Strokes and Seizures

Generally, we don’t think much about how our brains work or what they need to function well until they don’t. The human brain is incredibly sophisticated. It has around 100 billion neurons that send nerve impulses around your body at speeds of around 250 mph. Like any other part of the human body, the brain, composed of at 73 percent water and weighing about 3 pounds, needs raw materials to function. The brain is just 2 percent of our body weight, but uses 20 percent of our glucose (or blood sugar) intake.

Your brain’s main source of energy is glucose, a simple sugar found in many foods. Unlike the rest of you body, your brain cannot store energy, so needs a constant and steady supply of glucose. Your brain can get into trouble when your blood sugar drops below 40, but a blood sugar of 20 or less is deadly, particularly if it persists for more than a few minutes. Babies are particularly sensitive to low blood sugar and low blood oxygen for their brains.

Brains also need fatty acids: choline, water soluble “B” vitamins, and vitamin D. So, it’s no surprise that your brain needs an adequate blood supply to deliver nutrients and oxygen. Since your brain is mostly water, it needs water to remain hydrated and it needs sleep for brain repair and consolidation of memories. It needs mental simulation like learning or problem-solving and social interaction to keep active. Chronic stress can impair brain function. It may come as a surprise to you that brains continue to develop and mature well into the mid to late 20s. Your prefrontal cortex (the front part of your brain) is responsible for planning and decision-making. The prefrontal cortex is one of the last areas of the brain to develop fully and one of the last areas to recover from a stroke, as we will see below.

Our brains do not do well without oxygen. Your brain can survive 4 to 6 minutes without oxygen. You can lose consciousness within 15 seconds to 3 minutes of oxygen deprivation. Brain cells begin die within one minute of oxygen deprivation. Permanent brain damage can occur within 4 to 6 minutes of oxygen deprivation. Death can occur within 5 to 10 minutes without oxygen.

People can recover substantial brain function after a stroke if they are treated quickly enough. Rapid reperfusion (return of blood and oxygen supply) is the best way to limit brain cell death. The most important aspect of stroke care management is to get treatment quickly enough and rapidly restore the brain's blood supply. Time is of the essence.

There are two kinds of strokes. The ischemic stroke is the most common (85 precent). The blood supply to a portion of the brain is shut off by a narrowing of a vessel (stenosis). The narrowing can continue until the blood vessel is completely shut off. A blood clot can also shut off a vessel. If either of these strokes are treated quickly with either placement of a stent or an removal of the clot, brain function can be regained quickly.

The second kind of stroke is hemorrhagic, that is the rupture of a blood vessel, which can either be caused by an aneurism you were born splitting open or the rupture of a normal vessel. Abnormal vessel rupture is different from normal vessel rupture caused by the very high blood pressure associated with preeclampsia or eclampsia. Extremely high blood pressure will cause the rupture of a normal artery. This is the most common way for a pregnant young woman to die from preeclampsia or eclampsia. In about 6000 births, none of my patients have died from any cause. Neither have any had eclampsia (preeclampsia plus seizures), but many had preeclampsia. I treated the patients with preeclampsia successfully and none of them died and none of them developed eclampsia (preeclampsia plus seizures).

To say that strokes are life-changing is an understatement. Years ago, Bette Davis appeared on the Johnny Carson show. She had had breast cancer, a fractured hip and a stroke all in one year. Johnny asked her what was the worst. She said, by far and away her stroke was the worst.

Years ago, I had the opportunity to care for a man in his 60s who had had a hemorrhagic stroke. He was slightly uncoordinated, but he could get around without a cane. His problem was that he was very emotional. I can remember the day he came to see me wanting a tranquilizer because he was going to a funeral and wanted to stop crying. And this is one of the issues that many people who have had any kind of brain injury will have. They have heightened emotions and loss of their prefrontal cortex filters.

I have a friend whose father died at the age of 67 from the stroke. My friend had his first stroke at the age of 46. He managed to get around all right. He did not seem to be uncoordinated in any way, but he was highly emotional, afraid of many things, was anxious, and developed quite a temper.

