Lost Chances
for Survival, Before and After Stroke
Dr. Diana Fite, a 53-year-old emergency medicine specialist in Houston,
knew her blood pressure readings had been dangerously high for five years.
But she convinced herself that those measurements, about 200 over 120,
did not reflect her actual blood pressure. Anyway, she was too young to take
medication. She would worry about her blood pressure when she got older.
Then, at 9:30
the morning of June 7, Dr. Fite was driving, steering with her right hand,
holding her cellphone in her left, when, for a split second, the right side
of her body felt weak. “I said: ‘This is silly, it’s my imagination.
I’ve been working too hard.’ ”
Suddenly, her
car began to swerve.
“I realized
I had no strength whatsoever in my right hand that was holding the wheel,”
Dr. Fite said. “And my right foot was dead. I could not get it off the
gas pedal.”
She dropped
the cellphone, grabbed the steering wheel with her left hand, and steered
the car into a parking lot. Then she used her left foot to pry her right foot
off the accelerator. She pulled down the visor to look in the mirror. The
right side of her face was paralyzed.
With great difficulty,
Dr. Fite twisted her body and grasped her cellphone.
“I called
911, but nothing would come out of my mouth,” she said. Then she found
that if she spoke very slowly, she could get out words. So, she recalled,
“I said ‘stroke’ in this long, horrible voice.”
Dr. Fite is
one of an estimated 700,000 Americans who had a stroke last year, but
one of the very few who ended up at a hospital with the equipment and expertise
to accurately diagnose and treat it.
Stroke is
the third-leading cause of death in this country, behind heart disease
and cancer, killing 150,000 Americans a year, leaving many more permanently
disabled, and costing the nation $62.7 billion in direct and indirect costs,
according to the American Stroke Association.
But from diagnosis
to treatment to rehabilitation to preventing it altogether, a stroke is a
litany of missed opportunities.
Many patients
with stroke symptoms are examined by emergency room doctors who are uncomfortable
deciding whether the patient is really having a stroke — a blockage or
rupture of a blood vessel in the brain that injures or kills brain cells —
or is suffering from another condition. Doctors are therefore reluctant to
give the only drug shown to make a real difference, tPA, or tissue
plasminogen activator.
Many hospitals
say they cannot afford to have neurologists on call to diagnose strokes, and
cannot afford to have M.R.I. scanners, the most accurate way to diagnose strokes,
for the emergency room.
Although tPA
was shown in 1996 to save lives and prevent brain damage, and although the
drug could help half of all stroke patients, only 3 percent to 4 percent
receive it. Most patients, denying or failing to appreciate their symptoms,
wait too long to seek help — tPA must be given within three hours.
And even when patients call 911 promptly, most hospitals, often uncertain
about stroke diagnoses, do not provide the drug.
“I label
this a national tragedy or a national embarrassment,” said Dr. Mark J.
Alberts, a neurology professor at the Feinberg School of Medicine at Northwestern
University. “I know of no disease that is as common or as serious as
stroke and where you basically have one therapy and it’s only used in
3 to 4 percent of patients. That’s like saying you only treat
3 to 4 percent of patients with bacterial pneumonia with antibiotics.”
And the strokes
in the statistics are only the beginning. For every stroke that doctors know
about, there are 5 to 10 tiny, silent strokes, said Dr. Vladimir Hachinski,
the editor of the journal Stroke and a neurologist at the London Health Sciences
Centre in Ontario.
“They are
only silent because we don’t ask questions,” Dr. Hachinski said.
“They do not involve memory, but they involve judgment, planning ahead,
shifting your attention from one thing to another. And they also may involve
late-life depression.”
They are also
warning signs that a much larger stroke may be on the way.
Most strokes
would never happen if people took simple measures like controlling their blood
pressure. Few do. Many say they forget to take medication; others, like
Dr. Fite, decide not to. Some have no idea they need the drugs.
Still, there
is much more hope now, said Dr. Ralph L. Sacco, professor and chairman of
neurology at the Miller School of Medicine at the University of Miami. Like
most stroke neurologists, Dr. Sacco entered the field more than a decade ago,
when little could be done for such patients.
Now, Dr. Sacco
said, there is a device, an M.R.I. scanner, that greatly improves diagnosis,
there is a treatment that works and there are others being tested. “Medical
systems have to catch up to the research,” he said. ....
