StrokeStrokeA Guide to Information &
Resources in Delaware
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Stroke: A Guide to Information and Resources in Delaware 1
Delaware Stroke Initiative 3
Stroke Education 6
Stroke is Brain Attack 10
The Basics of Brain Attack 12
A 10-Point Plan for Ischemic Stroke 13
Preventing Stroke 15
Quit Smoking to Reduce Stroke Risk 17
Atrial Fibrillation: Understanding & Managing an Irregular Heartbeat 19
Having a Stroke 21
My Stroke 22
Call 911 at the First Sign of Brain Attack/Stroke 23
Emergency Management of Stroke 25
Stroke Centers Help Reduce Death and Disability 27
The Role of Surgery in Stroke Prevention and Treatment 28
Neurologists Specialize in Treatment of Stroke 29
Neuropsychological Assessment of Stroke 30
Stroke Treatments: Hope for the Future? 32
St. Francis Specializes in Stroke Care 34
Healthy Spirituality & Well-Being 36
Physical Rehabilitation After Stroke 37
Recovery: A Time of Relearning 39
Aging with a Disability 40
Caregivers Need Care, Too! 44
Stroke Information Resources 46
Resources include a glossary of terms, suggested reading list, web sites, national
organizations, state and local organizations, adult day care, care or case management,
companion programs, counseling/mental health services, elder law programs, employment,
home health care agencies, exercise programs, transportation, senior services and health
organizations, stroke support groups, accessible activities, technology, telephone
reassurance programs, and other resources and products.
Stroke Risk Screening Questionnaire 65
DSI Stroke Resource Guide Order Form & Free Listings 67
Delaware Stroke Initiative Membership & Volunteer Form 68
2 Delaware Stroke Initiative
The purpose of this resource guide published by the Delaware Stroke Initiative (DSI) is to provide stroke
survivors as well as their families, friends, and caregivers with useful information to help them adjust to life
following a stroke or brain attack. It also provides information about prevention for those who may be at
risk for stroke and how to prevent another stroke after recovering from a stroke.
It has been estimated that approximately one-third of all stroke survivors will have another stroke within
5 years of their initial stroke. In American today, approximately four out of five families will be touched
by a stroke. According to the Framingham Study data collected in 1991 and published by the American
Heart Association in 1996, approximately 31% of stroke survivors will require assistance following a stroke;
about 20% will require help walking and 16% become institutionalized; and 1/3 of stroke survivors will be
impaired, 1/3 will be moderately impaired and 1/3 severely impaired.
The guide includes educational information about the types of stroke, warning signs of stroke, stroke risks
as well as a collection of articles that address prevention, personal experiences, diagnosis and treatment
of stroke. Resources listed in this publication include a glossary of stroke terms, suggested reading
material, web sites, and national and state organizations that provide information, social activities and
assistance for stroke survivors.
The Delaware Stroke Initiative (DSI), a 501 (c)(3) non-profit association, was founded by Ellen Barker in
1999 as the only non-profit organization in Delaware that is totally dedicated to stroke. DSI’s mission is to
reduce the incidence of stroke and to improve outcomes. The organization is comprised of a Board of
Directors (BOD) with representation from the medical community, corporate sponsors, support groups,
local businesses, stroke survivors and a passionate base of volunteers. DSI recognizes stroke as a major
health problem and the third leading cause of death in Delaware and the leading cause of adult disability.
With the knowledge that more women die each year from stroke than die of beast cancer and that every
minute in the United States someone experiences a stroke, DSI is committed to reducing death, disability
and dependency from stroke in Delaware. The best treatment is prevention.
For more information about DSI, visit our Web site at: www.destroke.org, call the DSI office at (302) 633-
9313, email us at: email@example.com or visit our office at the Metroform Medical Complex,
620 Stanton-Christiana Road, Suite 302 in Newark, Delaware.
NOTE: This publication is presented for the purpose of education about stroke. Nothing herein should be
construed as medical diagnosis or treatment advice. The information contained should not be used in the
place of calling your physician or health care provider. Please contact your physician or health care provider
for your individualized health care, questions or additional information about stroke.
Stroke: A Guide to Information and Resources in Delaware 3
DELAWARE STROKE INITIATIVE
In 1998, a group of concerned Delawareans recognized the need for a non-profit organization dedicated
solely to stroke prevention, risk assessment and recovery within the state of Delaware. The organization
would serve to create increased public awareness that stroke is a “brain attack” and a major health
problem in our state. Stroke is the third leading cause of death after heart disease and cancer and the
number one cause of adult disability in Delaware that commonly affects individuals over the age of 55,
often with permanent, life-long neurological deficits or disabilities. Stroke affects not only the individual,
but the entire family with serious economic and emotional burdens. Of particular concern was the minority
populations which have a higher stroke rate than Caucasians.
Despite medical advances and the approval
of tissue Plasminogen Activator (tPA) in 1996
as the first drug to treat acute ischemic stroke,
individuals with symptoms of stroke fail to arrive at
a hospital emergency department within the three-
hour treatment time for the best outcome. Public
education on how to recognize the warning signs and
the need to call 911 for immediate transportation to
the hospital has not been effective.
Ellen Barker, a neuroscience nurse, founded the
Delaware Stroke Initiative (DSI) with support from
a dedicated group of members that included
physicians, health care providers, business and
corporate interests, and very importantly, stroke
survivors. The non-profit association was formed
with guidance from Jeffery Dano, MD, president of
the Philadelphia Stroke Organization. Nicholas Teti,
president and CEO of DuPont Pharmaceuticals,
became the first president. In 1999, the IRS granted
DSI tax exempt, non-profit status as a Delaware
Since DSI’s inception, its mission has been to
prevent stroke, offer risk assessment with free Stroke
Screening, and improve the clinical management of
those hospitalized. Programs have included annual
educational conferences for medical professionals,
family health fairs, free stroke screenings, the
“Thumbs Up” free stroke support group, a Stroke
The Delaware Stoke Initiative’s mission
is to improve stroke prevention, risk
assessment and recovery through
education, support and advocacy.
It is important to educate the public that
stroke is a life-threatening “Brain Attack.”
For our goals, DSI endeavors to:
g Foster awareness that many stroke
can be prevented
g Increase awareness that strokes need
to be treated as an emergency
g Educate the public to recognize the
warning signs of stroke
g Encourage the public to call 911
at the first symptoms for rapid
transportation and medical care
g Promote free stroke risk screenings to
identify individuals at risk and for risk
g Promote recovery and rehabilitation
g Develop and implement programs to
advance our mission and goals
g Strengthen and expand partnerships
that share our goals and mission
4 Delaware Stroke Initiative
Resource Guide and a speaker’s bureau for community groups interested in stroke prevention or how to
reduce death and disability from stroke. DSI has served Delaware with many programs and activities to
further its mission to improve education, risk assessment and recovery, through education, support and
The Board of Directors has consistently maintained a strong belief that because of its single-minded
focus on stroke, DSI is uniquely capable of collaborating with other organizations in the state to marshal
resources, activities and commitment to deliver consistent and complementary stroke programs for stroke
within the state of Delaware.
DSI “Thumbs Up” Support Groups
Following a stroke, individuals may need support in understanding and dealing with stroke-related
effects and physical and social functioning. Stroke survivors may be young or older adults, minimally or
severely physically or cognitively impaired, employed or unemployed, and have few family and community
resources available to them. Successful recovery from a stroke is not limited to physical recovery or
return to the pre-stroke level.
Reintegration to normal life at home may require many adjustments. There may be very subtle or
very noticeable changes in personality after a stroke that affect mood, sexual functioning, problem-
solving, and sensory changes that affect the quality of life. DSI is pleased to support the “Thumbs Up”
support group as an important community service to help stroke survivors and their families learn about
community resources, get educational information and share their personal experiences in a positive and
Anyone who has recovered from a stroke, their families and friends are welcome to attend. Health
care professionals are also invited to attend and participate in meetings. Parking and all meetings are
free of charge. The facility is on the first floor and is wheelchair accessible
If you would like to be considered as a speaker or if your agency would like to sponsor an activity,
special lecture or presentation for the DSI support group, please call the DSI office and leave a message
for Ms. Johnson.
Facilitator: Lola Johnson, MS, RN, CS, an advanced practice nurse
Meetings: Second and fourth Thursdays of the month, September through June.
Time: 7:00 p.m.
Location: NewArk United Church of Christ, 300 East Main Street, Newark, Delaware
Information: Call (302) 633-9313 or visit our web site at www.destroke.org
Stroke: A Guide to Information and Resources in Delaware 5
Executive Board of Directors
Chair: Lee Dresser, MD
Wilmington Neurology Consultants
Vice Chair: Ross Megargel, DO
State of Delaware Emergency Services Director, Emergency
Secretary/Treasurer: Ellen Barker, MSN, APN Neuroscience
Susan G. Whitehead
MEMBERS OF THE BOARD
Sandi Bihary, MSN, RN
Director of Pubic Relations ALLY Development Public Affairs,
Kathryn M. Curtis, RN, APN
Christiana Care Health System, Liaison for the Delaware
Nurses Association (DNA) Advanced Practice Nurse Council
Clinical Specialist/Vascular Division Genetech
Vance A. Funk, III, Esquire
Stroke Survivor and Mayor of Newark
Glen D. Greenberg, PhD
Clinical Psychologist, N& G Neurobehavioral Group
Alberta Iaia, M.D.
Kathy Janvier, RN, PhD
Delaware Technical Community College
Lola Johnson, MS, RN, CS
DSI Support Group Facilitator
Moonyeen Klopfenstein, RN, MS
Christiana Care Health System
Yakov Koyfman, M.D.
Jeffery H. McMahon
Anne Murray, MS, RN
Parish Nurse Representative and Liaison
Edward Sobel, D.O.
