Stroke

1 What is Stroke?

A stroke occurs if there is a block in the flow of oxygen-rich blood to a part of your brain, which deprives the brain tissues of oxygen and essential nutrients.

Within a few minutes, brain cells begin to die due to lack of oxygen. If the brain cells get damaged because of stroke, symptoms involve the parts of the body that these cells control.

Sudden brain hemorrhage may also lead to stroke if it damages the brain cells. It is a serious medical condition that requires prompt care.

A stroke may cause permanent damage to the brain, long-term disabilities, and even death. Early treatment can reduce potential damage to your brain and other complications.

Stroke is a leading cause of death in the United States, but the good news is that strokes can be treated and prevented, and many fewer Americans die of stroke now than even 15 years ago.

Types of Brain Stroke

2 Symptoms

The signs and symptoms of stroke usually develop quickly, but may sometimes take several hours to days. 

Watch for these signs and symptoms if you think you or someone else may be having a stroke. Note when your signs and symptoms begin, because the duration and severity of your symptoms guide your treatment decisions.

Signs and symptoms of a stroke may include:

  • Trouble with speaking and understanding speech: You may experience confusion, and may slur your words while speaking or have difficulty in understanding speech.
  • Paralysis or numbness of the face, arms or legs: You may develop sudden weakness, numbness or paralysis in your face, arm or leg, especially on one side of your body. Try raising both your arms over your head simultaneously. If one of your arm begins to fall, you may be having a stroke. Similarly, when you smile, one side of your mouth may tend to droop.
  • Trouble with seeing in one or both eyes: You may suddenly develop a blurred or blackened vision in one or both eyes, or you may have double vision.
  • A headache: A sudden, severe headache that is associated with vomiting, dizziness or loss of consciousness indicates a stroke.
  • The trouble with walking: You may stumble or experience unexplained fall due to loss of balance and coordination.

When to see a doctor?

Seek immediate medical attention if you note any of the signs or symptoms of a stroke, even if they tend to fluctuate or disappear.

Remember the acronym – "FAST" and do the following to evaluate the signs:

  • Face: Ask the person to smile. Does one side of the face droop?
  • Arms: Ask the person to raise both arms. Does one arm drift downward? Or is one arm not able to raise up?
  • Speech: Ask the person to repeat a simple phrase. Is his or her speech appear slurred or strange?
  • Time: If you observe any of the above signs, call 911 immediately. Call 911 or your local emergency number immediately. Do not wait to see if the symptoms resolve on their own.

Every minute counts

The longer a stroke remains untreated, the greater is the potential for long-lasting brain damage and disability.

If you are along with someone you suspect is having a stroke, observe the person carefully while waiting for emergency assistance.

Stroke in Women

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3 Causes

A stroke is caused when the blood supply to your brain is interrupted or blocked. The cells in your brain become deprived of oxygen and nutrients, which can cause the death of these cells.

A stroke caused by a blocked artery is called ischemic stroke or stroke due to leakage or bursting of a blood vessel is called a hemorrhagic stroke.

Sometimes, when people experience only a temporary interruption of blood flow to their brain, it is called a transient ischemic attack, or TIA.

Ischemic stroke

Around 85% of the strokes are ischemic strokes. These develop when the blood vessels supplying your brain become narrow or blocked resulting in severely low blood flow (ischemia).

The most common ischemic strokes include:

Thrombotic stroke: A thrombotic stroke occurs when a blood clot (thrombus) forms in one of the arteries supplying blood to your brain. Clot forms as a result of fatty deposits (plaque) that build up in the arteries and cause decreased flow of blood (atherosclerosis) and other conditions in the arteries.

Embolic stroke: An embolic stroke occurs when a blood clot or other debris that is formed away from your brain — commonly in your heart — is swept along your bloodstream to get lodged in the narrow arteries of your brain. This type of blood clot is called an embolus.

Hemorrhagic stroke

Hemorrhagic stroke occurs when a blood vessel of your brain ruptures or leaks. Brain hemorrhages occur as a result of uncontrolled high blood pressure (hypertension), weak spots in the walls of your blood vessels (aneurysms), and prolonged treatment with anticoagulants.

