Stroke

Stroke is the third most common cause of death in the United States. Stroke also results in substantial health-care expenditures; according to the American Heart Association (AHA), the mean lifetime cost resulting from an ischemic stroke is estimated at $140,000 per patient. The Centers for Disease Control and Prevention (CDC) estimate that direct and indirect costs related to stroke in the US alone are expected to reach $73.7 billion in 2010.

Symptoms of stroke are caused by the interruption of blood flow to an area of the brain. They can include one or more of the following:

1. Sudden numbness, paralysis, or weakness in your face, arm, or leg.
2. New problems with walking or balance.
3. Sudden vision changes.
4. Drooling or slurred speech.
5. New problems speaking or understanding simple statements, or feeling confused.
6. A sudden, severe headache that is different from past headaches.

Stroke Diagnosis

If a stroke is suspected, prompt, accurate diagnosis and treatment is necessary to minimize brain tissue damage. A quick diagnosis within the first 3 hours may enable treatment options that can lead to a better recovery.
Diagnosis includes a medical history and a physical and neurological examination to evaluate the level of consciousness, sensation, and function (visual, motor, language) and determine the cause, location, and extent of the stroke.

Physical examination includes assessing the airway, breathing, and circulation (ABCs) and vital signs. The head (including ears, eyes, nose, and throat) and extremities are also examined to help determine the cause of the stroke and rule out other conditions that produce similar symptoms.

Blood tests and imaging procedures (e.g., CT scan, ultrasound, MRI) help the physician determine the type of stroke and rule out other conditions, such as infection and brain tumor.

Imaging Procedures: When stroke is suspected, computed tomography (CT scan) is performed as soon as possible. MRI/MRA, carotid ultrasound and PET scans are other commonly used imaging modalities used to diagnose and determine the nature and severity of a stroke.

Ischemic vs. Hemorrhagic Stroke

It is important that the type of stroke is determined early as treatment options are different for patients suffering ischemic strokes vs. hemorrhagic strokes.

Ischemic Stroke

Ischemic strokes are the most common type, making up about 83 percent of all strokes. An ischemic stroke occurs when a blood vessel becomes blocked, usually by a blood clot. Clots can form when blood vessels become clogged with fat and cholesterol, a condition known as atherosclerosis. In an ischemic stroke, the clogged artery prevents blood from reaching the brain, causing brain cells to suffer from the lack of nutrients and oxygen that they would normally get.
Treatment options for ischemic stroke include:

Clot-dissolving medications such as a tissue plasminogen activator (TPA) may be injected into the veins to dissolve a blood clot. Anticoagulants and antiplatelet drugs may also be administered during or immediately after a stroke to help prevent clot formation. Although these medications work differently, the result in both cases is to help to keep blood vessels open and delivering oxygen and nutrients to brain cells.

In addition to medical management, ischemic strokes are also managed using the following surgical techniques:

1. Carotid endarterectomy:  This procedure is used to remove atherosclerotic plaque from the carotid (neck) artery when it is narrowed. The surgeon makes an incision in the neck, the artery is opened and the plaque is removed.
2. Bypass Surgery:  This technique is used to establish a new route for blood to reach the brain, usually by grafting another vessel to a cerebral artery.
3. Angioplasty and Stenting:  In this procedure, a balloon-tipped catheter is maneuvered into the obstructed area of the artery. The balloon is inflated, compressing the plaque against the artery walls. A metallic mesh tube (stent) is usually placed in the artery to act as a scaffold to prevent recurrent narrowing. A doctor may recommend angioplasty for patients who are not good candidates for endarterectomy, or for narrowing in arteries that are not accessible with surgery.

Hemorrhagic Stroke

A hemorrhagic stroke occurs when a blood vessel in the brain bursts or breaks, causing bleeding in the brain. Hemorrhagic stroke is less common but more frequently fatal than ischemic stroke.

Hemorrhagic stroke can most often be traced to high blood pressure, but it may also be caused by an aneurysm. Another possible cause of hemorrhagic stroke is an arteriovenous malformation, or AVM, a group of malformed blood vessels that can rupture, again resulting in bleeding in the brain.

Treatment modalities for Hemorrhagic Stroke include:

1. Carefully controlling blood pressure, which can be too high or too low.
2. Drugs to control brain swelling.
3. Medications to relieve headaches
4. Seizure medications such as phenytoin

Sometimes, surgery is needed to save the patient’s life or to improve the chances of recovery. The type of surgery depends upon the specific cause of brain bleeding. One common problem related to brain bleeding is hydrocephalus, which is the build up of fluid within the brain. A procedure called ventriculostomy may be needed to drain the fluid.

Medical-Legal Considerations

Patients who complain of weakness in their face or extremities, drooling or slurred speech, are experiencing new problems speaking or are suffering from sudden, severe headaches different from past headaches present diagnostic challenges. They may be sent home or kept for extended periods in the ER while waiting for diagnostic testing for suspected intracranial emergencies like stroke, hemorrhage, abscess, meningitis and hypertension, and for less emergent problems like tumor or migraine. Failure to diagnose and treat not only stroke, but these other intracranial emergencies in a timely manner has a significant impact on patient outcomes. Physicians have been held liable for failure to diagnose stroke, hemorrhage and infection and obtain appropriate consultation in these situations. A high index of suspicion is necessary to avoid this medical-legal pitfall.