Stroke–let us talk about it more

It is the start of the New Year and I want to begin by wishing all the readers of my blog a very happy and healthy New Year 2013. May you all be blessed with not only a healthy brain but also a healthy mind!.

I decided that my first post in the New Year 2013 should be on strokes and more importantly on how to recognize a stroke in a timely fashion and how to prevent it. After all a stroke prevented is a brain saved.

So let us begin without delay. Keeping things simple the best way to describe a stroke is to compare it to a heart attack. A heart attack occurs when one of the main arteries of the heart suddenly gets blocked. The sudden lack of blood flow leads to ischemia of the heart (basically the part of the heart supplied by that blood vessel does not get blood/oxygen and if the blocked artery is not opened/ recanalized in time irreversible death of cardiac muscle/tissue occurs). Something similar happens during a stroke and hence sometimes strokes are referred to as brain attacks. A blood vessel in the brain either gets blocked (ischemic stroke) or ruptures (hemorrhagic stroke) and if not opened in time the part of the brain supplied by that blood vessel perishes. The signs and symptoms of the stroke depend upon which part of the brain is involved.

Warning signs of a stroke:

1. Sudden onset of weakness  in the arm and leg on one side of the body (for example abrupt onset of motor weakness in the right arm and leg usually indicates ischemia/lack of blood flow or hemorrhage involving the left side of the brain). That said strokes may be more subtle or unusual in their presentation–weakness in only one arm or one leg, weakness in one arm and contralateral face and so forth.

2. Sudden onset of numbness (loss of sensation but no marked weakness) on one side of the body. Again presentation may be more unusual–abrupt onset of numbness one side of face or just in one arm.

3. Sudden onset of vision problems–double vision or loss of vision in one eye or loss of vision in one half/part of visual field.

4. Sudden onset of difficulty walking or balance–unable to walk in a straight line, dizziness (not all dizziness is stroke though).

5. Sudden onset of speech difficulty–either unable to speak (words are mumbled, not clear, language difficulty), unable to comprehend speech.

6. Sudden onset of complete loss of hearing in one ear (rare form of stroke).

7. Sudden onset of a combination of the above symptoms-usually this is the case.


One of the major problems with stroke is that frequently the symptoms and signs are very subtle and may be ignored by the patient and his family/friends. By the time the patient seeks medical attention, the stroke is already completed (remember when it comes to stroke–TIME IS BRAIN) and the damage is already done. In the case of a heart attack the signs are hard to ignore–sudden onset of squeezing chest pain along with sweating and a sinking sensation. Patients are forced to go to the hospital and seek attention. On the other hand the brain is far more quieter when it suffers a brain attack–no pain, no sweating just quiet suffering of the ischemia.

So what to do when you or someone close to you is suffering a stroke? The most important thing is not to delay seeking attention. You can only be helped if you reach the hospital in a timely fashion ideally within the first hour to 90 minutes of the stroke.  So seek attention at once. It is better to reach the hospital and be told that you misread your symptoms and did not suffer a stroke rather than reach late when nothing can be done to help you apart from supportive care.

So let us start the New Year 2013 by preventing strokes. Remember your brain is your best friend. Protect him, nourish him, take care of him.


Nitin K Sethi, MD


Thrombolysis for stroke- sooner the better!!!

Thrombolysis for stroke- sooner the better!!!

Nitin K.Sethi, MD

A new study on treatment of stroke was published this week in the New England Journal of Medicine (NEJM). The study concerns thrombolytic therapy for stroke and since I feel very strongly about stroke prevention and treatment, I thought I would share the relevant details with my readers. The study “Thrombolysis with Alteplase 3 to 4.5 hours after acute ischemic stroke” and the accompanying editorial by Dr. Lyden appears in the Sep 25th issue of NEJM.

Ischemic stroke (stroke due to lack of blood flow to the brain) can be devastating leaving survivors with neurological deficits (paralysed on one half of the body, unable to walk or talk). When a patient lands up in the ER with an acute ischemic stroke (I like to refer to it as “brain attack” kind of similar to “heart attack”  which patients and family members find easier to understand), as doctors we try hard to salvage the brain tissue at risk of “death”. One of the main drugs in our armament in this fight is a drug called tPA (Tissue plasminogen activator). tPA acts like a clot buster (the drug lyses/ bursts the clot in the brain and helps to reestablish blood flow).

Let me try to explain this in a more simple way. A blood clot breaks from the heart and travels up to the brain, there it lodges in a small blood vessel of the brain preventing blood flow distally (beyond the clot). Patient presents with left arm and leg weakness to the hospital. The brain tissue supplied by the blocked blood vessel now gets no blood and starts to die. “A STROKE IN EVOLUTION” . If blood flow is not reestablished soon, the brain tissue suffers irreversible necrosis and death. This patient is given tPA, the drug lyses/ bursts the clot and helps to reestablish blood flow. The patient who was weak on one side starts moving his arm and leg again.

It is not as simple as I made it out to be above. Patients have to meet strict inclusion criteria before tPA can be administered. Also the drug has a window period and has to be given intravenously within 3 hours of the stroke starting. 3 HOURS THAT IS THE GOLDEN PERIOD. Patients presenting to the ER after 3 hours are usually denied tPA for 2 main reasons-one the tissue which was at risk for stroke is now irreversibly destroyed and thus cannot be salvaged and second the risk for intracranial hemorrhage (bleeding inside the brain) is high. 

The study reported in NEJM extends this window period (golden period) from 3 to now 4 and half hours. You can now understang why this study is generating so much interests among doctors and neurologists in particular. Patients presenting to the hospital upto 4 and half hours after an ischemic stroke can be given tPA provided they meet the other inclusion criteria (and none of the exclusion criteria).

But as Dr. Lyden in his editorial rightly points out, this should not be taken to mean that now you have more time to wait before going to the hospital to seek help (or for us doctors as more time to wait before we decide to administer tPA). When it comes to stroke, TIME IS BRAIN. The more you wait, the more brain tissue is lost, the more brain cells die, the more disability the patient is left behind with.

It is extremely important that the public learn to recognize the early warning signs of stroke and seek help as soon as possible. You can read more about the early warning signs of stroke either on my blog here or on my website


Salt and stroke: what is the connection?

                                                    Salt and stroke: what is the connection?

            Nitin K Sethi, MD

I recently read an editorial written by Norman Campbell and David Spence on “Stroke prevention and sodium restriction” in the Canadian Journal of Neurological Sciences in which they talk about the effect of dietary sodium restriction on the incidence of stroke. As we all know stroke prevention is a much more cost effective strategy as compared to treatment of acute stroke. Unfortunately more attention is being paid to treatment and management issues surrounding acute stroke and precious little to the prevention of stroke. I strongly feel that for every 1 lecture which a neurologist gives about treatment of acute stroke, he should give 10 lectures about the prevention of stroke.

Restriction of dietary sodium or rather salt in the diet is one such cost-effective strategy to prevent strokes.  Increased salt in the diet raises the blood pressure and blood pressure is the number one risk factor for strokes.  The authors make a strong point for government legislation to cut down the amount of salt added to processed foods or that eaten in restaurants. As they rightly say advise to patients to reduce salt intake is by itself relatively ineffective because sodium (salt) sources are ubiquitous and not apparent to the consumer. You may not add any salt to your diet when you cook at home but salt is added to nearly every food item at the time of processing. It is only by government legislation and action that salt content of food items can be lowered. Low salt content shall help in lowering blood pressures and thus prevent cardiovascular and cerebrovascular events (heart attacks and brain attacks!!!)

So watch the salt in your diet everyone. Remember a stroke prevented is a brain saved!!!