STROKE New treatments bring hope. Better Homes and Gardens, September 1997 © by Gary Legwold It is a stroke story you would not have heard a couple years ago. Gregory Byrd, M.D., saw a 65-year-old patient who suffered a stroke that paralyzed the right side of her body. Luckily, her family was nearby and heard her hit the floor. They rushed her to the emergency room, and Bryd was called.          Byrd administered a new stroke medication called tissue plasminogen activator (t-PA). A half hour later, and one and one-half hours after the stroke occurred, “she was totally normal,” says Byrd, an internist in Woodstock, Virginia. “Usually, patients like this leave the hospital weeks later in a wheelchair. Now she was leaving as her normal self.”           Stroke has been a disease that draws out the fatalism in us. Stroke was considered unpreventable and untreatable, and it was thought that avoiding stroke was up to the whims of fate, not the skills of neurologists. “In the past,” says Byrd, “there was nothing we could do with stroke. We could not intervene. The old joke about neurologists was they could diagnose everything and treat nothing.”          That changed in June of last year. The U.S. Food and Drug Administration (FDA) approved t-PA for stroke therapy—and is on the verge of approving other stroke drugs as well. “We finally found something that works,” says Patrick Lyden, M.D., director of the University of California at San Diego Stroke Center. “Generations have grown up with the idea that stroke is a hopeless disease. Now we have tremendous hope.” Hope Is Spelled t-PA           Stroke is a sudden interruption of blood supply to a part of the brain. This interruption can be ischemic, the result of a blood clot within a vessel. Eighty-three percent of strokes are ischemic, and 17 percent are hemorrhagic, meaning the result of a breakage of a blood vessel in the brain.           T-PA is effective against ischemic strokes because it re-establishes circulation in the brain by dissolving blood clots. A five-year study by the National Institute of Neurological Disorders and Stroke found t-PA helped carefully selected stroke patients who received the drug within three hours of onset of stroke symptoms. In fact, the patients were at least 33 percent more likely than placebo patients to recover from their stroke with little or no disability after three months.           While t-PA can produce dramatic outcomes, the drug has its drawbacks. T-PA is new, and only a minority of doctors and hospitals know how to administer t-PA therapy. Those who do tend to be neurologists in large cities, leaving rural populations without a neurologist on call more vulnerable. The drug also has a 1 in 16 chance of causing bleeding in the brain, thus worsening the stroke’s effects. Because of this, t-PA cannot be used with hemorrhagic stroke. “The medical community is reluctant to embrace t-PA,” says Byrd. “The first rule of medicine is do no harm, and with a one in 16 chance of doing that, many doctors get gun-shy.”           Harold P. Adams, M.D., says using t-PA means balancing the bleeding risk against the potential for improved outcome. “Treating the clot represents a desperate situation, but not treating it is also a bad situation,” says Adams, a professor of neurology at the University of Iowa College of Medicine. “T-PA is not a guarantee, but at least it gives patients a chance.” Other New Treatments           T-PA is a break from medicine’s traditional passive position with strokes of “watchful waiting.” Led by the National Stroke Association (NSA), there is a new push for prevention and early detection (see sidebars). Just as heart attacks are preventable and treatable, so are “brain attacks,” as the NSA calls strokes.           Regarding prevention, doctors are using procedures that reduce the plaque buildup inside arteries. This buildup can be where blood clots form. Neurosurgeons are testing angioplasty, in which a small balloon is threaded into the artery and then inflated to compress the plaque. Doctors are also cleaning out clogged carotid (neck) arteries using carotid endarterectomy. While there is the risk that this procedure may cause a stroke, studies show carotid endarterectomy may reduce stroke risk as much as 55 percent when the artery is at least 60 percent blocked.           Dentistry has also contributed to stroke-prevention. A recent University of Buffalo study showed that a routine dental X-ray can detect calcium buildup in the carotid arteries. Calcium is a component of plaque.           Regarding treatment, t-PA may be the first of many new drugs. While the FDA has yet to approve most others for stroke therapy, it is clear that “we are stepping across the threshold of what is a revolutionary time in neurology,” says Richard Koller, M.D., a Minneapolis neurologist and president of the Minnesota Stroke Association (Martha, his id changes this summer). “In the next five years all kinds of new treatments may be used against stroke.” These new treatments include: Blood clot busting drugs. These medications break up blood clots that cause ischemic strokes. T-PA is one thrombolytic, as these drugs are called. Others are prourokinase and streptokinase. Ancrod, which is derived from the venom of a Malayan pit viper, is an enzyme that breaks down a protein essential to clotting. Low molecular weight heparin inhibits blood