History of Stroke

May is National Stroke Awareness Month, brought to you by the following sponsors:

Richard Nixon, Ginger Rogers, Ted Williams, Robert Lewis Stevenson, Ray Bradbury, Joseph Cotton, Ava Gardner, Gerald Ford, Charles Dickens, Woodrow Wilson, Oscar Peterson, Dwight Eisenhower, Cary Grant, Warren G. Harding and Thomas Jefferson.

These prominent people share one common characteristic:  they all suffered strokes.  The truly interesting thing about this short list is that is represents only a small fraction of the famous and noteworthy people who have suffered strokes at some time in their lives.  An exhaustive list would take up pages.

The reason for this is that stroke is quite literally an everyday occurrence.  It is the second most common cause of death worldwide and the leading cause of disability in the United States.  With something so mundane, you may ask, why do we need to designate a month for awareness?

Somewhere there is a committee that comes up with such designations—deciding national days of this or that—and I can’t speak to their intentions when they decided to honor stroke awareness with an entire 31 days.  I can, however,  share my own opinion on why this is important.

And I’ll do this with an embarrassing personal anecdote.  Prior to medical school I had put as much thought to the idea of stroke as a cockroach puts to Greek literature.  It was a term I’d heard, something associated with old people.  During my first year of medical school I was in a small group of people learning the pertinent physical diagnosis skills of the neurologic exam.  The instructor led us through the steps of performing a detailed inspection of the cranial and peripheral nerves and concluded by showing us some of the deficits that might accompany a stroke.  Perplexed, I interrupted with one of the dumbest medical questions I’ve ever asked (someday I might write about the single dumbest medical question I’ve ever asked): “But stroke is a heart thing.  What does it have to do with the brain?”

I guess I’d always associated stroke with heart attacks, believing the two were somehow synonymous.  Here I was, a college graduate, smart enough to fake my way into medical school, and I had no idea what a stroke is.  Now, I imagine that most people in this country are not as clueless as I am, but if even a fraction are, then this in and of itself represents a darn good reason to dedicate a month to awareness of stroke.

I have previously written on the clinical attributes of this disease and I would encourage any interested reader to follow these links to learn more about risk factors for stroke, stroke in women, and my top ten list of things you can do to avoid stroke.  As my own small contribution to the awareness of this disease, I herewith present you with a definitive history of stroke over the last two and a half millennia:

400 BC – Hippocrates first describes the phenomenon of sudden paralysis and coins the term apoplexy, meaning “struck down with violence.”  Later gets back to work on what he calls his “oath” despite Mrs. Hippocrates insisting no one will ever read it.

1599 – The term “stroke” is first used as a fairly literal translation of the Greek “struck down.”  The Germans and French adopt similar translations (Schlag and Coup, respectively).  Greece takes offense at the loss of apoplexy and boycotts exports of baklava for 2 centuries.

1658 – Johann Jacob Wepfer was the first to suggest that stoke arises from a disruption of blood flow to the brain and describes cases of paralysis arising from cranial bleeding.  Three and a half centuries later Dr. Wepfer’s name is attached to an annual award for stroke research, an honor that more than makes up for the fact that Dr. Wepfer’s wife was indeed correct that his “oath” really was never read by anyone.

1730 – Progress in stroke research is temporarily derailed by Herman Boerhaave’s lectures linking stroke to cacochymia leucophlegmatica, a pathologic excess of white phlegm.  Boorhaave’s new term goes nowhere despite it being an excellent name for a heavy metal band.

1847 - Rudolf Ludwig Karl Virchow, a German pathologist, establishes atherosclerosis and clotting as a definitive cause of ischemic stroke.  Years later, during a less sane time in his life, he was challenged to a duel by the German Chancellor Otto von Bismark (as detailed in Wikipedia): “Virchow, being entitled to choose the weapons, chose two pork sausages: a cooked sausage for himself and an uncooked one, loaded with Trichinella larvae, for Bismarck. Bismarck declined the proposition as too risky.”

1920s – The development of x-ray technology and iodinated dye allows doctors to visualize the arteries leading to the brain and diagnose blockages.  Unfortunately, the patients who learned of their disease have to wait another 30 years for someone to discover a way to fix it.  Thankfully, the waiting room contained enough back issues of Good Housekeeping to tide them over.

1945 – President Franklin D. Roosevelt, long plagued with poorly controlled hypertension, appeared ill at the historic Yalta conference that brought him together with Churchill and Stalin.  The British Prime Minister’s physician commented on the President’s apparent health: “He is a very sick man. He has all the symptoms of hardening of the arteries of the brain in an advanced stage, so that I give him only a few months to live.”  Just 3 months later the President died of a hemorrhagic stroke.  Stalin and Churchill both followed suit by dying of stroke in 1953.

1953 – Famed heart surgeon Michael DeBakey performs the first carotid endarterectomy in Houston, Texas.  He unfortunately failed to patent this procedure that is now performed over a hundred thousand times a year in the USA alone.  In his defense, he lived out his life in monetary comfort thanks to investing early into hula hoops and poodle skirts.

1960s – Doppler ultrasound is developed and used as a noninvasive method of evaluating the arteries of the neck.

1970s – Population studies conclude that hypertension is a definitive risk factor for stroke.  We now know that high blood pressure accounts for up to half of all stroke risk and that even small reductions in pressure among the American population could cut the rate of stroke by 40%.

1980s – Cigarette smoking is clearly linked to stroke.  Despite the obviously deadly nature of this recreational pastime, American teenagers remain enamored with the concept of sucking carcinogens into their lungs despite being young enough to still have a fear of cooties.

1990s – A wealth of research data establishes the role of various medications in the prevention and treatment of stroke.  Warfarin is proven to be effective for patients with atrial fibrillation; aspirin and dipyridamole find a niche in primary and secondary prevention; statin medications seen to drop the risk of stroke by a third; and thrombolytics (clot busters) serve as the first really effective treatment for patients with acute symptoms.

21st century and beyond – This is the real question.  Where do we go from here?

The first steps we need to take are the most obvious.  We know that hypertension is a significant risk for stroke, yet we continue to do a poor job of recognizing and treating this chronic condition.   The same can be said of cigarette use.  I can understand the 70-year-old not being able to kick the habit, but I simply can’t grasp why our culture and media continue to foster the use of tobacco among our youth.  It is here that I display the cantankerous “old man” side to my personality: I cringe every time I watch a movie or TV show where tobacco use is glamorized or see popular celebrities photographed with a cigarette dangling from their lips.  If we could do no more than to end the youthful fascination with smoking I would consider it a monumental victory.

Stroke is one of the most preventable illnesses of the modern world.  Research has brought a long way from the days of “white phlegm.”  What we need now is to simply put into practice all the lessons we’ve learned so that we can truly progress from awareness to eradication.