Rarely, hemorrhage may occur due to rupture of an abnormal tangle of thin-walled blood vessels (arteriovenous malformation) that are present right from birth.Types of hemorrhagic stroke include:

Intracerebral hemorrhage: In an intracerebral hemorrhage, a blood vessel in the brain bursts and blood spills into the surrounding brain tissue, damaging the brain cells. Brain cells beyond the leak are deprived of blood and also damaged. High blood pressure, trauma, vascular malformations, use of blood-thinning medications and other conditions may cause an intracerebral hemorrhage.

Subarachnoid hemorrhage: In a subarachnoid hemorrhage, an artery on or near the surface of your brain bursts and spills into the space between the surface of your brain and your skull. This bleeding is often indicated by a sudden, severe headache.

A subarachnoid hemorrhage is often a result of the bursting of a small sack-shaped or berry-shaped outpouching on an artery known as an aneurysm. After the hemorrhage, the blood vessels in your brain may widen and narrow down erratically (vasospasm), causing brain cell damage due to further reduction of blood flow.

Transient ischemic attack (TIA)

A transient ischemic attack (TIA), also called a ministroke is a brief period of symptoms similar to those you would have a stroke. A temporary reduction in blood supply to part of your brain causes TIAs, which often lasts less than five minutes.

As in an ischemic stroke, TIA occurs when a clot or debris blocks the blood flow to a part of your brain. A TIA does not cause lasting symptoms as the blockage is temporary.

Seek immediate medical care even if your symptoms seem to go away. The occurrence of a TIA puts you at a greater risk of developing a full-blown stroke that causes permanent damage. If you have had a TIA, it means that there is a partially blocked or narrowed artery leading to your brain or a clot source in the heart.

It is not possible to differentiate whether you are having a stroke or a TIA, based only on your symptoms. Almost half of the people whose symptoms disappear, actually, would have had a stroke causing brain damage.

4 Making a Diagnosis

A stroke in progress is often diagnosed in a hospital. If you are having a stroke, immediate care will be focused on minimizing brain damage.

If you haven't yet had a stroke, but you're worried about your risk in future, you can discuss your concerns with your doctor at your next scheduled appointment.

What to expect from your doctor?

In the emergency room, you may see an emergency medicine specialist or a doctor trained in brain conditions (neurologist), as well as nurses and medical technicians.

Your emergency team's first priority is to stabilize your symptoms and overall medical condition. Then, they will determine if you are having a stroke. Doctors will try to find the cause of your stroke to determine the most appropriate treatment.

During a scheduled appointment, your doctor will evaluate your risk factors for stroke and heart disease. Your discussion will focus on avoiding these risks, such as not smoking or using illicit drugs.

Your doctor also will discuss lifestyle strategies or medications to control high blood pressure, cholesterol and other risk factors for stroke.

Your doctor may recommend certain tests and procedures, which will help the doctor to better understand your risk of stroke. They may also help to treat underlying conditions that can increase your risk.

To find out the most appropriate treatment for your stroke, your emergency team will evaluate the type of stroke you are having and the areas of your brain affected by the stroke. They also need to preclude other possible causes of your symptoms, such as a brain tumor or a drug reaction.

Your doctor may use several tests to determine your risk of stroke, including:

