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Featured Stories

Breaking The Silence: STROKE

Written by  Susan Dubuque

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This series explores diseases that can be devastating to the individuals and families they affect — yet no one is talking about them. That is, until now. In each edition of OurHealth, we bring these medical issues into the light and dedicate these stories to the courageous patients and families living with them and the providers and researchers who commit their lives to treating and seeking cures for these silent killers.

It started with subtle symptoms — little bouts of dizziness and headaches that would only last a few minutes. At first it only happened about once a week. Then two or three times a week. Finally, the spells became a daily occurrence.

Scott Garrett, a busy industrial equipment supplier, spent long days driving throughout his sales territory that spanned from Gloucester to Chesapeake, calling on as many as 10 clients a day. “When the dizziness would hit, I would pull off the highway and rest for two or three minutes until it passed,” he says. “I knew I should see a doctor to find out what was going on, but life and work just kept getting in the way.”

On July 10, 2014, the daily grind came to a sudden halt when his wife, Keeley Garrett, found him lying on the floor at the foot of the stairs. When Scott Garrett was roused, he tried to convince his wife that he was just tired and was “lying on the floor resting.”

Fortunately, Keeley Garrett is a nurse, and she was not fooled by Scott Garrett's story. She checked his blood pressure, and when she discovered it was elevated, she insisted on calling 911. He was taken to a hospital close to their home.

“I was asked to stay in the waiting area while Scott was being examined,” says Keeley Garrett. “By the time I was taken back into the exam room, Scott was chatting and laughing with the medical staff. He assured them that his only problem was a ‘touch of vertigo’ — which he had self-diagnosed on the Internet.”

The hospital conducted an EKG, CT scan and physical examination and took his medical history but could not pinpoint any reason for Scott Garrett’s dizziness, so he was discharged from the hospital.

“A few hours later, I felt that something was just not right. I know my husband better than anyone,” says Keeley Garrett. She called 911 again, and Scott Garrett was taken back to the hospital where a second CT scan revealed a small area of blockage in an artery in his brain.

“Scott's speech was now slurred, one side of his mouth seemed slightly twisted and he had vision problems. The scariest part was when Scott told me he could only see about a quarter of my face,” recalls Keeley Garrett.

It was apparent that more advanced care was needed, and Scott Garrett was transferred by ambulance to VCU Health’s Comprehensive Stroke Center in Richmond.

Additional tests conducted at VCU Health showed that he'd had an ischemic stroke. Since too much time had passed, he was not able to receive the clot-busting drugs to treat his stroke. “We were fortunate to be at a major medical center,” says Keeley Garrett. “Dr. Felton immediately called in Dr. John Reavey-Cantwell, a neurovascular surgeon. He was able to remove the blood clot in Scott’s brain through a catheter inserted through his upper leg.” Warren Felton, MD, is medical director of VCU Health's Stroke Center.

Scott Garrett was admitted to the Neuroscience Intensive Care Unit, and after a few days he was transferred to the progressive care neuroscience floor. “We were all pretty amazed at how quickly he recovered,” says Keeley Garrett.

“I was in a hurry to go home,” says Scott Garrett, “and that motivated me. When I first woke up I couldn’t move my left arm or leg. But by the next morning I had feeling on that side of my body. I was anxious for the physical therapist to come help me walk.”

“Scott’s short-term memory was impaired. But that only lasts for about two days,” says Keeley Garrett.

“The doctors told me I had ‘the trifecta’ — three major problems related to my stroke,” says Scott Garrett. The first was a patent foramen ovale — a small hole between the upper chambers of the heart. Millions of people have PFOs, and they typically cause no problems. Medical issues can occur when the blood leaking from the right to the left chamber of the heart contains a blood clot. The PFO doesn’t cause a stroke, but it does provide a portal where the blood clot can enter the circulatory system and travel to the brain.

Scott Garrett’s second problem was a narrowing of the vertebral arteries that carry blood to the brainstem. “That’s what caused my dizziness and vertigo,” he says. “So, my Internet research wasn’t totally off base.”

