Hospital aims to cut risks

The Queen's Neuroscience Institute is participating in several clinical trials to find ways to protect the brain from disabilities caused by stroke.

Stroke Risk factors: High blood pressure and cholesterol, diabetes, overweight/obese, cigarette smoking Symptoms: Call 911 if you or someone you know suddenly has: » Numbness or weakness of the face, arm or leg, especially on one side of the body » Confusion; trouble speaking or understanding » Trouble seeing in one or both eyes » Trouble walking, dizziness, loss of balance or coordination » Severe headache with no known cause Help: Caregivers for stroke survivors can get help for their own health and emotional well-being from the American Heart Association Web site: americanheart.org/caregiver. Source: American Heart Association/American Stroke Association

"Stroke continues to be the primary cause of adult disability in our state and in our country," Dr. Cherylee Chang, the institute's medical director, said in an interview. It is the third leading cause of death and prevents many survivors from doing things they once enjoyed, she said.

More than 750,000 people nationally are known to have strokes every year; Chang believes the number actually may run into millions because many people don't recognize them.

Stroke risks can be reduced through diet and exercise, controlling blood pressure, managing cholesterol, stopping smoking and knowing family risk factors, she said.

"We may not be able to entirely prevent it," she said.

The state Health Department, Chang and other doctors are working on a state system to combat the disease with education and prevention, pre-hospital, in-hospital and post-hospital care, Chang said.

It's important that people seek help immediately because the only clot-busting drug approved by the U.S. Food and Drug Administration, tissue plasminogen activator (tPA), must be used within three hours after the first symptoms, she said. There is some risk for bleeding and risk of stroke if the medication is given after that, she said.

The drug is used for ischemic strokes, the most common type, caused by a clot that blocks blood flow in an artery to the brain.

There is no treatment for hemorrhagic or "bleeding" strokes, which occur when a defective artery in the brain bursts or a blood vessel ruptures on the brain's surface. These strokes have a much higher fatality rate than those caused by clots.

Dr. Linda Rosen, director of the Hawaii Emergency Medical Services Branch, said clot-busting drugs and mechanical devices to remove clots or blockages are "time sensitive," and doctors want to reduce the time from onset of symptoms to interventions, "which is a really big challenge."

"People recognize chest pain as an emergency and call 911," she said. "Not so much with stroke, weakness or change in speech. They don't take it as seriously."

Treatment for stroke does not begin until a patient reaches the hospital, Rosen said. However, she said some pre-hospital interventions can be done. For instance, oxygen and general treatments can be given to someone who is dizzy or nauseated, she said.

There is interest in designating hospitals as stroke or specialty centers similar to the Queen's Medical Center's designation as a trauma center.

Chang said researchers "are trying to find ways to push out the window" for treatment. For example, Queen's researchers are doing studies using the venom of Malayan pit vipers in a drug to provide effective treatment to break up blood clots beyond the traditional three-hour limit.

The neuroscience institute also is planning clinical trials with lasers to try to protect the brain with low level energy, she said. Putting a balloon in the aorta to divert more blood to the brain from the legs also is under study to extend treatment up to 10 hours after symptoms, she said.

Chang said many patients have a second event in the next year.

The American Heart Association and American Stroke Association have launched a quality improvement program called Get with the Guidelines -- Stroke to ensure that stroke patients are treated and discharged according to performance measures.

"Traditionally, a stroke patient is last seen in ER, because there is nothing we can do. Now, part of it is moving the stroke patient to the forefront of the minds of those in the medical field. There's stuff we can do," Chang said.

Figures aren't collected in Hawaii on incidence of stroke, just on hospital admissions, Chang said.

Queen's receives 15 percent to 20 percent of the state's stroke patients.

The numbers of stroke patients have slowly dropped in all hospitals statewide the past few years, Chang said, adding the hope that prevention is making the difference.

About 80 percent are ischemic strokes, which "are not going to be the ones that hurt," she said.

"People think they just worked hard in the garden and are tired. ... By the time we see them they are totally weak and there is nothing we can do except get them to rehabilitation, learn why they had a stroke and prevent a second one."