Quality Insights of Delaware and Family Practice Physician
John Scholz, PhD
University of Delaware Physical Therapy and Biomechanics &
Movement Disorders Science Doctoral Program
Wilmington Trust Company
DSI ADVISORY BOARD
Jerry Castellano, PharmD
Corporate Director, Institutional Review Board, Christiana
Linda Swartley, RN, JD
Contracts, Christiana Care Visiting Nurse Association
The Delaware Stroke Initiative (DSI) Board of
Director meets quarterly on the first Tuesday of
March, June, September and December. All Board
of Directors’ dinner meetings are held at 6:15 p.m.
at St. Francis Hospital, 7th and Clayton Streets in
The public part of the meeting is open to
anyone who would like to attend. We request that
you call the DSI office at (302) 633-9313 at least
three days prior to the meeting so that additional
food can be ordered for the number of guests
2004-2005 DSI BOARD OF DIRECTORS
6 Delaware Stroke Initiative
What is a Stroke?
The brain is responsible for coordinating how we move, think, speak, hear, see, feel, and behave. To
function properly, brain cells must have a continuous supply of oxygen and other nutrients from the blood.
When the blood supply is disrupted, even for a few minutes, areas of the brain may be damaged and a
person may suddenly lose some of the functions controlled by that region of the brain. This sudden loss
of function is referred to as a stroke.
Blood is continuously pumped from the heart to the brain via several artery groups. Within the brain,
these arteries branch into smaller and smaller arteries and then into tiny thin-walled vessels (called
capillaries) which supply the oxygen and nutrients that the brain tissue needs. It is when this continuous
blood supply is disrupted that brain cells die and a stroke results. A stroke is the result of a sudden
blockage caused by a clot, narrowing of an artery, or bursting of a blood vessel. It is this distinction that
defines the main types of stroke.
Types of Stroke
The two main kinds of strokes are known as ischemic and hemorrhagic.
Ischemic is the most common type of stroke and
constitutes an estimated 80 percent of all strokes. An
ischemic stroke results when a blood vessel leading to the
brain becomes blocked. This type of stroke may occur for
three main reasons:
1) A blood clot (or thrombus) forms inside an artery
in the brain, blocking the flow of blood. Referred to
as thrombotic stroke, this is the most common type
of ischemic stroke. Blood clots form most often in
arteries damaged by atheroscelerosis, a disease in which rough fatty deposits, or plaque, build
up on the walls of the artery and can break off. These de-posits slow the blood flow and provide a
surface that supports the formation of blood clots.
2) A clot forms in the blood, but unlike thrombotic stroke, it originates somewhere other than the
brain. This type of stroke is referred to as an embolic stroke and occurs when a piece of clot
(an embolus) or plaque fragment breaks loose and is carried in the bloodstream to the brain. An
embolus can form in many places in the body, including the heart and the arteries of the neck
that transport blood to the brain. The embolus travels through the arteries, which branch off into
smaller vessels. When it reaches a point where it can go no further, it plugs the vessel and cuts off
the blood supply to the area of the brain that is supplied by that vessel.
An estimated 80 percent
of all strokes are ischemic,
resulting when a blood
vessel leading to the brain
Stroke: A Guide to Information and Resources in Delaware 7
Note: Both thrombotic and embolic strokes
are referred to as ischemic because the
blood supply has been blocked to the
brain area. You may hear of the term
cerebral infarction in connection with
thrombotic and emobolic types of stroke.
Cerebral refers to the brain. An infarct is an
area of tissue death due to a blockage of
blood flow, such as a blood clot. It is also
a result of ischemia, which refers to an
inadequate blood (and therefore oxygen)
supply to a certain part of the body.
3) Blood flow decreases to the brain which
can result from poor overall blood flow
in the body due to heart damage or
dysrhythmia (irregular heart rhythm that
makes pumping inefficient or ineffective).
This less common type of ischemic stroke
is called systemic hypoperfusion.
The second main type of stroke is hemorrhagic
and occurs when a blood vessel in or around the
brain ruptures or explodes. This rupture not only
denies the blood from reaching its destination, it
also causes a leakage of blood into the brain or the
area surrounding the brain. When this happens, the
cells nourished by the artery are unable to obtain
their normal supply
of nutrients and stop functioning properly. Blood
begins to accumulate and clot soon after the rupture
of the artery, causing a disruption of brain function
and potentially increased pressure on the brain
itself. Cerebral hemorrhage is most likely to occur in
people who suffer from a combination of atheroscle-
rosis and high blood pressure.
Warning Signs and
Symptoms of Stroke
Symptoms of stroke may vary greatly
depending on the cause of the stroke, the
specific part of the brain affected, and the
amount of damage. Some common signs
and symptoms following a stroke include:
g Sudden weakness, numbness, or
paralysis of the face, arm, or leg—
especially affecting one side of the
body (hemiplegia, hemiparesis)
g Loss of speech or difficulty talking
or forming words, the inability to
understand what others are saying
(apraxia, aphasia, dysarthria)
g Temporary loss of memory;
g Sudden blurring or loss of vision,
particularly in only one eye
g Sudden severe headaches with no
g Unexplained dizziness, loss of balance
or coordination, unsteadiness, or
sudden falls (especially if associated
with any of the above symptoms)
8 Delaware Stroke Initiative
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If you or your loved-one has had a stroke, recovery will require multiple therapies.
Easter Seals offers physical,occupational,and speech therapies as well as
Adult Day Health Services and AssistiveTechnology all in one convenient location.
For more information call
Adult Day Health Services
AdultDayHealthServicesprovides a safe alternative to long
term care for stroke survivors that should not be home alone.
The program includes activities, meals, and nursing
supervision in a comfortable and dignified environment.
Assistive Technology, referred to as AT, is devices or tech-
niques used to increase,maintain or improve functional
capabilities of individuals with disabilities.
Occupational Therapy - Finding new ways to use your
hands and upper body to perform tasks like dressing,eating,
bathing, or preparing meals.
Physical Therapy - treatment to improve strength, flexibil-
ity, tone or balance and coordination in walking or moving.
Speech Language Therapy - Help with communicating
with language or speech, and exploring alternative means
Easter Seals is a proud
Transient Ischemic Attack (TIA)
About one-third of all strokes are preceded by one or more transient ischemic attacks (TIAs) or what
are sometimes referred to as “mini-strokes.” TIAs can occur days, weeks, or even months before a stroke
and are caused by temporary interruptions in the blood supply to the brain. The symptoms resemble
those of a stroke, but occur quickly and last a relatively short time.
Because TIAs are temporary and quickly allow the body to return to complete recovery, it is easy to
ignore them or to believe the problem has disappeared. However, the underlying problem that caused the
TIA continues to exist. Therefore, attention must be paid to these symptoms and a TIA must be viewed as
an early warning sign of a potentially serious stroke in the future.
If you or someone you know experiences a TIA, it is important to seek the assistance of a health
care professional. Call your doctor immediately or go to the closest emergency department, even if the
symptoms seem to be disappearing or getting better.
Some of the most common risk factors, which may increase the likelihood of a stroke, are listed below.
It is possible that lifestyle modification or medical treatment can change these factors.
g High blood pressure
g Irregular heartbeat (atrial fibrillation)
g Narrowing of the arteries of the neck (carotid)
g Heart disease
g Previous stroke or TIA
Stroke: A Guide to Information and Resources in Delaware 9
g Excessive alcohol use
g High cholesterol level
g Obesity and failure to exercise 30 minutes daily three times per week
g Prolonged and extreme stress
g Substance abuse (cocaine, crack, heroin, speed, amphetamines, diet pills or ecstasy)
g Use of oral contraceptives (especially for women who smoke)
There are some risk factors based on hereditary factors, which cannot be controlled by lifestyle
changes or medication. These factors relate to demographic categories for which there
is an increased likelihood of experiencing a stroke.
g Age—Two thirds of strokes occur in persons over the age of 65
g Gender—Stroke is 25 percent more common in men than women
g Race—African Americans have a higher rate of stroke than Caucasians and more often suffer
strokes at an earlier age
g Sickle Cell disease
Reducing Your Risk
Below is a list of suggested measures to control
your stroke risk through medical treatment as well as
healthy lifestyle modifications.
g Regular medical check-ups
g Control blood pressure
g Stop smoking
g Improve diet—avoid excess fat and sodium
g Limit alcohol intake
g Engage in appropriate exercise 30 minutes
per day, three times per week
g Take medicines as directed
g Reduce and better manage stress
g Never use drugs such as cocaine, crack,
heroin, ecstasy or speed
g Control diabetes
10 Delaware Stroke Initiative
STROKE IS A BRAIN ATTACK
by Cynthia Callaghan
Public Affairs, AstraZeneca Pharmaceuticals LP
By the time you finish reading this article, three Americans will suffer and one will die from a brain
attack/stroke. Annually, brain attacks are the leading cause of serious, long-term disability in the United
States and the third leading cause of death (160,000 fatalities annually). Brain attacks strike approximately
750,000 Americans every year, with the highest rates occurring in the southeastern part of the United
States, commonly referred to as the Stroke Belt.
As a communication professional, my job is to create educational initiatives that convey important
information and key messages to targeted audiences through national and local media efforts, and
grassroots programs (e.g., the Delaware Stroke Initiative). This dedicated group of volunteers provide
accurate information about prevention, detection, and treatment of the disease. In the case of brain
attack, the key messages we deliver inform the public about risk factors, symptoms, and treatment
Reducing the Risk of Brain Attack
DSI develops educational materials to reach the public
through various communication vehicles, such as the media.
These vehicles provide individuals with tools and information
that can empower them to change their lifestyles (e.g. quit
smoking, lose weight, reduce high cholesterol and excessive
alcohol consumption, and stop illegal drug use). We encourage
people to see their doctors and health care providers about
treatment for modifiable risks (e.g. hyper-tension, diabetes,
atrial fibrillation, carotid artery disease, and transient ischemic
attacks). Of course, some risk factors are uncontrollable, such
as age, gender, race, and family history, but we strive to ensure
that those at risk are aware.
Stroke is a Brain Attack and a Treatable Emergency
Since time between onset of brain attack symptoms and treatment is critical to survival and
minimization of disability, the public needs to be well informed of the symptoms and the urgency to call
911 if they feel the onset of symptoms. The warning signs that accompany a brain attack occur suddenly
and can include:
g Sudden numbness or weakness of the face, arm or leg, especially on one side of the body;
g Sudden confusion or trouble speaking or understanding speech
g Sudden vision problems in one or both eyes;
g Sudden trouble walking, dizziness, or loss of balance or coordination; and
g Sudden severe headache with unknown cause.
