Brain Attack-Prompt care equals better outcomes

If there’s no blood and gore and no unbearable pain, most of us think there’s no need for urgent medical treatment. We’ll tough it out and see what happens. But some symptoms can indicate a stroke and the person who opts to “wait it out” may pay with a lifetime of disability — or death. The truth is, for effective treatment of stroke, every minute counts. Or as one doctor put it, “Time is brain.”

Stroke is a brain attack, claims Dr. Vladimir Hachinski, Richard and Beryl Ivey Professor and Chair, Department of Clinical Neurological Sciences at the University of Western Ontario. “Even a little difference in treatment makes a difference in the outcome. There are relatively simple things that can be done in any emergency room, in any hospital. We have to get that knowledge there and reorganize so that people have an availability of knowledgeable doctors and also access to CAT scans.”

CAT scans are a vital tool for treating stroke. In southwestern Ontario, at least, residents are within an hour’s drive of a CAT scan. The scan enables doctors to assess what’s happening to the brain, so they can treat the patient in a more informed way.

The London Health Sciences Centre has aong-established stroke unit that has pioneered many treatments, says Hachinski. They’re now a pilot for an effort by the Heart and Stroke Foundation to convince governments and key health authorities to deal with stroke in a systematic manner, from emergency and acute settings through rehabilitation.

If people can get to a dedicated stroke unit, their chances of dying or suffering disability decreases by about 30 per cent, and more make it back home, says Hachinski.

A carefully-noted history is important, because not all patients who arrive at the emergency department with stroke-like symptoms are actually having a stroke. Some 15 per cent may have an infection such as meningitis, a drug overdose, or even a seizure that was not witnessed. For the stroke patient, it’s extremely important to control blood pressure; high glucose levels can damage the brain; high body temperature is also dangerous. (Experimentally, lowered or hypothermic body temperatures have been shown to protect the brain.)

The London-based stroke unit has initiated a telemedicine project to share cases with a Windsor hospital. Physicians can confer with one another and even talk with patients in the other city. Hachinski hopes smaller centres will be similarly connected in the future.

The patient may need to be prescribed blood thinners if doctors suspect the clot that caused the stroke has come from the heart. But from day one, patients must begin a partnership in their own recovery. They need a multi-disciplinary team to help them recover as much function as possible and to avoid complications. Exercise, even if someone else is actually moving the limb, is vitally during this acute stage, to avoid the development of complications.

Part of the treatment for stroke must include taking action to avoid a second stroke. Risk factors like high blood pressure, high cholesterol levels and irregular heartbeat must be attended to and controlled. Drug therapy to avoid clot formation may be necessary. Also, some people may be candidates for surgery to remove the fatty plaque that has built up in their carotid arteries.

“I’m very optimistic,” says Hachinski. “A lot is happening. We have two gaps though: We have to discover more. We also know a lot and if we applied it, it would make a big difference. That’s part of what the Heart and Stroke Foundation’s effort is — to really change stroke care.”

New treatments show promise

Drug therapy to limit stroke damage is constantly evolving. The Heart and Stroke Foundation is working to educate healthcare providers so they’ll be informed when specific drug therapies are available in Canada. Some drugs shown to have dramatic effects on outcomes are not yet approved for treatment of stroke, although they’re in use for other conditions.

Clot-busters or thrombolytic drugs dissolve the clots that are causing the blockage. Tissue plasminogen activator (TPA) is particularly effective if administered within three hours of a stroke’s onset. It must be appropriately used to avoid damage if blood flow is restored where blood vessels are leaky and only a small percentage of patients are candidates for its use. Hachinski is optimistic that neuroprotective drugs, if they prove safe enough, will be administered to stroke patients on their way to emergency, to begin their task of protecting the vulnerable brain. “They won’t be as dramatic as clot-busters,” he says “but because they can be used more widely, they will have far-ranging effects.” (These drugs have also not yet been approved for use in stroke in Canada.)

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Dr. Ken Walker practises medicine in Toronto and also writes under the pen name of Gifford-Jones.—>