Few stroke victims properly diagnosed, treated

New York Times News Service

Dr. Diana Fite, a 53-year-old emergency medicine specialist in Houston, knew her blood pressure readings had been dangerously high for five years.

But she convinced herself that those measurements, about 200 over 120, did not reflect her actual blood pressure. Anyway, she was too young to take medication. She would worry about her blood pressure when she got older.

Then, at 9:30 the morning of June 7, Fite was driving, steering with her right hand, holding her cell phone in her left, when, for a split second, the right side of her body felt weak. "I said: 'This is silly; it's my imagination. I've been working too hard.' "

Her car began to swerve.

"I realized I had no strength whatsoever in my right hand that was holding the wheel," Fite said. "And my right foot was dead. I could not get it off the gas pedal."

She dropped the cell phone, grabbed the steering wheel with her left hand, and steered the car into a parking lot. Then she used her left foot to pry her right foot off the accelerator. With great difficulty, Fite twisted her body and grasped her cell phone.

"I called 9-1-1, but nothing would come out of my mouth," she said. Then she found that if she spoke very slowly, she could get out words. So, she recalled, "I said 'stroke' in this long, horrible voice."

700,000 cases

Fite is one of an estimated 700,000 U.S. residents who had a stroke last year, but one of the very few who ended up at a hospital with the equipment and expertise to accurately diagnose and treat it.

Stroke is the third-leading cause of death in this country, behind heart disease and cancer, killing 150,000 Americans a year, leaving many more permanently disabled, and costing the nation $62.7 billion in direct and indirect costs, according to the American Stroke Association.

But from diagnosis to treatment to rehabilitation to preventing it altogether, a stroke is a litany of missed opportunities.

Many patients with stroke symptoms are examined by emergency room doctors who are uncomfortable deciding whether the patient is really having a stroke - a blockage or rupture of a blood vessel in the brain that injures or kills brain cells - or is suffering from another condition. Doctors are therefore reluctant to give the only drug shown to make a real difference, tPA, or tissue plasminogen activator.

Many hospitals say they cannot afford to have neurologists on call to diagnose strokes and cannot afford to have MRI scanners, the most accurate way to diagnose strokes, for the emergency room.

Although tPA was shown in 1996 to save lives and prevent brain damage, and although the drug could help half of all stroke patients, only 3 percent to 4 percent receive it. Most patients, denying or failing to appreciate their symptoms, wait too long to seek help - tPA must be given within three hours.

Even when patients call 9-1-1 promptly, most hospitals, often uncertain about stroke diagnoses, do not provide the drug.

"I label this a national tragedy or a national embarrassment," said Dr. Mark J. Alberts, a neurology professor at the Feinberg School of Medicine at Northwestern University. "I know of no disease that is as common or as serious as stroke and where you basically have one therapy and it's only used in 3 to 4 percent of patients. That's like saying you only treat 3 to 4 percent of patients with bacterial pneumonia with antibiotics."

More than 700,000 Americans have strokes each year, and 150,000 die. Half the survivors end up with permanent disabilities - loss of vision, paralysis, difficulty speaking. But many strokes that could be successfully treated are not. And most strokes could have been avoided with appropriate medical care.

Among the findings by The New York Times:

n With strokes, rapid treatment is crucial. During a stroke, an estimated 1.9 million nerve cells and 7.5 miles of nerve fiber die each minute.

n One drug is approved to treat strokes, tPA. But only 3 percent to 5 percent of patients receive it. Less than a third of patients get to the hospital early enough, within three hours of the onset of symptoms. And even if they do, many hospitals do not offer the drug for reasons that have to do with money and the availability of stroke specialists.

n Half of all strokes could be prevented if patients controlled their blood pressure, and others could be prevented by controlling other risk factors such as smoking. But most patients were unaware of their risks or did not appreciate the importance of stroke prevention.