Stroke Centers Have Specialists On Call, Yet many stroke patients simply do not act when stroke occurs. Many do not recognize the wide array of symptoms, which may include confusion, paralysis, numbness or impaired vision.The temptation for many patients is to wait and to hope that the discomfort will subside. Most wait hours, some even days, before seeking help, and as a result, many never recover. On average, a third of stroke patients die and another third are permanently disabled. Worse, available clot-busters are not at all effective for the one in six stroke patients who suffer a hemorrhagic stroke, bleeding into the brain. All that physicians can do now is try to limit the damage by means of surgery.
It doesn’t have to be this way. Recently the American Stroke Association recommended that ambulances take patients with stroke symptoms to hospitals that are designated as stroke centers. Unlike most community hospitals, stroke centers have specialists on call, offer tPA and recommend supportive care.
Yet the recommendation has yet to make a difference. Ambulances follow different rules in different communities, and many smaller hospitals say they cannot afford the equipment and personnel to become full stroke centers. Most do not offer M.R.I. scans to stroke patients in the emergency room; many do not even offer tPA. As a result, even patients who react quickly are taken to emergency rooms where they do not receive optimal care.
If the window for emergency care could be extended, patients would have a much greater chance at recovery wherever they were taken. Researchers are testing a type of M.R.I. scan, called diffusion-perfusion, that can show whether brain cells have died or are merely “stunned” by the loss of oxygen. Even many hours after the onset of stroke, studies suggest, areas of the brain with surviving cells may still be helped by administration of tPA or similar drugs.
Experts also are ramping up efforts at prevention. In the weeks leading up to a stroke, patients often receive a warning sign, like weakness on one side or a temporary loss of vision. So-called transient ischemic attacks, or T.I.A.’s, are caused by blood clots lodged in arteries supplying the brain; they dissolve before permanent damage is done.
Unfortunately, T.I.A.’s often are followed by full-blown strokes that result in much more severe damage. But the warning provided by a T.I.A. can be lifesaving. Patients at risk benefit from low-dose aspirin, which can prevent future blood clots, according to many studies; these days patients at highest risk are candidates for more powerful anticlotting drugs like warfarin. A T.I.A. tells patients they must stop smoking, that their blood pressure must come under control — high blood pressure is the leading risk factor for strokes. Recent studies also have found that cholesterol-lowering statin drugs can help prevent strokes in people who have had T.I.A.’s even if their cholesterol levels are normal.
Prevention may also involve surgery to clear plaque from the carotid artery in the neck, the usual source of clots that are swept into the brain. Stents — tiny wire cages used to hold back plaque — may be useful as well, but researchers are not certain that stents are as effective as surgery. Medicare recently announced that it would not reimburse patients for stents if they could also have surgery, unless the patients were enrolled in a clinical trial comparing the two treatments.
If the studies continue to show that more patients could be helped, health care providers will be faced with some difficult decisions. It is too difficult and too expensive, many have said, to have specialists on call day and night, or to deploy M.R.I.’s in emergency rooms for the occasional stroke patient. But the standard of care is changing, and with it, patient expectations. There is no time to waste.