STROKE – New Stroke Management Guidelines can Benefit More Patients

Sunset in Hawaii. (Dr. Noorali Bharwani)
Sunset in Hawaii. (Dr. Noorali Bharwani)

Every nine minutes someone in Canada has a stroke. In the U.S., it happens once every minute. Usually the prognosis is not good.

But the odds of survival are getting better because of a new emergency intervention being offered at many hospitals across Canada and USA.

While the majority of strokes strike people over the age of 65, 10 to 15 per cent affect individuals 45 and younger. What is alarming is this number is on the rise.

Stroke is the second-leading cause of death in the world and a leading cause of adult disability.

According to the Heart and Stroke Foundation’s 2014 annual report, strokes in people in their 50s have increased 24 per cent over the last decade.

That is the bad news. The good news is Heart and Stroke Foundation is making changes in its stroke treatment guidelines, extending the window for endovascular thrombectomy from six hours to 24 hours.

Endovascular thrombectomy is the emergency procedure to remove the damaging blood clots from the blood vessel that is blocking the blood flow to the vital parts of the brain.

The change in the management of acute stroke comes after both the Heart and Stroke Foundation and the American Heart Association reviewed research suggesting it’s possible for some patients to benefit from the procedure even after many hours have passed since their first symptoms of stroke.

All patients may not be eligible for treatment if they are seen after six hours. But it is expected some patients may be eligible for treatment within six to 24-hour window.

Patients living in remote areas or who suffer a stroke in their sleep expected to benefit most from the new 24-hour guidelines.

Removing blood clots:

Mechanical thrombectomy (endovascular thrombectomy) is a procedure where doctors remove blood clots using a device passed through a blood vessel. New research shows some carefully selected patients may benefit having this procedure even after the six-hour window has passed (up to 24-hours). Up to 20 per cent of all ischemic stroke patients are currently eligible for clot removal. This number is expected to increase.

Dissolving blood clots:

In the second method doctors use clot-dissolving intravenous medication called alteplase (tPA). Alteplase was approved to treat ischemic stroke about 20 years ago and remains the only medication approved by the FDA to dissolve clots. It has been proven to decrease disability when given promptly (within six hours of onset of symptoms).

These two procedures can only be used for ischemic strokes (strokes caused by a blood clot), as opposed to those caused by a bleed in the brain.

Recognizing signs of stroke:

Studies have shown one in seven young patients were given a misdiagnosis of vertigo, migraine, alcohol intoxication, seizure, inner ear disorder or other problems – and sent home without proper treatment.

Age of the patient does not matter. If they have the FAST signs, whether they resolved or not, it was probably a stroke. Call 911 right away. Remember the acronym FAST:

Face: Is it drooping?

Arms: Can they raise both?

Speech: Is it slurred or jumbled?

Time: To call 911 right away.

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Primary Progressive Aphasia

Casa Batlló, a building designed by Gaudí in Barcelona. (Dr. Noorali Bharwani)
Casa Batlló, a building designed by Gaudí in Barcelona. (Dr. Noorali Bharwani)

Primary progressive aphasia is a rare nervous system syndrome. It is an acquired condition that affects a person’s ability to communicate.

An aphasic person cannot express himself or herself when speaking, has trouble understanding speech, and has difficulty with reading and writing or finding words.

Brain damage causes aphasia. This quite often happens after a stroke or head injury. It can happen if a person has a brain tumour or Alzheimer’s disease. It is important to remember primary progressive aphasia is not Alzheimer’s disease. In primary progressive aphasia the problem is a disorder of language with preservation of other mental functions of daily living for at least two years. Symptoms may get worse after that.

The effects of aphasia differ from person to person and can sometimes be eased by speech therapy. Most people affected by this condition can maintain ability to take care of themselves and pursue hobbies. In some instances a person can remain employed.

Primary progressive aphasia may present in a number of different ways but it commonly appears initially as a disorder of speech, progressing to a near total inability to speak in its most severe stage, while comprehension remains relatively preserved.

Symptoms begin gradually, often before age 65, and worsen over time. People with primary progressive aphasia have a difficult road ahead. They are fighting against a condition in which they will continue to lose their ability to speak, read, write, and/or understand what they hear. The illness progresses slowly.

