tv Democracy Now LINKTV May 17, 2012 3:00pm-4:00pm PDT
the heart beats more than two and a half billion times-- without ever pausing to rest. this fist-sized organ pumps blood to all parts of our body. it's a feat we often take for granted-- unless something interferes with that heartbeat. the most common form of heart disease is coronary heart disease, a narrowing of the coronary arteries that feed the heart. it's the #1 killer of both men and women in the united states. david faxon: atherosclerosis, hardening of the arteries, is a disease of childhood. in a recent study on autopsies of children and young adults in the teenager range, a very high percentage had plaques, had hardening of the arteries evident before the age of ten, and by age 20, the majority had plaques. this thickening, or hardening, narrows the space for blood flow,
decreasing and sometimes completely cutting off the supply of oxygen and nutrients to the heart. hodis: and what we know statistically is that if you live long enough, you will get atherosclerosis, or hardening of the arteries, usually in the heart and in the neck, eventually. usually starts down in the lower parts of the body in what's called the "aorta" and migrates upward in humans. but eventually we all get it if we live long enough. and that's sort of a given, that's part of the aging process. who dies from it is the mystery. in 99% of atherosclerosis cases, the patient has high levels of cholesterol built up on the artery walls. jim goldenetz: my father had passed away during bypass surgery in 1986. so i was somewhat aware-- more than most-- that there could be problems with high cholesterol.
well, cholesterol is a fatty substance that is in... produced by our bodies or ingested through certain products such as meats. eggs have a lot of cholesterol, for example. so if you were to really describe this molecule called cholesterol, it's a waxy, lipid-type substance that is very similar to fat. the body needs cholesterol to function normally. it is present in all the cell membranes and it helps produce many hormones. but it only takes a small amount of cholesterol to meet the body's needs. hodis: cholesterol is a catchall term of which there are many, many particles that float in the bloodstream that make up this cholesterol measurement. each one of these carries its own risk and, potentially, its own protective function also. high-density lipoprotein (hdl) carries cholesterol from the cells to the liver for removal from the body.
that's why it's called the "good" cholesterol. low-density lipoprotein (ldl) is the "bad" cholesterol. it carries cholesterol to the cells-- including the cells that line the blood vessel walls. as the level of ldl rises, so does the risk of atherosclerosis. when it was first tested, it was up in the 600 range, and so with the cholesterol lowering medication, it was in half. it was in the 300s, so, to me, that was great. hodis: it's clear, if you come from a high-risk family, then you're at high risk yourself, as an offspring. there are certain disorders, such as familial hyperchyolesterolemia, where there's a bad gene in the family and the families have very high cholesterols, 300,400 milligrams per deciliter, whereas, if you're looking at something to compare that to, you'd say around 150 or less would be...
you know, 130, 120 would be really an adequate level. goldenetz: you know, our daughter's been tested, and our son, for cholesterol. our son's is okay. our daughter, who's a vegetarian, her cholesterol was over 300 at 20 years old. hodis: most people don't fall into that category of that extreme risk. but we're all at risk, and if it's in the family, a parent or a sibling, then you're very high risk if... of also having that outcome of either stroke or heart disease. goldenetz: well, it's funny, the first time i really noticed some symptoms was 1997... january... i'd had a cold and i had a sore throat, but i also had a strange tightness in my chest, and i attributed that, at first, to the cold and the sore throat. that kind of was the way things went for several months where i'd feel okay for a while
and then get this kind of tightness, trouble breathing. there are things we can do with people like that to either find out they have the disease before they have a heart attack or die or have a stroke, things like electron beam cat scan of the heart where we look for calcium deposition within the arteries as an early marker of this inflammatory disease, and an early marker of plaque build-up. we're also working with cardiac mri, which is another fancy test to actually look within the arteries and look at plaque build-up and the composition of plaque. there are other techniques, such as looking at ultrasound of the arteries in the neck, the carotid arteries, and looking if there's a thickness in those arteries or a build-up, and you can actually measure the responsiveness of arteries elsewhere in your body, like in the arm. there are also some standard diagnostic procedures used to test for coronary heart disease. a doctor may use several to determine the extent of the disease.
