“Advances in the management of stroke promise to significantly improve outcomes for patients,” says an article in the CMPA Perspective in their September 2015 newsletter. CMPA (Canadian Medical Protective Association) advises physicians on medico-legal issues.
The most important thing is prompt recognition of signs and symptoms of stroke. Often the benefits of these advances are best realized if stroke is promptly recognized and treated. The efficacy of thrombolysis (clot busting drug) is up to 4.5 hours from the onset of symptoms and studies have confirmed the importance of the time to treatment for positive outcome.
Ischemic stroke (stroke due to a blood clot) is a medical emergency. It requires fast and effective collaboration between a neurologist and radiologist.
Stroke is the second leading cause of death. Stroke affects people of all ages. The lifetime risk of overt stroke is estimated at one in four by age 80 years.
There are two types of stroke, either ischemic (in 85 per cent of cases) or hemorrhagic (in 15 per cent of cases). Hemorrhagic strokes are divided equally into intracerebral hemorrhage (bleeding in the brain) and atraumatic subarachnoid hemorrhage (bleeding in the lining of the brain).
The public can be taught to recognize and act upon stroke using the acronym FAST, for facial droop, arm drop, speech disturbance and time. There may be other symptoms too.
A review article in the Canadian Medical Association Journal (CMAJ September 8, 2015) says, “The most important historical feature of stroke is the suddenness of its onset. Identification of a stroke syndrome is relatively easy: sudden onset of acute neurologic symptoms, peaking within a few minutes, is deemed a stroke until proven otherwise.”
In a review of cases, CMPA found that the biggest issue was the difficulty of early diagnosis. Most patients first present in a hospital emergency. Some went to their family physicians or a walk-in clinic.
More than a quarter of the patients died. Another 40 per cent were left with permanent disability. That means about 70 per cent of the patients who have a stroke either died or became permanently disabled. That is not a very good outcome.
Research suggests that about 10 per cent of the cases are not diagnosed initially because the patient presents with atypical symptoms. In the cases reviewed by CMPA, the most common symptoms were headache, dizziness, nausea and vomiting.
A full clinical exam is important and patient should be observed. If symptoms deteriorate then further evaluation should be done. Special attention should be given to patients who have risk factors like smoking, obesity and hypertension.
Thorough clinical evaluation is important. You cannot solely rely on CT scan. In ischemic stroke CT scan is quite often normal in the first 24 hours. In case of subarachnoid hemorrhage the CT scan will be positive in the first six hours but this number drops to 85 per cent if the CT is done after six hours.
Rapid clinical diagnosis, urgent CT scan and urgent use of clot busting drug within 4.5 hours is critical in achieving positive outcome in ischemic stroke.
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