A Heart Attack of the Brain When It Comes to Strokes, Time Is of the Essence

Every 40 seconds someone has a stroke, and every four minutes someone dies of a stroke, making it the third leading cause of death in the U.S. Strokes hit very suddenly without any warning, but the problem is that, since strokes are painless, people often ignore the symptoms.

“A stroke is like a heart attack of the brain,” said Dr. Emilio Melcionna of Springfield Neurology Associates, who heads up the stroke program at Mercy Medical Center in Springfield. “When people have chest pain and nausea, they rush right to the hosptial. But because strokes are painless, there has been a lag in awareness about them.”

In fact, a generation ago the symptoms of stroke were often missed by hospitals because patients sat quietly and didn’t complain, Melcionna said. “Things have changed a lot since that time, but it’s critical for people to get to the emergency room as quickly as possible when they have symptoms.”

There are two types of strokes. The most common, which affects 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of stroke victims, is an ischemic stroke which occurs when a blood clot obstructs the flow of blood to the brain. When that happens, brain cells immediately begin dying. About five years ago, a drug was approved called tissue plasminogen activator (tPA), which breaks up the blood clots. However, the drug is effective only when adminstered within three hours after a stroke.

“Our goal is to administer tPA in cases of ischemic strokes within 60 minutes when it is appropriate,” said registered nurse Fayla Learning, the stroke program coordinator for Baystate Health. “We have given the drug 26 times this year, but only 5{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of people with strokes arrive at the hospital in time to receive it. The quicker people get here, the quicker we can treat them, and the better the medication works. It can mean the difference between being able to go home and being in a nursing home.”

The second type of stroke, which occurs when a blood vessel ruptures and prevents blood flow to the brain, is called a hemorragic stroke. When this happens, “if we can locate the clot, there are procedures that can be done to remove it,” said Learning.

In some cases, people get a warning before a stroke actually strikes, which is called a TIA, or transient ischemic attack. It happens when a clot isn’t large enough to completely block the vein and does block it enough to allow only a limited amount of blood to get through. When that occurs, people experience stroke symptoms which can last up to 24 hours. “Someone may have a very narrow blocked vessel which plugs up, then releases,” said Melchionna. “If this happens, we can do a carotid test” which determines whether the person has carotid artery disease. “If so, measures can be taken which will prevent a future, full-fledged stroke.”

It’s extremely important to call an ambulance when stroke symptoms arise, and tell the driver what’s happening. Angela Smith, clinical manager of Holyoke Medical Center’s Stroke Program, says this allows the hospital to get things ready to treat the person the minute they arrive. “Time is of the essence because, every second after a stroke, 32,000 brain cells die,” she said, adding that Holyoke’s stroke team is immediately readied when an ambulance calls and says it is transporting a stroke victim.

Stroke symptoms can be be remembered by the acroynm ’FAST.’ The initials stand for sudden facial weakness, paralysis, or slurred speech; arm or leg weakness, which can cause someone to suddenly fall; sudden speech problems, which can cause someone to slur their words; and time, because getting to the emergency room quickly is critical, even if someone isn’t sure if they are having a stroke. “Symptoms can vary quite a bit,” Melchionna said, adding that they depend upon which artery is blocked and what section of the brain it supplies with blood.

“The key is that there is a sudden onset of symptoms,” Learning said.

Taking Charge

Massachusetts hospitals that have earned the designation of ’primary stroke centers’ have adopted programs developed by the American Heart Assoc. (AHA), the American Stroke Assoc., and the Department of Public Health, which can enhance patient outcomes and save lives.

The first thing they do is diagnose whether the stroke is real, because some conditions can mimic one, including blood sugar that is too high or too low. This (and appropriate treatment) is accomplished via a neurological assessment, medical history, lab work, and a CT scan.

The goal, outlined in the AHA’s Get with the Guidelines program and the Stroke Collaborative Reaching for Excellence (SCORE) program, say that ’door-to-needle time,’ which begins the second a person arrives at the hospital, should not be longer than 60 minutes. This means that all testing must be completed within an hour so tPA can be given within 60 minutes after arrival, when the drug is deemed appropriate.

