Better let the Ambulance go once again

Why can't we recognize a stroke in time

Irina Baglikova, "Doctor Peter"

Since the advent of vascular centers and programs to help stroke patients, in-hospital mortality has increased, and there are more disabled people. "Previously, patients with a massive stroke were left to die at home, and now they are being taken to hospitals. Fortunately, many can be saved," Oleg Pavlov, head of the Department of Neurosurgery at the Mariinsky Hospital, explains the paradoxes of statistics.

– Oleg Anatolyevich, when a person is struck by a stroke, often neither he nor others can immediately orient themselves and figure it out: this is a stroke, we urgently need to call an ambulance. Because the signs of a stroke do not always coincide with the FAST rule known all over the world: face (face – asymmetry), arm (arm – weakness can be both in the arm and in the leg), speech (speech – violation), touch (touch – sensitivity disorders more often – on the one hand).

– To know all the signs of a stroke, you need to study at a medical institute. The FAST rule is very general and does not cover the whole variety of possible violations. But at least one of them is found in the general series of changes, indeed, often. To suspect an apoplexy, as a stroke was called before, should be with any neurological disorder that occurred suddenly and acutely. In addition to the listed signs, this is a sudden headache, which the patient classifies as the most severe pain he has experienced in his life, vomiting and dizziness, visual impairment, pupil asymmetry, difficult movements of the eyelids, eyeballs, problems with speech, coordination disorders, sudden numbness of some part of the body. There may be other symptoms that manifest both together and separately.

– How to distinguish a headache with a stroke from a migraine? Her attack can also start suddenly. They say that if a severe headache is not relieved by painkillers, then it is a stroke. Is it so?

– This is the most difficult symptom, since about 50 diseases are known, the leading symptom of which is a severe headache. In any case, we must try to find its cause. And yes – if the headache is relieved by drugs, then this does not exclude a stroke at all. Alertness should be in everything.

– A person who rarely goes to doctors, doubts both his diagnosis and the need to call an ambulance, is afraid to hear: "Why was called?"

– It is better to let the ambulance doctors be outraged about an erroneous call than a person will receive irreversible changes leading to disability and even death due to underestimation of the seriousness of the situation. And this often happens, especially in patients with ruptured cerebral aneurysms (hemorrhagic stroke). We often come across the fact that our patients or their relatives call an ambulance 2-3 times or go to a doctor's appointment in a polyclinic for a week. Hemorrhagic stroke with rupture of a cerebral vessel is a rare condition, and doctors underestimate the situation: they are hospitalized at the wrong address or begin to treat the patient on an outpatient basis. For example, his headache may be accompanied by vomiting, clouding or loss of consciousness, an increase in body temperature, photophobia. Often, against this background, blood pressure rises, and this condition is regarded as a hypertensive crisis. In other situations, the clinic treats osteochondrosis of the cervical spine and even acute respiratory infections. And during an epidemic of influenza or other colds, about 20% of such patients end up in an infectious hospital with suspected meningitis.

If the patient himself does not understand the danger hanging over him, then his relatives should force him to consult a doctor (neurologist, cardiologist), even if it seems like a reinsurance. Because a stroke is always very serious.

– And if the symptoms both came and went, and after a sudden indisposition, the person feels fine?

– Yes, there are situations in which symptoms can regress within a few minutes or hours. This is called a transient ischemic attack. But all the same, these manifestations should alert a person, and he should turn to specialists. Perhaps the sudden deterioration is due to the narrowing of the cerebral arteries (branches of the aortic arch) that feed the brain. And in this situation, it is necessary to perform surgery to prevent the development of a more severe stroke, with a pronounced neurological deficit. In addition to preventing a second stroke, the importance of removing a collapsing plaque with a blood clot is that the full lumen of the vessel is restored and blood flow to the brain tissue is significantly improved. Operations to remove carotid artery plaques or carotid artery stenting are either minimally invasive interventions using radiopaque angiography or traditional atherectomies. The need for these operations in Russia is very high.

If an aneurysm rupture has been suffered "on the legs" and a person feels bad for a week, and sometimes more, the symptoms may also go away, and the hemorrhage, if it is small, may spontaneously heal. But some patients have a risk of repeated hemorrhages, which can become fatal or lead to severe neurological consequences.

– What determines the severity of these consequences?

– Each case is different. It all depends on the degree of lesion of the vessel with an atherosclerotic plaque, namely, the degree of narrowing of its lumen. As a rule, it depends on age, the presence of severe concomitant diseases, localization of neurological damage and partly on treatment.

Example: the day before yesterday, we removed a large hematoma, the cause of which was the use of an anticoagulant – warfarin (reduces blood clotting to prevent the formation of blood clots). The patient was taking this drug because he had a heart operation a month ago. Due to a decrease in blood clotting, a brain hemorrhage occurred. The hemorrhage was huge in the frontal lobe, it led to a violation of speech, psyche, movements of the right arm and leg. After the operation, everything partially recovered, and this is not the limit – the recovery continues.

– How often do you have to resort to surgical treatment and how important is it for a positive outcome of the disease?

– Aneurysm rupture requires quick solutions and emergency measures. With hemorrhages associated with hypertension, atherosclerosis – the so-called hypertensive hemorrhages, patients need surgery in about 10% of cases, in other situations they should be treated conservatively – this is drug treatment and rehabilitation.

