Treating Ministrokes is Crucial to Preventing More Devastating Strokes | WSJ | 6.7.05
Jose Yagin woke up feeling dizzy the morning of March 18, and his left side was numb. He went to a nearby emergency room in San Francisco, but doctors sent him home without treating the dangerous condition afflicting him: He was having a ministroke.
The symptoms soon went away, but returned a week later. This time, a friend took him to the University of California at San Francisco, a stroke center. There, an imaging test quickly revealed that the carotid artery on the right side of his neck — a key artery feeding the brain — was more than 90% blocked. The doctors did surgery the next day to clear out the fatty blockage, and Mr. Yagin, 65 years old, has felt fine since.
There is a growing concern among neurologists that, in many cases, patients and other doctors aren’t recognizing or acting on the symptoms of a ministroke, a warning sign that often means a larger, more devastating stroke is on its way. Strokes are the leading cause of disability in the U.S., and the No. 3 cause of death. Many of these major strokes are preceded by a ministroke, in which symptoms such as numbness and vision changes often vanish within an hour or two. Because these symptoms go away, people often ignore them and some doctors miss them, misdiagnosing symptoms as a migraine, low blood pressure, a heart attack, anxiety or a seizure.…
Officially, ministrokes are called “transient ischemic attacks” or TIAs. The word “ischemic” means that oxygen flow to the brain is blocked, usually by a blood clot and fatty plaque in an artery. Brain tissue dies by the minute. The only difference between a full-fledged stroke and a ministroke is the severity and the persistence of symptoms: A ministroke’s symptoms tend to disappear on their own, typically in minutes or within one to two hours. Symptoms can last up to 24 hours, but that is unusual.…
JCAHO’s list of Primary Stroke Centers.
TIAs are the cerebral equivalent of unstable angina to heart.
{ 4 comments… read them below or add one }
I am a bit worried about these JACHO approved “Stroke Centers.” Granted, I agree, as a fellow ED Doctor, that TIAs are frequently misdiagnosed. However, aside from an OUTPATIENT workup with carotid duplex ultrasound there is little more to do in the mean time other than aspirin or plavix. IF the ultrasound shows carotid blockage than, yes, surgery may help (if the patient doesn't stroke on the table!).
However, if the patient is having a stroke, what good is a stroke center. The NINDS study for thrombolytics is arguably deeply flawed and the American Association of Emergency Medicine even has a position statement saying that “clot busters” should NOT be given. SOOOO, What does a stroke center offer other than good rehab?
I keep a copy of the AAEM statement in my emails at all times so I can print it out and give to the patient or family if they question my abilities/reason for refusing to give tpa and its bretheren. The 3 times I have ever given the drug (and yes the pts met all the criteria of the NINDS study) the patients DID improve for about an hour before they ALL worsened secondary to cerebral hemmorhage and subsequently died. A 6% risk of death is WAY too high in my book. Now, IF a stroke center is offering angio guided thrombolysis that is a different story. I do believe that the angio guided therapy is where the “money” is.
All in all, I must say that I am a bit dismayed when a hospital, like UCIrvine, touts that they are a JACHO approved stroke center. We STILL don't have a good, well studied approach to treat strokes so WHY do we have/need JACHO approved Stroke Centers other than to kill off 6 out of 100 stroke victims?!?!
Just my two cents.
Greg
Agree. That is the dilemma with AHA and these particular neurologist — they want to be aggressive and want to treat CVAs/TIAs like unstable angina and AMIs — but there is not the infrastructure or the wherewithal in the neurologic community to effect the types of capabilities and capacities we see in the cardiac community. When we first started using thrombolytics in the ED there was a very willing and supporting infrastructure of cardiologists and cardiac surgeons — lots of cath labs. Where is the similar committment for CVAs. Its not the same and NINDS is part of it. I don't think either of us would want thrombolytics for ourselves or our families' CVAs but we would want it for ours and theirs AMIs. There is a tremendous disconnect and of course JCAHO seems to be oblivious to the danger of ratcheting up demand for a service that has a non-existent supply side. California has over 400 hospitals and only about 10 have stepped forward for CVAs. All have stepped forward for AMIs.
I am a bit worried about these JACHO approved “Stroke Centers.” Granted, I agree, as a fellow ED Doctor, that TIAs are frequently misdiagnosed. However, aside from an OUTPATIENT workup with carotid duplex ultrasound there is little more to do in the mean time other than aspirin or plavix. IF the ultrasound shows carotid blockage than, yes, surgery may help (if the patient doesn’t stroke on the table!).
However, if the patient is having a stroke, what good is a stroke center. The NINDS study for thrombolytics is arguably deeply flawed and the American Association of Emergency Medicine even has a position statement saying that “clot busters” should NOT be given. SOOOO, What does a stroke center offer other than good rehab?
I keep a copy of the AAEM statement in my emails at all times so I can print it out and give to the patient or family if they question my abilities/reason for refusing to give tpa and its bretheren. The 3 times I have ever given the drug (and yes the pts met all the criteria of the NINDS study) the patients DID improve for about an hour before they ALL worsened secondary to cerebral hemmorhage and subsequently died. A 6% risk of death is WAY too high in my book. Now, IF a stroke center is offering angio guided thrombolysis that is a different story. I do believe that the angio guided therapy is where the “money” is.
All in all, I must say that I am a bit dismayed when a hospital, like UCIrvine, touts that they are a JACHO approved stroke center. We STILL don’t have a good, well studied approach to treat strokes so WHY do we have/need JACHO approved Stroke Centers other than to kill off 6 out of 100 stroke victims?!?!
Just my two cents.
Greg
Agree. That is the dilemma with AHA and these particular neurologist — they want to be aggressive and want to treat CVAs/TIAs like unstable angina and AMIs — but there is not the infrastructure or the wherewithal in the neurologic community to effect the types of capabilities and capacities we see in the cardiac community. When we first started using thrombolytics in the ED there was a very willing and supporting infrastructure of cardiologists and cardiac surgeons — lots of cath labs. Where is the similar committment for CVAs. Its not the same and NINDS is part of it. I don’t think either of us would want thrombolytics for ourselves or our families’ CVAs but we would want it for ours and theirs AMIs. There is a tremendous disconnect and of course JCAHO seems to be oblivious to the danger of ratcheting up demand for a service that has a non-existent supply side. California has over 400 hospitals and only about 10 have stepped forward for CVAs. All have stepped forward for AMIs.