Targeting Stroke in the Stroke Belt

When I was a young neurologist, back in the mid-1980s, there wasn’t much we could do about a stroke except manage a patient’s vital signs, try to avoid complications and help him recover.

I love the way the practice of neurology relies on understanding my patients, on talking with them and their families and tracing their symptoms back to my knowledge of the brain. And I am fascinated by the brain’s intricate structure, organization and mystery.

But I am frustrated that people don’t know the signs of stroke, especially here in the stroke belt. I can’t repeat these often enough. Sudden weakness, numbness or paralysis, trouble speaking or understanding, loss of vision, dizziness, imbalance or severe headache – are all signs of stroke. Get to the emergency room, because today we can do more than watch the stroke progress. We now have treatments which can help to limit the size and severity of a stroke.

For many years treating stroke was more of a waiting game than anything else. Then came a breakthrough that transformed the way we treat stroke. In 1997 the FDA approved a class of drugs known as “clot busters,” or thrombolytics, such as tPA, which could interrupt a stroke as it was occurring. Instead of watching my patients as a stroke robbed them of their speech or movement, in many cases I could stop the stroke from progressing, and prevent disability and death. That was incredible.

Breaking Down the Numbers

Stroke is the fifth-leading cause of death in the U.S., after heart disease and cancer. And it’s a leading cause of permanent disability in the elderly. According to the Centers for Disease Control and Prevention, someone in the United States has a stroke every 40 seconds. The numbers add up. About 795,000 people have a stroke each year. Of those, 610,000 are first-time strokes; 185,000 are a recurrent stroke. Finally, every 4 minutes, someone dies of a stroke.

The figures are even worse here in North Carolina. We live in a part of the country known as the stroke belt. Which means that for reasons no one understands, the incidence of stroke and death from stroke are higher in North Carolina and 10 other southern states than in any other part of the country. In the U.S., the death rate from stroke is about 49 deaths per 100,000 of population. The rate in North Carolina is 57, and in some counties it’s more than 100.

At Wake Forest Baptist Health we’ve been alarmed by these high rates for a long time. Some of my colleagues in Public Health Sciences have been researching why people in the stroke belt have such a higher incidence of stroke. Is it our southern diet? Genetics? An infectious agent? There are all kinds of theories, but the bottom line is, nobody knows.

Caring for Patients in the Stroke Belt

My colleagues and I treat about 1,000 strokes a year, which means we have tremendous experience diagnosing stroke and figuring out which patients are candidates for the clot-busting drugs. We’ve also taken some practical steps to reach out to surrounding counties with the latest computer and robotic technology to create a Telestroke Network. This allows me to examine patients, and talk with them and their families in the emergency rooms at Lexington Medical Center, Wilkes Medical Center, Ashe Memorial Hospital, Allegheny General Hospital and others.

I share on-call duty with 4 other stroke neurologists here at Wake Forest Baptist. When a patient with stroke symptoms arrives at the emergency room in Lexington, Wilkesboro or Jefferson, the emergency room calls us. I log on to my laptop that connects to a computer-driven robot stationed in the emergency room. From my office in Winston-Salem, I guide the robot to the patient’s bedside and we talk. The patient can see me on the computer screen, and I can see him. I can ask about his symptoms. I can see whether there’s any sign of paralysis. I can hear for myself whether his speech is slurred. I can even use an electronic stethoscope to listen to the lungs or heartbeat if needed. What I can’t do is put my hand on him and feel him but I can talk to the family and understand the patient’s recent medical history. I can then make an informed recommendation about whether the patient is a good candidate for a clot buster.

Using clot busters can be tricky. First of all the drug only works in strokes caused by a blocked artery, which is the mechanism in about 85 percent of strokes. Except here’s a hitch: the drug only works if given within 3 hours (in some cases up to 4 ½ hours) of the onset of symptoms. In other words, a patient who felt weak and dizzy at breakfast, but waited until supper to call an ambulance, is too late. There are many other reasons we would not give the drug, such as blood pressure being too high.

Clot busters also carry a risk of hemorrhage, so patients need to be monitored in an intensive-care unit during treatment. And many emergency room doctors are reluctant to start clot-busting treatment without a consultation with a neurologist. So there’s a lot to consider. But when the timing and other factors are right, these drugs can work in ways I never imagined possible. They can actually stop the stroke, and in some cases reverse any disability. It is truly amazing.