Advanced treatment protocols and technology are helping save the lives of Central Ohio patients.
Stroke is the third-leading cause of death in America, and the number one cause of disability. Occurring when blood flow to a portion of the brain is interrupted, a stroke starves brain cells of oxygen, often leading to permanent damage or even death. The good news is that 80 percent of strokes can be prevented, and new technology has vastly improved treatment options.
A stroke may be caused by the blockage of a cerebral artery with a blood clot (an ischemic stroke), or the rupture of a blood vessel within the brain (a hemorrhagic stroke). When blood flow ceases, affected brain cells begin to die, and the functions controlled by that part of the brain are lost. Unless treatment occurs quickly, the loss can be permanent. The golden window for stroke treatment is three hours, but every second counts. With each passing moment, brain cells are lost, never to be replaced.
Dr. Regan Miller is the medical director for the Mount Carmel Stroke Program. He says many people miss the opportunity for timely treatment because they ignore the symptoms of a stroke. "It's a hassle to come into the ER," he says. "People are hoping it's something transient, and many times they would rather wait to see if it passes."
Miller says stroke victims are sometimes hesitant to alert emergency personnel for something that could be minor, or they dread a long wait in the emergency room. "That isn't the case if a person is having stroke symptoms," he says. "They are seen immediately, and that is almost universal in all medical centers."
Medical personnel take stroke symptoms seriously. "There are benchmarks for how fast each step in the treatment process is performed," Miller says. "We review those times, and try to exceed not only national standards, but also our own expectations."
Miller says stroke-related expenses total more than $50 billion per year in the United States alone. "Unlike some other conditions, stroke hurts us more than once," he says. "It is Medicare's second-leading chronic expense."
Stroke victims may lose or have greatly diminished speech, vision and memory, along with weakness, numbness and difficulty walking. Following a stroke, many can't return to their jobs, can't drive and have difficulty with everyday tasks, Miller says. Secondary problems that arise after the initial recovery can include depression, memory problems and fatigue.
"In many cases, I'll see a patient six or eight weeks after the stroke, and everything is going great," he says. "But for others, life has become a major burden."
Dr. Peter J. Pema, a neurointerventional surgeon with Riverside Radiology and Interventional Associates, says stroke victims frequently end up in nursing homes and sometimes lose the ability to communicate.
"There are miraculous recoveries, and others who are markedly improved and only mildly weak as a result of the stroke," Pema says. "But all of them are better off because we saved that part of the brain that was dying."
Recognizing the Signs
Because stroke can be so debilitating, medical professionals treat it vigorously and advise potential victims to do the same.
Classic symptoms of stroke include numbness or weakness on one side of the body, facial droop, slurred speech and headache. The acronym FAST helps people keep the symptoms of stroke in mind:
• Face (Does one side droop when smiling?)
• Arms (Can both be raised equally well?)
• Speech (Ask the affected person to repeat a phrase, and listen for slurred or strange speech.)
• Time (If signs are positive, call 911 immediately.)
Miller urges people to err on the side of caution, especially if they feel odd and are home alone. "A lot of times, it's difficult to recognize the symptoms in yourself," he says. If a person suspects a stroke might be occurring in themselves or someone else, they should summon help right away.
Lisa Leech didn't recognize the symptoms of her stroke. The 48-year-old, in great shape with healthy eating habits, wasn't a typical candidate for stroke. Consequently, she didn't quite believe her paramedic husband when he assessed her condition.
Leech was hot and dizzy and says she felt like she had the flu. When her husband found her on the floor, she told him he was overreacting. She was lucky that only about 15 minutes had elapsed since the symptoms began. Paramedics arrived quickly at her home north of Delaware, getting her to Riverside Methodist Hospital in about 30 minutes despite pouring rain.
"Everything lined up for me," she says. "Time is gray matter, and I was really fortunate." Clot-busting drugs didn't work for Leech, so doctors retrieved a clot mechanically. In spite of initial slurred speech, a drooping face and weakness on her left side, Leech made a full recovery. She spent about five days in the hospital, and was back in the gym the following week.
Stroke affects more than 795,000 Americans each year, and 137,000 of those die as a direct result. Although its medical facilities make Central Ohio a great place to be if a stroke does occur, the best recourse is avoidance.
The National Stroke Association works to educate the public and increase awareness of stroke, or cerebrovascular disease. Among the myths the organization works to dispel:
• Stroke only happens to the elderly. In fact, it can happen to anyone at any time, regardless of age, gender or race.
• Once a stroke occurs, it can't be treated. Although every second counts, stroke can be treated, very effectively in many cases.
• Stroke can't be prevented. The vast majority of strokes are preventable, with many of the same lifestyle adaptations that prevent heart disease, cancer and other debilitating conditions.
Dr. Martin Taylor of OrthoNeuro says risk factors for stroke include high blood pressure, diabetes, high cholesterol and family history.
"Family history can't be treated," he says. The rest can. The same things that lead to an overall healthy lifestyle--good diet, moderate exercise, not smoking--can prevent stroke.
