Musings on Stroke

Apathy around National Stroke Awareness Month is real

I have spent the past week debating whether to post publicly about an email I received from The State (South Carolina’s most widely distributed daily newspaper). Ultimately, I concluded that it was important to do so. Stroke patients need a voice, and while The Stroke Blog was started to empower the younger stroke population through sharing information pertaining to their circumstances, empowerment leads to advocacy.

Following my post on May 18, 2017, Call To Action: Americans Fear Terrorism More Than What Is Likely To Kill Them, I decided to submit the text to The State in hopes of reaching a broad audience in a place that lies in the heart of the “Stroke Belt.” Over half of hospital admissions for stroke in South Carolina involve patients under the age of 65. It seemed an appropriate medium for providing education about stroke during National Stroke Awareness Month.

The email response I received from one of the editors, frankly, shocked me: “THanks [sic] but we’ll have to pass. We don’t generally run columns on all these made-up months, weeks and days…”

“Made-up months”?

I had difficulty understanding what prompted this. Stroke has created a public health crisis, has disabled millions of Americans, and remains the fifth leading cause of death in the U.S, killing over 130,000 people annually in our country. In addition to these alarming numbers, according to the National Stroke Association, as many as 80% of strokes can be prevented. Plus, we have effective treatments within the first few hours of when a stroke starts! Therefore, stroke seemed like the perfect condition upon which to build more awareness. It’s devastating, but we have the power to change that on a large scale, both through preventative efforts and by rapidly treating strokes when they occur.

After deliberating, I replied to this particular editor, and explained that Stroke Awareness Month was being recognized by the mainstream media and hospitals across the country. This person’s quick response was that all months/days devoted to causes should be viewed the same way, whether they were about heart attacks, diabetes, “or chocolate of bicycling or … anything.”

At that point, I called a friend who has worked with hundreds of stroke patients professionally, and asked her what I was missing. I understood that there were numerous “_____ Awareness Month” recognitions, but it made perfect sense to me that the importance of calling 911, the recognition that prompt medical attention can save a person from lifelong disability, the understanding that stroke is not just a disease of the elderly, that education about the importance of smoking cessation was critical, that the knowledge that patients with high blood pressure should comply with taking their medications would all be important points for coverage in the media. And raising awareness around issues that can lessen the incidence of a disease that kills so many people annually still seemed like a good thing to me. As much as I love chocolate (and I do – seriously), lumping awareness around stroke and awareness around chocolate into the same statement rubbed me the wrong way.

In talking with my friend, she reminded me that Stroke Awareness Month was, indeed, “made up” – by President George H.W. Bush in 1989 when he signed a proclamation declaring every May as “Stroke Awareness Month.” I then began reading articles, editorials, and reflections about Stroke Awareness Month, and contemplated how important this time is to so many people affected by stroke. One of my favorites was a piece by Kirk Douglas from 2014 on The Huffington Post (click to read it).

I truly believe that everyone has the right to his or her opinions, and the right to express these opinions with language. The State can makes its own choices about the importance or lack of importance of Stroke Awareness Month, and I can make mine. I believe we do need more awareness around stroke, because I want to be treating more patients with t-PA and mechanical thrombectomy, but I can’t if they don’t call 911 or get to an emergency department quickly after a stroke starts. If they lie down on the couch to take a nap, there is a good likelihood that it will be too late to treat them once they show up at a hospital. That decision – whether to call 911 or lie down – often alters the course of a person’s life, determines whether that person will ever return to work again, will be able to care for himself or require assistance from others for decades to come.

What ultimately shifts people in the 911 direction over the lying down direction?

Awareness.

It’s Raining, It’s Pouring: Why the old man couldn’t get up in the morning

Disclaimer: Read no further if you have a special fondness for nursery rhymes and do not wish to have one ruined for you permanently.