Medically speaking, primary progressive aphasia is caused by a shrinking of the frontal, temporal or parietal lobes in the brain, primarily on the left side. The condition affects the language centers in the brain.

Who is at a higher risk of being affected by primary progressive aphasia? A person having learning disabilities and a person who has certain gene mutations – meaning that it may run in the family.

An individual who has aphasia should carry an identification card and obtain materials available from the National Aphasia Association ( This helps in communicating about the person’s condition to others.

Unfortunately, people with primary progressive aphasia eventually lose the ability to speak and write, and to understand written and spoken language. As the disease progresses, other mental skills, such as memory, can become impaired. Some people develop other neurological conditions. With these complications, the affected person eventually will need help with day-to-day care.

People with primary progressive aphasia can also develop behavioral or social problems as the disease progresses, such as anxiety or irritability. Other problems might include blunted emotions, poor judgment or inappropriate social behavior.

The diagnosis of the condition is based on history of worsening communication skills, changes in thinking and behaviour over one to two years. Besides physical examination a doctor will order several test including blood tests, speech and language tests, genetic tests, MRI, etc.

Unfortunately, primary progressive aphasia cannot be cured, and there are no medications to treat it. The good news is, some therapies, like speech and language therapy, may help improve or maintain the ability to communicate and manage the condition.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Stroke Misdiagnosis in Young Adults on the Rise

Piazza dei Miracoli (English: Square of Miracles), formally known as Piazza del Duomo (English: Cathedral Square), is a walled 8.87-hectare area located in Pisa, Tuscany, Italy. (Dr. Noorali Bharwani)
Piazza dei Miracoli (English: Square of Miracles), formally known as Piazza del Duomo (English: Cathedral Square), is a walled 8.87-hectare area located in Pisa, Tuscany, Italy. (Dr. Noorali Bharwani)

A 2009 study by the Department of Neurology and Stroke Program at Wayne State University/Detroit Medical Center found that among 57 young stroke victims, one in seven were given a misdiagnosis of vertigo, migraine, alcohol intoxication, seizure, inner ear disorder or other problems – and sent home without proper treatment.

While the majority of strokes strike people over the age of 65, the incidence of strokes in individuals 50 and younger is on the rise. Because people associate stroke with the elderly, symptoms in younger victims can often be missed or dismissed – even by medical professionals.

What are the signs of stroke?

Recognizing the signs of stroke can be the first step to getting correct treatment. Experts recommend you use the mnemonic device FAST.

Face: is it drooping?

Arms: can you raise both arms?

Speech: is it slurred or jumbled?

Time is of the essence: to call 9-1-1 right away.

How can you be diagnosed and treated early?

For a good outcome early intervention and treatment is important.

A person has symptoms, the paramedics are called and the person is brought to the hospital. The ER physician does clinical examination and investigations and comes to a diagnosis. All this should not take more than one hour.

Once the diagnosis is made the standard of treatment is administration of medication called tPA (tissue plasminogen activator) intravenously. When tPA is promptly administered, it can save lives and reduce the long-term effects of stroke. It needs to be used within three hours of having a stroke.

According to Alberta Health Services, Alberta’s stroke treatment is now reported to be among the fastest in the world. Alberta’s quality improvement program cuts time for life saving drug treatment from 70 to 36 minutes. A similar effort in the United States saw average door-to-needle times in participating hospitals drop from 74 minutes to 59.

The accepted benchmark has been to treat patients within 60 minutes of their arrival at the hospital. The Grey Nuns Hospital in Edmonton currently holds the provincial record with the fastest door-to-needle time – six minutes.

The medication (tPA) was introduced 20 years ago. But the results are not perfect. Although tPA is successful in recanalyzing the blocked artery in up to 78 per cent of cases, this rate of success is dampened by a high rate of acute repeat occlusion leading to an ultimate rate of 33 per cent partial and 30 per cent full recanalization.

Doctors are working on newer methods to treat stroke patients. Now doctors are able to pull a clot from the brain of patients while they are having a stroke. It is called an endovascular procedure or a mechanical thrombectomy. The procedure should be done within six hours of acute stroke symptoms. The entire procedure takes about 10 minutes. This treatment is not available in all centers across Canada.

The message is clear. Whether the patient is young or old, for the best possible results, it is important to identify stroke symptoms and seek treatment immediately.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Early Detection of Stroke Improves Outcome

Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)
Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)

“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.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!