Archive for the ‘Stroke’ Category

FES Equipment Coming to Baltimore’s Mount Washington Pediatric Hospital

Thursday, September 8th, 2011

Author - Sarah Keogh

Back in February, Jon Stefanuca wrote about a study in the Journal of Neurorehabilitation and Neural Repair about Functional Electrical Stimulation (FES) and the benefits it can provide to those individuals who have suffered spinal cord injuries. He explained how FES is able to provide electrical impulses to stimulate paralyzed muscles. The study’s authors found improvements based on using FES that led them to recommend using stimulation therapy in conjunction with occupational therapy for patients with incomplete spinal cord injuries. This technology is now also being used to help people with a wide range of injuries and illnesses including, stroke, multiple sclerosis, traumatic brain injury, and cerebral palsy, in addition to spinal cord injuries. According to the Christopher and Dana Reeves Foundation website, FES works by applying “small electrical pulses to paralyzed muscles to restore or improve their function”. The benefits can be extensive:

FES is commonly used for exercise, but also to assist with breathing, grasping, transferring, standing and walking. FES can help some to improve bladder and bowel function. There’s evidence that FES helps reduce the frequency of pressure sores. From: Christopher and Dana Reeves Foundation website

Improved Technology To Be Locally Available

Since FES was originally developed, the technology improved from being something that was typically integrated into large expensive equipment, such as exercise bikes and wheelchair based equipment, into smaller more portable devices. The good news for individuals with neuro-motor injuries in Baltimore City and the surrounding areas is that this type of FES treatment is about to become more available locally. At the end of August, Mount Washington Pediatric Hospital announced that they have received a “Quality of Life” grant from the Christopher and Dana Reeve Foundation. The article explains:

The money will help Mt. Washington Pediatric Hospital purchase Bioness® equipment for its Adaptive Equipment Rehabilitation Clinic (the clinic). The clinic works with patients with neuro-motor disorders to maximize their movement as much as possible given their physical limitations.

From Bioness.com

The Bioness website explains that they produce a variety of “medical devices designed to benefit people with Stroke, Multiple Sclerosis, Traumatic Brain Injury, Cerebral Palsy, and Spinal Cord Injury. These products use electrical stimulation to help people regain mobility and independence, to improve quality of life and productivity.” While I do not know what particular equipment will be available at the Mount Washington Pediatric Hospital, Bioness makes equipment to assist patients with hand paralysis, foot drop and thigh weakness among other conditions.

MWPH Uses Interdisciplinary Approach Combining FES and Therapy

The article about the grant explains some of the many wonderful things available for patients at the Mount Washington Pediatric Hospital (MWPH):

  • …[an] interdisciplinary approach to the assessment and management of adolescents and children with neuromuscular impairments, paralysis and/or movement disorders
  • … [a] team of 21 experienced specialists in physiatry, occupational therapy, and physical therapy.

The new equipment at MWPH will be used along with the other occupational and physical therapy options available to patients. A study described in US Neurology looked at stroke victims and found the combination of FES and traditional therapies that include repeated motion provide the best results:

Stroke patients with limited voluntary movement could now benefit from technologies such as functional electrical stimulation (fes) combined with necessary repetition of functional tasks (use-dependent plasticity) to enhance the neural repair process and improve outcomes, thus enabling them to begin to overcome their previous limitations and to improve their physical capabilities.

From Bioness.com

The goal at MWPH for children and adolescents is based on a similar idea:

Patients whose muscles can be retrained will require several months of therapy to gain normal range of motion and strength. For those patients with more severe conditions where muscles cannot be retrained, the Bioness® equipment will be used to augment their range of motion. Using these two therapy modalities, patients will acquire greater functionality, range of motion, muscle strength, and the ability to move independently.

This multi-disciplinary approach should allow these children and teens to have the best chances of improved motor use and the most independence in their future lives.

Related Articles:

Coming Soon? Restored Breathing for Spinal Cord Injury Patients

Spinal Cord Injury Updates: More Reasons for Optimism?

New Treatment Holds Promise for Patients With Spinal Cord Injuries

New Microchip Promises to Make Life Much Easier for Paraplegic Patients

Acquired Brain Injuries: Hypertensive Brain Hemorrhages

Friday, July 15th, 2011

So what if my blood pressure is high, right? I’m under a lot of stress. I’ll cut back on my caffeine.  I don’t use that much salt.  It’s hot outside.  All reasons to ignore an abnormal blood pressure reading, right?  NOT!

View Image

On the heels of Rachel Leyko’s blog about heat stroke, and in keeping with some topics I’ve been blogging about on acquired brain injuries, hypertensive brain hemorrhages seemed to be a good topic du jour!

