Sickle-cell disease

Infectious arteritis (caused by bacterial, fungal, tuberculous meningitides or diseases such as tertiary syphilis, malaria, Lyme disease, rickettsial diseases, mucormycosis, aspergillosis, trichinosis, schistosomiasis, herpes zoster, basal meningitis)

Noninfectious arteritis (caused by systemic lupus erythernatosus, polyarteritis nodosa, granulomatous angiitis, temporal arteritis, Takayasu's arteritis, Behcet's disease, Wegener's granulomatosis, Sjbgren's syndrome, sarcoidosis, irradiation arteritis, drug use and abuse including cocaine, heroin, amphetamine, phencyclidine, and LSD)

Polycythemia

Thrombocythemia

Thrombocytopenic purpura

Dysproteinemia

Antiphospholipid antibody syndromes

Leukemia

Disseminated intravascular coagulation

Sneddon's syndrome

Protein C and protein S deficiency

Antithrombin III deficiency

Resistance to activated protein C

Vasospasm (migraine)

fibromuscular dysplasia

Carotid artery dissection

Brain or neck radiation

Homocystinuria

Moyamoya disease

Fabry's disease

Pseudoxanthoma elasticum

Intracranial aneurysm Arteriovenous malformation

Anticoagulant therapy/Thrombolytic therapy

Disseminated intravascular coagulation (often associated with leukemia or thrombocytopenia) Head trauma

Cortical vein and dural sinus thrombosis Bleeding disorders (for example, hemophilia) Arterial dissection Brain tumor Cerebral vasculitis Spinal lesions Drugs, including alcohol abuse and cocaine abuse

Hypertension

Arteriovenous malformation

Intracranial aneurysm

Anticoagulant therapy/Thrombolytic therapy

Antiplatelet agents

Bleeding disorders (for example, hemophilia)

Cerebral arteritis

Thrombocytopenia

Cerebral amyloid angiopathy

Head trauma

Brain tumors

Arterial dissection

Moyamoya disease

Venous thrombosis

Infection

Abscess

Drugs, including cocaine, phenylpropanolamine, alcohol, and heroin

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If tPA is administered according to guidelines, the results are much more favorable. Four major studies have found that between 31 and 50 percent or patients given the treatment within three hours of the onset of ischemic stroke symptoms had a complete or near-complete recovery, compared with 20 to 38 percent of patients given a placebo, or inactive, treatment. Brain hemorrhage occurred in between 6.4 and 8 percent of treated patients, as opposed to 0.6 to 2.4 percent of those given a placebo.

These studies underscore just how important it is to choose a hospital with experienced and well-trained stroke emergency staff. It doesn't matter how good the technology may be at any given hospital if the medical personnel don't understand how and when to administer thrombolytic therapy.

As I mention in chapter 6, not all hospitals arc equipped to diagnose and treat acute stroke. Although most hospitals have computed tomography (CT) or magnetic resonance imaging (MRI) scanners, not all have the equipment available twenty-four hours a day on an emergency basis. Not all have a radiologist on call to interpret the results of these scans. Not all have a neurologist or other doctor familiar with stroke treatment on call twenty-four hours a day. Even if a hospital has the ability to determine quickly that a person is suffering an ischemic stroke, it may not be able to offer state-or-the-art treatment. Only a small percentage of the nation's hospitals are currently equipped to deliver thrombolytic therapy. To benefit from the advances we have achieved in stroke treatment, it's not only crucial to recognize the signs and symptoms of stroke and to get help immediately, but also to get that help from the right hospital—a hospital that is equipped to diagnose stroke and handle emergency stroke treatment.

I recommend that you evaluate the hospitals in your area before stroke strikes so that you will know which is best equipped in the event of an emergency. This information is particularly pertinent if you or a member of your family is at high risk for stroke, but it's information from which virtually anyone can benefit.

Take some time to find out the answers to the following questions about the hospitals in your area, either from your doctor or a hospital administrator. The answers will tell you a lot about whether the hospitals in your area are prepared to treat acute stroke.

1. Do YOU HAVE AN ACUTE STROKE TEAM OR AN EXPERIENCED NEUROLOGIST, NEUROSURGEON, OR OTHER DOCTOR EXPERIENCED IN STROKE MANAGEMENT AVAILABLE AROUND THE CLOCK TO DIAGNOSE AND TREAT ACUTE STROKE?
Not all doctors are equipped to diagnose and treat acute stroke. In tact, even some neurologists and neurosurgeons lack experience in treating stroke. Both fields have become more and more specialized over the years. The best care, in general, comes from experts who are experienced in treating a particular condition—in this case, cerebrovascular disease. The need for experienced treatment is so important that the Brain Attack Coalition, a group of professional, volunteer, and government organizations dedicated to improving stroke treatment and prevention, recently put having an acute stroke team available around the clock at the top of its recommendations for the establishment of stroke centers in hospitals. The group defines an acute stroke team as a doctor with experience in diagnosing and treating cere-brovascular disease and at least one other health care provider who can evaluate any patient who may have suffered a stroke within fifteen minutes. The importance of time cannot be understated. Recent research indicates that even within the three-hour window, the earlier a patient receives treatment, the better his or her outcome.

