On the evening of March 10, Audrey Kreibich had nearly all the dinner dishes washed; only two pans remained.
"I couldn't wash them," said Kreibich, 74. "I was losing the feeling in my arm. It was coming on real fast," she says. "I was falling, hanging on to the sink."
She told her husband Art, who has Alzheimer's disease, to call 911.
"I told the paramedics I thought I was having a stroke," she says. "I didn't know what the symptoms are. It just came to me. I just kind of knew."
Warning signs
The following symptoms indicate a brain attack is about to occur. If you experience these warning signs for longer than two minutes, doctors recommend that you immediately call 911. Do not call your family doctor and do not attempt to drive yourself to the hospital.
A sudden weakness or numbness of the face, arm or leg on one side of the body
Sudden dimness or loss of vision, particularly in one eye
Loss of speech, or trouble talking or understanding speech
Sudden severe headaches with no apparent cause
Unexplained dizziness, unsteadiness or sudden falls ? especially in combination with any other of the above symptoms
Recent change in personality or mental ability.
Risk factors
Treatable risk factors for stroke include:
High blood pressure
Heart disease
High red blood cell count
Diabetes
Cigarette smoking
High blood cholesterol
Excessive alcohol consumption
Physical inactivity
Obesity
Unchangeable risk factors
Age ? risk increases over age 55
Gender ? men have a 30 percent greater risk than women
Race ? blacks have a 60 percent greater risk than whites. This is associated with the higher rate of hypertension in blacks.
Prior stroke
Family history of stroke.
? Information provided by Boulder Community Hospital
A recent survey by the American Heart Association showed that one-third of Denver area adults could not recognize warning signs of a stroke, and almost half believe there is no emergency medicine for the disruption of cerebral blood flow.
This summer, the Heart Association is launching a campaign to familiarize the public with stroke symptoms, coinciding with the spread of a new treatment which can halt some strokes in progress. Medical professionals believe the combination of public awareness and innovative therapies can substantially reduce the number of stroke deaths and the impact on the lives of people who suffer a "brain attack."
Advanced warning
The onset of a stroke might involve weakness or numbness in the face, arm, leg or side of the body; confusion, trouble speaking and understanding, vision problems, loss of coordination. Timing is critical when a person experiences a stroke, during which a clot or rupture disrupts blood flow to the brain. Delay in getting to the hospital increases the potential for a negative outcome.
Nationally, stroke is the third-leading cause of death and the No. 1 cause of longterm disability. In 1998, 1,736 Coloradans died from a stroke; 106 of those lived in Boulder County.
Sometimes strokes are preceded in days or months by transient ischemic attacks (TIAs). The symptoms are identical to full-blown stroke, but pass within minutes or hours and leave no permanent damage, says Richard Hughes, M.D., chairman of the Heart Association's desert/mountain regional stroke advisory committee.
"People who get a warning are fortunate," says Hughes, the chief of neurology at Denver Health Medical Center and associate professor at the University of Colorado. "It's not something everyone has."
The Heart Association recommends anyone experiencing symptoms longer than three minutes call 911. While the incident could be a TIA, it's better to be safe than sorry, says Pam Nettro, Boulder County chapter board member and neuroclinical resource nurse for Boulder Community Hospital.
"We never know when a TIA will be a full-blown stroke," she says. "In the best-case scenario, we would say, 'You don't have a stroke.' If it's TIA, we can give treatment to prevent full-blown stroke."
Many strokes occur when a large blood clot in the heart or neck fragments and a small piece travels to the brain. TIAs give doctors a heads-up that clotting is occurring; if they can address the clot at its source, they can prevent a future stroke. Only about half the people who experience TIAs go on to have a full-blown stroke.
The Heart Association uses the term "brain attack" to promote the concept that a stroke, like a heart attack, should be treated as an emergency. Thanks to heart disease awareness campaigns, most people can name common symptoms of a heart attack, such as chest pain, lightheadedness and shortness of breath.
"Heart attack symptoms are very painful. When anything is painful, you remember and think about it more," Hughes says, adding that heart attacks are often similar from one person to the next. The same is not true about strokes, the majority of which are painless, and can differ greatly (a small percentage experience intense headaches). The event of a stroke can rob the person of cognitive ability to recognize what is happening; it's often a family member who takes action.
John McFetridge suspects he lay on the bathroom floor for four or five hours following a stroke before his wife came home from a ski trip. Rather than being frightened, he says, he felt nothing.
"I don't think the public understands. It literally is a brain attack. As a result, I did not have a clue what was going on," he says. "I've been in (the health-care) business my whole professional life. I did not know I was having a stroke."
