Deborah Cort RN, MSN, CRRN
If you are like most people, the diagnosis of stroke conjures up images in your mind of long hospital stays, wheel chairs, inability to talk, being unable to care for yourself and even death. However, if you are aware of the signs and symptoms of stroke and get to a hospital with a primary stroke center FAST, then those images can be removed from your mind for good. Many people do not take the signs and symptoms of a stroke seriously. For years, people have been educated about heart attacks and the need to seek treatment quickly. They know that a heart attack can happen to the young and the old. Well, so can a stroke! Strokes can occur in children, young adults, middle age people and the elderly. We need to seek treatment for stroke as quickly as a heart attack. That is why the American Stoke Association has encouraged health professionals to use the term Brain Attack when they discuss the diagnosis of stroke with people in the community and with patients. A Brain Attack is as serious as a heart attack and needs immediate attention.

According to the American Stroke Association statistics for 2007, Brain Attack is the third leading cause of death in the United States. Each year about 700,000 people experience a new or recurrent stroke. About 500,000 of these are first attacks and 200,000 are recurrent attacks. On average, every 45 seconds someone in the United States has a Brain Attack. Approximately every 3 to 4 minutes someone dies of a stroke. Each year, about 46,000 more women than men have strokes. African Americans risk of a first stroke is almost twice that of whites.Brain Attack is the leading cause of serious, long term disability and the estimated direct and indirect cost for stroke in 2007 is $62.7 billion. Of all strokes, 87% are ischemic and intracerebral and subarachnoid hemorrhage make up the other 13%. An ischemic stroke is a blockage. This type of stroke occurs when the blood vessels to the brain are blocked. Ischemic strokes are caused by fatty deposits lining the blood vessel wall within the brain. An ischemic stroke can be caused by a thrombus which is a development of a blood clot at the fatty deposits or by an embolus which is a traveling particle too large to pass through a small vessel.A hemorrhagic stroke is bleeding in the brain. This is caused by a burst or leaking blood vessels in the brain. A hemorrhagic stroke occurs when a weakened blood vessel ruptures. This could be an aneurysm, a ballooning of a weakened region of a blood vessel or an Arteriovenus Malformation (AVM), a cluster of abnormal blood vessels.

Some people are more at risk for a Brain Attack than others. According to the American Stroke Association, some risk factors cannot be treated. They are:

Age The chance of having a stroke more than doubles for each decade of life after age 55. While stroke is common among the elderly, a lot of people under 65 also have strokes.
Heredity (family history) and race Your stroke risk is greater if a parent, grandparent, sister or brother has had a stroke. African Americans have a much higher risk of death from a stroke than Caucasians do. This is partly because blacks have higher risks of high blood pressure, diabetes and obesity.
Sex (gender)Stroke is more common in men than in women. In most age groups, more men than women will have a stroke in a given year. However, more than half of total stroke deaths occur in women. At all ages, more women than men die of stroke. Use of birth control pills and pregnancy pose special stroke risks for women.
Prior stroke, TIA or heart attack The risk of stroke for someone who has already had one is many times that of a person who has not. Transient ischemic attacks (TIAs) are “warning strokes” that produce stroke-like symptoms but no lasting damage. TIAs are strong predictors of stroke. A person who’s had one or more TIAs is almost 10 times more likely to have a stroke than someone of the same age and sex who hasn’t. Recognizing and treating TIAs can reduce your risk of a major stroke. If you’ve had a heart attack, you’re at higher risk of having a stroke, too.
Risk factors that can be treated are:

