The Warning Signs and Treatment of Stroke

Date:
9/24/2009 | 12:00 pm

Would you know if you were having a stroke? Do you know the warning signs? Is there something you should do to reduce your risk of stroke?

Thomas R. Mirsen, M.D., will answer these questions and more live on cooperhealth.org.

The Stroke Program at Cooper in the Cooper Neurological Institute provides patients with expert diagnosis and treatment of transient ischemic (TIA) symptoms and acute strokes. Patients are provided a full range of specialized services on an inpatient and outpatient basis to reduce disability and suffering due to stroke while providing the most advanced care possible.

Thomas R. Mirsen, M.D., is a member of the Cooper Department of Neurology and practices in the Cooper Neurological Institute. He is board certified in both Neurology and Vascular Neurology. He earned his medical degree from SUNY Health Science Center at Brooklyn. He completed an internship at the Bronx Municipal Hospital Center and a residency at Bellevue - NYU Medical Center in New York City. He was a Fellow at the University of Western Ontario in Canada. Dr. Mirsen sees patients in Cherry Hill, Camden, and Washington Township.

Over 2 years ago, i had a "small" stroke, although I was told it was not a TIA which resulted in double vision for approximately 5 weeks-resolved completely, thank God. My MRI showed signs that other small strokes had previously occurred in different parts of my brain, although I never experienced noticeable signs of same. I was only 43 when the "event" occurred, and there was no reason ever given for this. I did go through the stress test, etc. to find out the source of the problem, with only good results-I exercise regularly and I am of otherwise normal very good health. Is this unusual? Debra from Erial

9/24/2009 12:01:48 PM

Thomas R. Mirsen, M.D.: Yes, it is unusual for strokes to occur at such a relatively early age. One would want to make sure that they were strokes, in fact. Other conditions can produce changes in the brain in young people, such as multiple sclerosis. Also, one would want to do a thorough search for all of the various causes of stroke, ranging from hypertension, smoking, elevated cholesterol and diabetes, to more unusual entities, such as disorders of blood clotting, and subtle heart abnormalities, to name a few.

How do the symptoms differ between a severe anxiety attack and a stroke? Jaine from Saddle Brook

9/24/2009 12:02:34 PM

Thomas R. Mirsen, M.D.: With anxiety attacks, one may have chest pain or shortness of breath, which typically is not seen with stroke. Dizziness or fear are often prominent symptoms, which are much less common in stroke. One may experience numbness or tingling throughout the body, or just in one part of the body, with anxiety attacks. Numbness on both sides of the body is distinctly uncommon in stroke. Numbness limited to one side of the body can be seen both in stroke and in anxiety attacks.
Also in stroke, one may experience disturbances of vision, speech, coordination, or strength. These are much less common in anxiety attacks.

What are the signs and symptoms of stroke? Debby from Marlton

9/24/2009 12:04:36 PM

Thomas R. Mirsen, M.D.: This isn't an exhaustive list, but the most common and important symptoms are:

• Loss of vision in one eye, or to one side
• Difficulty with speech, or with understanding what is spoken
• Weakness on one side of the body
• Numbness on one side of the body
• Staggering or poor coordination
• A very unusual or severe headache

The symptoms vary because different parts of the brain are responsible for different functions.

My mother died of a massive stroke and I'm certainly concerned that I might be prone to strokes. If I think I'm having a stroke, what's the first thing I should do? Should I take an aspirin? Susan from Haddonfield

9/24/2009 12:06:13 PM

Thomas R. Mirsen, M.D.: No, I wouldn't take an aspirin. If there is bleeding in the brain, which only a CT or MRI scan can rule out, it's not the best thing to do. I would call 911 and have the ambulance take me to the nearest stroke center.

My mother has tia's. Is there treatment for those? Jane from Westmont

9/24/2009 12:10:27 PM

Thomas R. Mirsen, M.D.: Certainly. Most people are placed on an antiplatelet agent, whether aspirin, clopidogrel (plavix), or the combination of aspirin with extended-release dipyridamole (aggrenox). They are all similarly effective, and aspirin is by far the cheapest, so it remains the drug of choice in most cases.

Under certain circumstances, an anticoagulant such as warfarin (coumadin) is used. This is most often used when people have a particular sort of abnormal heart rhythm, atrial fibrillation. There are other indications for the use of anticoagulants, but this is the most common.

