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Ineffective stroke treatment an ‘embarrassment’

By Gina Kolata

New York Times News Service

An estimated 700,000 Americans had a stroke last year, but very few end up at a hospital with the equipment and expertise to accurately diagnose and treat it.

Stroke is the third-leading cause of death in this country, behind heart disease and cancer, killing 150,000 Americans a year, leaving many more permanently disabled, and costing the nation $62.7 billion in direct and indirect costs, according to the American Stroke Association.

But from diagnosis to treatment to rehabilitation to preventing it altogether, a stroke is a litany of missed opportunities.

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Many patients with stroke symptoms are examined by emergency room doctors who are uncomfortable deciding whether the patient is really having a stroke — a blockage or rupture of a blood vessel in the brain that injures or kills brain cells — or is suffering from another condition. Doctors are therefore reluctant to give the only drug shown to make a real difference, tPA, or tissue plasminogen activator. Many hospitals say they cannot afford to have neurologists on call to diagnose strokes, and cannot afford to have MRI scanners, the most accurate way to diagnose strokes, for the emergency room.

Although tPA was shown in 1996 to save lives and prevent brain damage, and although the drug could help half of all stroke patients, only 3 percent to 4 percent receive it. Most patients, denying or failing to appreciate their symptoms, wait too long to seek help — tPA must be given within three hours. And even when patients call 911 promptly, most hospitals, often uncertain about stroke diagnoses, do not provide the drug.

"I label this a national tragedy or a national embarrassment," said Dr. Mark J. Alberts, a neurology professor at the Feinberg School of Medicine at Northwestern University. "I know of no disease that is as common or as serious as stroke and where you basically have one therapy and it’s only used in 3 to 4 percent of patients. That’s like saying you only treat 3 to 4 percent of patients with bacterial pneumonia with antibiotics."

Most strokes would never happen if people took simple measures like controlling their blood pressure. Few do. Many say they forget to take medication; others decide not to. Some have no idea they need the drugs.

Still, there is much more hope now, said Dr. Ralph L. Sacco, professor and chairman of neurology at the Miller School of Medicine at the University of Miami. Now, Sacco said, there is a device, an MRI scanner, that greatly improves diagnosis, there is a treatment that works and there are others being tested. "Medical systems have to catch up to the research," he said.

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