A Stroke of Luck
Monday, November 12, 2007
Sean Donahue, DO
Stroke is the leading cause of adult disability worldwide, and is the 3rd leading cause of death in the United States (1). Last year in this country, there were over 5 Million strokes among adults older than 20, and on the average, every 45 seconds someone has a stroke, and every 3 minutes someone dies of one (1). The symptoms can be far ranging from sudden onset of weakness of a particular part of the body, difficulty speaking, or vision loss, to numbness or dizziness. Approximately 80-89% of all strokes are caused by a blockage within the blood vessels of the brain (Ischemic Stroke), while 10-15% are caused by an actual ruptured blood vessel (Hemorrhagic Stroke) (2).
Sometimes we are able to “stack the deck” in our favor of lessening the damage from a stroke. Stanford University Medical Center is a nationally recognized Stroke Center and holds many of the cards needed for a positive outcome. A dedicated team of Neurologists and Nurses, known as the “Stroke Team”, Emergency Department personnel, and Paramedics must work in concert to not only properly diagnose, but to treat and manage individuals who may be suffering from a stroke. In my career as an Emergency Department Resident, I have never seen a higher level of teamwork, or corroboration amongst care providers, as when a caring for a stroke victim:
7:15 pm: John’s wife realized that something was drastically wrong, she dialed 911.
7:22 pm: Paramedics arrived at their home. They realized John was suffering a stroke. Their rapid response, and correct diagnosis, set in place the optimal chain of events to aid in his care.
7:40pm: The Paramedics called Stanford University Hospital and notified us of a “Stroke Code.” Immediately the Stroke Team was paged to the Emergency Department. The radiologist and technicians were immediately notified to have a CT scanner ready in order to obtain pictures of the patient’s brain. These pictures help determine if the sufferer is a candidate to receive certain life saving treatments. In perfect synchrony, all necessary Emergency Department personnel arrived at the currently vacant bed…
7:48 pm: John arrives in the Emergency Department. Within minutes the general diagnosis of stroke is confirmed, and he is whisked away to the CT scanner for a more detailed inspection. The Radiologist confirms that John did not suffer a bleeding stroke, but instead, a blockage in one of the major blood vessels of the brain.
8:00 pm: Because John’s symptoms were detected within 3 hours, and because of the nature of his stroke (Ischemic rather than Hemorrhagic ), he is deemed a candidate for tPA, or Tissue Plasminogen Activator, a potent clot buster- the only FDA approved drug for the treatment of Ischemic Stroke. We explained to John and his wife that approximately 6% of patients receiving tPA suffer bleeding into the brain, but there is a 30% or greater chance of a good neurological outcome after 3 months (3). These odds are a calculated risk, and both John and his wife are willing to take the risk and proceed with the medicine.
8:15 pm: After John is deemed stable enough to receive the drug, his treatment is started. His wife sits silently holding his flaccid right hand.
“I have never been so scared in my life,” John proclaimed. His words came out crystal clear. “My right hand still feels weak, and a little numb, but I think I’ll be able to work on my truck again!” He gave me a thumbs up. John was lucky. Less than 3-5 % of patients who present with his type of stroke are able to receive this drug for therapy (1). Unfortunately, most are beyond the 3 hour window, or are too unstable, and at a greater risk of having severe complications. The dedication, experience, and efficiency of every team member involved in John’s case played a crucial role in his recovery. “We never gave up hope,” his loving wife said, “we trusted you all knew what you were doing.”
REFERENCES:
1) Adams HP Jr, Del Zopo G, Alberts MJ, et al. American Heart Association; American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke. 2006.
2) Braunwald et al. Harrison’s Principles of Internal Medicine. 15th Edition. 2369-2371. McGraw Hill, New York City, NY 2001.
3) Bellolia F, Stead L et al. Stroke update 2007: Better Early Stroke Treatment (BEST). Emergency Medicine Practice . 2007; 9,8: 1-21.
10 Comments:
At Thu Nov 15, 08:23:00 AM 2007,
Anonymous said…
great job coordinating and delivering high level care. kudos to the team
At Thu Nov 15, 09:02:00 AM 2007,
ERMurse said…
What most patients are not told in the informed consent process is that TPA will not save your life. There is no difference in mortality (although some studies have shown it to be higher) in patients who receive TPA and those who do not comparing simular groups. Its use is controversial and also not endorsed as the standard of care by the major ED physician organizations. The message patients get in the marketing by some stroke centers and the drug maker is different and creates false expectations. I still see and hear advertisements in various forms about getting to the hospital right away to get the lifesaving clot buster medication. TPA has its place and so does fully informed consent.
At Fri Nov 16, 12:30:00 PM 2007,
Anonymous said…
It's a good thing you got LUCKY on this case and didn't thrombolyse an aortic dissection (extending into a carotid artery) which can present in exactly the same way. The thought that a standard chest xray wasn't done (or at least mentioned) is scary. Please tell me this was an innocent omission, as I would hope the Stanford's "stroke center" recognizes this and at least ATTEMPTS to rule it out (although a standard 1 view chest xray in NO WAY rules out this disease. Also, the fact that you are commenting that tPA is a "life saving drug" is just scary, as many people on the WWW would consider this blog written by a professional, yet those of us who know the reality, know that instead it appears this was written by somewhat playing the role of a professional. We need to educated the public that tPA VERY RARELY works, and the fact that it is used in 3% of cases illustrates the MOST EM doctors are educated about it's dangers, and they consider, in many instances, that the risk/benefit ratio is far too high and rather than saving their own but from a lawsuit, attempt to do what is best for the patient and withhold this potentially deadly treatment.