Traumatic brain injury (TBI) presents in a very similar way to strokes. I had a patient years ago who came to my office to see me about a year after he had been involved in a train accident. He had worked for the local railroad company. Naturally, the train company wanted to blame him for the accident so they would not have to pay for his insurance or his recovery in any way. The issue with brain injury of any kind is the damage to the prefrontal cortex. This is the area for judgment, problem-solving, decision making, and filtering socially acceptable behavior.

Needless to say, dealing with North Dakota Worker’s Comp department, his friends from the railroad, and the railroad lawyers was complex and vexing. Worker’s Comp was almost impossible to deal with as were the railroad and the railroad lawyers. In addition, his accident insurance didn’t want to pay for his care either.

For me as a physician, my job was to take care of this man, physically, emotionally, and mentally. The North Dakota state government has a state supported TBI division, but refused to help. Navigating the hostility of the lawyers, the Workers Comp, and the railroad was so complex and so hostile that this brain-injured man could not have managed to get the help he needed from any of these organizations.

It has been said often that you can judge the functioning health of a society by how it takes care of its moms and babies, and we don't do that very well. Our society should be judged on our ability to help the vulnerable, the people who need it, the people who have less than most of us do. Don’t forget. They should not be deprived of needed care by blaming them for their injury. Taking care of TBI patients or stroke patients is difficult for all the wrong reasons.

Years ago, in this same small railroad town, a 40-year-old woman came to see me for seizures. She was not aware of them because they occurred while she was sleeping, but her husband was aware of them. After testing, we determined that what we thought were seizures were actually small strokes occurring many times daily. She had a stenosis of her front anterior cerebral artery. Taking care of this patient was difficult for all the wrong reasons. First of all, she had no insurance because she had been working as a housekeeeper. Secondly, she had North Dakota Medicaid which is always adamant that any care it pays for be done in-state. In this case, there was nobody in North Dakota who could have done this surgery. We now have a patient who is rapidly losing brains cells daily, not to mention the trouble she was having with her activities of daily living. She couldn’t keep working because she couldn’t decide how to vacuum. She lost her ability to drive her car because she saw a dog in the road and didn’t know what to do. She came to my office crying.

I explained the situation to the folks at Mayo several times. Finally, somebody said, “Well, we have charity care.” Great! But this decision had to pass through several layers or approvals and eventually after another six months came the needed "yes" for charity care. Durng all this time my patient continued stroking several times weekly, destroying a few more brains cells with every new stroke.

Eventually the patient made it to Mayo and had her stent placed, but on the way home she had the mother of all seizures and was airlifted back to Mayo where they did another procedure and once again, sent the patient back home. This time she did alright for another three months, only to have this process start all over again. In the meantime, her Mayo doctor who had performed her previous surgeries had relocated Fargo, North Dakota, so she could be scheduled for the needed surgery in North Dakota, to Medicaid's satisfaction. When my patient awakened from this third surgery in Fargo, she knew the procedure had been successful because she could see the ceiling tiles and actually count them.

One of my other patients was a 62-year-old man who has been on many seizure medications for many years and had seen many neurologists and had even made a once-a-year trip to Mayo. On numerous occasions he had come to see me in my office with his symptoms, his diagnosis, and his treatment. He volunteered that the seizure medications didn’t seem to be helping him.

I finally had an opportunity to hospitalize the patient and I put him on continuous heart rate monitoring. The next morning, I was called at home. The nurses said he had had another “seizure”, but it was accompanied by a six second pause in his heart rate. To make a long story short, this man was not having seizures at all, at least not primary seizures. His “seizures” were caused by the prolonged pauses in his heart rate. Once he had his pacemaker placed, he had no more “seizures” and needed no more meds.

My last story is about a North Dakota farm boy. Being one myself, I know we were brought up to not complain even if we were sick or in pain.

