STR Equals Stroke? Yes and No

I have been hanging out on myspce.com a lot more often. I have my reasons, but mostly my increased profile awareness is because I am on my computer so often with residency applications, email and working out future rotation schedules.

So today when I viewed my profile, I saw a bulletin from Kohler titled, “In Case I have a Stroke.” I was curious so I read it.

The bulletin concerned a friend of someone who had had a stroke. In order to help others understand how a stroke may present, i.e. signs and symptoms, this person/persons have come up with a simple screening tool for strokes or cerebral vascular accidents (CVA). They employed the acronym “STR” as an easy and applicable way to identifying a stroke.

The “S” stands for smile; the “T” is for talk, as in have the person speak a simple sentence; and finally the “R” is for the patient to raise both arms.

These three simple screening questions do correlate to a stroke, but why do they correlate and what else could they mean? Here are some of the answers.

Often a CVA will cause what is known as an upper motor neuron lesion, which is in simple terms damage to the beginning of a nerve/neural pathway. The innervation of the facial muscles/expressions is cranial nerve seven. The upper face receives bilateral innervation, while the lower face receives only unilateral innervation. Therefore, in a stroke a patient may not be able to smile on one side of their face, but will still be able to wrinkle their forehead and close their eyes.

Simply not being able to smile does not mean the person is having a CVA. For example, the person may have a Bell’s Palsy. In the latter case, there will be an entire ipsilateral (one side) facial paralysis. This means the person will not be able to blink, wrinkle their forehead or smile/grimace. A Bell’s Palsy still should be treated as an emergency, because early interventions with corticosteroids can save/delay neuronal damage.

Often in a stroke the patient will begin to slur their speech, a term known as dysarthria. This can be very alarming and may be a CVA. Again, there are other situations in which one may become dysarthric. For example, an individual who just had a seizure may be dysarthric during the seizure or in the post-ictal state. However, if someone does have a seizure, he/she should be taken to the emergency room for the appropriate work-up and treatment.

Finally, raising one’s arms is another fine screening tool to see if a person is stroking out a part of their brain. However, the patient characteristics must be included and understood to rule-in or rule-out a stroke. For instance, a 22-year-old female may develop sudden weakness in her upper or lower extremities. This may not be a sign of stroke, but rather could be an acute exacerbation or onset of multiple sclerosis. Furthermore, a 54 year old man complaining of left arm pain and cannot raise his arm may be having a myocardial infarction (heart attack). These last two cases are medical emergencies, but are not strokes.

An individual also may have neurological/stroke symptoms but not have a true CVA. Often in these cases, the person has a transient ischemic attack (TIA) or mini/warning stroke. The person needs prompt emergent medical work-up in this case as well. An individual who suffers a TIA will progress to a full-blown stroke in one-third of the cases, with the greatest risk for CVA being within the first couple weeks after the TIA.

Strokes are the third leading cause of death in the United States and are one of the leading health care costs due to the secondary disabilities that follow after such a traumatic insult to the brain. Early recognition of strokes is very important. Morbidity and mortality can be improved if the patient is treated within the first three hours.

The simple STR screening tool is an excellent way to identify a potential neurological event, but it does not always mean a person is stroking. Regardless, prompt emergent interaction is needed and the person should be taken to the nearest emergency department.