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Ariel Sharon and Stroke Treatment

Marc Siegel, MD
Medical Progress Today
January 6, 2006

The fate of nations can swing on the health of its leaders—as the world is learning this week, as Ariel Sharon struggles for survival. In 1919, while campaigning for the U.S. to join the League of Nations, Woodrow Wilson suffered a devastating stroke that left him crippled and basically ended any hopes of the Senate approving the Versailles Treaty. In 1945, FDR suffered from debilitating hypertension, part of a downward health spiral which may have undermined his effectiveness at the Yalta negotiations with Churchill and Stalin. Later, that year, FDR died of a stroke. In 2006, Sharon has been felled as he pushed for radical change in Israeli politics through his new Kadima party.

Stroke (death to a portion of the brain) is the number one cause of disability in the world. According to the American Heart Association, 700,000 Americans will suffer strokes this year—and stroke is the nation’s third leading killer behind cancer and heart disease. At the same time, enormous strides have been made in stroke treatment in recent years that at first seemed likely to help Ariel Sharon.

Just a week ago Sharon was preparing to return to work after a mild stroke—and doctors saw a path for treatment without long lasting effects. Unfortunately, the blood thinners that were used to treat Sharon while a procedure was being planned to close a hole in his heart, appear now to have precipitated a large bleed in Sharon’s brain that has effectively ended his political career and quite probably his life.

Despite this unfortunate result, it is clear that modern medicine has evolved enormously in the treatment of stroke patients, and chances for recovery with minimal disability are better than ever before. Magnetic Resonance Imaging(MRI) and Computed Tomography (CT) scans of the brain can quickly identify the type of stroke and location of blood clots. Clot dissolvers such as Tissue Plasminogen Activator (TPA) have markedly improved the treatment of stroke, if they are administered soon after a stroke is identified right to the affected artery. The invention of better anti-platelet drugs (Plavix) and clearer indications for the use of anti-coagulants such as Coumadin (for heart arrhythmias and blood clots), have dramatically improved the treatment for stroke in the past few years. Routine use of the latest MRI scan and intra-cranial doppler study have pushed the boundaries of stroke diagnostics. Identifying risk factors and predicting and preventing a stroke before it happens are key features of all top level stroke centers.

Strokes range from very mild to life threatening events, and the treatments and speed of recovery also vary significantly depending on the size of the stroke as well as the stroke center where patients are treated.

Unfortunately, Sharon was a prime candidate for a stroke, thanks to years of inactivity, obesity, a poor diet, and extraordinary stress. For all of our modern stroke treatments, no magic wand can protect patients who don’t—or can’t—find the time to take responsibility for their own health.

News reports indicated that Sharon, obese and a heavy meat eater, suffered a brief period of slurred speech and weakness after his initial stroke, but by the time he reached state-of-the-art Hadassah Hospital, he was treated with blood thinners and quickly recovered. In all likelihood, his first symptoms may have been transient, indicative of a so-called Transient Ischemic Attack, where no actual damage or tissue death is sustained. If such is the case, the patient may return to work fairly soon, under strict medical observation, and treatment with blood thinners or aspirin is used to prevent further strokes. President Jacques of France experienced just such an event in September 2005 and returned to work quickly, with no known further events to date. Unfortunately, in Sharon’s case, the potential side effect of a treatment that helps many others appears to have done him in. Most ischemic strokes or near strokes occur because a blood clot either clogs a carotid artery in the neck that supplies the brain, is thrown up to the brain from the heart, or occurs in one of the tiny blood vessels of the brain itself.

Unfortunately, around the world—even in the U.S. and in Israel—there is a great deal of variability in the facilities to treat stroke from one hospital to the next. It will be several years before all hospitals have the latest equipment and can reverse a stroke before the damage is permanent.

In Sharon’s case, symptoms like his were a warning sign that a larger event could be in the offing. Woodrow Wilson, in fact, suffered a series of smaller strokes throughout his life before the most devastating episode in 1919. Patients who are in similar lifestyle categories should take Sharon’s inattention to his health as a grave warning: improvement in diet and exercise can help patients reduce their risk of stroke and cardiovascular disease in general.

Sharon’s doctor identified an additional potential risk factor through an echocardiogram (sound wave test of the heart): a patent foramen ovale (hole in the heart) which has been associated with strokes of unknown cause 40% of the time. Doctors had planned to repair this defect by inserting a catheter into the heart, although it is not as yet known if this treatment is superior to treatment with blood thinners alone. Sharon’s latest attack came just two days before the scheduled PFO surgery.

Of course, no course of treatment is without its own risks. Blood thinners are often used in the situation Sharon was faced with, and hemorrhages are a well a known complication of treatment with these drugs. The length of time Sharon was in surgery (seven hours) indicates that he won’t return to work, and that his overall prognosis is quite grim. As of this writing, his death appears imminent.

Science will continue to evolve new methods to identify the warnings signs of incipient strokes and react rapidly to prevent additional complications. In the interim, the world must grapple with the absence of a great leader at a time when it can ill afford it.

Marc Siegel MD is an internist and associate professor of medicine at the NYU School of Medicine. He is the author of False Alarm and the upcoming Bird Flu.

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