Hypertensive brain hemorrhage is just one of the many complications of uncontrolled high blood pressure.  We are currently seeing an epidemic of hypertension, much of it caused by lifestyle and the current epidemic of obesity in the U.S. And, yes, childhood and early adulthood hypertension is on the rise!  In a recent post by MedPage Today, as many as 1 in 5 young adults may have hypertension! The article goes on to cite studies measuring and monitoring patient blood pressures over several years. It is interesting to note that most of the hypertensive individuals did not know that they had high blood pressure! In 2009, DukeHealth.org posted doctor’s advice on managing childhood hypertension, recognizing that the incidence of the condition is on the rise.

Organ Systems Affected by Hypertension

The Mayo Clinic provides an excellent overview of the effects of hypertension on the various organ systems required for bodily functions.  Uncontrolled blood pressure causes damage to the following organs and results in the following conditions:

-Arteries/blood vessels: “hardening of the arteries” and cholesterol-plaque formation leading to stroke, kidney failure, heart attacks, “poor circulation”; aneurysm formation and rupture

-Heart: coronary artery disease (heart attacks); left ventricular hypertrophy and dilated cardiomyopathy; congestive heart failure

-Brain: TIA (transient ischemic attack); stroke (hemorrhagic & ischemic); dementia; mild cognitive dysfunction

-Kidneys: renal failure; renal scarring (leading to failure); renal artery stenosis or aneurysms

I have to admit that one of my “scare tactics” for encouraging patients to treat their hypertension was elaborating on the horrors of hemodialysis; hypertension and diabetes are the two main culprits for patients requiring hemodialysis.  Imagine having to spend 3 days every week hooked up to a dialysis machine (either by a large needle in one’s arm or via a “permanent” catheter tunneled under one’s skin), having to monitor fluid intake, being at increased risk for various infections, and requiring all kinds of specialized drugs to do what the kidneys would normally do! Not fun for anyone! For some reason, this had more effect that the risk of a stroke!

Hypertensive Brain Hemorrhages

I’m going to focus on these types of strokes as opposed to ischemic strokes, knowing that uncontrolled hypertension causes both types.

According to a MedScape Reference Article,

Intracerebral hemorrhage accounts for 8-13% of all strokes and results from a wide spectrum of disorders. Intracerebral hemorrhage is more likely to result in death or major disability than ischemic stroke or subarachnoid hemorrhage. Intracerebral hemorrhage and accompanying edema may disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially fatal herniation syndromes.

Apparently, over time, the high blood pressures in the arteries and arterioles of the brain causes damage to the inner lining of the walls, making them stiff, weak and less compliant to that pulsation we feel everytime our heart pumps blood throughout the body.  As the pressures inside the vessels exceed the compliance of the vessel walls, ruptures occur, leading to bleeding or hemorrhage into the brain tissue.  The blood can extend into the brain ventricles or into the subarachnoid space, or it can localize and clot within the brain tissue. Not only is the blood flow to brain cells disrupted, but there is now this increased pressure being exerted by the blood collection onto adjacent brain tissue causing even more damage. That brain tissue responds by leaking fluid, causing more brain swelling and increased pressures. It is a bad cascade of events that leads to serious brain injury, permanent neurologic problems and even death.

Watch the following You Tube Animation for both ischemic and hemorrhagic strokes:

httpv://www.youtube.com/watch?v=M_fo6ytlmD0

Some Epidemiologic Statistics

According to the same MedScape article, 350 per every 100,000 elderly individuals sustain hypertensive brain hemorrhages every year in the U.S. The overall mortality rate for general intracerebral hemorrhages is very high, with 20,000 people dying annually in the U.S., 44% of which die within 30 days, and 75% of those with pontine or brainstem hemorrhages dying within 24 hours!

From a race perspective, African Americans have a higher incidence of these brain bleeds due to the higher incidence of hypertension within the population.

Women have a higher incidence of brain aneurysms while men have an overall increased incidence of intracranial hemorrhage (general term includes trauma).

With respect to age,

Incidence of intracerebral hemorrhage increases in individuals older than 55 years and doubles with each decade until age 80 years.

Although the overall incidence of hypertensive brain hemorrhages has decreased between 1950 and 2005 with improved diagnosis and management of hypertension, this trend could change with the increasing incidence of hypertension in the young and lack of diagnosis and treatment; hypertension has historically been a disease of the “middle age” patient.

Medical Diagnosis & Treatment

Time is brain tissue when it comes to any kind of stroke, much like the American Heart Association’s motto regarding Acute Coronary Syndrome, “Time is heart muscle.” In each event, the time from onset of symptoms to diagnosis and treatment is absolutely critical.  In some cases, the severity of the injury might not be amenable to any medical interventions, but then again, a lesser injury can sometimes be treated and managed medically or surgically with a fairly good outcome.  Know the signs and symptoms of stroke (similar for ischemic & hemorrhagic) and do NOT delay in contacting “911″ for rapid transport and medical attention!

SOME RELATED POSTS:

Acquired Brain Injuries: Causes and Impact

Acquired Brain Injuries: Subdural Hematomas

Stroke Warnings:Most People Who Experience Minor Strokes Do Not Recognize Its Symptoms\

Image courtesy of “Baxters Blog”.

