Running head: A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES 1

A Look at the Past, Present, and Future of Strokes

Michael W. Walker

University of San Diego

A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES

Abstract

Chronic diseases are the leading cause of death and disability in the United States and are

hampering our healthcare system with enormous costs in the billions. The number of people

with at least one chronic disease will reach crisis level unless we learn to manage it better. One

of these chronic diseases that our healthcare system is focusing on is stroke. It’s a disease that’s

been around for centuries and has had a tremendous impact on individuals and their families.

Researchers are working to determine why strokes are more prevalent in some ethnicities and

areas of the United States. Additionally, they are working on new technologies to be more

proactive in prevention and treatment of the disease. While this disease is currently having a

devastating effect on our healthcare system, the long-term outlook on managing the disease is

trending upward.
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Diseases make up the majority of the leading causes of death in the United States. Most

of these diseases are chronic and cannot be cured by medicine or prevented by vaccines.

Approximately 92% of older adults have at least one chronic disease and 77% have at least two

(National Council on Aging, n.d.). Chronic diseases also account for 75% of the money our

nation spends on health care, yet only 1% of health dollars are spent on public efforts to improve

overall health (National Council on Aging, n.d.).

One of these chronic diseases is a stroke, which is also one of the leading causes of death

in the United States, attributing to about 5.1% of all deaths. Every year, more than 795,000

people in the United States have a stroke, and it kills more than 130,000 Americans each year

(Centers for Disease Control and Prevention, n.d.). Strokes are also one of the leading causes of

long-term disability, resulting in paralysis, difficulties speaking or understanding language,

problems with thinking and memory, emotional disturbances, and sensory disturbances including

pain (Mayo Clinic Staff, 2017).

The social and economic implications of this disease are great. The costs to treat strokes

are projected to more than double and the number of people having strokes may increase 20

percent by 2030, according to the American Heart Association/American Stroke Association.

Costs to treat stroke could increase from $71.55 billion in 2010 to $183.13 billion in 2030, and

loss of productivity costs could rise from $33.65 billion to $56.54 billion (Hughes, 2013). Many

stroke victims can no longer hold a job, and victims with paralysis may be unable to continue

enjoying activities and sports like they did prior to having a stroke. Strokes also have

implications on family and caregivers. It’s noted that caregivers of stroke survivors tend to have
A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES

elevated levels of depression and stress during both acute and chronic phases of care. The

demand in caring for the physical care needs, communication, and coordinating services is

immense (Family Caregiver Alliance, 2010).

It’s also interesting to note that strokes are more prevalent in certain ethnicities, and the

reasons are treatable with the right corrective actions. In addition, age plays a factor in the

frequency and mortality rate of stroke victims, as does gender. It’s also found that strokes are

more common in certain parts of the United States than others and the reasons may surprise you.

Luckily, some of our countries best and brightest researchers are working on new

solutions and technologies that will help the healthcare industry with early detection, prevention,

and treatment of this terrible disease. These solutions will benefit everyone and help reduce the

frequency of strokes and mortality rate. They will especially help ethnicities that are more

susceptible to strokes as prevention measures and early detection will be easier to obtain and

administer. At the forefront of these new solutions will be Machine Learning.

Stroke has been a devastating disease that has affected us for centuries. Advances in

treatments and preventive measures have us trending in the right direction, and federal and state

programs providing financial assistance to victims and their families have increased.

Background

Hippocrates, the “father of medicine,” first recognized stroke more than 2,400 years ago.

He called the condition apoplexy, which is a Greek term that stands for “struck down by

violence.” In the 16th century a doctor named Jacob Wepfer discovered that something disrupted

the blood supply in the brains of people who died from apoplexy. In some of these cases, there

was massive bleeding into the brain. In others, the arteries were blocked. Medical science
A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES

continued to make advances in the causes, symptoms, and treatments of the disease. A result of

this advancement was dividing the apoplexy into categories based on the cause. From this, the

term stroke was born (Nall, 2016).

Today the medical community recognizes two types of strokes, ischemic and

hemorrhagic strokes. Ischemic strokes occur about 85% of the time and are caused when the

arteries to the brain become blocked or narrowed, which results in severely reduced blood flow.

Hemorrhagic strokes occur when a blood vessel in the brain leaks or ruptures. These usually

result from conditions that affect blood vessels, like high blood pressure or aneurysms. It’s also

important to note transient ischemic attacks, or TIA. These are caused by the temporary

disruption of blood flow to the brain and the symptoms usually don’t last long (Family Caregiver

Alliance, 2010).

Symptoms of strokes include numbness or weakness mainly on one side of the body,

confusion, trouble seeing or walking, and severe headaches with no known reason. Risk factors

for strokes include high blood pressure, smoking, and high cholesterol and excess weight

(Family Caregiver Alliance, 2010).

It’s very important with strokes to get treatment as quickly as possible. The sooner blood

flow to the brain can be restored increases the likelihood of a more favorable outcome. The

length of time with reduced blood flow, the degree of the reduced blood flow, and the

vulnerability of affected cells to ischemia all play a factor in the degree of permanent

neurological disability. Many current treatments can be ineffective if introduced after the initial

3 hours of a stroke (Galindez, Sanabria, & Borroto, 2014).