"The major risks are the things we commonly see the doctor for," Miller says. "These are the things you want to try to modify, and if you have those conditions, follow them diligently with your doctor."
When stroke occurs, the key is to seek help immediately. If treatment begins within three hours, doctors can administer tissue plasminogen activator, or tPA, a clot-dissolving drug, in cases of ischemic stroke. If the stroke occurs more than three hours before treatment begins, there is a high risk of cerebral bleeding and use of tPA is not advised.
Although Miller says there is no link between stroke and time of day or state of consciousness, many patients wake up having had a stroke. Because they cannot pinpoint the moment symptoms began, doctors may elect not to use tPA. In some cases, when too much time has elapsed, patients may have no choice but to wait it out and work to repair any damage in later therapy.
Modern technology has brought advances in stroke treatment. Pema uses tools such as CT (computed tomography) perfusion imaging to look inside a patient's brain to see where blood is and isn't flowing. Doctors can then determine whether it's safe to use tPA or if they should take another treatment route.
One alternative is the retriever coil, a tiny device that is threaded through a catheter and into the cranial arteries, where it snags blood clots for removal. Some devices are shaped like a small corkscrew, while others are like a miniature cage that traps the clot. Used in conjunction with a balloon, which blocks the artery to create a vacuum, doctors can be certain that the entire clot is safely removed.
Another technique used in conjunction with tPA employs a catheter with an ultrasound tip, which allows the drug to more thoroughly permeate the clot. "It gives off microsonic energy," Pema says. "We put it right in the clot, and it breaks up the bands, called fibrin, that hold the clot together. It's breaking the crosslinks within the clot, allowing the drug to work more effectively."
Administering the drug directly at the site of the clot also prevents anticoagulants from being dispersed throughout the patient's body, thereby reducing the risk of bleeding elsewhere in the brain.
The devices are tiny--only a couple millimeters across, Pema says, roughly the width of a grain of rice. The catheter is threaded through the groin, giving doctors a straight pathway up the torso and into the brain. "It's a big artery, so there is plenty of room to work," Pema says. "There is also bone there, so we are able to compress the artery to prevent bleeding."
Doctors use other tools to project what's going on inside the body onto an external screen. "We use road-mapping techniques," Pema says. "I inject dye, and even though the blood washes the dye away, the machine remembers where the dye was. I can see pictures of the vessels as I'm going."
Images appear on a 50-inch video monitor. "It can expand a half-millimeter aneurism to two inches," Pema says. "It is crystal clear, and incredibly useful." Although only about 10 percent to 15 percent of strokes occur in the large vessels where these tools can be used, Pema performs the procedure several times each week.
While all doctors need to weigh the benefits and risks of a given treatment, Miller says there are some types of stroke he treats aggressively. When a patient's ability to speak or to understand language appears to be affected, he jumps in with both feet.
"When that part of the brain is affected, it can have horrible consequence in the long term," he says. "Language is what makes you human, and that deficit holds much higher value for me."
Hospitals in large cities often have the latest technology and nearly limitless resources of equipment and skill. Several Central Ohio hospitals have personnel on staff 24 hours a day to deal with major health crises like stroke. Both OhioHealth and the Ohio State University Medical Center have created programs that extend these resources to smaller cities and rural areas.
OSU's Telestroke program is an audio and video connection that networks the university with hospitals in Cambridge, Coshocton and Barnesville. Dr. Michel Torbey, medical director of OSU's Stroke Center, says the system allows specialists to diagnose and treat patients in remote locations. With medical personnel in the local hospitals serving as their hands and video cameras serving as their eyes, OSU doctors can do all of the tests they would do on a patient in Columbus. "Through the Internet, we can examine the patient and provide treatment decision plans based on that assessment," Torbey says.
When a potential patient comes into a rural ER, the staff initiates a stroke alert, which hails medical personnel at the partner hospital. "The advantage is that patients have access to specialized care within minutes," Torbey says. "Not all rural hospitals have neurologists on call 24 hours a day."
Prior to the technology becoming available, patients might have been transferred to a Columbus hospital, which could take 30 minutes or more, even by helicopter. "Every minute counts," Torbey says.
Telestroke initially partnered OSU with three hospitals, but physicians hope to expand that number to 20 by the end of 2011. The initial project was funded through a $265,000 grant from the Ohio Department of Health, but the university is footing the bill for the expansion.
OhioHealth's Stroke Network operates on the same principles. Riverside Methodist Hospital and Grant Medical Center serve as hubs for eight partner hospitals: Marion General, Grady Memorial, Adena Regional Medical Center, Hardin Memorial, Marietta Memorial, O'Bleness Memorial, Morrow County and Genesis HealthCare System.
Jim Holbrook's life was saved by the Stroke Network. He was diagnosed remotely in Marion and flown by medical helicopter to Riverside, where stroke experts had already formulated a plan of action. He was treated in Columbus and returned to Marion General for recovery. Stroke experts at Riverside continued to monitor his progress over the Internet. "I was getting the best care possible," Holbrook says.
Kristin Campbell is a freelance writer.
Reprinted from the October 2011 issue of Columbus C.E.O. Copyright © Columbus C.E.O.