 

 

 

 

 

Dog Days of Summer Bring Pool Parties and Cookouts but Increase Your Risk for Heat-Related Injury

Monday, July 11th, 2011

The dog days of summer are upon us and with that heat and humidity comes an increased risk for injury.

Recently I ran a 7 miler race through the streets of downtown Baltimore on a hot and humid morning.  During that race, I saw at least one person suffering from what appeared to be heat exhaustion.  Luckily for that runner there was race support nearby and EMS on its way.  Had there not been race support there to cool the runner down with bottles of water he may not have survived.  Running is not the only outdoor summer activity that can result in heat exhaustion or heat stroke.  Any outdoor event in this heat can lead to an emergency situation.  It is important to know how to prevent such heat-related injury from happening but it’s also imperative to know what to do should someone suffer from heat exhaustion or heat stroke because if not properly treated death can occur.

What is Heat Exhaustion?

Heat Exhaustion usually develops after several days of exposure to high temperatures and inadequate intake of fluids. The elderly and people with high blood pressure are prone to heat exhaustion as well as people working or exercising in the heat. Heat exhaustion symptoms include heavy sweating, paleness, muscle cramps, tiredness, weakness, dizziness, headache, nausea, vomiting, and/or fainting. With heat exhaustion, a person’s skin may feel cool and moist.  Cooling off is the main treatment for heat exhaustion. Drinking cool, non-alcoholic liquids may help as well as taking a cool shower, bath, or sponge bath. Getting into an air-conditioned environment will also help. If the conditions worsen or have not subsided within an hour, seek medical attention. If heat exhaustion is not treated, it may lead to heatstroke which needs immediate emergency medical attention. Call 9-1-1.

What is Heat Stroke?

Heat Stroke is the most severe of the heat-related problems. Like heat exhaustion, it often results from exercise or heavy work in hot environments combined with inadequate fluid intake. Children, older adults, obese people, and people who do not sweat properly are at high risk of heatstroke. Other factors that increase the risk of heat stroke include dehydration, alcohol use, cardiovascular disease and certain medications. Heatstroke is life threatening because the body loses its ability to deal with heat stress. It can’t sweat or control the body’s temperature. Symptoms of heatstroke include rapid heartbeat, rapid and shallow breathing, elevated or lowered blood pressure, lack of sweating, irritability, confusion or unconsciousness, feeling dizzy or lightheaded, headache, nausea, and/or fainting.  If you suspect heatstroke, call 9-1-1 immediately. Then try to move the person out of the sun and into a shady or air-conditioned space. Cool the person down by spraying them with cool water or wrapping them in cool damp sheets. Fan the person, and if possible, get the person to drink cool water.

Tips for Prevention

An article on the Active.com website highlights 10 tips to prevent a heat-related injuries:

1.  Acclimatize – It takes your body time to adjust hot and humid weather.  Just because you can run a 10-miler at an 8-minute pace, doesn’t mean you can do the same when the dog days of summer approach.  The same goes for any outdoor exercise! The American Running and Fitness Association recommends that on your first run in the heat, you should cut your intensity by 65 to 75 percent. Then over the next 10 days, slowly build back to your previous level.

2.  Check the Index – Before you leave the comfort of your air conditioner, check the heat index and air quality index.  The Air Quality Index (AQI) is an index for reporting daily air quality. It tells you how clean or polluted your air is, and what associated health effects might be a concern for you. The Heat Index tells you what the temperature feels like when combining the air temperature and the relative humidity.  Both indexes should be checked before heading outdoors.  Your health depends on it!

3.  Hydrate! Hydrate! Hydrate! – Always remember to rehydrate after outdoor exercise! But it’s even more important to be well-hydrated BEFORE you exercise or spend time outdoors.  Hydration during your run depends on the temperature and the length of your run.  Don’t wait until you feel thirsty to drink. If you’re thirsty, that means you’re already low on fluids. Also, as you age, your thirst mechanism isn’t as efficient and your body may in the early stages of dehydration and you may not even feel thirsty. After 60 minutes of outdoor exercise, you will need to start using a sports drink or supplementing with a sports gel or a salty food such as pretzels. After 60 minutes, you begin to deplete vital electrolytes (i.e., sodium, potassium, etc.). Sodium is needed in order for your body to absorb the fluids you are ingesting and depleted potassium levels can increase your chances of experiencing muscle cramps.  Also, packing an extra bottle of water during outdoor exercise to pour over your head can help increase the evaporation-cooling effect.  Lastly, when you finished exercising, you need to replace the water you’ve lost.

4. Know the Warning Signs – Dehydration occurs when your body loses too much fluid. This can happen when you stop drinking water or lose large amounts of fluid through diarrhea, vomiting, sweating, or exercise. Not drinking enough fluids can cause muscle cramps. When you’re dehydrated, you may feel faint, experience nausea and/or vomiting, have heart palpitations, and/or experience lightheadedness. Runners also need to be aware of the signs of severe dehydration such as heat exhaustion and heatstroke, not only for yourself, but so you’ll be able to identify the symptoms if a fellow runner is experiencing heat-related problems.

