I came through the stroke fine because I went to the hospital right away and have been on warfarin ever since. My question is: If there’s no shunt, is the hole present?

A: The heart defect (or hole) responsible for a stroke is usually located in the top chambers of the heart, or atria. Diagnostic tests may detect an atrial septal defect (ASD) or a patent foramen ovale (PFO), both of which are “holes” in the tissue separating the right and left atria. A “shunt” is the term used to describe blood flow across such a defect. In your case, the concern is a right-to-left shunt, meaning that a blood clot could travel from the right to the left side of the heart, and then on to the brain and cause a stroke. Even if testing did not show a right-to-left shunt, it could still happen on occasion, such as after coughing or sneezing. Ask your cardiologist whether you indeed do or do not have a shunt. Treatments include closing the shunt via a device implanted during a heart catheterization (rather than open-heart surgery) or lifelong anti-coagulation with warfarin.

Heart Defect Often Causes No Symptoms The Saturday Evening Post

Mark McEwen, former TV weatherman for The Early Show on CBS, found out during a flight to Orlando in 2005. He had been dozing, then woke up, feeling odd. “It was like being underwater and trying to swim to the surface,” says McEwen, now 55. “You’re just trying to survive, to make sense of something that is senseless.” He had no clue it was a stroke. Nor apparently did the attendant who helped him off the plane—or the skycap who left McEwen sitting curbside in a wheelchair. McEwen could barely talk, but he did manage to ring his wife’s cell phone and convey a basic message. “Help me. Not good.”

If someone near you, like McEwen, were having a stroke, would you recognize it? Would you know what to do? Stroke is the third leading cause of death in this country—and every 40 seconds on average, someone in the United States suffers one. About 30 percent of strokes 
are mild, resulting in no disability. But the 20 percent that are severe, yet survivable, can be crippling.

“A major stroke can change everything—the ability to speak, to move, to work,” says Dr. Walter Kernan, professor of medicine at Yale University School of Medicine. “It may seem to rob a person of his life without actually taking it.” Fortunately, new therapies are in the works that may help improve outcomes.

Striking Out Against Stroke

The most significant advance is the clot-busting drug, known as tissue plasminogen activator, or tPA, which can help the 85 percent of patients whose strokes are caused by clots in the brain. “Sadly,” says Dr. Ralph Sacco, a neurologist and president-elect of the American Heart Association (of which the American Stroke Association is a division), “only about 5 percent of patients actually get it because they don’t reach the hospital in time or they don’t go to a [hospital certified as a] primary stroke center, which can give it rapidly.” Administered intravenously, it takes time to dissolve a clot, particularly a large one and as neurologists say, “time is brain.” Last year, the AHA revised its guidelines, saying that tPA could be given up to four hours and 30 minutes after the onset of stroke—a significant increase over the previous three-hour window. But sooner remains better.

“The best outcomes are still in patients with small clots who receive tPA in less than 90 minutes,” says Dr. Rishi Gupta of Vanderbilt University Medical Center.

Other technologies are already available at comprehensive stroke centers (a notch above primary stroke centers, which are mainly geared to giving tPA). At the Cleveland Clinic, doctors are using stents to prop open blocked blood vessels during a stroke, as well as two FDA-approved devices to help remove clots. One, the Merci Retriever, works like a miniature corkscrew to pull the clot out. The other, the Penumbra, breaks up a clot with microjets of water, then suctions out the pieces. Both devices require highly skilled specialists, and not every patient is a candidate. “You have to image the brain first to see if functional tissue remains that could benefit from restored blood flow,” says Dr. Irene Katzan, medical director of the stroke program at the Cleveland Clinic.

Refining Recovery

Acute treatment is only the first step in stroke recovery. Fortunately, therapists are getting better results with post-stroke rehabilitation than ever. “We used to say to patients, ‘you have three to six months to improve, and after that you can’t expect a whole lot,’ ” says Dr. Richard Zorowitz, chair of physical medicine and rehabilitation at Johns Hopkins Bayview Medical Center. Now, knowledge about the brain’s ability to rewire itself—a concept called neuroplasticity—has encouraged therapists (and patients) to try longer and harder.

“Thanks to the neuroplasticity of the brain—the ability of the brain cells to rearrange their connections, our brain has more capacity than we ever imagined to rewire itself for greater levels of recovery,” says researcher and stroke survivor Dr. Jill Bolte Taylor (read “Life After Stroke”).

