I’ve been meaning to write a post about Strokes and Head Injuries (sometime after the long-delayed Trauma And You, Part IV), and this isn’t going to be it. It’ll just be a few quick notes.
You have two basic causes for strokes. One is an occlusive stroke: A blood clot gets loose and blocks an artery in the brain. This is very similar to a heart attack, where a blood clot gets loose and blocks a coronary artery (or a pulmonary embolism, where a blood clot breaks loose and blocks one of the pulmonary arteries). The other is a hemorrhagic stroke, where a blood vessel bursts, causing bleeding into the brain, your classic apoplexy. This is similar (in some ways) to a ruptured aortic aneurysm.
When you have someone come down with signs and symptoms of stroke (and these vary depending on how big the stroke is and what part of the brain is affected), you have three hours from the time of onset of symptoms to the start of therapy if you’re going to treat it with anything other than time.
Here are the rock-bottom signs and symptoms of stroke:
What to do: Do not waste time. You don’t have it. Note down the exact time the symptoms started. Call your friends from 9-1-1. You do not need to have all of these signs or symptoms. Any of them should initiate an immediate call to EMS. This is a true medical emergency.
I’m sure you’ve seen those e-mails about How To Tell if Someone Is Having a Stroke. The three tests (arm drift, smile, repeat a phrase). That’s called the Cincinnati Stroke Scale, and while it’s a wonderful tool, and we use it ourselves, it isn’t diagnostic (and lots of things that have stroke-like symptoms, that aren’t strokes, are plenty serious all on their own).
What happens when the nice EMTs take the person away:
1) We give him oxygen, and establish an IV. We ask him (or you) all kinds of questions about his medical history, allergies, medications, and particularly what time it started. The clock is running.
2) Once at the ED, the emergency physician will order a no-contrast CAT scan or MRI, and at the same time run down the checklist for why not to give thrombolytics. This checklist is about three pages long (“Any recent surgeries? Any recent tooth extractions?”) where any “yes” means the thrombolytic path is closed. The first item on the list is “Has it been more than three hours since the first symptoms?” If yes … well. Make the patient comfortable and see how things go.
Now that MRI: The brain scan has to be normal. In the early stages of an occlusive stroke, there are no visible changes. Free blood in the brain shows up as a lighter area, and bleeding in the brain means we don’t want to break up any clots. Dead tissue shows up as a darker area, and if the tissue has already died, well, no point in going on. Or you could see a tumor, and thrombolytics won’t help with that.
3) If the MRI comes back normal, and the patient said “No” to all the questions on the checklist, then comes the big question: “This therapy could kill you. Do you want to go ahead with it?” Being put on thrombolytics is essentially the same as getting an instant case of hemophilia. If you can’t answer the question because you can’t talk (or can’t hear or can’t read), because of the stroke, better hope you have a Living Will that spells out what you want done, or have someone with a Power of Attorney for Healthcare standing by to answer for you.
4) If you say, “Yes” to going forward … the first drops of thrombolytic have to hit your veins inside that three-hour window. That’s why helicopters get involved. To get you to an MRI machine, to get you to a center where they have the guys who’ve done this more than once a year. Then, you have about a 70% chance of getting All Better.
Of course, if you have a hemorrhagic stroke, what you need is a neurosurgeon to tie off the bleeder and relieve pressure in your skull. Different ball game.
Then there are TIAs—Transient Ischemic Attacks. These are so-called “mini-strokes.” The difference between them and a full-bore stroke is that the TIAs spontaneously resolve within twenty-four hours. Don’t ignore them for that reason: They’re a red flag that a major stroke will hit (60% chance) within twelve months.
So what I think is going on with Kennedy: The helicopter was to get him to a good MRI and a major hospital within that three-hour window. The fact that he’s calling people on the phone and talking to them means that he’s (probably) sitting somewhere watching thrombolytics drip into his veins, bored out of his gourd. Chance of recovery? About 70%.
For all of y’all: If you have, or someone around you has, stroke-like symptoms, Don’t Screw Around. Call 9-1-1.
As always, I am not a physician. I can neither diagnose nor prescribe. This post is presented for amusement purposes only, and is not medical advice for your particular situation or condition.