Stroke (Cerebrovascular accident, CVA)
Keep track of signs and symptoms if you think you may have a stroke. Note when signs and symptoms begin because the length of time symptoms are present can guide treatment decisions.
Stroke (Cerebrovascular accident, CVA)
A stroke occurs when the blood supply to part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die.
A stroke is a medical emergency. The right treatment is very important. Early action can minimize brain damage and potential complications.
Strokes are treatable and preventable, and far fewer Americans die from strokes now than 15 years ago. Better control of major stroke risk factors such as high blood pressure, smoking, and high blood cholesterol.
Keep track of signs and symptoms if you think you may have a stroke. Note when signs and symptoms begin because the length of time symptoms are present can guide treatment decisions.
The trouble with walking. Sudden tripping or dizziness, loss of balance or coordination may occur.
The trouble with speaking and understanding. May slur or cannot find words that explain what is happening (aphasia). Try to repeat a simple sentence. If so, you may have a stroke.
Paralysis of one side of the body or face. May develop sudden numbness, weakness, or paralysis on one side of the body. Try to raise both hands above your head at the same time. If an arm begins to fall, a stroke is possible. Likewise, the mouth may droop when trying to smile.
Vision problems in one or both eyes. Sudden blurred or dark vision or double vision may occur.
Headache. A sudden severe headache, which may be accompanied by vomiting, dizziness, or altered consciousness, may indicate a stroke.
Seek immediate medical attention if you notice any signs or symptoms of a stroke. Every minute counts, don't wait to see the symptoms go away. A stroke, if left untreated, is more likely to cause brain damage and disability. To maximize the effectiveness of evaluation and treatment, it is best to go to the emergency room within 60 minutes of the first symptoms.
If someone is suspected of having a stroke, watch them carefully while you wait for emergency help. It may be necessary to:
Start mouth-to-mouth resuscitation if breathing stops.
Turn your head to one side if vomiting occurs, which can block breathing.
Do not eat or drink.
A stroke disrupts normal blood flow through the brain and causes damage to brain tissue. There are two main types of stroke. The most common type - ischemic stroke - results from a blockage in an artery. The other type - hemorrhagic stroke - occurs when a blood vessel drains or bursts. A transient ischemic attack (TIA) - sometimes called a ministroke - temporarily disrupts blood flow through the brain.
Almost 90 percent of strokes are ischemic strokes. They occur when the arteries to the brain are narrowed or blocked, causing a severe reduction in blood flow (ischemia). Anemia causes brain cell loss due to a lack of oxygen and nutrients, and cells can begin to die within minutes. The most common ischemic strokes are:
Thrombotic stroke. This type of stroke occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to the brain. Blood clots often form in areas damaged by atherosclerosis, a disease in which arteries become blocked by fatty plaques. This process can occur in one of the carotid arteries that carry blood to the brain, as well as in other arteries of the neck or brain.
Vascular stroke. An embolic stroke occurs when a blood clot or other debris in a blood vessel travels to the brain - often in the heart - down the bloodstream to a narrower brain artery. This type of blood clot is called an embolism. It is usually caused by an irregular heartbeat (atrial fibrillation). An irregular heartbeat can lead to blood pooling in the heart and the formation of blood clots that travel elsewhere in the body.
Hemorrhage is the medical term for bleeding. A hemorrhagic stroke occurs when a blood vessel in the brain leaks or bursts. A brain hemorrhage can be caused by a number of problems affecting blood vessels, including uncontrolled high blood pressure and a weak spot in the wall of a blood vessel (aneurysm). An uncommon cause of bleeding is the rupture of an arteriovenous malformation (AVM), which is abnormally thin blood vessels at birth. There are two types of hemorrhagic stroke:
Hemorrhage in the brain. In this type of stroke, a blood vessel in the brain bursts and spills blood into the tissues surrounding the brain, damaging cells. The brain cells of the leaky area are stripped of blood and also damaged. High blood pressure is the most common cause of hemorrhagic stroke. Over time, high blood pressure can make the small arteries inside the brain brittle and prone to cracking and rupturing.
