Stroke

A stroke, or “brain attack”, happens when blood flow to your brain is stopped. This is an emergency situation. Call 911 if you think you might be having a stroke or stroke symptoms. 

The brain needs a constant supply of oxygen and nutrients in order to work well. If blood supply is stopped, even for a short time, this can cause problems. Brain cells begin to die after just a few minutes without blood or oxygen.

When brain cells die, brain function is lost. You may not be able to do things that are controlled by that part of the brain. 

A stroke may affect your ability to:

• Move.

• Speak.

• Eat, drink, and swallow.

• See clearly.

• Think and remember.

• Control your bowel and bladder.

• Control your emotions.

• Control other vital body functions.

A stroke can happen to anyone at any time.

• Weakness. You may feel a sudden weakness, tingling, or a loss of feeling on one side of your face or body, including your arm or leg. 

• Vision problems. You may have sudden double vision or trouble seeing in one or both eyes.

• Speech problems. You may have sudden trouble talking, slurred speech, or problems understanding others.

• Headache. You may have a sudden and severe headache.

• Movement problems. You may have sudden trouble walking, dizziness, a feeling of spinning, a loss of balance, a feeling of falling, or blackouts.

• Seizure. You may also have a seizure with a large or hemorrhagic stroke. 

Remember: If you have any of these symptoms, call 911 immediately.

Act F.A.S.T

F.A.S.T. is an easy way to remember the signs of a stroke. If you or a loved one is experiencing any of these signs or symptoms, call 911 immediately. F.A.S.T. stands for:

• F is for face drooping. One side of the face is drooping or numb. When the person smiles, the smile is uneven.

• A is for arm weakness. One arm is weak or numb. When the person lifts both arms at the same time, one arm may drift downward.

• S is for speech difficulty. You may notice slurred speech or difficulty speaking. The person can't repeat a simple sentence correctly when asked.

• T is for time to dial 911. If someone shows any of these symptoms, even if they go away, call 911 right away. Make a note of the time the symptoms first appeared.

There are two main types of stroke: ischemic and hemorrhagic. Ischemic stroke is caused by a blockage in the blood vessels leading to the brain, while hemorrhagic stroke is caused by bleeding in or around the brain. 

• Transient ischemic attacks (TIAs) are "mini-strokes" that happen when blood flow to the brain is briefly interrupted. Although transient ischemic attacks don't last as long as full-blown strokes, they're still serious and can be a warning sign that a more serious stroke is coming.

Strokes are either:

• Ischemic. These are strokes caused by blockage of an artery (or rarely, a vein). Most strokes are this type.

• Hemorrhagic. These are strokes caused by bleeding. About 13 in 100 strokes are this type.

An ischemic stroke occurs when plaque or a blood clot blocks blood flow to an artery in or on the brain. Ischemia, or severely reduced blood flow, causes brain cells and tissues to die within minutes from lack of oxygen and nutrients. 

Ischemic strokes are further divided into two groups:

• Thrombotic strokes. These are caused by a blood clot that develops in the blood vessels inside the brain.

• Embolic strokes. These are caused by a blood clot that develops elsewhere in the body. The clot then travels to one of the blood vessels in the brain through the bloodstream.

Thrombotic stroke

Thrombotic strokes are strokes caused by a blood clot (thrombus) that develop in the arteries supplying blood to the brain. This type of stroke is usually seen in older people, especially those with high cholesterol and a buildup of fat and lipids inside the walls of blood vessels (atherosclerosis) or diabetes. 

Sometimes, symptoms of a thrombotic stroke can occur suddenly. They can happen during sleep or in the early morning. At other times, it may occur gradually over a period of hours or even days.

Before a thrombotic stroke occurs, some patients may experience mini-strokes, or TIAs, that typically last for a few minutes or up to 24 hours. . They are often a warning sign that a stroke may occur. Symptoms of a TIAare often mild and temporary, but they are similar to those caused by a stroke.

Another type of thrombotic stroke that occurs in the small blood vessels in the brain is called a lacunar infarct stroke. The word lacunar comes from the Latin word meaning "hole" or "cavity." Lacunar infarctions are often found in people who have diabetes or high blood pressure.

