Learning from Sharon’s Brain Attack
By Dr Shaik Ubaid
Long Island, US

Prime Minister Ariel Sharon of Israel suffered a stroke. He is still in coma and is reported to have exhibited some movement in his left limbs in response to painful stimuli.
One good thing that can come out of the high profile coverage of Mr. Sharon’s stroke and the course of the disease is an increased awareness of this serious, common and debilitating condition. Stroke is also called brain attack and time is of critical importance in its treatment.
Analyzing the course of Sharon's stroke will help understand this disease better. His second stroke in a matter of weeks did not come as a surprise to neurologists. The risk of a recurrent stroke is highest after a stroke. Ironically it might have been the overzealous physicians who could have caused the second stroke. Sharon obviously has "non-modifiable risk factors" for stroke such as male gender and old age. He also had “modifiable” risk factors such as a "hole” or birth defect in his heart. He also might have been a smoker and most likely had high cholesterol and high blood pressure because of his obesity.
This recent massive stroke is being described as a "bleeding" in his brain and most likely was not caused by the birth defect in his heart. The small hole in the heart has the potential of allowing small clots in the blood returning from his legs and other parts of the body to the right side of the heart and from there to the left side without first going through the "strainer-filter" of the lung capillaries. From the left side of the heart these clots can travel to vital organs such as the brain where they can get lodged, cutting off blood supply to small areas. The birth defect was most likely not the cause of his first stroke either. If it had not caused any problems for 77 years, it is highly unlikely that it had begun to cause them now.
Indirectly though, the previous small stroke did cause his massive new stroke. Mr. Sharon was put on anticoagulants or blood thinners to prevent future strokes while he awaited a procedure to close the birth-defect. Treatment by anticoagulants is not so popular these days because of the risk of unstoppable bleeding. Apparently this is what happened in this case. Any common patient would not have been given the blood thinners or scheduled for the closure of the heart defect but Sharon was a VIP and this might have accounted for the physicians to have become overzealous. Most neurologists use another class of drugs called anti-platelets to prevent ischemic strokes
Eighty five percent of all strokes are called ischemic strokes. These strokes are caused when the blood supply to the brain is cut off by a clot that has either formed in the arteries of the brain or has traveled from the heart or other arteries and even from the limbs. Some common causes of ischemic stroke include blockage of large arteries because of high cholesterol and a clot traveling to the brain from the heart or the arteries. Other common causes are high blood pressure and diabetes causing a blockage of the smaller arteries in the brain. Smoking contributes to both these mechanisms of stroke.
Fifteen percent of the strokes are caused by bleeding and are called hemorrhagic stroke. We still do not know the cause and location of bleeding in the case of Mr. Sharon. The bleeding was either too massive and was pushing and compressing the narrow brainstem where the vital centers controlling respiration and heart are located thereby necessitating the need for respiratory support. The cause for such bleeding in a man of Sharon’s age could be a degenerative condition called amyloid angiopathy or less likely an aneurysm rupturing. The bleeding could also have taken place directly in the brainstem because of changes in the small arteries in the brain caused by longstanding hypertension or diabetes.
Another cause of bleeding in the brain is a secondary one that occurs after the blood clot causing the ischemic stroke disintegrates and the damaged blood vessels start to bleed in the stroke.
The doctors might not have ruled out the presence of these conditions before starting him on blood thinners.
The long-term effect and the extent of neurological deficits will only be evident as time passes and Mr. Sharon’s general health improves. The deficits in a stroke as well as its initial manifestations depend on the affected areas of the brain.
Stroke is the third leading cause of death and the leading cause of disability in the United States. Approximately 600,000 strokes, or brain attacks, occur in the United States each year and of these, approximately 25% prove fatal. The incidence of stroke is higher in African Americans than Caucasians.
Stroke occurs at a slightly higher rate in men than women, but women are more likely to die. Ischemic stroke occurs more frequently in people over age 65 and hemorrhagic stroke is more common in younger people.
Another important factor of this common medical condition is the economic impact.
Estimates of the total cost of stroke in the United States vary and by some studies are as high as $30 billion per year when the patients' lost wages are included.
Unlike the past, many strokes can be treated effectively through the use of clot-busting medicines if the patient gets to a hospital within three hours of the onset of the symptoms. Unfortunately because of lack of public education and the myriad ways in which a stroke can manifest, most stroke patients seek medical help after the lapse of this three-hour window. Many smaller hospitals have yet to train their ER staff about using this window.
Once the stroke has taken place, doctors focus on stabilizing the patient and prevention of recurrent strokes and rehabilitation. Therefore it is still important for the patients to seek immediate medical care.
It is critical that any sudden onset of weakness, numbness, loss of balance or vision, dizziness, loss of consciousness and other similar symptoms be taken seriously and the patient be rushed to a hospital. It is important to remember that stroke is brain attack.
(Shaik Ubaid is a neurologist based in Long Island)



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