Stroke: Emergency Treatment
Guest: Dr. Ed Jauch – Emergency Medicine, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Ed Jauch, who is new to MUSC. Dr. Jauch, I understand you were at the University of Cincinnati for 20 years, working in the emergency department there, with a special interest in early detection and emergency treatment of stroke. So, we’re delighted to have you here, and we certainly do need you here in the Lowcountry.
Dr. Ed Jauch: It’s my pleasure to be here.
Dr. Linda Austin: Dr. Jauch, let’s talk about the presentation of stroke. We think of stroke as an old person’s disease. Who is susceptible to stroke though?
Dr. Ed Jauch: Everybody’s susceptible to stroke. We see it in the pediatric population. We clearly see it more in the elderly, but any age is susceptible to having a stroke. There are clearly different reasons why you may have a stroke, depending on your age. Young patients may have it because of things like sickle cell disease, congenital heart abnormalities, traumatic injuries, and things like that. But, any age is at high risk for having a stroke, depending on their disease status.
Dr. Linda Austin: What are early warning symptoms of stroke?
Dr. Ed Jauch: The ones that we classically teach and train people on are the simple ones; abnormalities with speech, either an inability to speak clearly or to understand speech; facial droop, where one side of the face is sagging; and any type of weakness in the extremities, a weak arm, unable to walk, balance issues. More subtle signs, that patients may not recognize, are problems with vision, where you may not be able to see off to one side of your visual field; patients who are in car accidents because of stroke cannot see off to one side, and difficulty with ambulation or dizziness. And in the forms of stroke that are caused by blood vessels rupturing, you have a sudden intense headache. That can also be a sign of a hemorrhagic stroke.
Dr. Linda Austin: So, in other words, there are two kinds of stroke?
Dr. Ed Jauch: There are two kinds of stroke. About 75 percent of all strokes are what we call ischemic. This is where a blood vessel in the brain has been blocked. It can be blocked from a clot that came from somewhere else, or it can be from what we call hardening of the arteries; or a plaque, like we see in patients with heart attacks. The other form of stroke is when the blood vessel ruptures. And it can either be caused by an aneurysm; which tends to be in the younger patient population, or it can be caused by hypertension, and then just, basically, the fragility of blood vessels as we get older. Both are classified as hemorrhagic stroke.
Dr. Linda Austin: From what you’re saying, it sounds as if it’s very important that if a person is wondering if a stroke is developing, they shouldn’t wonder too long. They should get help very quickly.
Dr. Ed Jauch: You’re stating it very clearly. Time is brain. We use that over and over again to stress the importance of seeking early care. The brain is an extremely fragile organ. It has very few mechanisms to protect itself, and injury can occur within minutes following onset of any type of stroke. So, the importance of seeking medical care cannot be overstated. Unlike many other diseases where you have hours to fix it, we have minutes to an hour or more to fix strokes; or to at least try to consider potential treatments for stroke patients.
Dr. Linda Austin: If a person is concerned that their loved one may be having a stroke, is it okay to drive that person to the emergency room?
Dr. Ed Jauch: No. Many people don’t want to be a nuisance. Many people are embarrassed to have an ambulance at their home. But it’s clear that the only way I may have options to try to treat your stroke, or limit the damage caused by your stroke, is if you use 911 and EMS, or prehospital care providers, to get to the emergency department.
We’ve looked at this over the last two decades, and it’s remarkable that only two thirds of all stroke patients, in most urban settings, actually utilize 911. So, if you don’t use 911, two things can happen. Most likely, you’ll come in well beyond any time window that I have to fix your brain. And, two, not all hospitals are equally capable of dealing with stroke. We work very closely with the EMS agencies to train them on recognizing strokes, start to treat some of these strokes, and triage the patient to the most appropriate hospital; that is best-equipped to handle their stroke.
Dr. Linda Austin: I understand that, in South Carolina, there are only five stroke centers, actually, in the whole state. So, in the Lowcountry, those are? We have one; MUSC.
Dr. Ed Jauch: We have one; MUSC. There’s one at Roper, and East Cooper was just designated by the Joint Commission as a stroke center.
Dr. Linda Austin: How about in the rest of the state?
Dr. Ed Jauch: The central part of the state, and the Upstate, is actually void of any stroke centers. We have one in Greenville, and we have one in Spartanburg. One of the ways we’ve tried to work around these limitations is to actually put a remote camera in some of the smaller hospitals that can then link up with the stroke experts back here at MUSC. We call that telemedicine.
Dr. Linda Austin: As an emergency room doctor, when a patient presents with symptoms that may be a stroke, what are the first things that you do?
Dr. Ed Jauch: There are, really, three pivotal things that we have to do in evaluating a potential stroke patient. The first thing is a physical exam. I need to identify any neurologic deficits. I have the patient smile. I check their vision. I check their speech. I check their ability to move their arms and legs. And I check their ability to feel, when I touch them. By doing that, I can get an idea whether their symptoms are produced by a stroke: Does it make sense from an anatomical standpoint?
If you have stroke expertise available in your hospital, like we do at MUSC, we call it a BAT, or brain attack. In so doing, the pagers go off to all the responsible parties in the hospital, which will be the neurologist, the neurology resident, the stroke attending; which may be me or some of my colleagues. It notifies Radiology that we have a potential stroke patient. One of the other very essential components in evaluating a stroke patient is a CAT scan of the brain. That helps us to determine whether it’s an ischemic stroke where the blood vessels are blocked, or the more devastating form where a blood has ruptured.
Dr. Linda Austin: And, why is that important?
