Personal Health

Want to Save Some Lives? Here is a Simple Formula for Identifying Strokes

Stroke is the third-leading cause of death in the United States. Not knowing its signs can be fatal.

Do you know when someone might be having a stroke and what to do about it? I didn't, and it spooked me. My sister died earlier this year -- probably from a stroke. But she lived far away from me, and when she noticed something might be wrong, she insisted she didn't want to go to a hospital. She was found dead the following morning.

A fellow board member of Talking Eyes Media, an energetic woman in her 50s, slurred her speech during the day some months ago and didn't think enough of it. She had a massive stroke that evening and will never recover. 

Each year, 600,000-700,000 Americans experience strokes, which are defined as "interruptions of the blood supply to any part of the brain, resulting in damaged brain tissue." Stroke is the third-leading cause of death in the United States. Persons surviving strokes often suffer lifelong physical problems involving their speech, limb movement and thought processes.

Since I have known stroke victims, I want to be as aware as possible when a stroke might be happening. I have been in denial in terms of not knowing some simple basic information that could be very helpful, to myself and to others. A stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke. But some doctors insist that if you can get a person help within three hours of a stroke, there are chances of reversing it. But that requires a) recognizing that it is happening, and b) getting them to the right medical care.

Meanwhile, there is an e-mail that has been making the rounds for years that provides a very simple, easy-to-remember tool for helping to recognize strokes. Much off-the-wall information flies around the Internet, so one has to be initially skeptical about what lands in your e-mail box. So I did a little research on Snopes.com, which confirms that this straightforward "STR" system of recognizing stroke systems is quite dependable and helpful. The Snopes.com write-up is included after this article.

So, the bottom line is that it is very possible for a bystander to recognize a stroke by asking three simple questions:

  • S -- Ask the individual to SMILE
  • T -- Ask the person to TALK and SPEAK (coherently) A SIMPLE SENTENCE (E.g. "It is sunny out today.")
  • R -- Ask him or her to RAISE BOTH ARMS   

If he or she has trouble with any one of these tasks, call 999/911 immediately and describe the symptoms to the dispatcher.

And to remember these three questions, try very hard to remember the letters STR, and remember that they stand for Smile, Talk, Raise. Maybe remember them as the first three letters of the word “stroke.”

As Snopes.com underscores:  "... it is important laypeople learn to recognize such events, because a new drug has been shown to limit disability from strokes caused by clots (ischemic), provided victims receive it within three hours of the onset of stroke symptoms. Tissue plasminogen activator (tPA)  is a clot-busting drug administered intravenously in cases of ischemic stroke; however, only 1 in 50 stroke patients has a chance of this drug helping them because currently only 2-4 percent of them reach an emergency room in time for tPA to be given.

Stroke Warning Signs

There needs to be a similar awareness of the warning signs of a stroke. Frequently, victims simply don't recognize that they are experiencing a stroke, nor do the people around them. "People really don't know much about strokes," says Dr. Bruce Ovbiagele, director of the Olive View/UCLA Stroke Program and a spokesman for the American Stroke Association. "Only about 27 percent of the public can name one stroke symptom."

In some cases, cognitive problems such as confusion caused by the stroke can impair a person's ability to understand what is happening. So, keep in mind that the warning signs include:

  • Sudden numbness or weakness of the face, arm or leg, especially on one side of the body.
  • Sudden confusion, trouble speaking or understanding.
  • Sudden trouble seeing in one or both eyes.
  • Sudden trouble walking, dizziness, loss of balance or coordination.
  • Sudden, severe headache with no known cause. 

In addition, some are suggesting another sign of a stroke -- a "crooked" tongue. If there is the possibility of a stroke, ask the person to 'stick' out his or her tongue. If the tongue is "crooked" -- if it goes to one side or the other -- that could also an indication of a stroke, although in some cases, this might be harder to identify. (See below analysis on this by Snoops.com.)

Now, like most complex medical issues, as one digs deeper, not everything is as it seems at first blush. First of all, many emergency rooms, particularly outside of urban areas are not equipped to deal with strokes or administer the tPA clot-buster.  For example, there are only 32 stroke centers in all of California and just one in Los Angeles, at UCLA Medical Center.

So try to make sure the emergency room you may take someone to is a stroke center. If going via ambulance, try to direct the EMT people to a stroke-center hospital.  Special equipment and staff are needed to diagnose strokes, and the clot-busting drug can be very dangerous.

On top of the very challenging time factors -- recognizing symptoms, getting emergency response, going to an equipped hospital and getting fast diagnosis, including a CT scan -- physicians disagree about whether tPA is an appropriate course of treatment. 