Also, in some cases one may find narrowing in the blood vessel that takes blood to the part of the brain responsible for the TIA. This may be amenable to treatment, usually with surgery (carotid endarterectomy), although angioplasty and stenting (through a catheter, as is done for the coronary arteries) is increasingly used. 

TIAs are the clearest sign of stroke risk, and can indicate what part of the brain is in danger. They should be investigated promptly and thoroughly to find the most appropriate intervention and avoid stroke. Treatment of underlying risk factors (diabetes, high blood pressure, elevated cholesterol, and smoking) should also be undertaken at the same time.

I had a stroke a couple of years ago and am looking for an exercise group to attend. Does Cooper have anything to offer? Tom from Cherry Hill

9/24/2009 12:14:24 PM

Thomas R. Mirsen, M.D.: We are in  the process of setting up a stroke support group,  which is a bit different, but may be helpful.

A physical therapist may be able to get you started on a home exercise program. There is a Cooper PT office run by Orthopedics on 123 Grove St. in Haddonfield. They also have an office on Centennial Boulevard near the CVS and the Main Street complex in Voorhees.

I have read about the use of hyberbaric oxygen to treat patients with certain symptoms. Do you recommend this type of treatment? Peter from Pemberton

9/24/2009 12:18:00 PM

Thomas R. Mirsen, M.D.: Hyperbaric oxygen is mainly used nowadays for decompression illness affecting scuba divers  (the "bends") and in some instances to assist in the healing of wounds. However, it has never been shown to be beneficial for stroke, and I would stay away from it for this purpose.

I have been taking my ani cholesterol drug for years but I continue to have some plaque build up. At 63 years old, at what point should I consider carotid artery stenting? Henry from Mt. Laurel

9/24/2009 12:21:48 PM

Thomas R. Mirsen, M.D.:
It all depends on the degree of plaque buildup and whether there are any stroke symptoms.

If there are stroke symptoms, then usually the carotid may be treated once its diameter is reduced by 70% or more. There is a more modest benefit in men ONLY to intervention when the narrowing is in the 50-69% range. This is usually determined on a case by case basis. Surgery is still the main option, although stenting is coming into greater use.

If there are no stroke symptoms, most physicians would withhold intervention until the carotid artery is narrowed by 80% or more. The data here are less conclusive, so physicians' opinions may vary, but I feel strongly that this is a good figure to rely on.

If the narrowing is less severe, it makes sense to observe it sequentially by means of follow-up studies. The easiest to do is a carotid ultrasound,. However, it usually needs to be validated by another test if it appears that the narrowing is approaching a critical range.

Carotid ultrasound is available through Cooper Radiology and Cardiology. Your primary doctor can certainly order this study if need be.

MR angiography (MRA) or CT angiography (CTA) are often employed.  CTA tends to be superior. In difficult cases, conventional angiography using arterial puncture and passage of a catheter may be utilized.

My mother (age 80) had a stroke last Nov 2008. She's not paralized, and she can swallow and understand. She can hardly vocalize, but can speak. She's in long-term care with peg-tube feeding, with occasional pureed food tray. I have noticed that not much effort is being made, suggested, or tried to help her improve or regain function. I think there's hope for her to improve. I make the effort to massage her on my nightly (generally) visits since Dec 2008.  She's now able to lift her right hand, reach for her face and head. Two weekends ago, we witnessed something impressive, we placed a short thin breadstick on her right hand, and she fed herself (the breadstik easily melts in the mouth). We also placed a 1/4 cup of thick juice in her hand, and she raised it up to her mouth and sipped. My question is, why don't they do more like this for her? My family and I end up doing this. We don't mind, but are surprised at the lack of focus for patient recovery - which should be their job. Are there other things we could/should do to help her? Quality of care and cleanliness is questionable, she's been sent to the hospital a few times for infection. Also, why can't they give her one of those hand-held tools placed at the throat to amplify voice. Thank you. Dee from

9/24/2009 12:25:45 PM

Thomas R. Mirsen, M.D.: I would see if your mom's doctor can get another therapist or therapists to re-evaluate her. The issues regarding rehab are two-fold. One is whether the examples of good function that you describe are reasonably consistent or occasional. The second is whether there is enough understanding on the part of your mom so that she can learn from one therapy session and have carry-over to the next. This is essential in order for therapy to be useful.

