On a Friday afternoon in October 1997, Earleen Cypress, a retired teacher, was in the kitchen of her Baltimore home when she heard a thud. Rushing into the family room, she found her husband sprawled on the carpet.

"Can you hear me?" she asked. But Zanes Cypress, a former government worker, was paralyzed and unable to speak.

Earleen immediately called 911, and an ambulance raced the couple toward the University of Maryland Medical Center in downtown Baltimore, a leading stroke-treatment facility. Less than ten minutes after the ambulance arrived, technicians slid Zanes Cypress headfirst into the opening of a CAT scanner . During the scan he was diagnosed with a major ischemic stroke.

A blood clot blocked an artery in the left of Cypress's brain, starving nearby tissue of oxygen. Toxic chemicals from the dying tissue would soon spread to kill more brain cells, resulting in irreversible neurological damage. The entire right side of his body would likely become permanently paralyzed.

    But Dr. Marian LaMonte, co-director of the Brain Attack Team, began intravenously administering a drug called tissue plasminogen activator (t-PA). Half an hour passed, then she asked Earleen Cypress to come into her husband's room.

    Earleen was expecting the worst. But Zanes raised his right arm and leg high over the table. The next afternoon he spoke coherently, and in a few days he was discharged from the hospital in good condition.

Chain of Recovery

    Had Zanes Cypress suffered a stroke a few years earlier, the outcome would have been far grimmer, for doctors could have done little to help him. "The general standard of stroke treatment was to stabilize the patient, then let nature take its course and focus on recovery," explains Dr. Audrey Penn, deputy director of the National Institute of Neurological Disorders and Stroke.

    That has changed, and today there is an exciting group of weapons in the medical arsenal against stroke. While not all "brain attacks" can be treated, clotbusting drugs and surgical techniques can save lives or prevent loss of neurological function. Meanwhile, scientists are testing chemicals to counteract the otherwise irreversible self-destruction of brain cells following a stroke.

    The need for these therapies is critical. Some 560 000 Americans annually suffer ischemic strokes, while about 140 000 are afflicted with hemorrhagic strokes, which are caused by a ruptured vessel in the brain. Someone suffers a brain attack every 53 seconds, and every 3.3 minutes someone dies from one. The annual death toll of 160 000 makes stroke the third-leading killer, after heart disease and cancer.

    Strokes are also our leading cause of long-term adult disability. More than four million survivors struggle with problems ranging from impairment of vision or speech to major paralysis and shattered mental ability. The American Heart Association and its new division, the American Stroke Association, estimate the cost of brain attack at more than $45 billion a year.

    Unfortunately, only a fraction of stroke victims currently receive the new treatments. Fewer than five percent receive t-PA, for example.

    Why? One reason is that most people, including some members of the medical profession, are still not aware that the damage of a stroke can often be reversed, provided the victim gets immediate care. In the past, people often ignored stroke symptoms for crucial hours or even days after their onset. Many 911 dispatches did not deal with calls about possible strokes as true emergencies. And in many emergency rooms, stroke patients were given low priority.

    To fulfill their potential, the new therapies require that stroke victims reach the hospital, be evaluated, and begin treatment as quickly as possible. The clotbuster t-PA, for example, is only safe and effective if administered within three hours of the first symptoms of an ischemic stroke.

    Patients who receive t-PA during that narrow window are at least 30 percent more likely to escape disabling brain damage than those not given the clotbuster. But before doctors can safely administer t-PA, the patient must undergo a CAT scan so a radiologist can rule out hemorrhagic brain attack. (The drug cannot be used in a hemorrhagic stroke, because it could aggravate bleeding in the brain.) Researchers are now studying drugs that may offer more options for the immediate treatment of ischemic stroke. And new surgical techniques are also being developed for hemorrhagic strokes.

