Presented by

Pennsylvania Neurological Associates, LTD.

Janice Morrow, Practice Administrator

108 Lowther Street

Lemoyne, PA 17043

(717) 774-2202

Some Thoughts on Stroke:

Stroke is such an important topic in neurology these days. We have available new treatments and quite a bit of research is being done in stroke treatment and prevention. We’ve recently been privileged to open a new Stroke unit at the Pinnacle Health System (Pinnacle) and to host a symposium on stroke and cerebrovascular disease at the Harrisburg Hilton in which we had excellent renowned speakers on stroke care.

Below you will find the text of a short talk I gave to the Pennsylvania State Senate Committee on Aging and Youth. It contains some of my thoughts about a proactive approach to stroke prevention and treatment. You will also find useful an outline of some of the more prominent acute SYMPTOMS of stroke as well as a section on RISK FACTORS, most of them modifiable.

-Charles S. Yanofsky, M.D.

 

Senate Speech:

Thank you for inviting me to speak before you today about stroke awareness. Within minutes your life can change forever. You or I can be reduced from a state of robust self-sufficiency to complete dependence. Stroke is more dramatic than any other neurological disease. Its very designation implies acuity, "stroke" the act of striking and indeed stroke affects the patient with an astonishing rapidity which is the hallmark of the illness. Imagine if you will, suddenly not understanding language and not being able to speak, or losing awareness and control of the one entire half of your body. Imagine being deprived of the simple pleasure of chewing and eating your own food, dressing yourself, getting about independently providing for your family.

We live in an exciting time. As a neurologist in Harrisburg I have been treating patients with stroke for over 18 years. I’m thrilled to take part in a revolution in stroke management spurred by the new use of clot-busting drugs and other exciting technologies. As you may know, a stroke is caused by an interruption of the brain’s delicate blood supply that affects about half a million Americans each year. This will cause permanent damage to irreplaceable brain cells, if bloodflow is blocked for more than a few minutes. The major cause of strokes is atherosclerosis related to high blood pressure, increased cholesterol, heart disease and diabetes.

Each year there are about 350,000 stroke survivors. Just the indirect or non- medical cost of disability relating to stroke in lost productivity of victims and family members is staggering, in the range of 15 billion dollars. The human costs are felt by patients and their families. At this juncture we have available treatments which reduce post-stroke disability. The problem is that patients need to have definitive care, within 3 hours of the onset of symptoms. It is a remarkable fact that treated patients are 30% more likely to escape significant disability.

When we care for a stroke victim, we are in a high stakes game. The early minutes of stroke care are critical for the patient. That’s why having a plan of action, an algorithm for care, is so critical. I had occasion to see a robust 39 year old weight lifter who came into the emergency room in the middle of the night. This enormously strong body builder had the presence of mind to rush into the hospital within moments of onset of left sided weakness. He was treated within about an hour of his deficit with the clot buster t-PA and his weakness initially cleared but then returned to some extent. We were able to determine that a common anomaly in his heart known as a patent foramen ovale had predisposed him to a stroke. This young man is now in an outpatient rehab program, and is back to work. His heroism in putting his life and body back together is an inspiration. I am sure that t-PA literally saved this his life. If we are to administer this brain saving treatment, patients need to be transported to a stroke center immediately. The very first step in the chain is for the person or observers to be aware that a victim may be having a stroke and to know that urgent treatment is required. The public must learn the warning signs of stroke such as sudden loss of speech or movement or sensation on one side of the body, just as most people know the warning signs of a heart attack. This is a matter for public education. Emergency transport teams need to take patients to hospitals best equipped to provide stroke care. Everyone must be ready to act - which means that stroke care plans have to be in place. The Hospital stroke unit is best equipped to provide quality seamless care for patients and achieve the best outcome.

Critics may say that comprehensive stroke care is an expensive proposition. Perhaps they are right. What is more costly both in human and financial terms is inept stroke care that ends with the human tragedy of a disabled patient. Great medical care is expensive, yes, but cheaper in the long run, than inadequate care. This implies that you will more than pay for front end cuts in medical care with custodial care and disability in the end.

Pennsylvania needs regional stroke care plans to get stroke patients into hospitals that can provide the best care. These would be facilities of large enough size to develop specialized stroke care units. Some hospitals have devised their own comprehensive care plans for stroke care, spearheaded by neurologists and other specialists, a stoke care algorithm, embracing everything from the suspicion of stroke and initial hit in the emergency room to the rehab discharge. Certain facilities and emergency rooms are much further along in this process than others. Do you know which of hospitals in your own region are prepared to deal with acute stroke? A standard care plan would improve efficiency and effectiveness minimizing hospital lengths of stay, while providing state of the art rehabilitation and caretaker and family supports.