Dr. Steven C. Cramer at the University of California, Irvine, is working with robotic therapy to help restore function as well as investigating two hormones that may encourage stem cells to develop into new neurons, key cells that transmit nerve signals to and from the brain. So far, early results look promising. Meanwhile, Dr. David Simpson at Mount Sinai School of Medicine in New York is using botulinum toxin (Botox) to help reduce the spasms that lead to twisted limbs and abnormal gaits, a frequent result of stroke.

For the most part, rehab consists of hard work—and lots of it. Three hours a day is the rule of thumb. But technologies like Nintendo’s Wii video game console keeps exercises interesting—engaging stroke patients in games such as bowling or tennis to improve balance and shifting of weight.

As for McEwen, he’s back on his feet after 14 months of rehab. Today the former weatherman, who described his experiences in his 2008 book Change in the Weather, is a motivational speaker and spokesperson for the American Stroke Association. The organization’s latest campaign (PowerToEndStroke.org) is directed at people with risk factors for stroke—high blood pressure, diabetes, excess weight, and a history of heart disease. “There are lots of things you can do to lower your risk for stroke,” says McEwen. “Knowledge
 is power.” And it could just save your life.

The Post Investigates: Stroke Advances The Saturday Evening Post

In this two-part series, we offer exclusive online information about stroke symptoms, risk factors, treatments, and rehabilitation strategies to accompany the May 2010 Post Investigates feature: “Stroke Advances,” in which researchers tap into the brain’s remarkable ability to rewire itself, by Anne Underwood.

First Things First

Remember that strokes strike quickly, and you should, too. If you think someone may be having a stroke, think F-A-S-T:

F = FACE

Ask the person to smile. Does one side of the face droop?

A = ARMS

Ask the person to raise both arms. Does one arm drift downward?

S = SPEECH

Ask the person to repeat a simple phrase. Does the speech sound slurred or strange?

T = TIME

If the person shows any of these symptoms, time is important. Call 911 or get to the hospital fast. Brain cells are dying.

According to the National Stroke Association, a stroke occurs when a blood vessel breaks (called a hemorrhagic stroke) or a clot in a blood vessel that leads to the brain eventually becomes lodged and blocks blood flow to the brain (an ischemic stroke). Stroke symptoms can come and go as damage progresses, and may be difficult to recognize.

“This is the time when you need to be aware of specific stroke symptoms. Watch for them in loved ones especially, because they can be hard to notice in yourself,” advises Dr. Mateo Dayo of the Venice-Ocala Heart Institute.

Women at Risk

Stroke statistics for women are alarming. While many think of stroke as a man’s disease, women are more likely than men to suffer a disabling stroke, and, sadly, to die from it. In fact, strokes pose a greater threat to women’s health than breast cancer.

A unique set of risks—including hormones (related to birth control pills and hormone replacement therapy), migraines, and pregnancy—put women at special stroke risk.

Lack of awareness also plays a role. In a recent survey, 40 percent of women said they were only somewhat or not at all concerned about having a stroke in their lifetime.

Yet another challenge is that stroke symptoms in women may differ from those that men typically experience.

Common warning signs of stroke include: sudden numbness or weakness, especially on one side of the body; confusion and trouble speaking or understanding; trouble seeing in one or both eyes; trouble walking, dizziness, and loss of balance or coordination; and severe headache with no known cause.

But women may experience sudden face and limb pain, hiccups, nausea, general weakness, chest pain, shortness of breath, and palpitations, according to American Stroke Association experts.

Health professionals are aware of these differences. Unfortunately, many stroke victims and their loved ones aren’t.

“Women experience 60 percent more stroke deaths than men every year,” Dr. Dayo says. “That’s why it is so important for women to be aware of any changes in their body’s normal functions. Call 911 and remember when symptoms first appeared so early medical action can be taken.”

Plan Now For ER Stroke Care

Timely treatment with the clot-busting drug tPa (tissue plasminogen activator) at a hospital certified as a primary stroke center can help the 85 percent of patients whose strokes are caused by clots in the brain.

“Sadly,” says Dr. Ralph Sacco, a neurologist and president of the American Heart Association (of which the American Stroke Association is a division) in the May 2010 Post article, “only about 5 percent of patients actually get it because they don’t reach the hospital in time or they don’t go to a primary stroke center, which can give it rapidly.”

Six out of 10 Americans don’t know where stroke-certified hospitals are in their communities. To find stroke care near you, click here http://maps.heart.org/quality/ for a stroke Web mapping site from the American Heart Association and enter your address or zip code.