goldenetz: the first doctor that ever said anything about coronary to me... it was really funny. judy and i had gone on a cruise, and i t this kind of tightness again and it was almost like my throat though, again. so i went to see the physician on the ship, not really feeling that bad, but i thought, "well, you know, i'll nip it in the bud." i didn't feel good enough to go on one of the tours off the ship. so i went to see the doctor on board the ship, and he gave me an ekg and did some other things. and he says, "anybody ever said anything about a coronary problem to you?" an electrocardiogram (ekg) is a graphic record of the electrical activity of the heart as it beats. it can detect abnormal heartbeats, inadequate blood flow and heart enlargement. goldenetz: i then decided, well, i'm gonna get this taken care of one way or another. so i went to my regular family doctor
who had seen me a couple of times with this same complaint. he decided, i think, because i was becoming annoying to him, that he would fax the ekg to a cardiologist. about a half an hour later, the cardiologist called back and asked to speak to me. ... very helpful information, you know... another way to diagnose coronary heart disease is a stress test, or treadmill test. a stress test records the heartbeat during exercise. this is because some heart problems only show up when the heart is working hard. an ekg is done before, during, and after exercising on a treadmill. the next morning he had a treadmill test set up for me. he was actually in while the treadmill was being done, which i later found out is not common. and i became short of breath real quickly on the treadmill.
he handed me a tablet, told me to put it under my tongue, which i then found out-- later found out was nitroglycerin and everything got better. and i was kind of interested because then i thought, "well, i can take a pill and i'll be better from now on," you know. and he told me, "no, we're gonna go... tomorrow morning, you're gonna have an angiogram done." if the symptoms persist, or if the non-invasive test shows that the problem is severe, and generally we recommend that the patient undergo an angiogram to define the severity and nature of the problem. an angiogram is an x-ray image of blood vessels after they have been injected with a fluid called a "contrast medium." first, a physician threads a thin plastic tube called a "catheter," through an artery in the arm or groin until it reaches the coronary arteries. the contrast medium is injected into the catheter. then the doctor takes high-speed x-ray movies
of blood flowing through the arteries. the x-rays can show irregularities and narrowing of the coronary arteries. doctor: there's the articulation. better in a second. they're injecting dye into me, which has a really funny feeling because the dye is... feels warm going through your body. and i was actually awake and the cardiologist, who, i must say, was very, very good, sat there with a laser pointer on a screen that was in a position where i could see it and he showed me where the dye was not going any further and was being stopped in-- totally stopped-- in four of the arteries. he said that they could've been up to, like, 90% occluded. and then three of the arteries were at least 60% blocked. if only one or two of a patient's coronary arteries is narrowed,
a physician may suggest an angioplasty procedure-- introduced in the united states in the early 1980s. after a few years in practice in boston, i went to an abstract session at one of our national meetings. a young swiss was there, andreas gruentzig. he presented an abstract about putting a balloon catheter inside the heart, inside the arteries of the heart and blowing it up, and showed on an experimental study, that it dramatically opened the artery. i was absolutely astounded by this. it was just an enlightening experience because putting anything into the coronary arteries was forbidden prior to that time. so he was breaking the rules. it is now the largest coronary procedure done, and there are about 500 to 600,000 procedures done per year now, which is significantly more than the number of bypass operations
that are done in the united states. the physician threads a catheter through an artery in the arm or the groin until it reaches the coronary arteries-- the same procedure as an angiogram. but then, the physician threads a second balloon-tipped catheter through the first. the balln is inflated, breaking up the plaque while compressing it againsthe arterial wall. faxon: the arteries are not like pipes. they're not hard lead or metal pipes. they are like your sk. the arteries are not like pipes. they have elasticity to them. and so the angioplasty ballo, en it's inflated, stretches e artery andreates a sort of anneurys but there are sadvantages to angioplasty angioplasty has an unfortunate problem of restenosis, which is the recurrence of that narrowing. it can be highly successful, but within three months on average. but up to six months afterwards, the narrowing comes back again. so the procedure has to be done again. or if it can't be done again,
the patient goes to a bypass operation. bypass surgery usually means "coronary artery bypass graft surgery." blood vessels are taken from another part of the body and grafted to the aorta, the large artery emerging from the heart. the other ends of the vessel are grafted to the coronary arteries-- those that serve the heart-- past the area of blockage. goldenetz: when i woke up from the surgery, everything was working fine except i felt like i needed to get better just to die. i'd never had the kind of pain i was feeling, and one of the worst things was my legs. you know, they take all the replacement arteries or veins out of your legs. so to get enough to do seven vessels, they had to take a lot out. and i learned later on that they cut them up
and lay them alongside the surgeon and let him pick and choose which ones he's gonna use. trying to, you know, kind of sizing it up like this is a... the right diameter to do this and put here. faxon: bypass surgery takes a week to ten days the hospital. sometimes shorter, but that's usually about at it normally is. the patient would go back to work, feel strong enough to go back to work, about a month after the procedure, on average. i can remember starting up... to walk up mt. rubideaux about-- i think it was like the third week that i was out of the hospital-- and i'd go just a few hundred yards and turn around. and now i'm going all the way to the top in... almost three years later. and that's... to me, that's a big accomplishment. and since the average life expectancy of a bypass patient is 15 years-- normally those wouldn't get done. that's another thing that sticks with you too,
is what the normal... i had people say, "well, you know, you gained 15 years." well, i was 47 years old. there was no way i wanted just 15 more years. so that's another thing that motivates me. there are certain unavoidable risk factors for heart disease. a family history of premature coronary disease doubles a person's chances of a heart attack. we can't change our gene pool, but we can alter other risk factors. faxon: so if you have heart disease in your family, you need to be more vigilant about making sure that the modifiable risk factors are taken care of, and those are high cholesterol, high blood pressure, cigarette smoking, physical inactivity-- which the american heart association just added to the modifiable risk factors. hodis: the heart's a muscle. the stronger that muscle is, if it becomes damaged or further damaged, you're going to do much better, clinically, than you would if you just had a floppy, sick heart.