Embolic stroke

Embolic strokes are usually caused by a blood clot that forms elsewhere in the body (embolus) and travels through the bloodstream to the brain. Embolic strokes are often caused by heart disease or heart surgery. They happen quickly and without any warning signs. About three in 20 embolic strokes occur in people with atrial fibrillation. This is a type of heart rhythm problem where the upper chambers of the heart (atria) don't beat well.

Hemorrhagic strokes occur when a blood vessel that supplies the brain ruptures and bleeds. When an artery bleeds into the brain, brain cells and tissues don't get oxygen and nutrients. Pressure also builds up in surrounding tissues and irritation and swelling occurs. This can lead to more brain damage.

Hemorrhagic strokes are divided into two main categories:

• Intracerebral hemorrhage. Bleeding is from the blood vessels within the brain.

• Subarachnoid hemorrhage. Bleeding is in the space between the brain and the membranes that cover the brain (subarachnoid space).

Intracerebral hemorrhage

Intracerebral hemorrhage is usually caused by high blood pressure. Bleeding occurs quickly. There are usually no warning signs. Bleeding can be severe enough to cause coma or death.

Subarachnoid hemorrhage

Subarachnoid hemorrhage results when bleeding occurs between the brain and the membrane that covers the brain (meninges) in the subarachnoid space. This type of hemorrhage is often because of an aneurysm or an arteriovenous malformation (AVM). It can also be caused by trauma.

An aneurysm is a weakened, ballooned area on an artery wall that may break (rupture). Aneurysms may be present at birth (congenital), orr they may develop later in life because of high blood pressure or blood vessel disease (atherosclerosis).

An AVM is a congenital problem that has a disorderly tangled web of arteries and veins. The cause of an AVM is unknown. It's sometimes genetic or part of certain syndromes.

If you are experiencing stroke symptoms you can expect to receive a complete health history and physical exam from your healthcare provider.  You will need tests for stroke such as brain imaging and measuring the blood flow in the brain.

Tests may include:

• CT (computed tomography) scan of the brain. An imaging test that uses X-rays to take clear, detailed images of the brain. A brain CT scan can show bleeding in the brain or damage to brain cells caused by a stroke. It is used to find abnormalities and help find the location or type of stroke.

• MRI (magnetic resonance imaging). This test uses a combination of large magnets, radiofrequencies, and a computer to make detailed images of organs and structures in the body. An MRI uses magnetic fields to find small changes in brain tissue that help to find and diagnose stroke.

• CTA (computed tomographic angiography). An X-ray image of the blood vessels. A CT angiogram uses CT technology to get images of blood vessels.

• MRA (magnetic resonance angiography). This test uses MRI technology to check blood flow through the arteries.  

• Doppler sonography (carotid ultrasound). A test that uses sound waves to create pictures of the inside of your carotid arteries. This test can show if plaque has narrowed or blocked your carotid arteries.

The following heart tests may also be used to help diagnose heart problems that may have led to a stroke:

• Electrocardiogram (ECG). This test records your heart’s electrical activity. It shows any irregular heart rhythms that may have caused a stroke.

• Echocardiography. This test uses sound waves to create a picture of your heart. This test shows the size and shape of your heart. It can check if the heart valves are working properly. It can also see if there are blood clots inside your heart.

Your healthcare provider will create a care plan for you based on:

• Your age, overall health, and past health.

• The type of stroke you had.

• How severe your stroke was.

• Where in your brain the stroke happened.

• What caused your stroke.

• How well you handle certain medicines, treatments, or therapies.

• Your opinion or preference.

There is no cure for stroke once it has occurred. But advanced medical and surgical treatments are available. These can help reduce your risk for another stroke.

Treatment is most effective when started right away. Emergency treatment after a stroke may include:

• Medicines and therapy to reduce or control brain swelling. Special types of IV (intravenous) fluids are often used to help reduce or control brain swelling. They are used especially after a hemorrhagic stroke.

• Life support measures. These treatments include using a machine to help you breathe (a ventilator), having IV fluids, getting proper nutrition, and controlling your blood pressure.

• Craniotomy. This is a type of brain surgery that is done to remove blood clots, relieve pressure, or repair bleeding in the brain.

