Indiscriminate Victims

During the heart of World War II, from November 28 to December 1, 1943, Joseph Stalin, Franklin Roosevelt, and Winston Churchill met at the Soviet embassy in Tehran, Iran to discuss strategies for the ongoing conflict. Though the Allied forces held several important conferences over the length of the war, this was the first of only two at which Churchill, Roosevelt, and Stalin were all present (the other being Yalta in 1945). The conference marked the first meeting in person between Roosevelt and Stalin. A number of objectives were discussed in Tehran, with the three world leaders at times having differing aims. The major result of the conference was the decision to begin a second front against Nazi Germany, with the aid of the Soviet Union. In return, the Soviets gained control over much of eastern Europe, with the border between the Soviet Union and Poland moving farther to the west. The three leaders are here seated on the portico of the Soviet embassy in Tehran, with Stalin and Churchill both dressed in military uniform.

Stroke strikes indiscriminately, with no concern for status, power, or wealth. Roosevelt, President of the United States from 1933 to 1945, Churchill, Prime Minister of the United Kingdom from 1940 to 1945 and again from 1951 to 1955, and Stalin, leader of the Soviet Union from 1922 to 1953, all suffered from strokes. On April 12, 1945, while sitting for a painted portrait by Elizabeth Shoumatoff, Roosevelt had an intracerebral hemorrhage and died later that afternoon. Churchill first had a mild stroke while vacationing in France in 1949, then a second, more disabling one on June 23, 1953, after dinner at Downing Street. Though partially paralyzed and with deteriorating health, Churchill continued to work, only retiring from his position as Prime Minister in April 1955. After leaving office, he suffered from several more strokes until his final and most severe one on January 15, 1965. It left him very ill, and he passed away, at age 90, shortly thereafter. On March 1, 1953 Stalin, too, suffered from a intracerebral hemorrhage, caused by hypertension, having previously had a minor stroke towards the end of the war. He was treated with leeches (customary at the time) and his condition, unsurprisingly, did not improve. He died on March 5. An autopsy was conducted at the time by the Soviet Ministry of Health, but not released until 2011, which confirmed that the cause of death was cerebrovascular disease due to high blood pressure.

Stroke is the leading cause of acquired disability in the United States and the fifth leading cause of death. Rather than a disease, it is a general term that refers to the interaction between the brain and blood vessels. It was originally described by Hippocrates in ancient Greece, who called it apoplexy, meaning “to strike down.” Though he was not aware of the interaction between the brain and the blood vessels, the word captures the essence of the event which is sudden in symptom onset. Strokes are divided into 1) ischemic and 2) hemorrhagic. Ischemic strokes are much more common and refer to a blocked blood vessel in the brain, eye, or spinal cord. Risk factors include hypertension, diabetes, high cholesterol, smoking, poor diet, inactivity, obesity, and obstructive sleep apnea. Much of what is known about risk factors for stroke comes from the long-running Framingham Heart Study in Framingham, Massachusetts. The cause of the blockage varies. It is the job of the stroke neurologist to determine, as best as possible, what was the cause for each individual patient. This helps to guide treatment aimed at reducing the risk of another stroke. Some patients have hypertension, or high blood pressure, which leads to progressive thickening of the walls of the arteries in the brain. The thickened walls encroach on the lumen, or inner channel where the blood is flowing, until eventually the artery closes off altogether. On the other hand, some patients have completely normal blood vessels in their heads, but a particle, usually a blood clot, may travel through the blood stream and then land in a vessel deep inside the brain. The source of such blood clots can be the heart (as in patients with atrial fibrillation) or other blood vessels like the carotid or vertebral arteries in the neck, or the aorta in the chest. Whatever the cause, when a brain artery becomes blocked, then the part of the brain supplied by that blood vessel loses its blood supply, stops working in seconds, and brain cells begin to die. Restoring blood flow (with medicine or by removing the clot) can help rescue some of those brain cells but must be done as quickly as possible (minutes or hours). Fortunately, most ischemic strokes are painless, but unfortunately, this leads some people to waste precious minutes and hours hoping the symptoms will go away rather than seeking help. Everyone should know a few things about stroke:

Hemorrhagic strokes occur when blood vessels burst open. This too occurs most commonly because of longstanding hypertension. Hemorrhagic strokes are less common than ischemic ones making up about twenty percent of all strokes. They are harder to treat and are more often fatal, but patients who survive can make remarkable recoveries. 

references:

Mahmood, Syed S., et al.  “The Framingham Heart Study and the epidemiology of cardiovascular disease:  a historical perspective.”  The Lancet Vol. 383 (March 15, 2014):  999-1008.