One-Fifth of Hospitals Give Bad Emergency Advice on Stroke

By Ed Edelson

Americans who think they're having a stroke face better than a one-in-five chance of getting the wrong -- and potentially fatal -- advice when they call local hospital personnel, a new study shows.

Although experts say the best thing to do when suspected stroke symptoms appear is to immediately call emergency 911, in 22 percent of cases, hospital personnel who answered the phone advised that patients call their family doctor.

"That might seem reasonable, but it often delays proper care," said lead researcher Dr. Brett Jarrell, an emergency department staff physician at the Cabell Huntington Hospital in Huntington, W.Va. "Sometimes they can't get through to the doctor, or there can be other delays," he noted.

An interlocking set of problems delay that emergency treatment too often, he said. Not only do many hospital workers not know what to do when a stroke might be occurring, but many Americans still don't recognize key symptoms that signal a stroke, Jarrell said.

The American Heart Association and other medical organizations have been successful in educating the public about the heart attack symptoms -- and what should be done about them -- Jarrell said. However, "That hasn't been attained yet with stroke," he said. "In fact, if you ask people about the symptoms of a stroke, they often give the symptoms of a heart attack -- pain in the chest and so on."

The symptoms of a stroke can include: sudden weakness of the face, arm or leg, especially on one side of the body; sudden confusion or trouble speaking or understanding; sudden trouble seeing; dizziness or loss of balance; or a sudden severe headache with no known cause.

Jarrell said he set up his study because "I work in a tertiary care center, and we inevitably get stroke patients transferred to us 12 to 15 hours after the initial emergency-room admission. I tried to find out why."

To do so, his team phoned 46 hospitals that offer neurology training to physicians, placing calls to either the hospital's main numbers or their help lines. They didn't pretend to be patients but instead outlined a scenario in which a 65-year-old man was experiencing weakness in the left arm and leg and having trouble speaking -- classic symptoms of stroke.

The hospital personnel who answered the phones were ask to choose one of four responses: wait for the symptoms to resolve, call a primary care doctor, drive to a local urgent care center, or call 911.

Reporting in the August issue of Stroke, Jarrell's team found that 78 percent of personnel picked the correct answer: Call 911. But that still left 22 percent of callers with the wrong advice -- namely, to call their primary care physician.

Nearly one in four operators also failed to correctly name one symptom of stroke, the researchers found.

There was a time when immediate response to stroke symptoms was not as urgent, because there was little that could be done, Jarrell said, but recent advances have changed all that. "Now, we have some possibilities with acute therapy, such as mechanical techniques, to remove blood clots," he said.

What the study shows is "a lack of understanding in the community about stroke and the treatment of stroke," Jarrell said. "The answer is much better community education."

Another expert agreed that better awareness of stroke symptoms, and the need for speedy care, is essential.

People need to be more aware of the early symptoms of stroke, because medical advances have made it possible to limit brain damage if quick action is taken, said Dr. Lee Schwamm, director of the acute stroke service at Massachusetts General Hospital, in Boston, and a spokesman for the American Heart Association.

"Until recently, we didn't really have hospitals ready to receive stroke patients," Schwamm said. "Now we have the 'stroke center' designation, which means we are really in the position to create the kind of targeted campaign that was done for heart attacks."

There are two messages in the new study, Schwamm said.

"The first is that if you or someone you see is having a stroke, call 911, and say, 'I think I'm having a stroke,' " he said. "The second is to find out [beforehand], by calling hospitals in your area, if a hospital has an acute stroke team, if it is equipped to care for a stroke. The education message needs to go to everyone involved."

Folic Acid Supplements Cut Stroke Risk

FRIDAY, June 1 (HealthDay News) -- Folic acid supplementation may reduce the risk of stroke by 18 percent or more, but it's not clear whether it boosts outcomes for other cardiovascular conditions, researchers say.

A study published last year in the journal Circulation found that there was a significant drop in stroke death rates in Canada and the United States after both countries mandated folic acid fortification of cereals and breads in 1998.

For the new research, a U.S. team reviewed eight studies of folic acid supplementation, which lowers concentrations of homocysteine in the blood. High homocysteine levels are believed to increase the risk of stroke, cardiovascular disease, and deep vein thrombosis.

Professor Xiaobin Wang, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues found that folic acid supplementation reduced the risk of stroke by an average of 18 percent.

