Central  South  Dakota  Medical News
The Clinical View
by P.E. Hoffsten, M.D.
10/18/2001

STROKES AND TIA'S

             One of the most frightening and devastating events that can happen in a person's life is a stroke. A stroke happens when a part of the brain loses it's blood supply and virtually dies. When that happens that part of the brain is not recoverable and whatever function it had for the body is lost. One type of stroke occurs when the "motor cortex" on the left side of the brain is damaged. The common result is loss of function of the right arm, the right leg, and the speech center. The person is unable to move the right arm or right leg or to speak. They can understand very well but the frustration that comes from the inability to speak can be maddening. As mentioned above, unfortunately once a true stroke happens there is no way back. You can not unstrike a match and you can not undo a completed stroke.

The question then becomes how do you prevent strokes from occurring and can you reverse a stroke in progress.

The person who is destined to have a stroke usually has one or more of three major risk factors. The most common cause of stroke is high blood pressure. This is especially true after the person has had high blood pressure for 20 years and the blood vessels have been damaged because of long being overstressed. The second leading cause of stroke is smoking cigarettes and the third cause is high blood cholesterols. While diabetes seems to predispose patients to heart attacks, it seems to play a lesser role in causing strokes. Addressing the above three problems in a preventive manner is the best way to prevent strokes.

The second question has to do whether a stroke in progress can be reversed. The answer is, under certain circumstances, yes. However, the considerations are very complex.       First there are two types of strokes. One type occurs when a blood vessel in the brain bursts and blood freely bleeds into the brain substance. Fortunately, this accounts for only 15% of the strokes that ever occur. Unfortunately, there is no meaningful way to prevent the loss of function or the mortality that occurs in 85% of these individuals. Commonly this type of stroke presents with a severe headache, sudden loss of function and loss of consciousness in a very short time.

A second type of stroke is called a subarachnoid hemorrhage. This occurs when a vessel on the surface of the brain bleeds. Half of these patients can be helped with surgical intervention but the mortality in this situation is still about 50%.

Once it occurs, stopping bleeding into the brain is very difficult. On the other side of the coin is the question of what happens when a blood vessel gets stopped up with a blood clot. Can the blood clot be melted and the person regain function in the area of the brain that was being lost? The answer to this question is yes under very carefully selected circumstances. Sometimes when a person is going to have a stroke, they have warnings which physicians call TIA's. A TIA is a `transient ischemic attack' which means that a blood vessel has a small clog in it, a part of the brain did not get enough blood for a short period of time and then the blood flow was re-established and that part of the brain starting working normally again. Common presentations like this could involve the loss of vision in one eye for 15 or 20 minutes followed by the eye regaining vision over the next half hour and being normal thereafter.  Another common presentation of a TIA would be the loss of function in the right arm and maybe the right side of the face for 15 minutes to half an hour followed by recovery of function in the next several hours and then no residual problem. These TIA's are one of natures little warnings that there is a bigger problem coming. If the person doesn't deal with the basic problem, the full stroke and permanent loss of function frequently follows. Fortunately, one aspirin a day will prevent many of the strokes that occur in our society. The use of a new medication called Plavix is somewhat more effective than aspirin in people that are having TIA's. Tylenol is no help in this area but Ibuprofen (Motrin, Advil, Nuprin), Naprosyn (Aleve), and Ketoprofen (Orudis) all prevent blood clots in the same manner that aspirin does if they are used on a daily basis. One of the beauties of aspirin is that the effect tends to last for about a week. Thus if a person forgets a dose for a day or two, they do not lose complete protection. Motrin, Aleve, and Orudis wear off in 24 hours and if one forgets a dose all the protection is lost after that day. In addition, aspirin is cheaper and would be the favored drug for that purpose.

The final question is what to do with a stroke in progress. Time is the most critical consideration in how to deal with this. The person must receive treatment within three hours of the onset of symptoms or the treatment has very little benefit and does have unacceptable risks after that time. Suppose a person has the onset of weakness in the right arm and the right side of the face and difficulty speaking. Marking the time when this begins is a critical part of care. The person must get to a hospital that has CAT scan capability and be examined with an x-ray of the brain. If the x-ray indicates that treatment may help, then a number of risk factors need to be reviewed to be sure that the treatment is not too dangerous to give. The patient needs to be carefully monitored to separate the difference between a TIA that does not need clot melting medicine and a true stroke that does need clot melting medicine. If the x-ray fits and there are no excluding considerations and a person is felt to be having a true stroke instead of a TIA, the last consideration is whether the risk of the medication is worth the potential benefit. The potential benefit is that 30% of the people who have a stroke will be normal in 3 months as opposed to around 20% who will be normal if they don't use the clot melting medicine. That accounts for 10 very happy people out of 100. Unfortunately, 6 out of those 100 people will have a bleeding problem in which a clotting type of stoke is turned into a bleeding type of stroke and the damage is usually permanent. Those 6 are felt to most likely have had permanent damage anyway but in some of the cases the damage is definitely worse if there is bleeding into the brain substance.

Currently the American Heart Association favors treating people with an early stroke that meet very strict criteria. Speaking for myself, I think it is a very risky business. Fortunately, the question arises relatively infrequently and I have yet to have to make this decision. I understand it has been done once in Pierre with a very favorable outcome but the experience in Rapid City and Sioux Falls is mixed as one might suspect. I go back to the earlier part of this article and say again prevention is by far the best answer to this problem. Your local clinics can help deal with high blood pressure, and high blood cholesterol and help with stopping smoking programs.