Dr. Diana Fite, a
53-year-old emergency medicine specialist in
Houston, knew her
blood
pressure
readings had been dangerously high for five
years. But she convinced herself that those
measurements, about 200 over 120, did not
reflect her actual blood pressure. Anyway,
she was too young to take medication. She
would worry about her blood pressure when
she got older.
Then, at 9:30 the morning
of June 7, Dr. Fite was driving, steering
with her right hand, holding her cellphone
in her left, when, for a split second, the
right side of her body felt weak. "I said:
'This is silly, it's my imagination. I've
been working too hard.' "
Suddenly, her car began
to swerve.
"I realized I had no
strength whatsoever in my right hand that
was holding the wheel," Dr. Fite said. "And
my right foot was dead. I could not get it
off the gas pedal."
She dropped the cellphone,
grabbed the steering wheel with her left
hand, and steered the car into a parking
lot. Then she used her left foot to pry her
right foot off the accelerator. She pulled
down the visor to look in the mirror. The
right side of her face was paralyzed.
With great difficulty,
Dr. Fite twisted her body and grasped her
cellphone.
"I called 911, but
nothing would come out of my mouth," she
said. Then she found that if she spoke very
slowly, she could get out words. So, she
recalled, "I said 'stroke' in this long,
horrible voice."
Dr. Fite is one of an
estimated 700,000 Americans who had a stroke
last year, but one of the very few who ended
up at a hospital with the equipment and
expertise to accurately diagnose and treat
it.
Stroke is the
third-leading cause of death in this
country, behind
heart
disease and
cancer,
killing 150,000 Americans a year, leaving
many more permanently disabled, and costing
the nation $62.7 billion in direct and
indirect costs, according to the American
Stroke Association.
But from diagnosis to
treatment to rehabilitation to preventing it
altogether, a stroke is a litany of missed
opportunities.
Many patients with stroke
symptoms are examined by emergency room
doctors who are uncomfortable deciding
whether the patient is really having a
stroke — a blockage or rupture of a blood
vessel in the brain that injures or kills
brain cells — or is suffering from another
condition. Doctors are therefore reluctant
to give the only drug shown to make a real
difference, tPA, or tissue plasminogen
activator.
Many hospitals say they
cannot afford to have neurologists on call
to diagnose strokes, and cannot afford to
have M.R.I. scanners, the most accurate way
to diagnose strokes, for the emergency room.
Although tPA was shown in
1996 to save lives and prevent brain damage,
and although the drug could help half of all
stroke
patients, only
3 percent to 4 percent receive it. Most
patients, denying or failing to appreciate
their symptoms, wait too long to seek help —
tPA must be given within three hours. And
even when patients call 911 promptly, most
hospitals, often uncertain about stroke
diagnoses, do not provide the drug.
"I label this a national
tragedy or a national embarrassment," said
Dr. Mark J. Alberts, a neurology professor
at the Feinberg School of Medicine at
Northwestern University.
"I know of no disease that is as common or
as serious as stroke and where you basically
have one therapy and it's only used in 3 to
4 percent of patients. That's like saying
you only treat 3 to 4 percent of patients
with bacterial pneumonia with
antibiotics."
And the strokes in the
statistics are only the beginning. For every
stroke that doctors know about, there are 5
to 10 tiny, silent strokes, said Dr.
Vladimir Hachinski, the editor of the
journal Stroke and a neurologist at the
London Health Sciences Centre in Ontario.
"They are only silent
because we don't ask questions," Dr.
Hachinski said. "They do not involve memory,
but they involve judgment, planning ahead,
shifting your attention from one thing to
another. And they also may involve late-life
depression."
They are also warning
signs that a much larger stroke may be on
the way.
Most strokes would never
happen if people took simple measures like
controlling their blood pressure. Few do.
Many say they forget to take medication;
others, like Dr. Fite, decide not to. Some
have no idea they need the drugs.
Still, there is much more
hope now, said Dr. Ralph L. Sacco, professor
and chairman of neurology at the Miller
School of Medicine at the
University of Miami.
Like most stroke neurologists, Dr. Sacco
entered the field more than a decade ago,
when little could be done for such patients.
Now, Dr. Sacco said,
there is a device, an M.R.I. scanner, that
greatly improves diagnosis, there is a
treatment that works and there are others
being tested. "Medical systems have to catch
up to the research," he said.
In medicine, Dr. Sacco
said, "stroke is a new frontier."
Promise Unfulfilled
One Tuesday morning in
March, Dr. Steven Warach, chief of the
stroke program at the National Institute of
Neurological Disorders and Stroke, met with
a team from Washington Hospital Center, the
largest private hospital in Washington, to
review M.R.I. scans of recently admitted
patients. They were joined in a
teleconference by neurologists at Suburban
Hospital in Bethesda, Md., the only other
stroke center in the Washington and suburban
Maryland area.
