Sunday, March 18, 2018

Half a World Away: Visual Field Cuts

a division of United Stroke Alliance
The following is from the StrokeConnection website:

I encourage you to visit their site because they have very good articles on stroke.


Strokes often affect vision and processing of visual information. The most common visual deficit is hemianopia (hem-ee-a-NO-pia) or visual field cut. Our visual field is the whole area that we see in front of us — left to right, top to bottom. Each eye has its own visual field, but the brain combines the information from both eyes so we only see the world as one visual field. Like so many processes in the brain, vision is processed on the opposite side, but it isn’t as simple as the left eye is handled by the right brain. Instead, visual stimulation from the left side of each eye is handled in the right visual cortex. Right-side stimulation of each eye is processed in the left visual cortex. The visual cortex is located in the back part of the brain (see How Vision Works below). A stroke that injures either the optic nerves running from the back of the eyeballs through the brain to the visual cortex or the visual cortex itself will cause a deficit of vision in the same area of both eyes. Thus, a stroke in the visual processing area of the right side of the brain causes a problem with the left visual field of the right eye and the left visual field of the left eye.
If the blindness involves the same half of the visual field of each eye, it is called a homonymous hemianopia. There are variations of field cuts that are much less common. For example, a field cut may involve less than half, say the upper left quadrant of both eyes. The top or bottom of the visual field might be gone or maybe a person can only see the center of the visual field (the edges are missing); or the center of the visual field is absent but the edges can be seen. Further, many of these other types of visual field defects can be caused by problems other than stroke. See our From the Eyes of the Beholder infographic for examples of how some common types of field cuts affect vision from a survivor's perspective.
It is not hard to imagine how vision loss would affect your life. “I think it’s fair to say that vision impacts your ability to be mobile, to be independent, to read, to drive and just be productive,” said neuro-ophthalmologist Adam Cohen, neurology inpatient medical director and teleneurology director at Massachusetts General Hospital. “So having vision problems, particularly severe ones like these, can impact any of those functions.”
If you can only see things in the right or left half of the visual field, why not just move your head to the left or right? Called ‘scanning,’ this is a basic lesson in the rehabilitation of a survivor’s vision, but it is a learned response. The brain of the survivor with a field cut is not receiving visual stimulation from the area of blindness so he may not be stimulated to move his head to take in what he is not seeing. And while scanning training may improve the ability to scan and read, it doesn’t actually improve the field cut.

Hemianopia differs from another stroke deficit known as one-side neglect. “In neglect, visual information is being received by the brain, at least at some level, but it is not available to the conscious state,” Cohen said. “For example, someone has a left neglect and you put a clown to the left of them, the neurons might be firing when the vision information is coming in, but the person is not aware of the clown. If you ask the person ‘What’s in front of you?’ They’ll say, ‘Nothing.’”
Of the two, neglect has a bigger impact on function — and a worse prognosis — than a field cut alone. “Someone who has an isolated field cut is more likely to be aware of their problem and thus, more able to compensate for it,” Cohen said. “Whereas a neglect patient is not aware of it because of that consciousness problem, so they’re unaware of the issue and less able to compensate.”
Returning as much function as possible is the goal of rehabilitation of field cuts, and much of that is accomplished by teaching compensation skills, like scanning. “It’s very much an occupational therapy approach,” Cohen said. “There are a host of devices and potential treatments for people with field cut to actually try to expand the visual field, to cure the root of the problem. But those are not yet widely adopted in the medical fields, like neurology, neuro-ophthalmology or rehabilitation medicine. These ‘expansion’ methods have not yet been validated [by scientific studies].”
Prisms are sometimes used to expand the visual fields. Set into a pair of glasses, the prisms bring in the light and objects from the blind side and make it available to the side with sight. “They can be helpful for some people, but I think most of us have found that patients really aren’t able to use them in a sustainable way,” Cohen said. “Most people actually find them annoying and distracting, which also applies to things like mirrors that direct the light from the blind visual field into the seeing visual field. We tend not to recommend those things.”
In the occupational therapy approach, which is delivered at vision rehabilitation clinics and some eye hospitals, the idea is to help the patient maximize existing function and find new tools and tricks to compensate for their problem. Reading provides an example: The survivor puts her finger on the first word of a line of print and then follows her finger with her eyes as she moves it along the line of type. “It’s a lot easier to direct your eyes doing that,” Cohen said. “The survivor’s function is effectively improved without healing the neurons and the neuron pathways that are the root of the problem.”
Visual rehab specialists focus on safety of the patient so in addition to giving them tools and strategies, they often evaluate their home or work environment. They assess how the survivor’s vision deficit affects their activities of daily living: How do they cook and clean and go to the bathroom?
In the recently published rehab guidelines for stroke, the committee said there is a very low level of evidence to support computer-based expansion of the visual field. Cohen agreed that the jury is still out because vision doctors have not fully verified this treatment or deciphered how it works. It may relate to brain plasticity, and the program is somehow recruiting other areas where vision is processed to take over. The problem for survivors seeking treatment is that “these therapies are not standardized, nor broadly adopted,” he said. “I don’t know that they should rule them out, but I wouldn’t dive into them, particularly when they were unproven, expensive and particularly if there were risks involved,” he said. “Approach them with skepticism.”
“The representation of vision is widespread in the brain, so visual loss after stroke is pretty common,” Cohen said. “Around a third of patients will have that problem. Of those with visual field defects, most are hemianopias . . . but we typically don’t see complete resolution of severe visual field cuts. They tend to be pretty resistant.”

