Stroke

A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die.

A stroke is a medical emergency. Prompt treatment is crucial. Early action can minimize brain damage and potential complications.

Approximately 185,000 people die from stroke each year, making it the fifth leading cause of death in America. It is also a leading cause of adult disability for those who survive stroke.

There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. The other kind, called hemorrhagic stroke, is caused by a blood vessel that breaks and bleeds into the brain. "Mini-strokes" or transient ischemic attacks (TIAs), occur when the blood supply to the brain is briefly interrupted.

Symptoms of stroke are:

• sudden numbness or weakness of the face, arm or leg (especially on one side of the body)
• sudden confusion, trouble speaking or understanding speech
• sudden trouble seeing in one or both eyes
• sudden trouble walking, dizziness, loss of balance, or coordination
• sudden severe headache with no known cause

If you have any of these symptoms, you must get to a hospital quickly to begin treatment. Therapies try to stop a stroke while it is happening by quickly dissolving the blood clot or by stopping the bleeding. Post-stroke rehabilitation helps individuals overcome disabilities that result from stroke damage. Drug therapy with blood thinners is the most common treatment for stroke.

These signs and symptoms may be present if you or someone else is having a stroke:

Trouble with speaking and understanding. You may experience confusion. You may slur your words or have difficulty understanding speech.

Paralysis or numbness of the face, arm, or leg. You may develop sudden numbness, weakness or paralysis in your face, arm or leg, especially on one side of your body. Try to raise both your arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your mouth may droop when you try to smile.

Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision in one or both eyes, or you may see double.

Headache. A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke.

Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination.

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

Use the acronym "FAST" to help you remember what to do during a stroke:

• 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 unable to raise up?
• Speech. Ask the person to repeat a simple phrase. Is his or her speech slurred or strange?
• Time. If you observe any of these signs, call 911 immediately. Do not wait to see if symptoms go away. Every minute counts. The longer a stroke goes untreated, the greater the potential for brain damage and disability.

A stroke occurs when the blood supply to your brain is interrupted or reduced. A stroke may be caused by a blocked artery (ischemic stroke) or the leaking or bursting of a blood vessel (hemorrhagic stroke). Some people may experience only a temporary disruption of blood flow to their brain (transient ischemic attack or TIA).

Most strokes (about 85 percent) are ischemic strokes. Ischemic strokes occur when the arteries to your brain become narrowed or blocked, causing severely reduced blood flow (ischemia). The most common ischemic strokes include thrombotic stroke and embolic stroke. A thrombotic stroke occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot may be caused by fatty deposits (plaque) that build up in arteries and cause reduced blood flow (atherosclerosis) or other artery conditions. An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of blood clot is called an embolus.

Hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures. Brain hemorrhages can result from many conditions that affect your blood vessels, including uncontrolled high blood pressure (hypertension), overtreatment with anticoagulants, and weak spots in your blood vessel walls (aneurysms).

Types of hemorrhagic stroke include intracerebral hemorrhage and subarachnoid hemorrhage. In an intracerebral hemorrhage, a blood vessel in the brain bursts and spills into the surrounding brain tissue, damaging 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.

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 signaled by a sudden, severe headache. A subarachnoid hemorrhage is commonly caused by 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 erratically (vasospasm), causing brain cell damage by further limiting blood flow.

A TIA — also known as a mini-stroke — is a brief period of symptoms similar to those you would have in a stroke. A temporary decrease in blood supply to part of your brain causes TIAs, which often last less than five minutes. Like an ischemic stroke, a TIA occurs when a clot or debris blocks blood flow to part of your brain. A TIA does not leave lasting symptoms because the blockage is temporary. A TIA is a warning sign for a future stroke, and more than one-third of people who have a TIA have a stroke within 1 year if they do not receive treatment.

It is not possible to tell if you are having a stroke or a TIA only on the basis of your symptoms.

Many factors can increase your risk of a stroke, including:

• being overweight or obese
• physical inactivity
• heavy or binge drinking
• using illicit drugs such as cocaine and methamphetamines
• high blood pressure
• cigarette smoking or exposure to secondhand smoke
• high cholesterol
• diabetes
• obstructive sleep apnea — a sleep disorder in which the oxygen level intermittently drops during the night
• cardiovascular disease, including heart failure, heart defects, heart infection, or abnormal heart rhythm
• personal or family history of stroke, heart attack or transient ischemic attack.
• being age 55 or older
• African-American race
• being male

If you are having signs and symptoms of a stroke, an emergency team must evaluate the type of stroke you are having and the areas of your brain affected by the stroke. They also need to rule out other possible causes of your symptoms. Several tests may be used as part of this evaluation. Some of these tests may also be used to evaluate your risk factors for future strokes.

