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During the past 25 years, more advances were made than ever before in our understanding of strokes and in our ability to prevent and treat them. Technology is readily available that can quickly and safely image the brain and heart and the blood vessels that supply them. Drugs can effectively treat and control risk factors that lead to stroke. Other drugs, surgery, and other interventions can now minimize stroke-related brain damage. Yet strokes continue to happen at an alarming rate, and stroke continues to be the third leading cause of death in the world and probably the most important cause of long-term morbidity. When people are asked to share their worries about their health as they age, they invariably mention two concerns: cancer and the pain related to it, and becoming disabled and dependent—losing the ability to communicate, think, use their arms and legs normally, or walk, all of which can be the result of a stroke.
Why is the medical profession not doing better at caring for people with a potential for stroke and those who have had a stroke? Why does the disconnect occur between what can be done and what is being done? We must do better.
Controlling Risk Factors for Stroke
Preventive strategies emphasize controlling risk factors that lead to stroke. Of course, some of the risks are beyond a person’s control. Men, older people, and those with strong family histories of hypertension, heart disease, and strokes have a higher risk of stroke than people without these histories. But people cannot choose their parents or sex at birth, and all strive to become seniors one day. Many risk factors, however, can be controlled.
Chief among them are: Hypertension (high blood pressure); Diabetes; Smoking; High cholesterol; Obesity; Inactivity, lack of adequate exercise; Recreational drug use, especially cocaine and amphetamines; Atrial ﬁbrillation (rapid irregular twitching of muscle in upper chamber of the heart); Overuse of alcohol.
Studies have estimated the number of strokes attributable to some of these risk factors and how many strokes could be prevented by their effective management.1,2 The results are dramatic.
Hypertension is clearly the most important risk. Being overweight, a serious problem worldwide, increases the frequency of hypertension. Unfortunately, blood pressure control is far from adequate in the United States, as you can see in Figure 2.3
Clearly, many people are unaware of having high blood pressure. Even when the diagnosis of hypertension is made, management is not as good as it could be. Why? Some explanations relate to patients, some to doctors, and some to medical care systems. People are accustomed to consulting doctors only when they become sick and to taking pills when they feel ill and stopping them when they feel better. Chronic conditions are more difﬁcult to manage than acute illnesses. Hypertension, at least initially, may be accompanied by no important symptoms or dysfunction. Often the prescribed pills have side effects—fatigue, light-headedness, depression, impaired sexual function—so that people may feel better when not taking them. In addition, doctors’ practices are customarily not focused on prevention (“well-adult” care), and remuneration for this type of care is scanty.Prevention also means systems need to be in place to issue reminders to both doctors and patients about follow-up. Nurses and other medical staff in addition to physicians could perform some of the monitoring and care. The practice of measuring blood pressure with wearable 24 hour monitors is not used as widely as it should be. A casual, infrequent measurement of blood pressure in a doctor’s ofﬁce may not reﬂect accurately a person’s blood pressure levels during activities of daily living, stress, and sleep.
Many of the other risk factors for stroke—diabetes, obesity, smoking, overuse of alcohol, and use of recreational drugs—are huge problems both in the United States and throughout the world. Management of these factors requires both sustained will power and support from family, friends, and the medical care system. Effective agents used to prevent stroke include statins, angiotensin-converting enzyme (ACE) inhibitors, ACE receptor blockers, agents that decrease platelet functions, and anticoagulants. Statins help lower cholesterol but also reduce plaque formation within arteries. Unfortunately, many doctors still only use cholesterol levels as an indication to prescribe statins, and often too low a dose is prescribed. Much evidence now shows that higher doses (the equivalent of 40-80 mg atorvastatin) are more effective than lower doses. ACE inhibitors have salutary effects on vascular endothelia (the internal lining of blood vessels). Platelet inhibitors are also effective in preventing stroke but are often either not prescribed by physicians or not taken by the patient. Anticoagulants in the form of warfarin compounds deﬁnitively prevent stroke in patients with atrial ﬁbrillation. Newer anticoagulants in the form of direct thrombin inhibitors are now being tested that may be more effective than heparin and warfarin and cause less bleeding. Often these platelet antiaggregants and anticoagulants are discontinued before minor procedures (for example, dental work, colonoscopy, or minor skin surgery) to avoid bleeding, but strokes and heart attacks occur while the patients are off these drugs, one of the still-unresolved dilemmas of prevention. In addition, many of these medications are expensive and beyond the economic capabilities of all-too-many older patients.