  • Physical examination: Your doctor will ask you or a family member about your symptoms, when they started and what you were doing when they began. Your doctor then will evaluate whether these symptoms are still present. Your doctor will want to know the medications you take and whether you have experienced any head injuries. You will be asked about your personal and family history of heart disease, transient ischemic attack or stroke. Your doctor will measure your blood pressure and use a stethoscope to listen to your heart and to listen for a whooshing sound (bruit) over your neck (carotid) arteries, which may indicate atherosclerosis. Your doctor may also use an ophthalmoscope to check for signs of tiny cholesterol crystals or clots in the blood vessels located at the back of your eyes.
  • Blood tests: You may have several blood tests, which can tell how fast your blood clots, whether your blood sugar is abnormally high or low, whether critical blood chemicals are out of balance, or whether you may have an infection.
  • Computerized tomography (CT) scan: A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show a hemorrhage, tumor, stroke and other conditions. Doctors may inject a dye into your bloodstream to view your blood vessels in your neck and brain in greater detail (computerized tomography angiography).
  • Magnetic resonance imaging (MRI): An MRI uses powerful radio waves and magnets to create a detailed view of your brain. An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. Your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography, or magnetic resonance venography).
  • Carotid ultrasound: In this test, sound waves are used to create detailed images of the inside of the carotid arteries in your neck. This test shows accumulation of fatty deposits (plaques) and blood flow in your carotid arteries.
  • Cerebral angiogram: In this test, your doctor inserts a thin, flexible tube (catheter) through a small incision made in your groin, and is guided through your major arteries and into your carotid or vertebral artery. Then, your doctor injects a dye into your blood vessels to make them visible through X-ray imaging. This procedure gives a detailed view of the arteries present in your brain and neck.
  • Echocardiogram: An echocardiogram makes use of sound waves to create detailed images of your heart. It can reveal the source of a clot in your heart that may have swept from your heart to your brain and caused your stroke. You may also have a transesophageal echocardiogram in which your doctor inserts a flexible tube with a small device (transducer) attached into your throat and down into the tube that connects the back of your mouth to your stomach (esophagus). As esophagus lies directly behind your heart, a transesophageal echocardiogram can create clear, detailed ultrasound images of your heart and any blood clots.

5 Treatment

Emergency treatment for stroke depends on whether you're having an ischemic stroke blocking an artery or a hemorrhagic stroke that involves bleeding into the brain.

Ischemic stroke

To treat an ischemic stroke, doctors must quickly restore the blood flow to your brain.

Emergency treatment with medications: Therapy with clot-busting drugs must start within 3 hours if they are given into the vein — and the sooner, the better.

Quick treatment not only improves your chances of survival but also may reduce complications. You may be given:

  • Aspirin: Aspirin is immediately given in the emergency room to reduce the likelihood of having another stroke. Aspirin prevents blood clots from forming.
  • Intravenous injection of tissue plasminogen activator (TPA): Some people can benefit from an injection of a recombinant tissue plasminogen activator (TPA), also called alteplase. An injection of TPA is usually given into a vein in the arm. This is a potent clot-busting drug, which should be given within 4.5 hours stroke symptoms begin. TPA restores blood flow by dissolution of the blood clot causing your stroke, and it is beneficial in people who have had strokes to recover more completely. Your doctor will consider certain risks, such as potential bleeding in the brain, to determine if TPA is appropriate for you.
  • Emergency procedures: Doctors sometimes treat ischemic strokes with procedures that must be performed as soon as possible, depending on features of the blood clot:
  • Medications delivered directly to the brain:  Doctors insert a long, thin tube (catheter) through an artery in your groin and thread it to your brain to deliver TPA directly into the area where the stroke has occurred. The time window for this treatment is somewhat longer than for intravenous TPA but is still limited.
  • Mechanical clot removal: Doctors may use a catheter to maneuver a tiny device into your brain to physically break up or grab and remove the clot. However, recent studies suggest that for most people, delivering medication directly to the brain (intra-arterial thrombolysis) or using a device to break up or remove clots (mechanical thrombectomy) may not be beneficial.
  • Other procedures: To decrease your risk of having another stroke or transient ischemic attack, your doctor may recommend a procedure to open up an artery that's narrowed by fatty deposits (plaques).

Doctors recommend the following procedures to prevent a stroke, and the options will vary depending on your situation:

  • Carotid endarterectomy: In a carotid endarterectomy, a surgeon removes plaques from arteries that run along each side of your neck to your brain (carotid arteries). In this procedure, your surgeon makes an incision along the front of your neck, opens your carotid artery and removes plaques that block the carotid artery. Your surgeon then repairs the artery with stitches or a patch made from a vein or artificial material (graft). The procedure may reduce your risk of ischemic stroke. However, a carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.
  • Angioplasty and stents: In an angioplasty, a surgeon establishes access into your carotid arteries most often through an artery in your groin. Your surgeon will gently and safely navigate to the carotid arteries in your neck, a balloon is then used to expand the narrowed artery. Then, a stent is placed to support the opened artery.