2. ARE EMERGENCY ROOM PHYSICIANS TRAINED TO RAPIDLY DIAGNOSE AND TREAT ACUTE STROKE?
Because most people with acute stroke are taken directly to the emergency room, staff in that area need to be familiar with the diagnosis and treatment of stroke, to notify the acute stroke team, assist, or in cases when an acute stroke team is not available, to diagnose and treat stroke.

3. Do YOU HAVE A CT OR MR SCANNER AVAILABLE AROUND THE CLOCK FOR EMERGENCY USE?
Having imaging equipment and a qualified image interpreter available around the clock is crucial for rapid, accurate diagnosis of stroke.

4. Do YOU HAVE A NEURORADIOLOGIST OR RADIOLOGIST OR, ALTERNATIVELY, A NEUROLOGIST OR NFUROSURGEON AVAILABLE AROUND THE CLOCK TO INTERPRET BRAIN IMAGING SCANS?
Of the four professionals listed in the question, the neuroradiologist is the most qualified to interpret brain imaging scans.

5. IS YOUR LABORATORY OPEN AROUND THE CLOCK?
Rapid blood, X-ray, ECG, and echocardiography results help ensure prompt, accurate diagnosis. If the lab isn't open when you show up a* the emergency room at three A.M., you're at the wrong hospital.

6. Do YOU OFFER THROMBOLYTIC THERAPY? Is YOUR STAFF EXPERIENCED AT ADMINISTERING THROMBOLYTIC THERAPY?
As I've said, not all hospitals offer this new therapy, which for some people means the difference between a life of disability and a life of ability. It's not enough* to simply find a hospital that offers thrombolytic therapy; you should also seek a hospital that is experienced in delivering it. Recent darn indicate that some of the hospitals that do offer the therapy aren't giving it to many of the patients who are eligible or are giving it after the three-hour window has passed. You need to find a hospital that will administer the drug to those who can benefit from it within a timely fashion. Thrombolytic therapy can worsen a stroke by causing hemorrhage or other complications and is more likely to do so if it is given at the wrong time or to the wrong person. Those most likely to know when and how to administer the drug are those who are experienced with its use.

7. do you provide coordinated care for stroke beyond the acute phase? do you have a "stroke team"?

As I explain in chapter 7, stroke treatment does not end with the acute phase. Continuing care includes treatment to prevent complications, treatment to address the underlying condition that caused the stroke, and rehabilitation. Generally, continuing stroke treatment involves an entire team of professionals, from the neurologist and primary care doctor to nurses and various therapists. It makes sense to seek a hospital that can handle both the emergency and continuing aspects of stroke treatment.

Yes. Location is also important. Once you have determined which hospital in your area is best equipped to treat acute stroke, find out how long it takes to get there. Find out if the ambulance service or services in your area serve that hospital and will take you to the hospital of your choice. You want to make sure you get to that hospital as soon as possible to ensure rapid treatment.

If you or your loved one has had a stroke, you are probably dealing more closely with doctors, hospitals, your insurance company, and other members of the health care community than you have in the past. You may need services or face problems you've never needed before. Some advice may help.

Although stroke can change many aspects of the lives of stroke patients, numerous services are available to help them recover and cope with any remaining deficits. The most obvious of these services is rehabilitation. As I explain in chapter 7, rehabilitation is designed to help a person regain as much of his or her previous abilities as possible and to learn to adapt to any remaining deficits. It can include physical therapy, occupational therapy, speech therapy, and counseling. These services generally begin in the hospital, then continue at a rehabilitation center and/or in the patient's home.

Home health agencies can provide many of the various therapies as well as medical and nursing care right in the patient's home. They can also link you up with home health aides and personal care aides, who can help with some activities of daily living and light housekeeping. In addition, you may be able to find housekeeping services, meal services, and adult day care services in your area. For family members and caregivers, respite care (temporary care for the stroke survivor to give the caregiver a break) may be available.

Home health agencies are a primary source of home medical and nursing care and often a source of home rehabilitation therapy. These agencies can be privately owned, based in a hospital, or, like the Visiting Nurse Associations of America, nonprofit. Your doctor or other members of your rehabilitation team may be able to recommend a good home health agency in your area. In addition, these agencies are generally listed in the yellow pages of the phone book.

In addition to the services provided by home health agencies, you may be able to find housekeeping services, adult day care, or respite care services from nonprofit agencies and volunteer programs sponsored by churches and other charitable organizations, like Meals on Wheels, or you can hire a housekeeping service. Members of your rehabilitation team may be familiar with the services in your area. You can also check the blue pages of your phone book, or, if the stroke survivor is a senior citizen, contact your local area agency on aging.