I must emphasize another key problem. Preventive measures need to be started much earlier in life than they now are—in fact, during childhood. A presentation I heard greatly impressed me. A school teacher in the southern United States described an experiment she performed with her sixth grade class. She asked the children, a mixed racial group of 12- and 13-year olds, to list medical conditions prevalent in their families. Few of the children could. Parents are reluctant to tell young children about their illnesses for fear of frightening them. The teacher then gave the children the assignment to inquire about illnesses and conditions in their family: parents, grandparents, aunts, uncles, and other close relatives. The children were also examined by a pediatrician, and blood tests were performed. Children whose parents had hypertension had higher than normal blood pressures. Children whose families were obese were overweight. In families with a high frequency of diabetes, children’s blood glucose was often high. All these conditions often begin quite early in life. After I heard this presentation, I decided to check the cholesterol levels of my six children. I had recently discovered that my cholesterol level was high, and ﬁve of my six children had cholesterol levels that were abnormal for their ages. My wife and I then began strategies to lower our cholesterol and fat intakes and those of our children.
When patients are hospitalized with a stroke or a heart attack, doctors often counsel them to change the amount and type of foods they consume and to get more exercise. But can the habits and customs of 70- and 80-year-old people be changed? A more important recommendation would be to urge them to have their children and grandchildren checked and to institute good health practices early in life. The eating and exercise habits of children need improvement. Sitting for hours before the television and chowing down fast-food hamburgers, fries, and sugary soda surely increases the likelihood of a premature heart attack or stroke.
Stroke’s Early Warning
Before a stroke, many patients have temporary decreases in blood ﬂow to portions of the brain. These episodes are usually referred to as transient ischemic attacks, or TIAs. The frequency of strokes after TIAs is high, and, critically, the hours, days, and weeks after a TIA carry the highest risk of stroke.
But people often do not recognize that a symptom they have could, in fact, be a TIA. If a hand goes numb or weak, they often attribute this to a local problem, for example, pressure on the arm. TIA episodes warrant urgent evaluation to detect the cause. Some are the result of severe disease of a carotid or vertebral artery in the neck or of a large artery within the head, and others are caused by small emboli (blood clots) from heart conditions and atherosclerosis of the aorta. These causes of stroke are treatable, and the treatment may prevent a stroke. Unfortunately, many TIAs are not only ignored by patients but also inadequately investigated by physicians. Some managed care insurers and other payers refuse to pay for hospital evaluation of TIAs. A quick and thorough evaluation is essential and should be promoted, not discouraged. Insurers should recognize that strokes are costly, so their prevention saves money as well as the health of the people who might otherwise develop a stroke.
Acute Treatment of Strokes
If prevention measures fail and a stroke occurs, what can and should be done? Newer technology that uses computer-assisted tomography (CT), magnetic resonance imaging (MRI), and ultrasound scanning can now reveal quickly and safely the presence of stroke-related brain damage and the heart, blood, and blood vessel abnormalities that are causing brain dysfunction. Having discovered the nature and extent of the problem, doctors have effective drugs and surgical and interventional techniques, such as angioplasty and stenting (surgical procedures to re-open blocked arteries), that can address the abnormalities. As an example, thrombolytic drugs (“clot-busters”) can dissolve clots blocking arteries that supply blood to the brain. These agents were approved for clinical use in 1996, and guidelines for their use were written and disseminated by committees of the American Heart Association4 and the American Academy of Neurology.5 Yet 10 years later, fewer than 5 percent of people eligible for thrombolytic treatment actually receive it. What explains this and how can it be improved?