Today I awoke to a rainy morning in Charlotte, North Carolina, and it continued to rain throughout most of the day. This evening, the steady rain transitioned into a downpour. One of my children said: “It’s raining, it’s pouring…”

Most of us are familiar with the well known nursery rhyme:

          It’s raining, it’s pouring;
         The old man is snoring.
          He went to bed and bumped his head,
          and couldn’t get up in the morning.

I vividly recall this nursery rhyme carrying an entirely different meaning for me after I started my neurology residency. It was a rainy day in Seattle, and as this rhyme came to mind while I was driving, it suddenly struck me – the old man sustained either a subdural hemorrhage or an epidural hemorrhage. He experienced a period of lucidity after hitting his head (enough such that he was able to get to bed), but he did not get up the following morning. The story became grim.

meninges

Layers of the meninges (tissue coating the surface of the brain); ref: http://www.merckmanuals.com

The meninges, or the thin tissue coating the surface of the brain, have three basic layers: the dura (outermost layer, which is adjacent to the skull), the arachnoid, and then the pia (adjacent to the brain). When an aneurysm ruptures, typically it is into the subarachnoid space, meaning just beneath the arachnoid layer of the meningeal coating. Thus, a subarachnoid hemorrhage occurs when blood fills the space below the arachnoid layer.

epidural hemorrhage CT scan

This is a CT scan taken from a patient with an epidural hemorrhage, or bleeding from the middle meningeal artery into the space between the skull and the dura. Note the severe compression occurring on the brain.

An artery that travels between the dura and the skull, known as the middle meningeal artery, is vulnerable to tearing with direct trauma to the skull. Typically there is a brief loss of consciousness followed by quick recovery, and these patients often do not seek medical attention because the immediate drama is so short-lived. However, as blood pools from the middle meningeal artery between the dura and the skull, the pressure on the dura creates significant compression on the brain and can quickly become a fatal situation. This is what occurred as the cause of death in actress Natasha Richardson when she fell while skiing in Canada in 2009. She died at the age of 45.

subdural hemorrhage CT scan

This is a CT scan taken from a patient with a subdural hemorrhage (the crescent-shaped collection of white material along the inside of the skull is blood), bleeding from a torn vein in the space beneath the dura layer of the meninges. I suspect this was the cause of death in the old man from the familiar nursery rhyme, given that these hemorrhages are more common in the elderly.

Subdural hemorrhages are more common in the elderly patient population. Large numbers of veins fill the space between the dura layer and the arachnoid layer, and as the brain ages and decreases in size (yes, the brain shrinks with aging), more sheer stress occurs on these veins. A relatively small hit on the head, or even a cough or a sneeze, can result in the tearing of one of these veins, and the subdural space begins to fill slowly with blood. The key word here is slowly. This is not usually as rapid of a neurological demise for the patient as occurs in a patient with an epidural hemorrhage, because epidural hemorrhages involve an artery, which carries blood under high pressure, filling the space rapidly. Blood flowing from a vein flows more slowly because the pressure is lower. Picture water gushing from a water hose (epidural hemorrhage) versus dripping slowly from a faucet (subdural hemorrhage). The pattern of blood layering on a head CT scan can also distinguish between an epidural hemorrhage and a subdural hemorrhage as well, as the images reflect.

I now carry the curse and the blessing of pondering traumatic intracranial hemorrhages every time I hear this nursery rhyme performed on a children’s CD or when I see it printed in an anthology. Perhaps I have passed this on to you as well and the rhyme will carry a different meaning going forward. The story of the old man offers an important lesson in neurological vigilance, though.

When a young person hits his or hear head after falling while skiing or in any other traumatic fashion, anytime there is even the briefest loss of consciousness, a head CT scan is strongly indicated, even if it does disturb vacation plans. When an elderly person hits his head just before going to bed, maybe it is not a terrible idea to wake him up several hours later and ask a few questions, just to be on the safe side. It’s also important to remember that after an elderly person hits his head, even if he does get up in the morning, when he still has a headache a week or two later, that head CT scan can be life-saving if it detects a subdural hemorrhage.