GETTYSBURG MEDICAL NEWS
The Clinical View
By P.E. Hoffsten, M.D.
1 November 2006

HOW DO WE TAKE CARE OF A STROKE?

          Strokes are the third leading cause of death in the United States.  While many people die with strokes, there are many more that are left with permanent neurologic damage such that one side of their body may not work or they may not be able to speak or they may not be able to swallow.  Those that cannot swallow need a feeding tube.  Strokes are devastating and cause a massive change in lifestyle.  They are best avoided.

          The most important single step in avoiding strokes is blood pressure control.  Current recommendations are that resting blood pressure should be 120/80 or less.  While many people feel that they can achieve this with diet and exercise, it is very unusual that diet or exercise are effective enough to control blood pressure.  Most people with high blood pressure will require a medication to keep their blood pressure down.

          The American Heart Association has made an effort to develop methods to treat strokes quickly so as to avoid permanent neurologic damage.  In 1995, a “clot busting medicine” called a thrombolytic was tested in a large number of people who had had strokes.  It turned out that the medication did prevent permanent neurologic damage but only in thirty percent of the people in whom “the clot busting medicine” (thrombolytic) was used.  But it was not without some cost.  Up to 6% of people using the thrombolytic bled into the damaged area of their brain and things actually got worse.  Overall, thirty percent of the people who used the thrombolytic had a beneficial effect.  It is a gamble with six to one odds in favor of a benefit.  When these findings were published, a very strict protocol on how to use the medication and when to use it was published with the findings.  Below is the story of someone who had a stroke in Pierre and underwent this type of treatment.

          The lady was in her 80s and had a history of high blood pressure felt to be controlled over many years’ time.  She was feeling well.  At about 1:15 in the afternoon, she got up from her chair to go to the kitchen.  She fell to the floor unable to walk.  Initially she was able to respond to her husband, but her speech was very slurred and difficult to understand.  Her husband struggled with what to do because initially the patient kept claiming she was okay.  The ambulance was called at 1:45 PM and arrived within two minutes.  Initial history was taken. At that time, blood pressure was determined to be normal and her pulse was in the 50s, an acceptable value.  On arrival the paramedics noticed that the patient’s left side was paralyzed and that her speech was very badly impaired.  A blood sugar was checked and found to be normal.  A medication was given to reverse any possible drug affect that might have been present.  Oxygen saturations were checked and found to be normal.  The patient did not appear to be in pain.  The rhythm of her heart appeared to be normal.  She was placed on a transportation cart, taken to the ambulance, and brought on to St. Mary’s Hospital where she arrived at 2:15 PM.  According to the American Heart Association guidelines, ambulance delivery of a stroke patient to the hospital should be achieved within half an hour from the time the ambulance was called and that was achieved with this patient.

          On arrival in the emergency room, the physician immediately recognized that the patient had had a stroke with a left sided paralysis.  He was aware that there was a time restraint on giving “clot busting medicines” that might help reverse her situation.  The first step in the emergency room was stabilization of the patient, determination of the history, and “how bad the stroke was.”  There is a scoring system whereby the degree of impairment that a stroke causes can be graded.  If the grade is very low, clot busting medicine is not really useful.  It is not necessary.  If the stroke score is very high, there is often too much damage for the clot busting medicine to do any good and the risk of a bleed into the brain tissue is much greater.  This lady’s stroke score was in the range where the clot busting medicine might be of help.  The next step in her care was to obtain a CT x-ray of the brain to be sure that there was not a bleeding problem as a cause for her stroke.

          Strokes are caused by an artery in the brain that clots or alternatively by an artery in the brain that leaks.  We don’t want to give a clot busting medicine to someone who already has a blood vessel that is leaking and make that leak bigger.  A CT x-ray can determine if the person has a leak.  If no leak is seen, then clot busting medications might be of help.

          This lady’s CT x-ray was not indicative of a leak and that made her eligible to receive clot busting medicine. 

          Clot busting medicine must be given within three hours of the onset of symptoms if it is going to be effective.  If it is given more than three and a half hours after the symptoms begin, there is only a ten percent chance of success and a much greater chance of complications.  Thus, it is important to get the medicine in within three hours of the time the symptoms begin.  A neurologist specialist in Sioux Falls was consulted by telephone and indicated that the use of medicine might be of help and was worth the try.

          The family was then addressed in regard to the choices to be made.  They were told that the clot busting medicine had a thirty percent chance of success, but that there was up to a six percent increased risk of bleeding into the brain tissue and that this could make matters worse or even be fatal.  Her advanced age, the fact that she was poorly conscious at this point, and the fact that her stroke scale score was somewhat high, all indicated a less likelihood for a  successful result.  Be that as it may, the family elected to proceed with the clot busting medicine stating that the patient would be willing to take the chance in order to regain function on her left side.

          The medicine was administered at 3:55 PM, two hours and forty minutes after the onset of her symptoms.  Very fortunately, by the following morning, her stroke scale score had dropped to six from a previous high of twenty six.  She was able to stand, she was awake and alert, and the long process of her rehabilitation was begun. 

          The American Heart Association has a set of standards recommended for the care of stroke patients.  Very fortunately, our healthcare system at St. Mary’s Hospital was able to meet and exceed these standards with a very positive result for the efforts that were made.  The use of a clot busting medicine is a risky business, but strokes are riskier.  The healthcare providers at your local clinics are the backbone of getting the healthcare system engaged and directed in dealing with problems such as this lady’s stroke.