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Stroke Stroke

  1. 1. StrokeStrokeA Guide to Information & Resources in Delaware 2004-2005 Third Edition Sponsored by
  2. 2. Trust your health to experience. 2004 REPORT CARD Ranked in the Top 5% in the Country for Clinical Excellence RANKED #1 IN DELAWARE #1 for Stroke Services Ranked Nationally in the Top 5% for Stroke Services ONLY Regional Provider with a 5-STAR Rating for Stroke Services* Christiana Care has been nationally recognized with the HealthGrades® 2004 Distinguished Hospital Award for Clinical Excellence.TM * ”Areas” or “Regions” are as defined on Looking for the best in stroke services? Check out Christiana Care.
  3. 3. Stroke: A Guide to Information and Resources in Delaware 1 CONTENTS Introduction 2 Delaware Stroke Initiative 3 Stroke Education 6 Contributed Articles 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
  4. 4. 2 Delaware Stroke Initiative INTRODUCTION 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:, call the DSI office at (302) 633- 9313, email us at: 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.
  5. 5. 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 charity. 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 Our Mission The Delaware Stoke Initiative’s mission is to improve stroke prevention, risk assessment and recovery through education, support and advocacy. Our Goals 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 reduction 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
  6. 6. 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 advocacy. 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 supportive environment. 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
  7. 7. Stroke: A Guide to Information and Resources in Delaware 5 OFFICERS Executive Board of Directors Chair: Lee Dresser, MD Wilmington Neurology Consultants Vice Chair: Ross Megargel, DO State of Delaware Emergency Services Director, Emergency Department Physician Secretary/Treasurer: Ellen Barker, MSN, APN Neuroscience Nursing Consultants EXECUTIVE DIRECTOR Susan G. Whitehead MEMBERS OF THE BOARD Sandi Bihary, MSN, RN Director of Pubic Relations ALLY Development Public Affairs, AstraZeneca Bernadette Burns-Day Stroke Survivor Kathryn M. Curtis, RN, APN Christiana Care Health System, Liaison for the Delaware Nurses Association (DNA) Advanced Practice Nurse Council Todd Fellenbaum 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. Neuroradiologist 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. Neurosurgeon Jeffery H. McMahon Financial Advisor 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 Elvce Tavarni Wilmington Trust Company DSI ADVISORY BOARD Jerry Castellano, PharmD Corporate Director, Institutional Review Board, Christiana Care Corporation Linda Swartley, RN, JD Contracts, Christiana Care Visiting Nurse Association Board Meetings 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 Wilmington. 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 attending. 2004-2005 DSI BOARD OF DIRECTORS
  8. 8. 6 Delaware Stroke Initiative STROKE EDUCATION 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 Stroke 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 becomes blocked.
  9. 9. 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. Hemorrhagic Stroke 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; forgetfulness; amnesia g Confusion g Sudden blurring or loss of vision, particularly in only one eye g Sudden severe headaches with no apparent cause g Unexplained dizziness, loss of balance or coordination, unsteadiness, or sudden falls (especially if associated with any of the above symptoms)
  10. 10. 8 Delaware Stroke Initiative Easter Seals HasYour Stroke Solutions. 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 800-677-3800 Adult Day Health Services AssistiveTechnologyServices 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. Outpatient RehabilitationTherapies Speech Language Therapy - Help with communicating with language or speech, and exploring alternative means of communication. Easter Seals is a proud recipientofUnitedWay supportthrough designatedcontributions. 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. Risk Factors 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
  11. 11. Stroke: A Guide to Information and Resources in Delaware 9 g Diabetes g Smoking 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
  12. 12. 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 options. 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 approximately 750,000 Americans every year, with the highest rates occurring in the southwestern part of the United States, commonly referred to as the Stroke Belt.
  13. 13. 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. WILMINGTON NEUROLOGY 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.* Main Office METROFORM MEDICAL COMPLEX 620 Stantion-Christiana Road, Suite 302 • Newark, DE 19713 302.892.9400 phone • 302.892.9407 fax Other Locations 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. Main Office METROFORM MEDICAL COMPLEX 620 Stanton-Christiana Road, Suite 302 • Newark, DE 19713 (302) 892-9400 phone • (302) 892-9407 fax Other Location ST. FRANCIS MEDICAL OFFICE BUILDING 7th & Clayton Streets, Suite 217 Wilmington, DE 19805
  14. 14. 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.
  15. 15. Stroke: A Guide to Information and Resources in Delaware 13 A 10-POINT PLAN FOR ISCHEMIC STROKE 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.
  16. 16. 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.
  17. 17. Stroke: A Guide to Information and Resources in Delaware 15 PREVENTING STROKE 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).
  18. 18. 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. Healthy Lifestyles 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.
  19. 19. 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 stop smoking. 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 follow-up. 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 at
  20. 20. 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 conditions. 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 two-way, ongoing communication between the patient and physician.
  21. 21. 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 side up. 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 meet. 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 passes. g Chest pain: a highly variable sensation of discomfort, pressure, or pain in the chest. 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 stroke.
  22. 22. 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 body. 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.”
  23. 23. 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 legs. 2) Sudden blurred vision or blindness in one eye. 3) Difficulty speaking or slurring of speech. 4) A severe headache that occurs without apparent reason. 5) Loss of balance or falling without apparent reason. 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...
  24. 24. 22 Delaware Stroke Initiative MY STROKE 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 pills. 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.
  25. 25. 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 attack/stroke. 2) A CT of the head is completed with a reading by a physician with expertise in evaluating a head CT. 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.
  26. 26. 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. 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 body 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 emergency treatment 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.
  27. 27. 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 blood. 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
  28. 28. 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. Helping Seniors Preserve Their Independence Through: • Health Care & Financial Planning • Case Management Via • Guardianship • Durable Power of Attorney • Health Care Power of Attorney • Daily Money Management • Consultation James R. Reynolds, LCSWCall us today. We can help. SENIOR PARTNER Financial and Health Care Management 302 - 764 - Helping People Preserve Their Independence Through: OUR 10thYEAR!
  29. 29. 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 prevention. 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 clot-busting therapy.
  30. 30. 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.
  31. 31. 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 bedsores. 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.
  32. 32. 30 Delaware Stroke Initiative NEUROPSYCHOLOGICAL ASSESSMENT OF STROKE 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. Cognitive Impairments 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 books.
  33. 33. 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 clinical care. Neuropsychological Testing 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.
  34. 34. 32 Delaware Stroke Initiative STROKE TREATMENTS: 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
  35. 35. 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 event. Summary 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 treatments. 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. NeedaDoctor?Call 1-866-BAY-DOCS We’re here for life Join the Bayhealth team! Call (302) 744-7143 640 South State Street, Dover, Delaware 19901 • 21 West Clarke Avenue, Milford, Delaware 19963 Toll Free (866) 229-3627 •
  36. 36. 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 immediately transported to a hospital that specializes in stroke care.
  37. 37. 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 function. 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.
  38. 38. 36 Delaware Stroke Initiative HEALTHY SPIRITUALITY & WELL-BEING by Anne Murray MS, RN Parish Nurse 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. Parish nurses: 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 have expired. 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
  39. 39. 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 rehabilitation? 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, rehabilitation should: 1) Begin as soon as possible 2) Practice functional activity on the affected side 3) Be as challenging as possible to the patient