Ignorance of Stroke s Warning Signs a Barrier to Treatment; More Education Needed, UC Researchers Report in JAMA

Demographic groups facing the greatest risk of death and disability from stroke are the least likely to recognize stroke’s warning signs and risk factors, according to a study by UC researchers published in the January 15 issue of the Journal of the American Medical Association (JAMA). The study found that while overall knowledge of stroke warning signs among residents of Greater Cincinnati improved significantly between 1995 and 2000, knowledge of stroke risk factors did not improve significantly during the same period. More alarmingly, groups with the highest risk and incidence of stroke – the elderly, African-Americans and men – were the least likely to be able to name a stroke warning sign or risk factor.

“This is important because one of the largest barriers to effective acute stroke treatment is knowledge that a stroke is occurring or has occurred,” said Alexander Schneider, MD, assistant professor of neurology at the UC College of Medicine and the study’s lead author. “We have to administer the medication TPA for acute stroke treatment in less than three hours after the onset of stroke. If patients don’t get to the hospital quickly enough, we’re not able to give that therapy.”

Patients suffering ischemic stroke who receive TPA in a timely manner are more likely to avoid disastrous consequences of stroke, which is the third leading cause of death and the leading cause of adult disability in the United States. Each year an estimated 700,000 Americans suffer a stroke. About 170,000 of them die, and thousands more suffer permanent disability.

“Unfortunately, stroke victims may not be able to speak and call 911,” said Joseph Broderick, MD, chair of the UC Department of Neurology and director of the Greater Cincinnati/Northern Kentucky Stroke Team. “Even worse, they may be unaware that they are paralyzed on one side of the body or are having a stroke. Therefore, everyone needs to know the signs of a stroke and to know the importance of calling 911 immediately if they recognize that they, or someone with them, is having a stroke.”

Doctors note that TPA can be used to treat only ischemic strokes, which account for 85 percent of all strokes and which occur when a clot interrupts blood flow to the brain. TPA cannot be used to treat hemorrhagic strokes, which involve bleeding into the brain. “If a CT scan determines there is no bleeding into the brain, TPA can be given to try to break up that blood clot,” Dr. Schneider said. “The sooner it's given, the better its chances of working.”

William J. Martin II, MD, dean of the UC College of Medicine, said public education efforts must continue, particularly with those groups most at risk of stroke. “The work by the UC College of Medicine faculty underscores why effective public health education is so critical to improving the care and the quality of life of patients with stroke,” Dean Martin said. “We now have the best tools with which to diagnose and treat strokes; and yet these new tools are of little help without a proper awareness by the public of the early warning signs and symptoms of stroke. Stroke experts in Cincinnati have helped the public become better informed, but we have much more work to do, especially in those populations at greatest risk for stroke.”

The JAMA article reflects the latest in a growing body of stroke research produced at UC. Researchers associated with the Greater Cincinnati/Northern Kentucky Stroke Team, which is based at UC, secured more than $30 million in federal research dollars in 2002. The JAMA study cited eight other UC researchers:  Dr. Broderick, Arthur Pancioli, MD, Jane Khoury, MS, Eric Rademacher, PhD, Alfred Tuchfarber, PhD, Rosemary Miller, RN, Daniel Woo, MD, and Brett Kissela, MD.

UC researchers surveyed 2,173 randomly selected individuals in a five-county area of Greater Cincinnati and Northern Kentucky in the year 2000. The survey mirrored a UC survey conducted in 1995 by the same group, enabling researchers to evaluate changes in public knowledge over a five-year period.

Overall, 70 percent of respondents could name at least one stroke warning sign in 2000, compared to 57 percent in 1995. The major warning signs of stroke are weakness, numbness or paralysis, especially on one side; decreased vision or double vision; dizziness; slurred speech or difficulty understanding; and severe, sudden headache.

Respondents’ ability to name at least one risk factor for stroke improved slightly, from 68 percent in 1995 to 72 percent in 2000. Risk factors include hypertension, smoking, diabetes, heart disease, prior stroke and high cholesterol. Respondents gained their information about stroke most frequently from the following sources: television (32 percent), magazines (24 percent), newspapers (22 percent), physicians (20 percent) and family members (19 percent).

The study also revealed that the presence of two key risk factors – high cholesterol and diabetes -- rose from 1995 to 2000. The prevalence of diabetes rose in respondents from 14 percent to 16 percent, and the prevalence of high cholesterol rose from 32 percent to 38 percent.

Whether the improvement in stroke knowledge in Cincinnati reflects that of the nation at large is not certain. The subject of stroke has gained significant media attention nationally since 1996, when the Food and Drug Administration approved TPA for treatment of acute ischemic stroke. In the JAMA article, the authors conclude that “continued and intensified educational efforts to promote knowledge of stroke, particularly among high-risk groups,” must be made by policy makers and by local and national organizations.