• Physical examination. Your doctor will ask you or a family member what symptoms you have been having, 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 check your blood pressure and use a stethoscope to listen to your heart. Your doctor may also use an ophthalmoscope to check for signs of tiny cholesterol crystals or clots in the blood vessels at the back of your eyes.
• Blood tests. You may have several blood tests, which tell your care team 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 create detailed images of the inside of the carotid arteries in your neck. This test shows buildup 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, usually in your groin, and guides it 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 under X-ray imaging. This procedure gives a detailed view of arteries in your brain and neck.
• Echocardiogram. An echocardiogram uses sound waves to create detailed images of your heart. An echocardiogram can find a source of clots in your heart that may have traveled from your heart to your brain and caused your stroke.

A stroke is a life-changing event that can affect your emotional well-being as much as your physical function. You may experience feelings of helplessness, frustration, depression and apathy. You may also have mood changes. Maintaining your self-esteem, connections to others and interest in the world are essential parts of your recovery. Several strategies may help you and your caregivers.

• Set realistic goals. Accept that physical and emotional recovery will involve tough work and that it will take time. Aim for a "new normal," and celebrate your progress. Allow time for rest.
• Stay active and engaged, even if it’s difficult. Try not to be discouraged or self-conscious if you move slowly and need a cane, walker or wheelchair to get around.
• Find support. 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.

One of the most frustrating effects of stroke is that it can affect your speech and language. Several things can help you and your caregivers cope with communication challenges.

• Practice. Try to have a conversation at least once a day. It will help you learn what works best for you, feel connected, and rebuild your confidence.
• Relax and be patient. Talking may be easiest and most enjoyable in a relaxing situation when you have plenty of time.
• Change how you communicate. When you are recovering from a stroke, you may need to use fewer words, rely on gestures, or use your tone of voice to communicate. You may find it helpful to use cue cards showing frequently used words, pictures of close friends and family members, or daily activities.

To prevent a stroke, know your stroke risk factors, follow your doctor's recommendations, and adopt a healthy lifestyle. If you've had a stroke or a transient ischemic attack (TIA), these measures may help you avoid having another stroke. The follow-up care you receive in the hospital and afterward will also play a role.

Many stroke prevention strategies are the same as those to prevent heart disease. In general, healthy lifestyle recommendations include:

• controlling high blood pressure (hypertension)
• lowering the amount of cholesterol and saturated fat in your diet
• quitting tobacco use
• controlling diabetes
• maintaining a healthy weight
• eating a diet rich in fruits and vegetables
• exercising regularly
• drinking alcohol only in moderation, if at all
• treating obstructive sleep apnea or other conditions that affect your risk of stroke, if present
• avoiding illicit drugs

Emergency treatment for stroke depends on the type of stroke you are having.

To treat an ischemic stroke, doctors must quickly restore blood flow to your brain. 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 prevents blood clots from forming. Aspirin is an immediate treatment given in the emergency room to reduce the likelihood of having another stroke.
• Intravenous injection of tissue plasminogen activator (TPA). Some people can benefit from an injection of a recombinant TPA, such as alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase). An injection of TPA is usually given through a vein in the arm. This potent clot-busting drug needs to be given within 4.5 hours after stroke symptoms begin if it is given in the vein. TPA restores blood flow by dissolving the blood clot causing your stroke, and it may help people who have had strokes recover more fully. Your doctor will consider certain risks, such as potential bleeding in the brain, to determine if TPA is appropriate for you.

Doctors sometimes treat ischemic strokes with procedures that must be performed as soon as possible, depending on features of the blood clot. Doctors may 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 is occurring. The time window for this treatment is somewhat longer than for intravenous TPA but is still limited. Doctors may also use a catheter to maneuver a tiny device into your brain to physically break up or grab and remove the clot.

Emergency treatment of hemorrhagic stroke focuses on controlling the bleeding and reducing pressure in your brain. Surgery also may be performed to help reduce future risk.

• If you take warfarin (Coumadin) or anti-platelet 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. Healing is similar to what happens while a bad bruise goes away. If the area of bleeding is large, your doctor may perform surgery to remove the blood and relieve pressure on your brain.
• Surgery may be used to repair blood vessel abnormalities associated with hemorrhagic strokes. Your doctor may recommend surgical clipping or endovascular embolization (coiling) or other procedures after a stroke or if an aneurysm or other type of vascular malformation caused your hemorrhagic stroke.

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.

• You may have problems with movement or sensation on one side of your body and you may experience trouble with breathing, swallowing, balancing, and vision.
• Most stroke survivors 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.
• If you have had an ischemic stroke or TIA, your doctor may recommend medications to help reduce your risk of having another stroke, including:
  • Anti-platelet drugs. Platelets are cells in your blood that initiate clots. Anti-platelet drugs make these cells less sticky and less likely to clot. The most commonly used anti-platelet medication is aspirin. Dipyridamole (in Aggrenox) and clopidogrel (Plavix) are anti-platelet drugs that can be used if you cannot take aspirin or if aspirin has not prevented a stroke in the past.
  • Anticoagulants. These drugs, which include heparin and warfarin (Coumadin, Jantoven), reduce the blood’s ability to clot.