By The Stroke Of God's Hand

I never gave much thought to the root of the term "stroke" but a recent lecture given by a neurologist enlightened me. It stems from the 1500's when "The stroke of God's hand" referred to what we now call just "stroke." I’ll also refer to it as a CVA, short for "CerebroVascular Accident,” in this article. With continued workup of a stroke, we will then diagnosis either a hemorrhage or infarction. Infarction refers to the process which begins when a blockage in blood flow occurs. The tissue that is fed by the blood will die, provided there are no other routes for the blood -- no other corollaries. Sometimes, like in the heart we can have new blood vessels grow over time in response to decreased rate of flow, due to the growing partial blockage. More specifics diagnosis are made based on the what the blockage is made of; we'll get into that, too. At most 18% of strokes are hemorrhagic. A blood vessel, often an artery in the Circle of Willis, a ring like structure deep in the forward part of the brain is often where we get the pop. Risk factors vary somewhat than those associated with ischemic strokes. Mortality is significantly higher with a burst cerebral artery than an infarction, but both can be fatal and is primarily dependent upon location, location, location. 

In this ongoing series Doctor, Doctor, Give Me The News I attempt to break down the complexities of modern healthcare and provide an insider's look as to why doctors do what they do. In this, the second installment, we'll discuss a disease process that is all to common, devastating and affects many of us or those we love, but also has so many incredible advancements in the acute treatment of the disease. Clot busting medicine and now interventional neurology and radiology and their ability to run a wire into the brain and grab the clots is nothing other than the best of technological advancements benefiting all of us. We'll go over what strokes are and the immediate evolution the brain tissue undergoes after a stroke. The common causes and the symptoms associated with a stroke and then the protocol associated with calling a "code stroke" in a stroke center will also be discussed

One is in danger of forming a blood clot in the atrium of the left side of the heart if it beats irregularly. Specifically, a condition we call "fibrillation" is known to cause the blood to form eddy's in the atrium, which are moving slow enough to allow clotting of that blood. You may already know that the left side of the heart receives the blood from the lungs -- first into the atrium (LA) which weakly pumps into the left ventricle (LV) which is, by far, the strongest of the four chambers of the heart, as it is responsible for systemic blood pressure (along with the contraction of the arteries, to a certain degree.) Of course the aorta comes off the LV and arches around, all the while shooting off arteries to the head and the arms, as it dives down behind the lungs and into the abdomen before splitting off into each leg.

A brief review of the above anatomy might beg the question of what happens when a clot goes somewhere besides the brain? Undoubtedly this does occur, I've seen it plenty, and it is referred to as a "acute infarction of X area" Interestingly, an infarction in the hands or belly is usually very painful; this is in contrast to the clot that goes to the brain, which is generally not painful and never acutely painful. There are no pain receptors in the brain tissue itself as it would be affected by a stroke, or an infarction specifically. There are times where a thunderous headache that comes on with a "thunderclap" can raise suspicion for a cerebrovascular hemorrhage. The patient who visits the ED with a complaint of "worst headache of life" is asking for a CT scan and a significant wait and won't get any opioids -- hopefully. This is not an indictment on those with legitimate headaches, but an ED is built and designed for heading off imminent death, loss of limb or deformity. That's why getting ibuprofen costs so much in an ED -- the same person complaining of that cost has no reservations or qualms of taking up that valuable bed and potentially causing someone else great harm, as they wait to be seen, or an ambulance has to drive longer distances because the ED is full and has to go on divert. I digress.

Let us follow a fictional patient who arrives at the emergency department in a hospital that functions as a "stroke center." Meaning that a CT scanner is available -- and if the case warrants it, a study that is already underway may be interrupted with the stroke patient shoved in emergently. It also means that an interventional radiologist/neurologist who is capable of sticking a wire into the brain and grabbing the clot are on call and available. The neurologist will also make a determination of whether clot busting medicine can or should be used. Let us call this patient Fibby.

I'm sure it isn't a surprise that time is of the essence in the acute evaluation and treatment of a suspected stroke. Fibby was in the ambulance on the way to the hospital when the code stroke was called. The paramedics identified a right sided facial weakness. Her grand daughter called 911 when she arrived in the morning to take her to her doctor's appointment and saw that Fibby was confused, slurring her speech but was insisting to go to the appointment. I arrive in the ED just in time to get report from EMS and while nursing gets the patient setup I take a moment to speak with the granddaughter lest I miss her. Getting a "last known normal" is very valuable and dictates certain treatments. She tells me that she was at her grandmother's house until 10pm the night prior, as she is painting the inside of the house in preparation to sell it. She arrived at 7am to take her to the appointment. It is now 7:30 in the morning and the last known normal was nine and a half hours ago. I ask if there are any other medical conditions -- she tells me high blood pressure for decades and diabetes, type II, for at least ten years. She has never had a heart attack, or stroke and she is not on dialysis. The granddaughter says she hates taking her pills and suspects she doesn't regularly take her medicine. I ask if she has every heard the term "atrial fibrillation" or "a-fib" thrown around. She said yes, she is supposed to take warfarin for it but she doesn't hardly ever take them. Her "number" is usually way too low, according to the doctor, per the granddaughter. I thank the daughter, ask if she has any questions. She doesn't -- I reassure that we'll answer them as they come up during her grandmother's stay.

