Posts tagged: cerebral vascular accident

A Stroke of Bad Luck

Business Logo for Psychological and Neuropsychological IssuesThe term “stroke” is a fitting name for a sudden unexpected happenstance.  In medicine the term “stroke” applies to the sudden onset of symptoms after circulatory problems arise in the brain.  The movies typically portray the sudden devastation to one’s physical functioning; for example the paralyzed father in “Legends of the Fall.”  The slow insidious onset of symptoms from circulatory problems is neither as dramatic or pictorial as the sudden manifestation, but it may cause as much or more functional impairment.  The sudden classic middle cerebral artery stroke with left or right paralysis may be diagnosed by many non-professionals.  The slow manifestation is often overlooked or misidentified by professionals.

Neuropsychological and medical training instills the belief that the former type of stroke is much more common than the latter; that the sudden “stroke” is much more common than the slowly evolving cerebral damage from altered circulation.   Given the unique and dramatic symptoms of a stroke are much easier to diagnose than the slowly evolving, it is likely that the figures taught to doctors are less than accurate.  Slowly evolving symptoms of stroke are directly related to uncontrolled high blood pressure.  While one would think that a slowly evolving hemorrhagic stroke (leaking blood vessel) would be more common than a blockage, this does not appear to be the case.   Most hemorrhagic strokes are of sudden onset, and are often difficult to differentiate from a blockage in a cerebral artery.

Most slowly evolving events related to blood pressure present with decreased attention, a decreased level of arousal, and an overall slowing of thoughts and actions.  There may be signs often considered focal or localized; for example speech and visual deficits, but this is hardly universal.  Family history often identifies a day or two where the patient had been inattentive or even partially paralyzed, but the symptoms tended to abate.  I recently interviewed a man with many years of uncontrolled high blood pressure.  The man had refused treatment for high blood pressure because he was convinced the issue was touted by physicians to increase their income.  His family noticed a few days of poor attention and impaired speech a year or two back, but his apparent rapid recovery dissuaded them from seeking medical consultation.  The symptoms returned and abated over a course of years, but the overall picture was of functional decline.  Diagnostic imaging of the brain was not remarkable, yet his performance on neuropsychological tests was indicative of one or more strokes.  As is often the case, one of his arms was significantly stronger than the other, but not affected to the point it was noticeable to the patient or his family.  He lost the power to ambulate as both legs became progressively weaker; not just the one side typically associated with a blockage of a cerebral artery.  Notice that not only were both sides effected, but the damage increased over time.  This is at odds with what most people would consider a cerebral vascular accident.

Another difficulty in the diagnosis of slowly evolving strokes is the overlap with other conditions.  The sudden dramatic onset of focal paralysis is not present in any other physical condition known to this clinician.  The clinician must differentiate between a stroke and a psychological conversion reaction producing the symptoms, and the latter is fortunately very rare.  The slow onset of bilateral weakness in the legs, as in my patient above, may be secondary to a host of factors other than brain damage.  The unfortunate person may have generalized weakness due to malnutrition, dehydration, anemia, a systemic infection or metabolic/endocrine disorders.  Bilateral weakness in the legs may be secondary to damage in the spinal column, a muscular dystrophy, arthritis or even an unwillingness to walk.  Regardless of age, failure to bear weight on one’s hips and legs quickly leads to muscular atrophy.  The burden on the physician is much greater when the symptoms are not focal and slowly evolving.  It is no wonder that statistics regarding different kinds of strokes may be unavoidably inaccurate.

Given these hurdles experienced by trained professionals, what is an educated layman to do?  The most practical and effective measure is to watch one’s blood pressure.  Over the course of my training and twenty years of practice, I have observed many medical “facts” and “breakthroughs” fall by the wayside for a lack of evidence and efficacy.  The evidence favoring control of blood pressure and its positive effects on health and overall well-being has only increased over the years.  Regardless of age, if you are a female smoker and use birth control, I suggest close monitoring of your blood pressure.  If you are older than 50, I suggest checking your blood pressure regularly; especially important if one has episodes of feeling dizzy and flush.  Please leave comments regarding this post in the space provided below.

Dementia-Clean or Dirty?

