Stroke is the number three cause of death, trailing only heart attack and cancer. Death can come quickly. With sufficient brain damage, whether due to a blocked artery or bleeding, swelling can put pressure on the automatic centers of the brain that control breathing and the heart and death is inevitable. But death can also occur later and much more slowly. The ability to swallow can be lost and the risk of aspirating saliva and food can cause pneumonia or a lung infection. The inability to move easily can cause blood clots that travel to the lung; skin can break down and cause major infection.
Stroke is bad but there is potential salvation if the patient gets to medical care fast enough. The window to make the diagnosis and inject clot busting drugs is measured in minutes and many of those are lost because neither the patient nor the family recognizes the signs of a stroke, or they choose to ignore them, hoping that the symptoms will resolve on their own. With symptoms of a transient ischemic attack (TIA), the body fixes itself. Unfortunately, there is no guarantee that the slurred speech, loss of vision, or weakness will get better.
There is a simple tool, known as the Cincinnati Prehospital Stroke Scale, which doctors use to help diagnose stroke. If the patient has a problem with:
- smiling (the face should move symmetrically),
- raising both arms (looking for weakness on one side of the body), or
- speaking a simple sentence,
the patient may be having a stroke and should receive emergency medical treatment.
Stroke is stressful for emergency personnel as well. Health care professionals must jump through many hoops to determine if a patient is a candidate for tPA, the clot buster. The history and physical exam needed to qualify the patient takes time. Blood tests and a CT scan of the brain need to be completely. IVs, EKGs, and catheters must be in place. Doctors must speak to the patient and their family at length about the potential risks and benefits of using clot-busting medications. The risk reward equation is challenging. One-third of patients may see benefit but up to 6% of patients may bleed in the brain because of the drug. Still, the benefit outweighs the risk, especially if tPA is injected as early as possible. The widow of opportunity runs out quickly. The magic number is 3 hours from time that the symptoms began, not the time that the patient showed up at the hospital door. Those 3 hours can be extended to 4 ½ in some circumstances and perhaps up to 6 hours if there is an interventional radiologist or neurosurgeon waiting. The preferred setting for stroke treatment is a certified stroke center hospital where such specialists are available.
The sadness for many stroke victims is that they do not make it to the appropriate hospital in time. Instead being able to focus on reversing the problem, the treatment team has only the options to look at salvaging brain tissue, minimizing further brain damage, and hoping that weeks and months of rehabilitation will allow the patient to return to a functional life. For that reason, the American Heart Association has worked hard to include stroke recognition as part of basic life support. The public knows to call 9-11- for a victim with chest pain and the potential for heart attack. The public has to learn that the same urgency is needed for a patient with stroke symptoms.
Call 9-1-1. Time is brain.