Recognize Symptoms of a Stroke
Less Response Time, More Brain Preservation

March 2007-- “When dealing with stroke, time is brain,” says Dr. Colin Derdeyn, Associate Professor of Radiology, Neurology and Neurologic Surgery at St. Louis’ Washington University School of Medicine, a PinnacleCare Center of Excellence and home to some of the nation’s leaders in stroke care and research. “The longer the brain is deprived of essential blood flow by a clot in an artery or the rupture of a blood vessel, the more neurons die, resulting in disability and death. Two million neurons die every second that blood flow is interrupted.”

But few Americans are even familiar with symptoms that indicate a stroke, causing the loss of valuable treatment time as they delay going to the hospital. “It’s important for each of us to know the symptoms of a stroke and act immediately,” stresses PinnacleCare’s Chief Medical Officer, Dr. Miles J. Varn.

The symptoms of the most common type of stroke include the sudden onset of:

• Numbness or weakness, especially on one side of the body
• Confusion
• Trouble speaking or understanding speech
• Vision problems
• Difficulty walking or dizziness and loss of balance
• Severe headache

There are also symptoms unique to women, including sudden:

• Face and limb pain
• Hiccups
• Nausea
• Weakness
• Chest pain
• Shortness of breath
• Palpitations

“When you’re dealing with a potential stoke, it’s wise to take a ‘better safe than sorry’ approach and get to the hospital immediately when faced with any of these symptoms,” Dr. Varn believes.

Stroke can attack at any age

There are three types of stroke: ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage. Ischemic stroke is the most common form, making up approximately 85 percent of the strokes suffered annually. These strokes are caused by a clot blocking an artery in the brain. Hemorrhagic strokes are the result of ruptures in the vessels of the brain.

Most think stroke is a disease of the later years, but a significant 28% of stroke patients are under the age of 65. Africans Americans face a greater threat, with a risk that is two to three times greater than whites. In addition, a recent study at the University of California at Los Angeles Stroke Center found that a woman’s risk of stroke rises steeply in middle age, particularly between the ages of 45 and 54. The researchers believe that this rise can be attributed to the fact that women experience steeper increases in blood pressure, cholesterol and blood sugar levels than men of the same age.

Depression, genes boost stroke risk

Depression is another emerging risk factor for stroke for people under 65. People who took part in the 8-year Framingham Heart Study who had symptoms of depression were four times more likely to suffer a stroke even when other stroke risks were factored out.

Other recently uncovered predictors of stroke risk include diabetic retinopathy (damage to the small vessels of the eye caused by diabetes), which was found to predict ischemic stroke independent of other risk factors.

Researchers have also identified a gene, phosphodieserease 4D (PDE4D), which significantly boosts the risk of stroke in young women between the ages of 15 and 49, a risk which is driven even higher if these women smoke.

The next revolution in stroke treatment:
corkscrews, vacuums, and rerouting blood flow

The last big breakthrough in ischemic stroke treatment was the 1996 approval of tissue plasminogen activator (tPA), a thrombolytic agent that breaks up the clots that cause ischemic stroke. But tPA must be administered within the first three hours after a stroke and less than 4 percent of patients make it to the hospital within that window of opportunity. In addition, tPA carries its own risks of bleeding within the brain.

Currently, there are two approaches that researchers are exploring to bring about the next revolution in stroke treatment—mechanical and pharmaceutical intervention. The Merci Retriever is one example of the mechanical approach. This corkscrew device is guided to the blocked vessel in the brain by a catheter inserted through a small puncture in the patient’s groin. The corkscrew ensnares the clot which is then pulled out and removed.

The most recent trial of this device found that 69.4 percent of patients had blood flow restored. One out of three of the patients were functionally independent 90 days post-procedure. All of the patients who took part in this clinical study had moderate to severe large vessels strokes, most with a large clot burden which makes them difficult to treat with clot-busting drugs like tPA. The usual prognosis for patients with this type of stroke is poor, with a death rate of 35 to 90 percent. In addition, treatment with the Merci Retriever was begun within 8 hours of symptom onset, expanding the potential treatment window by 5 hours. One potential drawback of the device is the risk of puncturing the blood vessel wall.

The Penumbra Stroke System is also delivered to the site of the stroke via a catheter introduced at the groin, but unlike the Merci Retriever, Penumbra does not enter the clot. It uses suction to remove it. The system is currently in Phase I trials. “The Penumbra Stroke System has the potential to minimize injury to the blood vessel wall," said Dr. Demetrius Lopes, a neuroendovascular specialist at Rush University Medical Center, one of the first sites to use the system. “We believe we may be able to remove rigid clots that we could not grab with the other mechanical device. Clots come in different shapes and sizes and are made of different materials. It's important to have a variety of tools available to handle all the different situations we face."

Rather than removing the clot, the NeuroFlo perfusion augmentation therapy system, which is currently in trial in 30 centers in the U.S. and Canada, redirects blood flow to bypass the blocked vessel. A dual-balloon catheter restricts the flow of blood via the descending aorta and increases flow to the brain by collateral circulation, reducing the size of and damage caused by the stroke.

Stents can cut the risk of a second stroke and boost brain function

An added benefit observed in those who received brain stents was improved mental function, according to a small study performed at Sacred Heart Medical Center in Spokane, Washington. Forty-three percent of the 37 patients with the implant scored higher on cognitive tests a year after implantation.