5.  Buddy-Up – In the severe heat, be sure to work-out with a buddy. That way you can keep tabs on each other. Sometimes it’s hard to tell if you’re starting to suffer the effects of the heat, but a buddy may be able to spot the signs before its too late.  Plus, working out is always more fun with someone else!

6.  Work-Out Early – If at all possible, get your work outs done in the early morning.  The hottest part of the day is typically around 5p.m.  So, if you can’t work-out until after work, wait until later in the evening.

7.  Go Technical – Wearing light-colored tops and shorts made of technical fabrics will keep you cool and allow moisture to evaporate more quickly.  Staying dry will also help prevent chafing.  Clothing made of Lycra, Nylon, CoolMax and Dry-Fit are some examples of technical fabrics. Be sure to hang dry your technical fabric clothes.  The fabric softener in dryer sheets can actually block up the fabric decreasing its moisture0wicking abilities.

8.  Change Your Route – If your normal running route or work-out spot is treeless, find one that provides more shade.  If this isn’t possible and you have access to a treadmill or gym, head indoors on really hot days.

9.  Lather It On – Be sure to wear sunscreen!! Use a sports sunscreen that is waterproof with an SPF of 15 or higher.  Also, be sure to wear a hat or visor.  This will help keep the sun out of your eyes as well as the sweat out of your eyes.

10.  Have a Plan – Let your family and friends know your running route or work-out location.  If you’re gone too long, they will know where to look for you.  If you are in a rural area or doing a trail work-out, you may even want to pack your cell phone.  Don’t change your plans at the last minute without letting someone know.  It’s better to be safe then sorry!

For additional information on heat related injury and illness, see the National Weather Services heat advisory information page – Heat Kills

Week in Review (April 16 – 20, 2011) The Eye Opener Health, Law and Medicine Blog

Saturday, May 21st, 2011

From the Editor (Brian Nash)

Another week of great posts (IMHO) by our blawgers. Apparently, I’m not the only one who thinks so since we have now surpassed 21,000 page views in the last 30 days. The number keeps rising. Our sincere gratitude to all our readers!

Our topics were once again quite varied. They spanned the law, health, science and medicine. We even had a piece on a local event – Marathon Kids. This piece is part of our new program to promote charities and civic organizations in our own backyard – Baltimore and Washington.

We try week in and week out to find topics of interest for you, our readers. If you ever have any suggestions for topics of interest to you, please leave a comment or send us an email or fill-out the contact form with your thoughts and suggestions. We’d love to hear from you.

Let’s get to it then. What did we cover this past week that you might be interested in reading? Take a look -

Why early settlement is a win-win for all

By: Michael Sanders

There is an old adage in the law that cases settle on the courthouse steps. There is a reason for that. When the parties are actually walking into court to try their case, they seem to suddenly recognize that there are significant risks to going to trial, and that there is serious money at stake. When you go to trial, only one side can win. The other side goes home a loser. Faced with such a stark outcome, both sides tend to become more reasonable in their assessment of their case and more willing to talk settlement. After all, despite all the years of experience that trial attorneys amass, no one can ever predict what a jury is going to do in any specific case. As one mediator I know likes to tell the litigants, going to court is like going to Vegas:  you roll the dice and you take your chances. Read more….

Milk from Mom: Effective in preventing common infant complication (NEC)

By: Jason Penn

The debate among parents regarding the use of human milk vs. formula wages on, but according to a recent study, you can chalk one up for the human body.  That study, headed by the Johns Hopkins University in Baltimore, concluded that premature babies fed human donor milk were less likely to develop the intestinal condition necrotizing enterocolitis (NEC).  Both sides has its advocates, willing to do battle at any time. When it comes to NEC, Mom’s milk has the decided advantage. Read more….

H.I.V. treatment advances, but what are the implications of terminating research early?

By: Sarah Keogh

Last week, I read some exciting news about H.I.V. treatment and transmission. A New York Times article reported that a large clinical trial found that “[p]eople infected with the virus that causes AIDS are far less likely to infect their sexual partners if they are put on treatment immediately instead of waiting until their immune systems begin to deteriorate…” The study found that “[p]atients with H.I.V. were 96 percent less likely to pass on the infection if they were taking antiretroviral drugs…” These findings are overwhelmingly positive and the implication for public health is huge. Read more….

A Windy, Rainy but Fabulous Day in Baltimore: Marathon Kids Final Mile Celebration

By: Rachel Leyko

Despite the wind and rain, this past Saturday I volunteered at the Marathon Kids Final Mile Celebration Event at Western Polytechnic High School in Northwest Baltimore.  I learned of the event through the Junior League of Baltimore and to be honest, prior to Saturday, I did not know much about the organization, its purpose or effect on the children it sought to serve.  However, after Saturday’s event, not only was I impressed with the purpose of Marathon Kids, but I saw firsthand the positive effect this program has had on the children who have participated. Read more….

