More heads are better than one: Stroke team offers best results
Karleen Swarztrauber, MD
Stroke is the third leading cause of death in the United States.Strokes do not happen just to older people. In fact, 28% ofstrokes occur in people under age 65, including children.1 Likea heart attack, a stroke is an emergency. It is a brain attack.If you have signs of a stroke (table), you need to get to ahospital immediately. Some strokes are treated with medicationsthat must be given within 3 hours of the first signs of a stroke.Other strokes may require surgical treatment. Many patientswith a stroke need special training (called rehabilitation)to learn how to move and speak again. Where are you likely toget the best care to increase your odds of surviving a stroke?
A stroke team is a group of health care providers with trainingand experience in stroke care. A stroke team usually includesone or more nurses and one or more neurologists (doctors withspecialized training in disorders of the brain and nervous system)with added training in stroke. The team may also include a neurosurgeon,a neuroradiologist, a rehabilitation doctor, and rehabilitationtherapists. For this reason, a stroke team is often called amultispecialty, multidisciplinary stroke team.
Mortality is one way to measure whether or not patients receivedgood stroke care. Mortality is defined as the number of peoplewho die during a certain period of time. For example, 30-daystroke mortality is the number of persons who have died in thefirst month following their stroke. About 10% of persons whohave a stroke die in the first month after a stroke. If fewerpersons died after a stroke, it could be because they receivedbetter health care. However, it might also be because theirstrokes were milder. Researchers try to find out why certainpatients are less likely to die after a stroke. It is importantthat the researchers make sure that the reason why one groupof patients was less likely to die is because they had bettercare and not because they had milder strokes.
Two very important findings came from this study. The firstis that persons who are admitted to a hospital in Californiafor a stroke and are seen by a multidisciplinary, multispecialtystroke team are less likely to die in the first month—andeven the first year—after a stroke. This was true regardlessof whether the hospital was a teaching hospital or a non-teachinghospital. As a result, the researchers estimated that 1,000deaths would have been prevented during this 2-year period ifall patients who were admitted to a hospital for a stroke hadbeen seen by a stroke team. The second important finding wasthat only 7.4% of surveyed hospitals had a stroke team. Thegood news is that patients who were transferred to a hospitalwith a stroke team were just as likely to survive as patientswho were first admitted to a hospital with a stroke team.
How do I find out if the hospital near me has a stroke team?
If you have risk factors for stroke, one of the most importantthings you can do is to sit down with your primary care provideror neurologist and discuss where you should go and what youshould do if you have symptoms of a stroke. Planning ahead mayprevent mishaps when you are in an emergency situation. TheJoint Commission on Accreditation of Healthcare Organizationsprovides a list of Stroke Centers in the United States. Youcan visit the Web site— http://www.strokeassociation.org/presenter.jhtml?identifier=3016808—to find a hospital near you. If there are no hospitalsnear you on this list, you can go to your hospital’s Website. If your hospital has a dedicated stroke team, the hospitalmay list the stroke nurse coordinator, the neurologist, andthe neurosurgeon on their Web site. Some larger hospitals withstroke centers may cover outlying hospitals, thus ensuring arapid transfer of patients to the main stroke center. Finally,if you have spoken with your primary care provider or neurologistahead of time, your doctor may be able to arrange your transferto a hospital with a stroke team, if necessary. Remember, timeto proper care is brain saved.
Preventing strokes is the best medicine. Your primary care provider(doctor or nurse practitioner) can help you identify your riskfactors for stroke and work with you to reduce those risks (table 1).Many different diseases and habits increase your risk for stroke.One of the most important is high blood pressure. Often peopleare unaware they have high blood pressure, so regular visitsto have it checked are very important. Other risk factors, oftenrelated to diet,??? are high cholesterol, obesity, and diabetes.Heart disease (for example, a heart attack) is another riskfactor for stroke. It is interesting that most of the risk factorsfor heart disease are the same as those for stroke. This isbecause blood vessels of the heart and brain are both affectedby the same factors. Smoking is a risk factor for both diseasesand should certainly be avoided. You and your doctor can worktogether to eliminate or reduce these diseases. Changing badhabits (smoking and unhealthy eating) as well as exercisingcan make big differences in your life. In addition, your doctormay choose a medication to reduce your risk of having a firststroke. It is also important that you and your primary careprovider or neurologist discuss whom you will call and whereyou will go if you have a stroke.
If you experience any of the symptoms of stroke (table 2), youwill need to go to an emergency room as soon as possible, bestwithin 3 hours of the first symptoms. You should not try to"sleep" it off. Many strokes progress over several hours untilyou cannot speak, see, or move a part of your body. In the emergencyroom, you will have a CT scan. If you have arrived early enough,the emergency room doctor or the neurologist on-call may beable to reverse your stroke using thrombolytic therapy to dissolvethe clot in your brain. If you have arrived too late or do notquality for this treatment, then the doctor will try other treatmentsto keep the stroke from progressing. Not all hospital emergencyrooms are able to give patients thrombolytic therapy. Speakwith your primary care provider or neurologist to find out whichhospital emergency rooms are able to give this treatment.
You may be admitted to the hospital for your stroke. Your doctorwill order additional tests, such as an MRI or angiogram, todefine better the extent, location, and cause of the stroke.These studies sometimes require a neuroradiologist (doctor withspecial training in reading changes in the brain). If you haveswelling or serious bleeding in your brain, a neurosurgeon maybe consulted. Your doctors will try to prevent seizures, aspirationpneumonia (due to difficulty swallowing), blood clots (usuallyin your legs), and other life-threatening illnesses that canresult from a stroke. Because many patients with stroke alsohave serious heart conditions, your doctors may also monitoryour heart and, if necessary, a cardiologist may examine you.If your condition is severe, you may go to an intensive careunit, where the doctors can watch more closely your level ofalertness, heart, blood pressure, and breathing.
Stroke is the leading cause of disability in the United States.The most common disability after stroke is difficulty walkingand simply getting around. Patients may also have trouble speaking,understanding, seeing, and remembering. A doctor with trainingin stroke rehabilitation helps patients relearn these skills.The rehabilitation doctor will design a plan for you which mayinclude physical, occupational, and speech therapy. The therapistswill help you relearn to walk, speak, eat, and even drive. Studiesshow that patients with stroke who have early rehabilitationare more likely to be alive 1 month and 1 year after stroke.In addition, 35% of patients who survive a stroke have depression.Patients may also have difficulty thinking, personality changes,anxiety, and sleep problems. All of these symptoms may respondto medications.
The most likely time to have a stroke is just after you havehad one. In fact, 14% of patients will have a second strokein the year after their first stroke. Because of this, yourdoctors will immediately begin medications to prevent a secondstroke. Your doctors may also order special studies of yourheart and, if you have a heart condition that can cause strokes,may put you on a blood thinner. In some cases, prevention offurther strokes requires surgery. One example is carotid endarterectomy.The surgeon opens and cleans out the narrowed or clogged arteriesin your neck that provide blood to your brain. If you have hada small stroke or a stroke that resolved, carotid endarterectomymay be done right away to prevent a second larger stroke.
Heart disease and stroke statistics—2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2006;113:e85–151.[Free Full Text]
Birbeck GL, Zingmond DS, Cui X, Vickrey BG. Multispecialty stroke services in California hospitals are associated with reduced mortality. Neurology 2006;66:1527–1532.[Abstract/Free Full Text]
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