Business Logo for Psychological and Neuropsychological IssuesIs it possible to find someone with a “clean” dementia?  While this sounds like a misnomer, it is intended to describe people who suffer with a specific dementing pathology, and no other complications are known to exist.  It is a form of progressive cognitive deterioration that corresponds perfectly with its diagnostic category.  Only symptoms of this particular dementia are present, uncontaminated by other forms of physical or mental illness.  Hypothetically, such a “clean” dementia should readily conform to existing treatment protocols.  When a patient consults a neuropsychologist, they expect some sort of diagnosis with treatment recommendations, and not “well, it might be this, or it might be that.”  Families often vacillate between different factors to explain the changes in behavior and cognition, such that they expect definitive answers from a professional.  It is not unusual for the patient to become agitated when the doctor invariably, stereotypically, calls for more tests before they can arrive at a definitive diagnosis.  Why can’t we just do our job?

Here is where I frustrate my audience by reporting that diagnoses are rarely simple and clear cut, and that it’s typically a disservice to the patient to arrive at a quick and dirty diagnosis.  For example, a new patient came into the office yesterday with an old severe closed head injury.  This person exhibited classic signs of a severe traumatic brain injury.  Their personality and mental functioning were permanently altered in a way that is very consistent with the pathology of TBI that I was taught in school.  The easiest route is to dazzle the family with my knowledge of traumatic brain injury, make some behavioral and medication recommendations, and then sit back until they return in two weeks.  During the course of the interview with the family and patient, it became apparent that the patient endured a cerebral vascular accident immediately subsequent to the closed head injury.  Unfortunately, this is not an uncommon occurrence after severe closed head injury, though rare in mild to moderate injuries without a period of coma.  There are aspects of the patient’s balance and overall ambulation that would be uncommon in a “clean” closed head injury.  While the patient is walking in a functional manner, they often trip and fall into objects.  Weakness in one of their arms makes it difficult to perform tasks that require two hands.  Functional impairment from the stroke is as or more important than the impairment secondary to the closed head injury.  Formulating recommendations based on one or the other diagnosis would be unsafe and unwise.  Only by thinking in terms of the patient’s holistic or overall functioning would I be able to make their life safer and more stimulating.  Stated another way, diagnoses are typically less important than the obvious difficulties the patient confronts in their environment every day.

How is a physician able to prescribe the correct medication without the correct diagnosis?  Since the Food and Drug Administration does not allow direct comparison between drugs, physicians cannot be confident that they are using the single best medication for a given illness.  While certain medications are believed by professionals to be better for organic conditions than psychiatric conditions, there is only modest support in the research for using one medication over the other.  The best clinicians tend to prescribe by side-effect; that is there are many medications that claim to do the same thing, but the risk of unwanted and possibly deleterious effects of any given medication are uppermost in their mind.  For example, the physician is weighing the benefit of two tranquilizers.  The med they typically prescribe for most neurologically intact patients causes memory and attentional impairments, and the other tranquilizer is known to have few cognitive side-effects, but may cause trouble with ambulation.  Most of us, physician or not, would avoid using the first medication in someone recovering from a closed head injury, and avoid the second for someone recovering from a stroke or movement disorder.  While this appears to make good sense, and even smacks of common sense, one has to keep in mind that common sense is anything but common.

The common sense approach to treatment of damage to the central nervous system is driven by symptoms and their expression in the patient’s unique environment.  A diagnosis helps alleviate the anxiety of family members and the insurance industry, but in isolation, does little to assist the patient.  Medications prescribed for their main effect rather than by their side-effect may help in one area and cause problems in another, rendering little to no net gain for the patient.  Clinicians that need to find neat categories and rapid solutions will please the family shopping for confidence more that the family looking for real gains.  Lastly, even the best of treatment protocols needs adjustment.  People change over time, and the cognitively impaired are no exception.  Any intervention that has positive results for a year or more should be considered a success-even if there is a subsequent decline.  Consider periodic adjustments to behavioral and medication protocols to be necessary and expected.

To answer the initial question, it is rare, indeed, to find a “clean” dementia.  Even if the initial stages of the dementia are uncomplicated and according to protocol, the illness rarely remains so orderly for its entire course.  Patients and family members often gain confidence from hurried and decisive experts; tending to view their curt behavior as a sign of social importance.  A clinician who is unsure and vacillating about treatment options exudes less confidence to others, but may ultimately be the most concerned and helpful.  Please leave comments regarding this article by clicking on “comments” immediately below this post.

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