Stroke or seizure? It can be a fine line between the two

'Stroke has a lot of mimics.'

Stroke survivor Mark Lester

It was a Sunday morning when 59-year-old Mark Lester of West Fargo, North Dakota, sat on the edge of his bed and couldn’t get up. His wife Karen asked him repeatedly what was wrong, but he didn’t answer, and she noticed his eyes were rapidly twitching back and forth. Knowing something was very wrong, Karen called 911, and when the fire department and ambulance arrived, they thought he might be having a seizure.

Mark doesn’t remember much about this period of time. He does remember the responders had a stair chair to bring him down from his upstairs bedroom, and this made him anxious as he thought they might damage the walls on the stairway. Although he couldn’t speak, he refused to sit in the chair. So the responders stood on either side of him and walked him down the stairs to the ambulance.

When he arrived at the emergency department at Sanford Medical Center Fargo, endovascular neurosurgeon Gautam Sachdeva, M.D., and the emergency department staff put him through a lot of tests.

“I remember them saying, ‘Grab my finger,’” Mark said. “And every time, I would touch my nose. I thought I was doing OK, but I obviously wasn’t. I couldn’t identify any of the items in the pictures they showed me, and I didn’t recognize my wife or my children.”

Stroke vs. seizure

“When someone is having acute neurological symptoms, including a change in mental status and difficulty with speech, there is a very fine line between a seizure and a stroke,” said Dr. Sachdeva. “Seizure is one of the most common mimics of stroke.

“Based on my medical judgment from what I was seeing with Mark, I called it a stroke and gave him the clot-buster medication TPA, which you need within the first three hours of a stroke to reduce any damage.”

It took a few days for Mark to get his memory back, and when he did, it came back quickly, as did his speech. The next step for Dr. Sachdeva was to determine what caused the stroke so another one could be prevented.

Looking for a cause

“We did a complete workup on Mark. An MRI confirmed he’d had a small stroke, but we were looking for a cause,” said Dr. Sachdeva. “He’s a pretty healthy guy for his age. There was no plaque in his arteries, he wasn’t a smoker, and he didn’t have any poorly controlled risk factors. We did CT scans, echocardiograms, and nothing showed up.”

Dr. Sachdeva went the extra step and did a transesophageal echo, which places a camera inside the throat to take pictures on the top of the heart. It showed Mark had a patent foramen ovale (PFO), a hole in the heart. Everyone has one at birth, and in the first few hours of life, it closes for most people, but it hadn’t for Mark. With a PFO, as blood flows through the heart at great pressure, stressful situations can cause a small clot to form. Blood clots can move to the brain and cause a stroke.

About six weeks after his stroke, Dr. Tom Haldis, interventional cardiologist at Sanford, did a procedure to close the hole in Mark’s heart that had caused his stroke. However, Mark’s body rejected the clip used to close the hole. As a result, he developed atrial fibrillation (AFib), an irregular heartbeat, where the heart flip-flops, skips beats and feels like it’s banging against the chest.

‘Wake-up call’

Mark had a few uncomfortable episodes with his AFib, but he now wears a monitor and takes medication to keep his heart beating regularly.

“Mark is absolutely fine and has no deficits,” said Dr. Sachdeva. “There aren’t any restrictions on his lifestyle, but he needs to take it slow as stroke can cause fatigue.”

Mark was able to ease back into his job as transportation manager at Border States Electric within a few months. He’s also back to working out at Sanford POWER, but not as aggressively as before.

“Having a stroke was a big wake-up call for me,” Mark said. “I had to learn to slow down. I used to be that guy who if he had a project would work until it was done. Now, I stop for some patio time, and I don’t worry that it’s not done.”

Act fast

“Stroke has a lot of mimics,” said Dr. Sachdeva. “Even if there is an ounce of suspicion it could be a stroke, you should act with the acute stroke treatments available. And stopping at a certain amount of workup without finding that cause is not enough. If we had stopped, we wouldn’t have found Mark’s PFO, and he probably would have had another stroke.”

Last summer, emergency department personnel at the Sanford Bemidji Medical Center saw 23 patients who were in the midst of a stroke. Unfortunately, reversing part of the damage caused by the strokes was possible for only three of those patients. Intervention was not an option for the other 20 because they didn’t come to the emergency department in time.

“Our biggest problem in treating stroke victims is that the patients don’t come immediately,” said Shannon Pitt, the stroke coordinator at Sanford Bemidji. “Patients wait, wait and wait some more, and by the time we see them, there often is not much we can do. The damage done each minute someone is having a stroke ages the brain three weeks as a result of the brain cells lost.”

Stroke signs

Health care professionals have a saying about stroke treatment: “Time is brain.”

Sanford Health has the only comprehensive interventional neurology team in the region trained to use devices that enable the retrieval of a stroke blood clot. The specialists making up the team say  a stroke victim starts losing neurons in the brain in as little as five minutes.

These neurons are the building blocks of the brain, continually processing activities from thinking to walking. Once neurons start dying, they continue to die — at a rate of 2 million per minute. Therefore, early detection is key.

That’s why it’s so important to be aware of potential stroke symptoms. Some signs may be subtle. But the acronym FAST can help identify the early stages of a stroke and remind you what to do:

  • F – Facial droop, usually on one side
  • A – Arm drift (one arm hangs or drifts down)
  • S – Slurred speech
  • T – Time to call 911

Stroke types

A stroke takes place when blood flow to the brain is stopped. The brain needs blood flow to receive the constant supply of oxygen and nutrients it needs.

There are two main types of strokes: ischemic and hemorrhagic.

“Between 70 and 80 percent of strokes are ischemic, which is acute loss of blood flow to the brain. Ischemic strokes are generally caused by a blood clot or a chunk of plaque buildup that floats around the body and finds its way to the brain,” Pitt said.

“Hemorrhagic is a bleeding type of stroke where a blood vessel bursts.”

Preventing stroke

A recent JAMA Neurology study showed an increase in strokes among young adults over the past two decades. It also found an increase in stroke risk factors for all adults.

“Everybody, regardless of age, can get a stroke,” Pitt said. “Strokes are more common the older a person is, but we also have had stroke patients in their 30s and 40s. I think the reason we are seeing more stroke patients nowadays is, first, because people are living longer and, secondly, the average life is quite sedentary, which increases obesity, high blood pressure, diabetes, elevated cholesterol, all of which are risk factors for a stroke.”

Maintaining a healthy lifestyle, making the right choices in terms of diet, and exercising regularly will help reduce the chances of experiencing a stroke.

“People should exercise at least 150 minutes each week, and they should think cardiovascular and aerobic,” Pitt said. “A good measurement for an exercise is when you can talk but you can’t sing.”

Eating healthy with a plant-based diet also is very important, Pitt said.

“A plant-based diet doesn’t mean that you can’t eat meat, but it means that a majority of the diet should be fruits, vegetables and whole grains. Meat, especially red meat, increases cholesterol while fruits and vegetables have fiber, which sweeps out the cholesterol.”

Other important tools people can use to reduce the risk of a stroke:

  • Reducing sodium intake
  • Maintaining a normal weight (under a 25 body mass index)
  • Controlling blood sugars to an A1C level under 6.5
  • Quitting smoking
  • Lowering blood pressure

Mark is thankful for his recovery and for the excellent care he received at the Sanford Stroke Center.

“Every day as I’m driving home from work and I see that billboard on I-94 that says, ‘ND’s only advanced comprehensive stroke center,’ I say, yes, yes, that’s true.”

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Posted In Brain & Spine, Health Information, Heart

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