The stroke coordinator has already assessed the patient using a standardized scale. At this hospital we use the NIHSS -- or, National Institutes of Health Stroke Scale and her score is high -- not good.

I spend a moment evaluating the patient myself as we prepare to take her to the CT scanner. This is important and while a CT scan is not the best at diagnosing exactly where a new infarction is in the beginning stages of forming, it can rule out hemorrhage, which is important; this serves as the first and arguably largest fork in the decision tree of treatment options for a stroke. Her vitals aren't great -- her blood pressure is nearly 185/110 and her heart rate is on the high end of normal at 91 but her she is in afib, as she is hooked up to the monitor now. She has a low grade fever, which is typical. Her oxygen saturation is okay at 91%, her blood glucose is high at 274. The phlebotomist zips away with the blood work just as she is whisked away to the CT scanner.

The scan is negative for acute hemorrhage. There is evidence of old, very small infarctions in the pons, a section of the brain stem. These are often asymptomatic at the time of occurrence, but this pattern is common and is often a prelude to the big embolic stroke on the horizon. Otherwise the scan is normal.

It is now nine hours and forty five minutes since the last known normal. We know it is not a hemorrhagic stroke. Risk factors for stroke have already begun to elucidate themselves -- long standing untreated high blood pressure causes atrial fibrillation (one of the reasons) which she has right at this moment, which has also been untreated, and of course, diabetes, untreated, and diabetes has a high correlation with vascular diseases of all kinds; most definitely strokes. Fibby is 59 years old.

I stop to discuss the case with the neurologist on call. He thought that he should take the patient into the radiology suite for a mechanical thrombectomy. He wanted to stick a wire into Fibby's wrist -- into the radial artery, to be specific, and with imaging feed it all the way up into Fibby's brain. On the end of the wire is a grasper thingy and he wanted to pull that clot right out of her brain. The patient had already agreed to this, had signed consent and was being prepped for the surgery.

The doctor operating the wire during the procedure must have a command of anatomy second to none. In this case, the neurologist has some clues as to where the clot has set up shop. Right sided facial weakness with left sided upper extremity weakness points to the right middle cerebral artery as the culprit. The brain is divided into right and left hemispheres, and the nerves that go from either hemisphere to the rest of the body cross over; however the cranial nerves, which include the nerves that serve the face do not.

X-rays are shot through the body. The metal wire shows up a a dark red line. Through the wire a dye can be released which is then wooshed away with the blood stream. This shows us where the blood vessels are so the wire can be advanced. It also shows us where the blood isn't going. And that is how one finds the clot.

Fibby did indeed have a clot removed from her brain.

And really, my work, as a primary care physician comes into play after the exciting, sexy action goes down. We had a really compelling reason for Fibby to form clots. Her INR (International Normalized Ratio) which is a measure of warfarin effectiveness in the blood (essentially) was 0.8, meaning she was way below where she should be. She remained in atrial fibrillation throughout her stay and easily another clot would be forming in the LA if not for anticoagulant medicines. Her diabetes was way out of control; her HgbA1c was 14.9, which means that her average daily blood sugar for the previous three months was over 400! Hyperglycemia is directly related to thromboembolic type strokes. When it comes to prevention of having a stroke in the first place, the issues above are the main things to focus on. Exercise of course, if nothing else for cardiovascular health goes a long way. 

The range of symptoms and sequelae related to having a stroke is as varied as the functions of the central nervous system. Often a person will recognize it themselves -- but this means that the parts of the brain that work to self-analyze and make problem solving decisions is intact. If one stands in front of the mirror and notices that half of their face is not working and then thinks to themselves that they should call 911 because they are having a stroke, they are among the fortunate. Sometimes a person thinks what they want to say, but they end up forming gibberish with their voice. These patients are often very frustrated -- and understandably so. Other patients may be saying recognizable words, but they will have no rhyme or reason -- random words. Perhaps the worst situation, in my opinion, is a condition referred to as "Locked In Syndrome." Essentially you are paralyzed except for your eyes and your brain works fine otherwise. Imagine your inner world -- where your inner voice lives and your thoughts trapped in a body where the only thing you could control was your eyeball movement. Hard to imagine. 