Massage and  passive movement of the weak extremity will help reduce stiffness and avoid the arm or leg assuming an unnatural posture., so they are important. They won't improve function, though.

Sometimes injections of Botulinum toxin (Botox) can help reduce the stiffness (spasticity, to use the medical term). They are available at Cooper as well. They do need to be done roughly every 3 months.

As far as the hand-held amplifier for speech, this isn't used for stroke patients, as it is of no benefit. It is used to replace the voice box after laryngectomy, which is a different situation. altogether.

Deceased father had multiple TIA and strokes. Deceased mother & two deceased brothers also had multiple TIA. Living brother had a stroke last October at 55 years old. He was given the medication that needs to be given within 3 hours. He is able to walk & use his right arm now. But, it is still extremely hard to understand his speech. Aetna only covered speech therapy for a short period. He can't work because he can't be understood. Are you aware of any programs in South Jersey that can help him? Also, he still can't taste anything. Will that ever get better? Lona from Haddon Heights, NJ

9/24/2009 12:28:57 PM

Thomas R. Mirsen, M.D.: One can find resources for stroke on the website of the Delaware Valley Stroke Council,  www.phillystroke.org.  From the main page,  click on the link for Stroke Support Groups. Some of the listings are specific for speech or aphasia.

As far as recovery, most people by a year have reached their maximal recovery,  but there are always exceptions. Small  gains can still be made with continued therapy, and may be very beneficial if properly targeted.  As far as taste, it is important to see if there are other reasons for a loss of taste or smell. Medications, endocrine disorders (such as hypothyroidism), collagen-vascular diseases (lupus or Sjogren's syndrome), as well as dryness of the mouth, can contribute to this difficulty. Treatment depends on the cause.

How does one know the percentage of blockage in one's arteries? When one goes on a cholesterol-free diet, what happens to the plaque built up on the artery wall before the diet changed? Does it dissolve or breakdown? Espi from Voorhees

9/24/2009 12:32:51 PM

Thomas R. Mirsen, M.D.:

One can have a carotid ultrasound, which I mentioned above. I would avoid the companies that come around and do screenings. You're better off going through your doctor.

It is possible for plaque to shrink, but it requires a very strict diet which most people find hard to follow. If it doesn't get worse, that's usually good enough as long as it's not severe to begin with.

If someone has an hemorrhagic stroke, how long would it take that person to fall into a coma? Maryann from Atco

9/24/2009 12:35:28 PM

Thomas R. Mirsen, M.D.: It varies. If the hemorrhagic stroke is small, coma may never happen (fortunately). If the hemorrhage is large, or if a crucial area of the brain (the brain stem) is affected, coma will be immediate. Otherwise, coma may occur at any point within the first week, assuming hemorrhage is not ongoing. The risk goes down over time. Coma after the first week is usually due to other medical complications.

One year ago my 90 year old mother was diagnosed with TIAs. She was prescribed Plavix and low dose aspirin. We have been concerned that Plavix instructions indicate one should not take aspirin with Plavix. We have asked the doctor, but he says to continue with both. Is this usual? Alyce from Turnersville

9/24/2009 12:37:21 PM

Thomas R. Mirsen, M.D.:

The latest data from two large clinical trials do indicate that combination therapy with both aspirin and clopidogrel (Plavix) is no better for stroke prevention than either one alone. Combination therapy does carry a higher risk of bleeding, so it is generally avoided.

Having said that, there are certain indications for combination therapy, the main one being stent placement. If someone has had a stent placed in an artery, they need to stay on both agents for a period of time, most commonly six months, but sometimes longer.

Also, if someone should have TIA or stroke despite the use of one agent, sometimes a second agent is added. However, as this is not a proven strategy, it's usually employed for a short period, such as three months.

I fall a lot, stumble over my speech, sometimes I black out for no apparent reason. Can you tell me why? I'm scared to death because nobody can seem to tell me why. My father died from a stroke. My mother died from congestive heart failure, and my youngest brother of a heart attack at age 47. Please help me. Irene from Camden

9/24/2009 12:39:42 PM

Thomas R. Mirsen, M.D.: These sorts of problems are hard to diagnose over the email. They could come from a very wide variety of causes, and probably a second opinion is in order. As long as you take care of your blood pressure and cholesterol, and you don't smoke and watch your blood sugar, you can probably avoid the problems that have affected the rest of your family.

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