The leading cause of disability in the United States is stroke – a medical emergency in which blood flow to the brain is cut off or a hemorrhage occurs causing injury to brain tissue. Depending on the severity of the stroke and how quickly treatment is administered, victims suffer mental and physical deficits ranging from slurred speech to vision loss to paralysis. According to the National Stroke Association, someone has a stroke every 40 seconds, affecting nearly 800,000 people per year. May is Stroke Awareness Month, observed to educate the public about the fifth leading cause of death in the U.S.
Lakewood Regional Medical Center, located in the City of Lakewood adjacent to North Long Beach, is in the process of expanding its stroke care services in order to become a certified comprehensive stroke center. This recognition, which hospital CEO John Grah expects to receive by the end of September, will designate the hospital as a receiving center for stroke patients transported by Los Angeles County Emergency Medical Services (EMS).
“The county EMS has pretty much adopted the national best practices for care for stroke treatment. They want patients to get to a location where they can get some advance care, and you want them from onset of symptoms to . . . [receive care within] 45 minutes,” Grah said. “EMS made some changes to their program back in January of 2018. . . . They started a program where they just divert to only comprehensive centers or designated centers that can do thrombectomies,” he explained.
A thrombectomy involves placing a small catheter into a patient’s blood vessel, usually the ephemeral artery, through a minimally invasive procedure, then unblocking the blood vessel that caused the patient to have a stroke, according to Dr. Radoslav Raychev, neuro-interventionist at Lakewood Regional.
Lakewood Regional services an area that is home to about 3.5 million people. For neighboring communities to the north, such as Downey, the hospital would be much faster to get to than certified stroke centers further south, Grah noted. “If you start looking at our traffic patterns [and] the density of our housing and all that, you can start to see [that with] our rush hour, getting from say Downey to Long Beach Memorial or St. Mary’s is probably not possible,” he said. For this reason, Grah and his staff are intently working to achieve certification. To do so, the hospital is expanding its neurology staff and building upon stroke support services such as neurosurgery and neuro-intervention.
The most common type of stroke is called an ischemic stroke, which occurs when a blood vessel to or within the brain is blocked by a clot, according to Raychev. The less common type is called a hemorrhagic stroke, in which bleeding in the brain occurs. Both types cause damage to brain tissue. In 2015, thrombectomies became standard of care in treating ischemic strokes, Raychev said. “We have a window of up to 24 hours to do this procedure,” he said. “Time is very important.”
Raychev explained, “Whenever there is a blockage of a brain vessel, there is poor blood flow to the brain, and the brain is suffering a lack of oxygenation, a lack of blood flow, a lack of important nutrients. That’s what stroke is. The sooner you open the vessel, the more likely the patient will recover.”
As Grah put it, when it comes to strokes: “Time is brain.”
The risk factors for strokes are similar to those for heart attacks, Raychev noted. These include high blood pressure, hypertension, obesity, diabetes and high cholesterol. “There is another condition that is unique to stroke; it is called atrial fibrillation,” Raychev said. “That’s a condition in which the heart doesn’t beat in a regular fashion and tends to form clots. And when a clot forms in the heart, it tends to go up into the brain.” These are considered modifiable risk factors in that they are able to be addressed or minimized with changes to diet and exercise, or with medication.
Dr. Nima Ramezan, stroke medical director at MemorialCare Long Beach Medical Center, said that there are also nonmodifiable, or unchangeable, risk factors for strokes. Age is one such factor – the older you get, the more likely you are to have a stroke, he said. A condition called hypercoagulability, which causes thicker than average blood, is another nonmodifiable risk factor, although it is uncommon, he noted.
Strokes are often referred to as “minor” or “major.” According to Ramezan a small or minor stroke occurs when the actual size of a stroke – the area of brain it affects – is small. A major stroke occurs when a major artery is blocked or there is a large hemorrhage in the brain. Raychev compared the concept to plumbing. “The bigger the pipe, the bigger the blockage, the more severe the stroke is,” he said.