Subarachnoid hemorrhage. In this type of stroke, bleeding in an artery starts at or near the surface of the brain and spills into the space between the surface of the brain and the skull. This bleeding is often signaled by a sudden severe "thunder" headache. This type of stroke is usually caused by the rupture of an aneurysm, which can develop with age or be present from birth. After a hemorrhage, blood vessels in the brain can widen and narrow erratically (vasospasm), causing brain cell damage by further restricting blood flow to parts of the brain.
Transient ischemia (TIA)
A transient ischemic attack (TIA) - sometimes called a ministroke - is a brief episode of symptoms similar to wanting a stroke. The cause of a transient ischemic attack is a temporary decrease in blood supply to part of the brain. The transient ischemic attack is less than five minutes.
Like an ischemic stroke, a transient ischemic attack occurs when a blood clot or clot fragments temporarily block the flow of part of the brain. But unlike a stroke, which has a prolonged lack of blood supply and causes permanent tissue damage, a transient ischemic attack has no long-term effects because the blockage is temporary.
Seek emergency care even if symptoms seem to get better. If you've had a transient ischemic attack, which means you've likely blocked or narrowed part of an artery to your brain, you're at risk of a full-blown stroke that could cause permanent damage later in life. And it can't tell if you're having a stroke or a transient ischemic attack based on symptoms alone. Up to half of the people whose symptoms appear and go away actually have a stroke that causes brain damage.
Many factors can increase the risk of stroke. Some of these factors can also increase your risk of having a heart attack. Stroke risk factors include:
Personal or family history of stroke, heart attack, or TIA.
Age 55 and up.
High blood pressure - the risk of stroke begins to increase with blood pressure higher than 115/75 millimeters of mercury (mm Hg). Your doctor will help you decide on a blood pressure goal based on your age, diabetes, and other factors.
High cholesterol - a total cholesterol level above 200 mg/dL (mg/dL), or 5.2 millimoles/liter (mmol/L).
Smoking or exposure to secondhand smoke.
Overweight (body mass index 25 to 29) or obese (body mass index 30 or higher).
No physical activity.
Cardiovascular disease, including heart failure, heart defects, heart infections, or abnormal heart rhythms.
Use birth control pills or hormone therapy that includes estrogen.
Drinking too much alcohol.
Using illegal drugs such as cocaine and methamphetamines.
Because the risk of stroke increases with age, and women tend to live longer than men. Black people are more likely to have a stroke than people of other races.
A stroke can sometimes cause temporary or permanent disability, depending on how long the brain is deprived of blood and the part affected. Complications may include:
Paralysis, loss of muscle movement. Sometimes lack of blood flow to the brain can cause paralysis on one side of the body, or loss of control of certain muscles, such as the side of the face. With physical therapy, an improvement in muscle movement or paralysis may be seen.
Difficulty talking or swallowing. A stroke can cause less muscle control in moving the mouth and throat, making it difficult to speak, swallow or eat. A person may have a hard time speaking because a stroke has caused aphasia, a condition in which it is difficult to express thoughts through language. Pathological and speech therapy can improve this disability.
Memory loss or trouble understanding. Some memory loss is common in people who have had a stroke. Others may develop difficulty making decisions, reasoning, and understanding. These complications may improve with rehabilitative therapies.
Pain. Some people who have a stroke may experience pain, numbness, or other strange sensations in the part of the body affected by the stroke. For example, if a stroke causes loss of sensation in an arm, you may develop an uncomfortable tingling sensation in that arm. May also be sensitive to temperature changes, especially cold. This is called a central stroke or central pain syndrome (CPS). This complication usually develops within a few weeks of a stroke, and it can improve over time. But because the pain is caused by a problem in the brain rather than a physical injury, there are several medications to treat CPS.
Change your behavior and take care of yourself. People who have had a stroke may become less talkative and social or impulsive. They may lose the ability to care for themselves and may need a carer to help with daily chores.
As with any brain injury, the success of treating complications will vary from person to person.