Brain attacks strike
Americans every year,
with the highest rates
occurring in the
southwestern part of
the United States,
commonly referred to as
the Stroke Belt.
Stroke: A Guide to Information and Resources in Delaware 11
Treatment Options Exist
For those who suffer a brain attack and reach the hospital within three hours, treatment options are
available. The type of treatment administered will depend on the type of stroke and the length of time
since onset. Therefore, it is important that individuals be aware of when their symptoms began and
receive medical attention as quickly as possible. For example, if an individual experiences an ischemic
brain attack (blood vessel blockage in the brain) and reports to a hospital within three hours, he/she may
be eligible for intravenous thrombolytic therapy. However, thrombolytic medications, such as t-PA (tissue
plasminogen activator), should not be given to those experiencing a hemorrhagic brain attack/stroke
(rupture of a blood vessel).
New Treatments on the Horizon
Patients should also be aware that there are new treatments under investigation called neuro-
protective agents, which minimize the effects of an ischemic cascade. These agents provide a
complementary clot busting and brain protection mechanism and may be a benchmark for the future of
acute stroke treatment.
At the Delaware Stroke Initiative, our most important job is not just communicating what we know
about brain attack, but rather to support research that will help us better understand the disease while
developing new, innovative medications to treat and minimize its long-term effects. In the interim, we will
continue to provide the public with accurate information through our ongoing commitment to brain attack
research, awareness, and treatment.
C O N S U L T A N T S, P. A.
WILLIAMS SOMMERS, D.O.*
PAUL A. MELNICK, M.O.*✝
N. JOSEPH SCHRANDT,M.D.* ■ ●
LEE P. DRESSER, M.D.* ■ ▲
RICHARD J. SCHUMANN,JR., M.D.*
K.ALVIN LLOYD, M.D.*
METROFORM MEDICAL COMPLEX
620 Stantion-Christiana Road, Suite 302 • Newark, DE 19713
302.892.9400 phone • 302.892.9407 fax
ST. FRANCIS MEDICAL OFFICE BUILDING
7th and Clayton Streets, Suite 217
Wilmington, DE 19805
UNION HOSPITAL OF CECIL COUNTY
106 Bow Street
Elkton, MD 21921
Diplomate American Board of Neurology • ✝
Diplomate American Board of Electrodiagnostic Medicine
Added Qualifications in Neurophysiology • ●
American Board of Clinical Neurophysiology
American Board of Sleep Medicine
WILLIAMS SOMMERS, D.O. LEE P. DRESSER, M.D.
N. JOSEPH SCHRANDT, M.D. RICHARD J. SCHUMANN, JR., M.D.
K. ALVIN LLOYD, M.D.
METROFORM MEDICAL COMPLEX
620 Stanton-Christiana Road, Suite 302 • Newark, DE 19713
(302) 892-9400 phone • (302) 892-9407 fax
ST. FRANCIS MEDICAL OFFICE BUILDING
7th & Clayton Streets, Suite 217
Wilmington, DE 19805
12 Delaware Stroke Initiative
THE BASICS OF BRAIN ATTACK
by Yakov Koyfman, M.D.
Delaware Neurosurgical Group
A stroke is a “Brain Attack” or a cerebrovascular event caused by an interruption of blood flow to the
brain—from either a clot inside the artery (ischemic stroke) or from a rupture of an artery in the brain
(hemorrhagic stroke). When the blood flow to the brain is interrupted, the affected brain cells are impaired
and can no longer function. The brain requires about 50 percent of the total blood supply that flows
through the body. The brain lacks the capacity to store glucose, or sugar, that is converted to energy that
helps the brain to function. The brain is unable to store oxygen and needs a steady supply to keep the
brain healthy and functioning normally.
Circulation of Blood in the Brain
Normally, the brain receives a constant supply of blood that provides essential nutrition and energy
(glucose) as well as oxygen. If the brain does not receive a constant flow of blood, brain cells begin to
starve and fail to function. This is called ischemia. During a brain attack/stroke, blood flow is cut off or
reduced to the core, or important parts of the brain, supplied by the artery that is obstructed by the
blood clot (infarction). In this core ischemic area, brain cells die within 3-5 minutes! There is a large area
surrounding the core known as the penumbra. Brain cells in this area are stunned and disabled, but still
alive. It is very important to know that brain cells can survive in this ischemic penumbra for up to 3-6
hours before dying. This is the area emergency teams try to salvage and treat when the patient is brought
in following a stroke.
Early Warning Signs
The most prominent warning sign of hemorrhagic stroke is a severe headache—“the worst headache
of my life!” To help distinguish this headache from common headaches, we use the saying: “First, Worst,
and Cursed!” It is absolutely imperative to seek medical attention if this is the first severe headache, worst
severe headache, or if you feel cursed with these symptoms. Sentinel headaches are much harder to rec-
ognize. These headaches are often caused by much smaller or “mini leaks” of blood in the subarachnoid
space of the brain or by the effects of an aneurysm enlarging. Most individuals are unaware of an aneu-
rysm in the brain until it leaks or ruptures. If there is something unusual about a headache, it is absolutely
mandatory to call the doctor.
Stroke: A Guide to Information and Resources in Delaware 13
A 10-POINT PLAN FOR
by Robert N. Albino
The risk of stroke increases with age, especially after age 65. My mother and father at ages 72 and 69
years, respectively, are moving onto the steep part of the curve for stroke. Like others in their age group,
they are fearful of strokes, and for good reason. While they are more likely to die of a heart attack, they
are much more likely to be seriously disabled by stroke. Their concern was heightened after the recent
stroke of a long-time friend, who they saw reduced from vigorous health to significant impairment in a
matter of days. Knowing of my work in stroke, they asked me what they could do to reduce the risk of
stroke and what they should do in the event of a stroke. This is the Ten-point Plan for Ischemic Stroke that
I developed for them.
1. Manage your Risk Factors
Personal behaviors that increase stroke risk are essentially the same as for heart disease: a high-fat diet,
smoking, excessive alcohol consumption, a sedentary life-style, and illicit drug use. Also, uncontrolled or
unmanaged high blood pressure, diabetes mellitus and atrial fibrillation or other cardiac or peripheral
artery disease contribute to stroke risk.
2. Know the Signs and Symptoms
Symptoms include: Sudden weakness or numbness of the face, arms or legs, especially on one side;
sudden difficulty seeing, especially out of one eye; sudden confusion, trouble speaking or understanding;
and nausea, headache or dizziness with sudden onset.
3. Don’t Ignore TIAs
A “TIA” or transient ischemic attack or “mini-stroke” is a stroke in which the signs and symptoms resolve
relatively promptly without apparent permanent effect. Don’t ignore even a single TIA; it indicates that
conditions are ripe for a stroke and is a strong predictor of future stroke. Usually, it is only a matter of time
until the “big one.” In the event of a TIA, see your doctor promptly.
4. Involve Your Physician
Many physicians are very attentive to stroke risk factors, other aren’t. Raise the subject yourself. Ask for
him to listen to your carotid (neck) arteries for telltale signs of narrowing. Ask if any brain imaging studies
are appropriate, and, if you have any of the diseases that add to stroke risk ask if it is appropriate to use
medical therapy to reduce that risk.
5. Know Where to Go in the Event of a Stroke
Hospitals are not equal when it comes to treating stroke. Look for a hospital with a dedicated stroke
center, preferably headed by a stroke neurologist. The facility must absolutely have 24-hour access to CT
scanning (including a CT technician) and experience in administering tPA for stroke. Ask the hospital, ask
your doctor, and visit the hospital. Do it now—not when you need it.
14 Delaware Stroke Initiative
6. Know How to Get There
Ambulance has certain advantages and disadvantages. First, it takes time for the ambulance to get to
your location. Second, not all ambulances will take you to the facility of your choice. Some localities have
a “closest facility” policy and that could cost valuable time if you have to be taken to a second facility
to receive tPA. Also, even when ambulances will normally take you to the facility you specify, or to a
designated stroke facility, that facility may be on “diversion,” meaning that they are temporarily sending
patients to an alternate facility. If you learn that the policies in your area don’t meet your needs, make
other arrangements to get to the hospital.
7. Know How Long You Have
Stroke is a progressive process. The earlier you intervene, the better your chances for a favorable
outcome. The only approved medical therapy for stroke is the “clot buster” tPA, which must be
administered within three hours of stroke onset. Considering it takes about an hour for the best of
hospitals to do the necessary tests to determine whether or not you qualify for tPA, you need to reach the
hospital within two hours of onset at the absolute latest. But don’t run the clock down.
I suggest you have no more than 15 minutes to decide whether your symptoms constitute a TIA or the
real thing. If the signs and symptoms have not resolved completely within this time, go to the hospital.
(NOTE: At the first sign of stroke, write down the time that symptoms began, put it in your pocket, and take
it with you to the hospital. More than a few patients have failed to receive tPA solely because it could not
be conclusively determined when the stroke began.)
8. Know What to do at the Hospital
Be sure you are getting prompt attention. You should be treated with the same urgency as a heart attack
patient. If you aren’t, speak up. Loudly. In order to receive tPA you will need a physical exam, medical
history, certain blood tests and a CT scan (not necessarily in that order). Make sure these are started
promptly, certainly within 15 minutes of arriving at the hospital.
9. Participate in Trials
If for some reason you are ineligible to receive tPA and are offered an alternative, take it. Many hospitals
with stroke centers participate in clinical trials of new, experimental therapies—and there is little to lose
and potentially much to gain from such therapies. If you are offered a non-medical therapeutic option, I
would give you the same advice. Trust the hospital and the treating physician to recommend a therapy
that is the best available in your situation.
10. Do Your Rehab
If you do have a stroke that results in any deficit, you will almost certainly be prescribed therapy to
improve function. Do the therapy. Religiously. The sooner therapy starts the more effective it is.
Stroke: A Guide to Information and Resources in Delaware 15
by Robert W. Frelick, M.D.