Even greater risk reduction were noted when treatment lasted more than 36 months (29 percent lower risk); when homocysteine levels were reduced by more than 20 percent (23 percent lower risk); or if a patient had no previous history of stroke (25 percent lower risk).

In regions that did not already have supplementation via fortified foods, the introduction of folic acid supplementation reduced stroke risk by 25 percent.

"Our meta-analysis provides coherent evidence that folic acid supplementation can reduce the risk of stroke in primary prevention," the study authors wrote.

The review appears in the June 2 issue of The Lancet medical journal.

"Although this meta-analysis helps clarify answers to some questions about the role of homocysteine lowering in CVD (cardiovascular disease) prevention, ongoing randomized trials are needed before we can conclude that the benefit of continued use of previously deemed 'safe' vitamin supplements outweighs the risk of other adverse CVD outcomes," Dr. Cynthia Carlsson, of the University of Wisconsin School of Medicine and Public Health, wrote in an accompanying comment article.

Women Have Double the Risk of Mid-Life Stroke

By Steven Reinberg

Twice as many American women than men are suffering strokes in middle age, a new study shows.

The trend may be largely due to increases in heart disease and weight gain among women, according to the report in the June 20 online edition of Neurology.

"In the age range of 45 to 54, women were more than twice as likely to report having had a stroke," said lead author Dr. Amytis Towfighi, of the Stroke Center and department of neurology at the University of California, Los Angeles.

The study also looked at what factors could be contributing to this increase in women having strokes. "We found that the independent predictors of stroke in women of that age group were coronary artery disease and waist circumference," Towfighi said.

The researchers also found that women have a steeper rise than men in several factors for heart disease and stroke, such as high blood pressure and high cholesterol.

"For example, while men's blood pressure raises four to five points each year in the mid-life years, women's blood pressure increases by eight to 10 points," Towfighi said.

In its study, the UCLA team collected data on 17,000 American women and men involved in the National Health and Nutrition Examination Survey. Among these adults, 606 reported having had a stroke.

The researchers found that women 45 to 54 years old were more than twice as likely as men in the same age group to have had a stroke. There were no differences in stroke rates found in the 35-to-44 and the 55-to-64 age groups, they noted.

Towfighi's group also found a greater than expected stroke rate among older middle-aged men. Men 55 to 64 were three times more likely than men 45 to 54 to have had a stroke. The reasons for this finding aren't yet clear, Towfighi said.

Medical care discrepancies may be driving much of the stroke "gender gap," Towfighi said. "Risk factors for women are not being as adequately controlled in middle-aged women," she said. "This might be because these women were not perceived to be at high risk for stroke, and also, a lack of awareness of controlling risk factors by women and primary-care physicians."

One expert was intrigued by the findings.

"These data certainly question what we previously thought of as fact -- that middle-aged men, simply by being men, are at greater risk of stroke," said Dr. Emil Matarese, spokesman for the American Heart Association/American Stroke Association and director of the Stroke Center at Saint Mary Medical Center in Langhorne, Penn. "But there is not enough data here to explain that disparity," he added.

However, stroke among middle-aged women is becoming a bigger problem as the society ages, Matarese said. "This is going to become a greater health-care crisis in our country with more women suffering strokes as they age than in the past," he said.

Matarese noted that other factors may boost the risk of stroke among middle-aged women, including reduced estrogen production, use of hormone replacement therapy and oral contraceptives, and an increase in migraines.

"This is a wake-up call for the health care community, regardless of whether the statistics here are adequate to make long term conclusions," Matarese said. "This is a wakeup call to start looking at women in a more aggressive manner and to start reducing their risk of heart attack and stroke."

Assessing Your Heart Attack and Stroke Risk

by Simeon Margolis, M.D., Ph.D.

The search for new ways to predict the likelihood that a person will have or die from a heart attack or stroke in the near future has become something of a cottage industry in biomedical research.

These efforts seem to have escalated into a wild scramble in the last decade, ever since the blood test for C-reactive protein (CRP) has been promoted as an almost magical "marker" or predictor of these dire events.

The barrage of scientific papers produced from this search for new markers has advanced many an academic career. Less desirable for consumers has been the need to pay for tests they may not really need.

A recent report from the Framingham Heart Study examined 10 such biomarker tests - 9 blood tests and one urine test - in more than 3,000 participants. Among the blood tests included were CRP, homocysteine, B-type natriuretic peptide, fibrinogen, and plasminogen-activator inhibitor. The urine test measured the ratio of albumin to creatinine. The participants were then followed for about seven years.