This information is provided as a resource to our readers. The tips, products or resources listed or linked to have not been reviewed or endorsed by the American Stroke Association.
Copyright is owned or held by the American Heart Association,Inc., and all rights are reserved. Permission is granted, at no cost and without need for further request, to link to, quote, excerpt or reprint from these stories in any medium as long as no text is altered and proper attribution is made to American Heart Association and American Heart Association News. See full terms of use.

Sunday, March 11, 2018

New Guidelines for Stroke Treatment


Retreat & Refresh Stroke Camp

a division of United Stroke Alliance

More stroke patients eligible for crucial treatments under new guidelines


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More stroke patients will be eligible for two critical treatments proven to reduce disability, according to new guidelines from the American Heart Association/American Stroke Association.

The guidelines issued Wednesday cover acute ischemic stroke, the most common type of stroke, one that is caused by a blood clot that reduces or stops blood flow to a portion of the brain. Stroke is the second-leading cause of death in the world and a leading cause of adult disability. It kills about 133,000 Americans every year, and occurs in the U.S. about once every 40 seconds.

The guidelines recommend more people should be considered to undergo a procedure called mechanical thrombectomy, in which doctors remove blood clots using a device threaded through a blood vessel. In addition, the guidelines suggest that more people should be considered eligible for a clot-dissolving IV medication called alteplase.

Some patients may now have mechanical clot removal up to 24 hours after symptoms begin. The limit used to be six hours, but new research showed that some carefully selected patients may benefit even after an extended amount of time.

“This is going to make a huge, huge difference in stroke care,” said Dr. William J. Powers, guidelines writing group chair and chair of neurology at the University of North Carolina School of Medicine in Chapel Hill.

The clot retrieval procedure requires a physician to thread a catheter through an artery, using a clot-grabbing device within it to reach and remove the clot.

Patients may qualify for the procedure if they have a blood clot in a large artery inside the head supplying part of the brain. This type of clot may not respond well to IV medication alone, can cause serious complications such as brain swelling, and can lead to considerable disability or death, said Dr. José Biller, a guidelines author and chair of neurology at Loyola University Chicago Stritch School of Medicine in Illinois.

“Removing blood clots from large arteries can mean the difference between stroke survivors being independent versus being dependent on others, which makes a big difference in their quality of life,” Biller said.

Up to 20 percent of all ischemic stroke patients are currently eligible for clot removal, Biller said, a number he expects to grow under the new guidelines and with further research.