Hemorrhagic stroke

Emergency treatment of hemorrhagic stroke is focused towards control of your bleeding and reduction of pressure in your brain. Surgery also may be performed to help reduce future risk.

  • Emergency measures: If you take warfarin (Coumadin) or antiplatelet drugs such as clopidogrel (Plavix) to prevent blood clots, you may be given drugs or transfusions of blood products to counteract the blood thinners' effects.

You may also be given drugs to lower pressure in your brain (intracranial pressure), lower your blood pressure, prevent vasospasm or prevent seizures.

Once the bleeding in your brain stops, treatment usually involves supportive medical care while your body absorbs the blood. If the area of bleeding is large, your doctor may perform surgery to remove the blood and relieve pressure on your brain.

  • Surgical blood vessel repair: Surgery may be used to repair blood vessel abnormalities associated with hemorrhagic strokes.

Your doctor may recommend one of these procedures after a stroke or if an aneurysm or arteriovenous malformation (AVM) or another type of vascular malformation that caused your hemorrhagic stroke:

  • Surgical clipping: Your surgeon will place a tiny clamp at the base of an aneurysm, to stop the blood flow to it. This clamp can prevent bursting of an aneurysm or it can prevent re-bleeding of an aneurysm that has recently hemorrhaged.
  • Coiling (endovascular embolization): In this procedure, your surgeon inserts a catheter into an artery in your groin and guides it to your brain with the guidance of X-ray imaging. Your surgeon then guides tiny detachable coils into an aneurysm (an aneurysm coiling). The coils fill an aneurysm, which blocks blood flow into an aneurysm and causes the blood to clot.
  • Surgical AVM removal: Surgeons can remove a smaller AVM if it is located in an accessible area of your brain, to eliminate the risk of rupture and lower the risk of hemorrhagic stroke.

However, it is not always possible to remove an AVM if its removal would cause too large a reduction in brain function, or if it's large or located deep within your brain.

  • Intracranial bypass: In some circumstances, surgical bypass of intracranial blood vessels can be done to treat poor blood flow to a region of the brain or complex vascular lesions, such as aneurysm repair.
  • Stereotactic radiosurgery: Using multiple beams of highly focused radiation, stereotactic radiosurgery is an advanced minimally invasive treatment used to repair vascular malformations.

Stroke recovery and rehabilitation

After emergency treatment, stroke care focuses on helping you regain your strength, recover as much function as possible and return to independent living. The impact of your stroke depends on the area of the brain involved and the amount of tissue damaged.

If your stroke affected the right side of your brain, your movement and sensation on the left side of your body will be affected. If your stroke damaged the brain tissue on the left side of your brain, your movement and sensation on the right side of your body may be affected.

Brain damage to the left side of your brain results in speech and language disorders. Additionally, you may have problems with breathing, swallowing, balancing and vision.

Most stroke survivors should receive treatment in a rehabilitation program. Your doctor will recommend the most rigorous therapy program you can handle based on your age, overall health, and your degree of disability from your stroke.

Your doctor will take into consideration your lifestyle, interests and priorities, and the availability of family members or other caregivers.

Your rehabilitation program starts before you leave the hospital. It may continue in a rehabilitation unit of the same hospital, another rehabilitation unit or skilled nursing facility, an outpatient unit, or your home.

Every person's stroke recovery is different.

Depending on your condition, your treatment team may include:

  • Speech therapy session
  • Speech therapy session
  • Doctor trained in brain conditions (neurologist)
  • Rehabilitation doctor (physiatrist)
  • Nurse
  • Dietitian
  • Physical therapist
  • Occupational therapist
  • Recreational therapist
  • Speech therapist
  • Social worker
  • Case manager
  • Psychologist or psychiatrist
  • Chaplain

6 Prevention

Knowing your stroke risk factors, following your doctor's recommendations and adopting a healthy lifestyle are the best steps you can take to prevent a stroke.

If you have had a stroke or a transient ischemic attack (TIA), these preventive measures help you avoid another stroke. The follow-up care you receive in the hospital and afterward may play a role as well.