A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES

The importance of early detection and treatment of symptoms cannot be overstated.

Patients who arrive at the emergency room within 3 hours of their first symptoms often have less

disability 3 months after a stroke than those who received delayed care. In one survey, 93% of

respondents recognize sudden numbness on one side as a symptom of a stroke. However, only

38% were aware of all major symptoms and knew to call 911 when someone was having a stroke

(Centers for Disease Control and Prevention, 2016).

The first known treatment of strokes was in the 1800s when surgeons performed surgery

on the carotid arteries, which supply much of the blood flow to the brain. Clots in these arteries

are often responsible for causing strokes. The first documented surgery of this type was in the

United States in 1807 when Dr. Amos Twitchell performed the surgery, which is designed to

reduce cholesterol buildup and remove blockages that could lead to a stroke. This procedure

today is known as a carotid endarterectomy (Nall, 2016).

It wasn’t until 1996 that a more effective treatment was introduced. The FDA approved

the usage of tissue plasminogen activator (TPA), which is a medication that breaks up blood

clots that could cause ischemic strokes. While this treatment is effective, it must be administered

within 4.5 hours of the onset of stroke symptoms to be effective. Again, this highlights the

importance of early detection and action on symptoms (Nall, 2016).

While TPA is still the preferred treatment for ischemic strokes, there’s a new treatment

first used in 2001 called the MERCI retriever. This device can physically remove blood clots in

someone having an ischemic stroke. However, this device has yet to become a preferred

treatment due to the cost of the device for hospitals and the lack of trained surgeons who can

perform the surgery (Nall, 2016).

A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES

Treatment for hemorrhagic strokes varies depending on the severity of the symptoms.

Like ischemic strokes, it’s important to get care as soon as possible. Controlling bleeding, blood

pressure, and intracranial pressure are vital. Medication used in treatment could include

anticonvulsants to prevent seizures, antihypertensive agents to reduce blood pressure, and

osmotic diuretics to reduce intracranial pressure. Unfortunately, no targeted therapy for

hemorrhagic strokes exists, although some promising early-stage treatments are in the pipeline

(Liebeskind & O'Connor, 2017).

Social and Economic Impact

The economic impact of strokes is devastating, both to the victim and the economy.

Approximately one-third of survivors aged 25 to 59 report they’ve had to “cut back” on food

because of the economic impact, and 65% report a serious decline in household income (Colella,

2013). Each year, stroke care costs add up to $43 billion nationwide with another $6 billion

spent on informal care given at home (Vann, 2009). As of 1990, the average lifetime cost of

caring for one stroke patient was estimated at $103,576, including care costs for all phases (acute

treatment, rehabilitation, ambulatory, and nursing home) (Feng & Belagaje, 2013).

Socially the impact of strokes is especially felt in minorities. African-Americans are

twice as likely to die from stroke as Caucasians and their rate of first strokes is almost double

that of Caucasians (National Stroke Association, 2016). The excess burden of disease and

mortality from stroke for blacks is accurately described as one of the major public health

problems in the United States. (Stansbury, Jia, Williams, Vogel, & Duncan, 2005). Some

reasons for this increased likelihood of strokes include high blood pressure, which is the number

one risk factor for stroke, and 1 in 3 African-Americans suffer from high blood pressure. Also,
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sickle cell anemia is the most common genetic disorder amongst African-Americans. If sickle-

shaped cells block a blood vessel to the brain, a stroke can result (National Stroke Association,

2016).

Hispanics in the U.S. also have greater stroke risks than their Caucasian counterparts.

Hispanics are more likely to suffer a stroke at a younger age than Caucasians, with an average

age of 67 as opposed to 80 for Caucasians. Reasons why Hispanics have a higher stroke risk

include high blood pressure, higher obesity rates, and an increase in diabetes (National Stroke

Association, 2016).

Some reasons why minorities have a higher risk of strokes include a greater delay in

arriving at the emergency department, use emergency medical service systems less, have longer

wait times in the emergency department, and are less likely to receive thrombolysis for acute

ischemic stroke. While it’s unknown why this occurs, we can’t rule out the presence of bias.

For some minorities, language barriers also contribute to these factors and cause delays in visits

to the doctor or avoid the doctor altogether (Cruz-Flores, et al., 2011).

Stroke is the second leading cause of death among women worldwide, after coronary

heart disease. Although many think of stroke as a disease of older men, over half of all strokes

and 60% of all stroke-related deaths occur in women, and over a quarter of female stroke victims

in a given year are under the age of 65. Stroke kills more women than the number who die from

breast cancer and AIDS combined (The Goddess Fund, n.d.).

Another interesting trend is that strokes are much more prevalent in the southern states.