According to Valerie Ulene, writing for the Los Angeles Times, "... time constraints aren't the only reason tPA isn't given. Some doctors who are unconvinced of its benefits will not administer the drug. In a survey of 1,000 emergency room physicians conducted in 2004, 40 percent reported that they were not likely to use tPA, even under ideal conditions. Officially, the American Academy of Emergency Medicine does not support tPA as the standard of care for strokes. The organization points to the drug's potentially serious side effects, particularly bleeding into the brain. ...  

" ' ... tPA can, in some patients, do more harm than good,' " she quotes Ovbiagele. "However, it's the only current hope for stroke victims. 'There are no other approved options for the treatment of acute ischemic stroke,' Ovbiagele says. 'It's tPA or nothing.' " 

*****
From Snopes.com  

Each year, an estimated 600,000 Americans experience strokes, which are interruptions of the blood supply to any part of the brain, resulting in damaged brain tissue. Of these victims, 160,000 die, making stroke the third-leading cause of death in the United States. Those persons this dread killer does not immediately send to the grave are often left with lifelong debilitating infirmities of speech, movement and even thought.

A stroke is a serious medical event, both because it can (and does) kill, and because it can inflict long-term harm on those lucky enough to survive it. There are two types of acute stroke: ischemic and hemorrhagic. Ischemic strokes account for 80 percent of all such "brain attacks" and occur when a blood clot lodges in a vessel responsible for supplying blood to the brain, killing off part of the brain. Hemorrhagic strokes occur when a blood vessel in the brain ruptures, resulting in bleeding, which causes swelling, hematoma and, ultimately, impairs brain function.

The advice given in this much-circulated e-mail appears to be sound, although it needs be pointed out that it has yet to be endorsed by American Stroke Association. It was drawn from a report presented in February 2003 at the American Stroke Association's 28th International Stroke Conference, and news of it can be found on the ASA Web site and the American Heart Association's Web site. However, as the ASA says in its official statement about the report, though the research was funded by a grant from the ASA, that body has not taken a position on the topic nor endorsed the test, because the results, although positive, arose from a very small study.

If the study's findings hold up, it would mean that recognizing a stroke has taken place would be something just about anyone could do and would be a skill worth mastering in light of the importance of getting medical attention for stroke victims at the earliest possible moment.

Focal neurological signs such as slurred speech, unilateral facial droop, blurred vision, discoordination and partial or total paralysis are often indicative of some sort of brain dysfunction and would be recognized as important markers by those in the medical profession. However, expecting lay people to diagnose that something has gone terribly wrong in a loved one on the basis of that checklist would be reaching for too much; in that key moment, few would be likely to remember what they were supposed to be looking for.

The e-mailed advice, as circulated in 2006, contains this additional suggestion: "NOTE: Another 'sign' of a stroke is this: Ask the person to 'stick' out their tongue. If the tongue is 'crooked', if it goes to one side or the other, that is also an indication of a stroke." While that is also likely true, as a test it is far less valuable than the original three because there is room for interpretation of the results. How crooked is crooked, after all? How far to one side does the tongue have to go before its having done so can be regarded as a clear sign of a stroke having occurred? Better to discard this fourth suggested test in favor of remembering the first three.

By distilling the assessment process down to three simple tests (smile, raise both arms, speak a simple sentence), anyone is likely to remember what to ask of someone they suspect has just undergone a stroke and to correctly interpret the information so gleaned. (The tests are pass/fail, after all, so if the person they were administered to couldn't smile, couldn't raise her arms and was incoherent, the party observing all this wouldn't be at a loss for what to make of the results -- she'd conclude her friend had suffered a stroke.)

And it is important laypeople learn to recognize such events, because a new drug has been shown to limit disability from strokes caused by clots (ischemic), provided victims receive it within three hours of the onset of stroke symptoms. Tissue plasminogen activator (tPA) is a clot-busting drug administered intravenously in cases of ischemic stroke; however, only 1 in 50 stroke patients has a chance of this drug helping them because currently only 2 percent of them reach an emergency room in time for tPA to be given.

(It's possible tPA's effectiveness can be boosted by simultaneous massaging of the clot with ultrasound. Early results from a 2004 study performed in Houston on coupling this drug with such treatment are most encouraging.)

A 2005 updating of the e-mail included this statement: "A neurologist says that if he can get to a stroke victim within three hours he can totally reverse the effects of a stroke ... totally. He said the trick was getting a stroke recognized, diagnosed and then getting the patient medically cared for within three hours, which is tough. While getting appropriate medical care for a stroke victim as soon as possible is extremely important, doing so does not come with a 100 percent guarantee that a stroke identified and treated within a three-hour time frame will not cause permanent damage."

Don Hazen is the executive editor of AlterNet.