Emergency treatment
In many cases, if a person arrives at an emergency room within three hours of stroke onset, doctors can administer tissue plasminogen activator, or t-PA, which can clear a blockage. A common antidote for heart attacks, the Food and Drug Administration approved use of t-PA for stroke in 1996. However, many things must fall into place for it to work, Nettro says.
"Few patients received it (when it was first available) because of the way (emergency room) systems were set up ? being able to get people in the system, evaluated and given the drug in time," she says.
Health insurance dictated that Kreibich be rushed from her home in Longmont to Boulder Community Hospital, where she received t-PA.
"When I first saw her in the ER, she could not speak and had facial droop. It was a clear-cut stroke," says Nettro, who was on duty the evening Kreibich arrived. "When I went back to the ER she said, 'Look, I can raise my arm.' I said, 'Look, you can talk.' It was a matter of 10 minutes. You could see it in her face."
A person meeting Kreibich for the first time has no indication she suffered a stroke five months ago. "I am so grateful to God and the medics that we got there in time," she says. "I tell everybody I see, 'You be sure to get to the hospital. Don't wait.' So what if it wasn't a stroke. It's worth finding out."
The biggest obstacle for patients is recognizing a stroke and getting to the hospital in time. If the stroke begins while a person is asleep, or if the patient or family members cannot pin down the time of onset, t-PA is not appropriate.
The hospital must be prepared to move stroke patients through quickly to capitalize on the three-hour window. The drug can potentially benefit the 80 percent of brain attack patients suffering from an ischemic stroke, or artery obstruction, but would be dangerous for the 20 percent suffering a hemorrhagic stroke, or bleeding in the brain. Doctors use a computerized tomography (CT) scan to tell the difference.
Nettro adopted industry protocols for Boulder Community Hospital, which went into place in February. Since then four people have received the drug during a stroke. Longmont United Hospital and Avista Adventist Hospital doctors have access to t-PA should they deem it necessary and appropriate. Hughes says not every emergency room in the country is prepared, but that is a goal of the American Heart Association.
"The next step is to get patients to come in sooner. Many more will have the opportunity to be treated," Hughes says. By 2003, the Heart Association wants to see 20 percent of stroke victims in the emergency room within three hours.
"Even if a patient doesn't get t-PA, there is a lot more we can do that we aren't doing," Nettro says. "With a hemorrhagic stroke, by getting them in here faster, the faster you get neurosurgery involved, the better the outcome."
Kreibich spent a relatively brief time in the hospital and outpatient therapy. She continues exercising three times a week through Kaiser Permante's Silver Sneakers program at the Longmont YMCA.
"I'm perfectly OK, that's what they say," she says. She feels more limited by last year's back surgery than the stroke. Kreibich also survived a heart attack in 1997.
Rehabilitation
As recent as the 1960s, stroke patients were sent home with no rehabilitation.
With developments in therapies, some patients make considerable strides in recovery, depending on the severity of the brain attack. This year, viewers of the ABC sitcom "Sports Night" watched the real-life recovery of actor Robert Guillaume unfold on screen. After Guillaume suffered a stroke, producers gave his character the impairments, which improved as weeks progressed.
Someone who survives a stroke can expect longterm effects, such as difficulty with communication and swallowing, rapid mood changes, an ability to feel temperature, touch or pain on one side of the body, incontinence and visual problems. If t-PA clears the clot in time, blood flushes out the deprived area and can prevent permanent damage. Not everyone responds as well as Kreibich did to t-PA, Hughes says, but for the people it does help, the turnaround is remarkable.
A primary goal in Kreibich's rehabilitation was helping her regain the ability to write, which returned after about a month. People who survive a stroke without t-PA have a much longer battle. Some never return to a normal life.
"The way it started, my speech pathologist asked me my name. I gave it," says John McFetridge, former CEO of Boulder Community Hospital, who suffered a stroke in 1993. "She asked my address and phone number. I didn't have a clue. She gave me the phone book, but I wasn't able to find it."
The extent of recovery varies with the severity of the stroke and the patient's frame of mind, Nettro says. "A lot depends on what their support is, who is encouraging them through the rehab process and how they have coped in the past. Someone who is strong-willed will push themselves to make things happen. Other people give up. They have no will to go through the work of rehabilitation."
After months of hard work with three speech pathologists each addressing different brain functions, McFetridge was able to return part-time to his job with a hospital consulting company. However, after a year and a half, he resigned and is retired at age 60. He continues to volunteer for the Rocky Mountain chapter of the National Stroke Association, which also offers prevention programs and survivor and caregiver resources.
As an outpatient at the Mapleton Rehabilitation Center, McFetridge attended a talk by a woman who had survived a stroke 25 years earlier.
"She said you will always see some improvement. That helped me understand the importance of rehab and the importance of never giving up," he says. "Recovery from a stroke is a never-ending process. To me that is very positive news for anyone who has a stroke."