Acquired Brain Injuries: Causes and Impact

By: Theresa Neumann

On the heels of Jason Penn’s blogregarding calling “911″ for signs of a possible stroke, I decided to introduce a variety of acquired brain injuries for further discussion in future blogs since damage to the brain results in some of the most catastrophic injuries possibly sustained by the human body with significant “collateral damage” for all of the friends and family involved in the individual’s life. Read more….


Sneak Peak of the Week Ahead

Some topics we’ll be covering next week…and then some…

  • You or someone you know has been diagnosed with cancer, now you have to deal with the horror. Jon Stefanuca will be writing a piece based on our experiences with a number of clients “living with cancer.”
  • Mike Sanders and I have both recently resolved cases involving families who have lost a child. Mike’s involved the death of a fetus very near term. He’ll share that story and the experience of the case with you.
  • Maybe those of you who have children with special needs are familiar with the local (Maryland and Washington, D.C.) resources to help you and your child. For those who may not be or just want to learn more, Jason Penn will be providing information on this next week.
  • You may have heard the recent news about labeling of certain medications for children. Sarah Keogh will report on this and also delve into some practical problems and issues that parents face every day in terms of medicating their children.
  • We’re going to begin a new series on exactly what is recoverable in our jurisdictions (Washington, D.C and Maryland) under what is known as the Survival Act and the Wrongful Death Act. We’ll be paying particular attention to issues involving what’s known as pecuniary benefits, loss wages and diminished earning capacity. Should be educational. We hope you enjoy it.

Have a great weekend, Everyone!

Acquired Brain Injuries: Causes and Impact

Tuesday, May 17th, 2011

On the heels of Jason Penn’s blog regarding calling “911″ for signs of a possible stroke, I decided to introduce a variety of acquired brain injuries for further discussion in future blogs since damage to the brain results in some of the most catastrophic injuries possibly sustained by the human body with significant “collateral damage” for all of the friends and family involved in the individual’s life.

What is an “acquired brain injury”?

Wikipedia defines acquired brain injury as damage to the brain occurring after birth but not including neurodegenerative diseases, such as Parkinson’s or Alzheimer’s, that occur later in life.  These injuries can further be divided into traumatic and non-traumatic acquired brain injuries.

Traumatic brain injuries are a result of some kind of trauma to the cranium/brain, but the actual causes can vary significantly. Trauma, in general, is the leading cause of death in the young-adult age group. An obvious example of a significant head trauma is the gunshot wound to the head sustained by Arizona Representative Gabrielle Giffords earlier this year. Other examples are assaults with blows to the head, falls with blows to the head, car or bicycle accidents with head injuries, sports-related head injuries/concussion, childhood playground head injuries, and even damage sustained during brain surgery. The degree of damage and permanent sequellae obviously varies as well, ranging from fully recoverable within a few days to catastrophic permanent deficits and even death. Interestingly, the amount of external damage (or lack thereof) does not necessarily reflect the damage inside the cranial vault.

Non-traumatic acquired brain injuries, on the other hand, have a wide range of etiologies not related to head trauma that have just as wide of a range of catastrophic effects and recovery times. One of these causes is a stroke, as described by Jason Penn; however, strokes can be either ischemic (blockage of blood flow to the brain by, for example, a blood clot) or hemorrhagic (when a blood vessel in the brain ruptures), and each is treated very differently!  Other possible causes are infections, brain tumors, failure of other body organs (liver, kidney), loss of oxygen delivery to the brain (heart attack, blood clot in lungs), other chemical or drug ingestions with toxic effects, aneurysm rupture, and build-up of carbon dioxide in the blood stream from other lung pathology, including smoking!

A Virtual Tour of the Brain

Described as the most complex organ in the human body, the brain has been the subject of numerous educational videos, which attempt to give the layman a better understanding of the parts and functions of the human brain. YouTube has numerous “brain anatomy” videos for you to peruse. Here’s one from the University of Bristol that does a good job of providing the basics of this incredible organ.

httpv://www.youtube.com/watch?v=9UukcdU258A

Effects of Brain Damage

The brain is the body’s 3-pound computer that controls every conscious and unconscious function of the body. Different areas of the brain control different cognitive, behavioral and emotional functions as well as the everyday metabolic functions of the body. Damage to specific areas of the brain result in specific functional losses, which is why someone with a “stroke” might experience numbness and weakness of one side of the body or no weakness but loss of balance or loss of vision. Larger injuries result in more brain tissue damage and more functional deficits. The object of “the game” is to rapidly diagnose the problem and rapidly treat the problem in order to minimize the amount of brain damage, and thus, minimize the functional deficits. Many acquired brain injuries progressively worsen due to different “normal” pathophysiologic mechanisms. It is imperative to intervene sooner whenever possible.

