Delay Can Be Dangerous For Patients Who Have Had A Stroke

February 25, 1999

LOS ANGELES (Feb. 18, 1999) -- When Lefred Williams woke up and coughed at 2 a.m. on April 7, 1998, he suggested his wife put down the book she was reading, turn off the light, and go to sleep. But Jackie noticed something unusual about the way her 64-year-old husband looked, and his speech was slurred. Against his wishes, she called paramedics.

"I was annoyed, very annoyed. I was more concerned about being to work on time in the morning," says Lefred, more commonly known as Lee. He was sure his wife was overreacting. He didn't want the paramedics' help. And he was convinced the trip to Cedars-Sinai Medical Center was just a waste of time. Instead, doctors confirmed that he had suffered a stroke.

Neurologist Cyrus K. Mody, M.D., says Lee's response is not unusual for patients who suffer a mild stroke. "A lot of people are very stoic and feel that the weakness or the slurred speech they're experiencing will just go away. That's the biggest mistake they could make," he says.

According to Dr. Mody, a stroke's impact on a patient depends on several factors: the size of the stroke, the area of the brain affected, and how quickly treatment is initiated. The type of treatment depends on whether the stroke is ischemic (caused by a blood clot restricting flow in an artery leading to or within the brain) or hemorrhagic (caused by a vessel rupture).

In the case of an ischemic stroke, such drugs as t-PA (tissue plasminogen activator) administered within three hours of onset often can dissolve the clot, restore blood flow and reverse the effects of the stroke. On the other hand, t-PA is not an option in massive strokes or those involving hemorrhaging. It also is not likely to be used in small strokes that are likely to resolve on their own.

Neuroradiologist Franklin Moser, M.D., director of the Division of Neuroradiology in Cedars-Sinai's Department of Imaging, says the medical center has developed a system to quickly evaluate emergency patients who might benefit from stroke treatment. Potential candidates arriving at the hospital are given priority status for a CT scan, which is used to rule out other diagnoses and to determine whether the stroke is ischemic or hemorrhagic. Based on these results, additional imaging or treatment can be quickly initiated.

Several new-generation imaging techniques, available at major medical centers and teaching hospitals such as Cedars-Sinai, provide highly detailed images that enable physicians not only to instantly assess the damage of a stroke but to treat it on the spot, according to Dr. Moser.

Using a new magnetic resonance imaging (MRI) procedure called diffusion imaging, for instance, physicians can see and diagnose a stroke immediately. Magnetic resonance spectroscopy helps doctors determine which areas of the brain are likely to survive the trauma of a stroke and which are not. Perfusion imaging, another MRI technique, shows precisely where blood is flowing.

With the clear, detailed images available today, Dr. Moser and other physicians at Cedars-Sinai can guide a tiny catheter into the blood vessels of the brain and inject urokinase, another of the "clot-busting" drugs, directly to the site of a stroke. This procedure, intra-arterial thrombolysis, may prove to offer better results than the customary intravenous administration of clot-busting medications -- but only if it is started within an hour of the time the stroke occurs.

In addition to offering state-of-the-art imaging and treatment capabilities, Cedars-Sinai is currently participating in a multi-center, national trial on an experimental medication called citicoline, according to Cameron Adams, M.D., a neurologist specializing in neuromuscular disease, and assistant director of the medical center's neurophysiology lab. Dr. Adams says the drug's manufacturer hopes this study will show citicoline to have long-term benefits for stroke patients. One of a new class of drugs, called neurorestoratives, citicoline is intended to actually promote regeneration of damaged cell membranes in the brain. One of citicoline's advantages over clot-busting drugs -- if it proves effective -- is that it can be started up to 24 hours after the onset of a stroke, according to the manufacturer.

"The problem with strokes is that patients don't necessarily feel pain and they don't seek help right away," says Dr. Moser. In fact, one-third of all strokes occur while the patient is sleeping. Because the patient wakes up in the morning with symptoms but there is no way to determine when the stroke actually occurred, early intervention medications cannot be given.

"By contrast, heart attacks wake you up in the middle of the night," says Dr. Moser. "They also tend to occur in younger people. Strokes more commonly occur in the late 70s and 80s. The patient may just say, 'I haven't been able to move my arm all day. I figured the problem would go away.'"

Lee Williams was fortunate that his wife took his symptoms seriously and insisted he go to the hospital. Although his was a minor stroke and he was not a candidate for clot-busting drugs, doctors were able to monitor his condition, provide treatment to prevent further complications, and develop a rehabilitation program to help him regain the functions lost to the stroke.

When Lee arrived at the hospital, the left side of his body was weak; he could not grasp with his left hand. But other deficits were a more significant problem. Cynthia Mathis, M.D., a specialist in physical medicine and rehabilitation, and director of the medical center's Transitional Care Unit, says Lee's physical strength recovered fairly quickly but the stroke affected his speech and swallowing, and to some extent his problem-solving abilities, thinking, judgment, and insight.