DSI Board of Directors
The most common type of stroke is caused by lack of blood supply to one or more vessels of the
brain. A stroke is more likely to occur after the age of 50. It is often associated with a history of high
blood pressure (hypertension) and a disturbance of the blood lipids (most commonly measured by the
level of cholesterol in the blood). Those lipids develop into plaques that slowly grow to obstruct one of
the main arteries to the brain, or within one of the smaller
end arteries to an area of the brain. These smaller arteries
in the brain are called “end arteries” because they lack the
risk capillary network found in most other parts of the body.
An obstruction of one of these small end arteries causes
damage to the part of the brain that it supplies.
Bleeding from a leak in one or more of the blood
vessels to the brain may also cause the lack of blood to the
brain. This frequently can be related to a small “bubble” or
aneurysm on a blood vessel. Such a finding may be present
because of a genetic abnormality or blood infection, or the
cause may be unknown. The aneurysm may rupture at any
age but more frequently occurs after age 50. Such bleeding
can be stimulated by high blood pressure, stress or a blow to the head. A brain tumor—whether a primary
cancer or secondary to cancer elsewhere in the body—can also cause obstruction to a blood vessel and
cause a stroke-like attack.
Brain Attack/Stroke Risk Factors
Abnormal blood pressure (hypertension), increased weight or obesity, elevated cholesterol, and high
blood sugars are risk factors that are often present years before a stroke.
Surgeon General David Satcher, M.D., reported recently that approximately 300,000 American die each
year from illnesses caused or worsened by obesity. Satcher estimates that approximately 60 percent of
adults are overweight.
Certain drugs and chemicals can also increase the risks for brain attack/stroke; e.g., nicotine
from tobacco, estrogen in birth control pills and the use of certain illicit drugs. People using warfarin
(Coumadin) for atrial fibrillation should carefully control their medication to prevent complications.
Lack of oxygen to the brain, whether mountain climbing, scuba diving, or from smoke inhalation from a
fire can also have adverse effects and stimulate a brain attack/stroke.
Following safety guidelines during these activities and avoiding “risk taking” is recommended.
Early preventive measures can reduce the risk of a stroke or delay its appearance.
The carotid arteries and other major blood vessels in the neck can also be tested to determine if a
blockage is present. The blockage must be more than 70 percent to significantly reduce the blood supply
to the brain. A neurosurgical consultation is indicated to review treatment options.
A stroke is more likely to
occur after the age of 50.
It is most often associated
with a history of high
blood pressure and a
disturbance of the blood
lipids (measured by the
level of cholesterol).
16 Delaware Stroke Initiative
Other Diseases Associated With Brain Attack/Stroke
Certain diseases have been associated with a brain attack/stroke; e.g., diabetes, heart disease,
hypertension, renal problems, sickle cell disease, diseases of the blood vessels, Lupus, and certain
cancers. These diseases are tied to genetic factors and can often be anticipated based on family history.
This is especially true for hemangiomas and aneurysms. Individuals experiencing any of the above risk
factors should consult their physician or health care provider.
Adopting a healthy lifestyle can reduce the risk of stroke as well as many other chronic diseases.
An important part of good health is diet. Eat a nutritious diet that is relatively low in saturated fats and
excessive sugars. Select reasonable portions, reduce calories, and increase fresh fruits and vegetables in
the daily diet.
It is time to “get off the couch” and engage in daily exercise activities. Use nearby sidewalks and
walking trails, and identify and include physical activity on the job. Set a goal of exercising at least
30 minutes at least three times each week. Keeping physically active is recognized as an important
preventive measure against stroke.
The wisdom of avoiding exposure to tobacco products (cigarettes, cigars, chewing tobacco) and
abuse of alcohol (more than two drinks of liquor, two glasses of wine, or two beers) and addicting drugs
(Cocaine, Crack, Heroin, Speed, Amphetamines, diet pills or Ecstasy) is clear.
Annual Physical Exams and Medical Follow-up
Seek expert medical advice. Have regular check ups and stay under medical surveillance. Follow the
advice of your physician and other health care providers regarding diet, cholesterol and lipids, weight,
diabetes, blood pressure control and cardiovascular diseases (e.g. brain attack/stroke and heart disease)
to reduce known and modifiable risk factors. Some people may be prescribed a baby aspirin a day, or
other medications, to reduce the risk of a stroke or heart attack.
Taking Action When You Have Symptoms
It is very important to be aware of and take immediate action to seek help in a hospital emergency
department at the first signs of a brain attack/stroke. They include:
g Sudden weakness or numbness
g Sudden change in vision
g Sudden difficulty speaking
g Sudden unusual headache
g Sudden dizziness
Do not wait for such symptoms to go away before taking action because they may gradually become
worse. Call 911 immediately for transport to the nearest hospital emergency department that treats
brain attack/stroke. Remember that there is a 3-hour time period for the most effective treatments by
competent medical help to be effective for the best outcome.
Stroke: A Guide to Information and Resources in Delaware 17
QUIT SMOKING TO REDUCE STROKE RISK
by Linda Swartley, RN, JD
Advisory Board, Delaware Stroke Initiative
Cigarette smoking is a known risk factor for stroke. Quitting smoking is the single most important step
you can take to lower your chances of stroke, cancer, and heart attack.
Once you make up your mind to quit, set a date one-week from today and mark it on your calendar.
Prepare to stop smoking by gradually cutting down 1 to 2 cigarettes per day. When you reach the quit
date on your calendar, get rid of all your cigarettes, ashtrays and smoking paraphernalia. Tell your family,
friends and coworkers you want their support to quit. Ask them not to leave cigarettes around, and not to
smoke around you. Change your habits and remove all cigarettes, lighters, and ashtrays from your home,
car, and anywhere else you usually smoke. Talk to your health care provider about aids to assist you to
The Food and Drug Administration has approved nicotine substitutes as aids to stop smoking
including the nicotine gum and nicotine patch, available over the counter, and the nicotine inhaler, and
nicotine nasal spray inhaler, available by prescription. Bupropion SR also called Zyban is available by
prescription as well. Talk to your health care provider and read the product literature carefully. These
medications will double your chances of success in quitting.
Programs are available at hospitals and health centers and
through the American Lung Association and the American Heart
Association. Hypnosis and acupuncture are options if given by a
reputable provider. Some of these offer telephone support and
Be prepared for difficult situations and relapses. Most
relapses occur within the first three months. When temptation
strikes, don’t smoke—not even a puff. Beware of situations
that lessen your resolve: being around other smokers, drinking
alcohol, and weight gain. Many smokers gain weight—usually less
than 10 pounds. Don’t let weight gain distract you from the main goal of quitting. As Mark Twain once said,
“Giving up smoking is easy, I’ve done it a thousand times.”
Learn new coping behaviors. Change your routine. Reduce your stress by exercising, reading a good
book, or taking a hot bath. Reward yourself by doing something enjoyable every day or buy yourself some
small treat with all the money you save by not smoking. When you are tempted to smoke, remember the
urge will pass, usually within 15-20 seconds. Brush your teeth so your mouth feels fresh. Every day gets a
little easier. If you do relapse, get right back on track and don’t give in or give up. Quitting takes a lot of
hard effort, but you can quit. You will realize the benefits almost immediately, and you will have reduced
your risk for having a stroke.
For online support
to quit smoking, visit
the American Lung
Association web site
18 Delaware Stroke Initiative
THE FAMILY PHYSICIAN’S ROLE
by Edward R. Sobel, D.O.
Director, Health Care Quality Improvement Program, Quality Insights of Delaware
Family Practice Physician
The family physician is among the most frequent medical contacts for the patient who may be at risk
for a stroke. If we believe that the best stroke is the one that doesn’t happen, then the patient’s primary
care physician is the most appropriate health care provider to do aggressive screening of patients at risk
for stroke. When the risk factors have been identified through careful evaluation, there is much that can
be done to benefit the patient.
Monitoring for stroke risk is not a one-time event. Because health is a fluid condition, it requires two-
way, ongoing communication between the patient and the physician. Patients generally provide a history
and assessment when they initially see a physician. It is important for the physician to inquire and the
patient to provide ongoing updates on both personal and family history for conditions that would suggest
increased risk of stroke.
Nor should stroke screening be considered an isolated
problem, since the risk factors for stroke are also risk factors
for heart disease and many other conditions. It is important to
have frank discussion and treatment of these risk factors and
There are important risk factors for stroke which cannot
be modified, including age, gender, heredity, race, previous
stroke or heart attack. However, working together, the patient
and physician can significantly modify risk factors such as high
blood pressure, diabetes, carotid or other artery disease, atrial
fibrillation, heart failure, cardiomyopathies, TIAs, certain blood
disorders, and high cholesterol that are amenable to treatment.
Aggressive management of these risk factors will significantly reduce the risk of stroke.
Other risk factors that require a personal decision to make lifestyle changes include tobacco use,
physical inactivity, obesity, excessive alcohol use and use of illegal drugs. There are resources within the
medical and general communities to help patients reduce their risk for illness.
Unfortunately, once a stroke occurs, patients often express remorse at not doing more to reduce their
risk before the event. Most commonly, the factors that can be modified must be addressed in a preventive
fashion over a long period of time to be effective. This requires commitment by the patient and guidance
by the physician. It is often difficult for patients to set and maintain long-term risk reduction goals, but
awareness of the potentially catastrophic change that stroke causes in families can be a strong reminder
of the importance of long-term goal setting. It is therefore important that patients and physicians set goals
early in life to reduce the risk of this often-disabling disease.
Monitoring for stroke
risk is not a one-time
event. It requires
the patient and
Stroke: A Guide to Information and Resources in Delaware 19
ATRIAL FIBRILLATION: UNDERSTANDING &
MANAGING AN IRREGULAR HEARTBEAT
by John Pergolini
You may have experienced a relatively common heart disorder called atrial fibrillation (also known as
AF or A-Fib). AF can be a dangerous condition if not diagnosed, treated, and monitored. In AF, the upper
chambers of the heart contract rapidly and irregularly. This can lead to the formation of small clots in
the heart. If the clot is pumped to the brain, it may travel in the small vessels of the brain until it ends up
blocking blood flow to that part of the brain. The clot in the artery is known as an “infarct” and prevents
that part of the brain from working normally, resulting in a “brain attack.” AF is, therefore, considered a
major risk for stroke, particularly in older adults.