Most of the stroke prevention strategies are similar to strategies that prevent heart disease. In general, healthy lifestyle recommendations include:

Control of high blood pressure (hypertension): One of the most important things you can do to reduce your stroke risk is to keep your blood pressure under control.

If you've had a stroke, lowering your blood pressure can help prevent a subsequent transient ischemic attack or stroke.

Exercising, managing stress, maintaining a healthy weight, and limiting the amount of sodium and alcohol you eat and drink are all measures to keep high blood pressure in control.

In addition to lifestyle changes, your doctor may prescribe medications to treat high blood pressure.

Reduce the amount of cholesterol and saturated fat in your diet: Eat less cholesterol and fat, especially saturated fat and trans fats to reduce the fatty deposits (plaques) in your arteries.

If you cannot control your cholesterol through dietary changes, your doctor may prescribe certain cholesterol-lowering medications.

Quitting use of tobacco: Smoking increases the risk of stroke for smokers and nonsmokers exposed to secondhand smoke. Quitting the use of tobacco reduces your risk of stroke.

Control of diabetes: You can manage diabetes with diet, exercise, weight control and medication.

Maintaining a healthy weight: Being overweight contributes to other stroke risk factors, such as high blood pressure, cardiovascular disease, and diabetes. Weight loss of as little as 10 pounds may lower your blood pressure and improve your cholesterol levels.

Eating a diet rich in fruits and vegetables: A diet containing five or more daily servings of fruits or vegetables may reduce your risk of stroke. Following the Mediterranean diet, which emphasizes olive oil, fruit, nuts, vegetables and whole grains, may be helpful.

Exercising regularly: Aerobic or "cardio" exercise decreases your risk of stroke in several ways. Exercise can lower your blood pressure, increase your level of high-density lipoprotein cholesterol, and improve the overall health of your blood vessels and heart.

It also helps you lose weight, control diabetes and reduce stress. Gradually work up to 30 minutes of activity — such as walking, jogging, swimming or bicycling — on most, if not all, days of the week.

Avoiding alcohol, or drinking in moderation, if at all you want to: Alcohol can be both a risk factor and a protective measure for stroke.

Heavy alcohol consumption increases your risk of high blood pressure, ischemic strokes, and hemorrhagic strokes. However, drinking small to moderate amounts of alcohol, such as one drink a day, may help prevent ischemic stroke and decrease your blood's clotting tendency.

Alcohol may also interact with other drugs you are taking. Talk to your doctor about what is appropriate for you.

Treatment of obstructive sleep apnea, if present: Your doctor may recommend an overnight oxygen assessment to screen for obstructive sleep apnea (OSA). If OSA is detected, it may be treated by giving you oxygen at night or having you wear a small device in your mouth.

Avoid illicit drugs: Certain street drugs, such as cocaine and methamphetamines, are established risk factors for a TIA or a stroke. Cocaine reduces blood flow and can cause narrowing of arteries.

Preventive medications

If you have had an ischemic stroke or TIA, your doctor may recommend medications to reduce your risk of having another stroke. This include:

Anti-platelet drugs: Platelets are cells in your blood that are responsible for clots. Anti-platelet drugs make these cells less sticky and less likely to clot. The most commonly used antiplatelet medication is aspirin.

Your doctor can help you determine the right dose of aspirin for you. Your doctor may also consider prescribing Aggrenox, a combination of low-dose aspirin and the anti-platelet drug dipyridamole, to reduce the risk of blood clotting.

If aspirin does not prevent your TIA or stroke, or if you cannot take aspirin, your doctor may prescribe an antiplatelet drug such as clopidogrel (Plavix).

Anticoagulants: These drugs, which include heparin and warfarin (Coumadin), reduce blood clotting. Heparin is fast-acting and may be used over a short period of time in the hospital. Slower acting warfarin may be used over a longer term.

Warfarin is a powerful blood-thinning drug, so should be taken exactly as directed and watch for side effects.

Your doctor may prescribe these drugs if you have certain blood-clotting disorders, certain arterial abnormalities, an abnormal heart rhythm or other heart problems.