so you want to keep muscle tone, not just in your arms and legs, but your heart also. goldenetz: the truth be known, i probably am more active now than i have been in 25, 30 years, and that's a good feeling. i really look forward to... in fact, i told my wife and daughter that the next davis stampede that i go to i'm gonna... i walked in the 5k. thne one, a year from now, i'm gonna run the 10k. sperling: we know that something as simple as walking four to five times a week, 30 m at a ti, decreases the risk of sudden death in both men and women. we know that optizing your weight decreases your chances of having a heart problem. any person weighing 20% over his or her desirable weight doubles the risk of heart disease. weight reduction lowers total blood cholesterol levels. clearly, there are some dietary programs
that we've learned by scientific evidence that can decrease the risk of heart problems. in the united states, we recommend the american heart association diet, the step ii diet, which was a low fat, a low saturated fat, and a low cholesterol diet. hodis: what we're focused on is moderation, not restricting. dieting never works. what we're talking about here is a lifestyle behavior, and can you adapt to these changes? absolutely. there's nothing like prime rib. i don't care what anybody says. there's a cinnamon roll from cinnabon... really is probably the neatest thing in the world to have for breakfast but i don't have any of those things anymore. and my wife has done a great job of making sure that, you know, what we have isn't high in fat. i do my best, and my cholesterol level is way down.
it's under 200, which is... a good diet and a ton of medication, more than i want to think about, but a lot. another risk factor is high blood pressure. faxon: high blood pressure is the most common heart disease in the united states. and unfortunately, only about a third of people with high blood pressure know they have it, and only about half of those are adequately treated. so, again, it's an educational process that's very important, from a public health standpoint, that people have their blood pressure measured. and if it's elevated, dropping it five or ten points into a normal range makes a huge difference. your pressure's excellent, 134/80. another way to lower heart disease risk is to stop smoking. cigarette smokers are five times as likely to develop cardiovascular disease as nonsmokers. goldenetz: and i smoked... right up to the day i had the angiogram done.
in fact, i can remember my last cigarette as i was quickly getting ready to go in, and, you know, have to get the angiogram done. after the surgery... i look at cigarettes as kind of... you know, i did my own thing to myself to cause me to be... need surgery. but i look at cigarettes as something that i... just like i look at alcohol, frankly. i'm allergic to those things, and i don't have anything to do with them. the other thing is, if you have a little bit of this and a little bit of that, and you add them up, they all add up together. so if your cholesterol's a little bit elevated, but not too bad, and your blood pressure's a little bit over, but not too bad, and you don't exercise as much as you ought to, and, you know... and you add those things together, they all add on top of one another. so now it becomes a very significant problem even though each one individually is not too bad. whatever the risk factors,
victims of coronary heart disease are often unaware that their arteries are blocked. they may not have any symptoms, or they may not notice them. one-third to one-half of people with coronary heart disease are stricken unexpectedly with a heart attack, a myocdi infction. faxon: but it's very clear that when a heart attack occurs, that heart muscle starts to die almost as soon as it occludes. within five or ten minutes of that occlusion, it starts to die. it dies slowly and progressively over a period of time. that's what a heart attacis-- the death of that muscle. an infarction is an area of heart muscle that dies because it doesn't receive enough oxygen due to insufficient blood. hyunah lee poa: if a person does not recognize they're having a heart attack, they're losing precious time to seek out treatment, and especially nowadays, where it's been encouraged that every hour counts that you really try
to start treatment of a heart attack or stroke within the first few hours, every hour counts. i mean, we're all human, and we obviously... when we get a symptom that's severe, we kind of want to wait, and maybe it'll go away, and maybe it's indigestion, and maybe something... i don't need to worry about it. so, we have a natural tendency not to want to go to the hospital. it might not ba heart attack. that'd be terrific. but if it is a heart attack, that's where you want to be because you want to get treated as soon as you possibly can. poa: the traditional description of a heart attack that medical students and doctors are trained to look for are the classic chest tightness, a gripping chest tightness over the left or central chestwall, possible radiation down the left arm with numbness or tingling, sweating, dizziness, shortness of breath. most of our knowledge about the expression of the symptoms of heart disease are based upon men, and it appears that women have different symptoms than men.