Treatment for hemorrhagic stroke is also beginning to include the use of stents and coils. “We’re increasingly developing less invasive techniques using stenting and the placement of coils in aneurysms to prevent rupture,” notes Dr. Ralph G. Dacey, Jr., a member of PinnacleCare’s Medical Advisory Board and Professor and Chair of the Department of Neurosurgery at Washington University School of Medicine and Neurosurgeon in Chief at Barnes-Jewish Hospital in St. Louis.

Viper venom and other novel treatments in development

In a new approach to an existing drug therapy, researchers are taking tPA to the source of the problem, delivering the drug directly to the clot. Many of the patients who took part in the study led by Dr. Joseph Broderick, Neurology Chief at the University of Cincinnati, were tremendously improved the day after treatment, often with no paralysis or speech loss. Another study found that patients who received this treatment were 65 percent more likely to be able to function normally three months after the stroke. The survival rate was also markedly improved. Ninety percent of those who had tPA directly delivered to the clot survived versus 74 percent of those who received IV tPA.

A new study performed at Ohio State University College of Medicine also had promising results, though researchers caution the study is still in its earliest phase. One quarter of those who received the tPA treatment experienced what researchers termed a “Lazarus Phenomenon,” experiencing a 50 percent reduction in the severity of limb paralysis, vision loss and speech problems.

Researchers are also continuing to examine another clot dissolving drug, ancrod, which is derived from the venom of the Malayan pit viper. According to a recent study of more than 4,000 stroke patients, the drug may stretch the potential treatment window to six hours. In addition, ancrod not only breaks up existing clots, it also prevents the formation of new ones and thins the blood, improving flow to the brain.

Treatment with high doses of atorvastatin, a cholesterol lowering medication, after a stroke cut the risk of a second stroke by 16 percent. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) is the first study to show that statins can reduce the risk of stroke in patients who have no history of heart disease.

Preventing brain cell suicide

Patients are now being enrolled in a study to assess the effectiveness of high doses of albumin, a blood protein, after a stroke. In rodents, use of albumin resulted in an improved neurologic score, decreased brain infarction and less brain swelling. When tPA was combined with albumin, the results were even more encouraging.

Another new pharmaceutical treatment on the horizon is the use of Activated Protein C (APC) or Xigris, a drug currently used to treat sepsis. APC works to counter the damage caused by stroke by interrupting the molecular signals that tell damaged cells to kill themselves. It also helps mitigate inflammation caused by the immune system and diminishes the side effects of tPA.

Others are also focusing on disrupting the molecular signals that incite cell death. At the University of Southern California, researchers are injecting mice with a decoy peptide that lures the toxic enzyme calpain to attach to it instead of attaching to brain cells.

Science that sounds like science fiction

While a helmet that cools the brain, a laser beam and a magnetic wand may sound more like science fiction than science, all three are currently under investigation as scientists strive to expand the number and type of tools available to treat stroke.

Infrared laser is being used to dissolve stroke-causing clots in the NeuroThera Effectiveness and Safety Trial (NEST)-1. To date, the 79 patients who received this treatment had a significantly better outcome compared to placebo. In addition, the treatment can be used up to 24 hours after a stroke.

Researchers in Japan and at Stanford have been testing a helmet that cools the brain to reduce stroke damage. It’s an improved approach over research that cooled the entire body, resulting in side effects for other organ systems.

At Harvard Medical School, neurologist Dr. Felipe Fregni discovered that placing magnetic wands over the heads of stroke patients can help them recover lost motor skills. The non-invasive treatment called transcranial magnetic simulation, delivers weak, pulsing electric currents to targets in the brain. Patients in the study experienced an up to 50 percent improvement in their reaction time. An Advocate can help you get smart about stroke PinnacleCare Members can rely on their Advocate to help them learn everything they need to help cut the risk of stroke, know the symptoms of the disease and pinpoint the best physicians and facilities for treatment.

Should you experience symptoms of a stroke, call 911. Even with exciting breakthroughs, time is still of the essence and rapid response can help save initial brain tissue.

“Tailoring treatment to each stroke patient is the future,” believes Dr. Derdeyn. “In five to ten years, people will be rapidly transported to a stroke center, plugged into a scanner that determines what type of stroke they’ve had, where the clot or rupture is and will then be triaged to appropriate care.”

Get free expert advice on cancer care from PinnacleCare

There is no substitute for a personal PinnacleCare Advocate ™ and all the resources and medical relationships available to PinnacleCare Members. Yet, PinnacleCare is also committed to helping the larger community learn how to seek out the best healthcare and more effectively deal with health challenges.

A year ago, we published the PinnacleCare Guide to Getting the Best Healthcare, and many Members requested copies for themselves, friends and family. Now, we are pleased to present the PinnacleCare Guide to Getting the Best Cancer Care. This is an easy to follow guide to help readers gain greater understanding and resources in handling a cancer diagnosis. Topics include:

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The new guide was written by health writer Fran Pulver who also authored our first healthcare guide. A PinnacleCare Member and cancer survivor herself, Fran is a highly respected, frequent contributor to Harvard Medical School’s Harvard Heart Letter and Better Health for Life. Fran is also co-author of A Guide to Alzheimer’s Disease, published by Harvard Health Publications.

You can access both free PinnacleCare guides on our website.