Author’s note: This is the third diary in a new series that I will post monthly, on medical topics related to emergency care. If you want to check out the first diary in the series, you can find it here, on the topic of insider tips to improve your ER visit, and the second one here, on the topic of heart attacks. Some of these diaries will focus on the medical system or process, and some will be disease-specific. My goal, as your friendly neighborhood ER doc to the Daily Kos community, is to provide useful information for this community to stay healthy and get the best results from our medical system. I hope you find it helpful!
While most people have heard of the term “stroke”, there is quite a bit of confusion around what the term means. Even more confusing is the often-used phrase “mini-stroke”, which usually is spoken when talking about a “TIA”, or transient ischemic attack. Stroke is very common, afflicting over a half million people each year in the US, and is a major cause of long-term disability and mortality (if statistics or epidemiology are your thing, check out this CDC website). Importantly, there have been significant improvements in emergency stroke care over the past ten years, which makes it all the more crucial that we all have some basic knowledge to prevent, suspect and react to loved ones (or ourselves) having a possible neurologic emergency.
First things first: what’s a stroke?
The brain is always hard at work, and requires a steady diet of oxygen and fuel delivered through the blood. There are four major blood vessels that feed the brain — the two carotid arteries (in the front of the neck, left and right) and the two vertebral arteries (in the back of the neck, left and right). These four arteries feed a complex system of blood vessels in the skull that nourish brain tissue night and day. Just like arteries to your heart, any of these blood vessels can get clogged (known as “atherosclerosis”). The material that slowly accumulates in our blood vessels, forming these clogs, is an unruly mix of cholesterol/fats/calcium/debris. Thankfully, this build-up is a slow process, and usually only becomes a problem as we age (such clogs are very uncommon among 20-40 year olds, but become increasingly common after 40 in many people).
Most of the time, these clogs are silent — we don’t notice them, and they don’t bother us. Until they aren’t. And here’s the problem: every so often, this blood vessel build-up can cause a small tear in the inner lining of the blood vessel, which in turn causes a blood clot. This blood clot forms quickly and often completely blocks blood flow in the injured vessel. When this happens in a coronary artery to the heart, it’s known as a heart attack. When it happens in a blood vessel to the brain, it’s a
stroke (if you want to be formal about it, this is an “ischemic stroke”. There is a second kind of stroke, a “hemorrhagic stroke” that may require another diary to avoid TL;DR. One step at a time). Just like a heart attack, a stroke involves choking off blood supply to a part of the brain, which is a true emergency. If blood flow isn’t restored quickly (within hours), brain tissue can die and long term disabilities can result.
One of the big reasons why stroke is confusing is that the symptoms are highly variable. A classic presentation of a stroke might be sudden slurring of speech and arm or leg weakness — maybe a stroke victim will fall to the ground from this, or drop their coffee cup. But sometimes, it’s a lot more subtle: sudden onset dizziness, or sudden changes in vision. There have been broad campaigns to increase stroke symptoms awareness, such as the act FAST program. You can also check out this set of infographics from the National Institutes of Health.Many strokes are missed by family members and medical professional alike because the symptoms are vague: as an ER doc, I see 70 year olds with dizziness almost every shift. Most of them don’t have strokes. How do I sort out the real thing? I’ll tell you this: it’s not easy. But let’s not get in the weeds of ER work, I would rather focus on what YOU can do.
First, it’s important to know that (1) warning signs can vary quite a bit — it is not always sudden weakness or speech issues, (2) time is essential, so if there is a sudden change in function or vision or sensation, it’s time to call your doctor or consider calling 911, and (3) there are ways to cut down your stroke risk. It is this latter issue I want to cover next.
Risk factors and what you can do about it
If you understand the business about the cholesterol clogging that I described above, then it should make sense to you that the very same things that put you at risk for coronary disease and heart attacks also put you at risk for strokes. What increases the arterial build-up of crud? Smoking and high blood pressure are two of the biggest contributors — and I mention them first because you can do something about both of these. I know it’s not easy, but quitting smoking is without question the best thing you can do for your health and your stroke risk. And managing your blood pressure is also critical — having your blood pressure checked a few times a year (more if it runs on the high side) is always a good idea. And if you have high blood pressure, DO NOT BLOW IT OFF. There are a wide range of inexpensive medicines that work very well to manage blood pressure for the majority of patients, and taking them lowers both heart attack AND stroke risk. Primary care physicians and nurse practitioners are highly trained for blood pressure management and are more than happy to work on this with you. There are other risk factors of course, but these are harder to manage: genetics (family history of strokes or heart attacks), diabetes, and high cholesterol (both diet and genetics factors). If you have diabetes, keeping your blood sugar under control is key — but this is a huge topic onto itself, perhaps for another diary.
