Many Ways to Treat a Time-Sensitive Disease

The clock is always ticking when it comes to treating strokes, but thanks to recent advancements the chances of recovery are greatly improved.

When it comes to strokes, the clock is always ticking.

That’s the first thing doctors and nurses want patients to know about the disease that kills brain cells when blood vessels to the brain are either blocked by a clot or suddenly rupture. But there’s also good news: compared to a generation ago, there’s now more hope than ever for those who experience a stroke.

In fact, up to 80 percent of strokes can be treated, says Dr. Ayman Gheith, an interventional neurologist at OSF HealthCare Saint Anthony Medical Center in Rockford.

The problem is, not everyone knows that.

“The consensus is, ‘There’s nothing I can do about this,’” says Gheith. “That’s absolutely false. We can do amazing things, but if you don’t get to me in time, I can’t do anything.”

Strokes are a time-sensitive disease for two reasons. First, the longer the brain goes without a fresh blood supply, the more extensive and permanent the damage may be.

“Every minute, the brain is losing 2 million neurons,” says Gheith.

Second, the medications and procedures that can be used to treat strokes – some of which are fairly new – have a time limit. If a patient doesn’t get medical treatment within a certain number of hours after a stroke begins, treatment options diminish.

Again, there’s good news: when a patient does make it in time, there’s a real possibility the outcome won’t be as severe as it could have been.

“We’re saving brain tissue with these treatments,” says Tracy Love, 50, a clinical nurse leader who has been the stroke coordinator at FHN in Freeport since 2010. “Some people are able to go home without symptoms.”

Advancements in stroke care have come a long way since the 1990s. It’s excited many physicians who have a better probability of saving more lives with these new techniques.

“Neuroscience, in general, is an incredibly exciting field,” Gheith says. “With stroke care, specifically, our devices are moving at light speeds. What I trained with, not even 10 years ago, is now obsolete. The more the improvement, the better the outcomes, the lower the risk.”

Signs and Symptoms

For nearly 75 years, stroke was the third-leading cause of death in the U.S. In 2008, it slipped down to the fourth-leading cause of death. Today, it’s the fifth.

However, it’s still the leading cause of disability in the U.S., and it can cause anything from issues with walking, talking or swallowing to severe memory loss, depending on which part of the brain the stroke has affected.

Unlike with other diseases, the symptoms of strokes – also known as cerebrovascular accidents – aren’t always understood well by the general population, doctors say.

“When someone has a heart attack, they have all of these uncomfortable feelings that are alerting them to a problem,” says Dr. Vibhav K. Bansal, a neuro-endovascular surgeon who specializes in stroke care at Mercyhealth in Rockford. “With a stroke, that’s not the case. Part of their body doesn’t work. Especially in younger people, they will oftentimes dismiss the symptoms: ‘I slept on my arm wrong; I worked out too hard.’ Instead, it’s the first sign of a stroke.”

Typically, strokes affect those 65 and older, says Bansal. But doctors are seeing strokes in younger patients each year.

“We’re seeing younger and younger people with co-morbidities that put them at risk for stroke: obesity, diabetes, heart disease, high blood pressure,” says Cody Monyelle, a registered nurse and the stroke coordinator at Beloit Health System. “Those are all high-risk factors for stroke, and we’re seeing younger and younger people with those diseases.”

With that in mind, it’s important for people of all ages to know the signs of a stroke – and that those signs don’t evolve slowly over time.

“One thing that sets stroke symptoms apart from other things is that they’re not there one minute, and then all of a sudden, they’re there,” Monyelle says. “If someone has trouble seeing or has a headache, they don’t tap in gradually.”

The easiest way to remember stroke symptoms is the mnemonic BE FAST.

B – Balance: coordination issues;
E – Eyes: sudden blurriness or changes in vision, even in one eye;
F – Face: a droopy face or crooked smile;
A – Arms: numbness or weakness in the arms or legs;
S – Speech: sudden slurring of words or trouble speaking;
T – Time: call 911 and/or Terrible headache.

That last letter has double the meaning: “T” reminds people that time is of the essence while also alerting them that a sudden “thunderclap” headache or terrible migraine – unlike those a person has experienced before – is another symptom.

“One of the common things we see is someone saying it’s the worst headache of their life,” Monyelle says.
While having one symptom means you could be having a stroke, two or more of these symptoms puts you at a much higher risk of having a stroke. As soon as those symptoms appear, it’s urgent to call emergency medical services right away, says Love.

“If you’re ever going to call 911, this is the time to do it,” she says. “Don’t call your son or daughter to come pick you up.”

Gheith agrees, noting hospitals have specific protocols for dealing with stroke patients, and calling EMS automatically assembles the medical professionals who are needed to save a person’s life.

