Room for Improvement: Learning the Subtle Signs of Stroke (Margarethe Goetz)

Which of these might be a stroke?

A 67 year-old woman with sudden right arm weakness and difficulty speaking.

A 25 year-old man complains of a sudden severe headache.

A 58 year-old man awakes with numbness and tingling of the left side of his body.

A 45-year-old woman suddenly cannot see things on her left side.

Each of these cases is a stroke until proven otherwise. Unfortunately, a study done by the Departments of Neurology and Emergency Medicine at the University of Cincinnati suggests that the last two individuals are less likely to be recognized as a potential stroke and get a timely trip to the Emergency Room by ambulance. Bystanders and stroke patients miss many stroke symptoms. Moreover, some stroke patients are unable to recognize their own symptoms or are incapacitated, requiring witnesses to help them.

What is a stroke?

Stroke is one of the leading causes of death and disability in the United States. Not all strokes are the same; they can have different underlying causes. The majority of strokes, ischemic strokes, happen because blood clots block blood flow through arteries to portions of the brain. A smaller number of strokes, hemorrhagic strokes, are due to bleeding into or around the brain. In either case, brain tissue can be irreversibly damaged. Stroke symptoms arise, within minutes, when a part of the brain is starved of oxygen and nutrients and no longer functions. For instance, when a stroke patient has a weak arm, it’s because the part of the brain that controls the arm is dying. 

Why does time to treatment matter?

Often, early evaluation and treatment can reverse or reduce the damage caused by a stroke. The clot busting drug rt-PA can be given to ischemic stroke patients to break up clot in the affected artery and restore blood flow. Unfortunately, the window for treatment is only 4.5 hours from symptom onset. Transportation by a 911 ambulance can speed arrival to the ER and increase the likelihood of receiving rt-PA. This means that a suspected stroke patient must be identified quickly, receive transportation by EMS to a hospital, be evaluated and treated within 4.5 hours.

In the less common case of a hemorrhagicstroke, time may be critical, even though clot-busting drugs are not indicated. In the worst cases, patients might need medications to correct blood clotting disorders, neurosurgical treatment or repair of a ruptured brain aneurysm. Again, time is of the essence for a stroke patient. The faster that definitive treatment is given, the more brain tissue can be saved.

Back to the study…

In the report from the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS), 2975 independent living stroke cases were identified from records for the year 1999. Sixty-one percent of cases were ischemic strokes, 11% were hemorrhagic strokes and 28% were transient ischemic attacks, or “ministrokes”. Only 40% of patients were transported by EMS to the ER. Symptoms associated with EMS use were weakness, decreased level of consciousness, speech difficulties, and dizziness. Emergency Medical Services were less likely to be contacted for numbness and vision problems, while headache was not associated with EMS contact.

It may be surprising that numbness and vision problems were not reasons to contact EMS. However, according to neurointensivist Steve Potter MD, PhD, “People frequently ignore vision changes because their subtlety can easily be brushed off.“ Neurointensivists are neurologists with additional training in ICU medicine and treat stroke patients daily. Numbness can also be a nonspecific symptom. “A patient may ascribe a numb arm in the morning to sleeping position and decide to wait the symptom out. When numbness persists, they contact their primary care physician who directs them to the hospital. Unfortunately, by then it’s usually too late to treat with t-PA.”

What should we do?

The most important thing to do when a stroke is suspected, is to act and call 911. Though other diseases can resemble a stroke, the only way to know for sure is medical evaluation. Subtle stroke symptoms pose a challenge for public education.  As the study authors suggested, public education campaigns should address stroke symptoms and also emphasize the importance of numbness, vision changes and severe headache. Suspicion of stroke should be linked with an action plan to call 911. Theoretically, encouraging utilization of EMS services might strain 911 systems. Ambulances might be unavailable to respond to other emergencies while transporting patients who may not actually be having strokes. In reality, though, too many people hesitate to call 911. The small potential increase in EMS utilization would be far outweighed by the potential reduction in long-term disability costs due to stroke. A suspected stroke is always adequate cause to request an ambulance. Remember, time saves brain and the next person who needs help might be a neighbor, friend, family member or you. Don’t be afraid to call 911.

Source: Kleindorfer D, et al. Am J Emerg Med. 2010 June; 28(5): 607-612. 

Margarethe Goetz PA-C, MMSc

An overcaffeinated neurocritical care Physician Assistant, former paramedic, and self-proclaimed geek, taking a hiatus from real life to study public health in hopes of keeping the public healthy and out of her ICU.