women may not even have chest pain. they may have an indigestion feeling or they feel dizzy, or they feel weak. so they don't have the typical symptoms that we usually ascribe to heart disease. alice ann hamilton: i had a heart attack on december the 17th, in 1991. i was walking at the time, and i did not have pain in my chest. i had pain in my jaw and the side of my neck. and when i got home i was totally exhausted, but i still didn't think anything about it. i never had a chest pain. so it can present very differently in a woman, and she may not recognize that she's having a heart attack, or having anginal warning. so i didn't go to the doctor until friday, the 20th of december, and he said, "i've called 911. you've had a heart attack. you..." i said, "i can't-- it's christmas!" anyway, i did go in the hospital at that time and i had a heart catheterization, which showed that i had had a heart attack, and that i had some blockage that they could handle with an angioplasty.
so i did have angioplasty and it was very successful. i've got a before and after picture of the artery. women believe that the #1 killer of their sex is breast cancer. in fact, it's important, no doubt about it, but if you look at the overall pie, 53% of women die of cardiovascular disease. four percent will die of cancer. one way to think about the difference between men and women is that women present with heart disease about ten years later than men. and that's largely because-- we believe-- that estrogen, in particular, helps protect women against having heart disease. but once they're post-menopausal, then they are just as susceptible as man is to heart disease. prevention, for women, i think really centers around some of the common sense things. take care of health in terms of exercising regularly,
avoiding excessive alcohol, avoiding cigarettes, avoiding excessive stress. i think people understand more and more that stress has a large impact on many risk factors. controlling weight-- maintaining as close to ideal body weight as much as possible. seeing the doctor regularly to check on all those factors. we have many different levels of cardiovascular care here in our clinic and our program overall. our mission right now is to detect heart disease, or risk for heart disease, at an early stage. that's one issue, but our other mission is to take patients who have known heart disea or cardiovascular problems and aggressively teach them to improve lifestyle, be on optimal medical therapy that we are learning more and more can improve their risk for future problems. you don't know... you feel like you're the only person that's ever had this. all the people around you care about you,
but they've never had this. and i go to the mailbox and i don't have the energy to walk out there. i couldn't sit back down, and i'm scared to move because i'm scared it'll happen again. so it's sort of a vicious cycle, and then you think, "well, here i am. i don't know what to do about this." my brother's a doctor and encouraged me to come to the emory cardiac rehab program. well, i didn't much want to but in february i did start. february of '92, i did come to the program. and the part of that that's so good is that they put a monitor on me and they start your exercises very slowly, you know, but you feel real secure. that's kind of like a security blanket-- the monitor. poa: i think the best thing for women to do nowadays is to understand their own risk factors, their family history, their own lifestyle, know... are they at greatly increased risk for heart disease? and modify the risk factors that have been proven with studies thus far. i just got off the treadmill.
hamilton: yes, i changed a lot of things. i quit smoking. never touched another cigarette. they did have a little program before i left the hospital on the diet. now, i grew up in macon, georgia and we ate... i grew up with vegetables cooked with fatback, and i... with bacon and eggs and grits and so forth, and you didn't go out without a good breakfast of eggs, grits and cheese and all that. but i have chaed it and i have found that there are many things you can do with herbs and spices and things that you don't have to use a lot of butter or fat in your food. yes, i did change my diet. i think ultimately we're gonna learn that programs like this are probably more effective than some of the revascularization techniques we have to offer patients like a bypass surgery or an angioplasty. i think there will always be a place for that type of treatment and therapy. i think there will always be people who are having heart attacks and strokes, and we need to hospitalize these patients and treat them with clot busters and all the other things
that we can do for patients right now. but really for overall benefit, there's nothing better than treating the disease itself, and that's really what we've begun to do. i think we'll be able to do that better and better in the future. faxon: so, it is a disease of our entire life, and therefore, prevention needs to start early in life, not late in life. but prevention at any stage makes a difference, by the way. it doesn't... because it is such a slow process, there are things, if you change your diet and lower your cholesterol, even at age 80, believe it or not, you will make a difference, because it has an immediate effect. it's not something that you have to wait many, many years before you see the benefit of it. i can just run rings around a lot of people younger than i am now, and i'm not bragging. i'm just very proud of what i've been able to do in the program. my doctors are very proud of me too.