Problems in treating acute strokes have various origins: patients and their families, doctors and hospitals, and our current medical care systems.
The Person with a Stroke
All too often, people who have a stroke do not get to medical centers in time for effective acute treatment, frequently because they do not recognize that their symptoms could be stroke related. The public is not well informed about the brain and its functions in general and, speciﬁcally, about stroke. If people on the street are asked,
“What happens to someone during a ‘brain attack’?” the most common answers are that a person will act crazy, have a seizure, go unconscious, or become dumb. People do not usually think of the brain as the repository of inputs from their vision, hearing, and sensations in their arms and legs and as the organ controlling their movement. When an arm feels numb or does not work as usual, many people attribute the dysfunction to a muscle or nerve within that arm. Visual difﬁculties are attributed to a problem in the eyes, not the brain.
Some people, of course, do realize that a symptom may be related to the brain and indicate a stroke, but, for a variety of reasons, they deny or choose to ignore the possibility, hoping it will go away. Because the brain is the organ that both recognizes a symptom and responds to that recognition, loss of some brain functions can impair the ability to identify the nature of the symptoms and to respond to them. The brain impairment can also render people unable to act, especially if they are alone. If a person cannot talk and his limbs are paralyzed, he cannot initiate a trip to a medical center by himself. Sometimes, too, the person having the stroke (or a family member or friend who is present) does not drive or does not have a car and waits for someone such as a son or daughter to drive to the hospital. Heavy trafﬁc or long distance from a medical center further delays arrival at the emergency room.
A rapid chain of response must occur in order to optimally manage people having a stroke. The possibility of stroke must be recognized quickly, and the stroke patient or a family member should immediately call 911. Calling a local physician or health maintenance organization only delays care. Then an ambulance, or someone accompanying the person with the stroke, should deliver that person to the hospital best equipped for stroke care. Unfortunately, many communities do not have adequate systems. In nearly every urban area, some medical centers have qualiﬁed as trauma centers, and emergency systems are in place to get the injured patients to those centers. The same approach should be instituted for stroke.
Doctors and Hospitals
When acute stroke therapy using thrombolytic drugs was approved by the regulating agencies in 1996, many doctors and medical centers were unprepared to put it into practice. Patients with stroke are ﬁrst seen and examined in the emergency rooms of hospitals staffed by physicians who specialize in emergency care. But, despite the large number of emergencies with neurological aspects, usually these physicians have little training in neurology or in examining and evaluating patients with strokes or other acute neurological problems. Worse, some emergency physician organizations have issued statements that thrombolytic drugs have not been shown to be standard treatment for acute strokes. In many emergency rooms, the emergency physicians will not give thrombolytics without a neurologist, but neurologists are often not readily available.
Neurologists, on the other hand, are trained and experienced in treating strokes but are usually based in ofﬁces, not hospitals. To examine a patient in the emergency room, a neurologist often must leave an ofﬁce full of patients. In addition, a trip to the hospital to examine and treat a patient with an acute stroke often takes hours and is poorly remunerated. For all of these reasons, many neurologists are also not enthusiastic about giving thrombolytic treatment.
Strokes are complicated. The brain anatomy, the many varied conditions that cause stroke, and the blood vessels that bring blood to and away from the brain are all quite complex. Some neurologists have had specialized training—even fellowships—in stroke, but there are too few stroke neurologists. Clearly, more are needed. Today, many hospitals are staffed by what are called “hospitalists”—doctors (usually internal medicine specialists) who work full time in the hospital to manage acute medical problems. Few hospitalist neurologists exist, but medical centers that recruit neurologists especially trained in acute neurological conditions such as stroke may be the best solution to the manpower problem. Some hospitals are also unprepared to apply the latest techniques in treating strokes. Brain and vascular imaging methods have improved rapidly. Newer MRI and CT scanners have more capability, but the equipment is costly and continued updating is expensive.