Mechanical clot removal was first recommended in 2015, and large hospitals offering specialized stroke care are staffed and equipped to perform the procedure, Powers said. Expanding the window of eligibility will require more regionalized, coordinated approaches to stroke care, he said.

Alteplase was approved to treat ischemic stroke in 1996 and remains the only medication approved by the FDA to dissolve clots. Alteplase is in a class of drugs known as tissue plasminogen activators (or tPA). It has been proven to decrease disability when given promptly.

The guidelines relax the “very, very rigid” guidelines established when alteplase was first used, Powers said.

“The way we look at alteplase used to be green and red,” he said. “Green go, red stop. Now we’ve taken some of the reds and made them yellow.” Previously, some patients who had milder strokes, recent surgery or spinal tap were not eligible, Powers said.

The guidelines also recommend video consultation to hospitals without stroke experts so doctors can give alteplase quickly. Ideally, hospitals should work faster than the current 60-minute standard for IV treatment, with a goal of treating at least half of patients within 45 minutes, according to the guidelines. Video consultation, or telemedicine, also can help hospitals determine which patients qualify for mechanical clot removal.

The new guidelines were published in the American Heart Association’s journal Stroke and announced at the American Stroke Association’s International Stroke Conference. Based on a review of more than 400 research studies, the guidelines replace the 2013 guidelines and all subsequent updates, Biller said.

The guidelines will hopefully increase and harmonize care in the U.S. and all over the world, Biller said.

For the public, the most important message remains recognizing the signs and symptoms of stroke and calling 911 immediately, Powers said. Stroke patients do better the faster they get treatment, he said.

“You shouldn’t make the decision about whether you’re having a stroke, and you shouldn’t wait around to see if it goes away,” he said. “Time matters. If you can get to the hospital even 15 minutes earlier, it really matters.”

Getting help quickly paid off for Terry Summers of Kansas City, Missouri, after his recent stroke.

In August 2017, he started slumping to one side and his speech suddenly became garbled. The 61-year-old attorney’s son, Sean, immediately recognized the stroke warning signs and called 911.

Treatment with alteplase began minutes after the symptoms started, and continued with mechanical clot removal at a nearby hospital. Summers was feeling better the next morning, and two weeks later he was back at work. Today he has occasional headaches and slight weakness on his left side, but no other lingering effects of the stroke.

Awareness helped – Sean’s mother is a stroke nurse who had drilled the signs of stroke into his head, Summers said. And, of course, taking immediate action to get the proper treatment was also crucial.

“I wouldn’t have called 911,” said Summers, who is glad his son was there to do it. “Timing has everything to do with the fact that I’m in one piece.”
Commentary from Dr. William J. Powers: Three Things Everyone Should Know About Stroke 

Science News: Stroke guidelines information for professionals

If you have questions or comments about this story, please email
American Heart Association News Stories

American Heart Association News covers heart disease, stroke and related health issues. Not all views expressed in American Heart Association News stories reflect the official position of the American Heart Association.

Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved. Permission is granted, at no cost and without need for further request, to link to, quote, excerpt or reprint from these stories in any medium as long as no text is altered and proper attribution is made to the American Heart Association News. See full terms of use.

Sunday, March 4, 2018

An Ode to Caregivers


Retreat & Refresh Stroke Camp

a division of United Stroke Alliance

Due to personal constraints (nothing bad) I have been posting a new article every two weeks instead of weekly. The plan is to go back to weekly postings on March 12th.
The following is from the StrokeNet Newsletter:
Making Stroke Recovery Possible

by Deb Theriault
Senior Contributing Writer and
Information Resources Administrator

Caregiver (care-giv-er/ noun: a person who provides direct care) Source: Meriam-Webster Dictionary

Is there a job out there that is more underestimated and more personally difficult, yet more essential, than that of the caregiver? Probably not. The caregiver function is largely swept under the rug, as society looks the other way and collectively says “there, but for the grace of God, go I”.

On one hand, people can dismiss how difficult a caregiver’s job is, while, on the other hand, fear that sometime in the future they, too, will either have to become a caregiver for someone, or rely upon one to care for themselves. Why is the caregiver function so undervalued and, often, misunderstood? Well, it’s time that we give caregivers their due and then some.