stroke is the most common sudden injury to the brain-- the third leading cause of death in the united states after heart disease and cancer. it is the principal cause of adult disability, and a common reason for people to be placed in nursing homes. in human terms, what is a stroke, and how can it do so much damage in a relatively short period of time? dr. jeffrey saver: a stroke really is an attack on the brain. a stroke is a damage to the brain due to blocking or rupture of a blood vessel leading to the brain. and in a stroke, either the brain is suddenly deprived of blood flow because an artery has been clogged or an artery has ruptured
and blood is escaping directly into the brain. stroke is an age-related disease. most of its victims are middle-aged and older. dr. saver: the incidence of stroke approximately doubles for every decade over the age of 45. two-thirds of all strokes occur over the age of 65. but stroke is also not uncommon in mid-adult life, or even in childhood. and there are more strokes in patients under the age of 45 than there are cases of multiple sclerosis. the risk factors for stroke, in certain respects, resemble the risk factors for other cardiovascular diseases. dr. saver: high blood pressure, hypertension, is the number one modifiable risk factor for stroke. high blood pressure increases the risk of stroke fivefold compared to people who don't have high blood pressure. the conventional definition for high blood pressure is having a systolic blood pressure-- the upper number-- that's 160 or higher, and the diastolic blood pressure, or lower number,
that's 85 or 90 or higher. if you have blood pressure in that range, then to work with your physician in lowering the blood pressure. usually the first steps are lifestyle changes: doing relaxation, identifying stressors in your life and removing those, and dietary interventions. many people have salt-sensitive high blood pressure, and reducing dietary intake of salt can reduce their blood pressure. if the blood pressure remains elevated despite these non-pharmacologic treatments, then drugs can be very helpful and very well tolerated. high blood pressure has been called the silent killer because people get no symptoms from it, while it's slowly producing all this damage to blood vessels in the heart and the brain. high cholesterol is also thought to be a factor, although major epidemiological studies have not supported this premise. however, there are now many cholesterol treatment studies
that have shown th treating patients with elevated cholesterol can reduce the risk of stroke, and therefore, there's pretty convincing evidence that cholesterol is a risk factor for a stroke. the most important of the cholesterol numbers probably is the ldl cholesterol, the low density lipoprotein cholesterol, the so-called bad cholesterol. and we recommend that individuals have a fasting ldl cholesterol that's less than 125 as a target, if they've never had heart attacks or strokes or any events in the past. if they have had symptoms in the past, then we aim even lower, for an ldl of less than 100. homocysteine, a byproduct of normal metabolism, is also emerging as a risk factor for stroke. now there's pretty convincing data from over 20 epidemiologic studies in large populations that mildly increased homocysteine does increase
your risk for heart attack and stroke. the exciting thing is that homocysteine is potentially usually treatable. taking extra doses of the vitamins that are involved in the metabolism of homocysteine-- b12, b6, and especially folic acid-- can lower homocysteine levels with extra intake. and so a number of clinical trials have now been organized to see if taking extra vitamins and lowering serum homocysteine does result in actually preventing stroke and heart attack. if so, it will be another important addition to our stroke prevention practices. it was a summer of promise for karen christiansen and ken jones. after ten years of marriage, they were expecting their first child. ken was teaching when he got the call... ken jones: it was a person from the y, and when they first started talking about karen, it was very strange because i thought it was going to have something to do with the pregnancy, and then when they said it was a stroke,
it took a few minutes for it to kind of sink in. i went to the class, and that's all i remember. i know now that the teacher, she saw that i wasn't acting as normal or whatever that the other women were. the source of the problem was occurring inside karen's brain, the body's control center. dr. saver: the brain is an incredibly complex organ. it's the seat of the personality and thinking in our humanity. it has millions, or perhaps billions of nerve cells, and billions upon billions of connections between these nerve cells. it is organized in a very regular pattern from individual to individual. it is fed by a number of blood vessels that bring nutrients to different areas of the brain. the brain is about the size of a basketball, a little smaller.
