A Stroke of Luck
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.”
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.