A Personal Story

My uncle had a stroke 1 month ago while working in the yard.  ”911″ was called immediately, and he was transported to the closest hospital.  He apparently had an undiagnosed abnormal heart rhythm (atrial fibrillation) that caused a large blood clot to form in the heart. This clot ultimately got pumped out into the carotid artery and lodged itself at the beginning of the middle cerebral artery on right side of his brain.  He was initially unconscious, but he later “came to”, only to deteriorate into unconsciousness again as the brain swelled from the blocked artery and infarcted brain tissue. He was transferred to another hospital that was capable of performing brain surgery, and he had back-to-back brain surgeries on 4/10 and 4/11 to try to minimize the damage. They actually had to remove a large part of his skull to allow for the brain swelling to occur without the brain’s tissue being compressed against the skull so as to prevent herniation of the brain.

He was in a coma for several days, but he is slowly making some recovery. In the meantime, he needed a tracheostomy and feeding tube in his stomach, both of which he still has. His entire left side remains completely paralyzed. It is difficult for him to stay awake, although he does seem to know who is around at any given time. My aunt, God bless her, has spent the last month at the hospital, 8 hours or more every day, and she is just exhausted. It is unclear when he will be going home or even if he will be going home. We are hoping and praying for the best recovery possible, but the future remains uncertain.

Collateral Damage

In addition to the person affected by acquired brain injury being functionally limited, whether temporarily or permanently, there is often collateral damage to himself/herself as well as to friends and family members. Emotional issues often arise, whether through mood disorders like depression and anxiety, or with actual personality changes. Those affected can become more belligerent or difficult, angry, withdrawn, and a host of other characteristics, making it very difficult on the person caring for the affected individual. The physical demands alone can overwhelm the care-provider (like bathing, toileting, feeding, transporting to appointments, etc.) and lead to care-provider stress and mood disorders.  Financially, these injuries are often devastating. Marriages end; relationships among family members suffer; sometimes, physical abuse and neglect can even occur when frustrations become overwhelming.

There are support groups available many of which can be accessed through local hospitals, associations or your health department.

Locally, you may want to visit the Brain Injury Association of Maryland and the Brain Injury Association of Washington, D.C.

Stay posted for more details on some of these causes of acquired brain injury specifically. In the meantime, do you have a story to tell?

 

Image from neuroskills.com

Brother, will you help me? If you don’t this stroke might kill me.

Thursday, May 12th, 2011

[Writer’s note:   It is my goal to write at least one blog entry each week.  The largest percentage of my time is spent looking for source material.  I want to provide the reader with timely and topical information.  In any given week I review dozens of research studies, medical advances, and cautionary tales.  Every once in a while I read an extraordinary piece that truly hits home.  So much so, I wonder whether or not I should write about it.  An element of vulnerability is revealed.  Maybe this can help someone…]

Mother’s Day is in the rearview mirror.  This past Mother’s Day someone told me a story about how their grandmother fell ill.  It was the holiday season, and as she climbed the ladder to decorate the tree, things took a tragic turn. She stumbled, lost her balance and fell.  She seemed “off.” A few short hours later, at the hospital, it was revealed that she had suffered a stroke.

I am college educated.  I have a law degree too.  I have been trained by some of the best and the brightest. Countless thousands of dollars have been spent on my education.  I am African American, and therefore at an increased risk of stroke. My profession has brought me very close to the medical profession and injured people.

As I listened to that story, I was stymied. Not only because of the shocking nature of the story, but because despite my education and experience I was not sure what I would have done. I am embarrassed to tell you that until a few minutes ago, I might not have acted quickly enough to save my friend’s grandmother. I would like to think that I wouldn’t take the situation lightly and that I would call 911 immediately.  But maybe not, because – simply put – I didn’t know the signs or symptoms of a stroke. Do you?  What would you do?

A recent study says that I am not alone:

Researchers interviewed 230 African Americans in the Washington DC metropolitan area and found that nearly 90 percent said that they would call 911 first if faced with a hypothetical stroke. However, when 100 acute stroke patients (or those who accompanied them to the hospital) were interviewed 75 percent said they called someone else first instead of 911 when they realized something was wrong.  Even more reported they waited a significant amount of time before seeking any medical attention.

Of course 230 people is a small sample set, but these numbers are certainly disturbing. The actual responses of persons confronted with seriously ill people suggest that maybe I wouldn’t act as diligently as I think.

According to the American Stroke Association, someone in the United States is having a stroke every 40 seconds.  It is the third-leading cause of death in the United States. In the United States, the rate of first strokes in African Americans is almost double that of whites, researchers say, because of higher incidences of risk factors such as high blood pressure and obesity. Also strokes tend to occur earlier in life for African Americans. Studies have also shown that fewer blacks than whites receive a treatment that breaks-up the blood clot in the brain causing the stroke, in part because blacks are not getting to the hospital in time.

So what should you do?  First, start by knowing the signs and symptoms of a stroke. According to the American Heart Association, the signs are:

  • 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

What else?