Urgent measures in case of rupture of a vessel are necessary to prevent repeated hemorrhages – they occur in 60% of cases in the first three weeks after a vascular catastrophe and in 20-30% of cases lead to death.

– Why is surgery not always required?

– With a hemorrhagic stroke, the hemorrhage may be small, or it may be in functionally significant parts of the brain, penetration into which causes harm – causes even greater damage than the stroke itself. For such patients, the results of surgical treatment are poor, they are even worse than the natural course of the disease.

In ischemic stroke (cardioembolic), a blood clot breaks off from the wall of the heart cavity and enters one of the vessels of the brain with the blood flow. Modern surgery allows you to remove this blood clot from the vessels using X-ray surgical methods. If it is technically possible and the brain damage is minor, surgery can achieve very good results in the patient's recovery. But we do not always have a chance to use the available technologies: it makes sense to carry out such an operation very quickly – the bill goes for minutes and hours (up to 3-6 hours). That is, the time of delivery of the patient to the clinic, which has the capabilities for such interventions (cerebral coronary angiography, computed tomography and angiography), plays an important role.

We have done only 10 such operations in five months, all of them were successful.

– Why so little?

– Most often the reason is the untimeness of seeking help, and as a result, the late delivery of the patient. Someone postpones calling an ambulance with the confidence that "it will pass by itself", and does not suspect that these are symptoms of a stroke. Someone vascular accident immediately led to a serious condition, and there is no one nearby who could call an ambulance. And it's quite difficult when a disaster happens in a dream. In addition, when the ambulance was called, it can't get to our traffic jams quickly. Rarely, of course, but it happens that the ambulance crew makes the wrong decision or doctors work slowly in the emergency room of a medical institution and underestimate the situation. The result is lost precious time to perform a life–saving operation.

About 10 years ago we were in one of the Israeli clinics and we were shown a patient who had a thromboextraction (removal of a blood clot) of the cerebral arteries and thereby saved him from death. They were very proud of him. This can also be done here – the technologies are available to everyone and at any time of the day or night – again, when everything is done on time. The time factor is a very important factor, it must be strictly observed. It's a shame that we can't always take advantage of this opportunity, and for a banal reason – because the patient or his environment does not know the signs of a stroke, which everyone should be able to recognize.

– It turns out that the time of the ambulance call and delivery to the hospital is important in ischemic stroke, and in hemorrhagic stroke it is not always of great importance for the outcome of the disease?

– In case of hemorrhagic stroke (cerebral hemorrhage), if there is no compression of the brain and a large hemorrhage, speed (hours and minutes) does not play a big role. In ischemic stroke, when a vessel becomes clogged and the blood supply to a part of the brain sharply decreases or stops altogether, it is necessary to remove a blood clot from the vessel as soon as possible. And here the speed of delivery of the patient to the hospital and the start time of the manipulations are very important. They determine the prognosis for the patient's future, because it depends on time how many brain cells will have time to die. Neither the surrounding people nor the ambulance doctors can always understand without the necessary examination, "on the go", whether it is a hemorrhagic stroke or an ischemic one, so as soon as it becomes clear that the patient has a stroke, we must always hurry. In the hospital, the first thing to do is to make an accurate diagnosis - to understand which parts of the brain are damaged and why. To do this, it is urgently necessary to carry out neuroimaging – computed tomography, magnetic resonance imaging or cerebral angiography - according to indications that are determined only by a doctor. Then a decision is quickly made on the appropriate method of treatment, and the patient is taken to the operating room.

We in the department of neurosurgery are doing this all the time, and sometimes we do not immediately determine what kind of stroke the delivered patient has, and whether there is one at all. They often take a patient with a preliminary diagnosis of "ischemic stroke", hurry, because it is urgent to remove a blood clot, and this is a hemorrhagic stroke and surgery is not required. Only after the necessary examination can the necessary measures be taken. And with any stroke, including hemorrhagic, the sooner you start treating, the better. And many people have chances to recover, although previously such patients, especially severe ones, were left at home and told: "An elderly man, unconscious, untransportable." Now I can responsibly state that many people have a chance to keep an active life, we use it and try to make sure that most of our patients have it.

– You say that specialists may have doubts about a patient with stroke symptoms: "whether there is one at all." Why?

– In some elderly patients with severe and prolonged damage to the cerebral vessels, chronic cerebral insufficiency, and widespread atherosclerosis, there may be manifestations similar to stroke. Some of them can be helped, more precisely, to improve the quality of life, if they are operated on. It happens that patients with stroke manifestations also come with other diseases – with a brain tumor (metastases or primary tumor): they experience weakness in the arm or leg, sudden headaches. Now we have three such patients in the department. Two of them had melanoma metastases in their heads, and we removed them. The third has metastases in the brain and a large kidney tumor. However, benign tumors can also "masquerade" as a stroke.

Therefore, we say that the acute onset of neurological symptoms requires urgent medical attention and a quick diagnosis. A stroke or any other problem requires immediate diagnosis and the same rapid medical care.

Portal "Eternal youth" http://vechnayamolodost.ru  22.06.2016