As you might expect, the presence of multiple markers was associated with a significant increase in a participant's risk of heart attack and stroke, and especially a greater risk of death during the follow-up period. B-type natriuretic peptide and the urinary albumin-to-creatinine ratio were the most effective individual markers to predict both the risk of cardiovascular events and death. Surprisingly, CRP predicted the risk of death, but not of cardiovascular events.

The most important finding from this study was that testing for these markers added "only moderately" to the information provided by the standard risk-factor tests - high LDL cholesterol, high blood pressure, cigarette smoking, low HDL cholesterol, diabetes, family history, and age - used to assess a person's risk of cardiovascular events.

These findings support the recommendation by most doctors that these markers be measured, if at all, only in those people who, after undergoing the standard risk-factor tests, are at intermediate risk for a heart attack or stroke. Some of the biomarker tests will continue to be widely used because most Americans fall into the intermediate-risk category.

Nonetheless, I think it is a good idea to ask your doctor why you have been told to obtain one or more of these tests, or to refrain from asking for these tests yourself unless your doctor believes your level of risk warrants them.

What Can Happen To A Person After A Stroke?

From : ehealthMD.com
A stroke affects different people in different ways. While some people make a full recovery, others may find that some problems do persist. These may include:

• Speech changes
• Vision changes
• Memory and concentration difficulties
• Paralysis
• Weakness and stiffness
• Difficulty eating and swallowing
• Mood changes
• Difficulties with personal relationships
• Other challenges
• Speech Changes

Some people have difficulty with speech. When stroke has damaged the part of the brain that controls the muscles used to produce speech, speech may become slurred. The survivor understands words and conversation but cannot speak distinctly. This condition is called dysarthria.

When stroke has damaged the part of the brain that controls language, the survivor may lose the ability to speak and understand speech. The ability to read and write can be affected. The person may have difficulty finding the right word or may use an incorrect word. He or she may find, when reading, that some words make no sense. This condition is called aphasia.

Nice To Know:

Some tips for caregivers of people with speech or language difficulties:

• Avoid distractions (do not have many other people in the room, turn off the television or radio when someone is speaking).
• Have a one-on-one conversation (do not allow more than one person to speak at one time).
• Give the person a lot of time to speak.
• Allow the person to speak for himself or herself if someone else asks a question; don't try to answer it yourself.

Vision Changes
Stroke may affect vision on one side (usually the same side that has been weakened by the stroke). When talking to someone with impaired vision, always stand or sit on the "good" side. Consider that the person may ignore people or objects on the other side and may bump into them.

Memory And Concentration Difficulties
Memory and concentration may be affected after a stroke. In the early stages, individuals may not be able to concentrate for very long and may become easily distracted. They may have problems with particular tasks, such as finding the way about the house or getting dressed, yet have no other major difficulties.

Paralysis
Stroke frequently causes paralysis on one side of the body. This condition is called hemiplegia. The paralysis may affect only the face, an arm, or a leg; or it may affect one entire side of the body and face.

A person who suffers a stroke in the left side of the brain may show right-sided paralysis.

A person who suffers a stroke in the right side of the brain may show paralysis on the left side of the body.

Weakness And Stiffness
Paralyzed limbs may recover their strength but may remain clumsy or stiff. Some types of muscular stiffness (a condition called spasticity) can be helped with medication. People with weak hands often are given a soft ball to squeeze to help improve their grip.

Difficulty Eating And Swallowing
Damage to certain areas of the brain can cause difficulty eating and swallowing. This condition is called dysphagia . Therapy to help the brain relearn these skills has shown great success. Until a person is able to eat again, he or she can receive sustenance intravenously (with an IV that delivers nourishment directly into the bloodstream). Most people who have had a stroke will recover their ability to swallow safely.

Mood Changes
The days and months after experiencing a stroke are a stressful time. The stroke survivor may be unable to return to work immediately and may lose independence for a while. After the immediate shock, a stroke survivor may feel anxiety, anger, and frustration. A lack of information may contribute to the anxiety. Anxiety and frustration can be reduced by support from doctors, therapists, and other caregivers.

Nice To Know:
Q: My wife just hasn't been herself since her stroke. She seems to have lost interest in many things and no longer seems to be enjoying life, even though her recovery is progressing well. What could be wrong?