coagulation. Brain-protecting drugs. During a stroke, brain cells die as the result of a lack of oxygen, which leads to a complex series of chemical and electrical processes. Brain-protecting drugs called neuroprotectives interrupt these processes. For example, during a stroke, excessive amounts of glutamate are released into the brain. Glutamate allows calcium to move into nerve cells and kill them. Drugs called glutamate antagonists interfere with the progression of glutamate and therefore protect brain cells. There are many neuroprotectives in the works, and they will usually be used as a complement to thrombolytic drugs. Other new treatments on the horizon include pumping an oxygen- and nutrient-rich emulsion to the brain through the cerebral spinal fluid. This can minimize the stroke’s damage. Neuroprofusion is an experimental procedure that reroutes oxygen-rich blood from an artery in the leg to veins in the back of the head. Blood then circulates to the stroke-affected area, carrying oxygen and helping the clot to dissolve or wash away. The Three-Hour Window          Doctors say to derive the most benefit from t-PA and many of these other new treatments, intervention should occur in the first three hours after a stroke.          However, Koller says that in his experience “probably 95 percent of those who suffer stroke do not come to the hospital in the first 3 hours.” Perhaps patients do not recognize the early warning signs, or they think the symptoms will disappear. They may worry about costs or believe nothing can be done anyway. Whatever the reason, stroke patients are not prompt in seeking help. The NSA reports that 42 percent of stroke patients wait as long as 24 hours to report, with 13 hours as the average.          The take-home message from doctors is two-fold. First, know the warning signs of stroke. What you know may save you and your family from disability and death. Second, now, more than any time in the past, doctors can help stroke patients. Give them a chance by calling 911 immediately. “Advancements such as t-PA give us optimism,” says Byrd. “Stroke is now potentially treatable. The key is getting patients to medical attention as soon as possible.” Warning Signs of Stroke (sidebar) About half of all strokes come with hints that they are happening. Survival and even full recovery may depend on how well you recognize the following early warning signs—and act on them. Sudden onset of numbness, weakness, or paralysis in one side of the body. These sensations may be preceded by a pins-and-needles tingling Loss of vision in one eye, or loss of vision in half of the visual field Sudden onset of dizziness, double vision, or the inability to walk Sudden onset of a facial droop Difficulty speaking or understanding speech Severe, sudden, and unexplained headache Nausea, fever, and vomiting that comes on much more suddenly than viral illness symptoms Brief loss of consciousness or period of decreased consciousness (fainting, confusion, convulsions, or coma)          Any of these symptoms may signal a transient ischemic attack (TIA), or “mini stroke.” TIAs, which precede 10 percent of all strokes, can last a few seconds to almost 24 hours. TIAs do not cause permanent neurological damage, and many people downplay TIA symptoms, attributing them to old age, fatigue, a virus, etc. However, 5 percent of those experiencing a TIA will have a stroke within one week, says the National Stroke Association, and 35 percent within five years.          Call 911 if you recognize these symptoms in a family member or friend. Call immediately even if you are not sure. “I’d rather see 100 false alarms than miss one person who became permanently disabled because someone just blew off the symptoms as simply dizziness or an ear infection,” says Gregory Byrd, M.D., an internist in Woodstock, Virginia.          For more information on strokes, contact the NSA at 96 Inverness Dr. E., Suite 1, Englewood, Colorado 80112-5112. Or call toll-free 1-800-STROKES. The ‘Stroke Belt’ (sidebar cutline to run below map) These twelve states and the District of Columbia have been dubbed the “stroke belt.” This region has stroke death rates that are consistently more than 10 percent higher than the rest of the country. One section, in the coastal plain areas of North Carolina, South Carolina, and Georgia, has a death rate that is twice as high as the rest of the country. According to the National Stroke Association, the higher incidence of stroke deaths may be linked to such factors as a higher than average population of older adults and African-Americans. Not only are African-Americans at least twice as likely as whites to have a stroke, they are also twice as likely to die from a stroke. Are You at Risk? (sidebar) Stroke strikes 550,000 Americans each year, which is about one victim per minute. Stroke kills 150,000 people annually, making it the nation’s third leading cause of death. Four out of every five American families will be altered by stroke, and 4 million Americans are living with the effects of stroke.          There are more grim numbers, but here is a brighter statistic from the American Heart Association: The age-adjusted death rate for stroke in the U.S. dropped from 89 per 100,000 in 1950 to 28 per 100,000 in 1990.           