Stroke: The First 24 Hours after a Brain Attack
by Gary Cordingley, MD, PhD
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Strokes are like Rodney Dangerfield--they just don't get any
respect. Odd, considering that for the usual stroke victim, it's the most
serious illness of their life.
Although stroke is the third-leading cause of death in the U.S. and the
number one cause of disability, this condition doesn't get the respect and
attention it deserves. When people have sudden chest pain, they know they
might have a heart attack. They call 9-1-1 and seek help immediately. But
people who suddenly become weak or numb on one side of their body, or
experience sudden problems with speech or vision, often act unhurried in
seeking help.
Why is this? One possibility is that heart attacks are usually painful.
Strokes are not necessarily painful, and even when pain is present, it can
be mild. Pain is a powerful motivator, and some people have the mistaken
belief that all serious medical conditions hurt, and the seriousness of
the problem is proportionate to the intensity of pain. Also, because the
brain is a more complicated organ than the heart, symptoms of strokes can
also be more complex, making them harder to identify.
In both strokes and heart attacks a portion of a body-organ has
experienced a sudden disruption of its circulation. Increasingly, strokes
are called "brain attacks" to emphasize the parallel with heart attacks.
As a neurologist, I sometimes describe a stroke as "a heart attack of the
brain." Reflecting my bias as a brain specialist, I also describe a heart
attack as "a stroke of the heart," but--what can I say?--this terminology
hasn't caught on.
If you suspect stroke in another person, the American Stroke
Association recommends a quick, 3-step, screening test to identify
cases:
- Ask the person to raise their arms and keep them up. In many stroke
victims one arm doesn't go up or, once up, sags.
- Ask the person to smile. A lopsided or one-sided smile can indicate
trouble.
- Ask the person to repeat a simple sentence. If it comes out garbled
or unclear--or not at all--a stroke is likely.
While it's better to have some system of detection than no system, this
screen misses strokes affecting the parts of the brain involved in
sensation or vision which are just as serious as strokes causing paralysis
or loss of speech.
So now that emergency help has been summoned, what happens next?
The emergency squad, upon arrival, sizes up the situation and measures
vital signs, including rate and adequacy of breathing, pulse rate and
blood pressure. They insert an IV line, check the blood-sugar level via a
finger-stick method, apply pads to the chest to monitor heartbeats, and
often administer oxygen as well. Then they transport the patient to the
nearest emergency department.
Upon the patient's arrival, the medical team obtains more history and
examines the patient more thoroughly. They draw blood to measure
blood-sugar, blood-counts and blood-clotting function, as well as other
blood-chemicals, including those showing the presence or absence of a
concurrent heart attack. They perform an electrocardiogram (EKG) and
continue the process of monitoring vital signs and heart-rhythms initiated
by the squad.
A computed tomographic (CT) scan of the head is usually done soon after
the patient's arrival. CT scans can detect the 1-in-6 kind of stroke
involving bleeding within the brain, but often fail to detect the more
usual kind of stroke, called an infarction, caused by a blocked
blood-vessel. This is because, in the first 24 hours, damaged brain-tissue
can look just like healthy tissue to the scanner's x-ray beam. The CT scan
also screens for other brain diseases, like brain tumors or infections,
that might mimic a stroke, but call for completely different
treatments.
So far, the discussion has been all about testing. What about
treatment? What can be done to improve outcome, reduce the severity of the
impairment and prevent death?
A useful way to think of a brain infarction is as a central core of
forever-lost brain cells that no treatment can revive, surrounded by a
larger zone of sick brain-tissue that may or may not recover. Early
treatments focus on this surrounding tissue that is "on the bubble,"
trying to influence it to survive rather than die.
One dramatic but controversial treatment is to use an intravenous
clot-busting drug called t-PA (tissue plasminogen activator). The
potential benefit of using this drug is to reduce the eventual impairment
of the patient caused by the stroke. However, the drug also increases the
likelihood of brain-hemorrhage, and physicians are not unanimous in
believing that the benefits of this treatment outweigh its risks. However,
one point of agreement is that if t-PA is going to be used, it has to be
administered within 3 hours of the stroke's onset. Arriving at the
emergency room after 2 hours and 59 minutes isn't good enough because a
clinical evaluation, CT scan and blood tests all need to be completed
before the drug is infused.
Less dramatic treatments are every bit as important--and quite possibly
more important--than use of a clot-busting drug. It's the simple things
that often matter most, but because they're so simple, sometimes they are
unappreciated or even forgotten.
One such treatment is to manage the body-temperature. Fever increases
the size of the stroke, so when an elevated temperature is present, it
needs to be decreased right away. Another little detail is to manage the
blood-sugar. Oddly, an elevated blood-sugar is toxic to the
oxygen-deprived but still-surviving brain cells. So the emergency team
should aggressively treat elevated blood-sugars by administering
insulin.
Yet another issue of crucial importance is to urgently treat severe
anemia (decreased red blood cells) by transfusing blood. Oxygen molecules
are transported to the brain attached to molecules of hemoglobin within
red blood cells. So if there are fewer red blood-cells, less oxygen is
delivered to the sick brain-tissue. Providing more red blood-cells
increases oxygen-delivery.
Of course, if the patient's blood-pressure is severely elevated, it
needs to be decreased, but mildly-to-moderately elevated blood-pressures
might actually improve blood-flow to the damaged tissue. If the patient's
blood-pressure is excessively low, this is bad, too, and is treated by
infusing salt-water or administering medication. Dangerous heart-rhythms
also need to be treated, as does a concurrent heart attack, when
present.
The principal value of being in a hospital with a fresh stroke is to
achieve clinical stability in a monitored environment where rapid
interventions can be made when called for. The hospital also provides a
setting in which more extensive tests can also be performed, though not
necessarily in the first 24 hours, that seek to understand why the stroke
occurred and what can be done to prevent another brain attack. (C) 2005
by Gary Cordingley
ABOUT THE AUTHOR
Gary Cordingley, MD, PhD, is a clinical neurologist, teacher and
researcher who works in Athens, Ohio. For more health-related articles see
his website at: http://www.cordingleyneurology.com/
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