Check for an Irregular Pulse
1) Place your left hand on a flat surface, palm
2) Run two fingers of your right hand along the
outer edge of your left wrist below the thumb,
to just below where your hand and wrist
3) Press down with your fingers until you feel
your pulse. DO NOT press too hard or you will
not be able to feel the pulsation. Move your
fingers until the pulse is easiest to feel.
4) Continue to feel for one minute. As you feel
your pulse beat, begin tapping your foot to
the beat of your pulse in a steady rhythm.
5) Notice if your pulse is beating in the same
regular rhythm as your foot (or a clock).
6) If your pulse drops a beat, skips or speeds
up without a pattern, make an appointment
with your health care provider as soon as
possible and provide this information.
Symptoms of AF
Unless an irregular pulse is identified, AF
may occur without noticeable symptoms.
When the heart beats too fast with the
irregular rhythm, it may cause the following:
g Heart palpitations: a sudden pounding,
fluttering, or racing sensation in your
chest, which may feel like “butterflies.”
g Dizziness: feeling light-headed, like
you’re going to faint. The best response
is to sit or lie down until the feeling
g Chest pain: a highly variable sensation
of discomfort, pressure, or pain in the
g Shortness of breath.
If you experience any of these symptoms,
check your pulse and contact a health care
provider. Remember that AF can cause a
20 Delaware Stroke Initiative
Who Gets AF?
Atrial fibrillation affects more than 2 million Americans. In fact, as many as 9 percent of Americans
over the age of 65 may have AF, which can be associated with rheumatic heart disease, myocardial
infarction (MI) and heart surgery.
How Do You Get AF?
AF can occur in healthy individuals. But most cases are associated with underlying heart disease in
older adults. AF can also occur following valve replacement and heart surgery, infections of the heart
called endocarditis, certain cardiac procedures and, occasionally, in individuals with thyroid disorders.
When Should You Suspect AF?
Not everyone with AF experiences the same symptoms. In fact, some people may have AF for years
without really knowing it. It is important to recognize the symptoms of AF so you can discuss them with
your health care provider and receive appropriate treatment to prevent a stroke.
What are the Risks of AF?
Even in cases where symptoms are barely noticeable, the consequences of AF can be serious if it is
left untreated. AF may increase your risk of stroke by more than five times. It can also lead to heart failure,
a condition in which the heart is unable to pump enough blood to support the rest of the tissues of the
Management of AF
The good news is that AF can be managed. Many
people continue to live normal lives with AF. Returning
your heart rate to normal with electrical stimulation
or medication can restore your normal heart rhythm
or slow the heart rate. Anticoagulants can prevent
harmful clots from forming in the heart and help
reduce the risk of stroke. Your doctor may use one
or more methods to manage your AF. Be sure you
understand all the risks and responsibilities involved
before you begin any treatment. Know the early
warning signs of stroke. Treatment for AF and stroke
can be more effective if given quickly. When it comes
to Atrial Fibrillation and stroke, “Time is brain.”
Stroke: A Guide to Information and Resources in Delaware 21
HAVING A STROKE
by Vance Funk, Esq.
Mayor of Newark, Delaware
Having a stroke is a unique experience. At age 50, within
10 minutes of experiencing my stroke, I was totally paralyzed
on the right side of my body. There was bleeding in the brain,
the fear of death, but no white lights. I was alive and wondering
what happened and how it could happen to me.
After 8 years in a row without one sick day, my health
seemed to be fine. A few weeks before my stroke, my right eye
was very blurry and for a few seconds it seemed like I lost my
vision. It went away, but it was enough of a scare for me to call
my eye doctor. He examined my eye, gave me a prescription for reading glasses and, although blurred
vision is a classic early warning sign for stroke, did not send me to the hospital. He did ask me when was
the last time I had a physical (1971 when I came back from Vietnam) and told me to get a physical.
The importance of detecting the early warning signs of a stroke cannot be understated. A clear
understanding of the signs and prompt medical attention will go a long way toward reducing the number
of strokes and the damage they cause. Those signs are:
1) Weakness, numbness or paralysis of arms or
2) Sudden blurred vision or blindness in one eye.
3) Difficulty speaking or slurring of speech.
4) A severe headache that occurs without
5) Loss of balance or falling without apparent
It is not necessary to have more than one
symptom. In my case, blurred vision in my right eye
happened several days before the paralysis occurred
in my right arm and leg. An understanding of the
stroke signs could have prevented some of the
damage that followed.
The next time you, your friend or relative
experiences a stroke sign, call 911 immediately. You
may save a life and improve the quality of that life.
A few weeks before my
stroke, my right eye was
very blurry and for a few
seconds it seemed like
I lost my vision...
22 Delaware Stroke Initiative
by M. Bernadette Burns Day
I remember my stroke like it was yesterday, and it has been 19 years. I was young—23 years old–and
had a 5-year-old son. I enjoyed cruising with my girlfriends in my like-new yellow Camaro, and I loved
to dance! I was also one week away from marrying my Junior High School sweetheart. Part of my
preparation for my wedding involved losing weight and I unwisely combined diet pills with birth control
My stroke took me completely by surprise. Although I was “warned” with horrific headaches almost
every day for about a week, in my naivete I ignored them. My son and I were returning to the home we
shared with my grandmother in a New Castle suburb when I became nauseated. Fortunately, I had to pull
over to correct my son’s behavior, and it was then that the stroke struck.
I spent several days in the hospital, then transferred to a rehabilitation hospital for physical and
occupational therapy. It was there the realization began to sink in: I could not use my left hand or leg.
I became angry and bitter and tormented with “Why me?” I hated being in rehabilitation and ultimately
cheated myself by cheating on my occupational therapy—using my right hand instead my left when no
one was looking. More years of therapy followed, most recently with therapy students at the University
of Delaware who helped me improve my gait. I had to learn to focus intently on my walking, which is
sometimes impossible in the fast paced world of today. But still, the “why me?” haunted my thoughts for
years to come.
I married and had two more boys, and now have two grandsons. I also divorced and found a
career in Real Estate that I am passionate about. I found and married a wonderful man, acquiring three
stepchildren. But something was still missing: WHY did I have a stroke?
Two years ago I found the answer. In August of 1999, I happened to read an article in the News Journal
about a conference sponsored by the Delaware Stroke Initiative’s Board of Directors featuring Senator
Joseph Biden to discuss what the State of Delaware could do to promote statewide education and
prevention through our hospital system. I “crashed” the luncheon at the Hotel du Pont and came away with
a tremendous amount of information including DSI’s mission and their goals of education, prevention, and
best practice management of stroke.
After learning what DSI is, and that there would be opportunities to talk with recent stroke victims
about life after stroke, I wanted in. I drafted a letter to Ellen Barker, the founder of DSI, requesting to be on
the Board. She accepted my proposal and I joined the DSI Board of Directors, recruiting others like myself
and helping with DSI activities and fundraising.
Although I cannot dance like I used to, my passion now is showing other stroke survivors that there is
life after stroke. I am living proof.
Stroke: A Guide to Information and Resources in Delaware 23
CALL 911 AT THE FIRST SIGN OF
A BRAIN ATTACK/STROKE
by Ellen Barker, MSN, APN
Neuroscience Nursing Consultants
Founder of Delaware Stroke Initiative
Most Americans immediately recognize the signs and symptoms of a heart attack, or myocardial
infarction (MI). They may have crushing, viselike chest pain that radiates down the arm or neck, feeling
like they have acute indigestion, turning ashen in color, sweating or feeling clammy, faint and anxious— a
“feeling of doom.” Many patients having a heart attack have described the event as feeling like death
is imminent. Bystanders usually are able to see visible signs that a person is having a heart attack. The
recognition of a possible heart attack by the individual or observers prompts a quick call to 911. State
emergency medical system (EMS) paramedics respond in minutes for rapid transport of the individual to
the emergency department (ED) for treatment.
In stark contrast, few Americans recognize the early signs and symptoms of stroke. The stroke is either
not recognized or not understood as a medical emergency. Only about 50 percent of patients having a
stroke call 911 for emergency transport.
Today, stroke is considered a “brain attack.” A brain attack is a medical emergency and the EMS
in Delaware are well prepared to respond and transport the patient with a brain attack with the same
urgency as they transport a patient having a heart attack.
The first drug approved by the Food and Drug Administration (FDA) for the emergency treatment of
stroke was Activase, a tissue plasminogen activator commonly known as tPA. This medication is called a
“thrombolytic.” When given intravenously (IV), the drug has the ability to dissolve the clot caused by an
acute ischemic stroke (AIS) or a blood clot that is obstructing the flow of blood in the brain.
An important part of emergency treatment is to give tPA within three hours of the onset of the stroke
symptoms. One of the side effects of tPA is that a small percentage of patients get bleeding in the brain.
When tPA is administered beyond the three-hour time frame, the incidence of bleeding may increase
and the beneficial effects of tPA are not predictable. Therefore, patients who are having a stroke caused
by a clot that is preventing normal circulation to the brain and are a candidate for tPA must arrive in the
emergency department within three hours!
Thrombolytic treatment is not indicated unless the following conditions are met:
1) The diagnosis of AIS can be established by a physician who has expertise in the diagnosis of brain
2) A CT of the head is completed with a reading by a physician with expertise in evaluating a head
3) The treating hospital Emergency Department is readily able to handle the treatment and potential
complications that may develop.
4) The treating hospital ED has adequate emergency resources for patient management.
24 Delaware Stroke Initiative
In Delaware, both the paramedics and the EMS dispatchers who receive the 911 call have been taught
how to respond appropriately to callers who are having a brain attack/stroke. As soon as they arrive at the
scene, the paramedics will check to protect the patient’s airway, administer oxygen, protect a paralyzed
arm or leg, elevate the head of the stretcher, provide emergency care and reassure the patient. They
are able to provide rapid on-the-scene identification or diagnosis of a brain attack/stroke and rapid
evacuation. “Time is brain.” The paramedics will attempt to determine the exact time of onset. The three-
hour window of opportunity begins with their timing of the first symptoms described by the patient or
Family members are urged to come to the hospital because history and information about the patient
is important to the treating ED team The receiving hospital will be notified by the paramedics that a
patient is enroute. This call alerts the ED staff to prepare the team of experts for emergency treatment of
the patient with a brain attack/stroke.