• Clot-busting medicines (thrombolytics or fibrinolytics). These medicines dissolve the blood clots that cause an ischemic stroke. They can help reduce the damage to brain cells caused by the stroke. To be most effective, they must be given within a certain amount of time from when stroke symptoms start.
  • Tenecteplase (TNK). TNK is a protein that can break up blood clots. It is a powerful clot-busting medication administered to patients experiencing an acute ischemic stroke. Intravenous (IV) clot-busting medications are given through a vein in your arm. A catheter (thin tube) is threaded through an artery in your arm and into your brain. TNK is then injected directly into the blocked artery dissolving the blood clot.
  • Tissue Plasminogen Activator (tPA). TPA is a clot-busting drug used to break up a blood clot and restore blood flow to the brain. TPA is administered through a vein in your arm. A catheter (thin tube) is threaded through an artery in your arm and into your brain. The clot-busting medicine is then injected directly into the blocked artery.

• Cerebral angioplasty and stenting. This procedure opens narrowed or blocked arteries in your brain. A small balloon is threaded through the blocked artery and widened. A small metal coil (stent) is often placed in the artery to help keep it open.

• Embolization procedures. An embolization procedure blocks or severs the artery that is supplying blood to the area of your brain affected by the stroke. This stops the flow of blood and oxygen to the damaged area and prevents further damage.

• Surgery. Surgery may be done to remove a blood clot, relieve bleeding in the brain, or repair a damaged blood vessel.Medicines and therapy to reduce or control brain swelling. Special types of IV fluids are often used to help reduce or control brain swelling. They are used especially after a hemorrhagic stroke.

• Neuroprotective medicines. These medicines help protect the brain from damage and lack of oxygen (ischemia).

• Life support measures. These treatments include using a machine to help you breathe (a ventilator), having IV fluids, getting proper nutrition, and controlling your blood pressure.
• Craniotomy. This is a type of brain surgery that is done to remove blood clots, relieve pressure, or repair bleeding in the brain.

Recovery from stroke and the specific ability affected depends on the size and location of the stroke.

A small stroke may cause problems such as weakness in your arm or leg.

Larger strokes may cause parts of your body to not be able to move (be paralyzed). Larger strokes can also cause loss of speech or even death.

How a stroke affects you depends on where the stroke occurs in your brain, and how much damage it caused. Many people who have a stroke are left with paralysis of one of their arms.

Other problems can include having trouble with:

• Thinking.

• Speaking.

• Walking.

• Swallowing, eating, or drinking.

• Doing simple math such as adding, subtracting, or balancing a checkbook.

• Dressing.

• Showering.

• Going to the bathroom.

Some people may need long-term physical rehabilitation. They may not be able to live in their home without help.

Support services are available to help with physical and emotional needs after a stroke.

Strokes can happen again. Call your healthcare provider if you have symptoms that seem like a stroke, even if they don’t last long.

If you have repeated damage to your brain tissue, you may be at risk for life-long (permanent) disabilities.

Anyone can have a stroke at any age. But your chance of having a stroke increases if you have certain risk factors. Some risk factors for stroke can be changed or managed, while others can’t.

Here are the risk factors for stroke that can be changed, treated, or medically managed:

• High blood pressure. Blood pressure of 140/90 or higher can damage blood vessels (arteries) that supply blood to the brain.

• Heart disease. Heart disease is the second most important risk factor for stroke, and the major cause of death among survivors of stroke. Heart disease and stroke have many of the same risk factors.

• Diabetes. People with diabetes are at greater risk for a stroke than someone without diabetes.

• Smoking. Smoking almost doubles your risk for an ischemic stroke.

• Birth control pills (oral contraceptives).

• History of TIAs (transient ischemic attacks). TIAs are often called mini-strokes. They have the same symptoms as stroke, but the symptoms don’t last. If you have had one or more TIAs, you are almost 10 times more likely to have a stroke than someone of the same age and sex who has not had a TIA.

• High red blood cell count. A significant increase in the number of red blood cells thickens the blood and makes clots more likely. This raises the risk for stroke.

