Sometimes, the symptoms start subtly.
Unlike the crushing pain of a heart attack, the assault begins as mere numbness. Faced with weakness on one side of the body, the temptation often is to turn over, go back to sleep and hope things will be better in the morning. Doctors say that is the worst thing to do. To ignore symptoms of a stroke is to disregard peril. Every year, 500,000 Americans suffer strokes and 150,000 die.
Strokes are the nation's third leading cause of death, behind only heart disease and cancer. For some survivors, the consequences can be devastating: disability, lost productivity and high medical costs. Many people view strokes as an inevitable consequence of aging, carrying the grim prognosis that little can be done. Doctors say that is starting to change.
Neurology still has its limits, but more and more the specialty is shifting from an almost exclusive focus on diagnosis to embrace new treatments -- especially if action is taken early.
For strokes -- and a range of other neurological illnesses -- doctors are experimenting with promising drugs and treatment techniques. Advances in imaging routinely provide remarkable pictures of the brain, allowing physicians to quickly pinpoint problems -- and begin the search for solutions. In neurology wards, triumphs are occurring in cases where once only tragedy reigned.
Caring for the brain under siege is a difficult task. Physicians often walk a tightrope between success and failure.
Nowhere is that more evident than on Payson Six, the neurology floor of the New York Hospital-Cornell Medical Center, which has evolved into one of the nation's leading treatment, teaching and research centers in large measure because of Fred Plum, M.D., the 70-year-old neurologist-in-chief.
The public caught glimpses of the gray-haired physician last spring, when he served as Richard Nixon's neurologist after the stroke that led to the former president's death.
Over more than four decades, Dr. Plum has seen perhaps 60,000 cases. If anything, the exposure to so many people only has increased his awe of the brain.
L "We are our minds," he says simply. "The brain is the self."
Twice a week, Dr. Plum holds teaching rounds on Payson Six.
One day, followed by young physicians and medical students, Dr. Plum strode to the bedside of a man in his 20s who lay unconscious. He had been that way for a month after falling 20 feet off an escalator. Dr. Plum focused the bright beam of his penlight into the patient's right eye. His pupil barely reacted. Above the bed, the green spikes of a cardiac monitor showed his heartbeat.
The man's right hand made small, scratching movements -- spasms that Dr. Plum explained were typical of overwhelmingly severe brain injuries.
"George, Henry, Mike," he said in a loud voice. There was no response. He moved the man's hand.
"The family has to be told we have no evidence he understands language or has sustained attention," Dr. Plum said. "We are very concerned about his outcome. In all likelihood, their son will never recover the thing that drives us, the business of enthusiasm and taking rewards from what the day brings."
Not all strokes are alike
Most strokes occur as a complication of illnesses such as heart disease, high blood pressure and hardening of the arteries. Patients may suddenly be unable to speak or move an arm or leg, to see or feel. Damage can be transient or permanent.
Not all strokes are alike. One kind takes place when a vessel inside the brain ruptures, flooding tissues with blood. About 80 percent occur when a blood clot formed elsewhere in the body blocks a brain artery. Brain cells deprived of oxygen can quickly die. Further injury from a cascade of biological reactions lasting for hours, even days, can spread the damage.
Once a stroke occurs, doctors now know, time becomes the enemy. They must be alert to a wide range of problems: potential threats to the lungs, the immune system, the joints. Stroke patients are prone to brain swelling but, encased in the skull, tissues have no room to expand. Without medical action, death can result.
Nurses in Payson Six's four-bed intensive-care unit constantly search for signs that swelling has begun. An early clue: Patients may suddenly become fidgety and fussy.
About 20 years ago, the Veterans Administration conducted a landmark trial examining the effects of hypertension on heart disease. It yielded an unexpected but important finding. When high blood pressure was reduced, deaths from strokes dropped dramatically. High blood pressure contributes significantly to 90 percent of strokes.
Other studies have shown that by giving anti-coagulants to patients with irregular heartbeats, the risk of stroke decreases by lessening the chance that blood clots, which can travel to the brain, will be formed in the heart.
Recent advances in cardiac imaging have refined clotting typography. Researchers have discovered that many clots thought to travel to the brain from the heart actually come from the aorta, the main artery that carries blood from the left ventricle of the heart.
With that knowledge, a few surgeons around the country are cleaning out patients' aortas, much in the way that partially blocked carotid arteries are cleared of fatty deposits.
Damage control
Researchers also are studying a variety of drugs designed to reducethe damage once a stroke occurs.
In a stricken patient's brain, an excess amount of glutamate, an amino acid, is excreted. This excess flow can kill healthy cells around the original site of the stroke. One drug being tested at New York Hospital and other institutions is designed to block the flow of glutamate.
On Payson Six, doctors Steven A. Goldman and Denise Barbut treated a man in his 60s who suffered a serious stroke while undergoing cardiac catheterization.
The patient, partially blind and paralyzed on the left side, was rushed to the neurology floor, and within an hour took part in the clinical trial of a new medication that blocks the glutamate flow.
After three days of medication, the patient was cured.
"We have had three or four enormous surprises," Dr. Barbut says, couching her excitement in the careful language of science. "I don't know to this day how many of those (in our study) actually had the drug and how many received a placebo. But we have never had the surprise without the drug, put it that way."
One of the first lessons physicians and nurses quickly learn on Payson Six is to appreciate their own mortality.
"When you close your eyes, it could be you," says Rita Kraut, head nurse on the floor. "It makes you realize there is nothing insignificant in this world. Everything is important. We have a tendency to put things off and do it tomorrow.
"But you see a lot of times there is no tomorrow."