November Meeting, Riverview

Sheila welcomed us and wished us all a very happy Thanksgiving, explaining that we were meeting early because the holiday preempted our usual meeting date.

Our speaker was nurse practitioner Rebecca Graboso, from the Stroke Center at RMC. She told us that Riverview’s stroke program began in early 2006 and is designated as a primary stroke center, meaning that it can take care of stroke patients from the ER right through rehab - but she hopes we won’t need it!

Unlike a heart attack, she told us, stroke symptoms vary greatly depending on what part of the brain is affected. We can identify a stroke event:

Face: facial asymmetry

Arm: one drifts down

Speech: sounds strange

Time to call 911!

Stroke almost always affects just one part of the brain, on one side, and these three symptoms are the most common indications of a brain injury. Other symptoms may be double vision, loss of balance or coordination, or sudden severe headache. Time is critical to prevent further injury to the brain.

Stroke treatment is about ten years behind heart attack treatment, she said. We are quicker to recognize a heart attack and summon emergency treatment for it than to recognize when somebody is having a stroke. Stroke is the third leading cause of death in the United States (after heart disease and cancer) and the leading cause of adult disability.

Some twenty years ago, when our speaker started nursing, there was no effective treatment for stroke. Then cardiologists began treating heart attack patients with clot-buster drugs and stents, and neurologists began to learn from them. Stroke care is better now.

About 88 percent of strokes are ischemic strokes, when an artery in the brain or leading to the brain is blocked (just as a heart attack occurs when a coronary artery is blocked). The cause is either a thrombosis (a clot that develops in the blocked artery) or an embolism (a clot that forms elsewhere in the body and travels through the bloodstream until it blocks an artery). A hemorrhagic stroke, when an artery bursts, is more often fatal or leads to a vegetative state.

The carotid arteries, one on each side of the neck, branch into the internal carotid artery, which supplies blood to the brain, and the external carotid artery which supplies the face and the skull. The retinal artery branches off as soon as the carotid artery reaches the brain, so a carotid artery blockage almost always affects vision - or speech.

If you fall, and the next day you’re limping, it could be a stroke. The worst headache of a person’s life could be bleeding in the brain. All these symptoms are sudden, because the brain can’t tolerate loss of oxygen for more than ten minutes. A stroke is a brain attack.

Don’t ignore a “ministroke” or TIA (transient ischemic attack) - a stroke that goes away with no apparent damage. Often an MRI can show that a stroke occurred; a CAT scan can show a stroke only after 24 hours. A TIA could be caused by a clot due to atrial fibrillation, or by narrowing of the carotid artery. Diagnosis can lead to preventive treatment.

risk factors

Unmodifiable risk factors for stroke include advancing age, female sex (because women live longer), family history, race (African-American or Hispanic), and prior stroke or MI.

Modifiable risk factors include atrial fibrillation, excessive alcohol consumption, and the familiar risk factors for heart disease.

If you or someone you know is at risk for stroke, be prepared. Have a list of local hospitals that can treat stroke. Keep the medical history in a convenient place, including current medications, doctors and insurance. Make sure everyone knows how to call 911, and note the time when the first symptom occurred. “Time lost is brain lost.”

To reduce risk, maintain a healthy body weight, eat fruits and vegetables and whole grains (i.e., complex carbohydrates), exercise, eat fish and don’t smoke. Reduce high blood pressure, cholesterol and alcohol consumption, control diabetes, and treat atrial fibrillation.

treatment

Within the first three hours, ischemic stroke can be treated with the “clot-buster” rt-PA (recombinant tissue plasminogen activator) to restore blood flow, so patients should be brought to the hospital quickly. To limit disability, the patient is stabilized and rehabilitation is begun as soon as possible. Other treatments are based on mechanical clot removal devices.

To try to prevent stroke, a narrowed carotid artery can be treated with carotid endarterectomy (surgically opening the artery to remove plaque) and stenting (using a catheter to insert a mesh tube in the artery). Drugs to prevent stroke include antiplatelet medications such as aspirin. Anticoagulants such as warfarin are used to prevent embolisms in patients with atrial fibrillation.

Conclusion: start early to prevent stroke; act quickly if a stroke occurs.