Testing and diagnosis
To determine the best treatment for a stroke, it is important to find out the type of stroke you are having and the parts that are affected. Other possible causes of symptoms, such as a brain tumor or a reaction to the medication, also need to be ruled out. Your doctor may also use several tests to determine your risk of stroke.
Clinical examination. The doctor needs to know what symptoms were present when it started, and what to do when it started, and will then evaluate the symptoms present. Doctors want to know the medications taken and the history of any head injuries. Doctors will also ask about your personal and family history of heart disease, TIA, or stroke. Your doctor will check your blood pressure and listen to your heart and listen for sounds in your carotid (neck) arteries, which can indicate atherosclerosis. Your doctor may also use an ophthalmoscope to check for signs of cholesterol crystals or clots in the blood vessels at the back of the eye.
Blood tests. Blood tests provide important information such as blood clotting speed and high or low blood sugar, chemicals in the blood, or whether infection may be present. Blood clotting time and important sugar and chemical levels must be managed as part of stroke care. Infections must also be treated.
Computed tomography (CT). Brain imaging plays an important role in determining the stroke and what type. Computed tomography (CTA) scan, in which dye is injected into a vein and an X-ray beam creates a 3D image of the blood vessels in the neck and brain. Doctors look for aneurysms or arteriovenous and arterial malformations and evaluate for narrowing. CT, done without dye, can provide images of brain hemorrhage but provides little insight into the blood vessels.
Magnetic resonance imaging (MRI). A strong magnetic field and radio waves create 3D images of the brain. An MRI can detect brain tissue damaged by an ischemic stroke. Magnetic resonance imaging (MRA) uses a magnetic field, radio waves, and dye injected into a vein to evaluate arteries in the neck and brain.
Carotid ultrasound. This procedure can identify narrowed arteries or blood clots in the carotid arteries. A wand-like device (transducer) sends high-frequency sound waves into the neck. The sound waves pass through the tissue and then back, creating an image on the screen.
Arterial passage. This procedure provides images of arteries in the brain that are not seen on X-rays. The doctor inserts the tube through a small incision, usually in the groin area. The tube passes through the major arteries and into the carotid or vertebral arteries. The doctor then injects a dye through the catheter to provide X-ray images of the arteries.
Echocardiography. This technology creates an image of the heart, allowing doctors to see if a blood clot (embolus) from the heart is traveling to the brain and causing a stroke. Your doctor may need to use a transesophageal echocardiogram (TEE) to check your heart more clearly.
Treatments and drugs
Emergency treatment for a stroke depends on whether you are having an ischemic stroke that blocks an artery - the most common type - or a hemorrhagic stroke that involves bleeding in the brain.
To treat an ischemic stroke, doctors must quickly restore blood flow to the brain.
Emergency medical treatment. Anticoagulation therapy must begin within 4.5 hours - and the sooner the better. Prompt treatment not only improves the chances of survival, it can also reduce the complications of a stroke.
Aspirin. Aspirin is the best, proven treatment immediately after an ischemic stroke to reduce the chance of stroke. In the emergency room, a dose of aspirin will most likely be given. Doses can vary, but if you've been taking daily aspirin for an effective blood thinner, it may be noted on your medical card so doctors know you've taken aspirin.
Blood thinners: Such as warfarin (Coumadin), heparin, and clopidogrel (Plavix) may also be prescribed, but they are not used as often as aspirin.
Intravenous plasminogen activator (TPA) injection. Some people who are having an ischemic stroke may benefit from plasminogen-activated injections
Doctors also recommend procedures to prevent strokes. Options may include:
Surgical removal of carotid plaque. The surgeon removes the plaque blocking the carotid artery. Blocked arteries are opened, plaques are removed. The procedure can reduce the risk of ischemic stroke. However, in addition to the usual risks associated with surgery, carotid artery plaque removal surgery can also cause a stroke or heart attack due to blood clots or fatty debris. Surgeons try to reduce this risk by placing filters (distal protective devices) at several points in the bloodstream to "catch" material that may be caused by the procedure.
