Diplomate, Board Certification of Emergency Medicine
Chairman, Department of Emergency Medicine Ma'ayenei Hayeshua
Hospital
Know Your Enemy
We've discussed it before, but it is definitely worthwhile to
review it. This is the number two killer of all adults,
notwithstanding the severe disability that survivors suffer.
Reb Reuven, the son-in-law of Reb Boruch Ber, the Lubavitcher
Rebbe, and Reb Chaim Shmuelevitz all suffered greatly from
this dreaded disease. Known by physicians as CVA, most people
call it a stroke.
Stroke is like a heart attack of the brain. Arteries get less
elastic with age, fill with cholesterol or clots and when
they clog or leak, part of the brain dies. Depending on what
part of the brain dies, a person may be robbed of their
ability to talk, take care of their personal needs, walk, or
even think. However, just like the heart, there is something
called angina, where there is a temporary clogging of an
artery that clears quickly, there is a concept of a
ministroke or a temporary stroke. We call these TIAs. They
serve as a warning to us to start therapy.
The three biggest correctable causes of stroke are
hypertension, atrial fibrillation and carotid stenosis.
Hypertension, or high blood pressure is a silent disease
which only starts to cause its effects once you have had it a
long time. You can feel fine, and still have high blood
pressure. You should have your blood pressure measured often,
and you should take your medication faithfully if you have
medication.
Atrial fibrillation is rhythm of the heart that occurs
usually in older people that causes a clot in the upper
chamber of the heart. If this clot travels, a stroke can
occur. People who feel unusual heart beats that do not pass
should have an EKG. If you have this problem, you must be on
blood thinners.
Carotid stenosis is narrowing of the main blood vessel
supplying the brain. If this clogs with a clot a stroke can
occur. This problem is picked up on routine physical exam or
in a search for the cause of sudden blackouts or blindness
that comes and goes. The treatment for this is aspirin, and/
or a relatively uncomplicated operation which cleans out
these arteries. Keep in mind that diabetics have a higher
likelihood for clogged arteries and high blood pressure if
they are not in good control. Same goes for smokers.
Recent studies have shown excellent results in hospitals that
have specialized stroke teams (Tel Hashomer is the first and
only in Israel). In the USA, they use the same clot opening
drugs that they use on the heart, provided the patient
arrives to the emergency department within three hours of the
start of symptoms. The European and middle eastern countries
have been less enthusiastic about the safety of this therapy,
therefore most strokes in Israel and Europe are treated with
supportive care only.
Strokes often present with higher blood pressure, and often
look much worse the first day. Miracles have happened with
aggressive rehabilitation. Stents and bypass are experimental
therapies which are also based on what we do in the heart,
but more evidence experience is necessary.
Based on what you know now about hearts and strokes, you can
understand why many physicians believe that taking low dose
aspirin (which prevents easy clotting) every day by everyone
over the age of 35 may be a good idea. In any case, treating
risk factors aggressively, taking your medications, and be
alert for the warning signs can make a difference. In both
the heart and the brain we have made much progress. Write me
in care of the Yated.
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