One reason for the decline is doctors have pushed prevention. This means identifying risk factors such as the following: · Age. Two-thirds of strokes happen to people over age 65, and the stroke risk doubles with each decade past 55. · Gender. Males have a 30 percent higher risk than women, says Richard Koller, M.D., a Minneapolis neurologist and president of the Minnesota Stroke Association. · Race. African-Americans are at least twice as likely as whites to have a stroke. · Diabetes, family history, prior strokes, and atherosclerosis (hardening of the arteries) are all risk factors as well.           “These are the uncontrollable risk factors,” says Koller. “You cannot change your age, family history, and all that. But you can change your blood pressure, your smoking and exercise habits, cholesterol, high fat diet, excess weight and alcohol consumption—the things you have heard all along about preventing heart disease.”           You may also want to change how often you visit your doctor for regular physicals. “I had a stroke patient who had an irregular heartbeat—called atrial fibrillation—which is a risk factor for stroke,” says Gregory Byrd, M.D., an internist in Woodstock, Virginia. “She hadn’t seen a doctor in 15 years. She said she felt good, but we could have picked up the atrial fibrillation with a routine physical and prevented that stroke in the first place.” Stroke: First Mom, When Me? (sidebar)           I remember waking up on my 44th birthday, wondering if this would be the year I have a stroke. My mom, Darlene Schumacher, had had a stroke when she was 44, and I wondered if the time bomb that had blown in her head at 44 was ticking down for me.           Over the 23 years since Mom’s stroke, my fear had not overwhelmed my normally upbeat nature. But stroke leaves its dark mark on families, and with my family the mark manifested in two lingering questions.           The first is “Why me?” At the time of the stroke, there were no real answers for Mom or the rest of us in the family. Doctors offered science, saying Mom had had a hemorrhagic stroke, an aneurysm. This weak or thin spot on a blood vessel wall looks like a tiny blister and is usually present in the brain at birth. The aneurysm can break any time, doctors said, but hypertension and smoking are factors. Mom smoked and had high blood pressure.           Scientific answers provided some solace, but “Why me?” was really not directed toward doctors. It was a question aimed at the heavens. Stroke victims and their families are often left feeling dumped on by fate.           This notion had nagged me until I was doing the reporting for this stroke story. I was interviewing Richard LeBlanc, M.D., a neurosurgeon at the Montreal Neurological Institute and Hospital. LeBlanc had done research on how genes influence stroke risk, especially with aneurysms. He said statistics show that if four people have aneurysms, two will die immediately and a third will survive but die soon after or be left severely disabled. Only the fourth will recover and live a satisfactory life.           Mom, who died last year of a heart attack, had had an almost full recovery. She lived an almost normal life after the stroke, although she never returned to full-time work and could not drive because her vision had been affected. As I listened to Dr. LeBlanc, I began to experience a shift: Instead of feeling dumped on by fate, I was now grateful, realizing that fate had been kind.           I asked Dr. LeBlanc the second question that has haunted me since Mom’s stroke: “When me?” Was there a genetic link between Mom and me that would cause an aneurysm in my head to burst? He said research has turned up some genetic links. However, most aneurysms occur “sporadically,” meaning they usually do not run in families. He said there would be concern of genetic influence if two or more in my family had had an aneurysm. No, I said, Mom was the only one that I knew of.           This was reassuring news, and yet I wondered if there were procedures I could undergo to make sure my head was aneurysm-free. Yes, he said, doctors can do computed tomography scanning, magnetic resonance imaging, and magnetic resonance angiograms. However, he only recommended this screening (which can cost up to $2,000) when two or more members of a family had had aneurysms. He gave the example of a 41-year-old woman with fears similar to mine. “She said, ‘Look doc, my mother was 51 when she had a ruptured aneurysm, and my sister was 38 when she had hers. Am I going to get one?’” said LeBlanc. “Testing showed she had an aneurysm that had not ruptured. We operated the next week and got rid of it.”           I probably will wonder “Why me?” and “When me?” the rest of my life, but less often, thanks to the information I have gathered. I believe I will feel less of a “sitting duck” about strokes, and I will ask a new question: “What can I do to protect myself?”           Well, I can do the above-mentioned testing, but, more likely, I can have regular physicals and follow the advice of doctors on preventing strokes. I can know stroke’s early warning signs. I can make sure my family knows them as well—and knows to call 911. I can take hope in the recent breakthroughs in stroke therapy.           I can also do one more thing: wake up on each birthday and enjoy the day. Back Gary Legwold glegwold@lutefisk.com (612) 926-1877 "Ideas Need Words" Home Page © Copyright 2004 Gary Legwold and Conrad Henry Press. All rights reserved.