In only six days, Scott Garrett had improved enough to be discharged from the hospital. Unfortunately, he suffered a setback. His third problem was a blood clot in his leg called a deep vein thrombosis. “A few days after going home, I had to go back to the hospital to be treated for the DVT,” he says. “But once that was taken care of, a physical therapist came to the house twice and gave me exercises that I could do on my own to regain my strength. I was on my way.”

By early September — less than two months after suffering a stroke and having brain surgery — Scott Garrett was back at work. “I started slowly, working mostly in the office,” he says. “But, by the end of September, I was back to 100 percent.”

“For a while, I would have little flashes of anxiety,” he admits. “For instance, if I stumbled over something, I would think, 'Did I trip or is it another stroke?'” Thankfully, those moments of unease have passed.

When the Garretts look back over Scott Garrett’s illness, they do so with a genuine sense of gratitude. “We were blessed that Scott received such good care at VCU,” reflects Keeley Garrett. “We have a lot of confidence in Dr. Felton, Dr. Reavey-Cantwell and the entire staff.”

“We feel fortunate that we know what caused my stroke,” says Scott Garrett. “And we know what it will take to prevent it from happening again. I’ve made some changes for the better in how I live. I take my medication (Warfarin and a baby aspirin) every day to prevent blood clots. I get plenty of exercise by walking. And I actually lost some weight.” When it comes to living a healthy lifestyle, he refers to himself as “a work in progress.”

And he learned another lesson. “If I could give any advice to others, it would be not to wait. And don’t rely on what you read on the Internet. If you’re not feeling right or if you have any symptoms of a stroke, get medical help right away. I was lucky not to have any permanent damage. But I have too much to live for. With a wonderful wife and our daughters, Ebonee and Sidney, I won’t ever take that for granted.

What is a stroke?

According to the National Stroke Association, a stroke is a brain attack that occurs when a blood vessel that carries oxygen to the brain bursts or is blocked by a clot. When the brain is deprived of oxygen, brain cells begin to die. A stroke can affect movement, speech, perception, memory or other mental and bodily functions.

“How a person is affected by a stroke will depend on the area of the brain where the stroke occurs and the extent of the brain damage,” says Dr. Felton. “Some people have very minor problems, like temporary weakness of an arm or leg, while others may suffer significant impairment, including permanent paralysis on one side of the body or loss of the ability to speak. Many people make a complete recovery from a stroke, but more than two-thirds of those who survive have some type of disability.”

Stroke is the fifth-leading cause of death and the No. 1 cause of adult disability in the United States. Each year 800,000 people experience a new or recurrent stroke. Virginia is located in the “stroke belt” — a region in the southeastern U.S. that is recognized by public health authorities for having an unusually high incidence of stroke and other forms of cardiovascular disease.

“There are different types of stroke,” says Dr. Felton. The major categories are:

•    Ischemic strokes account for about 85 percent of strokes. They occur when the artery that supplies oxygen-rich blood to the brain becomes blocked.

•    Hemorrhagic stroke occurs when an artery leaks blood or a brain aneurysm ruptures. The leaked blood puts pressure on brain cells, which damages them.

•    Transient ischemic attack (TIA), also known as a "mini stroke," is caused by a temporary clot. TIAs produce strokelike symptoms but do not cause lasting damage.

Risk factors for stroke

Anyone can have a stroke, but there are a number of factors that increase the risks. “Some risk factors cannot be controlled,” says Dr. Felton, “but you can take action to prevent a stroke by understanding and managing factors that you can control.”

Risk factors that cannot be controlled

•    Age – Although individuals of any age can have a stroke, the risk increases with age. The chance of having a stroke doubles every 10 years after age 55.

•    Gender – Stroke is more common in men than in women for most age groups. But women of all ages are more likely to die from a stroke, which kills twice as many women as breast cancer every year. Women also suffer greater disability than men after having a stroke.

•    Ethnicity – African Americans, Hispanics, Native Americans, and Alaska Natives have a greater chance of having a stroke than do non-Hispanic whites or Asians. African Americans have a greater chance of having a stroke, in part due to their higher prevalence of high blood pressure, diabetes and sickle cell disease.