it has perhaps... the consistency of toothpaste. it floats in liquid that helps to protect it from the minor buffeting we get every time we take a step, and it is, of course, encased in the hard skull in order to provide protection against injury. what clues or warning signals suggest that the brain is under attack... that someone is experiencing a stroke? dr. saver: whatever the brain can do, which is everything we do, it can do wrong if that part of the brain has been damaged. so the symptoms of a stroke can be virtually anything. there are, however, certain major themes of brain action that are impaired when a stroke occurs. the warning signs that the american heart association is educating patients to look out for include:
just having one of the symptoms may not mean a stroke is in progress, but if one of the symptoms lasts for ten minutes... 911 operator: houston fire and ambulance. what's your emergency? stroke? is he able to move his arms and legs, and talk as usual? dr. saver: then at the ten minute mark, you should call 911 or be driven directly to the emergency room. don't waste time trying to reach your doctor or reach aunt minnie, who had a stroke ten years ago, and is the family expert on a stroke. call 911 and come directly to the hospital. that's the only way we have a chance of getting to patients in time. we have a 54-year-old white female, 54-year-old white female, possible stroke. in the past, before doctors had the means to check the damaging effects of a clot, stroke victims were not considered a priority,
by paramedics or emergency personnel. now that we have proven interventions available, that attitude is changing, and more and more emergency medical systems are recognizing that stroke is an emergency that should be treated as equally important as heart attack or trauma, or any other level i priority. and the same with triage nurses, and other decision makers in the emergency department after arrival. you're going to the chest pain center. do you know where that is? ken arrived at the hospital an hour and a half after karen. within minutes, half a dozen specialists rushed him through a maze of corridors to her side. they were just pumping me for information, background information about karen, and they were trying to be very calming as well. as we spoke, she was having an mri and bone scan, you know, basically they were prepping her and describing to me what... this procedure they were going to do. dr. saver: in the past, our treatment decisions were guided by deductions from the neurologic exam as to what was happening in the brain,
rather than directly visualizing the brain process itself. but with diffusion weighted mri scanning, we can see changes occurring within minutes of the start of low blood flow, and we can make a decision in an individual patient that is tailored specifically to what's occurring, to where in the brain the ischemia is, to how large a brain region is being threatened, and to what the mechanism is that's producing that injy to the brain. mri scanning vified that karen was experiencg an ischemic stroke. dr. saver: in this type of stroke, a blood clot has blocked blood flow to a region of the brain. not enough oxygen and nutrients are reaching nerve tissues, and then the tissues die as a result. tpa is a proven agent for the treatment of ischemic stroke. it is a clot buster. it reopens clots that are blocking blood vessels
and restores blood flow to threatened regions before irreversible injury has occurred. one of the main surgeons felt it was very important that i see her right before they started the procedure, and so they took me in, and they were just very quickly preparing her. at that point, she wasn't... she couldn't speak, she couldn't say anything. we didn't have more than a minute, and karen doesn't remember anything. i just went in and tried to pretend that it was no big deal, and it was like holding back tears and stuff. time was critical in the use of the clot buster, tpa, to counter the effects of karen's stroke. when blood flow is blocked to the brain, a number of processes leading to cell injury begin to occur immediately, and unless the blood flow is restored within a few hours, then the brain that's at risk is irretrievably lost. so unfortunately, we have learned that the time window for intervention in acute stroke is very brief, on the order of three to six hours.
and if you reopen a blocked blood vessel beyond six hours, all the damage that was going to occur has likely occurred, and you may even be doing harm by reopening the blood vessel at that point. tpa procedures are designed to be simple and available at any hospital emergency room which has a cat scanner. a patient arrives, you do a neurologic physical exam, testing the strength and cognition and reflexes. you do a brain cat scan to rule out a brain hemorrhage and then you give the tpa as an intravenous solution over an hour. you follow the patient's blood pressure, and you follow their neurologic exam, their strength and cognitive abilities, but there's no sophisticated monitoring that's required. that allows it to be a simple procedure that's widely available. at specialized centers, there are much more sophisticated ways of monitoring brain function--
with continuous eegs, continuous electric graphic recordings, or brain activity or with frequent mri imaging, looking at how the brain ischemia is evolving. the first reports about karen were guarded. although the clot buster had been administered, not enough blood was getting through. the surgical team even tried angioplasty to increase the flow. while they were able to open up some of the artery and get some blood flow going, the thing... the words that stuck in my head were "unsuccessful" and "significant," meaning a significant portion of brain tissue was damaged. but during that first night in icu, it became obvious that the clot-dissolving medication was continuing to work. it was really a bad night. but when karen finally woke up, like later that night, you know, it just became pretty obvious to everyone that it had been more successful than they had...