Angioplasty and stents. Angioplasty is a technique that can widen the passage of plaque vessels leading to the brain, usually the carotid artery. During this procedure, a balloon catheter is inserted into the blocked artery area. The balloon is inflated, compressing the atherosclerotic plaque against the wall. A metal mesh tube (stent) is placed in the artery to prevent recurrent narrowing. Intracerebral artery stenting is similar to carotid artery stenting. Using a small incision in the groin, the doctor inserts the catheter through an artery and into the brain. Sometimes, angioplasty is used to widen the artery first.
Emergency treatment for hemorrhagic stroke focuses on controlling bleeding and reducing pressure in the brain. Surgery may also be used to help control future risks.
Emergency measures. If you take warfarin (Coumadin), an antiplatelet medicine such as clopidogrel (Plavix) to prevent blood clots, you may be able to take certain medications or infuse blood products to counteract their effects. Medicines may also be given to lower blood pressure, stop seizures, and reduce bleeding brain reactions (vasospasm). People with hemorrhagic strokes should not take anticoagulants such as aspirin and TPA because these drugs can worsen bleeding.
After the bleeding in the brain stops, treatment usually involves rest and supportive medical care. If the area of bleeding is large, surgery may be used in certain cases to remove blood and relieve pressure on the brain.
Vascular repair surgery. Surgery may be used to repair abnormal blood vessels associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if there is a high risk of spontaneous aneurysm or arteriovenous malformation (AVM) rupture:
Aneurysm clamp. A small clamp is placed at the site of the aneurysm, isolating the arterial circulation. This may keep the aneurysm from bursting or may prevent re-bleeding of a recent aneurysm. The clamp will stay in place permanently.
Prevent aneurysm. This procedure replaces the aneurysm clamp. The surgeon uses a small coiled catheter into this aneurysm. This coil creates a scaffold where a blood clot can form and seal the ruptured aneurysm.
Surgical removal of the AVM. The AVM cannot always be removed if it is too large or if it is located deep in the brain. Surgical removal of a smaller AVM from an easily accessible part of the brain, although it can eliminate the risk of rupture, reduces the overall risk of hemorrhagic stroke.
Stroke recovery and rehabilitation
After emergency treatment, stroke care focuses on helping to regain strength, regain as much function as possible, and return to independent living. The impact of a stroke depends on the area of the brain involved and the number of damaged cells. Damage to the right side of the brain can affect movement and sensation on the left side of the body. Damage to brain tissue on the left side can affect the right side, which can also cause damage and language disturbances. Also, if you've had a stroke, there may be problems with breathing, swallowing, or balance. There may also be loss of vision and loss of bladder or bowel function.
Most stroke victims are treated in a rehabilitation program. Your doctor will recommend the most rigorous program based on your age, overall health, and degree of disability from the stroke. Recommendations are also based on lifestyle, interests and priorities, and the availability of other family members or carers.
A rehabilitation program can begin before leaving the hospital. It may continue in a rehabilitation unit of the same hospital, other unit or rehabilitation nursing facility, outpatient unit, or at home.
Each person's stroke recovery is different. Depending on the complications, the team of people who help with recovery may include specialists:
Rehabilitation doctor (physiatrist).
Psychologist or psychiatrist.
Coping and supporting
Stroke is a life-changing problem that can affect emotions, many physical functions. Feelings of helplessness, depression, frustration, and apathy are not unusual. Reduced sex drive and mood swings are also common.
Maintaining self-esteem, connections to others, and caring in the world is an essential part of recovery.
Don't be hard on yourself. Accept that physical and emotional recovery will involve hard and time-consuming work.
Get out of the house even if it's hard. Try not to get discouraged or self-conscious if moving slowly and needing a cane, walker or wheelchair to get around.
Join a support group. Meeting with others who are dealing with stroke allows for recognition and sharing of experiences and information exchange.
Let friends and family know what to expect. People may want to help but can't be sure how.
Not alone. Nearly 800,000 Americans have a stroke every year. About 6.5 million people live with a stroke.
One of the most frustrating effects of a stroke is that it can affect speech and language. Here are some tips to help both stroke survivors and caregivers deal with communication challenges:
Practice talking. Try having a conversation at least once a day. It will help learn what works best, help feel connected, and rebuild confidence.