A checklist to perform thrombolytic or tPA therapy is prepared. If the patient has had a previous
brain attack/stroke caused by a hemorrhage in the brain at
any time, a previous ischemic stroke from a blood clot within
the past year, a known brain tumor, active bleeding anywhere
in the body, or a suspected aortic dissection, tPA will not be
given. There are other relative contraindications that could also
prevent the patient from receiving tPA. These will be carefully
reviewed. If the patient begins to display rapid improvement
and is experiencing a mini-stroke or transient ischemic attack
(TIA), tPA will not be necessary.
Only a hospital emergency department is prepared
to provide emergency treatment for a brain attack/stroke.
To receive appropriate emergent care, call 911 for rapid
transportation and treatment.
Call 911 Immediately
If someone is experiencing any of the early warning signs of brain attack/stroke, call 911 immediately.
Stroke warning signs include:
g Sudden weakness, numbness, or paralysis of the face, arm, or leg on one or both sides of the
g Sudden blurred vision, or blindness in one or both eyes
g Sudden difficulty speaking, slurring or speech or difficulty understanding
g Sudden severe headache with onset that occurs without apparent reason
g Sudden loss of balance, dizziness, or falling without any apparent reason
An important part of
is to give tPa within
three hours of the onset
of stroke symptoms to
dissolve the clot that
is preventing normal
circulation of blood
to the brain.
Stroke: A Guide to Information and Resources in Delaware 25
EMERGENCY MANAGEMENT OF STROKE
by Howard A. Rubinstein, M.D
Emergency Medicine Physician
Eileen Smith was washing the dishes when she dropped the plate out of her right hand. Her hand felt
suddenly weak and numb. She went to sit down and found her right foot scrapping on the floor. She tried
calling her husband and noticed that she was having difficulty getting words out. She knew what she
wanted to say but the actual words were escaping her. Her husband wanted to take her to the hospital
but she refused. She just wanted to rest. After about an hour, the symptoms started to disappear and
Mrs. Smith decided to make a doctor’s appointment to have a check up. One week later she suffered a
massive stroke and remains paralyzed on her right side. She has been placed in a skilled nursing facility,
as her husband is not able to care for her at home.
Does the above scenario sound believable? It should, as it’s a story we hear many times in the
Emergency Department (ED). A large percentage of the people do as Mrs. Smith did in the above
scenario. They wait at home, hoping that the symptoms will disappear. Most do not get any additional
medical care because of denial, fear, or ignorance.
Stroke is the third leading cause of death in the United States and the leading cause of adult disability.
Every 53 seconds a stroke occurs in the U.S. Every 3.3 minutes someone dies as a result of stroke.
Until recently, the outcome from ischemic stroke (the type caused by a clot or embolism rather than
an aneurysm or bleeding) was determined by its natural course with the additional medical supportive
measures. This has changed over the past five years. Not only is detection and prevention improved, but
new treatments for the acute stroke are also available.
Prevention is the mainstay of stroke treatment. Ms. Smith was having a TIA (transient ischemic attack
also known as a “mini-stroke”). By definition, a TIA is brief, lasting only 7–10 minutes. At the time of a TIA,
medical attention should be sought as soon as possible. There are a number of reasons for this: 1) It is
unknown if this is truly a TIA or the beginning of a full stoke; 2) the source of the embolus must be found;
and 3) treatment such as anticoagulation may be necessary to prevent further TIA’s or strokes. These
emboli can come from the heart or carotid arteries, or can indicate a problem in the natural clotting of the
In the Emergency Department, a number of tests are quickly performed on the stroke/TIA patient. The
amount and order of the tests are determined by the severity of the symptoms. A CT scan of the brain is
immediately done to be certain that no bleeding has occurred. Blood and other tests such as ultrasound
may also be performed. Depending on the results of these tests, a drug such as heparin (which is a
anticoagulant or “blood thinner”) may be started in the ED to protect against further emboli or clots.
Specialists such as neurologists and neurosurgeons will be called in consultation with both the ED and
the patient’s private physician.
The most significant and exciting advancement in the treatment of brain attack/stroke is the use of
thrombolytics or “clot busting” drugs. Tissue Plasminogen Activator tPA or is the same drug that is used
in treating heart attacks. If the brain attack/stroke is caused by a blood clot, this drug will dissolve the
clot and allow increased blood flow to the area of the brain originally affected by the clot. This is the first
26 Delaware Stroke Initiative
real treatment for patients who are actively having a brain attack/stroke. Studies have shown that 15-
20 percent more patients will attain a favorable outcome at three months when tPA is used. However,
not every patient is a candidate for tPA therapy. There is a strict three-hour window from onset of
symptoms in which tPA can be given. Thus, it is very important to come to the ED as soon as possible
after the symptoms begins.
Additionally, there are a number of things that will exclude a patient from receiving thrombolytic
therapy. Some of these include evidence of intercranial bleeding on the CT scan, uncontrolled high
blood pressure, major surgery within 14 days, pregnancy, and a known aneurysm, among other things.
The apparent size of the stroke may also influence the decision to use tPA.
Using tPA is not without some risk. Studies have shown a 6–7 percent incidence of intercranial
bleeding after the use of tPA. While these numbers are significant, one must remember the
devastating effects that a major stroke will have on a person’s lifestyle or even survival. By carefully
using the accepted criteria, the ED physician will determine if the patient is eligible for this treatment
and keep the risks to a minimum.
In addition to tPA, a number of new drugs are under development including “neuroprotective”
drugs which are designed to protect the brain and lessen the damage sustained during a stroke. The
key to conquering stroke is to recognize the symptoms early and seek medical care immediately to
maximize the treatment options available to ED physicians as well as initiating preventive measures.
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Stroke: A Guide to Information and Resources in Delaware 27
STROKE CENTERS HELP REDUCE
DEATH AND DISABILITY
by Ryan Diez
Clinical Representative, Genentech, Inc.
Former Delaware Stroke Initiative Board Member
In the June 21, 2000 issue of the Journal of the American
Medical Association (JAMA), members of the National Brain
Attack Coalition announced its recommendation that all
hospitals establish a stroke center or other programs to reduce
deaths and disabilities from stroke. The Brain Attack Coalition
is a group of professionals, volunteers and government
organizations dedicated to improving stroke treatment and
Mark J. Alberts, M.D., the author of the article, serves as the chairman of the Stroke Belt Consortium,
director of the stroke acute care unit at Duke University Medical Center in Durham, N.C., and a leader in
The Brain Attack Coalition. Dr. Alberts maintains that the goals of the Brain Attack Coalition are similar
to those of trauma centers—getting patients to facilities where specialists and the hospital have the
resources to evaluate and treat individuals quickly. Their position has been that, if hospitals can put
together resources to treat trauma patients, why can’t they do the same for stroke patients?
Since the Food and Drug Administration (FDA) approved a clot-busting medicine called tissue
plasminogen activator or tPA in 1996 for the treatment of acute ischemic stroke (AIS), physicians have had
a treatment for AIS (which accounts for about 80 percent of all strokes in the U.S.). Yet, many hospitals
still lack the necessary staff and equipment to triage and treat stroke patients within the three-hour time
frame that the clot-busting therapy must be administered in to be safe and effective.
The two major goals of the stroke center recommendations are:
1) To improve the level of care provided to stroke patients.
2) To standardize some aspects of acute care for patients who have a stroke.
The article by Dr. Alberts presents a blueprint and includes estimated costs. The authors express
their hope that the adoption of these recommendations will increase the use of appropriate diagnostic
and therapeutic resources to reduce the complications from stroke. Michael D. Walker, M.D., the Brain
Attack Coalition’s chair and former director of stroke disorders at the National Institutes of Health (NIH),
described a way for hospitals to significantly improve outcomes for stroke patients by dedicating the
resources necessary to diagnose and treat stroke patients quickly. Dr. Walker defined two types of stroke
centers to be established:
1) Primary Stroke Centers to stabilize and provide emergency care to stroke patients
2) Comprehensive Stoke Centers to provide extensive care for the most complicated cases
The Delaware Stroke Initiative will be working closely with the professional organizations and groups
described in the article to learn and promote best practices for the prevention, diagnosis, treatment and
rehabilitation of brain attack/stroke.
Many hospitals still lack
the necessary staff and
equipment to triage and
treat stroke patients
within the three-hour
time frame for
28 Delaware Stroke Initiative
THE ROLE OF SURGERY IN STROKE
PREVENTION AND TREATMENT
by Yakov Koyfman, M.D.
Delaware Neurosurgical Group
If detected before a major hemorrhage, the hemorrhagic brain attack/stroke is most often a subject
for conservative treatment. High blood pressure must be controlled and carefully regulated to prevent
further damage. Medications, diet, exercise, and reduction of stress can help to lower blood pressure.
Following a hemorrhage, however, neurosurgery is an option. Sometimes the clots can be surgically
removed if done quickly, usually within six hours of the bleeding. An AVM, which is an abnormal
connection between arteries and veins that form a tangle of fragile blood vessels, can rupture and cause
an intra-cerebral hemorrhage. The individual may experience a severe headache or seizure. The AVM
can be surgically removed. Because of the devastating effects of an AVM, the neurosurgeon treats AVMs
before the major rupture, if detected.
Aneurysmal treatment may involve the clipping of the aneurysm where the neurosurgeon places a
small clip around the neck of the aneurysm to pinch it and cut off the blood supply that circulates in the
outpouching or weakened area in the artery.
Neuro-endovascular techniques treat the aneurysm from inside the blood vessel with a catheter that
is inserted in the groin. The technique involves placing tiny coils inside the aneurysm to reduce the blood
flow to the aneurysm sac and prevent rupture and hemorrhage.
The good news about prevention is that carotid stenosis, for example, is very detectable and very
treatable. If less than 50 percent of stenosis is found, antiplatelet medications, e.g., aspirin, remain the
cornerstone of treatment to reduce brain attack/stroke. For patients with greater than 50 percent stenosis
shown on diagnostic testing, a surgical procedure called a carotid endarterectomy may be required.
Studies have shown this to be a safe and effective way of reducing the risk of a brain attack/stroke.