“EMS activates the team: the CT is already cleared out and lab folks are at bedside to get everything done as soon as possible,” Gheith says.

How to Treat a Stroke

There are two types of strokes. Hemorrhagic, or bleeding strokes, occur when a blood vessel ruptures.

Ischemic, or dry strokes, occur when a blood clot has lodged itself into an artery of the brain, lessening blood flow to the rest of the body.

Hemorrhagic strokes are far less common; of the 800,000 strokes that occur every year in the U.S., 80 percent are ischemic, Bansal says.

Unfortunately, strokes have increased slowly but steadily over time, he adds. However, the mortality rate has decreased because of new treatments.

Love has seen firsthand how stroke care has changed.

“I’ve been a nurse for 27 years,” says Love, who also chairs the Illinois State Stroke Advisory Committee. “I remember back in the ’90s, when someone came in with a stroke, all we could say was, ‘We’ll get you rehab; we’ll try to get you back to where we can.”

Since the mid-1990s, however, a medication called tPA (tissue plasminogen activator) – a super clot-breaker administered through an IV in the arm – has been a game-changer.

Today, tPA – or alteplase – is considered the first line of treatment for ischemic strokes. But it has a short window of effectiveness.
“When there’s a clot in the blood vessels in the brain – an ischemic stroke – everything downstream isn’t getting blood. Tissue is starting to die,” Love says. “That medication breaks the clot up. But we only have up to 4.5 hours from the time the patient was OK or without symptoms to administer the drug. After that, the benefits of the drug do not outweigh the risks of the drug.”

The goal is to have a doctor assess a stroke patient within 10 minutes of entering the hospital; have a CAT scan done within 20 minutes; and administer the drug within 60 minutes – if that is determined to be the correct treatment plan for that patient, she says.

Not everyone can be given tPA. Those who are on blood thinners or have had recent surgery or trauma have to be triaged out, Love says.

“But for those patients who are able to get that drug, it can make a major difference in their life,” she says.
As well as it has performed against smaller blood clots, tPA isn’t very effective against large blockages in a major artery, Gheith says.

That’s why the advancement of thrombectomies has become so important since their adoption in 2015. This is an endovascular procedure in which the surgeon goes through an artery in the groin, up to the brain to remove a blood clot.

“We have the ability to go into a person’s body and pull out a clot from the brain,” Gheith says. “Our outcomes now are amazing. Patients come in near death – you see death in their eyes – and you go into the body and pull that clot out, and they wake up and go home in a matter of days.”

Thrombectomies have a longer time window than tPA – successful procedures can be done up to 24 hours after stroke symptoms first present. Hospitals with comprehensive stroke centers – including OSF Saint Anthony and Mercyhealth – are specially equipped to handle such procedures.

It’s another time-sensitive complication in stroke treatment, and it’s just another reason to call an EMS team as soon as stroke symptoms are recognized.

Still, the future looks bright for continued advancements in stroke care, says Bansal.

“Today, if you have three groups of 100 people, and one group received no treatment, 20 of them would return to a normal baseline in three to six months,” he says. “With a tPA, 30 would return to a normal baseline; a thrombectomy, 60. These are patients who probably would have died; with a large artery occlusion, they would have passed away within three months. I think that this revolutionary care in stroke will only get refined over time.”

What Can I Do?

Many of the risk factors that lead to stroke are possible to control: high blood pressure, smoking, diabetes, obesity, high cholesterol and heart disease.

Of those, high blood pressure – the silent killer – is the single highest risk factor for stroke. And for those who smoke and are thus more likely to develop high blood pressure, quitting could save their lives.

“If I could put everything in one basket and quitting smoking in another basket, I’d choose smoking nine times out of 10,” Gheith says. “I wish high blood pressure hurt, because if it did, people would take it much more seriously.”

Once a person has a stroke, his or her risk of having another stroke is very high, says Love. That’s why, when someone experiences a second stroke, doctors and specialists do a full workup to figure out what caused the first one, with the hopes of preventing a subsequent attack.

The take-home message is this: stroke is preventable by controlling the risk factors, Monyelle says.

She recommends keeping blood pressure under control and eating a healthy diet, especially if you have diabetes. People with a heart arrhythmia or AFib (atrial fibrillation) should make sure to take their medications as prescribed by their doctors.

Of course, sometimes it’s the simple things that can make the most difference.

“Lead a healthy lifestyle as much as possible,” says Monyelle.

And in the moment, don’t worry about “overreacting” to possible symptoms.

“Don’t waste time,” Gheith says. “It’s better to be safe than sorry. I can’t tell you how many times patients have said, ‘I wanted to sleep it off and see if it got better on its own.’ Don’t do that.”