•    Family history – Stroke risk increases if a family member (parent, grandparent or sibling) has had a stroke or a heart attack at an early age.

Risk factors that can be managed

Amandeep Sangha, MD, medical director of the Joint Commission Advanced Stroke Program at Bon Secours St. Mary’s Hospital, offers the following insights into understanding and managing the medical conditions that increase the risk for stroke.

•    Hypertension – Hypertension, or high blood pressure, can cause both ischemic and hemorrhagic strokes. Many people don’t know they have high blood pressure, so regular blood pressure checks are essential. Eat a balanced diet, maintain a healthy weight and exercise regularly to help reduce blood pressure, and talk with your healthcare provider about medication if needed.

•    Diabetes – Individuals with diabetes are up to four times more likely to have a stroke than those who don’t. In part, this is because people with diabetes often have other risk factors for stroke, such as high blood pressure and high cholesterol. Diabetes can be controlled by losing weight, exercising, changing your eating habits and, if needed, taking oral medications or insulin shots.

•    Cholesterol – Cholesterol is the fatty substance in the blood. It is produced by the liver and found in certain foods. If we take in more cholesterol than the body can use, the extra cholesterol can build up in the arteries, including those in the brain, which can lead to narrowing of the arteries, stroke, heart disease and atherosclerosis. Cholesterol levels can be checked with a simple blood test. Healthy eating, exercise, fish oil supplements and medications can help lower cholesterol.

•    Heart disease – Certain heart disorders can increase the risk for stroke because plaque builds up in the arteries and blocks the flow of oxygen-rich blood to the brain. Other heart conditions, such as heart valve defects, irregular heartbeat — including atrial fibrillation — and enlarged heart chambers, can cause blood clots that could break loose and cause a stroke.

•    Prior stroke or TIA – An individual who has had a stroke is at increased risk for having another one. Someone who has had one or more TIAs is almost 10 times more likely to have a stroke than someone of the same age and gender who has not. It is important to recognize and treat a TIA as a medical emergency in order to reduce the risk of a major stroke.

“About 80 percent of strokes are preventable,” says Dr. Sangha. “You can reduce your risk of having a stroke through lifestyle changes. It isn’t magic. There are some basic guidelines that I recommend to my patients.” They include

•    Quit smoking. Smoking doubles the risk of stroke and is even higher among women who also take oral contraceptives. It increases clot formation and plaque buildup in arteries, and it thickens the blood. If you smoke, try to quit. If you can’t quit on your own, ask your doctor about stop-smoking aids like nicotine patches, counseling and smoking cessation programs.

•    Use alcohol in moderation. Drinking too much alcohol can elevate blood pressure and increase your risk of stroke. If you drink, do so in moderation — no more than two drinks a day for men and one drink a day for women.

•    Eat healthy. Eat a variety of nutritious foods from all the food groups. Vegetables and fruits are high in vitamins, minerals and fiber, and they're low in calories. Unrefined whole-grain foods contain fiber that can help lower blood cholesterol and help you feel full, which may help you manage your weight. Recent research shows that eating oily fish containing omega-3 fatty acids — including salmon, trout and herring — can help lower your risk of death from heart disease or stroke.

•    Exercise. “Exercise is a huge factor in reducing your stroke risk,” says Dr. Sangha. “You don’t have to run a marathon. Walk or do other physical activities for at least 30 minutes on most days. You will lower your risk for heart disease, hypertension, diabetes and stroke.” But before you start, check with your doctor.

•    Maintain a healthy weight. To lose weight, use more calories than you eat every day. Before starting a diet, check with your doctor.

Signs and symptoms of stroke

According to the American Stroke Association, someone in the U.S. suffers a stroke every 40 seconds. The warning signs of stroke can be subtle and often going unnoticed by the individual experiencing symptoms and the people around them.

“A stroke is a medical emergency,” says Mary Morrissette, neuroscience administrator at Chippenham and Johnston-Willis hospitals. “Learn the signs, and if you or a loved one experiences these symptoms, seek help immediately. Too often people wait, hoping the symptoms will pass.”

Treating a stroke within three hours is vital to avoiding serious and permanent damage. An ischemic stroke, caused by a blocked artery, can be reversed 85 percent of the time if treatment is initiated in a timely manner.