    Priorities for the care of stroke patients began to change in 1996, when the FDA approved t-Pa. Since then, national organizations have joined in a campaign to fight stroke, offering a model treatment concept that some experts call the Chain of Recovery.

    The Chain begins with potential victims, family members and co-workers learning to recognize the warning signs of stroke. Too many people brush off transient ischemic attacks (TIAs). The symptoms accompanying these so-called mini-strokes may last only a few minutes but often are a warning of an impending major attack.

    Unfortunately, fewer than a quarter of our hospitals today have acute stroke teams. When Dr. Mark Alberts, director of Duke University Medical Center's Stroke Acute Care Unit, urges doctors in smaller communities to take stroke treatment seriously, they often say, "I can't leave my busy practice to rush down to the hospital, read a CAT scan and decide whether a patient needs t-PA."

    Alberts counters, "Would you act differently if someone was having a cardiac arrest?" When they answer, "Of course," he points out that the ultimate reason for treating cardiac-arrest patients immediately is to prevent brain damage due to interrupted blood flow. "So why shouldn't we take action quickly when a stroke cuts the brain's blood supply?" he asks.

    Communities also need to make sure that the transportation of suspected stroke victims gets a Priority One (critical) status. Currently, only about four to ten percent of stroke victims reach hospital emergency rooms within three hours of their first symptoms. The emergency medical service (EMS) goal should be to deliver brain-attack patients to hospitals within 20 minutes of the 911 call.

    The success of Baltimore's brain-attack program, for example, reflects the advanced statewide EMS network in Maryland. Due to the diligence of 911 dispatchers, paramedics, and state-police medevac-chopper crews, stroke victims from as far away as the southern tip of the state, about 100 miles from Baltimore, can reach the medical center less than an hour after their first symptoms. "Patients, the EMS and our staff are now working as a team," notes Dr. LaMonte.

    Medical authorities also recommend that every hospital offering around-the-clock emergency care should have trained stroke-treatment specialists either on duty or on call. Ideally, a patient should be evaluated in the first 15 minutes at the hospital, while laboratory blood analysis is under way. A radiologist should read a CAT head scan within 45 minutes of the patient's arrival. This would ensure "door-to-drug" (t-PA or other treatment) time of 60 minutes following delivery to the hospital.

    Alberts recommends that doctors in private practice and HMOs create community-wide networks to provide smaller hospitals with standby stroke-treatment stall day and night.

"Drano for the Braino"

    In July 1996, just after the FDA approved the use of t-PA, Woodstock, Va., internist Dr. Greg Byrd helped colleagues at Shenandoah Memorial Hospital improve their stroke-care capabilities. That same summer they treated their first patient successfully. "Even though we're in a small, rural community," Byrd notes, "our patients are much better protected than in the past."

    In Eugene, Ore., neurologist Dr. Ray Englander led the effort to reconstruct stroke care at Sacred Heart Medical Center. "In 1996 it took us hours to evaluate and treat a stroke victim," Englander notes. "Today a patient goes from initial evaluation to CAT scan and neurological evaluation to treatment in only 45 minutes on average."

    Scared Heart's most famous stroke survivor is Ken Kesey, the counterculture novelist. Englander successfully treated Kesey with t-PA after the writer suffered a serious stroke in October 1997. Kesey improved dramatically within days and eventually recovered fully. True to his offbeat manner, he called the clotbuster "Drano for the braino."

    Dr. Thomas Brott, chairman of the American Heart Association Stroke Council, urges all "Americans to recognize stroke as a true emergency that has to be treated quickly." Dr. John Marler, who supervised major t-PA research, agrees. "If America takes brain attack as seriously as it did heart attack in the '70s," he predicts, "we can save hundreds of thousands of people from death and disability in coming years."

    Zanes Cypress can attest to that. He has regained almost complete neurological function, including the ability to play guitar. "I feel very thankful that medical science has reached this point," he says. "If people with a stroke like mine act quickly, they, too, may recover."

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