The images were mementos
of suffering.
There was a 66-year-old
woman with a stroke so big the scan actually
showed degenerating fibers that carry nerve
signals across the brain.
There was a 75-year-old
who had trouble moving her right arm and
right side in the recovery room after heart
surgery. At first doctors thought she was
just slow to wake up from the
anesthesia.
Now, though, it was clear she had suffered a
stroke. She had lost the right half of her
vision in both eyes and her right side was
weak.
There was an 88-year-old
who slumped forward at lunch, losing
consciousness. When he came to, he had
trouble forming words.
There was a middle-age
man whose stroke was unforgettable. When Dr.
Warach saw his initial M.R.I. scan, in his
basement office at his home, he cried out in
astonishment so loudly his wife ran
downstairs. "I have never seen anything so
severe," Dr. Warach said. None of the three
arteries that supplied the man's right
hemisphere were getting any blood.
Now the man lay in a
coma, twitching on his left side, paralyzed
on his right, breathing with the help of a
ventilator. If he survived, he would have
severe brain damage.
There was Michael
Collins, a 49-year-old police officer who
had had a stroke in his police car in Takoma
Park, Md. Unlike the others, Mr. Collins
seemed mostly recovered. The next few days,
though, would determine whether he was among
the lucky 10 percent of stroke patients who
escape unscathed or whether he would always
be weaker on his left side. If that
happened, Mr. Collins said, he could never
return to his job.
"You have to be able to
shoot a gun with either hand," he explained.
But as time passed, Mr. Collins continued to
be plagued by numbness in his left hand and
on the left side of his face. He wanted to
return to work — "I'm doing great," he said
this month — but the Police Department
insisted that he retire, telling him, he
said, "it's an officer safety issue."
The rest of the patients
in the stroke units at the two hospitals
that day were less fortunate: almost certain
to live, but also almost certain to end up
with brain damage. Some would have to spend
time at a rehabilitation center.
On average, said Dr.
Brendan E. Conroy, medical director of the
stroke recovery program at the National
Rehabilitation Hospital, which is attached
to the Washington Hospital Center, a third
of the Washington hospital's stroke patients
die, a third go home and a third come to
him.
Those whose balance is
affected typically spend 20 days learning to
deal with a walker or a cane; those who are
partly blind or paralyzed must learn to care
for themselves. Many functions return, Dr.
Conroy said, but rehabilitation also means
learning to live with a disability.
But what was perhaps
saddest to the neurologists viewing the
M.R.I. scans that morning was that tPA,
which only recently appeared to be a triumph
of medicine, had made not a whit of
difference to these patients. They either
had not arrived at the hospital in time or
had been considered otherwise medically
unsuitable to receive it.
Few would have predicted
that fate for the drug. In 1995, after 40
years of trying to find something to break
up blood clots in the brain, the cause of
most strokes, researchers announced that tPA
worked. A large federal study showed that,
without it, about one patient in five
escaped serious injury. With it, one in
three escaped.
The drug had a serious
side effect — it could cause potentially
life-threatening bleeding in the brain in
about 6 percent of patients. But the
clinical trial demonstrated that the drug's
benefits outweighed its risks.
When the study's results
were announced, Dr. James Grotta of the
University of Texas
Medical School at Houston expressed the
researchers' elation. "Until today, stroke
was an untreatable disease," Dr. Grotta
said.
But the expected sea
change did not occur.
One problem was that
patients showed up too late. Many had no
choice. Strokes often occur in the morning
when people are sleeping. They awake with
terrifying symptoms, paralyzed on one side
or unable to speak.
"That's the challenge —
we have to ask the patient" when the stroke
began, said Dr. A. Gregory Sorensen, a
co-director of the Athinoula A. Martinos
Center for Biomedical Imaging at
Massachusetts General Hospital.
"If they don't know or can't talk, we're out
of luck."
Another problem is
deciding whether a patient is really having
a stroke. A person who has trouble forming
words could just be confused. Or what about
someone whose arm or leg is weak?
"A lot of things can
cause weakness," Dr. Warach said. "A nerve
injury can cause weakness; sometimes brain
tumors
can be suddenly symptomatic. Sometimes
people have
migraines
that can completely mimic a stroke."
In fact, he said, a
quarter of emergency room patients with
symptoms suggestive of a stroke are not
actually having one.
Most get CT scans, which
are useful mostly to rule out hemorrhagic
strokes, the less common type that is caused
by bleeding in the brain and should not be
treated with tPA. Stroke specialists can
usually then decide whether the patient is
having a stroke caused by a blocked blood
vessel and whether it can be treated with
tPA.