Simply put, caregivers make it possible for others to go on living (literally), as well as to live more comfortably and with dignity. To do this, caregivers assist with hygiene and daily-living activities that cover a very wide spectrum.

On one end, they may make meals, housekeep, assure that medications are taken, take their charges to doctor and therapy appointments, shop for their food and sundries, take them to church or other social activities, and, often, provide their charge with companionship.

On the other end, in addition to many of the above functions, they may have to hand-feed their charge, wash / bathe the person, turn them over in bed throughout the day and night, and tend to their most intimate of toilet functions. This is a huge range of responsibilities.

It’s worth noting that some caregivers are actually paid to do their jobs, but most people rely on un-paid caregivers: spouses, relatives, even friends who step up and do the right thing by helping out a dependent adult, or child, in need. To complicate things, the caregiver often has other job or family responsibilities, which leaves little time for themselves and their own personal needs. No matter how well-intentioned, it’s unrealistic to expect such super-human output of anyone. No wonder “caregiver burnout” is such a huge problem.

Let’s stop here for a moment and recognize that even “commercial” caregivers need to be commended. The caregiver-for-hire needs to enjoy taking care of people, or get some sort of satisfaction from helping others out, otherwise they wouldn’t be able to do their jobs effectively. But, even though they get paid for their services, they can still experience the same emotional fallout as unpaid caregivers. This is especially true if they bond with their patient and the patient declines physically or emotionally, and /or becomes more difficult to care for.

Also, (and I hate to mention this) I feel an obligation to shine a light on the elephant in the room. Unfortunately, because caregiving can be so backbreaking, there is an underbelly to the caregiving function. Sadly, there are caregivers out there who are not so kind, and not so competent (both paid and un-paid). Over the years, I’ve heard of a few.

If a caregiver truly doesn’t want to be a caregiver, they can become surly and resentful when discharging their caregiving duties. Worse yet, they can become less careful, and less vigilant, with their charge, which can cause them to overlook changes in their patient’s health status and needs. They can also make the patient feel fearful or uncomfortable, not to mention, put them in physical danger.

The caregiver then becomes a “I-could-care-less-giver,” a lose / lose situation for everyone involved. This is an extreme case, of course, but it does happen. More often than not, the hapless caregiver simply becomes overwhelmed and exhausted, which can make them a bit careless or take longer to do their job.

From a personal standpoint, I wish I had a workable solution to caregiver burnout, but I don’t. I do know that while it’s not a solution to burnout, caregiver “respite” can help ease things a bit. There are caregiver respite services available in many cities and towns around the U.S., but these services aren’t always obvious; you have to work to find them.

Many times, churches step in and find people from their congregation to volunteer respite time to caregivers. If I were a caregiver, I’d try to see whether my church has such a volunteer workforce. Sometimes, Senior Community Centers also offer similar caregiver respite services to their community, again relying upon volunteers. And, while these aren’t available everywhere, there are also organizations dedicated to helping veterans. Again, one has to do some research to locate them.

The last option is to hire a qualified, professional caregiver on an occasional basis, to give the permanent caregiver breathing room and to find some time for themselves. (Regardless of the route one takes, as a society, on the whole, we need to find better solutions to help our citizens who require caregiver services, as well to provide help to the caregivers themselves. I’ve said it before, and I’ll say it again: we can do better.)

With that, let’s hear it for the thousands of selfless, hard-working caregivers out there. They are true angels to those who need them. In this “hearts and flowers” month of February, I‘m sending them a HUGE “virtual” Valentine brimming with sincere gratitude, and many warm hugs and pats on the back, for the vital service they provide, and for the super-important role that they play in peoples’ lives.

I thank you, marvelous people, from the bottom of my heart. You’re more important than you’ll ever know.
Deb survived her third stroke in 2006. In addition to her work with the Stroke Network, Deb is Treasurer for the W. Pa. Division of the US Fencing Assoc., does community gardening in her neighborhood and is a professionally-trained artist who has been specializing in figure drawing for many years.
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