High blood pressure High blood pressure is the most important controllable risk factor for stroke. Many people believe the effective treatment of high blood pressure is a key reason for the accelerated decline in the death rates for stroke.
Cigarette smoking In recent years, studies have shown cigarette smoking to be an important risk factor for stroke. The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system in many ways. The use of oral contraceptives combined with cigarette smoking greatly increases stroke risk.
Diabetes mellitus Diabetes is an independent risk factor for stroke. Many people with diabetes also have high blood pressure, high blood cholesterol and are overweight. This increases their risk even more. While diabetes is treatable, the presence of the disease still increases your risk of stroke.
Carotid or other artery disease The carotid arteries in your neck supply blood to your brain. A carotid artery narrowed by fatty deposits from atherosclerosis (plaque buildups in artery walls) may become blocked by a blood clot. Carotid artery disease is also called carotid artery stenosis. Peripheral artery disease is the narrowing of blood vessels carrying blood to leg and arm muscles. It’s caused by fatty buildups of plaque in artery walls. People with peripheral artery disease have a higher risk of carotid artery disease, which raises their risk of stroke.
Atrial fibrillation This heart rhythm disorder raises the risk for stroke. The heart’s upper chambers quiver instead of beating effectively, which can let the blood pool and clot. If a clot breaks off, enters the bloodstream and lodges in an artery leading to the brain, a stroke results.
Other heart disease People with coronary heart disease or heart failure have a higher risk of stroke than those with hearts that work normally. Dilated cardiomyopathy (an enlarged heart), heart valve disease and some types of congenital heart defects also raise the risk of stroke.
Sickle cell disease (also called sickle cell anemia) This is a genetic disorder that mainly affects African-American and Hispanic children. “Sickled” red blood cells are less able to carry oxygen to the body’s tissues and organs. These cells also tend to stick to blood vessel walls, which can block arteries to the brain and cause a stroke.
High blood cholesterol People with high blood cholesterol have an increased risk for stroke. Also, it appears that low HDL (“good”) cholesterol is a risk factor for stroke in men, but more data are needed to verify its effect in women.
Poor diet Diets high in saturated fat, trans fat and cholesterol can raise blood cholesterol levels. Diets high in sodium (salt) can contribute to increased blood pressure. Diets with excess calories can contribute to obesity. Also, a diet containing five or more servings of fruits and vegetables per day may reduce the risk of stroke.
Physical inactivity and obesity Being inactive, obese or both can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke. So go on a brisk walk, take the stairs, and do whatever you can to make your life more active. Try to get a total of at least 30 minutes of activity on most or all days.
Recognition of Brain Attack symptoms “FAST” and knowing the time of the symptom onset (the time when the person was last seen well or normal, not when the person was found with the stroke symptoms) are important because time saved is brain function saved. Learning the signs and symptoms of a Brain Attack can save time and precious brain function. By using the easy mnemonic device FASTto remember stroke symptoms you can help expedite medical and surgical stroke intervention. According to Dawn Kleindorfer, M.D. associate professor of neurology at the University of Cincinnati, It is so important to realize that rapid treatment can sometimes reverse stroke, break up clots and turn it all around but you have to get to the hospital right away. Only a health care professional can determine if someone is having a stroke. However, by Thinking FAST, you may be able to save someone’s life. You can Think FAST by looking for the following signs and symptoms:

F- Face (uneven smile, facial droop/numbness, visual disturbances) Have person try to smile. Does one side droop down? Is one eye more closed than the other? Do they have a difficult time seeing you?
A- Arm and Leg (weakness, numbness, difficulty walking) Have person raise both arms out in front of them. Are they able to raise both arms? Does one arm fall to their side? Can they feel you touch their arm or leg? Can they walk?
S- Speech (slurred speech, inappropriate words, can’t speak, can not follow simple commands)
T- Time Call 911 immediately if one or more of these symptoms occur. Report to EMS the time of the onset of these symptoms or if you are not aware of the time, let EMS know the last time you saw this person normal. Also report the symptoms that you observed. The information you provide can make a difference in the kind of treatment that can be safely provided.

