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Publication Date: Wednesday, November 09, 2005 Health & Fitness: When stroke strikes
Health & Fitness: When stroke strikes
(November 09, 2005) Strokes are still devastating, but new research and therapies offer hope
By John Flood
Special to the Almanac
For Dr. Peter Nelson, a physician in obstetrics and gynecology, the morning of January 1, 1996, was just another workday. After spending the previous day skiing at Lake Tahoe with his family, he woke prepared to start his new year doing what he did best: delivering babies at Stanford hospital.
He was 47 years old, an upwardly mobile professional working 16-hour days, with the best working years of his life ahead of him. And, except for the sensations of numbness in his left arm and left leg, he seemed fine that morning.
But, unknown to him, something was seriously wrong. A blood clot had suddenly blocked his carotid artery, cutting off the blood supply to the right side of his brain.
"I waited, thinking that it was just some stiffness," Dr. Nelson recalls. "I wasn't convinced it was a stroke because I discounted it as something that didn't happen to someone my age."
Dr. Nelson suffered an ischemic stroke, caused by a blood clot, which accounts for 83 percent of all strokes. Hemorrhagic strokes, caused by a sudden bursting of a blood vessel in the brain, represent the rest.
After spending 10 days in the hospital, he was admitted to a rehabilitation unit, where he received physical therapy until his insurance ran out and he was sent home.
"I was on my own," he says. "They told me that this was as good as it gets."
Left without a coordinated rehabilitation plan, Dr. Nelson had a severe attention deficit disorder that made it difficult for him to read three pages of a book at a stretch. He had a visual spatial deficit that showed up in making routine tasks, like hanging Venetian blinds, a five-hour project. And, his judgment was so impaired, and the damage to his left arm was so extensive, that he had to retire from his medical practice.
"I needed help getting dressed. I could not supervise my 3-year-old child. That was devastating," he says. "I went from a totally competent care provider to someone who was totally incompetent."
Quick action
Understanding and treating stroke have come a long way since Dr. Nelson was stricken. By mid-1996, a new drug called tissue plasminogen activator, or TPA, was approved by the federal Food and Drug Administration for stroke survivors.
TPA is a clot-busting medication that, if administered within three hours of the onset of an acute stroke, can dramatically improve the outcome for the stroke survivor.
According to Dr. Christine Wijman, director of the neural critical care program at the Stanford Stroke Center, TPA is now considered the standard of care for stroke patients.
Since TPA was approved, stroke treatment places emphasis on immediate, aggressive action that combines a variety of approaches: new drug therapies, stroke intervention devices and experiments in physical therapies.
New drug therapies offer hope to lessen disabilities. Neuroprotective agents, such as NXY-059, might help patients with ischemic strokes by increasing blood flow in the stricken areas of the brain.
For hemorrhagic stroke patients, a pro-coagulant called "activated factor seven" is designed to inhibit bleeding and reduce hemorrhaging in the brain within the first few hours of onset. NXY-059 and activated factor seven are now in phase-three clinical trials.
In the area of device intervention, the FDA approved the use the Merci Retrieval System in 2004. Created by Concentric Medical Inc., a medical device company in Mountain View, the Merci system removes a blood clot from the brain by using a catheter device. The catheter is inserted in the groin area and the retriever is guided into the carotid artery in the neck that leads to the brain. It finds the clot, captures it and removes it with a corkscrew-like effect.
"We can use the Merci device up to eight hours after the onset of symptoms," says Dr. Wijman. "I have seen it used more than 20 times. Sometimes it works beautifully," she says.
In addition to drug therapies and intervention devices, stem cells are being studied for their ability to regenerate brain cells and restore function.
The long road back
One of the biggest challenges in stroke-recovery research is the quest to find effective rehabilitation therapies that result in the stroke survivor's regaining his independence.
According to the National Institute of Neurological Disorders and Stroke, 700,000 people suffer a stroke each year, and as many as two-thirds require rehabilitation. Disabilities can include paralysis; problems with motor control; sensory disturbances; problems understanding language; loss of memory and cognitive disorders; and depression.
"When I was in medical school, stroke victims were told to go home and do nothing," says Dr. Wijman. "They stayed in bed. There were no therapies."
Today, with the assistance of advanced imaging technology, new physical rehabilitation machines, electrical stimulation devices, and pharmacological experiments, researchers are studying ways to create new neural pathways -- essentially rewiring the brain and the nervous system -- to assume new tasks.
Dr. Carolynn Patten, a research scientist at the Veteran's Administration hospital in Palo Alto, studies new techniques to adapt the nervous system and the brain after a stroke.
"What we know now is that the adult brain is capable of significant remodeling," Dr. Patten says. This does not mean that new cells are generated, she adds, but that existing cells may assume new functions.
The goal is to enhance repair and regeneration of the central nervous system by stimulating brain plasticity to improve motor function. Techniques, such as constraint-induced (CI) movement therapy and transcranial magnetic stimulation to see if the brain can reorganize itself, are two areas of interest to researchers.
CI forces the stroke survivor to use the affected side, such as a left arm, by restraining it. The survivor uses the left arm repetitively and intensively for several weeks.
According to a June 2000 study published in Stroke: Journal of the American Heart Association, brain activity improves with the CI therapy treatment.
Determination
Today, except for not being able to practice medicine, Dr. Nelson is doing remarkably well. While he still has limitations with his left hand, he enjoys many of the same things he did before the stroke.
He spends time with his 12-year-old and 6-year-old sons. He takes long walks. He hangs Venetian blinds in 20 minutes. He's active in the Peninsula Stroke Association, speaking to groups about stroke prevention and awareness. And, he can read an entire novel in one sitting.
"I even went skiing for the first time in 10 years, and I was fine," he says.
For Dr. Nelson, rehabilitation was largely a self-help program. "I've always had the attitude, when I have a problem, I'm going to work on it. No obstacle is too big to get over," he says.
"The unwillingness to pursue getting better leads to getting worse. The alternative is to quit and be a vegetable."
Even though caregivers told him not to expect significant improvement after one year, he still sees improvements today.
"The location of the stroke, and its magnitude, may be significant predictors of ultimate outcome," Dr. Patten says. "Other factors come in to play such as age, the general state of pre-morbid health, family and social support systems."
While it is difficult to predict to what extent a person will recover, anecdotal evidence suggests that the will to recover can play an important role in the outcome.
"I can see improvements between years nine and 10," Dr. Nelson says. "As long as I push myself, I know I'll get better. I haven't quit."
The warning signs of stroke
Stroke experts identify the following
symptoms as possible stroke indicators:
** Numbness of the face, arm or leg, especially on one side of the body.
** Confusion, trouble speaking or understanding speech.
** Difficulty seeing in one or both eyes.
** Difficulty walking, dizziness, loss of balance.
** Severe headache with no known cause.
Act quickly
The National Stroke Association emphasizes
the need to act quickly, and offers the following test, "Act F.A.S.T."
(Face - Arms - Speech - Time), if you think someone may be having a stroke:
F : Ask the person to smile. Does one side of the face droop?
A : Ask the person to raise both arms. Does one arm drift downward?
S : Ask the person to repeat a simple sentence. Are the words
slurred? Can he/she repeat the sentence correctly?
T : If the person shows any of these symptoms, time is important.
Call 911 or get to the hospital fast. Brain cells are dying.
Information about stroke
More information about stroke is available
at the following Web sites:
** Peninsula Stroke Association, www.psastroke.org; or call 565-8485.
** Stanford Stroke Center, strokecenter.stanford.edu/index.html.
** National Stroke Association, stroke.org.
** American Stroke Association, strokeassociation.org.
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