I was 15 years old when my grandmother had a stroke. She was perfectly healthy until she needed a knee replacement. She recovered completely after having total right knee arthroplasty. She may have been a little overweight and had high blood pressure, but was otherwise a very active individual. She raised 9 children almost single-handedly. She seemed like superwoman. She worked as a midwife.
Cultivating over 40 years of experience, people started calling her Dr. Huda, although she had not spent a single second in a medical school classroom. She was indeed the most capable woman I have ever seen. I was mesmerized by her as an individual, looked up to her as a professional, and loved with all my heart as my grandmother. She took care of everyone; children, grandchildren, family, neighbors, and friends. She was Ms. Independent. Until that moment came. A left middle cerebral artery stroke made superwoman become completely dependent on those that she took care of. Within seconds, her life and the lives of everyone around her had changed forever. Life was never the same after that, not for Dr. Huda, and not for me.
Odds are, this story isn’t any different than any you’ve heard or experienced. However, this story gave me the capability to write this article. This story led me to choose a career in medicine, neurology, and vascular neurology to be more specific.
Every 40 seconds, someone suffers from a stroke. Stroke is the most common cause of disability in the United States and is the fifth leading cause of death. A stroke can be an ischemic stroke or a hemorrhagic stroke. An ischemic stroke is when an artery in the brain becomes blocked, causing ischemia, or lack of oxygen to that particular part of the brain. The signs and symptoms depend on the part of the brain being affected. The larger the blocked artery, the more devastating the symptoms. It is for this reason, signs and symptoms of stroke can differ and vary from one person to another. A hemorrhagic stroke is when a blood vessel in the brain ruptures causing decreased oxygenation to that particular part of the brain, thereby causing symptoms. Further damage is caused by the toxic byproducts of the deoxygenated blood to the tissue. As mentioned above, signs and symptoms depend on the location of the ruptured vessel. It is impossible to distinguish an ischemic stroke versus a hemorrhagic stroke based on symptoms alone. A computed tomography scan (CT scan) is needed emergently to separate between the two and steer the direction of treatment. Ischemic stroke is by far much more common and will be the bulk of this article.
Stroke symptoms, as mentioned earlier, can vary from person to person. It can range anywhere from simple numbness to the face, arm, and or leg, to complete debilitating weakness of one half of the body, loss of ability to speak, understand, and even death. No stroke should be taken lightly. Advances in medicine have allowed us to become more aggressive in the treatment of acute stroke. A clot-busting medication, tissue plasminogen activator (tPA) was approved in the early 1990s to be given to anyone with stroke symptoms within the first 3 hours of symptoms if no contraindications were present. Several years later, further research found beneficial to most patients up to 4.5 hours after initial symptom onset. More technological advances have guided the field of interventional endovascular management of ischemic stroke, allowing for manual clot retrieval up to 24 hrs of symptom onset in select patients. None of the above interventions are useful, however, if the patient is not present in the hospital within the appropriate time frame.
I made the move to South Texas from upstate New York in the middle of 2017. I was eager to start my career in a region I felt needed my presence. I completed four years of general neurology training and one year of dedicated vascular neurology subspecialty training. It has been a striking experience thus far. While I love every aspect of feeling appreciated, the truth of the matter is, my job is very limited to many patients. As a vascular neurologist, I have three main duties: 1) treat an acute stroke the best I can within the first 4 hours, and if after that time window, recognize whether the patient is a candidate for manual clot retrieval and send to the appropriate facility as quickly and swiftly as possible. 2) Perform every measure in my capability to ensure the worst has passed and their symptoms do not worsen while in my care. While stroke symptoms are usually maximal at onset, without the appropriate management, symptoms can certainly worsen and lead to further disability and a poorer outcome. Lastly, and maybe as important as the first two duties, is to determine the source of the stroke and address the cause to reduce the likelihood of suffering another stroke. Without doing so, patients are a ticking time bomb for another stroke.
Some of the troubling experiences I’ve faced so far are the time frames of which some patients present to the hospital. In some cases, patients present days, even weeks after symptoms have occurred, only presenting because of worsening symptoms. So despite all the medical advances, a good percentage of our patient population still presents too late to the hospital for timely care. About 1.9 million Neurons die each minute in an untreated stroke. An untreated brain ages roughly 3.6 years for each hour during an untreated stroke. Time is brain indeed. Whether it’s a financial, cultural, geographical, or social restraint, it is our continued responsibility to educate and raise awareness to the community. Stroke does not just affect the patient, but the family as well. Entire family dynamics can change after a stroke. The increasing cost of care has made stroke one of the most expensive and costly diseases in our country. An average 65 billion dollars is spent on stroke annually.