At Sat Nov 17, 10:07:00 AM 2007,
Sean Donahue, DO said…
ERMurse:
Thanks for the comments!! The medical community has moved beyond the point of TPA use being controversial, and it is now deemed the standard of care for all individuals suffering acute ischemic stroke who fit criteria. All patients undergoing treatent MUST consent to its use. Fully informed consent with regards to TPA usage would include patients understanding a 6-7% risk of hemorrhage, but the possibility of a 30-40% better outcome at 3 months (data backed by metanalysis of approximately 12,000 patients-tPA to placebo global odds ratio of 2.1!). Although these statistics are very strong, they by no mean elude that TPA is a wonder drug, but to patients with an ischemic stroke who exhibit acute debilitating symptoms, its usage may be a risk well worth taking. Thanks for reading.
Sean
At Sat Nov 17, 04:25:00 PM 2007,
ERMurse said…
I wasent aware that the medical community has come together on this. Have the leading ED MD organizations revised their position statements. The Doc's I work with are part of a large ER Group. There is mixed opinion among them about the risk benifit ratio of TPA use in ischemic strokes. They are however told that if they want to work this contract you will give TPA if the criterial are met or you can work elsewhere. They are in a bad spot because of that hanging over their heads and patients expectations of tpa based on marketing initiatives by their own facility that are overly optomistic. Does not sound like coming together quite yet.
At Tue Nov 20, 12:01:00 PM 2007,
Anonymous said…
TPA use in acute ischemic stroke is NOT standard practice. The NINDS study has never been reproduced. Your useage of relative (30%) improvement rather than absolute (12%) improvement is very misleading.
At Tue Nov 20, 04:28:00 PM 2007,
Sean Donahue, DO said…
Anonymous:
Thanks for the comments! We obtain chest xrays on all patients who might receive TPA-sorry for the over look. Individuals with Type A Aortic Dissections, especially with extension into the Carotid Artery, are extremely hemodynamically unstable, may be in pain, and might have a widened mediastinum on CXR, and would not be candidates for tPA. With regards to administering tPA, we follow all evidence based guidelines for when and when not to administer it. I presented the evidence for and against its use. tPA is used only 3 % of the time because people are out of the 3 hour window, or are too unstable to receive the drug. We are rigorously trained about when and when not to use this drug.
Lastly, I am a professional in training-an Emergency Department Resident. If you should have more questions for an expert with regards to tPA use, I would direct you to the Stanford Stroke Center website. I only present what I feel are unique experiences in the ED through the eyes of a Resident.
Thanks,
Sean
At Thu Nov 22, 11:34:00 PM 2007,
Anonymous said…
As a "Stroke Neurologist" I can say you handled this case well. Good job. This presentation shows how, and why tPA works. If you HAD NOT given tPA in this case you could have been sued! I do not understand the "arm chair quarterbacking?"
Glenn, Neurologist, East Lansing MI
At Fri Nov 30, 05:13:00 PM 2007,
talljane said…
Alot of people say that 38 is too young to have a stroke. After I had my stroke, I learned different. I was getting ready for work, I work in a hospital, my hands could not hold anything, I couldn't even put one hand to the other. 10 seconds later I lost the ability to speak, only guttering sounds would come out of my mouth. I tried to walk down the hall to my 9 year old sons room, I made it and tried to wake him up, he thought I was kidding, I was not making any sense. I made it to the telephone, but couldn't remember my husbands phone number at work. Somehow I noticed our phone bill on the counter and knew that I had to try to use the invoice to call him. I dialed the first 5 numbers on the bill, and on the fifth call I reconized his voice machine, I tried to leave a message but I couldn't speak. I tried to speak, finally the words "jane,,,stroke..." then I collapsed on the floor, my 9 year old heard me and ran to me and called 911. I don't remember much after that. I was taking to the emergency room, had all the usual tests, the doctor admitted me, and did a T.E.E the next morning. He discovered that I had a hole in my heart. That caused my stroke. I went to Boston and had a Catherization and they repaired the hole with a new device the doctors are using on infants. The children can go home usually, the next day. My point is that one never knows what is going to happen, we all say that it will never happen to me, but it did happen to me, and I enjoy everyday. Because of the quick thinking of the doctors in the emergency room, I am fine today and back to work. I enjoy every day, I actually look and enjoy everything I see.
Has anyone out there ever had this type of surgery? talljane
At Thu Jan 17, 09:58:00 AM 2008,
Anonymous said…
Great save!!! If Family agree to tpa, and understands risks/benefits, you need to give tpa. The patient/family always in control of treatment-we as physicians are just conduits of information for them. Great case.
Amir, Neuro Fellow
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