Omaha World-Herald
OMAHA, Neb. — Researchers say too few stroke victims make it to the hospital in time to benefit from a medication that can minimize permanent brain damage.
And many of those who do arrive quickly receive sluggish diagnoses and treatment at the hospital, according to North Carolina researchers whose findings have been publicized by the American Heart Association.
“Patients don’t recognize that they are having a stroke,” said Dr. Pierre Fayad, director of the Nebraska Medical Center Stroke Center and chairman of the American Stroke Association’s advisory committee. “So they wait it out at home before they seek help.”
Improving the situation can be complicated. Some victims are simply unaware they are having a stroke, and others are rendered unable to communicate.
Some hospitals, typically smaller ones, are not well-equipped to get patients the key drug, called tPA, within three hours of the onset of symptoms, experts say. If it’s not delivered by then, the clot-busting medicine can do more harm than good.
An advisory committee appointed by the Nebraska Department of Health and Human Services hopes to put together a statewide system for stroke treatment.
Fayad, a member of the committee, said the panel wants to devise a system in which hospitals that can’t provide excellent stroke treatment would be bypassed by ambulances for hospitals that can. Treatment services that are considered essential include CT scans, a stroke team and medication.
A study of more than 80 Nebraska hospitals two years ago found that only 21 percent were ready with appropriate technology, medicine, staffing and planning to diagnose and treat stroke quickly. Fifty-four percent were almost ready. The study was conducted by the Nebraska Center for Rural Health Research at the University of Nebraska Medical Center.
Katherine Jones, one of the UNMC researchers who did the study, said a follow-up has not been conducted to determine whether there has been any improvement.
Jill Duis is among the lucky stroke victims, if such a thing can be said. Duis, a registered nurse who lives about 25 miles southwest of Beatrice, Neb., was in the process nine years ago of helping create a stroke treatment plan for the Beatrice Community Hospital. She also spoke to groups about the signs of stroke and about a new stroke-fighting drug called tissue plasminogen activator, commonly known as tPA.
During dinner with her family in October 1999, her speech began to slur. Her left hand dropped to her lap, the left side of her face drooped and she began to drool. The advocate for stroke treatment suffered a stroke herself.
Her husband knew the symptoms and rushed her to the Beatrice hospital. She underwent a CT scan of her brain and was diagnosed and given tPA within 2 1/2 hours.
She has undergone intensive rehabilitation and, although not entirely free of the stroke’s effects, is doing much better. “I never knew what work was until I tried to get the left side of my body to do what it could do all over again,” she said.
Stroke ranks third among all causes of death, behind heart disease and cancer, and is a leading cause of long-term disability.
It occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts. When either happens, part of the brain cannot get the blood and oxygen it needs and starts to die.
Clots that block an artery cause ischemic strokes, the most common kind of stroke.
Ruptured blood vessels cause hemorrhagic, or bleeding, strokes.
When part of the brain dies from lack of blood flow, the part of the body it controls is affected.
The North Carolina research was conducted from January 2005 to April 2008 and involved 15,117 patients at 46 hospitals in the state.
It found that only 23 percent of patients arrived at the hospital within two hours of initial symptoms. Two hours is the deadline for arrival, according to national stroke-treatment guidelines.
The guidelines say a patient should be assessed and given a CT scan of the brain within 25 minutes of arrival. Of those arriving within two hours, only 24 percent received a scan within 25 minutes.
One of the reasons speed is important: After three hours have passed since symptoms started, tPA can harm the patient.
The medication, approved by the federal government in the mid-1990s, dissolves the blood clot and restores blood flow to the damaged area. But if tPA is administered too late, the damage is too widespread and the drug can increase the harmful bleeding.
Further, the drug can be helpful when a blood clot is involved but has negative effects on a hemorrhagic stroke, in which a vessel bursts.
Dr. Mark Kestner, chief quality officer for Alegent Health, said there are many patients to whom tPA cannot be given. They include those who have multiple areas of the brain affected, evidence of bleeding on the CT scan, a history of previous brain bleeding, pregnant women and recent heart attack victims.
A study made public last month indicated that some stroke patients can benefit from the medicine even if they receive it 90 minutes beyond the current three-hour deadline. Fayad, the Nebraska Medical Center Stroke Center director, said the earlier the drug is given, the more it benefits the patient.
“Again, stroke is an emergency and should be treated as such,” he wrote in an e-mail. “Time lost is brain lost.”
Duis, now 54, said her effective treatment resulted from the stroke protocol on which she and others at Beatrice Community Hospital had been working. She still has trouble with depth perception and coordination. Her left hand is weaker than her right. But all in all, she said, she feels excellent.
Having a stroke causes a huge interruption in life, she said. “And then you deal with it. And that’s what we did,” she said.