What to Do during The First 24 Hours
after A Stroke
Stroke: The First 24 Hours after a Brain Attack
by Gary Cordingley
Although stroke is the third-leading cause of death in the U.S.
and the number one cause of disability, this condition doesn't
get the respect and attention it deserves. When people have
sudden chest pain, they know they might have a heart attack.
They call 9-1-1 and seek help immediately. But people who
suddenly become weak or numb on one side of their body, or
experience sudden problems with speech or vision, often act
unhurried in seeking help.
Why is this? One possibility is that heart attacks are
usually painful. Strokes are not necessarily painful, and even
when pain is present, it can be mild. Pain is a powerful
motivator, and some people have the mistaken belief that all
serious medical conditions hurt, and the seriousness of the
problem is proportionate to the intensity of pain. Also,
because the brain is a more complicated organ than the heart,
symptoms of strokes can also be more complex, making them
harder to identify.
In both strokes and heart attacks a portion of a body-organ has
experienced a sudden disruption of its circulation.
Increasingly, strokes are called "brain attacks" to emphasize
the parallel with heart attacks. As a neurologist, I sometimes
describe a stroke as "a heart attack of the brain." Reflecting
my bias as a brain specialist, I also describe a heart attack
as "a stroke of the heart," but--what can I say?--this
terminology hasn't caught on.
If you suspect stroke in another person, the American Stroke
Association recommends a quick, 3-step, screening test to
identify cases:
Ask the person to raise their arms and keep them up. In many
stroke victims one arm doesn't go up or, once up, sags.
Ask the person to smile. A lopsided or one-sided smile can
indicate trouble.
Ask the person to repeat a simple sentence. If it comes out
garbled or unclear--or not at all--a stroke is likely.
While it's better to have some system of detection than no
system, this screen misses strokes affecting the parts of the
brain involved in sensation or vision which are just as serious
as strokes causing paralysis or loss of speech.
So now that emergency help has been summoned, what happens
next?
The emergency squad, upon arrival, sizes up the situation and
measures vital signs, including rate and adequacy of breathing,
pulse rate and blood pressure. They insert an IV line, check
the blood-sugar level via a finger-stick method, apply pads to
the chest to monitor heartbeats, and often administer oxygen as
well. Then they transport the patient to the nearest emergency
department.
Upon the patient's arrival, the medical team obtains more
history and examines the patient more thoroughly. They draw
blood to measure blood-sugar, blood-counts and blood-clotting
function, as well as other blood-chemicals, including those
showing the presence or absence of a concurrent heart attack.
They perform an electrocardiogram (EKG) and continue the
process of monitoring vital signs and heart-rhythms initiated
by the squad.
A computed tomographic (CT) scan of the head is usually done
soon after the patient's arrival. CT scans can detect the
1-in-6 kind of stroke involving bleeding within the brain, but
often fail to detect the more usual kind of stroke, called an
infarction, caused by a blocked blood-vessel. This is because,
in the first 24 hours, damaged brain-tissue can look just like
healthy tissue to the scanner's x-ray beam. The CT scan also
screens for other brain diseases, like brain tumors or
infections, that might mimic a stroke, but call for completely
different treatments.
So far, the discussion has been all about testing. What about
treatment? What can be done to improve outcome, reduce the
severity of the impairment and prevent death?
A useful way to think of a brain infarction is as a central
core of forever-lost brain cells that no treatment can revive,
surrounded by a larger zone of sick brain-tissue that may or
may not recover. Early treatments focus on this surrounding
tissue that is "on the bubble," trying to influence it to
survive rather than die.
One dramatic but controversial treatment is to use an
intravenous clot-busting drug called t-PA (tissue plasminogen
activator). The potential benefit of using this drug is to
reduce the eventual impairment of the patient caused by the
stroke. However, the drug also increases the likelihood of
brain-hemorrhage, and physicians are not unanimous in believing
that the benefits of this treatment outweigh its risks.
However, one point of agreement is that if t-PA is going to be
used, it has to be administered within 3 hours of the stroke's
onset. Arriving at the emergency room after 2 hours and 59
minutes isn't good enough because a clinical evaluation, CT
scan and blood tests all need to be completed before the drug
is infused.
Less dramatic treatments are every bit as important--and quite
possibly more important--than use of a clot-busting drug. It's
the simple things that often matter most, but because they're
so simple, sometimes they are unappreciated or even
forgotten.
One such treatment is to manage the body-temperature. Fever
increases the size of the stroke, so when an elevated
temperature is present, it needs to be decreased right away.
Another little detail is to manage the blood-sugar. Oddly, an
elevated blood-sugar is toxic to the oxygen-deprived but
still-surviving brain cells. So the emergency team should
aggressively treat elevated blood-sugars by administering
insulin.
Yet another issue of crucial importance is to urgently treat
severe anemia (decreased red blood cells) by transfusing blood.
Oxygen molecules are transported to the brain attached to
molecules of hemoglobin within red blood cells. So if there are
fewer red blood-cells, less oxygen is delivered to the sick
brain-tissue. Providing more red blood-cells increases
oxygen-delivery.
Of course, if the patient's blood-pressure is severely
elevated, it needs to be decreased, but mildly-to-moderately
elevated blood-pressures might actually improve blood-flow to
the damaged tissue. If the patient's blood-pressure is
excessively low, this is bad, too, and is treated by infusing
salt-water or administering medication. Dangerous heart-rhythms
also need to be treated, as does a concurrent heart attack,
when present.
The principal value of being in a hospital with a fresh stroke
is to achieve clinical stability in a monitored environment
where rapid interventions can be made when called for. The
hospital also provides a setting in which more extensive tests
can also be performed, though not necessarily in the first 24
hours, that seek to understand why the stroke occurred and what
can be done to prevent another brain attack.
(C) 2005 by Gary Cordingley
About the Author
Gary Cordingley, MD, PhD, is a clinical neurologist, teacher
and researcher who works in Athens, Ohio. For more
health-related articles see his website at: http://www.cordingleyneurology.com
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