HEALTHY LIFESTYLE · MAY 2018
HEALTHY LIFESTYLE · MAY 2018
SHE SEEMED LIKE
SUPERWOMAN
I
was 15 years old when my grandmother
had a stroke. She was perfectly healthy
until she needed a knee replacement.
She recovered completely after having
total right knee arthroplasty. She may
have been a little overweight and had high
blood pressure, but was otherwise a very
active individual. She raised 9 children
almost single-handedly. She seemed like
superwoman. She worked as a midwife.
Cultivating over 40 years of experience,
people started calling her Dr. Huda, although
she had not spent a single second in a
medical school classroom. She was indeed
the most capable woman I have ever seen.
I was mesmerized by her as an individual,
looked up to her as a professional, and
loved with all my heart as my grandmother.
She took care of everyone; children,
grandchildren, family, neighbors, and friends.
She was Ms. Independent. Until that moment
came. A left middle cerebral artery stroke
made superwoman become completely
dependent on those that she took care of.
Within seconds, her life and the lives of
everyone around her had changed forever.
Life was never the same after that, not for Dr.
Huda, and not for me.
Odds are, this story isn’t any different than
any you’ve heard or experienced. However,
this story gave me the capability to write
this article. This story led me to choose a
career in medicine, neurology, and vascular
neurology to be more specific.
Every 40 seconds, someone suffers from a
stroke. Stroke is the most common cause of
disability in the United States and is the fifth
leading cause of death. A stroke can be an
ischemic stroke or a hemorrhagic stroke. An
ischemic stroke is when an artery in the brain
becomes blocked, causing ischemia, or lack
of oxygen to that particular part of the brain.
The signs and symptoms depend on the
part of the brain being affected. The larger
the blocked artery, the more devastating
the symptoms. It is for this reason, signs
and symptoms of stroke can differ and vary
from one person to another. A hemorrhagic
stroke is when a blood vessel in the brain
ruptures causing decreased oxygenation
to that particular part of the brain, thereby
causing symptoms. Further damage is caused
by the toxic byproducts of the deoxygenated
blood to the tissue. As mentioned above,
signs and symptoms depend on the location
of the ruptured vessel. It is impossible to
distinguish an ischemic stroke versus a
hemorrhagic stroke based on symptoms
alone. A computed tomography scan (CT
scan) is needed emergently to separate
between the two and steer the direction of
treatment. Ischemic stroke is by far much
more common and will be the bulk of this
article.
Stroke symptoms, as mentioned earlier, can
vary from person to person. It can range
anywhere from simple numbness to the face,
arm, and or leg, to complete debilitating
weakness of one half of the body, loss of
ability to speak, understand, and even death.
No stroke should be taken lightly. Advances
in medicine have allowed us to become
more aggressive in the treatment of acute
stroke. A clot-busting medication, tissue
plasminogen activator (tPA) was approved
in the early 1990s to be given to anyone with
stroke symptoms within the first 3 hours
of symptoms if no contraindications were
present. Several years later, further research
found beneficial to most patients up to 4.5
hours after initial symptom onset. More
technological advances have guided the field
of interventional endovascular management
of ischemic stroke, allowing for manual
clot retrieval up to 24 hrs of symptom
onset in select patients. None of the above
interventions are useful, however, if the
patient is not present in the hospital within
the appropriate time frame.
28 HEALTHY MAGAZINE
I made the move to South Texas
from upstate New York in the middle
of 2017. I was eager to start my
career in a region I felt needed my
presence. I completed four years
of general neurology training and
one year of dedicated vascular
neurology subspecialty training. It has
been a striking experience thus far.
While I love every aspect of feeling
appreciated, the truth of the matter
is, my job is very limited to many
patients. As a vascular neurologist,
I have three main duties: 1) treat an
acute stroke the best I can within
the first 4 hours, and if after that
time window, recognize whether the
patient is a candidate for manual clot
retrieval and send to the appropriate
facility as quickly and swiftly as
possible. 2) Perform every measure
in my capability to ensure the worst
has passed and their symptoms do
not worsen while in my care. While
stroke symptoms are usually maximal
at onset, without the appropriate
management, symptoms can
certainly worsen and lead to further
disability and a poorer outcome.
Lastly, and maybe as important as
the first two duties, is to determine
the source of the stroke and address
the cause to reduce the likelihood
of suffering another stroke. Without
doing so, patients are a ticking time
bomb for another stroke.
