired. A stat head scan revealed a large blocked vessel in the right side of his brain — pinpointing an ischemic stroke.
The patient was still within the three-hour window from his first symptom, and the ER staff put him on the clot-busting treatment known as tissue plasminogen activator, or tPA. As the IV ran, an ER doctor consulted with a top neurologist at one of the state’s comprehensive stroke centers. The decision was made to fly in the patient for cutting-edge treatment with a clot-retrieval device.
Below, national experts from two U.S. stroke centers describe the basics of ischemic stroke.
What stroke is: Some people call it a brain attack. When the brain loses the constant blood flow it needs for energy, it doesn’t work right. Depending on the part of the brain that’s affected, the functions it’s responsible for falter. “It could be seeing, speaking, moving an arm or a leg, vision problems or recognizing faces,” says Dr. John Cole, an associate professor of neurology at the University of Maryland School of Medicine and a neurologist at the University of Maryland Medical Center and Baltimore VA Medical Center.
Ischemic vs. bleeding stroke: Ischemic stroke is when blood vessels leading to the brain get blocked by a clot. Hemorrhagic or a bleeding stroke is when a blood vessel bursts or leaks. Ischemic stroke makes up about 85 percent of cases. A transient ischemic attack, or mini-stroke, is a temporary blockage that resolves on its own. According to the American Stroke Association, a TIA should be considered a “warning stroke,” because it can be a forerunner to a full-blown stroke.
One-sided weakness: “The most common sign, far and away, is something’s wrong with one side of the body,” says Dr. Sidney Starkman, co-director of the UCLA Stroke Center. One side of the face, often the corner of the mouth, goes crooked, and speech can slur. The arm becomes weak, particularly the hand. “Suddenly you can’t hold up a pen; suddenly you can’t lift your arm,” Starkman says. “That’s a stroke.”
Think FAST: The American Stroke Association has a simple way to remember stroke signs: F is for facial drooping. A is for arm weakness. S is for speech difficulty. T is time to call 911. You can also download a stroke-spotting app.
Take symptoms seriously: Ischemic strokes tend not to hurt much, Cole says — you might get a mild headache. So you need to recognize less-obvious symptoms that arise for no apparent reason. “If you’re eating dinner and you can’t pick up your fork, or your arm is heavy, and these come on suddenly — call 911 and get to the ED right away.”
By trying to sleep off symptoms, people wake in the morning doing worse. “We can do a lot of different treatments if people show up early and quickly,” Cole says. “But if they show up late, then the brain tissue is already dead, and then removing the clot is very risky — people can experience brain hemorrhage.”
Call 911: If someone you know is showing signs of stroke — call 911. Don’t waste precious moments trying to call their doctor. Don’t drive the person to the hospital — that could make matters worse. Ambulance paramedics can get care started and pre-notify the emergency department, says Starkman, who is also a professor of emergency medicine and neurology at the David Geffen School of Medicine at UCLA.
Clot-busting treatment: In the emergency department, the team rapidly assesses and stabilizes the patient, who undergoes brain imaging by CT scan or MRI to reveal whether it’s an ischemic or bleeding stroke. For patients with ischemic stroke who qualify, their path leads to treatment with tPA.
“Intravenous tPA basically activates your own anti-clotting system — it will chew up a clot,” Cole says. “There are very defined criteria allowing physicians to give it up to three hours in most people; up to 4.5 hours in some people.” After that, the bleeding risk outweighs the benefit.
Starkman says that while tPA is “wonderful,” it’s not a cure-all: “It will open up a clot in one out of three patients.”
Recovery and rehab: Extent of stroke recovery depends on each person. If the language area of the brain was affected, communication will suffer. Often, patients with weakness in one side of the body can recover very well, Starkman says. But if they have profound weakness where they can’t move an arm or leg at all, he says, “There’s no better than a 50-percent chance they’ll be able to walk again.”
The bulk of recovery occurs by about three months after the stroke, Cole says. After that, gains are incremental. Still, he says, people who are diligent with their rehabilitation can continue to improve for up to two years. Physical, speech-language and occupational therapy help restore function to the body. Cognitive therapy, including computer-based programs, helps people retrain an injured brain.
Stroke risk and prevention: Atherosclerosis, a buildup of plaque and fat in the blood-vessel walls, causes arteries to narrow and clots to form. Blockage of the large carotid arteries in the neck can lead to massive strokes. Chronic conditions such as diabetes, high blood pressure and high cholesterol can narrow blood vessels over time. Stroke is preventable — whether it’s staving off a first stroke, avoiding a full-blown stroke following a TIA or a second major stroke.
Depending on their risk factors, doctors put some patients on statin drugs and daily aspirin. Keeping chronic health conditions under control with medication helps prevent stroke. It’s important to stay physically active, maintain a normal weight, avoid heavy drinking and follow a healthy diet. Starkman recommends the Mediterranean diet.
Smoking is anathema to doctors who daily see the effects of stroke. “About 1 in 5 strokes is specifically due to smoking,” Cole says. “If you want to die young — smoke.”
Unexpected causes: Because it can cause nighttime high blood pressure, sleep apnea raises stroke risk, Cole says. Chronic infections are also tied to stroke: Bad teeth and gum disease are associated with inflammation, which stimulates the immune system in a way that eventually makes people more prone to developing clots and atherosclerosis in blood-vessel walls.
There’s a heart-stroke connection too. Atrial fibrillation, the irregular heartbeat known as “A-fib,” can lead to formation of clots in the heart which can eventually dislodge and travel to the blood vessels of the brain, causing a stroke.
Latest stroke treatment: A new study in the June 11 New England Journal of Medicine looked at a device to battle stroke-causing clots. It compared patients with acute ischemic stroke who received tPA alone, to those who had tPA plus a clot-retrieval procedure using a special stent-retriever device.
In this procedure, known as thrombectomy, a thin wire tube is threaded up through large blood vessels to rapidly grab and pull the clot from the brain. After 90 days, patients who had the stent procedure had better function than those who received tPA alone. Unlike tPA, this treatment isn’t available at local hospitals. The catheterization procedure must be done within hours of the stroke, by highly skilled specialists at a major stroke center.
The Maryland patient Cole flew in for evaluation was fortunate. After the flight, scans showed that the tPA had worked — the clot was eliminated and blood flow returned — and soon, he was moving his arm again. He didn’t need the clot-retrieval procedure after all. While Cole thinks the patient will sustain some “mild permanent deficits,” he should continue to improve in the upcoming weeks.
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What You Should Know About Ischemic Stroke originally appeared on usnews.com