But most stroke patients
are handled by emergency room physicians who
often say they are not sure of the diagnosis
and therefore hesitate to give tPA.
Dr. Richard Burgess, a
member of Dr. Warach's stroke team,
explained the situation: There is no
particular penalty for not giving tPA.
Doctors are unlikely to be sued if the
patient dies or is left with brain damage
that could have been avoided. But there is a
penalty for giving tPA to someone who is not
having a stroke. If that patient bleeds into
the brain, the drug not only caused a tragic
outcome but the doctor could also be sued.
Few emergency room doctors want to take that
chance.
Treatment Barriers
There is a way to
diagnose strokes more accurately — with a
diffusion M.R.I., a type of scan that shows
water moving in the brain. During a stroke,
the flow of water slows to a crawl as dead
and dying cells swell. In one recent study,
diffusion M.R.I. scans found five times as
many strokes as CT scans, with twice the
accuracy.
A diffusion M.R.I.
"answers the question 95 percent of the
time," Dr. Sorensen said.
It seemed the perfect
solution, but it was not.
Most hospitals say they
cannot provide such scans to stroke
patients. They would need both an M.R.I.
technician and an expert to interpret the
scans around the clock. They would need an
M.R.I. machine near the emergency room. Most
hospitals have the huge machines elsewhere,
steadily booked far in advance for other
patients.
It is simply not
practical to demand the scans at every
hospital or even every stroke center, said
Dr. Edward C. Jauch, an emergency medicine
doctor at the
University of Cincinnati
and a member of the Greater
Cincinnati/Northern Kentucky Stroke Team.
"If you made M.R.I. the
standard of care before giving tPA, most
centers would not be able to comply," Dr.
Jauch said. And if it takes more time to get
a scan — as it often does — it might be
better to forgo it and give tPA immediately
if the patient's symptoms seem unambiguous.
Doctors do not need an
M.R.I. to diagnose and treat stroke, said
Dr. Lee H. Schwamm, vice chairman of the
department of neurology at Massachusetts
General Hospital. But, Dr. Schwamm added, if
the question is whether it helps, there is
one reply: "By all means."
It has still not been
shown, though, that M.R.I. scans actually
improve outcomes. It might depend on the
circumstances and the hospital, said Dr.
Walter J. Koroshetz, deputy director of the
National Institute of Neurological Disorders
and Stroke.
But some who use M.R.I.
scans, and who have studied them in
research, say the system has to change. They
say enough is known about the scans to
advocate having them at every major medical
center that will treat stroke patients.
"All these problems could
be solved if there was a will to do it," Dr.
Sorensen said. In his opinion, it comes down
to old and outdated assumptions that there
is not much to be done for a stroke, to
financial considerations and to a medical
system that resists change. But the most
significant barriers, he said, are
financial.
Another approach, stroke
specialists say, is to direct all patients
with stroke symptoms to designated stroke
centers. There, stroke patients would be
treated by experienced neurologists and
admitted to stroke units for additional
care. For the first time, in its newly
published guidelines, the American Stroke
Association recommended the routing of
patients to stroke centers.
But even with such a
system in place, many patients end up at
hospitals that are not prepared to treat
them, as Dr. Grotta discovered in Houston.
He thought he could
change stroke care in Houston with the
stroke center idea. The first step went well
— the city's ambulance services agreed to
take all patients with stroke symptoms to
designated stroke centers.
Then, Dr. David E.
Persse, the city's director of emergency
medical services, asked every one of
Houston's 25 hospitals if it wanted to be a
stroke center. While seven have said yes,
others have declined.
Stroke
patients,
unlike heart attack patients, are not
moneymakers. Because of the way medical care
is reimbursed, most hospitals either lose
money or do little more than break even with
stroke care but can often make several
thousand dollars opening the arteries of a
heart attack patient. And being a stroke
center means finding and paying stroke
specialists to be available around the
clock.
Soon another problem
emerged. As many as a third of the patients
refused to let the ambulance take them to a
stroke center, demanding to go to their
local hospital.
"By law in Texas, we
cannot take that man to another hospital
against his will," Dr. Persse said. "We
could be charged with assault and battery
and kidnapping and unlawful imprisonment."
The Joint Commission,
which accredits hospitals, recently started
certifying stroke centers, requiring that
the hospitals be willing to treat stroke
patients aggressively. But only 322 of the
4,280 accredited hospitals in the nation
qualify, and most patients and doctors have
no idea whether a hospital nearby is among
them. (The list is available on the site
http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DSCOrgs/
under "primary
stroke centers.") Some states, like New
York, Massachusetts and Florida, do their
own certifying of stroke centers.