"As a mortgage broker he is obviously in the business of having to speak articulately. Therefore, the impact was devastating. He had, appropriately so, a reactive depression associated with this loss," says Dr. Mathis. "We opted to bring him into the acute rehabilitation setting because we wanted his treatment to be comprehensive and multidisciplinary, providing the best chance of a good outcome."

Physical therapists worked with Lee on strength, coordination and reintegration into the community. Occupational therapists helped him improve the functional skills he would need when he went home and returned to work. A psychologist provided further insight as to the extent of his impairment and dealing with these and their impact on his life. Speech therapists developed an oral motor program and devised compensatory strategies to adapt his speaking and swallowing. Dr. Mathis coordinated his medical care, directed therapies, and provided encouragement and ongoing education.

"His prognosis was excellent for a full recovery," she says, "and patients need to hear that. It's devastating to feel normal one moment and then all of a sudden be unable to even communicate basic needs, as is often the case."

According to Dr. Mathis, whenever the Department of Physical Medicine and Rehabilitation receives a request for a consultation, a comprehensive patient history, review of medications, and physical exam are used to determine which services and facilities will best meet the needs of the patient. "Does this patient require an inpatient, interdisciplinary, concentrated approach to get the maximum recovery? Does he require a slower pace on our Transitional Care Unit so that he's allowed to regain the endurance he'll need in order to make significant gains in a more intensive program later? Does he need an outpatient program? Does he need a home health program? We make those determinations and are committed to making the best possible choice to ensure that the patient has an optimal chance of a full recovery," she says. In addition, the rehab program now offers services to patients who may need infusion therapy or hospice care.

As they progress and their needs change, patients typically transition from one program to another. Following his release from the hospital's acute rehab unit, for example, Lee was able to go home, but he returned to the medical center's outpatient rehab facility for follow-up therapy over the next three months. And although he still has to remember to slow down and speak clearly, his progress has been dramatic, in part because of his drive and determination. In fact, he was released from the hospital on Friday, April 17 -- just 10 days after his stroke -- and he want back to work at the family-owned business the following Monday, "at 9 o'clock sharp," he points out.

"One of the best things he had going for him was an excellent outlook and attitude," according to Dr. Mathis. "We've had other patients who have had similar deficits who did not do as well because of their outlook. He is not fully recovered himself but he said, 'I'm going to make a difference in other people's lives.' Even before he was discharged, he said, 'Dr. Mathis, I'm going to come back to this medical center and I'm going to work with patients and I'm going to share with them what I've been through.'"

Every Wednesday, for four hours, Lee now returns to the rehab unit as a volunteer. He renews relationships he developed with doctors, nurses and hospital employees. "Not only did they help me, they're now my friends," he says. "They're very sincere. They were my crutches and my security blanket." He says the personal attention his therapists provided in preparation for his return home -- walking with him, shopping with him, going out to eat -- helped him regain confidence and made a lasting impression.

Armed with his warm personality and sense of humor, he offers friendly advice to other patients recovering from strokes. In fact, acknowledging his own independent streak -- which he says comes from being the oldest of 13 children -- his first suggestion to patients is to learn to let go and follow directions.

"I would advise anyone else who has this experience to first of all stop thinking and let the doctors take charge," he says. "Do what they tell you. If they tell you to eat spinach or broccoli, just do what they ask because attitude has a lot to do with it. And don't feel sorry for yourself. Be thankful. I'm very thankful."

Although Lee's blood pressure had occasionally been high in the past, he says he had no other warning of his impending stroke. High blood pressure, however, is one of the important risk factors for stroke, according to his neurologist, Dr. Mody. While some risk factors cannot be controlled -- men are at slightly higher risk than women, for example, and African-Americans have a greater risk than other groups -- paying attention to those that are controllable can significantly reduce risk.

Typical candidates for a stroke, according to Dr. Mody, include people who have high blood pressure, diabetes, irregular heartbeats, older people who have atherosclerosis (the accumulation of cholesterol in the arteries), smokers, and people who abuse certain drugs, such as cocaine and amphetamines.

Still, even under the best circumstances, no one is immune. Symptoms of a stroke may include weakness or numbness in the face, arm or leg; blurry vision or loss of vision; sudden, intense headache; dizziness or loss of balance or coordination; or inability to speak or understand simple statements.

"If anyone even suspects that they are having a stroke or have had a stroke, they should call 911 and get to an emergency room right away," Dr. Mody advises.
-end-
AVAILABLE FOR INTERVIEWS:
Cyrus K. Mody, M.D., neurologist; Franklin Moser, M.D., director of the Division of Neuroradiology; Cameron Adams, M.D., neurologist; Cynthia Mathis, M.D., physical medicine and rehabilitation

For media information and to arrange an interview, please call 1-800-396-1002.



Cedars-Sinai Medical Center

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