they had originally thought. we were able to reopen the blocked blood vessel and limit the damage from the stroke, but not prevent... but not prevent damage altogether. and for the next two weeks, there were many touch-and-go issues having to do, in part, with how best to go ahead with the delivery, and how much of a threat to the mother continuing to carry the pregnancy was. karen was pretty anxious to have the baby, but she was pretty anxious even before the stroke. she was wanting to get on with it. they were actually thinking of doing a c-section, but then they decided against it. they were all saying, "the baby's fine," and they even brought up an ultrasound to show karen that the baby was just fine, but karen wasn't really going to be convinced until she was here. the neurology team and the ob team worked together throughout labor and delivery, carefully monitoring karen's blood pressure and the baby's progress.
so she really felt all the contractions, all through the night. they told me never to... never to push. and so, finally, the attendant kind of... the attending physician sort of stuck his head in, saying, "okay, you know, if she doesn't come in the next two or three contractions, then we have to go to section." and then the very next contraction, out she came and... ( baby crying ) this is, um... scouten elaine christiansen. when i saw her... that was... yeah, that was wonderful because they brought her... brought her to me. and i had... i had like, needles up and down my arms. the night after the surgery, i was sort of like trying to picture myself as this caregiver, with someone who's non-ambulatory and project my, you know, how we were gonna deal with all that, and well, we didn't. that was a non-issue because karen was walking. karen christiansen: yeah, on my right side,
the leg and the arm were a little off, but it wasn't-- it wasn't that bad. ken jones: and the more i talked to people who have known stroke victims, the more i realized what a wonderful thing that... that karen got the treatment that she did. despite all they've been through, ken and karen have found that humor is a great help in recovery. karen was calling formula "fodor" or "fodder." you know, she couldn't think of the word for baby formula. some funny things come out, and that's helpful for everybody to sort of take away some stress. i can't get the words out. i mean, i know the word that i want, but it won't come out of my mouth. i mean, she really has to work at it. it's like learning a foreign language. the main thing that i have to do is not... try to remember not to finish her sentences, but to let... to let her, you know, struggle through that.
"struggle" and "perseverance." both words characterize the path to recovery for a victim of stroke. so do the words "resourceful" and "adaptable," in referring to the brain itself. we've learned a little bit from neuroscience about how the central nervous system works and how it might respond to inputs-- how it learns, how it adapts-- and we can even image some of th adaptatio using functional imaging techniques. this is a series of functional mri scans done at four points in time: right after a person had a stroke; a few weeks later; several months after that; and six months after that. so this man had a stroke that caused him to have paralysis of his right arm, at the time that we did this study, we asked him to try to open and close his hand a little bit. and he was unable to do that at all.
what we see is a tiny activation of the hand area over the area that it should occur in the motor cortex of the brain. but, interestingly, we see the opposite side, the normal side of the brain, becoming activated and some supplementary motor areas, even though he really can't move the hand yet. in the second set of scans, he can now move his fingers a little bit, and what we see is a little bit of activation again in the abnormal side of the brain, the side that had the stroke, and that suggests that both sides of the brain-- both hemispheres in the motor areas-- are forming a network to try to carry out this task, even though he's still doing it rather poorly. he's still at home practicing for three hours a day-- pinching, grasping, reaching-- and his arm is getting better. and when we look again at the third set of scans, we find that there is a fair activation w on the normal side of the brain, we see a smaller contribution now as he's getting more control
on the side that w affected by the stroke. in the final scan, the hand is moving now rather well. he can squeeze with about 75% of normal force, and move his fingers fairly fast in opening and closing them. and we see very little activation now on the normal side of the brain that no longer is needed to be brought into play in this network for movement. and so now as he's learned this task, relearned it, using leftover pathways that weren't damaged and driving the plasticity or adaptability of the brain by his consistent practice for three hours a day, opening and closing his hand and pinching his fingers, we now get back to a smaller area of activation, more like normal, but still larger than normal, and he now has a functional hand. five months ago, jim krakowski experienced the second major type of stroke, a cerebral hemorrhage, while he was getting ready for work.