  • Not all the warning signs occur in every stroke. Don’t ignore signs of stroke, even if they go away!
  • Check the time. When did the first warning sign or symptom start? You’ll be asked this important question later.
  • If you have one or more stroke symptoms that last more than a few minutes, don’t delay! Immediately call 9-1-1 or the emergency medical service (EMS) number so an ambulance (ideally with advanced life support) can quickly be sent for you.
  • If you’re with someone who may be having stroke symptoms, immediately call 9-1-1 or the EMS. Expect the person to protest — denial is common. Don’t take “no” for an answer. Insist on taking prompt action.

So what is the take-home lesson here?  When in doubt, call.  When I say call, I don’t mean to phone a friend.  This isn’t Who Wants to Be a Millionaire. Uncle Stephen might know the answer to Meredith Viera’s question, but he probably can’t help you if I am having a stroke. Please. Please.Please. Pick up the phone.  Call 911. With appropriate intervention, a fully recovery is possible for some. A delayed response time, however, can be life altering.  Please, do not delay.  The life of your mother, brother, father, or spouse can depend on your reaction time.

It doesn’t say “leave a response” down below for nothing. Feel free to let us know YOUR thoughts.

Question: What would you do? Are you certain that you would call 911? Have you ever been faced with a life or death situation?

 

Spinal Stroke: An atypical cause of back pain

Monday, April 11th, 2011

When one hears the word stroke, what typically comes to mind is a “brain attack” with slurred speech or numbness and weakness of the right or left side of the body. Well, the spinal cord is considered part of the central nervous system and is truly a direct connection to the brain. All of the data received through nerve endings in our bodies passes through the spinal cord to be interpreted in the brain. Likewise, the messages our brain is sending to our bodies, both consciously and unconsciously (e.g. walk, run, write, speak; and digest food, breath, increase heart rate, etc.), travel through the spinal cord to our peripheral nerves.

The spinal cord is a vital structure that has its own blood supply, much like other organs, including the heart and brain. Just like the blood vessels supplying the other organs, the spinal arteries, especially the anterior spinal artery, can become occluded (i.e. blocked) resulting in spinal cord ischemia or infarction. The nerve information can no longer travel to and from the brain or the body freely; it is interrupted. This equates to a “stroke” of the spinal cord with resultant numbness, weakness, paralysis, as well as bowel and bladder dysfunction below the level of the infarction/stroke.

What causes a “spinal stroke”?

The most common cause of spinal stroke is the same as that for brain stroke or heart attack……atherosclerosis, an accumulation of cholesterol plaque in the arterial wall that ultimately blocks the artery. No blood flow means no oxygen or nutrients to the cells and tissues of the spinal cord resulting in them “starving to death.” There are other causes, as well; anything that compresses one of the supply arteries can block blood flow to a region of the cord and result in “stroke.”

Tumors, either primary or metastatic, can compresses blood vessels and other structures as they grow in the spinal region. Anterior disc herniations and disc ruptures or bone fragments from traumatic fractures of the vertebrae can compress blood vessels in the immediate vicinity.

Collections of pus from infectious processes can interrupt the blood supply either by compressing a vessel or disintegrating the blood vessel.  Small pieces of blood clots (called emboli) can break-off from larger clots (called thrombi) and circulate through the bloodstream until they get “stuck” in a smaller vessel somewhere else in the body; the spinal artery is just one location. Other systemic diseases can result in vasculitis, or an inflammation of the blood vessel, that leads to clotting and occlusion of that vessel, and the spinal artery is just one of the vessels that can be affected.

Surgery and spinal stroke

Interestingly, inter-abdominal and spinal surgical procedures can also lead to spinal cord ischemia and stroke. Individuals undergoing repair of an aortic aneurysm or iliac-to-femoral artery bypass often require “cross-clamping” of the aorta above the level of the surgery. The “golden hour” referred to in heart attack victims can also be applied to other vascular ischemic conditions, like spinal artery ischemia; if complications arise and the cross-clamp time is too long, it can result in ischemia from which the patient may never recover, remaining paralyzed for life. Similarly, an aortic dissection can disrupt blood flow to the smaller arteries branching from the aorta to feed the spinal cord leading to ischemia.

Spinal surgeries take one of two approaches, anterior (going through the belly) or posterior (going through the back). Because of the proximity of all of the vital structures, including the major blood vessels, small errors or retained fragments can lead to occlusion or disruption of the spinal blood supply.

Who is at risk for spinal stroke?

Those individuals with risk factors for heart disease or brain stroke are also at risk for spinal stroke since they share a common etiology. This includes those individuals with poorly-controlled diabetes, high cholesterol or dyslipidemia, abnormal clotting of the blood, peripheral arterial disease or history of aneurysms.

What are the symptoms of a spinal stroke?

