Stroke Treatment Advances
Minimizing neurological damage
SOURCE: American Stroke Association
True story: A few years ago, two executives were sitting in their Anchorage conference room discussing the future of their engineering business. Hopeful discussion, bright future. Then suddenly, one of the two felt dizzy and lightheaded, saw his hands shaking almost uncontrollably. He waited a bit and the symptoms settled slightly. He went to his office and tried to make a phone call only to find he couldn’t control his fingers sufficiently to dial. He waited a bit longer and all the symptoms vanished. Wrong answer! That man was very lucky. He had suffered only a transient ischemic attack (TIA), described by the American Heart and Stroke associations as a warning stroke. He didn’t take it seriously, but it is serious—deadly serious.
According to the national Centers for Disease Control and Prevention, stroke is a leading cause of death in the United States, killing nearly 130,000 Americans each year. Alaska’s Department of Health and Social Services said in a 2009 report that the state’s stroke death statistics were higher than the national average.
Death and debilitation from strokes, however, can be minimized and in many cases completely eliminated if the victim can get to an emergency room quickly enough. “Even if you’re not sure what’s happening,” says Dr. Peter Osterbauer of the Alaska Neurology Center, “if you can get there within about three hours, you can be given the ‘clot-busting’ drug.” That drug will help loosen the clot but has to be administered, Osterbauer emphasizes, within three hours of onset of symptoms.
Christie Artuso, the director of Neuroscience Services for Providence Alaska Medical Center, says the drug is called Activase and is the only such drug approved by the FDA for use in dissolving blood clots. “If we can administer the drug within ninety minutes, there is a strong possibility for complete reversal,” Artuso says. “Every patient is a little different, and some may have a massive stroke, and the extent of the damage may determine how well we can reverse affects. Generally, though, the drug works well if administered within three to four and a half hours. We’ve seen patients given the drug recover in an hour, literally before our eyes.”
Artuso adds that the Activase injection treats only the ischemic, not the hemorrhagic, stroke. “Approximately 87 percent of stroke patients are suffering from an ischemic stroke, so the treatment is focused on the most common type,” Artuso says. “The most important thing to remember is that time is of the essence. The longer the patient is without oxygen to the brain, the more brain cells die. That becomes very, very significant as time goes by.”
With either type of stroke, Artuso says, if it’s necessary, surgeons can remove a small piece of the skull temporarily to let the brain swell and heal. “Swelling causes less pressure damage on the neurons,” she says. In both cases, she emphasizes, time is critical. “We can treat within three to four and a half hours—in some cases, up to twenty-four hours, but damage will have been done within those hours and [resulting] disabilities may remain significant.”
What is a stroke? And what symptoms should you know? Osterbauer says there are two types of stroke, ischemic and hemorrhagic.
“An ischemic stroke happens when one of the blood vessels to the brain gets blocked by a clot that has come from somewhere else in the circulatory system,” he says. “The part of the brain that’s deprived of oxygen becomes starved for whatever amount of time the clot exists and begins to die.”
With a hemorrhagic stroke, a blood vessel bursts in the brain and blood leaks out and destroys surrounding parts of the brain. As brain cells die from a stroke, abilities controlled by that area of the brain, such as memory and muscle control, are lost.
Symptoms of a stroke include the sudden numbness or weakness of face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking, or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance, or coordination; or sudden severe headache with no known cause.
Diane Lada, nurse practitioner at PEAK Neurology and Sleep Medicine LLC, says symptoms can vary according to the site of the stroke. “Most commonly, it’s weakness of an arm or leg or both,” she says. “Speech can slur; speech comprehension can be affected as well as the ability to form distinct words. Sometimes a stroke may include a facial droop.” Most often a stroke affects one side of the body, but Lada says rare strokes can mean symptoms affect both sides.
Risk factors for strokes are myriad and vary from high blood pressure, high cholesterol, diabetes, smoking, excessive alcohol use, atrial fibrillation, and genetics to sleep apnea, Lada says. “We’re seeing all those risk factors in younger people now and we believe part of the reason for this is that the younger population is not as healthy as we used to be. There is no age protection from a stroke,” she says.
Osterbauer agrees and says genetics and drug use are often factors in youth who have strokes.
