Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 22 September 2005

A TALE OF A STROKE – TO TREAT OR NOT TO TREAT?

            Someone a long time ago listed the seven deadly sins (pride, envy, anger, sloth, greed, gluttony, lust).  Some people feel that the list was stopped a little bit short.  In these modern times perhaps pizza should be added to the list.  Others suggest that gambling should be added to the list but then every farmer in South Dakota would be guilty every day.  Gambling with your crops is one thing but gambling with your life is quite another and gambling is exactly what occurs when a person has a stroke.  Below I am going to try to simplify the complex gambles that occur when the person has a stroke.

            First rule – Don’t get the stroke to begin with.  This means appropriate preventive measures including blood pressure and cholesterol control and avoidance of cigarette abuse.  But in spite of these preventive steps, there is still a gamble.  Statistics show that about 25% of people who develop a stroke don’t have any of the above risk factors.  But avoiding those risk factors does give 3:1 odds of not getting a stroke to begin with.

            So what if the stroke does come?  The recent example is a 58 year old gentleman who went to work one morning.  While sitting at his desk he noticed that he was having difficulty writing.  His hand just didn’t seem to work.  He thought perhaps his hand was asleep but it wasn’t really numb.  Try as he would, he couldn’t make his pen work.  As he became more alarmed, he tried to call his secretary and noticed that his speech was slurred.  He had trouble getting words out.  As this alarmed him more, he went to the mirror and noticed that the right side of face was drooping.  He was having a stroke.  He did not have a headache and he did not feel nauseous nor did he vomit.  He lived 62 miles from the nearest medical facility and called the clinic for advice.

            On discussing the situation with him, he was instructed to get onto the clinic as quickly as possible.  Now comes the second gamble.  Statistics show that a gentleman with this presentation will have a blood clot blocking an artery as the cause of his stroke 5 out of 6 times.  One time out of six, the cause of his stroke will be a bleed from a leaking blood vessel.  Usually, a leaking blood vessel will cause a headache, nausea, and vomiting but not always.  He happened to have a blood pressure cuff at home and his wife took his blood pressure while he was on the telephone.  It was found that his blood pressure was normal.  Of the one out of six persons who will have a bleeding blood vessel to cause their stroke, very high blood pressure is an expectation.  Thus, this gentleman was felt to have more than five out of six chances that his stroke was being caused by a blood clot.  If a person with a stroke has a bleeding blood vessel and takes a blood thinner such as aspirin, the bleeding can get worse.

            It was inquired as to whether or not he ever took aspirin and he bragged that he never took any medication.  He was advised that his best gamble to avoid a permanent or worsening loss of function of his right arm and the right side of his face was to take an aspirin at this time.  Grudgingly, he took the aspirin and his wife brought him onto the clinic.  By the time he in arrived in the clinic, his right arm had become very clumsy.  He was unable to close his right eye and the facial droop on the right side was very prominent.  He was immediately taken to the x-ray department where a CAT scan of his head was taken.  This scan was negative confirming the impression that the basic problem was more than 99% likely due to a blood clot.  The aspirin was the right thing to have taken when he did.  It was now about 10:45 am, an hour and 15 minutes after the onset of his symptoms.

            Now came the biggest gamble of all.  There are medications called thrombolytics that will melt a blood clot.  Thrombo- has to do with a blood clot;  -lytic means to break up.  Thus a thrombolytic is a medicine that breaks up a blood clot.  These medications need to be injected intravenously.  Unfortunately, they are not selective.  Unfortunately, they will not just go to the brain and melt the blood clot there alone.  They will melt blood clots anywhere that they might be.  Thus, if a person had an ulcer that was clotted over and not bleeding, using a thrombolytic can make an ulcer bleed.  If the person had recent surgery, and several blood clots were in place, those too could be melted with resulting bleeding into the surgical site.  If a person had a recent fall within internal injuries that were self limited, using the thrombolytic could cause bleeding to occur at the site of the injury.  Thus, there is a definite risk with using a thrombolytic.

            Just how much is that risk?  In the past 10 years since this therapy was started, there have been thousands of individuals in various study groups upon which to base conclusions.  Statistics show that if a thrombolytic is used, there are 19 people in 1,000 who will die from the use of the thrombolytic.  This is about a 2% chance.  On the other side of the coin, there are 55 individuals who might have died from their stroke but instead survived with less neurologic disability.  This is a 5 ½% likelihood that benefit will come from the use of the thrombolytic.  If the stroke patient is an “ideal candidate”, there is a 10% likelihood that a life will be saved with the ability for independent, continued living at home.  The ideal candidate is less than 80 years old, and is seen and treated within 3 hours of the time that their symptoms begin.  There is a long check list of various other things that have to be considered before a thrombolytic can be given.

            So what is a stroke victim to do?  The bottom line comes back to the gamble alluded to above.  If a person has a stroke and they are considered an appropriate candidate for thrombolytic therapy, there is a 10% chance that they will better with the thrombolytic.  But there is a 2% chance that they do worse.  Calculated out, that is 5:1 odds in favor of the thrombolytic agent.  But for the 2% of people that do poorly and perhaps die that is little consolation.  As any South Dakota farmer can tell you, “Life is a gamble and you are playing the odds on everything that you do”.  The healthcare providers at your local clinics are aware of these statistics and these very difficult considerations.  Decisions regarding whether to use a thrombolytic or not rest with your local providers in central South Dakota.  There is not time for a person to have a stroke in central South Dakota and then get to a big city medical center.  By the time you would get there, it is too late to use a thrombolytic.

            The 58 year old gentleman above was overwhelmed with the thought that a medicine might be the cause of a worse outcome or mortality.  He elected not to use the thrombolytic.  Fortunately, most of his symptoms went away over several days time and he was left with only slight clumsiness in his right arm and a distinct deterioration in his ability to write with a pen.  It will never be known whether the thrombolytic might have led to a better result.  The gentleman said he is pleased with the result he had.  At least I did get his attention regarding his smoking and his high blood cholesterol.  He is taking aspirin and a cholesterol medication to prevent the next stroke.  The healthcare providers at your local clinics are aware of the complex considerations when a person has a stroke and can help to advise when the crisis occurs.