A: Your wife could be suffering from depression. After recovery from a stroke, many people do feel depressed. This depression is normal, and usually disappears within three months after the brain attack. Medication is available to relieve symptoms of depression.

Personal Relationships
Many people worry that sexual intercourse may bring on another stroke. This is not true. A person who has recovered from a stroke can return to all normal activities, including sexual relations. Even people who are still experiencing some difficulties related to a stroke can resume normal loving and intimate relationships.

Nice To Know:
Open discussion and careful consideration of each other's needs is the secret to maintaining a successful relationship after stroke. Restoring a warm, loving relationship with a partner is an important step in returning to a normal life.

Other Challenges To Face
Because a stroke affects each person differently, there may be other physical challenges:

• The sensitivity of the skin may be altered after a stroke. Some people experience numbness while others feel as if their skin is extra sensitive.
• Certain individuals experience pain, uncomfortable numbness, or strange sensations after a stroke. These sensations may be caused by many factors, including damage to the sensory regions of the brain.
• Control of bowels and bladder may be lost temporarily after a stroke, but most people do recover function.

Pneumonia

Pneumonia is an inflammation of the lungs most often caused by infection with bacteria or a virus. Pneumonia can make it hard to breathe because the lungs have to work harder to get enough oxygen into the bloodstream.

Symptoms of pneumonia caused by bacteria often begin suddenly and may follow an upper respiratory infection, such as influenza (flu) or a cold. Common symptoms include fever, a cough that often produces colored mucus (sputum) from the lungs, and rapid, often shallow breathing.

Older adults may have different, fewer, or milder symptoms. The major sign of pneumonia in older adults may be a change in how well they think (confusion or delirium) or a worsening of a lung disease they already have.

Symptoms of pneumonia not caused by bacteria (nonbacterial) include fever, cough, and shortness of breath, and there may be little mucus production.

Antibiotics are used to treat pneumonia caused by bacteria.

Transient ischemic attack (TIA)

by Healthwise

What is a transient ischemic attack (TIA)?

A transient ischemic attack (TIA) is a warning sign of a stroke. It happens when blood flow to part of the brain is temporarily blocked or reduced, often by a blood clot. This causes the same symptoms as a stroke, but after a few minutes, blood flow is restored and the symptoms go away. With a stroke, however, the blood flow is not restored, and damage to the brain is permanent.

Even though the effects of a TIA are temporary and your symptoms may have gone away, you still need to see a doctor right away to help prevent a future stroke.

Many people do not even know that they have had a TIA until they tell their doctor later about their symptoms.

What are the symptoms of a TIA?

Symptoms of a TIA come on suddenly. They can vary depending on which part of the brain is affected. Common symptoms include the following:
You may feel weak on one side of your body, or you may not be able to move an arm, a leg, or your face on one side of your body. Or, you may not be able to move at all on one side of your body.
You may feel numbness, tingling, or heaviness on one side of your body.
You may not be able to see, or you may have changes in vision such as blurring or double vision, dimness, or a sensation that a shade has been pulled down over your eyes.
You may have trouble speaking or finding or understanding words.
You may feel unsteady, dizzy, or clumsy. You may walk unevenly or faint. You may also have a drop attack, which is a sudden loss of strength in your legs.

It is not always easy to recognize a TIA because you may think that your symptoms are caused by aging or other conditions. Symptoms usually disappear by the time you go to a doctor. In some people, however, symptoms can last up to 24 hours.

What causes a transient ischemic attack?

A blood clot is the most common cause of a TIA. The clot may form in an artery in the brain or may travel through the bloodstream from the heart.

Within seconds of the blockage, brain cells are affected and cause symptoms in the parts of the body controlled by those cells. Once the clot dissolves, blood flow returns, and the symptoms go away.

Hardening of the arteries (atherosclerosis), heart attack, and abnormal heart rhythms are the most common causes of blood clots that result in a TIA or stroke.

In some cases, a TIA may be caused by a severe drop in blood pressure that reduces blood flow to the brain. This type—called a "low-flow" TIA—occurs less often than other types.

See an illustration of a transient ischemic attack.

What tests do I need if I have had a TIA?

If you think you are having a TIA, call 911 immediately. There is no way to know whether your symptoms are caused by a stroke or a TIA. If your symptoms have gone away, it is still important to see your doctor immediately and to describe your symptoms in detail.