Other newer blood thinners may be used if your TIA or stroke was caused by an abnormal heart rhythm.

7 Lifestyle and Coping

Lifestyle modifications are necessary in order to cope with stroke.

A stroke is a life-changing disorder that can affect your emotional well-being as well as your physical functioning.

You may experience feelings of helplessness, frustration, depression and apathy. You may also have mood changes and a reduced sex drive.

Maintaining your self-esteem, connections with others and interest in the world are important aspects of your recovery. Several strategies may help you and your caregivers, including:

  • Don't be hard on yourself: You have to accept that both physical and emotional recovery will take time. Aim for a "new normal," and celebrate your progress. Allow time for rest.
  • Try getting out of the house even if it is difficult: Try not to be discouraged or self-conscious if you move slowly with the help of a cane, walker or wheelchair to get around. Getting out is good for you.
  • Join a support group: Meeting with others who are coping with a stroke lets you get out and share experiences, exchange information and forge new friendships.
  • Let friends and family know what you need. People may want to help, but they may not know what to do. Let them know how they can help, such as by bringing over a meal and staying to eat with you and talk, or attending social events or religious activities.
  • Know that you are not alone: Nearly 800,000 Americans have a stroke every year. That means approximately every 40 seconds someone has a stroke in the United States.

8 Risks and Complications

There are several risks and complications associated with stroke.

Various factors can increase your risk of a stroke. Some factors can also increase your chances of having a heart attack.

Potentially modifiable stroke risk factors include:

  • Lifestyle risk factors
  • Being overweight or obese
  • Physical inactivity
  • Heavy or binge drinking
  • Use of illicit drugs such as cocaine and methamphetamines

Medical risk factors

High blood pressure — the risk of stroke begins to increase at blood pressure readings higher than 120/80 millimeters of mercury (mm Hg).

Your doctor will help you decide on a target blood pressure based on your age, whether you have diabetes and other factors:

  • Cigarette smoking or exposure to secondhand smoke
  • High cholesterol
  • Diabetes
  • Obstructive sleep apnea — a sleep disorder in which the oxygen level transiently drops during the night.
  • Cardiovascular disease, including heart failure, heart defects, heart infection or abnormal heart rhythm.

Other factors associated with a higher risk of stroke include:

  • Personal or family history of stroke, heart attack or transient ischemic attack.
  • Age: Being age 55 or older.
  • Race: African-Americans have a higher risk of stroke than do people of other races.
  • Gender: Men have a higher risk of stroke than women. Women are usually older when they have strokes, and they are more likely to die of strokes than are men. Also, they may have some risk from some birth control pills or hormone therapies that include estrogen, as well as from pregnancy and childbirth.

Complications

A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain lacks blood flow and which part was affected. Complications may include:

  • Paralysis or loss of muscle movement: You may become paralyzed on one side of your body, or lose control of certain muscles, such as those on one side of your face or one arm. Physical therapy may help you return to activities affected by paralysis, such as walking, eating and dressing.
  • Difficulty in talking or swallowing: A stroke may cause you to have less control over the way the muscles in your mouth and throat move, making it difficult for you to talk clearly (dysarthria), swallow or eat (dysphagia). You also may have difficulty with language (aphasia), including speaking or understanding speech, reading or writing. Therapy with a speech and language pathologist may be helpful.
  • Memory loss or thinking difficulties: Many people who have had strokes may experience some loss of memory. Others may have difficulty in thinking, making judgments, reasoning out and understanding concepts.
  • Emotional problems: People who have had strokes may have more difficulty controlling their emotions, or they may go into depression.
  • Pain: People who have had strokes may have pain, numbness or other strange sensations in parts of their bodies affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm. People also may be sensitive to temperature changes, especially extreme cold after a stroke. This complication is known as central stroke pain or central pain syndrome. This condition generally develops after several weeks of a stroke, and it may gradually improve with time. As the pain is caused by a problem in your brain, rather than a physical injury, there are very few treatments available.
  • Changes in behavior and self-care ability: People who have had strokes may become more withdrawn and less social or more impulsive. They may need help with grooming and daily chores.

As with any brain injury, the success of treating these complications differs from person to another.

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