Nonetheless, most
ambulances do not consider stroke center
designations when they transport patients.
And, said John Becknell, a spokesman for the
National Association of Emergency Medical
Technicians, national programs can be
difficult because every community has its
own rules for which ambulances pick up
patients and where they take them.
As a result, most stroke
patients have no access to the recommended
care and even fewer get M.R.I.'s, a
situation Dr. Warach said he found
appalling.
"How can it ever be in
the patient's best interest to have an
inferior diagnosis?" he asked. "It borders
on
malpractice
that given a choice between two noninvasive
tests, one of which is clearly superior, the
worse test is the one that is preferred."
Averting Catastrophe
In those awful moments
when she realized she had had a stroke, Dr.
Fite, unlike most patients, knew what to do.
She told the ambulance crew to take her to
Memorial Hermann Hospital, even though it
was about an hour away. She knew that it was
one of the Houston stroke centers, that Dr.
Grotta worked there, and that its doctors
had experience diagnosing strokes and giving
tPA.
When she arrived, Dr.
Grotta asked if she was sure she wanted the
drug. Did she want to risk bleeding in the
brain? Dr. Fite did not hesitate. The
stroke, she said, "was just so devastating
that I would rather die of a hemorrhage in
the brain than be left completely paralyzed
in my right side."
"In my horrible voice, I
said, 'Yes, I want the tPA,' " Dr. Fite
said.
Within 10 to 15 minutes,
the drug started to dissolve the clot.
"I had weird spasms as
nerves started to work again," Dr. Fite
said. "An arm would draw up real quick, a
leg would tighten up. It hurt so bad I was
crying because of the pain. But it was
movement, and I knew something was going
on."
Now, she looks back with
dismay on her cavalier attitude toward high
blood pressure. She knew very well how to
prevent a stroke but, like many patients and
despite her medical training, she found it
all too easy to deny her own risk.
Researchers have known
for years the conditions that predispose a
person to stroke —
smoking,
diabetes,
high
cholesterol
and an irregular heartbeat known as atrial
fibrillation. But the major one is high
blood pressure.
"Of all the modifiable
risk factors, high blood pressure leads the
list," Dr. Sacco said. "With heart disease,
you think more of cholesterol; with stroke
you think of high blood pressure."
The reason, Dr. Sacco
said, is that with high blood pressure, the
tiny blood vessels in the brain clamp down
so much and so hard to protect the brain
that they can become rigid. Then they get
blocked. The result is a stroke.
Often, people decide they
do not need their blood pressure medication
or simply forget to take it because they
feel well. But, Dr. Sacco said, patients are
not solely to blame. Doctors may not have
time to work with patients, monitoring blood
pressure, telling them about changes in
their
diet
and exercise that might help, or trying
different drugs and combining them if
necessary.
And it is not so simple
for people to keep track of their blood
pressure. Machines in drugstores and
supermarkets are not always accurate.
Doctors may require appointments to check
blood pressure.
Even when people do try
to control their pressure, doctors may not
prescribe enough drugs or high enough doses.
"They're on a couple of
drugs, and the doctor doesn't want to push
it," said Dr. Jeffrey A. Cutler, a
consultant to the National Heart, Lung and
Blood Institute and a retired director of
its clinical applications and prevention
program.
The result is that no
more than half the people with high blood
pressure have it under control, Dr. Cutler
said. He estimated that half of all strokes
could be prevented if people kept their
blood pressure within the recommended range.
Another lost opportunity
to prevent strokes is the undertreatment of
atrial fibrillation, in which the two upper
chambers of the heart quiver. Blood can pool
in the heart and clot, and those clots can
be swept into the brain, lodge in a small
blood vessel and cause a stroke.
Strokes from atrial
fibrillation can largely be prevented with
anticlotting drugs like warfarin. Yet many
who have the condition do not know it and
many who know they have it were never given
or do not take an anticlotting drug.
Some strokes can also be
prevented by procedures to open obstructed
arteries in the neck that supply blood to
the brain.
As for Dr. Fite, she
completely recovered. And she has changed
her ways.
She was sobered by the
cost of her treatment and brief hospital
stay — $96,000, most of which was paid by
her insurance company. But she was even more
sobered by how close she came to
catastrophe.
Now, Dr. Fite takes three
blood pressure pills, a drug to prevent
blood clots and a cholesterol-lowering drug.
She plans to take those drugs every day for
the rest of her life.
"I was so stupid," she
said. "Boy, when you go through this, you
never want to go through it again."
"I have been given that
precious second chance," she said. "I was so
blessed."