On average,
said Dr. Brendan E. Conroy, medical director of the stroke recovery program
at the National Rehabilitation Hospital, which is attached to the Washington
Hospital Center, a third of the Washington hospital’s stroke patients
die, a third go home and a third come to him.
Those whose
balance is affected typically spend 20 days learning to deal with a walker
or a cane; those who are partly blind or paralyzed must learn to care for
themselves. Many functions return, Dr. Conroy said, but rehabilitation also
means learning to live with a disability.
But what was
perhaps saddest to the neurologists viewing the M.R.I. scans that morning
was that tPA, which only recently appeared to be a triumph of medicine, had
made not a whit of difference to these patients. They either had not arrived
at the hospital in time or had been considered otherwise medically unsuitable
to receive it.
Few would have
predicted that fate for the drug. In 1995, after 40 years of trying to
find something to break up blood clots in the brain, the cause of most strokes,
researchers announced that tPA worked. A large federal study showed that,
without it, about one patient in five escaped serious injury. With it, one
in three escaped.
The drug had
a serious side effect — it could cause potentially life-threatening bleeding
in the brain in about 6 percent of patients. But the clinical trial demonstrated
that the drug’s benefits outweighed its risks.
When the study’s
results were announced, Dr. James Grotta of the University of Texas Medical
School at Houston expressed the researchers’ elation. “Until today,
stroke was an untreatable disease,” Dr. Grotta said.
But the expected
sea change did not occur.
One problem
was that patients showed up too late. Many had no choice. Strokes often
occur in the morning when people are sleeping. They awake with terrifying
symptoms, paralyzed on one side or unable to speak.
“That’s
the challenge — we have to ask the patient” when the stroke began,
said Dr. A. Gregory Sorensen, a co-director of the Athinoula A. Martinos Center
for Biomedical Imaging at Massachusetts General Hospital. “If they don’t
know or can’t talk, we’re out of luck.”
Another problem
is deciding whether a patient is really having a stroke. A person who has
trouble forming words could just be confused. Or what about someone whose
arm or leg is weak?
“A lot
of things can cause weakness,” Dr. Warach said. “A nerve injury
can cause weakness; sometimes brain tumors can be suddenly symptomatic. Sometimes
people have migraines that can completely mimic a stroke.”
In fact, he
said, a quarter of emergency room patients with symptoms suggestive of
a stroke are not actually having one.
Most get CT
scans, which are useful mostly to rule out hemorrhagic strokes, the less common
type that is caused by bleeding in the brain and should not be treated with
tPA. Stroke specialists can usually then decide whether the patient is having
a stroke caused by a blocked blood vessel and whether it can be treated with
tPA.
But most stroke
patients are handled by emergency room physicians who often say they are not
sure of the diagnosis and therefore hesitate to give tPA.
Dr. Richard
Burgess, a member of Dr. Warach’s stroke team, explained the situation:
There is no particular penalty for not giving tPA. Doctors are unlikely
to be sued if the patient dies or is left with brain damage that could have
been avoided. But there is a penalty for giving tPA to someone who is not
having a stroke. If that patient bleeds into the brain, the drug not only
caused a tragic outcome but the doctor could also be sued. Few emergency room
doctors want to take that chance.
There is a way
to diagnose strokes more accurately — with a diffusion M.R.I.,
a type of scan that shows water moving in the brain. During a stroke, the
flow of water slows to a crawl as dead and dying cells swell. In one recent
study, diffusion M.R.I. scans found five times as many strokes as CT scans,
with twice the accuracy.
A diffusion
M.R.I. “answers the question 95 percent of the time," Dr. Sorensen
said. It seemed the perfect solution, but it was not.
Most hospitals
say they cannot provide such scans to stroke patients. They would need both
an M.R.I. technician and an expert to interpret the scans around the clock.
They would need an M.R.I. machine near the emergency room. Most hospitals
have the huge machines elsewhere, steadily booked far in advance for other
patients.
It is simply
not practical to demand the scans at every hospital or even every stroke center,
said Dr. Edward C. Jauch, an emergency medicine doctor at the University of
Cincinnati and a member of the Greater Cincinnati/Northern Kentucky Stroke
Team.