Seeking immediate emergent care is the key point of the national stoke campaign. Known as FAST (Face, Arm, Speech, Time). Speaking broadly, any symptoms involving the face, arm, or speech, require a 911 call and to seek immediate medical attention. While not every hospital is the same, most hospitals are capable of providing acute care for stroke, and the closest hospital should be visited anytime a stroke is suspected. When 911 is called, emergency medical services can determine the severity of symptoms and transport patients to the appropriate hospital. Stroke care is comprised of a multidisciplinary team. Active members include the neurologist, and in some cases, a neurosurgeon, hospitalist, at times other specialists (cardiologists, intensive care), dedicated nursing staff, nutritionists, speech therapists, and physical therapists all working together in order to achieve the best possible outcome for the patient. Studies have shown the most important predictor of a good outcome in stroke is being treated in a dedicated stroke unit.
Stroke risk factors are well known and are no different than those of cardiac disease and peripheral vascular disease. For example: hypertension, diabetes, tobacco use, and elevated cholesterol. Aside from these very common diseases, atrial fibrillation is also a major risk factor for ischemic stroke. Even non-sustained atrial fibrillation can carry a high stroke risk. Identifying the etiology of the stroke is critical in an attempt to reduce the risk of a recurrent stroke going forward. Another unfortunate and gut-wrenching experience is the number of patients whom I’ve seen who were diagnosed with a stroke years ago. When asked, “why did you have a stroke?” they answer with a blank face, which is sometimes better than the, “they said it was stress,” response I’ve heard countless times.
An etiology of a stroke, to a vascular neurologist, can be suspected based on its appearance on imaging, MRI, for example. A stroke caused by hypertension typically looks different than a stroke caused by atrial fibrillation or any other cardiac cause. Strokes on both sides of the brain are likely to be caused by a more central source, thrombus from within the heart for example, or a tendency to develop clotting due to underlying malignancy, genetic causes, etc. And for that reason, the cause of stroke needs to be determined. There are circumstances, in some literature, where up to 40 percent of strokes are without an etiology or undetermined source. These strokes are termed cryptogenic strokes. Our job as physicians is to assure that every potential etiology is investigated to determine the source of stroke. It is also important for every patient, family member, and loved one to ask and understand the diagnosis in order to address the underlying cause to prevent recurrence. When my grandmother had a stroke, I remember asking my aunts who were taking care of her, “how and why?” The response was, “she just had surgery a few weeks before, so she had a stroke.” I accepted the answer as much as it confused me and didn’t bring it up again until seven years later when things made more sense to me. No one had investigated why this mildly overweight hypertensive right-handed female developed what appeared to be an embolic ischemic stroke causing severe long-term disability. It was upon further questioning, about seven years after the stroke, that it was revealed that my grandmother had paroxysmal atrial fibrillation and was placed on oral anticoagulation for further stroke risk reduction.
Being in the Rio Grande Valley over the past several months, I’ve learned a lot about this region. Some good, some bad. The weather is hot, except for when it snowed for an hour. The food is amazing. People are genuine and sincerely appreciative. People will also do whatever it is you need, but tomorrow. People in the Valley are down to earth, genuine, sincere, and very appreciative of our efforts as physicians. I was in awe of the amount of respect they show towards physicians and healthcare providers. Again, coming from New York, you can see why it’s a culture shock for so many different reasons. One of the biggest things I’ve learned while here in the Valley is the value placed on family. Family is everything. It has helped me constantly remember the keys to happiness. God, family, and health. With change come growing pains. But I can assure you this; I’ve come to the Valley as the only stroke neurologist to provide a service that wasn’t provided to my grandmother. I see my Dr. Huda in every stroke patient I encounter. I wish I never had to meet anyone in the hospital, but when we are met with the unfortunate circumstance, I guarantee that everything in our power, knowledge, and skill-set as physicians and health care providers will be applied to your recovery. We will always do our part; we just need our patients to allow us to do so.
By Hamzah M. Saei, MD