Time is of the essence in treating stroke. Patients have a window of only about three hours from the time of the stroke in which tPA, the clot-buster medication that can reverse the effects of a blood clot-caused stroke, can be effectively administered. According to American Heart Association stroke statistics, 760,000 people have a first stroke each year. Of those, 87 percent are ischemic strokes from blood clots cutting off oxygen to part of the brain, and 13 percent are from cerebral hemorrhages. Clot busters should not be given for hemorrhagic stroke, so part of that three-hour window must be devoted to determining symptoms and diagnostic scans to tell the difference.
Dr. Peter Panagos, an emergency physician at Barnes-Jewish Hospital and co-director of the BJC Stroke Network, says there are many therapies for stroke, but people often present too late for reversal treatment because they don’t recognize the symptom or they delay going to the emergency room. “For the clot buster to be given, several things have to fall into place,” Panagos says. “The family member or caregiver must recognize the signs of a stroke; they must call 911 immediately; and they have to get the patient to a hospital with stroke expertise. It is not possible for the family or the EMT to make the distinction between ischemic or hemorrhagic stroke. They have to get to the ER quickly and have a CAT scan.”
He says that a patient could be paralyzed with an ischemic blockage and still have a normal CAT scan. However, a hemorrhagic stroke, or bleeding, would show up. Patients who are given tPA are monitored for 24 hours. Then they can be moved out of the ICU, and expect to be discharged soon.
“Time is brain,” says Panagos. “People have become much better at recognizing signs of a heart attack and calling 911 promptly, but stroke signs are more signs of exclusion. Without pain, patients may be unaware that parts of their bodies are not working correctly, that they have less feeling in one arm than the other. It can be very difficult for an older person who lives alone or with an aging spouse who doesn’t grasp the seriousness of the situation. Nine-one-one should be called, and the person should instruct the ambulance to take him to a stroke center.” Barnes-Jewish Hospital is a Joint Commission-certified stroke center, one of eight in Missouri.
Dr. Salvador Cruz-Flores is a SLUCare neurologist and director of Saint Louis University’s Souers Stroke Institute. He cautions that the symptoms of stroke in patients with Alzheimer’s disease or Parkinson’s may differ from traditional stroke symptoms. These patients may not develop noticeable weakness but may just fall over, or become confused or agitated. In an older healthy person, the symptoms are similar to those in a younger person: visual impairment, slurred speech, and weakness on one side.
Cruz says everyone with an older person in the home or for whom one is providing care should know the FAST assessment:
F: Facial asymmetry or droopiness (have the person smile)
A: Arm weakness on one side (have them raise both arms to the side)
S: Speech (have them repeat a sentence to see if it’s slurred)
T: Time (get to the hospital fast; tell EMS you need them immediately)
Age is one of the factors that affects recovery from stroke, says Cruz. Older people may recover slower and have more residual impairment. A larger stroke tends to have a worse prognosis; and hemorrhagic stroke patients, in general, have bleaker outcomes.
Risk factors for stroke in younger people, Cruz says, include atherosclerosis, smoking, high blood pressure and diabetes. “In people under 45 we also look for heart problems that may cause clots, like abnormal heart rhythms, aneurysms or heart anatomy that make stroke more likely. In seniors, the stroke may not be readily apparent, especially with dementia or Parkinson’s disease.”
Eugene Davis, owner of Webster Groves Senior Helpers, sees stroke from the perspective of a caretaker, usually after one has occured. “Most often, we get called in to do homecare after the stroke has already happened because the person lived alone and didn’t get the help he needed at the time,” he says. “It’s a challenging problem, determining the warning signs and not missing the window. When a person has a stroke, especially a severe stroke, he can’t be left alone. It changes everything. One-sided paralysis greatly increases the risk of falling, which can lead to fractures and larger problems.”
Davis cautions families to keep close tabs on their older loved ones, even keeping a journal with changes in behavior and symptoms, and getting the doctor involved. Sometimes a patient is being prescribed medications by more than one doctor, and interactions can mimic stroke. “It’s natural for family members to want to save money or be swayed too much by their older relative’s preference for independence and privacy,” says Davis. “But left on their own, the older adult may lose that window for treatment and end up needing equipment and skilled care. If we had had someone in the home trained to recognize these signs and symptoms, much could be prevented.”