Most patients present with sudden, severe pain, much like a heart attack, in either the chest or the back or both. This pain is typically rapidly followed by numbness, or loss of pain sensation and temperature sensation, in the extremities below the level of the stroke. Because of the anatomy of the blood supply, vibration sensation and position sense are maintained in the affected region since the posterior region of the cord has a different blood supply. As the spinal stroke progresses over an hour or so, the extremities affected become weaker and weaker, often experiencing paralysis, and the bowel and bladder lose their innervation leading to dysfunction and incontinence. This is a fairly rapid progression, much different that other myelopathies.

What is the treatment?

Due to the relative rarity of this condition, not many studies have been done regarding treatments. Unlike “heart attack” or “brain attack,” there are no standards of care except for aspirin therapy and (potentially) anti-platelet therapy after the stroke has occurred. More often than not, there is a delay in diagnosing the condition due to the rarity of the condition and the need to confirm the diagnosis by a diffusion-weighted enhanced MRI of the spine, such that “clot-busting” agents are time-excluded from use. Treatments are then focused on preventing additional vascular events, preventing deep vein thromboses in the paralyzed limbs, preventing bladder infections and fecal impactions, preventing decubitus ulcers and soft tissue infections, and preventing the additional morbidity associated with paralysis. This is not a comforting thought!

We are blessed with today’s medical technological advances that allow for so many life-saving procedures and procedures that preserve body function, such as spinal surgery, vascular stenting procedures and epidural injections. Unfortunately, some of these procedures have increased the incidence of spinal strokes due to the nature of the procedures themselves. The current epidemic of obesity and metabolic syndrome is also indicative of more cases of diabetes and atherosclerotic vascular disease which, according to the law of probability, will increase the incidence of this potentially devastating medical condition.

Clinical Trials Underway

Do you know someone who has had a spinal stroke? What was his or her age? What might have precipitated the “attack”? Some individuals have been in their early 20′s when the attack occurred. Needless to say, this is truly devastating! With all of our advanced technology, we should be doing a better job of preventing, diagnosing and treating this condition. The National Institutes of Health (NIH) does offer clinical trials for this condition; please refer to their website for further information. ( http://www.ninds.nih.gov/disorders/spinal_infarction/spinal_infarction.htm)

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Study reveals “staggering” statistics on Medicare patients who will die or be readmitted within one year of stroke

Wednesday, December 22nd, 2010

Today I came across an excellent post in theheart.org entitled “Death and readmission rates after stroke “staggering” for Medicare Patients.” As a general comment, if you are not familiar with this online journal, I would strongly recommend you register (it’s free). They post a number of excellent pieces on a consistent basis.

Dr. Gregg Fonarow and colleagues did a study examining the outcomes for 91,134 Medicare patients, who had suffered an ischemic stroke between April 1, 2003 and December 31, 2006. The researchers themselves described their findings as “staggering.” Here is the essential finding:

Almost two-thirds of Medicare beneficiaries discharged from the hospital after suffering an ischemic stroke die or are readmitted within a year.

Does the type of hospital make a difference?

While ostensibly not the major focus of the study, Dr. Fonarow’s research team did examine data to determine if the outcomes were significantly better if the patient was seen for the initial acute ischemic stroke at an academic center versus a non-academic (e.g. community hospital). The finding in this regard was not what I expected.

Rates were only slightly lower for academic hospitals than nonacademic centers. “That was surprising,” said Fonarow. “Whether a hospital was academic or bedside or, more important, a joint commission primary stroke center really did not make a large difference in outcomes.”

The impact on the healthcare system is obvious and alarming

I don’t claim to have any expertise in statistical analysis or application of such data to a system-wide root cause analysis. That being said, does it really take a statistician or mathematician to grasp the import of this “staggering” data? If you or someone you know is on Medicare and has suffered an acute ischemic stroke, there is a 2 out of 3 chance you (or the person you know) will be readmitted or die within one year of suffering that stroke!

The big questions: Why and What can be done?

Dr. Fonarow readily admits that the data he collected does not lend itself to the ultimate answers. What he does note, however, is that while further studies are clearly warranted, since more than one-half of the cases for readmission analyzed involved non-cardiovascular causes, “there’s room for better secondary-prevention efforts.”

“When you looked at causes of readmission, in many cases it was not a recurrent stroke or cardiovascular event but other comorbid conditions, such as pneumonia, falls, and GI bleeds,” he said. “It shows you that when caring for someone after a stroke, managing these comorbid conditions and related risks is going to be critical.”

He added that the period after discharge for an ischemic stroke offers a “window of opportunity” for interventions to reduce the burden of post-ischemic stroke morbidity and mortality.

The information shared by Dr. Fonarow is unequivocally “staggering.” One can only hope that further system-wide studies are performed soon to identify what improvements can and need be made in the delivery of health care to this population to reduce such loss of life and burden on the healthcare system secondary to readmissions.

What’s your reaction to Dr. Fonarow’s study? Are you aware of any data that is known for death and readmission rates in the non-Medicare population? If there is a significant difference in death and readmission rates between Medicare and non-Medicare patients, what is being done in the non-Medicare population that can be adopted for all patient populations?

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