So, when this patient came to my office, I listened carefully. He had rolled his four-wheeler while chasing cattle, but he had not gone for medical care at that time. Instead, he drove his semi-truck half-way across the country, unloaded it, and passed out. He was hospitalized and had a head CT which showed nothing. He was released from the hospital and allowed to drive 1000 miles home. A week later he came to see me for follow-up. Another CT was “normal.” A month later he returned for routine follow-up. Another head CT showed a “congenital anomaly” on the right side of his brain.

Two months later he returned with a “bad headache.” Bearing in mind that he had had four “normal” head CTs, I though he should see a neurologist. I sent him off to our next biggest city with two large healthcare systems, where he was seen in the ER. I had called the ER doctor to make sure she understood the situation. From there he was sent home without having a head CT or MRI and told to rest in bed over the weekend. And this is where AI, med school and residency wouldn’t help, but knowing his context did help. I knew he would not complain easily.

He called to tell me he had been sent home to remain in bed over the weekend. I immediately saw him again in the clinic and ordered the fifth and final head CT, well aware of the fact that his insurance company would most likely not pay for the fifth head CT in four months. Sometimes you just need to bite the bullet and do the right thing. I’m glad I did because that CT showed bilateral (both sides) subdural hematomas, one an inch thick and the other an inch 1/2 thick. Thank goodness there was a locums (traveling) neurosurgeon on sight. The surgery lasted 13 hours. My patient would have died at home in bed had he followed the ER doctor's advice. Exactly why the ER doctor did not order a head CT when my patient had been in to see her previously that day, I don’t know. It might have been because of the four previous “normal” head CTs in his recent history.

My patient did alright over the next six weeks, then returned sick. The locums neurosurgeon who had done his surgery originally had moved on so I called Mayo to try to get him an appointment. After four or five hours trying to find someone at Mayo who could make a decision to accept my patient, I gave up. I sent him without talking to the right person and Mayo was furious with me. Incidentally that’s the last patient I referred anyone to Mayo.

Owning the results of your care is something that is often overlooked. AI can’t own care, can’t care, and unfortunately there are many providers who don’t care either. And if you think that AI and mid levels are the answer to your prayers, you are sorely mistaken. Medical care can go wrong with systems errors six ways from Sunday, and every time I gave an order, I had to think of all the ways that order could be messed-up and made ineffective. For example, if I thought my patient had a melanoma, but I didn’t anticipate all the ways an order to refer the patient could have gone wrong, my straightforward order could have be terminally messed up. Had I simply written a “machine order,” the patient would be given an appointment with a dermatologist to be seen in eight or nine months. The melanoma would have had an additional eight or nine months to grow. But because I knew how receptionists, nurses, and dermatologists work, I did the biopsy, got the diagnosis, and referred the patient to the dermatologist for treatment of the melanoma, which could then be made next week.

When I was providing care, I actually cared that my simple, straight-forward order would not be screwed up by layers of faulty systems and people who were “just doing their jobs.”

So, when I had a heart patient, I would spend 45 minutes making sure that I talked to one of the providers (hopefully the one who would see the patient). Of course, during that time, I couldn’t be reimbursed for caring, nor could I recover the time I had to take from other patients, because the time it takes to care is not built into the schedule. Nobody knows except for that doctor and that patient. Try replacing that with AI.

A conscientious provider thinks and cares about all the ways a simple straightforward order can go wrong and often follows-up to make sure the order has been carried out as intended. All of that takes time for which we are neither credited nor paid, but if the straightforward order goes awry in any way, we certainly hear about it.

In summary, a lot of unseen work goes into making an accurate diagnosis and treatment plan, especially with head injuries. We must rely on systems that go wrong in ways that are even hard to imagine, and we must rely on hostile reimbursement and management systems, that are again hostile in ways we can’t even imagine, until we learn the hard way, from experience.

A few days ago, one of my previous patients came by for some free eggs (my chickens are my hobby). He said, “I wish you were back in practice because you cared.” He further said, “We don’t see that anymore.” Today providers are defensive, more than anything else, and unfortunately their defensiveness is probably necessary, a requirement just to stay alive in an increasingly cut-throat business. But I can tell your this, for me, caring has been fun and very rewarding.