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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