Dr. Ed Jauch: Well, their treatments are vastly different; for the two forms. Patients with hemorrhagic stroke, actually, tend to deteriorate fairly quickly, so we need to be more vigilant with them. They need to be put on a breathing machine. The often need better management of their blood pressure. The treatments, again, specific for the type of stroke, are vastly different, so we have to discriminate between hemorrhagic stroke and ischemic stroke.
Dr. Linda Austin: If a blood vessel is blocked, which is the more common type, right?
Dr. Ed Jauch: Correct.
Dr. Linda Austin: What do you next, after you’ve determined that?
Dr. Ed Jauch: Well, we try to find out where the blockage is, although that’s not critical. But we need to determine that it is an ischemic stroke. And we need to evaluate the patient for the appropriateness of delivering a blood clot dissolving drug called TPA. It also goes by the name of tissue plasminogen activator. It’s actually a protein that we all have in our bodies already. It’s just that this drug is given in a larger concentration. It actually goes to the site of occlusion; or blockage, where there’s a blood clot and starts to try to dissolve it.
The importance of early identification and 911 activation, and EMS transport, is that we can only give that, currently, out to three hours of symptom onset. So, you can imagine, with time being brain, it’s very important to get to the hospital. I have to evaluate you. I need to do some blood tests to look for stroke mimics. I also need to get a CAT scan and be able to interpret it; all within that three hour window, to determine your eligibility for this potentially lifesaving drug.
Dr. Linda Austin: Now, I would bet that some people listening to this podcast are those whose loved ones have already suffered a stroke, maybe even recently. If one is in that situation, what happens then, in the days and weeks, and months, following a stroke?
Dr. Ed Jauch: That’s a great question. It really depends on the extent of your deficits after you’ve had a stroke. Some patients, actually, rehab very well. There’s a broad spectrum of how disabled you may, or may not, be after you’ve had a stroke. Some people, about ten percent, actually, make a full recovery. Sadly, and regrettably, somewhere between 15 and 20, 25, percent actually die in the short term after their stroke, and they tend to be the larger strokes that occur. So, there’s that middle ground of patients who are left with some form of neurologic deficit, or clinical problem, that they didn’t have prior to their stroke that may be amenable to rehab. And we’re learning the importance of early aggressive rehab to maximize the patient’s chance for a good functional outcome.
One of the biggest things we face, that’s been recently recognized, is the prevalence of stroke depression. These are patients who have lost a certain degree of independence. They’ve lost their ability to, perhaps, hold a job. They may require others, like their loved ones, to also quit their jobs. So, post-stroke depression is probably as high as, maybe, 75 percent, to some degree, in all of our patients; and some of their care providers, because the stroke has really changed their way of living and, perhaps, their quality of life. So, we need to be very cognizant that this can occur and try to treat it.
Dr. Linda Austin: Now, I know that for patients who’ve had a heart attack, even though depression is common, and even though depression can be a rather ominous marker for not doing well after a heart attack, those patients often don’t respond to antidepressants like regular patients do, and it’s though that, maybe, there are biochemical factors; chemicals released into the body, that may be causing depression in a different kind of way than a regular psychological depression. Is that true for stroke also? Do those patients do well with antidepressants?
Dr. Ed Jauch: They’re a bit more refractory to antidepressants, although some people do respond. We also find other interventions, like developing family support; getting stroke survivor groups together, identifying peer groups that can kind of give them ideas of how to get back to a certain quality of life and regain some of their independence, to be very helpful. So, peer support, I think, is extremely beneficial in those patients who are clinically depressed after their stroke.
Dr. Linda Austin: I’m sure family support and a positive attitude…
Dr. Ed Jauch: Family support, like in all diseases, is huge, and a positive attitude goes a long way. If you see a patient who’s had a stroke and is fatalistic about their outcome, it really tends to define how well they’re going to do, or how well they don’t do.
Dr. Linda Austin: Now, you mentioned that early aggressive treatment is really key, but over what period of time does recovery from a stroke occur?
Dr. Ed Jauch: That’s a tricky question. So, like I mentioned before, we have a current therapy where we can give TPA to break up the blood clot within three hours. And, often within the first several hours after giving the drug, you see recovery. You see dramatic improvement in the patient’s symptoms.
Dr. Linda Austin: It must be exciting to see that.
Dr. Ed Jauch: We call it the Lazarus effect. We don’t see it very often, but it’s certainly rewarding when you somebody, who’s been devastated, go back to being completely normal. And, often, we have to convince them that they’ve had a stroke. They’re ready to go home, because you’ve made them normal. There are patients with big strokes that we can take to the catheter lab, where we go up into the brain with a special catheter to try to try to break up the clot, and we can do that out to about six hours. But those are very large strokes, in general.
If we can restore blood flow to the brain, we tend to see reasonable recovery. If we expect to see recovery, it’s going to be within the first 24 hours. After that; after a stroke, recovery is a bit more gradual. And, to a certain extent, it depends on other illnesses you may have, and other limitations that you have had prior to your stroke. Like you mentioned before, it may depend on the family and their degree of engagement, and how aggressive they are with rehab. So, there are a lot of factors that really contribute to the rapidity, if you will, of improvement. So, there’s no single answer. But, in terms of a restoration of blood flow to that part of the brain, if we’re going to see benefit from those interventions; either the drug or the catheters, we’re going to see that in the first couple days.
Dr. Linda Austin: Dr. Jauch, thank you so much for talking with us today.
Dr. Ed Jauch: My pleasure.
If you have any questions about the services or programs offered at the Medical University of South Carolina, or if you’d like to schedule an appointment with one of our physicians, please call MUSC Health Connection at: (843) 792-1414.