Relax. It can be easiest and most enjoyable in a relaxing situation when there is plenty of time. Some stroke survivors find that after dinner is the best time to relax.
Speak the right way. While recovering from a stroke, it may be necessary to use fewer words or to rely on gestures or tone of voice to get ideas.
Use props and communication aids. May find it helpful to use cues that show commonly used words, pictures of loved ones and family members, and daily activities such as a favorite TV show.
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've had a stroke or TIA, these measures can also help prevent a recurrence. Many stroke prevention strategies are similar to those for preventing heart disease. In general, a healthy lifestyle means:
Control hypertension. One of the most important things you can do to reduce your risk of stroke is to keep your blood pressure under control. If you've had a stroke, lowering blood pressure can help prevent transient ischemic attacks or subsequent strokes. Exercise, stress management, maintaining a healthy weight, and limiting salt and alcohol intake are all ways to keep high blood pressure under control. Adding more potassium in the diet can also help. In addition to recommending lifestyle changes, your doctor may prescribe medications to treat high blood pressure, such as diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers. II and beta-blockers.
Lower cholesterol and saturated fat in the diet. Eating less cholesterol and fats, especially saturated and trans fats, can reduce plaque in the arteries. If your cholesterol cannot be controlled through dietary changes, your doctor may prescribe a statin such as simvastatin (Zocor) or atorvastatin (Lipitor), or another that lowers cholesterol.
No smoking. Smoking increases the risk of stroke for both smokers and non-smokers exposed to secondhand smoke. Quitting smoking reduces the risk - years after quitting, ex-smokers have the same risk of stroke as non-smokers.
Control diabetes. Diabetes can be managed with diet, exercise, weight control, and medication.
Maintain a healthy weight. Being overweight contributes to other risk factors for stroke, such as high blood pressure, cardiovascular disease, and diabetes. Weight loss of at least 5% can lower blood pressure and improve cholesterol levels.
Eat a diet rich in fruits and vegetables. A diet containing 5/10 or more daily servings of fruits or vegetables may reduce the risk of stroke.
Exercise regularly. Exercise reduces the risk of stroke in several ways. Exercise can lower blood pressure, increase high-density lipoprotein (HDL, or "good") levels, and improve the overall health of your blood vessels and heart. It also helps with weight loss, diabetes control, and stress relief. Gradually work up to 30 minutes of activity - such as walking, jogging, swimming or biking - on most days, if not all days of the week.
Drink alcohol in moderation. Alcohol can increase both risk factors and measures for stroke prevention. Excessive drinking and heavy alcohol consumption increase the risk of high blood pressure and ischemic and hemorrhagic strokes. However, moderate alcohol consumption can increase HDL cholesterol and decrease its tendency to clot. Both factors may contribute to a reduced risk of ischemic stroke.
Do not use illegal drugs. Some drugs, such as cocaine and methamphetamines, are established risk factors for TIA or stroke.
If you've had an ischemic stroke or TIA, your doctor may recommend medication to help reduce your risk. These include:
Antiplatelet drugs. Platelets are cells in the blood. Antiplatelet drugs make these cells non-sticky and less likely to form blood clots. The most commonly used antiplatelet drug is aspirin. Your doctor can help determine the dose of aspirin.
Your doctor may also consider prescribing Aggrenox, a combination of low-dose aspirin and the antiplatelet drug dipyridamole, to reduce blood clotting. If aspirin does not prevent a TIA or stroke, or if aspirin cannot be taken, your doctor may prescribe an antiplatelet drug such as clopidogrel (Plavix) or ticlopidine (Ticlid).
Anticoagulants. These drugs include heparin and warfarin (Coumadin). They affect blood clotting differently than antiplatelet agents. Heparin is quick to act and is used for a short time in the hospital. Warfarin slow is used for a long time.
Warfarin is a strong blood thinner, so it will be necessary to take it exactly as directed and watch for side effects. Your doctor may prescribe these drugs if you have a blood clotting disorder or certain artery abnormalities; abnormal heart rhythms, such as atrial fibrillation or other heart problems.