Act Fast to Help Stroke Care

Act Fast to Help Stroke Care

By Eve Becker

Last January, Mark Kirk woke up with a headache. It worsened as the morning progressed, followed by vision problems and numbness in his hands. Symptoms became alarmingly more severe. His staff drove him to the emergency room, where it was determined that the junior senator from Illinois had suffered an ischemic stroke; his right carotid artery was blocked, reducing blood flow to his brain.

Kirk underwent three major brain operations at Northwestern Memorial Hospital (NMH): The first was to remove a 4-by-8-inch section of his skull to relieve dangerous brain swelling, the second was to remove the dead portion of the brain to allow for more swelling, and after the swelling had subsided, the third was to later put his skull back together.

More than a year of intense inpatient and outpatient therapy has followed at the Rehabilitation Institute of Chicago, with Kirk making significant progress to overcome partial paralysis on his left side.

Stroke is a brain attack. And it can come on as suddenly as a  lightning strike to cut off vital blood flow to the brain. About 795,000 strokes occur each year, according to the National Stroke Association, making them the fourth leading cause of death in the United States and a leading cause of serious, long-term adult disability.

During stroke, two million brain cells die every minute, increasing the risk of permanent brain damage, disability or death.

The key is to act rapidly, call 911, and head for the hospital when you notice any of these symptoms. A clot-busting drug called tissue plasminogen activator (tPA) can restore blood flow to the brain in some stroke patients, but tPA must be given within three to four hours of the first symptom. At primary stroke centers, dedicated teams of specialists work together to quickly diagnose and treat stroke patients, leading to better outcomes.

“The problem with stroke is that most people are slow to react. When they have a heart attack, they understand the symptoms and signs, and they high-tail it to the emergency room, but they don’t do that with stroke,” says Dr. James Young, chairperson of the Department of Physical Medicine and Rehabilitation at Rush University Medical Center.

“If there’s any concern that the symptoms you experience are new to you, then you have to be in the emergency room immediately,” Young says. “When I say every minute counts, I mean every minute counts. Because neurons, or the nerve cells, are dying minute by minute if you don’t restore circulation to the brain.”

About 87 percent of strokes are ischemic strokes, like Kirk’s, with a clot in a blood vessel supplying blood to the brain. The other 13 percent are even more dangerous hemorrhagic strokes, when a blood vessel ruptures and bleeds into the brain. TIAs, transient ischemic attacks, are mini warning strokes caused by a temporary clot that still require immediate medical attention.

New surgical therapies can help patients, says Dr. Richard Bernstein, director of Northwestern Memorial Hospital’s Stroke Center and associate professor of neurology at Northwestern University Feinberg School of Medicine.

“We’ve got a number of new treatments, mostly revolving around opening up blood vessels that are blocked in the first several hours,” Bernstein says. “The main reason we don’t get to use all these therapies is that people come in too late. If they come in the next day, we can work on preventing the next [stroke], but there’s not a lot we can do for [the one the patient just experienced].”

“We are getting better at preventing [stroke],” Bernstein says. Up to 80 percent of strokes can be prevented by addressing risk factors. “The number one treatable risk factor for stroke is high blood pressure, so, if people were to do one thing, it would be to make sure their high blood pressure is treated. [A second thing] would be to stop smoking, [and a third] would be to address other risk factors like high blood sugar and high cholesterol.”

Advanced surgical techniques and digital brain imaging can help treat stroke, says Dr. Fady Charbel, professor and head of the department of neurosurgery at the University of Illinois College of Medicine at Chicago, citing surgical interventions for ischemic stroke, such as carotid artery surgery, and new treatments for ruptured aneurysms in hemorrhagic stroke.

It’s also key to find out the cause of stroke such as aneurysm, high blood pressure or blocked carotid artery, he says. “Once that is done, that’s really the first step in preventing it from occurring again.”

Rehabilitation has also advanced. Rehab now focuses on intensively strengthening a patient’s impaired side, says Dr. Richard Harvey, medical director of the Center for Stroke Rehabilitation at the Rehabilitation Institute of Chicago (RIC) . “If you don’t use it, you will lose it,” Harvey says. “If we don’t get you using that impaired limb, you’re going to limit your recovery.

“We do very intense training with both the upper and lower limbs for people with stroke,” he says. “Instead of carefully getting them to start putting weight on their leg and maybe shifting their balance from one leg to the other, we just get them up and walking. We put them in a harness, get them on a treadmill, and we’ll walk them. We’ll walk them at as fast a pace as they can tolerate.”

Intensity is also key. “If you increase the number of repetitions of walking that somebody does with stroke, then you get a better outcome. Preliminary findings suggest that people will end up walking faster and more independently if they practice more intensely,” Harvey says.

Kirk underwent a rigorous rehab program at RIC. His office released YouTube videos that at the time of filming showed the senator hooked up to a harness on a treadmill and wearing weights on his impaired leg, working vigorously toward recovery.

“They have some devious ways of making things more difficult,” Kirk says in a May video. “Yesterday, I was wearing a 10-pound weight—they described it as the weight of a baby around your ankle, which really does slow you down.” The senator’s condition has improved since then, and in early January, he returned to his publicly elected job in Washington, D.C..

Harvey, who is one of Kirk’s doctors says that in general, “We actually put weights on the impaired leg of patients with stroke. It sounds kind of crazy, but there are two reasons to do it. One is that if you have to lift your leg with the extra weight on it, it is going to build strength. The other thing is that when you take that weight off, you take a bigger step. … One of the ways to increase walking speed is to take bigger steps. You might not take as many steps per minute, but if every one of those steps is a little bit bigger they’re going to get from Point A to Point B faster.”

For Kirk, the intense rehab has led to improvement. In November, holding a handrail and wearing a brace on his left leg, Kirk climbed 37 floors of the Willis Tower in a RIC fund-raiser.

Advanced surgical techniques and specialized care in stroke centers have improved the outlook for patients. “All of those things, if done promptly, accelerate the recovery of the patient and reduce the amount of brain that is injured,” Charbel says. “The availability of a team that can apply all the diagnostic and therapeutic treatment modalities to understand [the specific cause of] why a stroke happened and treat it as quickly as possible is really changing the game.”

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Published in Chicago Health Winter/Spring 2013