Saving the Brain After a Stroke

When Joe woke up that chilly night, he knew something was terribly wrong. He tried to stand up, but instead he suddenly slid to the floor as if his body pulled him down. That’s when he realized the right side of his body had gone “dead” on him. He tried to verbalize and orient himself to his surroundings. He concluded his mind was still working. He tried “shaking off” the problem on his right side but it would not go away. “Maybe”, he sighed, “I’ll sleep it off. It should be okay by tomorrow.”

Joe just had a stroke, which solely affected the motor pathway in his left brain. He got lucky that the speech center, which is also on the left side (on right-handed individuals) was spared, thus his ability to talk and comprehend remained intact. 'Stroke' is a too-familiar word for everyone. It is unfortunate, however, that the majority of Americans do not know the symptoms of stroke, or those who know do not know the significance of early medical evaluation and intervention.

Stroke affects 750,000 Americans each year. It is the fourth leading cause of death and the leading cause of serious long-term disability. The cost of care for stroke victims approximates $43 billion a year and a significant proportion of this is spent on long-term rehabilitation and nursing home care.

A stroke occurs when the blood flow to a part of the brain is impeded due to sudden blockage of an artery supplying that area of the brain. The needed glucose and oxygen will not reach that particular brain tissue, which eventually will suffer and die if the blood flow is not immediately restored. The result will be loss of function of the part of the body which that part of the brain controls. This is known as ischemic stroke.

Another cause of stroke is sudden bleeding into the brain substance when a weakened wall of an artery ruptures. This is known as hemorrhagic stroke. Stroke is also called “brain attack” to connote the necessity of seeking immediate medical attention, that is as soon as the symptoms occur. However, compared to a heart attack, in which the symptom seems universal (chest pain), a stroke can have different manifestations, depending on what part of the brain is ailing or dying. For example, if the verbal speech area on the dominant side of the brain (which is left on right-handed individuals) loses blood supply causing death to the brain cells, the patient will suddenly lose the ability to talk.

Some of the more common warning signs of stroke are:

• Sudden weakness or numbness of the face, arm and leg on one side of the body
• Sudden blurring of vision or blindness in one or both eyes
• Sudden incoordination
• Trouble walking
• Dizziness
• Sudden confusion
• Trouble speaking or understanding
• Sudden severe headache with no known cause

Of course, there are other less obvious signs of stroke, like sudden-onset double vision, difficulty with swallowing, nausea, and vomiting. These latter signs are more commonly seen in brainstem strokes.

There is a nationwide campaign to improve stroke awareness. Every stroke must be treated as a life-threatening emergency. The available stroke treatment modalities can only be administered if the patient is brought for evaluation and treatment within four and a half hours of stroke onset for the intravenous clot-buster (tissue plasminogen activator, tPA) and within six hours of stroke onset for the intra-arterial clot-buster. At comprehensive stroke centers, a procedure called thrombectomy/clot retrieval can be done, or the stenosed artery can be stented to restore blood flow. Recent data, however, have to be taken into account that these invasive procedure may not have statistically significant benefits compared to intravenous (IV) clot buster alone, during acute management, and aggressive medical management later, towards stroke prevention.

Not all stroke patients are candidates for these treatments. It is very important that the emergency room (ER) physician and the neurologist adhere to the protocol and weigh the risk versus benefit. If given appropriately to eligible patients, the treatment can decrease or even reverse the neurologic deficits that the patient had at the onset.

Better understanding of the causes of stroke and the changes that happen in the brain before, during, and after stroke has led to better overall patient management. Even if the patient is not a candidate for the clot-buster therapy, emergent medical intervention can easily be started that may protect or save the ailing brain. It may be as simple as maintaining good diastolic blood pressure, controlling fever, treating concomitant infections as soon as recognized (the latter is considered a risk factor for stroke), normalizing the blood sugar, and improving oxygenation, especially on those with pre-existing lung conditions. These measures may help “protect the ailing brain cells”. If these cells are not rescued, they will eventually die, resulting in increased-neurologic deficits, thereby increasing disability.

Control of other risk factors should also be started acutely, such as treatment for high cholesterol, diabetes, and homocysteinemia. Cessation of smoking, controlling other risk factors, and compliance with stroke prevention treatment (taking the appropriate antiplatelet medications and blood thinners) can not be overemphasized. Healthy lifestyle and consumption of foods rich in antioxidants have a role in stroke prevention.

Young people who have suffered from a stroke should be worked up for clotting disorders (hypercoagulable state), congenital or acquired heart problems, or connective tissue disorders as well as blood vessel inflammation (vasculitis). Drug abuse, especially methamphetamine and cocaine, and especially in the alkaloidal form (crack), can cause strokes. Another important cause of stroke for young people is dissection of the arteries supplying the brain either from trauma or from an inborn defect of the wall of the arteries. Each stroke patient is different.

Joe, the patient I mentioned earlier, is my father. He improved dramatically. It could be that the ailing part of the brain was rescued by blood supply from other territories.

Our brain, although gifted with the power to autoregulate its own blood flow, can be chronically challenged by several medical insults like hypertension, diabetes, heart disease, and cigarette smoking. This power of the brain can get exhausted. We still have time to correct such things before our brain gives up on us.

Take care of your brain. Control the risk factors and help in disseminating information to improve awareness. At the first sign of stroke, seek immediate medical attention (call 911). The faster we act, the better chance we have of saving or protecting the brain from the effects of stroke.

Update: My father passed away. He initially survived a massive cerebral hemorrhage, then after recovering some functions, succumbed to rupture of aortic aneurysm.

Arlyn M. Valencia, M.D. is Neurologist, Stroke Subspecialist. She is a Fellowship-trained Stroke Neurologist.