As a result, state-of-the-art equipment, and stroke neurologists and neuroradiologists competent to use it, are often miles away from the emergency room where a stroke patient is awaiting care. In addition to recruiting appropriate specialists and acquiring advanced technology, hospitals must generate systems to ensure rapid evaluation of patients with stroke, efﬁcient shepherding throughout the process (what hospitals call “throughput”), and follow-up. Hospitals often self-designate and advertise their capabilities. To attract patients, hospitals may call themselves “stroke centers” even though they may not have adequate personnel, technology, and systems for effectively managing patients who had a stroke. Consequently, the American Stroke Association and many states have begun to issue requirements for designation of “primary” and “secondary” stroke centers. The difference between the designations is that primary centers have the rudimentary necessities for managing stroke, whereas secondary centers have advanced specialized capabilities for medical, surgical, and interventional treatments.
What is the solution to these hospital issues? I urge the following steps be taken. Hospitals must acquire the appropriate personnel and technology and put in place the systems needed to qualify as a stroke center, or they should not accept patients who may have had a stroke. Those patients should be sent instead to a nearby qualiﬁed stroke center. All hospitals cannot—and should not—specialize in everything. For hospitals that cannot become qualiﬁed stroke centers -and have no such centers nearby to which they can refer patients, a new alternative is “telemedicine.” Computer technology enables doctors at a local hospital to have patients assessed quickly by specialists at stroke centers.
Doctors at the stroke center can talk to the patient, watch and direct examinations, and review scans sent by computer, then consult with the local physicians on managing the case. Telemedicine is a growing ﬁeld and now in use in France, Germany, and parts of the United States. This option seems especially attractive for rural hospitals that are far away from stroke centers.
The Continuing Challenge of Recovery
Even the best prevention and acute treatment will not completely eliminate the occurrence of strokes. As people live longer and acquire more medical problems, strokes will continue to happen. So we must also direct our attention to recovery. What medications and rehabilitation strategies facilitate recovery? Which drugs and procedures delay and impede it? Until recently, little research had been done on how people recover from stroke. We are now trying to ﬁnd out whether brain regions that were temporarily dysfunctional improve, new areas take over for injured regions, or people learn to do activities differently, using brain regions that were not injured. As more patients survive the acute phase of a stroke, both clinical neurologists and neuroscientists must focus on facilitating recovery. Newer technologies, including functional MRI and magnetic stimulation, are yielding much information on what happens after a stroke and enabling a more scientiﬁc evaluation of rehabilitation strategies. Their increased efforts will undoubtedly lead to better rehabilitation strategies and programs soon.
Stroke prevention and treatment has come a long way, but not far enough. Not as far as it could, given what we know now, and certainly not as far as would be ideal. Much can and should be done now to optimize care of this critical public health problem.
For more detailed information about the brain and stroke in lay language, see Striking Back at Stroke: A Doctor-Patient Journal, which I cowrote with Cleo Hutton (Dana Press, 2003), and Stroke, my most recent book for the public, commissioned by the American Academy of Neurology (Demos Publishing, 2005).
- Gorelick PB. Stroke prevention. Archives of Neurology. 1995;52:347-355.
- Gorelick PB. Stroke prevention therapy beyond antithrombotics: unifying mechanisms in ischemic stroke pathogenesis and implications for therapy: an invited review. Stroke. 2002;33:862-875.
- Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Journal of the American Medical Association. 2003;289:2560-2572.
- Adams HP, Brott TG, Furlan AJ, et al. Use of thrombolytic drugs. A supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for Health Care Professionals from a special writing group of the Stroke Council American Heart Association. Stroke. 1996;27:1711-1718.
- Quality Standards Subcommittee of the American Academy of Neurology, Practice advisory: thrombolytic therapy for acute ischemic stroke—summary statement. Neurology. 1996;47:835-839.