i was awake in the bathroom, tryi to wonder, "what can i do?" all i can remember is, "you're dead if you try that, that's a terrible idea." but i managed to crawl into the bedroom. it was just terrible. i couldn't do anything, and i couldn't dial, because if i dialed anywhere i couldn't even get the response out. so the only thing i could do was lay there and jim. when his wife mary returned home that night, the house was strangely dark. i kept calling his name and i was looking all around, and then i looked in the bedroom, and it looked like-- it was dark in there, but it looked like someone was on the bed, and i started the feeling of panic. and i turned on the light, and jim was laying in the bed.
and he rolled over, and i am yelling his name by this time, and i just saw the look on his face when he finally looked up, rolled his head up toward me. and it was just, i'll never forget that look. it was just... he was so scared. i remember that feeling of mary coming home from work that night. she was the thing that touched me, first of all, and she looked at me a little like she was scared for herself. that's a bad thing to do. so i kind of knew i was going to the hospital. dr. dobkin: the hemorrhage was quite large and deep,
and the surgeons had to go in and try to remove as much of the clot as they could because he was just deteriorating so fast. he then spent a week or ten days being extremely lethargic and confused and developed a little pneumonia, and couldn't swallow, couldn't communicate. he came down to our rehab unit once he was at least a little more medically stable. initially, the focus was on getting jim to eat on his own, to sit up, and to understand what was being said. dr. dobkin: when he first came down, if i said to him, "there are... how many elephants are in the room?" he'd nod. now when i say it, he laughs and, you know, looks at me like i'm crazy. this is a funny memory. there i was, yelling out, you know, i've got this terrible... but nobody hears m and that seems to be the need i have--
to be heard-- because i could only catch the small bits that would come out of my mouth. okay, left arm through like a jacket. dr. dobkin: as recently as three or four days ago, he just had a hard time even standing up. ... two, three, up. very nice. actually, much to my amazement, after one treadmill training session, he was able to put weight into the right leg some and control the knee a little bit. he has no feeling on the right side, as well as virtually no voluntary movement. the climbing harness holds jim's weight as he is suspended over a treadmill. okay, let's start. dr. dobkin: we've developed these techniques so that the therapist can optimize what the nervous system sees that's relevant to walking. so speeds that the nervous system is used to seeing,
joint angles at the hip and the knee and the ankle, changes in balance, shifting of weight, loading of one leg and the other-- by providing as normal sensory inputs as we can, we see that the spinal cord reads this information coming from the legs and the joints and the muscles, sends that information up to the brain, distributed in different parts, and that this helps reorganize the networks for walking. jim krakowski: i was so gratified to be able to get on the treadmill. so, just being upright, you know, just feels great, and it allows us, perhaps, to prevent a lot of medical complications that might occur when people lay in bed, like pressure sores on the skin or blood clots in the legs, or loss of muscle bulk. muscle atrophies very fast. one of the terrific things about rehab is that it's not about being sick, it's about getting well. good! that's it. step... after a month in acute rehab, jim came home to continue his recovery efforts.
the one thing i felt is like i didn't have time to think through some of the changes i knew i was going to have to make. one was i had to measure doorways. i had to make sure carpets-- no loose carpets around-- because with his initial walking, he couldn't pick up his leg well enough so that he would be tripping on carpets and things like that. jim's brother helped build the ramp into the house, and helped take the door jamb out of the way of the bathroom so jim could get the wheelchair into the bathroom so that he could be able to do that himself. recovery, as jim learned, is hard work, and at times, progress seems painfully slow. dr. dobkin: the key to any rehabilitation in patients is to practice and practice those things that you want to do. it's just as if you were going to learn how to hit a tennis ball and play tennis. you've got to practice that swing or you end up
playing like i do, you know, which is terrible. it is hard not to be able to do things for jim-- to watch him stumble through getting his own brace on and doing those tough things for himself when you know that you can do it faster and easier by helping him. i was pretty shocked that stuff could really drain you as much as this stuff does. dr. dobkin: well, the myth is that people only get better for the first three months, or six months, a relatively short time. we can even take a patient who's five or ten years post-stroke, who walks slowly still and give them a little burst of therapy and often improve their walking speed by 30%. you're doing so much better! dr. dobkin: with his kind of stroke,
we tend to see a much slower course of improvement, but people do improve. he has his youth, his athleticism, all going for him-- his motivation, his terrific family. it's likely that, given the progress we've seen just in the past few days, that that will start to spiral and snowball. "... took the subway downtown." it's gotten easier. it's not as difficult as it was before. and, as it gets... every day... goes by, there is less and less pressure on me. i think jim and i both feel that this is a team effort, and he's doing the hardest work, but that i'm another component of that, because i feel that we both need to heal from this. we're both on this adventure that we hadn't planned on.
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