During the procedure, the plaque in the artery of the neck is removed, the blood flow is improved, and the
patient returns home from the hospital within 48 hours.
Another procedure, neuro-endovascular stenting, is currently being evaluated as an alternative to
carotid endarterectomy. A special small angioplasty balloon catheter is inserted as the balloon is inflated
the stent expands, locks in place and forms a rigid support to hold the artery open. The stent remains in
the artery permanently.
This is a brief description of the current roles of a neurosurgeon in the treatment of brain attack/
stroke. There are new and exciting treatments for all types of brain attacks/stroke. As technology and
science continue to discover new therapies, the future looks optimistic. The role of the neurosurgeon is
substantial as developments continue into the 21st century.
Stroke: A Guide to Information and Resources in Delaware 29
NEUROLOGISTS SPECIALIZE IN
TREATMENT OF STROKE
by Lee Dresser, MD
Wilmington Neurology Consultants
Neurologists are medical doctors who are trained in the treatment of diseases of the nervous system.
They have experience in managing stroke and are familiar with the functions of different parts of the brain
and how those areas are affected by stroke. Neurologists are expert at recognizing the warning signs and
symptoms for stroke and evaluating persons at risk for stroke.
Once a stroke occurs, it is important to minimize the damage to the brain, determine why the stroke
occurred, help the patient in the early recovery, and prevent future strokes. Almost as big a problem as
the injury to the brain from the stroke are the resulting complications.
The neurologist takes the lead in managing all of the above facets of stroke care. Diagnosing stroke
can sometimes be complicated. A neurologist is the best prepared to make this diagnosis. Other
conditions such as seizure, brain tumor and migraine often need to be considered. Once the diagnosis is
made of stroke, which is usually caused by interruption of blood flow to the brain, it is important that blood
pressure be managed carefully. While high blood pressure (hypertension) is the most common contributing
factor to stroke, it is usually best immediately after a stroke to keep the blood pressure high. This ensures
the injured brain receives all the oxygen and nutrients it requires. Treatment of stroke is now possible with
a clot dissolving medicine called tPA. While tPA can be helpful in reversing the effects of a stroke, it is
also a potentially very dangerous medication. Emergency department physicians almost always consult
with neurologists before using tPA for patients suffering from stroke. Stroke patients frequently require
evaluation with specialized tests. These include brain CT and MRI scans, ultrasound evaluations of the
blood vessels of the neck and heart, and blood tests to check for conditions which make atherosclerosis
and abnormal clotting more likely. The neurologist is usually consulted to help determine which tests are
necessary and when they should be performed.
The risk of stroke is often decreased by the use of certain medications to help prevent blood
clots. Aspirin and similar medications, as well as stronger blood thinners, are available for use. The
ideal medication to use depends on the cause of the stroke and the patient’s other medical problems.
Additionally, some stroke patients may benefit from surgery to open narrowed blood vessels or,
infrequently, operations on the heart for abnormal valves or to close holes between the heart’s chambers.
The decision of which medication to use or when to refer a patient for surgery is often made by the
neurologist. Neurologists also provide valuable input on how best to prevent complications from occurring
after stroke, such as pneumonia from swallowing difficulties, other infections, blood clots in the legs, or
New and better methods to diagnose and treat stroke will become available in the near future, and it
is neurologists who will be using these tools to best aid patients.
30 Delaware Stroke Initiative
by Glen D. Greenberg, PhD
N & G Neurobehavioral Group
The brain is the organ of behavior. Behavior, broadly defined, is everything that we do, from the
words we speak and memories we form to the mood we are in and the activities we engage in everyday.
Therefore, a stroke has the potential to affect any part of who we are and result in problems in cognition
(intellectual abilities), emotions (e.g., depression), and personality.
Depending on where a stroke occurs in the brain very different problems may arise. The most common
cognitive problem occur in the following areas:
Speech and Language include expressive language (problems finding the right word to say, naming
objects correctly, fluency of speech) and receptive language (comprehension) such as one’s ability
to understand what others say. Some people experience problems in related skills such as math
(dyscalculia), reading (alexia) or writing (dysgraphia).
Memory can be affected by stroke in a variety of ways. Most strokes affect recent memory, or short
term recall. Stokes affecting the temporal lobe area of the brain can affect encoding so that memories
are not stored at all or very poorly. Therefore, giving someone a hint or reminding them of something
will not help them remember. Other strokes can affect retrieval of memories that have been stored. In
these cases, giving the person a cue or association to latch onto the memory can help them remember.
Strokes that affect the left side of the brain can affect verbal memory, such as items on a shopping list,
while strokes in the right side of brain can affect visual memory, such as recall for faces. Another class of
memory is involved in recalling facts versus recalling pre-learned skills. Thus, one can have post-stroke
problems recalling information but still learn and retain new skills (e.g., how to operate a wheelchair).
Executive functions are complex skills associated with the front part of the brain. They include
planning, adapting to new situations, being flexible in our thinking, problem solving, exercising self-control,
and understanding and managing time. The executive system monitors what we do and it provides
ongoing feedback so there is a constant communication system traveling from the front of the brain to
the back and then returning to the front. This leadership and control mechanism is crucial to successful
functioning in everyday life.
Visuoperceptual skills: In some cases, a stroke can affect one’s ability to pay attention to one side of
visual space despite intact eyesight. A person may therefore bump into walls while walking or have traffic
accidents. This “neglect” of space can be so severe that a person may deny that a body part belongs to
them, or in less severe cases, may not use one side of their body despite intact physical ability. When the
right side of the brain has been impaired by a stroke, we will often see problems with drawing or solving
nonverbal problems (e.g., puzzles). Other people may fail to recognize objects they should know (agnosia).
When there is a defect in the visual system the individual may fail to read sections of labels or pages in
Stroke: A Guide to Information and Resources in Delaware 31
Emotional functioning: Depression occurs in 30-50 percent of the 750,000 people who suffer a
stroke each year. Recovery from a stroke is poorer in people who are depressed. The individual who lost
expressive language skills may not be able to express their sense of distress, but depression may then
be expressed nonverbally (e.g., lack of interest or motivation in rehabilitation, low frustration tolerance) and
the depression can be quantified by using depression questionnaires. If a person is failing to progress in
their rehabilitation program it can be a red flag that depression is present.
Personality changes: The two most common types of changes in personality are disinhibition (doing
things without thinking, loss of social graces or social inappropriateness) to a complete lack of drive
or interest in activities. This lack of drive can often appear to be depression, but in many instances it
represents dysfunction in the executive system where initiative and planning begins. Discussion with the
family about changes in the person’s mood and personality is often a very important part of post-stroke
A neuropsychological evaluation is a method by which one’s abilities are assessed after a stroke. A
comprehensive evaluation can take several hours to evaluate all of the important skills and produce a full
picture of the personal strengths and weaknesses. A doctor may refer a person who has had a stroke to a
neuropsychologist for several reasons:
g Can the individual continue to work, and if so, what modifications or accommodations are
required? What will be the impact of the stroke on functioning in the home?
g Impaired reaction time, visual processing or memory can affect skills such as driving. An
assessment can help the physician determine if driving may or may not be possible.
g A stroke affects some skills but not others. In some cases a person can compensate using
preserved skills, such as writing and organizational skills to help with forgetfulness.
g Neuropsychological testing can complement neuroimaging results (CT or MRI scans) to assess
functional capabilities. The relationship between what we see on a CT or MRI scan and the
functional problems is not always perfect. Some people may have large areas of damage on a
scan but quite modest cognitive or behavioral deficits, while other people who have small but
strategically placed lesions can experience much more difficulty in activities of daily living.
g With the information from a neuropsychological assessment, suggestions for a cognitive
rehabilitation program can be developed. This information is often used as part of a
comprehensive treatment program that may include a team of many professionals (psychiatrist,
neurologist, speech/language therapist, occupational therapist, physical therapist, social worker)
so that the neurologic, cognitive, behavioral, emotional and social aspects of the stroke can all be
understood and addressed.
The more information that an individual who has experienced a stroke can learn about the brain, the
easier it may be to seek the right health care professionals for assistance in recovery. A stroke can occur
quickly, but the recovery process can take a long time as the brain takes time to heal. Each person who
has a stroke is an individual and recovers individually. Learning about this process will make it easier to
regain lost abilities and maximum recovery.
32 Delaware Stroke Initiative
HOPE FOR THE FUTURE?
by Bruce Shook
Despite many years and billions of dollars in research, there remains only one FDA-approved treatment
for acute ischemic stroke. Neuroprotectants, whose goal is to keep oxygen-starved cells alive longer
or make them more resistant to low levels of oxygen, have a disappointing history of failed human
clinical trials. The use of a blood-dissolving (or “thrombolytic”) agent to reduce or remove the clot from
the affected artery in the brain offers some hope. The only FDA approved treatment for acute stroke is
one such drug: tissue plasminogen activator (or “tPA”). However, patients must get to the hospital within
three hours for this therapy to be administered. There is a critical unmet need for an effective treatment
for this disease that is the number three cause of death and number one cause of disability in the
U.S. Researchers and patients are not without hope, however, as there are many promising therapies
undergoing clinical trials.
Hypothermia or Cooling the Body
One potential approach is the use of systemic hypothermia, or “total body cooling” to reduce the
brain’s need for oxygen while perhaps also helping the brain avoid the often fatal brain swelling that can
occur after a major stroke. The use of this technique has been supported by many animal studies that
have shown that reducing the body’s core, or internal, temperature reduces the size of the brain damage
(“the infarct”) after a stroke. The hope is that this will lead to improved outcomes for patients, and that
those who receive the hypothermia will improve more than those who were not made cold. Methods for
cooling include catheters placed inside a major blood vessel to cool the blood directly, and “blankets”
placed over the body to cool from the outside in. Patients have also been packed in ice and given chilled
intravenous fluids. The blankets and catheters can effectively reduce the body’s temperature and the
hope is that this reduced temperature reduces or prevents stroke damage. This technique has been
shown to have some effect in animal studies, and is now being studied in human clinical trials.