The take home is this -- precious time is the one variable that can make all the difference when a stroke occurs. The threshold for calling for help or going to the ED should be low. I say this despite being overwhelmingly aware of the inappropriate reasons people use to seek emergency medical care. 

The immediate care for a patient who has a stroke which cannot be addressed with mechanical thrombectomy or tPA (clot buster) is interesting. For those who (God forbid) are reading this who will go who through this in the future or who will have loved ones who suffer from this there are a few elements that should be explained. I've have had many discussions with family members about these very things. 

So first we tell the patient and their family that the long standing high blood pressure may have played a role in having the stroke in the first place. This is easy to understand. Damage to blood vessels secondary to higher than normal pressures over time is understandable. Then for the next twenty four hours we only treat high blood pressure at the extreme end of high -- if systolic pressure (the top number) is above 220 then an antihypertensive medication will be used. 220 is high. In most other situations, medications are used way before a patient gets that high. However, permissive hypertension is something that has been shown to have better outcomes in thromboembolic cerebrovascular infarctions not treated with a clot buster. Circling back around to the anatomy -- imagine a blood vessel, as it courses through the brain, feeding the brain tissue; now imagine a blockage and all the tissue after that point is now deprived of blood. Some of the brain cells get their blood from the blocked artery and that artery alone. Other cells further away get blood from that same blocked artery, but also from another artery. The cells that have a singular blood supply will die. The cells that have two, are just injured and have a chance of survival. As you can see from the image below; the penumbra is why permissive hypertension is an important factor. It didn't take me long to counsel families and patients about this when admitting them to the hospital. 

Another aspect worth discussing is swallow evaluations. Out of concern that there may be a motor derangement in the symphony of actions it takes to properly swallow food or drink instead of sending it all to the lungs, an evaluation must be done. Protocol dictates that all patients admitted for CVA get a swallow eval. Sometimes it is obvious that a patient has no impairment. In this case a bedside eval by the RN will suffice. If, however, a bedside eval by the RN shows a deficiency in being able to swallow, an official evaluation needs to be done by the speech therapist. We cannot let a patient eat before this eval. Now, a patient who is comes to the ED late morning, spends hours in there before a bed is available upstairs. I see the patient at seven in the evening -- speech has gone home. No eval until the morning. Patients can be very upset. However, especially in the elderly, aspiration pneumonia is a deadly killer. First a stroke followed by a terrible bout of pneumonia? Not a recipe conducive to leaving the hospital in anything other than a box. For those of you unfortunate enough to deal with this first hand, just know we feel bad not feeding you but would feel worse if we killed you by feeding you. 

There are many scenarios where a person can demonstrate symptoms easily mistaken for having a stroke. Diabetic patients with hypoglycemia will be confused and sometimes lose muscle strength and coordination. A good rule to use is unilateral vs bilateral symptoms. A person with weakness on the left or right only, in other words. Also Bell's Palsy is a dramatic paralysis of the face which is not a stroke, but the acute nature of the malady will have people worried -- and rightly so. Bell's Palsy is a disorder of one cranial nerve in particular -- the Facial Nerve, (CN VII) controls facial muscles and is divided on the midline of the face into the right and left nerve distribution. It is easy to see how the unilateral nature by itself can mimic a stroke to the non-discerning eye. As you can see in the image below, we rely on the fact that the brain cells that send signals down the tracts actually split in a way that some fibers cross midline, and some do not. As we have been discussing, an infarction that affects the cells of either the ride or right hemisphere of the brain that control CN VII, the Facial Nerve, we will have sparing of the forehead on the side opposite of the infarction. And while it is possible that an infarction could happen on both sides of the brain at the same time, affecting the right and left cells that have the same function but it is overwhelmingly unlikely and on the verge of impossible. Bell's Palsy is a compromise of the Facial Nerve after the nerves have left the warm squishy confines of the brain. There is a good chance that the palsy arises from a usually latent virus flare in the nerve -- HSV most likely. It should go without saying that if you or a loved one has symptoms of either a stroke or Bell's Palsy, seeking emergency medical care is indicated. 

There are many exciting advancements in this field and there are more to come. In the face of the many elements of greed and injustice that surrounds the medical-industrial complex, there are some things that are getting better. And herein lies the double edged sword that comes with any experience associated with having a glimpse of the machinations behind the curtain, and the mysterious lever pullers. I come to a better understanding of the evils and the positive aspects of our healthcare system on a daily basis. Even a natural pessimist and person who keeps expectations low like myself has to admit that not everything is bad, or worsening in our world.