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Treating Stroke: How to Reduce the Damage

Posted Aug 24 2008 1:49pm
PAUL J. MONIZ: I'm Paul Moniz. Thank you for being with us on this webcast. Today's topic is stroke, more specifically what it means to suffer an acute stroke. We have all heard the expression "time is money." Well, when it comes to stroke care "time is brain," specifically your brain. The longer you wait to get help, the better your chances are of becoming brain injured and/or paralyzed.

It may surprise you to learn a stroke can actually be in the works a full week before you show any symptoms. Recognizing early warning signs is key to surviving this potential killer. Studies suggest that does not happen often enough with some patients waiting hours or even days to get help -- which is often too late.

Here to walk us through acute stroke are two specialists in the field. Dr. Ralph Sacco is the Associate Chairman of Neurology at Columbia University. Thank you for joining us.

Next to him is Dr. Dara Jamieson, a neurologist at Pennsylvania Hospital and an Assistant Professor of Neurology at the University of Pennsylvania.

Dr. Jamieson, let's begin with you. What is meant by the term "acute stroke"?

DARA JAMIESON, MD: Acute stroke means that the process of brain damage is occurring by the minute. As far as the patient is concerned, the patient will notice the sudden onset of neurologic symptoms. One minute the patient may be home relaxing and all of a sudden the patient will notice an inability to move say the right side of her body and difficulty speaking. That's a patient who is having an acute stroke who needs to recognize those symptoms immediately, needs to get to the hospital immediately and get treatment immediately.

PAUL J. MONIZ: Walk us through, Dr. Sacco, what's happening. 911 is called. Hopefully, they are either calling right away -- we should bring that up right at the top. Don't wait.

RALPH L. SACCO, MD: Don't wait.

PAUL J. MONIZ: How quickly should they call? Two minutes after symptoms? How important is that call?

RALPH L. SACCO, MD: If you have these neurologic symptoms that Dr. Jamieson just mentioned, then you need to call right away. You don't want to wait. The key for stroke treatment is less than three hours. That's why we use the term "time is brain." The best effective therapy we have only works if you get it within three hours.

So the person calls 911. In most cities, 911 gets there right away and gets them to the nearest hospital. At the hospital they'll be stabilized in transport and then the key is to find out what kind of stroke it is. So often a brain scan is done. That brain scan can tell us whether it's a bleeding stroke or an ischemic stroke.

If it's one of the ischemic strokes, which are the majority -- close to 85 percent -- then maybe you would be a candidate for these clot-busting medicines to reduce the damage from stroke and improve outcome.

PAUL J. MONIZ: How do these clot-busting medicines work and what are they?

DARA JAMIESON, MD: The clot-busting medicines are given intravenously to people who do meet certain criteria. They have to be people who have significant amount of deficit who can be treated with three hours of the onset of their stroke symptoms and who are medically stable. They have normal to only slightly elevated blood pressure and don't have any bleeding problems to begin with.

But if you have a patient who qualifies for the clot-busting medicine, the idea is to give by vein. It will go into the artery that is clogged and dissolve the clot within that artery and permit normal blood flood to occur in the brain.

PAUL J. MONIZ: Can it reverse or minimize the damage? In other words, is a stroke going on for several hours even as the patient is making the call or is it a quick event? Is it over and then you're just stuck with the results basically?

DARA JAMIESON, MD: It's a continuous process. The brain damage that occurs is a cascade of different events that occur within brain cells so that different things may occur at different times. Clearly the faster you move the more likely you are to preserve brain cells.

The damage will be minimized if you can restore blood flow to the brain as quickly as possible. Although the studies using the clot-busting drugs have shown that the improvement is actually seen relatively far off. It's seen at three months. It's not seen instantly at the bedside.

PAUL J. MONIZ: You mentioned that 85 percent of patients have an ischemic attack. What about the other 15 percent? How are they treated if the clot-busting drugs are not an option?

RALPH L. SACCO, MD: If you've had a bleeding stroke, unfortunately we have less things available right now to treat it acutely. We're working on things, but nothing is really proven. But clearly there are things that we would do to stabilize you in a hospital, try to prevent further injury and in some cases there is even surgery to evacuate those clots. But we're really focused on the ischemic stroke where we do have proven therapies.

PAUL J. MONIZ: So bleeding stroke again still a long way to go on that and considered much more serious.

RALPH L. SACCO, MD: Much more serious. Much greater chance of actually dying from a stroke if it's a bleeding stroke.

There are also some bleeding strokes which are do to aneurisms that affect younger people that may be treated differently where there you have to find out if you have aneurism and then maybe surgically remove, if needed.

PAUL J. MONIZ: Dr. Jamieson, is a certain type of stroke more dangerous depending on where it occurs in the brain -- left vs. right, central vs. --?

DARA JAMIESON, MD: There are certain areas of the brain that have many more functions. For instance, if you have a stroke in your brain stem or the lower part of the brain, chances are you will have more serious outcome. That's an area of the brain that is very densely packed with cells that are regulating things in your face, such as your eyes, your speech. It's an area where cells regulate breathing and heart rate.

If you have a stroke that is in the front part of your brain, you may actually have a relatively large stroke but still have relatively small problems.

If you have a stroke on the left side of your brain, for most people, it affects your speech and certainly that is devastating.

PAUL J. MONIZ: The use of aspirin, how important? How quickly can the patient begin taking aspirin at home?

RALPH L. SACCO, MD: That's a good question. The heart attack people often say, "Take an aspirin right away." In stroke, we're not yet sure. It's often done. Aspirin does have an effect. It's a small effect, but at least in the studies that have been shown in a stroke within 48 hours, the people who take aspirin vs. those who didn't in this study, had a better outcome at six months. But it is small. I think the main thing really is to get medical treatment first. For example, if you had a bleeding stroke, you don't want to be taking aspiring. Then once you have the medical treatment and the diagnosis established, medicines will be given like the clot-busters, like aspirin for some and maybe even other medicines.

PAUL J. MONIZ: Dr. Jamieson, why do you think it is that there seems to be less awareness about stroke than heart attack and people are much less likely to seek treatment in a quick fashion.

DARA JAMIESON, MD: One of the problems with stroke is that there is no pain. Pain is something that gets people to the emergency room because pain hurts and you want to find a way to get rid of it. But if you have transient weakness or numbness, you're pretty good at rationalizing it away.

However, if you ask people what are they most scared of having -- a heart attack or stroke? Most people will tell you they're most scared of having a stroke because that's going to leave them with a deficit that's going to take them away from their family, take them away from their job, and take them away from life as they know it. It's difficult to get people to understand how important it is to recognize the warning signs and get help.

PAUL J. MONIZ: Dr. Sacco, final comments on acute stroke, recognizing it and getting help.

RALPH L. SACCO, MD: There are so many strokes occurring in this country and I can't tell you how many do not get the medicine that we know is effective. That's the clot-busting medicine. So the key is recognizing the symptoms again, getting treatment -- because if you're beyond three hours, unfortunately we don't have these kinds of medicine available to treat your stroke.

PAUL J. MONIZ: Okay. Dr. Ralph Sacco of Columbia University, thank you for your time. Dr. Dara Jamieson of Pennsylvania Hospital, thanks as well.

Again, if you have questions about acute stroke, you should ask your doctor. Visit a neurologist. Remember you need to take this seriously because each year more than 700,000 Americans have a stroke and it could be you.

I'm Paul Moniz. Thanks for joining us.

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