Some of the troubling experiences I’ve faced so far are
the time frames of which some patients present to the
hospital. In some cases, patients present days, even weeks
after symptoms have occurred, only presenting because of
worsening symptoms. So despite all the medical advances,
a good percentage of our patient population still presents
too late to the hospital for timely care. About 1.9 million
Neurons die each minute in an untreated stroke. An
untreated brain ages roughly 3.6 years for each hour during
an untreated stroke. Time is brain indeed. Whether it’s a
financial, cultural, geographical, or social restraint, it is our
continued responsibility to educate and raise awareness to
the community. Stroke does not just affect the patient, but
the family as well. Entire family dynamics can change after a
stroke. The increasing cost of care has made stroke one of
the most expensive and costly diseases in our country. An
average 65 billion dollars is spent on stroke annually.
A stroke
caused by
hypertension
typically looks
different
than a stroke
caused
by atrial
fibrillation
or any other
cardiac cause.
Strokes on
both sides of
the brain are
likely to be
caused by a
more central
source,
thrombus from within the heart for example,
or a tendency to develop clotting due to
underlying malignancy, genetic causes, etc. And
for that reason, the cause of stroke needs to be
determined. There are circumstances, in some
literature, where up to 40 percent of strokes
are without an etiology or undetermined
source. These strokes are termed cryptogenic
strokes. Our job as physicians is to assure
Stroke risk factors are well known and are
that every potential etiology is investigated
no different than those of cardiac disease
to determine the source of stroke. It is also
and peripheral vascular disease. For example:
important for every patient, family member,
hypertension, diabetes, tobacco use, and
and loved one to ask and understand the
elevated cholesterol. Aside from these very
diagnosis in order to address the underlying
common diseases, atrial fibrillation is also a
cause to prevent recurrence. When my
major risk factor for ischemic stroke. Even
grandmother had a stroke, I remember asking
non-sustained atrial fibrillation can carry a
my aunts who were taking care of her, “how and
high stroke risk. Identifying the etiology of the
stroke is critical in an attempt to reduce the risk why?” The response was, “she just had surgery
a few weeks before, so she had a stroke.” I
of a recurrent stroke going forward. Another
accepted the answer as much as it confused
unfortunate and gut-wrenching experience is
me and didn’t bring it up again until seven years
the number of patients whom I’ve seen who
later when things made more sense to me. No
were diagnosed with a stroke years ago. When
asked, “why did you have a stroke?” they answer one had investigated why this mildly overweight
hypertensive right-handed female developed
with a blank face, which is sometimes better
than the, “they said it was stress,” response I’ve what appeared to be an embolic ischemic
stroke causing severe long-term disability. It was
heard countless times.
upon further questioning, about seven years
after the stroke, that it was revealed that my
An etiology of a stroke, to a vascular
grandmother had paroxysmal atrial fibrillation
neurologist, can be suspected based on its
and was placed on oral anticoagulation for
appearance on imaging, MRI, for example.
further stroke risk reduction.
Seeking immediate emergent care is the key
point of the national stoke campaign. Known
as FAST (Face, Arm, Speech, Time). Speaking
broadly, any symptoms involving the face,
arm, or speech, require a 911 call and to seek
immediate medical attention. While not every
hospital is the same, most hospitals are capable
of providing acute care for stroke, and the
closest hospital should be visited anytime
a stroke is suspected. When 911 is called,
emergency medical services can determine
the severity of symptoms and transport
patients to the appropriate hospital. Stroke
care is comprised of a multidisciplinary team.
Active members include the neurologist, and
in some cases, a neurosurgeon, hospitalist, at
times other specialists (cardi ologists, intensive
care), dedicated nursing staff, nutritionists,
speech therapists, and physical therapists all
working together in order to achieve the best
possible outcome for the patient. Studies
have shown the most important predictor of
a good outcome in stroke is being treated in a
dedicated stroke unit.
Being in the Rio Grande Valley over the past
several months, I’ve learned a lot about this
region. Some good, some bad. The weather
is hot, except for when it snowed for an hour.
The food is amazing. People are genuine and
sincerely appreciative. People will also do
whatever it is you need, but tomorrow. People
in the Valley are down to earth, genuine,
sincere, and very appreciative of our efforts
as physicians. I was in awe of the amount of
respect they show towards physicians and
healthcare providers. Again, coming from New
York, you can see why it’s a culture shock for
so many different reasons. One of the biggest
things I’ve learned while here in the Valley is the
value placed on family. Family is everything. It
has helped me constantly remember the keys
to happiness. God, family, and health. With
change come growing pains. But I can assure
you this; I’ve come to the Valley as the only
stroke neurologist to provide a service that
wasn’t provided to my grandmother. I see my
Dr. Huda in every stroke patient I encounter. I
wish I never had to meet anyone in the hospital,
but when we are met with the unfortunate
circumstance, I guarantee that everything in our
power, knowledge, and skill-set as physicians
and health care providers will be applied to
your recovery. We will always do our part; we
just need our patients to allow us to do so.
By Hamzah M. Saei, MD
29 HEALTHY MAGAZINE