Probably the saddest part of my job is witnessing the slow progressive decline of one of my patients. The joy of Family Medicine comes from years of intimate conversations regarding not only various health conditions but also the ups and downs of life in general. My patients and I share more than just their systolic and diastolic blood pressures. We engage in meaningful, thought-provoking discussions within our 15-20 minute time allotments.
Therefore when I hear that one of my patients has recently had a stroke and is now in a long term care facility and is no longer able to communicate, it simply devastates me. I wrestle with that information for hours at a time wondering what else could have been done to prevent such a situation. What additional measures could have been in place to avoid destruction to their brain?
Cerebral vascular accidents or strokes as they are commonly known are basically blood flow interruptions in the brain. These brain attacks can either be ischemic (not enough blood transfusion due to a clot) or hemorrhagic (bleeding in the brain from a leaky blood vessel or a ruptured aneurysm).The sequelae from these vascular events depend upon the location of the affected vessels and how extensive of an area has been involved.
87% of the strokes that occur are ischemic in nature. Hypertension is the number one risk factor for these types of strokes. When a blood clot or plaque forms somewhere in the body such as the heart, it can travel to the brain and cause blockages in the vessels there. This is known as an embolic stroke. Roughly 15% of people with irregular heart rhythms known as atrial fibrillation, have embolic strokes. Basically the left atrium of the heart does not have normal contractility and that causes blood to pool, eventually forming clots which then travel to the brain.
Clots can also originate in the vessels supplying blood to the brain. These are known as thrombotic strokes and are a result of atherosclerosis-plaque build-up. People with high cholesterol experience these types of strokes.
In contrast, the hemorrhagic strokes result from conditions such as high blood pressure, over treatment with blood thinners like Coumadin, and aneurysms. Another less common cause of bleeding in the brain is the rupture of an arteriovenous malformation, an abnormal tangle of vessels that were present at birth.
The brain makes up only about 2 percent of human body weight but requires about 15-20 percent of the body’s blood supply. Red blood cells are important for carrying not only oxygen to the brain but carbohydrates, amino acids, fats, hormones, and vitamins. If a disruption occurs in that supply, brain cells will immediately start to die resulting in permanent brain damage.
Occasionally, mini-strokes (transient ischemic attack – TIA) occur in which brief episodes of decreased blood flow causes symptoms similar to those in strokes. TIAs do not leave permanent damage like those seen in cerebral vascular accidents since the vessel blockages are temporary. However, TIAs are warning signs that more ominous problems are looming and full blown strokes are likely in the future.
There are numerous risk factors for strokes, many of whom are modifiable. For example, heavy drinking, being overweight or obese, the use of illicit drugs such as cocaine, methamphetamines or physical inactivity are all risk factors that are mostly self-induced but possess potential for change. On the other hand, family history also contributes to future stroke risk. Controlling blood pressure, managing high cholesterol appropriately, and maintaining regular check-ups with your primary care provider are all recommendations for reducing stroke risks.
Chest pressure with radiation to the left arm is synonymous with a heart attack and public campaigns have done an excellent job of educating people to seek help immediately when symptoms occur. Brain attacks deserve the same level of urgency as well. The quicker your symptoms can be assessed and your brain is imaged, the greater likelihood of slowing the progression of your stroke. Although heart attacks cause a certain degree of morbidity, brain attacks affect your ability to perform everyday tasks such as putting on your clothes or feeding yourself. I have seen too often how patients lose their independence from a single stroke.
Arm or leg weakness, facial drooping, and speech problems are a few of the more common symptoms exhibited by stroke victims. I have had family members of my patients report how their loved ones were engaging in normal conversation when all of a sudden their speech became incoherent. Unfortunately, patients make the sometimes fatal error of deciding to just wait and see if the symptoms resolve spontaneously instead of proceeding directly to the emergency room. The window of opportunity to improve stroke outcomes is within three hours. Therefore, there is little time to waste during a brain attack.
Yours in Service,
Denise Hooks-Anderson, M.D.
Assistant Professor
SLUCare Family Medicine
yourhealthmatters@stlamerican.com