Another risk factor that you might not be aware of: atrial fibrillation. Remember I told you that strokes are from blood clots in the brain? Indeed, they are — but they don’t always form in the brain at the site of clogs. Sometimes, the blood clots form in the heart and are flung downstream where they lodge in brain blood vessels. The good news is that this is very uncommon . . . UNLESS you have a condition called atrial fibrillation, which is an electrical problem in the heart tissue that causes an irregular (and sometimes rapid) heartbeat. Atrial fibrillation (known in the business as “A fib”) is common, and people can live with it for decades. The problem is that A Fib is a set-up for blood clots forming in the heart, which in turn increases stroke risk. SO: if someone has A Fib, they really need to be on a “blood thinner”, a medication that lowers the risk of blood clots. These medications (such as coumadin, lovanox, xarelto and others) don’t actually thin the blood at all, what they do is affect the delicate protein machinery in the blood that controls clotting, making it harder to do. Being on blood thinners is no picnic — every scrape or cut bleeds a lot more, falls or bumps are more likely to make for big unsightly bruises, and flossing the teeth can led to increased bleeding. But they are crucial for patients with A Fib, as they dramatically lower the risk of strokes. There are reasons people can’t take blood thinners — so for them, even a daily baby aspirin can slightly thin the blood and reduce stroke risks. Here’s the take home point: if you or your loved one has atrial fibrillation, make sure they are either on a daily blood thinner or aspirin. If they aren’t, make sure there is a darn good reason why they aren’t. And if you or your loved one feels like your heartbeat is irregular, or “skipping beats”, you should get checked out for possible A Fib. Diagnosing A Fib is actually fairly easy and cheap — an electrocardiogram (or “ECG”) can often detect it, which is a simple office test that doesn’t require needles or blood. Apple watch aficionados probably are aware that the newer apple watches have an ECG feature that allows for A Fib detection at home.
My loved one is having symptoms of a stroke: what do we do?
If you or loved ones experience sudden weakness, slurred speech, vision changes, or dizziness, especially if they are of a certain age (say, above 40) and have risk factors (smoker, high blood pressure, and/or diabetes) — you should strongly consider calling 911 and seeking emergency medical attention. This of course is tricky if you or the person in question often has weakness or dizziness, so there is some judgement call that is required. But the reason why you should have a low threshold to call 911: there are important treatments for stroke, relatively newly developed, that only work in the first hours after a stroke, not the next day or next week. These include a powerful clot-busting medication known as tPA, which ER docs can give in consultation with neurologists on an emergency basis, and catheter-based treatments (much like a coronary angiogram) that can be done at some hospitals by expert “invasive neuroradiologists”.
Here’s the really important inside tip on ER treatments of stroke: not all ERs can do this. There is a national system of “comprehensive stroke centers”, meaning hospitals that have specialized training and resources to give tPA and do catheter stroke treatments. You can (and should!) find the nearest comprehensive stroke center near you, which you can find on this public website — it may not be your closest hospital. If you are having stroke-like symptoms, you don’t want to go to an ER that isn’t part of a comprehensive stroke center. They just won’t handle this as well, and it could mean worse outcomes. For more information on comprehensive stroke centers, check out this infographic from the American Stroke Association.
OK, I have a better understanding of stroke: what about a TIA?
You may have heard the term “mini-stroke”. While there are indeed major and minor strokes (with bigger or lesser impact on long-term function), in most cases this term is misused to actually mean a “TIA” or transient ischemic attack. A TIA isn’t actually a stroke, but shares a common feature — both strokes and TIAs are caused by blood clots in the arteries to the brain, and both can have similar symptoms (such as weakness, vision changes, dizziness). Here’s the difference: a TIA is a temporary blockage that clears itself, while stroke is a more durable blockage that will kill brain tissue if not treated. If someone has stroke-like symptoms, and the symptoms go away in 15 minutes, 30 minutes, or 2 hours, that is likely a TIA, not a stroke. If the symptoms don’t go away after hours, it’s more likely a stroke. So as you can imagine, this is a problem: it’s impossible to tell a TIA from a stroke in the initial minutes, and you don’t want to wait. Go to the ER, and let THEM tell you it was a TIA if the symptoms get better there. If it was a TIA, this has important implications — it means the patient is more likely to have a stroke in coming weeks or months. A TIA is basically a warning flare, saying that a stroke may be more likely in future. So anyone with a TIA really needs close follow-up with a neurologist; indeed, sometimes patients with TIA need to be hospitalized for further testing and arrangement of close follow-up.
OK, so there is a brief overview of some key facts about stroke and TIA. I apologize for the inadequacy of this diary, as information about these topics could fill a book (indeed, such textbooks exist and even THEY don’t do the topic justice). Hopefully it helps a bit — and I’ll stick around to answer question during the day, as I have with prior diaries.
My next ERDoc 411 diary, mid-April, will cover travel emergencies — what to bring when on the road, how to seek medical care away from home, and related issues. The reason — I’ll be traveling with my family as I write it, and it just seemed like the right theme. So stay tuned!