“The earlier the drug is given, the better the outcome is,” Melchionna said. “One out of eight people who receive it do extremely well, and one in four see a significant improvement. The drug can make a remarkable difference and allow a person to return home after observation and/or more treatment with little or no damage, but also carries the potential for side effects, as one in 16 people who receive it can hemorrhage.”

Experts say the vast majority of strokes could be prevented. “Risk factors that are genetic or gender-related can’t be helped,” Melchionna said, referring to the fact that more men than women have strokes. However, more than half of stroke deaths occur in women, and the use of birth control pills and pregnancy pose special stroke risks.

Other risk factors include smoking, obesity, a sedentary lifestyle, high blood pressure, high cholesterol, alcohol and drug abuse, and cancers such as sickle cell anemia which can cause blood to clot more easily. “The healthier a person is, the less likely he or she is to have a stroke,” Melchionna said. “I have told many people they wouldn’t be here if they weren’t a smoker.”

Dr. Carmel Armond, chief of neurology at Baystate Health, agrees. “The biggest change we have seen in the last 20 years is the spread of obesity. It is on the rise and puts people at risk for stroke and coronary artery disease. So, although awareness of stroke symptoms is higher and medications to treat it are better, what we can give is being taken away by obesity in our population.”

He said some strokes are devastating from the outset, while others are less severe. “Medical teams do the best they can to try to open up blood vessels,” he said, adding that mechanical methods can be employed when appropriate. “But brain cells always die. The best medicines can’t save people from themselves, and there is nothing as good as stroke prevention, which is in the minds, hearts, and hands of people.”

In addition to obesity, substance abuse, in particular cocaine, is a rising risk factor. “I have heard it said that 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of strokes could be prevented if people kept trim; avoided substance abuse, including alcohol in excess and smoking; and made sure their blood pressure is managed. The best thing that could happen would be if people took responsibility for their health,” Armond said, noting that people with health problems need to make sure their conditions are monitored and cannot afford to run out of medications for high blood pressure or high cholesterol.

“There are only a small minority of individuals who have strokes that we cannot figure out the reasons for,” he added. “Most people know if they have risk factors, and the majority of strokes which occur are in people who are not managing the risks.”

Extraordinary Treatment

Holyoke Medical Center and Noble Hospital in Westfield have been recognized with Gold Plus Awards from the AHA, and Holyoke is on the Target Stroke Honor Roll due to its quick response to stroke victims.

Smith said Holyoke’s door-to-needle time is less than an hour, and she spends a lot of her budget on public education to make people aware of how important it is to call an ambulance if they have stroke symptoms. “We have the passion and determination to make a difference and have made stroke care a priority,” Smith said. The hospital was also honored in 2008 with an award from the American Stroke Assoc. for going above and beyond with stroke patients. “Our priority is always the patient, which is why we have received these acknowledgements.”

Baystate Health recently hired an endovascular specialist who can do complex, involved procedures sometimes needed in the case of a hemorragic stroke. Baystate also has a telemedicine hospital setup, which allows patients at Mary Lane and Franklin to be assessed remotely. And Armond said the 2010 scores from Baystate Health were better than average for the state in terms of the mortality index for strokes. “We are seeing fewer deaths than would be expected.”

Mercy, Holyoke, and Baystate are among 57 medical centers and hospitals in the state participating in the SCORE collaborative, which provides support to primary stroke centers.

“All participating hospitals in the state meet every three months for an eight-hour conference and meet regionally in between,” Smith said. “Our goal is to find the best ways to treat stroke. It’s the one disease that is talked about every three months so that hospitals can provide the best outcomes for patients.”

This is especially meaningful, she said, because, “years ago, there wasn’t anything we could do to reverse the effects of stroke when it was happening.”

Melchionna agreed. “In the past, treatment varied from one institution to the next and from one neurologist to the next,” he said. “But now hospitals share information and act cooperatively using evidence-based treatment that studies have proven is effective.”

Smith, meanwhile, said advances in the field are exciting and vital.

“Stroke hits people of all ages,” she said, “but there can be wonderful outcomes if people get to the hospital right away.”