Editor's note: Beginning with this column by Dr. Nicholas Browning, a Hospitalist with Sierra Nevada Memorial Hospital, The Union will run a series of columns by area doctors on a variety of topics. Dr. Browning welcomes questions to answer in future columns. His e-mail address is at the end of the column.



As a Hospitalist, I treat patients with strokes on a daily basis.

Stroke, or cerebrovascular accident, results from the loss of blood flow to a part of the brain. The most common form results from a clot closing off a blood vessel, called ischemic stroke.

Hemorrhagic stroke generally results from the bursting of a blood vessel in the brain.

Stroke is the third leading cause of death and a large cause of long-term disability in America. Stroke can result in loss of function, loss of independence, depression and is a leading cause of nursing home placement.

They are not always dramatic, and not everyone has symptoms. Many patients are surprised to hear that old strokes are present on brain scans. While asymptomatic, over time, multiple small strokes can cause dementia.

Medical treatment for stroke is unfortunately limited, as the brain does not tolerate loss of blood supply for long. Since each part of your brain plays a crucial role in how you live your life, even small strokes can have big consequences. Given all that, prevention is the best medicine. I'll discuss the treatment, and then the prevention of stroke.

Treatment of a stroke

Immediate treatment of stroke can include the use of a clot-busting drug called tPA, but there are several things that limit the drug's usefulness and safety. The most difficult problem with tPA is time - tPA must be given within 180 minutes of symptom onset, and ideally it is given in less than 90 minutes.

That means that you must immediately recognize the symptoms, call 911, be transported to the ER, be examined and verified as a candidate for treatment, get a CT scan, have it read, consent to treatment, and have the drug administered, all within 180 minutes. From a physician's perspective, it is very difficult to do all of the above so quickly.

Typically someone has already lost 10-20 minutes just from the ambulance ride alone, and that is if they called 911 immediately. This time factor means that less than 10 percent of patients with stroke are eligible for treatment. The benefits of the drug are also limited - about one out of three people will be helped. About one out of 15 will suffer bleeding in the brain from the drug, and half of those that bleed die from it.

On balance, the drug may help more people than it hurts (when patients are selected very carefully), but it is not a panacea. With such serious side effects, the decision is difficult to make given the time constraints. I suggest researching the drug on your own, and making a decision as to whether or not you would want it. Communicate your decision to your family as they may be called upon to make the decision if you cannot. If you decide in favor of the drug, remember that every minute counts.

Stroke treatment when tPA is not used focuses on preventing a second stroke. Since the biggest risk factor for stroke is high blood pressure, lifestyle changes to lower blood pressure are the pillar of therapy.

Unhealthy behaviors limit the usefulness of medications. Quitting smoking, limiting alcohol intake, exercising daily, and maintaining a healthy body weight are all very important.

Medical therapy starts with an antiplatelet drug such as aspirin, Plavix, or Aggrenox. These drugs prevent the platelets from sticking together and forming another clot. If you have a heart rhythm called atrial fibrillation, the usual drug is Coumadin (warfarin). Statin drugs, such as Lipitor, and Zocor, have also been shown to decrease the risk of further strokes.

Preventing a stroke

Prevention is definitely the best treatment for stroke and starts with the lifestyle changes mentioned above, regardless of whether or not you have had a stroke.

The biggest risk factor for stroke is high blood pressure. What is normal blood pressure? A systolic (top number) of less than 120, AND a diastolic of less than 80 is normal. Anything higher is considered abnormally high. This is a change from the old numbers of 140 over 90. Going from a blood pressure of 120/80 to 140/90 roughly doubles your overall risk of stroke and heart attack.

Lifestyle changes can result in a significant reduction in blood pressure, but often medication will be necessary, and usually two drugs at a minimum are needed. You can find more information at http://www.cdc.gov under the topic of stroke.

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To contact Dr. Nicholas Browning, e-mail Nicholas.BrowningMD@gmail.com



About Dr. Nicholas Browning:

"My name is Nicholas Browning, and I am a Hospitalist who works at Sierra Nevada Memorial Hospital. I graduated from UC Davis in 1994 with a B.S. in Biochemistry and a minor in Nutrition. I went on to graduate from UC Davis Medical School in 2000, and did two years of residency at University of North Carolina Chapel Hill in Internal Medicine/Pediatrics. I decided to focus solely on Internal Medicine and returned to UC Davis to finish my residency in December 2003. My wife Wendy and I moved to Rough and Ready to be closer to family and I have been practicing at Sierra Nevada Memorial Hospital since graduation. We have two wonderful children, Aiden and Ashlynne.

"My approach to medicine is strongly evidence-based, in that I look for treatments that have plenty of high-quality data to recommend them. I also do my best to look at therapeutics in the context of the patient's overall health state, limiting invasive and uncomfortable testing when it will not benefit them. I believe that comfort is a priority and relief of suffering is my duty. I feel that patient education and involvement in their healthcare choices result in the best outcomes.

"I have chosen to work solely in the hospital because my training was strongly weighted toward hospital work and I find myself most comfortable there. I find Sierra Nevada Memorial Hospital an excellent hospital to work in and I am privileged to work with all the staff there, especially the nurses."



About Dr. Nicholas Browning

"My name is Nicholas Browning, and I am a Hospitalist who works at Sierra Nevada Memorial Hospital. I graduated from UC Davis in 1994 with a B.S. in Biochemistry and a minor in Nutrition. I went on to graduate from UC Davis Medical School in 2000, and did two years of residency at University of North Carolina Chapel Hill in Internal Medicine/Pediatrics. I decided to focus solely on Internal Medicine and returned to UC Davis to finish my residency in December 2003. My wife Wendy and I moved to Rough and Ready to be closer to family, and I have been practicing at Sierra Nevada Memorial Hospital since graduation. We have two wonderful children, Aiden and Ashlynne.

"My approach to medicine is strongly evidence-based, in that I look for treatments that have plenty of high-quality data to recommend them. I also do my best to look at therapeutics in the context of the patient's overall health state, limiting invasive and uncomfortable testing when it will not benefit them. I believe that comfort is a priority and relief of suffering is my duty. I feel that patient education and involvement in their healthcare choices result in the best outcomes.

"I have chosen to work solely in the hospital because my training was strongly weighted toward hospital work and I find myself most comfortable there. I find Sierra Nevada Memorial Hospital an excellent hospital to work in and I am privileged to work with all the staff there, especially the nurses."

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To contact Dr. Nicholas Browning, e-mail Nicholas.BrowningMD@ gmail.com