Care from a Distance

About 80 percent of Americans live within 60 minutes of a primary stroke center.

But, if you are not one of them, try searching for a nearby hospital that is equipped with a sophisticated telecommunications link to a specialized stroke center.

Such collaborations, called stroke “systems of care,” enable physicians in suburban and rural areas to provide fast and coordinated treatment and are gradually emerging across the country.

St. Luke’s Episcopal Health System in Houston, Texas, recently implemented a stroke system of care with the help of GE Healthcare.

“The minutes and hours following the initial onset of stroke symptoms are very critical to a patient’s outcome or survival. However, most often strokes don’t happen in the lobby of St. Luke’s,” said Connie Boyd, Service Line Director of Neuroscience and leader of the System of Care project within St. Luke’s. “Working with GE Healthcare, we realized that establishing relationships with community hospitals, some of which may even be considered competitive, was key to extending the reach of our stroke care capabilities and ultimately improving patient outcomes.”

Leslie Welborn and his wife, Ann, are grateful for the innovative approach to stroke care.

After her husband suffered a stroke in January, Ann took him to their local hospital, St. Elizabeth’s, which is located about three hours from Houston. Fortunately, the facility was involved in the St. Luke’s system of care.

Guidance from the experts in Houston enabled local physicians to quickly treat Welborn with tPA, dissolving the clot that was causing his stroke and buying much-needed time to transport him safely to St. Luke’s for surgery.

Less than one week later, Leslie returned home. “I can’t believe how well he is doing,” reports Ann—thanks to a system of collaborative care that stroke experts hope will help save countless lives.

Coming in Part 2: Promising new rehab methods help stroke survivors reclaim their lives.

Stroke Advances The Saturday Evening Post

The analysis, completed at St. Michael’s Hospital and the University of Toronto, involved reviewing three studies on chocolate and stroke.

In the first study, people who ate one serving of chocolate per week were 22 percent less likely to have a stroke than those who ate none. In the second study, those who consumed 50 grams (1.7 oz) of chocolate once a week were 46 percent less likely to die following a stroke than the nonchocolate eaters. The third found no link between eating chocolate and risk of stroke or death.

Chocolate is rich in antioxidants called flavonoids and polyphenols which may help protect against stroke. A 1.4-ounce portion of dark chocolate contains an estimated 600 mg of polyphenols, compared to red wine (170 mg in 3.4 oz) or a medium apple (200 mg).

“More research is needed to determine whether chocolate truly lowers stroke risk, or whether healthier people are simply more likely to eat chocolate than others,” said Canadian study author Sarah Sahib, who suggests that additional and larger tests are needed.

Want to volunteer? Go to clinicaltrials.gov and search for “chocolate” http://www.clinicaltrials.gov/ct2/results?term=chocolate&pg=2. The last time we checked, we found five active studies related to chocolate.

Chocolate: A Sweet Treat for Health The Saturday Evening Post

“This is a minimally invasive procedure performed through a pinhole incision in the groin, but it can have a life saving impact,” said Dr. Michael J. Alexander, director of the Cedars-Sinai Neurovascular Center and a member of the study’s steering committee.

According to the study protocol, the experimental stent may be placed within 30 days of stroke onset. Financial help may be available when the patient’s insurance does not cover the medical and surgical costs.

For more information and to contact participating centers, visit www.clinicaltrials.gov and enter the study identifier NCT00576693.

New Way to Stop Stroke The Saturday Evening Post

Lisinopril is a generic drug that is FDA approved for two brand name products—Prinivil and Zestril. It may be prescribed alone or with other medicines to treat high blood pressure and heart failure. Lisinopril may also be given to people who have suffered a heart attack. Left untreated, high blood pressure may damage the heart, kidneys, and eyes. Taking lisinopril helps relax the blood vessels and reduce the risk of heart attack and stroke.

Lisinopril is Good for the Heart The Saturday Evening Post

For the study, investigators are particularly seeking caregivers and stroke survivors who are experiencing symptoms of depression or anxiety. Participants without a computer or Internet access who live within a 50-mile radius of Kent State University will be provided the necessary equipment to participate. Those residing outside of Ohio are required to have their own computer and Internet service provider.

For more information about the study and to enroll, call toll-free 866-300-6657.

From the National Stroke Association The Saturday Evening Post

For more information about diabetes, visit diabetes.org.

Stike Out Strokes The Saturday Evening Post