Unfortunately, most people with stroke symptoms do not get to the hospital in time to receive the full range of possible treatments. It is crucial that you get to the hospital quickly. Do not drive yourself. Call EMS. Many people are afraid to call EMS or go to the emergency room. They think, “What if I am wrong? I don’t want to look stupid. But what if you are right? If the stroke is the result of a clot, you may receive a clot busting drug called Tissue Plasminogen Activator (t-PA). However for this drug to work, it must be given within three hours of the onset of symptoms. That is why it is so important to know the time the symptoms began. If t-PA is given with in 3 hours of the onset of stroke symptoms, t- PA has been shown to improve outcomes of all Brain Attack patients. Patients treated with t-PA are 30 -55% more likely to have minimal or no disability at 3 months after the stroke. (NINDS New England Journal of Medicine 1995, 333:1581-7). Currently < 5% of eligible patients are getting t-PA nationwide. Mostly because people do not get to the emergency room on time. Two thirds of Brain Attack patients wait 24 hours from the time of onset of their symptoms before coming in for treatment. The health care providers will need to determine the cause of the stroke before treatment is started. If the cause of the stroke is hemorrhagic, surgical intervention may be necessary.

Besides Thinking FAST and getting to the hospital quickly, it is important to know if your hospital is equipped to provide the latest treatment for stroke. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) launched a Primary Stroke Center Certification in 2003. Founded in 1951, the Joint Commission seeks to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits nearly 15,000 health care organizations and programs in the United States, including more than 8,000 hospitals and home care organizations, and more than 6,800 other health care organizations that provide long term care, assisted living, behavioral health care, laboratory and ambulatory care services. The Joint Commission also accredits health plans, integrated delivery networks, and other managed care entities. In addition, the Joint Commission provides certification of disease-specific care programs. An independent, not-for-profit organization, the Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. The recommendations for a primary stroke center is based on the criteria published by the Brain Attack Coalition and the American Stroke Association. To be considered for Primary Stroke Center designation, the hospital must:

Have a qualified Medical Director responsible for the stroke program
Have an effective process in place in the Emergency Department to ensure that all stroke patients receive timely care and that the number of patients eligible for and receiving TPA is maximized
Demonstrate effective multidisciplinary team effort in the treatment of stroke patients
Develop and implement a series of care protocols that follow the “Get With the Guidelines” program
Have adequate neurologists on staff to cover emergency call
Have adequate neurosurgical coverage to support emergent stroke patient surgical needs
Have 24 hour a day, 7 day a week, 365 days a year coverage in key imaging and diagnostic areas including:
CT, MRI, MRA
Cerebral Angiography
Carotid Ultrasound
Transthoracic/Transesophegeal Echocardiogram
Submit clinical data on all stroke patients to the American Stroke Association
Use an ongoing stroke team structure to evaluate stroke patient data and strive to continuously improve on compliance to stroke protocols and performance against industry recognized stroke care benchmarks
Have a structure in place to ensure that ongoing stroke education is provided for physicians, nursing and ancillary staff

The best thing for you to do if you have the risk factors for stroke is know if there is a primary stroke center in your area. You can do this several ways. You can call your local hospital and ask if they are a primary stroke center. You may need to speak to the manager for the Emergency Department or to the Chief Nursing Officer to find out this information. Another resource is contacting your local Emergency Medical System provider. They will know which hospital in the area provides this care. You can also contact the following people at the Joint Commission related to disease specific care certification:

Jean Range
Executive Director

jrange@jointcommission.org

M.J. Hampel
Associate Director

630-792-5720

mhampel@jointcommission.org

Or you can log onto the Internet Stroke Center: Stroke Center Directory at http://www.strokecenter.org/strokecenters.html. This site shows you a map of the United States. Click on your state and it will give you information on the stroke centers in your area.

Preventing a Brain Attack by knowing your risk factors and controlling the controllable is the best way to not become a statistic. Other ways to prevent yourself or your loved one from suffering permanent disability or death from a Brain Attack is being knowledgeable about the signs and symptoms of a Brain Attack, knowing that you have to Think FAST, calling 911 at the onset of stroke symptoms and knowing where in you area there is a primary stroke center.

For more information on stroke go to StrokeAssocaition.org or call 1-888-4-stroke

Deborah Cort is a registered nurse with 19 years of clinical and healthcare management. She is chief nursing officer at SouthLakeHospital in Central Florida where she directs and evaluates all aspects of patient care.