Headstrong
Barbecues and Labor Day. Flipping burgers and drinking beer, without a care in the world. Life is good, the planets are aligned, and credit card bills have all been paid. Then a sudden fall to the ground, a slurring of speech, weakness in arms or legs, loss of coordination, partial blindness, or a failure to sense light touch on the skin signals that all is not well in Oz. The transition from devil-may-care to “I’d better care” comes at too high a price, with too little done, too late. Even if witnesses to the tragedy maintain their wits about them and remember the three simple steps to identifying a stroke, STR (asking the victim to smile, talk, and raise both arms), the damage already done may portend poor future quality of life, or worse. Do we throw in the towel, or wave a white flag? Answers don’t come easy to this complicated medical challenge, and, with stroke ranking second after ischemic heart disease as a cause of death and disability worldwide, we had better begin to look for some solutions.
Eighty percent of strokes are caused by arterial occlusion that cuts off adequate blood flow to the brain, and the remaining 20% are due to hemorrhages. Within thirty days of a stroke, it’s “adios, amigos” for between 10% and 17% of the unlucky. Throw increasing age, coexisting diseases (ischemic heart disease and diabetes mellitus), and increasing size of the brain infarct into the mix, and those numbers go up significantly. To make matters worse, consciousness is generally normal or affected only slightly during an acute ischemic stroke, breeding a semblance of normality in the hapless victim that causes precious moments to be lost. The initial headstrong “I’m ok” in the first minutes to hours after a stroke is deceptive to both victims and observers, and has little to do with the head being strong. In fact, clinical deficits appearing early correlate poorly with the irreversible damage that sets in later, as time marches on and reperfusion of the brain with blood continues to remain inadequate.
Alas, we know the problem. Let’s try to make sense of the solution. The old adage, “An ounce of prevention is worth a pound of cure,” while trite, is nowhere more relevant than when our brains become fertile for attack. You’ve heard it all before, but driving a stake through the monster requires both a cool wit and seasoned experience built on knowledge. In both victims of stroke and strong candidates for a first stroke, prevention is the name of the game, and the arsenal at our disposal consists of low-dose aspirin and dipyridamole, oral anticoagulation, treatment of hypertension, statin therapy to lower lipid levels, glucose control in diabetes, smoking cessation, and carotid endarterectomy, a surgical cleaning of crusted carotid arteries comparable to a plumber’s rodding of clogged pipes. When those measures reflect a level of impotence on the part of our defenders, we must first be certain that we are dealing with stroke, before initiating the next phase of our defense. Migraine headache, postictal paresis (impaired movement after epileptic seizure), hypoglycemia, conversion disorder (paralysis from hysteria), subdural hematoma, and brain tumors can all simulate acute ischemic stroke, and their treatment in most cases is drastically different from the emergent intervention imposed in the latter.
We set out on the trail of brain vampires such as atherosclerosis, which leads to thromboembolism or local occlusion, and cardioembolism that drain our brains of their life’s blood. The instruments in our little black bags, while not as genial and romantic as those in Van Helsing’s bag of tricks, are nonetheless much more sophisticated and efficacious. They run the gamut from signs and symptoms (irregular pulse, very high blood pressure, carotid bruit sounds), measurement of glucose level, complete blood count, prothrombin time and partial thromboplastin time (for blood clotting), electrocardiogram, and cardiac monitoring to transthoracic and transesophageal echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI). In all patients with suspected ischemic stroke, CT or MRI of the brain are required.
Once our blissful Sunday afternoon has gone from barbecue to emergency department to diagnosis of acute ischemic stroke in a reasonably short period of time, it becomes necessary to intervene in all haste. To do otherwise, and with no intent to make flippant of that which goes beyond serious, would be to harvest “vegetables” from once fertile and dynamic minds. We then turn our attention to the practice guidelines set forth by the Stroke Council of the American Heart Association and the American Stroke Association and by the European Stroke Initiative. A patient presenting to the emergency department within 3 hours after the onset of symptoms of stroke should be treated with the intravenous thrombolytic agent, called recombinant tissue plasminogen activator or rt-PA (alteplase). A maximum total dose of 90 mg of rt-PA results in a favorable neurologic or functional outcome at 3 months of 31% to 50%, and thus preserves functional quality of life and perhaps life itself in up to half of those “barbecue” victims. In addition to rt-PA, aspirin administration is recommended 24 hours after stroke (300 mg daily for the first 2 weeks, and then lower doses thereafter) to reduce rates of death and risk of recurrent ischemic stroke. This simple 1,2-combination will not only K.O. acute ischemic stroke in its tracks, but also ensure that the “headstruck” once again become headstrong.