The resulting health impacts of strokes vary depending on the individual, the length of time it takes to receive care, and the areas of the brain that were damaged. “I cannot predict how much injury somebody will have,” Ramezan said. “Somebody can have a really tiny stroke in a critical part of the brain that would make half their body not work at all, or somebody could have a very large stroke and you see mild deficits from it.”
Raychev said resulting disabilities may include loss of functionality related to speech and movement that vary in severity. “Patients who receive the proper treatment can recover within 90 days to completely normal. Patients who don’t receive the treatment will be disabled for life with very little recovery. . . . It highly varies,” he said.
Michelle Chung, a clinical specialist in neurologic physical therapy at Long Beach Memorial, and Jane Lapham, a speech pathologist at the hospital, assist stroke patients in their recovery process. Common issues experienced by stroke victims include weakness on one side of the body and/or in facial and tongue muscles, as well as slurred speech, according to Lapham. “We can also see cognitive impairments, so difficulty with memory and reasoning. We can also see something called aphasia, which is a language impairment, where they know what they want to say but they have trouble getting the words out,” she explained.
Chung added, “I have also seen issues with sensation. They may be able to move their leg, but if they can’t feel it or know where it is, then it makes it very challenging for things like standing and walking.”
When working with a stroke patient, Chung and Lapham conduct initial assessments to determine what deficits the patient is experiencing. They then work with a team of physicians, therapists and nurses to ensure the patient remains medically stable and to plan rehabilitation strategies. The first step is to initiate mobility as soon as possible, Chung said.
When it comes to speech therapy, Lapham said the first step is to determine the cause of speech impairment and what needs to be treated. “If they are having trouble speaking, is it because those muscles aren’t getting the impulses from the brain to make them move? Do I need to work on strength? Or is it because they can’t put the sentences together to get the words out to communicate what they want to communicate?” she said.
Treatment plans are catered to each patient. “Every plan is individualized according to their needs and also their support [system]: family support, caregiver support and other resources,” Chung said. Lapham explained, “It’s kind of a combination of looking at what does the patient need to do and how much therapy can they tolerate. . . . Some patients might be able to do two or three hours of therapy in one day, and some patients might not be able to tolerate that much.”
Know The Signs
Health care professionals encourage the public to learn the mnemonic BE FAST to help recognize stroke symptoms. According to MemorialCare, the letters stand for:
- Balance lost
- Eyes blurring
- Facial drooping
- Arm weakness
- Speech difficulty
- Time to call 911
“Family members have to be observant when all of the sudden their loved ones look different or sound different,” Raychev said. Often, people are able to realize that they are experiencing a stroke, but they are sometimes unable to call 911 or reach out for help depending on how the stroke is affecting their ability to speak or move, he explained. This is particularly problematic for people who live alone. “That is the time when we rely on medical technology,” he said, referring to buttons that patients can wear that connect them immediately with emergency services.
Prevention
To prevent a stroke, the best thing a person can do is simply to be healthy, Raychev said. “Everything that you can do to be healthy, do it. And go to your doctor regularly,” he said.
If patients are seeing a doctor for diabetes, high cholesterol or other conditions that are risk factors for stroke, Laphum emphasized that adhering to their medications for those conditions is crucial. “I see a lot of people who, especially with blood pressure meds and diabetes meds, they don’t realize that just a day or two of going off medications can result in a stroke,” she said.
Chung highlighted exercise as an important strategy for minimizing stroke risk. “I don’t think people realize that if you participate in a regular exercise program – it doesn’t have to be that long, just 20 minutes a day – you can decrease your risk factor,” she said.
Technology is evolving in ways that Raychev expects will help prevent strokes in the future. The Apple watch, for example, now has an app that is proven to detect atrial fibrillation, a cause of stroke, he explained. “I think in the future technology is going to alert us about our risk factors being heightened,” he said.