I was 15 years old when my grandmother had a stroke. She was perfectly healthy until she needed a knee replacement. After having total right knee arthroplasty. She was a little overweight and had high blood pressure, but she was otherwise a very active individual. Raising nine children almost single-handedly, she seemed like a superwoman.
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. I have to say she was indeed the most capable woman I have ever met. As an individual, I was mesmerized by her, looked up to her as a professional, and loved with all my heart as my grandmother. Always taking 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 utterly 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.
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. This causes symptoms—toxic byproducts of the deoxygenated blood to the tissue cause further damage. 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 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.
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. Stroke is a serious condition. 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. This medication was given to anyone with stroke symptoms within the first 3 hours of symptoms if no contraindications were present. Several years later, further research found it 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. However, none of the above interventions are helpful if the patient is not present in the hospital within the appropriate time frame.
I made a move to South Texas from upstate New York in the middle of 2017. Eager to start my career in a region I felt needed my presence. After completing four years of general neurology training and one year of dedicated vascular neurology subspecialty training. It has been a fantastic 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 primary duties:
1) Treat an acute stroke the best I can within the first 4 hours. 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 to the best of my abilities, ensuring the worst has passed and their symptoms improve while in my care. While stroke symptoms are usually maximal at onset, symptoms can certainly worsen and lead to further disability and a more unsatisfactory outcome without the appropriate management.
Lastly, and maybe as important as the first two duties, 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.
Despite all the medical advances, a good percentage of our patient population still shows too late to the hospital for timely care
Some of the troubling experiences I’ve faced so far are the time frames some patients present to the hospital. In some cases, patients come after days, even weeks after symptoms have occurred, only because of worsening symptoms. 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, our continued responsibility is to educate and raise awareness in 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. An average of 65 billion dollars is spent on stroke annually.
Seeking immediate emergent care is the crucial point of the national stoke campaign. They are known as FAST (Face, Arm, Speech, Time). Speaking broadly, any symptoms involving the face, arm, or speech, require a 911 call and immediate medical attention. While not every hospital is the same, most hospitals can provide acute care for stroke, and the closest hospital should be visited anytime a stroke is suspected. Calling 911 will help determine the severity of symptoms and transport patients to the appropriate hospital.
Stroke care is comprised of toxic byproducts of the deoxygenated blood to the tissue 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 to achieve the best possible outcome for the patient. Treating a patient in a dedicated stroke unit plays an essential role in good results.
Stroke risk factors
Stroke risk factors are well known and are no different from cardiac disease and peripheral vascular disease. For example, hypertension, diabetes, tobacco use, and elevated cholesterol. Aside from these prevalent diseases, atrial fibrillation is also a significant 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 reducing the risk of a recurrent stroke in the future. 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. As physicians we investigate every potential etiology to determine the source of stroke. It is also essential for every patient, family member, and loved one to ask and understand the diagnosis to address the underlying cause to prevent a 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 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.
Family is everything
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 fantastic. People are genuine and sincerely appreciative. Also, people will also do whatever it is you need, but tomorrow. One amazing quality, is 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 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. Still, when in the unfortunate circumstance, I guarantee that you will be our priority, and we will do everything in our power, knowledge, and skill-set as physicians and health care providers. We will always do our part; we need our patients to allow us to do so.
By Hamzah M. Saei, MD