Sleep apnea is one of the most recently recognized risks for strokes, Osterbauer says, and many people aren’t aware of that. Treatment of sleep apnea can decrease the potential for a stroke and help people recover after one. According to the American Heart Association, up to 91 percent of patients who had a stroke had sleep apnea. Osterbauer’s Alaska Neurology Center offers sleep apnea treatment and, he adds, there are other sleep clinics in the state, as well.
Although socioeconomic and racial disparities do exist, heart disease and stroke touch Alaskans of every race, ethnic group, age, occupation, and social class. They are also gender blind.
Women suffer stroke on a par with men and symptoms are generally the same. However, according to Lada, “gender differences in stroke are revealed in how symptoms are experienced. Men generally seek medical help when they experience numbness, weakness, and speech difficulties. Women are less likely to report these classic symptoms and experience their first stroke later in life. Women have shown less compliance with blood pressure control and cholesterol—some of the risk factors leading to stroke.”
Lada and Artuso are excited about advances the Center is making on stroke care locally and statewide. In addition to providing stroke education to audiences young and old in urban and rural communities, Artuso says they can do a great deal through telemedicine. She says if a person comes into a rural clinic with stroke symptoms, there’s almost instant interaction with professional medical help at the stroke center. Likewise, Dr. Robert Lada, director of Providence’s stroke program, can treat a patient from any location through cameras and computers at the hospital. This kind of help is also available through partnerships with several hospitals in the state, such as Bartlett Hospital in Juneau, allowing specialized physicians to provide expertise with a much broader reach.
Medical professionals agree that getting treatment immediately is key to getting the best results after a stroke, but there are treatments for those who aren’t so fortunate and sought treatment too late for a full recovery.
Neuropsychologist Russell Cherry, who, with his partner Heather Macomber, operates Alaska Neuro Associates LLC in Anchorage, is often part of a multidisciplinary medical team that evaluates and treats stroke victims. A neuropsychologist such as Cherry earns a doctorate in neuropsychology and does three years of post-doctorate and clinical work studying the structure and function of the brain. In this capacity, Cherry helps treat behaviors that are directly related to brain function after a stroke has damaged a section of the brain itself.
As Osterbauer says, once the stroke has damaged a part of the brain, the damage is permanent and different types of therapy can help a patient live with his or her new reality. “A patient can still make progress up to a year, maybe two years,” Osterbauer says. “With physical therapy, speech and/or occupational therapy, a person can strengthen an arm or a leg that has been weakened by a stroke and learn how to adapt to the activities required by day-to-day living.”
Cherry’s expertise in neuropsychology helps patients treat such stroke results as depression and cognitive disabilities. “Approximately 60 to 70 percent of all stroke victims will have clinical depression,” Cherry says. “If a stroke injures the left hemisphere of the brain, a person will have significant depression that can be at least somewhat disabling.”
Stroke victims are very often unable to do their prior activities, he says, “that could affect employment or daily living. There may be language issues that get in the way of their social life. There may also be some neurochemical changes to the brain. These are very good reasons to become depressed and depression can interfere with their recovery and impair their functioning.”
In the Lower 48, Cherry adds, stroke patients are evaluated and treated by a neuropsychologist more frequently than patients in Alaska. “The ones I see here usually have some sort of catastrophic event that could have been prevented if it had been identified and treated earlier,” he says.
Cherry and his associates are working to change that dynamic. He says he’s been in contact with a local hospital and is in discussions about better coordination on patients with strokes or traumatic brain injuries. “A database could trigger a case manager to do follow up with a patient—to determine if that person has issues after discharge that may need neuropsychological evaluation,” he says. “Depression, particularly, can interfere with patient treatment. Someone may not follow through with taking medications [or] physical or speech therapy. Depression does, however, respond well to treatment.”
The take-away advice to prevent stroke from these medical professionals: Watch your diet and control your weight, blood pressure, cholesterol, diabetes, and alcohol intake. Stop smoking. Seek treatment for sleep apnea. Most importantly, get to a qualified hospital immediately if you notice symptoms.
Gail West writes from Anchorage.
This first appeared in the February 2015 print edition of Alaska Business Monthly magazine.