“If you
made M.R.I. the standard of care before giving tPA, most centers would not
be able to comply,” Dr. Jauch said. And if it takes more time to get
a scan — as it often does — it might be better to forgo it and
give tPA immediately if the patient’s symptoms seem unambiguous.
Doctors do not
need an M.R.I. to diagnose and treat stroke, said Dr. Lee H. Schwamm, vice
chairman of the department of neurology at Massachusetts General Hospital.
But, Dr. Schwamm added, if the question is whether it helps, there is one
reply: “By all means.”
It has still
not been shown, though, that M.R.I. scans actually improve outcomes. It might
depend on the circumstances and the hospital, said Dr. Walter J. Koroshetz,
deputy director of the National Institute of Neurological Disorders and Stroke.
But some who
use M.R.I. scans, and who have studied them in research, say the system has
to change. They say enough is known about the scans to advocate having them
at every major medical center that will treat stroke patients. ...
In those awful
moments when she realized she had had a stroke, Dr. Fite, unlike most patients,
knew what to do. She told the ambulance crew to take her to Memorial Hermann
Hospital, even though it was about an hour away. She knew that it was one
of the Houston stroke centers, that Dr. Grotta worked there, and that its
doctors had experience diagnosing strokes and giving tPA.
When she arrived,
Dr. Grotta asked if she was sure she wanted the drug. Did she want to risk
bleeding in the brain? Dr. Fite did not hesitate. The stroke, she said, “was
just so devastating that I would rather die of a hemorrhage in the brain than
be left completely paralyzed in my right side.”
“In my
horrible voice, I said, ‘Yes, I want the tPA,’ ” Dr.
Fite said.
Within 10 to
15 minutes, the drug started to dissolve the clot.
“I had
weird spasms as nerves started to work again,” Dr. Fite said. “An
arm would draw up real quick, a leg would tighten up. It hurt so bad I was
crying because of the pain. But it was movement, and I knew something was
going on.”
Now, she looks
back with dismay on her cavalier attitude toward high blood pressure.
She knew very well how to prevent a stroke but, like many patients and despite
her medical training, she found it all too easy to deny her own risk.
Researchers
have known for years the conditions that predispose a person to stroke —
smoking, diabetes, high cholesterol and an irregular heartbeat known as
atrial fibrillation. But the major one is high blood pressure.
“Of all
the modifiable risk factors, high blood pressure leads the list,” Dr.
Sacco said. “With heart disease, you think more of cholesterol; with
stroke you think of high blood pressure.”
The reason,
Dr. Sacco said, is that with high blood pressure, the tiny blood vessels in
the brain clamp down so much and so hard to protect the brain that they can
become rigid. Then they get blocked. The result is a stroke. ...
Even when people
do try to control their pressure, doctors may not prescribe enough drugs or
high enough doses.
“They’re
on a couple of drugs, and the doctor doesn’t want to push it,” said
Dr. Jeffrey A. Cutler, a consultant to the National Heart, Lung and Blood
Institute and a retired director of its clinical applications and prevention
program.
The result is
that no more than half the people with high blood pressure have it under control,
Dr. Cutler said. He estimated that half of all strokes could be prevented
if people kept their blood pressure within the recommended range.
Another lost
opportunity to prevent strokes is the undertreatment of atrial fibrillation,
in which the two upper chambers of the heart quiver. Blood can pool in the
heart and clot, and those clots can be swept into the brain, lodge in a small
blood vessel and cause a stroke.
Strokes from
atrial fibrillation can largely be prevented with anticlotting drugs like
warfarin. Yet many who have the condition do not know it and many who know
they have it were never given or do not take an anticlotting drug.
Some strokes
can also be prevented by procedures to open obstructed arteries in the neck
that supply blood to the brain.
As for Dr. Fite,
she completely recovered. And she has changed her ways.
She was sobered
by the cost of her treatment and brief hospital stay — $96,000, most
of which was paid by her insurance company. But she was even more sobered
by how close she came to catastrophe.
Now, Dr. Fite
takes three blood pressure pills, a drug to prevent blood clots and a cholesterol-lowering
drug. She plans to take those drugs every day for the rest of her life.
“I was
so stupid,” she said. “Boy, when you go through this, you never
want to go through it again.”
“I have
been given that precious second chance,” she said. “I was so blessed.”
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