Donna Doherty, SCRN, a stroke certified registered nurse at Chippenham and Johnston-Willis hospitals, teaches this simple, easy-to-recall acronym to help identify the signs of stroke: BE FAST.

Balance – The severe, sudden onset of balance problems and ataxia, the inability to walk normally.

Eyes and vision – Unusual trouble with sight in one or both eyes.

Face drooping – Numbness or tingling of the face, a crooked or uneven smile.

Arm weakness or leg numbness – Weakness, numbness or tingling on one side of the body.

Speech difficulty – Trouble speaking or understanding words, slurred or garbled speech.

Time to call 911 – Even if symptoms appear temporarily, call 911 immediately. Survive, don’t drive. Make note of the time the symptoms first appeared. Remember, time is brain.

“I can’t stress enough the importance of not waiting,” says Doherty. “The symptoms of stroke are usually not painful making them easy to ignore. And many people don’t want to be a bother.”

How is stroke diagnosed and treated?

When a patient arrives in the emergency department with an apparent stroke, accurate diagnosis is the vital first step. The signs of stroke can be caused by a variety of medical conditions. For example, Bell’s palsy produces paralysis or weakness of the muscles on one side of your face that may look like a stroke.

The type of stroke — ischemic caused by a clot or hemorrhagic resulting from a leaky or ruptured blood vessel — will dictate the appropriate treatment, according to Dr. Sangha. A CT scan or MRI typically will be done to show if a stroke has occurred and the location and type of the stroke.

The gold standard for treating ischemic strokes is tissue plasminogen activator, commonly referred to as "tPA." This clot-busting drug, given through an IV, must be administered within three hours of the onset of symptoms — up to four and a half hours in certain circumstances. The tPA dissolves the blood clot and improves blood flow to the brain, which can improve the chances of recovering from a stroke. “This is why it is important to identify a stroke and call 911 immediately,” advises Doherty.

Another treatment option is an endovascular — which means within the blood vessels — procedure called "mechanical thrombectomy." A neurosurgeon, interventional radiologist or endovascular-trained neurologist will attempt to remove a large blood clot by sending a stent retriever that resembles a tiny wire cage to the site of the blocked blood vessel in the brain. The doctor threads a catheter through an artery in the groin up to the blocked artery in the brain. The stent opens and grabs the clot, and the physician removes the stent with the trapped clot. This procedure should be done within six hours of acute stroke symptoms.

Hemorrhagic strokes may be treated in several ways. If you’re taking blood thinners, you’ll be taken off the medication. Medicines to lower blood pressure might be prescribed.

A leaky or ruptured blood vessel (aneurysm) can be repaired with endovascular embolization, or “coiling.” Similar to the process used to remove a clot, a catheter is threaded through an artery in the groin or arm to the brain, and a tiny platinum coil is inserted to block or reduce the flow of blood. The blood then clots around the coil, essentially sealing the leak. An alternative surgical procedure, referred to as “clipping,” could be performed to treat hemorrhagic strokes.

“Once a patient is stabilized from the initial assault of a stroke, it is important that we understand the reason for the stroke,” explains Dr. Sangha. “That way we can take steps to reduce the risk of a recurrence.”

Treatment continues

Treatment for stokes can continue for many months following the initial event to help patients regain as much function as possible and learn skills to compensate for any lasting deficiencies.

“Stokes can result in physical, sensory, communication, cognitive and emotional deficits,” says Stacie Stevens, stroke program coordinator for VCU Health.

Stroke survivors can experience muscle weakness or paralysis, typically on one side of the body. Physical and occupational therapy could be prescribed to help patients regain mobility, dexterity and the skills of daily living, such as dressing, feeding, tying shoes and the like.

Speech therapy can be useful for treating communication deficits, including the inability to understand or produce speech correctly (aphasia), slurred speech due to weak muscles (dysarthria), difficulty in programming oral muscles for speech production (apraxia) and problems swallowing (dysphagia).

A speech therapist can also help patients with exercises to improve cognition, including memory, attention, problem-solving, reasoning, following directions, initiating activity and comprehension.