Americans living in that region have a 15% higher stroke risk, and the death rate from stroke in

these states is 30% to 40% higher than the rest of the country. To understand why this is the case
A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES

researchers are looking into lifestyle factors that could play a role in the prevalence of strokes in

these states. Some factors they found that are contributing to this higher rate is smoking, diet

and genetics, and access to care due to the southern states having many rural areas (Rodriguez,

2009).

Emerging Trends in Management

The field of stroke rehabilitation has a promising future as further advances in stroke

recovery and rehabilitation occur. Many studies and trials are currently underway to answer the

questions about timing and intensity in regards to rehabilitation. Stroke recovery is a

complicated process that has many factors that can alter the recovery duration. Recent advances

in imaging tools, neurophysiological methods, and genetics have increased our understanding of

the recovery process and can only aid in the advancement of stroke rehabilitation (Feng &

Belagaje, 2013).

Machine learning will also have a significant effect on stroke prediction and care. The

explosion of medical records has resulted in a massive amount of data that can be used to

improve healthcare. In using machine learning to mine this data, it allows researchers to use

unstructured data as well from medical images, discharge summaries, and clinical narratives.

IBM researchers in Beijing developed a set of cognitive tools that use machine learning and built

a highly intelligent cognitive model in order to identify key factors that could predict stroke

onset. After building thousands of patient features they applied machine learning to discover

what could cause or prevent strokes. What they found is living with a spouse or partner was a

significant protective condition in avoiding strokes. They also found that patients with atrial

fibrillation are often given a type of anticoagulant to reduce the risk of having a stroke. What
A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES

they found out was the opposite effect occurs in some patients and it ends up increasing the

chances of a stroke (Shen, 2017).

A company called MedyMatch Technology, a machine learning startup, claims to have

technology that can extract information from complex scans of the brain and correctly diagnosis

the occurrence and type of stroke with 95% accuracy, compared to 70% with the human eye.

Their goal is to help radiologists perform like “experts” by analyzing the images, sending them

back to the hospital through the cloud, with the crucial areas highlighted. The company believes

its technology can help prevent strokes, save lives, and also save money (Fierce Biotech, 2016).

Federal or State Programs

There are several federal or state programs available for stroke victims. Social Security

Disability Insurance (SSDI) can help stroke victims who are unable to work. SSDI is a federal

insurance program that can provide income to stroke victims if unable to work due to a

disability. Benefits include a regular monthly income, Medicare benefits, and long-term

disability benefits. Medicare Plan B covers some home care which can help with caregiver home

costs. People who care for stroke victims can also receive financial aid through Carer’s

Allowance. Young adults and children who have strokes can apply for college scholarships

specifically designed for stroke victims. Some states also can provide grants to stroke victims to

help alleviate costs (Vann, 2016). In addition, the Affordable Care Act has a provision where no

insurance plan can reject or charge you more due to a pre-existing condition. This is essential for

stroke victims who do not have insurance and need financial help. Once enrolled, the plan can’t

deny a person coverage or raise their rates based solely on their current health (American Heart

Association, 2016).
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Many states also have Aphasia Centers, which provides direct services to people with

Aphasia. Aphasia is a communication impairment caused by brain damage typically resulting

from a stroke. Services they provide include Aphasia assessments, clubs and groups, speech

therapy, and education classes about effective communication techniques (Aphasia Center of

California, n.d.).

Conclusion

The impact of strokes in our country cannot be overstated. Victims and their families are

impacted emotionally, physically, and financially. Emotionally, stroke victims may feel

depression or sudden bursts of emotion. Physically, victims may suffer from paralysis or

weakness on one side of the body, aphasia, and vision problems (National Caregivers Library,

2016). Financially, 29% of stroke victims say medical costs from their stroke wiped out “most”

of their savings (Colella, 2013).

But there’s hope in sight. A national, population-based, longitudinal study called

REasons for Geographic And Racial Differences in Stroke (REGARDS) is underway using

30,000 African American and white adults over 45. The goal is to determine the causes for the

increase in stroke mortality in African Americans and in the Southeastern United States. This

will allow for the creation of a national cohort to address geographic and ethnic differences in

stroke (Howard, et al., 2005).

Additionally, the benefits of Machine Learning for stroke risk and outcome prediction are

already being seen. Researchers using ultrasound and machine learning together are creating a

classification tool for unhealthy carotid blood vessels. This tool can provide an assessment of
A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES

both the near and far walls of the carotid artery using grayscale morphology of the plaque which

in turn helps doctors predict the risk of strokes (Kanevsky, 2016).

Finally, additional funds are being made available for stroke treatment and prevention.

The Governor of New York in 2015 awarded a $3.75 million grant to enhance the prevention and

treatment of strokes (New York State, 2015). The National Institute of Health awarded $40

million in grants aimed at lowering stroke risk among racial and ethnic minorities in the United

States (National Institutes of Health, 2015).

Stroke is a devastating disease that has impacted millions of Americans. However, it

looks like we are on the right track in both predicting and treating strokes in order to reduce the

effects of the disease. In turn, this should help reduce the financial burden of strokes on our

health care system and individual families.

A LOOK AT THE PAST, PRESENT, AND FUTURE OF STROKES

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