• High blood cholesterol and lipids. High cholesterol levels can contribute to thickening or hardening of the arteries (atherosclerosis) caused by a buildup of plaque. Plaque is deposits of fatty substances, cholesterol, and calcium. Plaque buildup on the inside of the artery walls can decrease the amount of blood flow to the brain. A stroke occurs if the blood supply is cut off to the brain.

• Lack of exercise.

• Obesity.

• Excessive alcohol use. More than two drinks per day raises your blood pressure. Binge drinking can lead to higher risk of stroke.

• Illegal drugs. IV (intravenous) drug abuse carries a high risk of stroke from blood clots (cerebral embolisms). Cocaine and other drugs have been closely linked to strokes, heart attacks, and many other cardiovascular problems.

• Abnormal heart rhythm. Some types of heart disease can raise your risk of stroke. Having an irregular heartbeat (atrial fibrillation) is the most powerful and treatable heart risk factor of stroke.

• Cardiac structural abnormalities. Damaged heart valves (valvular heart disease) can cause long-term (chronic) heart damage. Over time, this can raise your risk of stroke.

Risk factors for stroke that can’t be changed:

• Age. For each decade of life after age 55, your chance of having a stroke more than doubles.
• Race. African Americans have a much higher risk for death and disability from a stroke than whites. This is partly because the African-American population has a greater incidence of high blood pressure.
• Gender. Stroke occurs more often in men, but more women than men die from stroke.
• History of prior stroke. You are at higher risk for having a second stroke after you have already had a stroke.
• Heredity or genetics. The chance of stroke is greater in people with a family history of stroke.

Other risk factors include:

• Where you live. Strokes are more common among people living in the southeastern U.S. than in other areas. This may be because of regional differences in lifestyle, race, smoking habits, and diet.
• Temperature, season, and climate. Stroke deaths occur more often during extreme temperatures.
• Social and economic factors. There is some evidence that strokes are more common among low-income people.

It is important to understand your own risk for stroke so that you can learn how to manage them. Many stroke risk factors can be changed, treated, or medically modified. Here are some ways to control your stroke risk factors.

Lifestyle changes

A healthy lifestyle can help reduce your risk for stroke. That includes the following:

• Manage your blood pressure. 

• Control your cholesterol.

• Stop smoking.

• Make healthy food choices.

• Maintain a healthy weight. 

• Be physically active.

• Limit alcohol use.

Medicines

Take your medicines as instructed by your healthcare provider. The following medicines can help prevent stroke:

• Blood-thinning medicines (anticoagulants) help prevent blood clots from forming. If you take a blood thinner, you may need regular blood tests.

• Antiplatelets, such as aspirin, are prescribed for many stroke patients. They make blood clots less likely to form. Aspirin is available over the counter.

• Blood-pressure medicines help lower high blood pressure. You may need to take more than one blood-pressure medicine.

• Cholesterol-lowering drugs make plaque less likely to build up in your artery walls, which can reduce the risk for stroke.

• Heart medicines can treat certain heart problems that increase your risk of stroke.

• Diabetes medicines adjust blood sugar levels. This can prevent problems that lead to stroke.

Surgery

Several types of surgery may be done to help treat a stroke, or help to prevent one. These include:

• Carotid endarterectomy. Carotid endarterectomy is surgery to remove plaque and clots from the carotid arteries, located in the neck. These arteries supply the brain with blood from the heart. Endarterectomy may help stop a stroke from occurring.

• Carotid stenting. A large metal coil (stent) is placed in the carotid artery much like a stent is placed in a coronary artery.

• Surgery to repair aneurysms and AVMs (arteriovenous malformations). An aneurysm is a weakened, ballooned area on an artery wall. It is at risk for bursting (rupturing) and bleeding into the brain. An AVM is a tangle of arteries and veins. It interferes with blood circulation and puts you at risk for bleeding.

• PFO (patent foramen ovule) closure. The foramen ovule is an opening that occurs in the wall between the 2 upper chambers of the heart. This opening usually closes right after birth. If the flap does not close, any clots or air bubbles can pass into the brain circulation. This can cause a stroke or TIA (transient ischemic attack). However, experts are still debating whether the PFO should be closed.