“Thanks to the plasticity of the brain — particularly among younger stroke patients — individuals may be able to redevelop some capabilities,” says Dr. Sangha. Plasticity refers to the brain's ability to repair and reorganize cells; healthy brain cells create new pathways to unaffected parts of the brain, taking over the jobs previously carried out by brain cells that have been destroyed.

“Addressing the physical effects of stroke is only part of the journey back to health,” says Morrissette. “Stroke patients may also need support and treatment for mental health problems that can include extreme mood fluctuations or inappropriate emotions, such as laughing when something isn't funny or crying for no apparent reason. This behavior is particularly common early in the recovery process.

“Stroke survivors may mourn the loss of capabilities and should be screened and, if needed, treated for depression.” says Morrissette. Younger stroke patients can have different concerns, such as educational, career and relationship issues that can require special attention.

And the patient is not the only person affected by a stroke. “Caregivers must also cope with dramatic changes in their lives, such as the loss of a spouse as they once knew or a parent now caring for her once-independent middle-aged child,” says Stevens.

What does the future hold?

“Medical and surgical treatments for patients with stroke are rapidly developing,” says Dr. Felton. Following are a few of the advances that suggest new hope for stroke patients:

•    Research studies published in the New England Journal of Medicine in 2015 found that ischemic stroke patients who were treated within six hours of the onset of symptoms with both tPA and a clot-removal device had significantly better outcomes than patients treated with tPA alone.

•    Researchers at the University of Texas-Dallas are conducting early studies of a new treatment to aid in the recovery of limb function after a stroke. Vagus nerve stimulation is an FDA-approved method for treating various illnesses such as depression and epilepsy. It involves sending a mild electric pulse through the vagus nerve, which causes the release of chemicals in the brain (neurotransmitters) that enhance learning and memory. It is hoped that vagus nerve stimulation will support neuroplasticity — the brain’s ability to change its neural circuitry — leading to long-lasting improvement in function for stroke patients.

•    When the brain is deprived of oxygen during a stroke, brain cells die. A second wave of brain injury can occur when excess amounts of toxic chemicals are released in the brain following a stroke. Researchers at the National Institute of Neurological Disorders and Stroke are studying the mechanisms underlying this secondary assault, which involves inflammation, toxicity and a breakdown of the blood vessels that provide blood to the brain. From this research, scientists hope to develop neuroprotective agents to prevent secondary damage.

“New developments in stroke care are happening right here in Richmond,” notes Dr. Felton.

•    Research at VCU Health includes newer blood thinners to reduce the chance of recurrent stroke and a drug to improve walking after stroke.

•    VCU Health Virginia Women’s Stroke Prevention Initiative is a study to determine whether incorporating enhancements to the electronic health record will lead to more effective screening and treatment of patients with stroke and cardiovascular risk factors.

“No matter how far we go in developing new techniques for diagnosing and treating stroke, prevention is still the best medicine. That is where our focus should be,” concludes Dr. Felton. ”We can make major strides in reducing the devastating effects of stroke by understanding and managing the controllable risk factors.”

Medical Experts
Donna Doherty, MSN, SCRN, RN, Stroke Coordinator, Chippenham Hospital and Johnston Willis Hospital Comprehensive Stroke Center
Warren Felton, MD, Medical Director, VCU Health Comprehensive Stroke Center
Mary Morrissette, BSN, RN, Neuroscience Administrator, Chippenham Hospital and Johnston Willis Hospital Comprehensive Stroke Center
Amandeep Sangha, MD, Site Lead, Department of Neurology and Medical Director, Stroke Program, Bon Secours St. Mary’s Hospital
Stacie Stevens, PHD, FNP-BC, RN, Stroke Program Coordinator, VCU Health Comprehensive Stroke Center

Research Assistance
Arthur Olivarez, Virginia Commonwealth University

Resources
National Stroke Association – Stroke.org
Centers for Disease Control and Prevention – CDC.gov
National Institute of Neurological Disorders and Stroke – NINDS.NIH.gov
American Stroke Association – strokeassociation.org
YoungStroke (organization for young stroke survivors) - youngstroke.org