Different Strokes

By Ian K. Smith, M.D.

After former President Gerald Ford suffered one or possibly two mild strokes while attending the Republican National Convention last week, his doctors quickly predicted a full recovery. But his illness raised a troubling question: How could a team of specially trained physicians initially misdiagnose a stroke, especially in a former President, who, one assumes, always receives the very best medical care? The answer, unfortunately, is quite easy. Strokes are often misdiagnosed, even by excellent doctors, for a simple reason. Many symptoms commonly linked with stroke are also seen in other illnesses.

Take, for example, Ford's shaky balance. Onlookers noticed it as he emerged from the Convention Hall Tuesday night. A few hours later, just after midnight, he went to the emergency room of Philadelphia's Hahnemann University Hospital complaining of an earache and dizziness. Concluding that he had a sinus or inner-ear infection, doctors treated him with antibiotics and sent him off within an hour. But while their treatment might be considered reasonable in light of what he told them at the time, the 87-year-old former Chief Executive subsequently returned to the hospital with classic stroke symptoms.

His speech was slurred, as was evident in replays of TV interviews he'd given on the convention floor. He had a weakness in his left arm, which occurs in many stroke patients along with weakness in the face or leg on the same side. Ford didn't exhibit two other common symptoms, blurred vision and a sudden, severe headache. But that's not surprising, since symptoms vary among patients.

The missed diagnosis understandably raised concerns about how doctors go about detecting and treating a stroke. Even for specialists this can be a tricky business, as there are two major groups of strokes and each requires different tests and treatments. In a hemorrhagic stroke, a blood vessel bursts and causes bleeding in the brain, which can be detected immediately by a C.T. or MRI scan. In the other, major family of strokes, ischemic, a clot obstructs the flow of blood, starving and killing brain tissue beyond the blockage. This kind of stroke, which Ford suffered in the balance center at the base of the brain, may also be seen by C.T. or MRI, but sometimes not until 24 hours after it occurs, and even then it doesn't always show up.

How a patient fares after a stroke depends on several factors, including how much of the brain has been affected; how soon and what sort of treatment is started (clot busters like TPA, or tissue plasminogen activator, should be administered within three hours for ischemic strokes but not for hemorrhagic strokes, lest they cause even more bleeding); how severe the symptoms are (paralysis is worse than simple weakness); and the patient's general health before the brain injury.

While Ford's doctors are optimistic about their octogenarian patient, who has been an active golfer and public speaker, they haven't escaped criticism for their missed first diagnosis. But casting blame won't do anyone much good. What the former President's experience should teach us is the importance of recognizing stroke symptoms and getting help fast.

Dr. Ian appears on WNBC-TV in New York City. E-mail him at [email protected] For more on strokes try americanheart.org