In recent years we have discovered the risk factors for stroke. Stroke kills twice as many American women than breast cancer for instance. Stroke deserves much more public health discussion. Risk factors can be reduced to prevent stroke and improve the general health and welfare of residents of the commonwealth. Diabetes, affects almost 1 in 9 Pennsylvanians making Pennsylvania one of the most affected states in the country. The public needs to be educated about the considerable health risks of obesity and diabetes and to measures that control these factors especially diet and exercise and aggressive medical therapy.

Persons at greatest risk for stroke, lack education and financial resources. Inadequate treatment of hypertension is a major cause of stroke especially in African-Americans who have twice the incidence of strokes as whites. This is a major tragedy. Each year I see so many patients whose strokes could have been prevented by adequate medical care. Over time hypertension itself creates vascular dementia, frequently mistaken for Alzheimer’s disease, caused by strokes which pick off and destroy tiny volumes of brain. This brain damage can be completely eliminated by the adequate treatment of hypertension. Our hospitals lack adequate funds for preventive outreach programs that over the long term will save the lives of Pennsylvanians.

In summary, lots of work needs to be done in the state of Pennsylvania in the vast area of stroke treatment and prevention. If we succeed in our task, we will have enhanced the lives of hundreds of thousands of persons at risk for stroke and their families and caretakers and will add immensely to the productivity of and quality of life of Pennsylvanians.

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Symptoms of Stroke:

The major characteristic of stroke is suddenness, rapid onset, sometimes rapid clearing of symptoms. Some more common features include:

Sudden numbness or weakness in one limb, typically a hand or arm, or especially on the right or left side of the body.

Loss of speech or ability to express oneself. It may affect word finding, fluency, pronunciation, comprehension and writing as well.

Sudden dizziness, especially associated with other symptoms, such as double vision, incoordination, unsteady gait. Any of these symptoms can occur alone or in combination with others.

Sudden vision loss, especially in one eye, likened to a shade going up or down over the eye, or sometimes loss of vision to one side which may cause you to subtly bump into or ignore objects on one side.

Most strokes occur painlessly but some are associated with headache, especially those with bleeding inside the head.

These are just some of the most frequent stroke symptoms. If there is any doubt, it’s best to get to an emergency room right away! Certain brain-saving treatments require immediate care. The stroke victim needs to be evaluated and tested and treated in under three hours to get clot-busting drugs. If you wait, you lessen your chances for recovery. Stroke is a medical emergency.

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Risk Factors:

Any of the above symptoms in conjunction with risk factors below, should raise your suspicion of your having a stroke.

Hypertension (high blood pressure): High Blood pressure is about the most important threat to good health. Doctors have learned to be very aggressive in normalizing blood pressure. High blood pressure is a far greater threat to your health than is high cholesterol, for example.

Previous stroke or TIA: A TIA is a transient ischemic attack, a short warning often involving some of the symptoms above which clears. A person whose already had a TIA or stroke, has an increased chance of having the problem again.

Advanced age. Strokes do occur in young persons (less than 50) but far less commonly than in old.

Smoking: A risk factor for many diseases as is well-known.

Atrial Fibrillation. Atrial fibrillation is a rhythm disturbance that is quite common and is sometimes not treated. It is such an important risk factor that if you have it you should talk to your doctor for the express purpose of lowering your risk for stroke, most frequently with Coumadin anticoagulation. Coumadin, once started, needs to be closely monitored throughout life.

Carotid artery disease. This is associated with atherosclerosis and heart disease, hypertension. A person who’s had a heart attack, for example, is a much greater risk for having blockage in arteries going to the brain. A blockage, caught early, can be cleared with surgery or treated medically.

Other kinds of heart disease, for example recent heart attack, and heart valve disease.

Diabetes.

Elevated cholesterol.

Sedentary life style.

Certain blood diseases that predispose to clotting, may be associated with stroke, especially in young persons, but they are relatively rare. Birth control pills may rarely be associated with stroke.

I’ve tried to list risk factors generally in relative order of importance as to strength of association and the number of people they affect. It is not meant to be a comprehensive list either and there are controversial points, for example, heredity. Stroke may run in families, but it may be through the mechanism of passing down unhealthful habits or via tendency to pass down atherosclerosis, high blood pressure, cholesterol, diabetes etc.

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Revised 10/19/99. © 1999 Charles Yanofsky