What is a stroke?
A stroke is defined as an interruption of the blood supply to the brain. Blood provides nutrients and oxygen while whisking away wastes from the brain tissues. Any time there is an interruption — even briefly — there are identifiable consequences. If they are reversible, we refer to this as a Trans Ischemic Attack or TIA. If they are not reversible, and they are fixed for longer than 24 hours, then we refer to this as a stroke. There is an area of damage from the interruption in blood flow, and that essentially is what a stroke is.
The importance of quickly treating a stroke
Time equals brain” is one of our most steadied mantras in vascular neurology because the longer period of time that goes by where the brain is not receiving the amount of blood and oxygen that it requires the more damage is done. The sooner we can initiate treatments, the more likely we can restore blood flow to brain tissue which may go on to infarct in the absence of treatment.
Our primary goal is to completely reverse the stroke if possible, but in the event that it is not possible, we want to minimize the damage. So, we always say “time equals brain” because brain cells are dying every second that they are starved for oxygen and nutrients that are transported by the blood.
Types of strokes
The principal types of strokes are strokes that are caused by bleeding in the brain, and strokes that are caused by the interruption of blood flow in the brain. The former are called hemorrhagic strokes and the latter are ischemic strokes. They are fundamentally different. The strokes caused by bleeding in the brain are usually the result of a vessel or aneurysm that has ruptured or another anatomic variant in a patient that has pre-disposed them to a bleeding stroke.
The treatment for these types of strokes is very different than for ischemic strokes, making the rapid diagnosis and differentiation of one verses the other very important. That first group represents about 15 percent of all strokes that present to an emergency department nationally. The overwhelming majority of strokes are the ischemic type. That is caused by an interruption of arterial blood flow which also disrupts the delivery of oxygen and nutrients that are critical to the brain.
There are a variety of mechanisms of ischemic stroke as well, there are cardio-embolic strokes, there are artery to artery embolic strokes, and sometimes it’s just the result of local and focal atherosclerotic disease that occurs in the brain and the vessels that feed the brain.
The way we will strategize with a patient to ensure that they don’t have another stroke is very dependent on the type of stroke they had in the first place.
Symptoms of a stroke
Sometimes a patient will not be able to speak or express themselves, or alternatively will not being able to understand what people are saying to them. This includes the written word, the spoken voice and the ability to speak back. Motor problems also occur such as focal weakness, usually involving the arm or the leg and the face, and you’ll see facial drooping on one side. You’ll see a clear asymmetry in a person’s face where the corner of the mouth may be down turned, the nose and the folds of skin surrounding the nose are flattened somewhat.
And if the face is affected there will be slurring of speech. A stroke victim may not be able to form their words appropriately because of weakness in their tongue and lips. They will be very disarthric and slur their speech fairly dramatically.
Other symptoms include difficulty with walking and then sensory symptoms. Some people will be numb, for example, on half of their body, and will not be able to feel light touch or painful sensations.
If you know of anyone who experiences any of these symptoms or if you have any of these symptoms yourself, you need to present for medical attention immediately. Don’t delay in calling 911. The earlier you present to a physician, the better the outcome is that those symptoms will be reversible, if not fully then there will be minimal residual the sooner you are able to come to a doctor.
Sometimes a stroke will affect a portion of the brain that is responsible for recognizing that something is wrong. Frequently a patient is weak on one side or their language is impaired, but it just doesn’t strike them as that serious. That’s because the portion of the brain that recognizes something is truly amiss is not able to recognize that in the patient, and in those cases it’s very, very important for family and friends to be on the alert for these signs in their loved ones.
What makes the Shands at UF program unique?
What makes the UF Stroke Program so successful is our philosophical approach to the patient and our efforts to provide a continuum of care. Continuum of care starts in the community, and one of the first things we want to do is to provide community outreach and education, not only to patients directly and their families or potential patients and families, but also primary care providers and other ancillary health providers in the community.
The second part of that process involves EMS personnel and paramedics in the community. EMS personnel are highly trained to make sure that they are able to recognize the signs and symptoms of a stroke very quickly and accurately and then be able to set into place what we call a “Stroke Alert.” This Stroke Alert puts everybody on alert, which includes staff in the imaging facility as well as the laboratory, the emergency department, the neurologists, the neurosurgeons, as well as the Neuro ICU and stroke unit are all immediately notified of the imminent arrival of the stroke patient.
Stroke patients do not sit in the emergency waiting room; they are immediately evaluated and assessed. The next portion of the Stroke Alert process really begins to integrate an inter-disciplinary approach to the stroke patient. The lab or the imaging facility know a stroke patient is coming. They are prepared to process the patient or patient’s lab samples in predetermined and prescribed ways that are part of the entire process of these protocols that have been written and are in place, and they ensure that we don’t miss anything.
Once we have our patient assessment and diagnosis in place then we are able to initiate treatment immediately. This can occur in the emergency department. We have pharmacists in the ED who are able to provide the appropriate medications. If we deem that it is necessary that the patient be transported to the Angiography Suite, the entire Angiography Suite is already staffed 24/7 by the time the patient arrives there. We have additional treatment options that may or may not be available in other places.
We also have a Neuro ICU. This is unit is dedicated to the neurological or neurosurgical patient. Expertise is focused on neurological and neurosurgical care, including trained nurse specialists.
Advanced equipment at Shands at UF for treating strokes
We have a Aquillion One Toshiba CT Scanner, for state-of-the-art stroke imaging. This is a 320-slice scanner with resolution to provide three-dimensional dynamic images of the brain, as well as the blood flow patterns in the brain that allows us to make very rapid and very accurate diagnoses to exactly what pathological process is going on which allows us to make the most appropriate judgments for the treatment of the patients.
Follow-up care and rehabilitation for stroke patients
During hospitalization stroke patients will receive rehabilitation as appropriate for them. They will be assessed as an inpatient for the appropriateness of transfer to our acute rehabilitation hospital.
There is a transition between the physical therapy, speech therapy and occupational therapy provided in the hospital, to a continuous care plan at the acute rehab hospital. Shands HomeCare can also provide further follow-up care necessary to optimize the patients chances for a full recovery.
Reducing the risk of stroke
There are things that you can’t change: age is a risk factor, gender is a risk factor, family history is a risk factor and there are some genetic predispositions that are risk factors. There are things people can do to reduce their risk of a stroke, including maintaining an ideal body weight and getting regular aerobic exercise on. Dietary decisions play an important role in your underlying risk factors, much like they do for a heart attack. We want to ensure if you have hypertension it’s well controlled. If you have diabetes, be aggressive about its control and work with your doctor to ensure that your blood sugar regulation is as normal as possible. If you are engaged at controlling your hypertension, diabetes you can significantly lower your risk for having a stroke.
Your cholesterol, your lipid profile, should be assessed and treatment should be initiated as appropriate according to the guidelines of your physician. One of the main risk factors for a variety of health concerns is cigarette smoking or smoking in general. We know that long term smokers have a much, much higher rate of stroke incidence than non-smokers.
If you have a combination of these risk factors, your risk goes up significantly. Somebody who has high blood pressure and diabetes that is poorly controlled and smokes is a patient who it’s almost a matter of when and not if.
Risk factors need to be re-assessed on an annual basis to ensure that we are doing everything that we can to absolutely minimize your risk of having a stroke.
If you or a loved one have symptoms of a stroke, you should call 911 immediately. If you live in Gainesville, Florida, ask the paramedics to take you to Shands.