© 2007, Albert M. Balesh, M.D. All rights reserved.
Eighty percent of strokes are caused by arterial occlusion that cuts off adequate blood flow to the brain, and the remaining 20% are due to hemorrhages. Within thirty days of a stroke, it’s “adios, amigos” for between 10% and 17% of the unlucky. Throw increasing age, coexisting diseases (ischemic heart disease and diabetes mellitus), and increasing size of the brain infarct into the mix, and those numbers go up significantly. To make matters worse, consciousness is generally normal or affected only slightly during an acute ischemic stroke, breeding a semblance of normality in the hapless victim that causes precious moments to be lost. The initial headstrong “I’m ok” in the first minutes to hours after a stroke is deceptive to both victims and observers, and has little to do with the head being strong. In fact, clinical deficits appearing early correlate poorly with the irreversible damage that sets in later, as time marches on and reperfusion of the brain with blood continues to remain inadequate.
Alas, we know the problem. Let’s try to make sense of the solution. The old adage, “An ounce of prevention is worth a pound of cure,” while trite, is nowhere more relevant than when our brains become fertile for attack. You’ve heard it all before, but driving a stake through the monster requires both a cool wit and seasoned experience built on knowledge. In both victims of stroke and strong candidates for a first stroke, prevention is the name of the game, and the arsenal at our disposal consists of low-dose aspirin and dipyridamole, oral anticoagulation, treatment of hypertension, statin therapy to lower lipid levels, glucose control in diabetes, smoking cessation, and carotid endarterectomy, a surgical cleaning of crusted carotid arteries comparable to a plumber’s rodding of clogged pipes. When those measures reflect a level of impotence on the part of our defenders, we must first be certain that we are dealing with stroke, before initiating the next phase of our defense. Migraine headache, postictal paresis (impaired movement after epileptic seizure), hypoglycemia, conversion disorder (paralysis from hysteria), subdural hematoma, and brain tumors can all simulate acute ischemic stroke, and their treatment in most cases is drastically different from the emergent intervention imposed in the latter.
We set out on the trail of brain vampires such as atherosclerosis, which leads to thromboembolism or local occlusion, and cardioembolism that drain our brains of their life’s blood. The instruments in our little black bags, while not as genial and romantic as those in Van Helsing’s bag of tricks, are nonetheless much more sophisticated and efficacious. They run the gamut from signs and symptoms (irregular pulse, very high blood pressure, carotid bruit sounds), measurement of glucose level, complete blood count, prothrombin time and partial thromboplastin time (for blood clotting), electrocardiogram, and cardiac monitoring to transthoracic and transesophageal echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI). In all patients with suspected ischemic stroke, CT or MRI of the brain are required.
Once our blissful Sunday afternoon has gone from barbecue to emergency department to diagnosis of acute ischemic stroke in a reasonably short period of time, it becomes necessary to intervene in all haste. To do otherwise, and with no intent to make flippant of that which goes beyond serious, would be to harvest “vegetables” from once fertile and dynamic minds. We then turn our attention to the practice guidelines set forth by the Stroke Council of the American Heart Association and the American Stroke Association and by the European Stroke Initiative. A patient presenting to the emergency department within 3 hours after the onset of symptoms of stroke should be treated with the intravenous thrombolytic agent, called recombinant tissue plasminogen activator or rt-PA (alteplase). A maximum total dose of 90 mg of rt-PA results in a favorable neurologic or functional outcome at 3 months of 31% to 50%, and thus preserves functional quality of life and perhaps life itself in up to half of those “barbecue” victims. In addition to rt-PA, aspirin administration is recommended 24 hours after stroke (300 mg daily for the first 2 weeks, and then lower doses thereafter) to reduce rates of death and risk of recurrent ischemic stroke. This simple 1,2-combination will not only K.O. acute ischemic stroke in its tracks, but also ensure that the “headstruck” once again become headstrong.
© 2007, Albert M. Balesh, M.D. All rights reserved.
posted by Dr. Al at
8/20/2007 06:45:00 AM
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