Your doctor will also check to see if there is another cause of your symptoms, such as a seizure, migraine headache, or Bell's palsy.

Tests that you may need include:
A CT scan of your head. A CT scan is a type of X-ray that can produce detailed pictures of your brain and blood vessels.
An MRI test and/or a magnetic resonance angiogram (MRA), which provide pictures of the brain and blood vessels.
Doppler ultrasound, which checks blood flow through the carotid arteries (the major arteries that lead to the brain).
Angiogram of your head and neck.

You may have an echocardiogram to check for blood clots in your heart and/or an electrocardiogram (EKG) to check for arrhythmias if your doctor thinks that heart problems may be the cause of the TIA.

What is the treatment for TIA?

If you have a TIA, you may need to take medicine to reduce your chances of developing more blood clots and having a stroke.

If you have narrowed carotid arteries, you may need a surgery called a carotid endarterectomy to reopen them. This surgery helps prevent blood clots that block blood flow to the brain.

A relatively new procedure called carotid artery stenting is another option for some people who are at high risk of stroke. This procedure is much like coronary angioplasty, which is commonly used to open blocked arteries in the heart. During this procedure, a vascular surgeon inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque. The surgeon may use a stent that is coated with medicine to help prevent future blockage.

What increases my risk of a TIA?
High blood pressure. You can lower your risk of TIA by lowering your blood pressure.
High cholesterol. High cholesterol increases your risk of atherosclerosis, which can lead to blood clots. By lowering your cholesterol, you can lower your chance of having a TIA.
Smoking. If you stop smoking, you can lower your risk of having a TIA.
Heart disease. The higher your risk of heart attack, the higher your chance of having a TIA. By lowering your risk of heart attack, you also reduce your chance of having a TIA.
Age. Most TIAs occur after the age of 60.
Family and medical history. If one of your family members has had a stroke or TIA or you have had a previous TIA, you are more likely to have a stroke or TIA.

Some diseases, such as diabetes and sickle cell disease, can increase your risk of having a TIA.

Prevention

You can help prevent a transient ischemic attack (TIA) by controlling your risk factors for stroke.

• Have regular medical checkups. Work with your doctor to control high blood pressure, high cholesterol, heart disease (especially atrial fibrillation), diabetes, and disorders that affect blood vessels and how your blood clots, such as polycythemia and sickle cell anemia.
• Quit smoking. Daily cigarette smoking can increase the risk of stroke by 2½ times. 8 Regular exposure to secondhand smoke also increases your risk of stroke. 1
• Check with your doctor about whether you should take an aspirin each day and medicine to lower your cholesterol, if you have been told that you have hardening of the arteries (atherosclerosis). It has been shown that for people who have had a stroke, a TIA, or an endarterectomy, taking aspirin or other antiplatelet medicines, such as aspirin with extended-release dipyridamole, daily may help prevent another stroke.
• Ask your doctor about taking cholesterol-lowering medicines called statins if you have high cholesterol or have had a heart attack. 9
• If you have had a prior TIA, taking blood pressure–lowering medicines may help prevent another TIA or stroke. 10
• Maintain a healthy weight. Being overweight increases your risk for high blood pressure, heart problems, and diabetes, which are risk factors for TIA and stroke.
• Eat a well-balanced diet that is low in cholesterol, saturated fats, and salt. Fatty foods may make hardening of the arteries worse. Eat more fruits and vegetables to increase potassium and vitamins B, C, E, and riboflavin.
• Get regular exercise, and reduce your stress
• Keep alcohol consumption low to moderate (from 1 drink per week to less than 2 drinks per day), which may decrease the risk of stroke caused by a blockage (ischemic stroke). 7 Excessive use of alcohol increases the risk of stroke.
• Avoid taking birth control pills (oral contraceptives) if you have other risk factors for TIA or stroke, such as smoking, high cholesterol, or a history of blood clots. Talk to your doctor about other forms of birth control that do not increase your risk of TIA and stroke.

Because atrial fibrillation increases your risk of stroke and because many people do not have symptoms of atrial fibrillation, the National Stroke Association recommends that everyone, particularly those age 55 or older, check his or her heartbeat once a month. To learn how to check your pulse, see taking your pulse. If you notice that your heartbeat does not have a regular rhythm, talk to your doctor.

If you have atrial fibrillation, use this tool to check your risk of stroke: Interactive Tool: Stroke risk from atrial fibrillation.