Hypothermia is not without drawbacks, however, as the body is not designed to react well to the deep
cold necessary for this therapy, and cooling of only a few degrees can lead to irregular heart beat and
blood clotting disorders. In addition, because the body is designed to function within a very narrow range
of “normothermia,” temperatures below a certain point induce the body to respond by trying its best to
raise body temperature; shivering, raising the hair on one’s arms to trap warm air, and increasing heart
rate are all ways in which the body tries to raise its temperature. These effects have just the opposite of
what is hoped; rather than cooling down the body, these reactions increase metabolism and the need for
oxygen in the attempt to keep warm. Patients undergoing systemic hypothermia therapy must therefore
be aggressively treated to avoid the body’s natural responses to cold.
Patients often need to be heavily sedated to prevent these reactions to the cold. Some of the newer
therapies attempt to override the body’s thermoregulatory defense system by “tricking” the mind into
thinking the body is warm by keeping the skin of the torso warm or placing a warming blanket around
Stroke: A Guide to Information and Resources in Delaware 33
the patient’s face. Clinical trials now underway hope to provide an answer regarding the effectiveness of
reducing stroke damage in the brain by keeping patients cold.
Open the Blocked Blood Vessel
Another area of promise is to physically open the blocked blood vessel and restore blood and oxygen
flow to the brain after a stroke. Numerous ideas are being pursued here, including direct delivery of
thrombolytic agents into the offending blood clot using micro-catheters, and catheters that deliver energy
into the blood clot using laser
or ultrasound technology to
help break the clot up. All
these therapies are intended
to clear the blockage that
caused the stroke, thus
minimizing damage to the
brain in the hours following the
Human clinical trials in
acute stroke treatment have
proven difficult to conduct.
One reason for this is that
“time is brain” and the longer
it takes to begin a therapy,
the more brain tissue will
be damaged. All these
promising therapies need to
be administered as rapidly
as possible to have the
most positive effect. General
awareness of stroke signs and
symptoms and quick action
to bring patients to stroke
centers are the most critical
steps toward developing new
Call Bayhealth’s Physician Referral and Information Line
for Kent General Hospital, Milford Memorial Hospital,
Middletown Medical Center and the St. Jones Center for Behavioral Health.
We’ll match you with the physicians best suited to meet your needs.
We call it the Bayhealth Link.
We’re here for life
Call (302) 744-7143
640 South State Street, Dover, Delaware 19901 • 21 West Clarke Avenue, Milford, Delaware 19963
Toll Free (866) 229-3627 • www.bayhealth.org
34 Delaware Stroke Initiative
ST. FRANCIS SPECIALIZES IN STROKE CARE
by Lee Dresser, M.D.
The doctors, administration and staff at Saint Francis Hospital in Wilmington realize that stroke is a
devastating medical problem. Stroke is the third leading cause of death in our country and the number
one cause of disability for adults. With our aging population, stroke will become an even bigger health
problem for our country and our community. St. Francis is committed to continuing its tradition of
excellence in prevention, evaluation, treatment and rehabilitation of stroke.
St. Francis Hospital is proud to be a strong supporter
of the Delaware Stroke Initiative (DSI) in its efforts to
prevent stroke in Delaware. We have provided financial
and logistical support to DSI because we know the best
treatment for stroke is prevention. To help prevent stroke,
St. Francis has active programs to assist patients with
smoking cessation, control of diabetes, and recognition
and treatment of hypertension. We applaud and actively
support the efforts by DSI to increase the awareness
of the signs and symptoms of stroke. We know that if
a person suffers a stroke his or her best chance for
recovery is to be immediately transported to a hospital
that specializes in stroke care.
The physicians and nurses on staff at St. Francis are specially trained to recognize and treat stroke.
When a patient with a possible stroke arrives in the Emergency Department, he or she is rapidly evaluated
for treatment with blood clot dissolving medications that can protect the brain from further injury. This
means that patients will be more likely to talk, walk, and use their hands to lead independent, productive
and enjoyable lives.
St. Francis has state-of-the-art CT and MRI scanners available 24 hours a day, which allow our doctors
to quickly and accurately determine what caused a stroke and how best to prevent future strokes. Our
hospital is staffed with highly trained neurologists and neurosurgeons who are expert in the treatment
of stroke. Special ultrasound equipment employed by skilled doctors and technicians allows detection
of blood clots in the heart or blockages in blood vessels that may cause strokes. Highly trained nurses
We applaud and actively
support the efforts by DSI
to increase the awareness
of the signs and symptoms
of stroke. We know that if
a person suffers a stroke
his or her best chance
for recovery is to be
to a hospital that
specializes in stroke care.
Stroke: A Guide to Information and Resources in Delaware 35
constantly monitor patients to
help prevent complications and
worsening of stroke symptoms.
This special care helps minimize
the time spent in the hospital
and maximizes return of brain
Stroke patients often need
special rehabilitation therapy. St.
Francis offers a full complement
of rehabilitation services,
including physical therapy,
occupational therapy and
speech therapy. If it is required,
we have an entire unit dedicated
to inpatient rehabilitation
directed by doctors who are
expert in helping stroke patients
maximize their recovery. Stroke
patients often also have heart disease and St. Francis is proud to offer the best cardiac care in the state,
with experienced cardiac surgeons and cardiologists who have state of the art diagnostic and treatment
equipment and facilities.
St. Francis Hospital is firmly committed to helping prevent stroke in Delaware and to providing the best
possible care when stroke occurs. We encourage you to learn the risk factors for stroke detailed in this
guide and the signs and symptoms of stroke. Please share this information with your friends and family.
Help educate people that a stroke is an emergency, and when a stroke is suspected, you must dial 9-1-1
for help. With your assistance, St. Francis Hospital and DSI can prevent strokes from happening and help
stroke patients receive the quick specialized care that can save a life.
When a possible stroke patient arrives at the St. Francis Emergency
Department, he or she is rapidly evaluated for treatment with blood clot
dissolving medications that can protect the brain from further injury.
36 Delaware Stroke Initiative
HEALTHY SPIRITUALITY & WELL-BEING
by Anne Murray MS, RN
Delaware Stroke Initiative Board Member
Recovering from a stroke is a struggle that challenges all aspects of a person's being—physical,
mental and spiritual. Physical therapy, speech therapy, learning a new way to dress, working to remember
how to make a sandwich can all be discouraging. It is easy to become overwhelmed and frustrated.
As humans we are naturally spiritual beings, whether or not we are connected to any organized
religion. Our spirituality affects our physical and emotional well-being every day, and spiritual health is that
aspect of our well being which is most basic to our wholeness. It organizes our values, beliefs and hopes
into some meaning and purpose. When one’s spiritual health is strong, often one finds grace and strength
to keep going, to cope and adapt and find joy in the daily journey that is life.
Help for your physical, emotional and spiritual health may be nearer than you think. Parish nursing
is being included by faith communities across the country and in our area. It is a part of the larger idea
of health ministry, or whole person health. Parish nurses are professional nurses whose practice has a
spiritual emphasis as well as a physical and emotional dimension.
g Believe, regardless of the faith tradition, that all persons are sacred and must be treated as such.
g Are not from any one religion and practice in any faith community.
g Work with clergy to care for those who need care.
g May provide care for a patient upon discharge from the hospital or rehabilitation center.
g Often provide support, spiritually centered care, and education after a persons health benefits
Inquire about parish nurses and other health ministry programs in your faith community-or one near
you, your hospital or neighborhood. For more information on health ministry and parish nursing in our
area, contact one of the following organizations:
DE Regional Health Ministries
785 Cherry Tree Rd. Apt. E9, Aston, PA 19019
Jane Connolly, 610-485-7533
DE Region Parish Nurse Network
709 Whitebriar Road, Hockessin, DE 19707
Joan Nelson, 302-239-2392
Christiana Care Health System
Health Ministries Nurse
LaVaida Owens-White, 302-765-4557
Stroke: A Guide to Information and Resources in Delaware 37
PHYSICAL REHABILITATION AFTER STROKE
by John P. Scholz, P.T., Ph.D.
University of Delaware, Department of Physical Therapy
A brain attack or stroke can have a devastating effect on the patient as well as his/her family. Motor
and sometimes cognitive functions that were once performed automatically now require great effort
and new strategies, if they can be performed at all. The patient’s family is often torn between sympathy
combined with the compulsion to do as much as possible for the patient and anger at the additional
burden this tragedy brings to their own lives.
In the early stages following a stroke, the patient is often bewildered by the sudden loss of even the
most basic functions. As initial recovery progresses, he/she becomes understandably torn between the
expectation that full recovery is only a matter of time
and the frequent reality that some functional deficit
is likely inevitable. What can the patient expect from
Immediately after the stroke, the focus of the medical
staff is to medically stabilize the patient. At this stage,
physical therapy (PT) consists largely of attempts to
prevent the loss of joint range of motion (ROM) and, to
a lesser extent, to prevent muscle wasting. As soon as
the patient’s medical condition has stabilized, however,
aggressive therapy becomes an essential ingredient to
promote the patient’s long-term recovery.
Because of the rising cost of health care, initial PT
treatment is often focused on teaching the patient to compensate for the loss of control on the involved
side by developing new strategies to use the intact side (that is, get the patient transferring and walking
as independently as possible so that he/she can be discharged in the shortest time possible). The
result is often the beginning of learned disuse of the involved side of the body by the time the patient is
transferred to rehabilitation or home. At this stage, therapy is resumed on a daily basis in rehab or, quite
often, one to a few days per week by a home health therapist. Such therapy is typically aimed at helping
the patient to further improve his/her function, partly by learning to use the affected side more effectively.
By this time, however, an important window of opportunity may have already closed. Thus, early attempts
to get the patient ready for discharge must be tempered by an understanding of the need to foster use
of the involved side of the body as much as possible.
The lessons to be gained from our present knowledge about recovery of motor function following
stroke is that rehabilitation should:
1) Begin as soon as possible following a stroke (i.e. once the patient is stable medically).
2) Focus on the practice of functional activities using the involved side of the body, in addition to
exercises that address specific motor impairments (e.g. muscle weakness).
3) Be as challenging as possible to the patient, while taking care to maintain safety.
For recovery of motor
function following stroke,
1) Begin as soon as possible
2) Practice functional
activity on the affected side
3) Be as challenging as
possible to the patient