Stroke

A stroke, also known as a cerebrovascular accident or CVA is when part of the brain loses its blood supply and the part of the body that the blood-deprived brain cells control stops working. This loss of blood supply can be ischemic because of lack of blood flow, or hemorrhagic because of bleeding into brain tissue. A stroke is a medical emergency because strokes can lead to death or permanent disability. There are opportunities to treat ischemic strokes but that treatment needs to be started in the first few hours after the signs of a stroke begin. The patient, family, or bystanders, should call 9-1-1 and activate emergency medical services immediately should a stroke be suspected.

A transient ischemic attack (TIA or mini-stroke) describes an ischemic stroke that is short-lived where the symptoms resolve spontaneously. This situation also requires emergency assessment to try to minimize the risk of a future stroke. By definition, a stroke would be classified as a TIA if all symptoms resolved within 24 hours.

Stroke Facts

  • A stroke occurs when part of the brain loses its blood supply and stops working. This causes the part of the body that the injured brain controls to stop working.
  • A stroke also is called a cerebrovascular accident, CVA, or "brain attack."
  • The types of strokes include:
    • Ischemic stroke (part of the brain loses blood flow)
    • Hemorrhagic stroke (bleeding occurs within the brain)
  • Transient ischemic attack, TIA, or mini stroke (The stroke symptoms resolve within minutes, but may take up to 24 hours on their own without treatment. This is a warning sign that a stroke may occur in the near future.)
  • A stroke is a medical emergency. The affected individual, family, friends, or bystanders need to call 9-1-1 (activate EMS) to access emergency care.
  • From onset of symptoms, there is only a 3 to 4 1/2 hour window to use clot-busting drugs (thrombolytics) to try to restore blood supply to the affected part of the brain.
  • Remember FAST if you think someone might be having a stroke:
    • Face drooping
    • Arm weakness
    • Speech difficulty
    • Time to call 9-1-1
  • Causes of strokes include ischemia (loss of blood supply) or hemorrhage (bleeding) in the brain occurs.
  • People at risk for stroke include those who have high blood pressure, high cholesterol, diabetes, and those who smoke. People with heart rhythm disturbances, especially atrial fibrillation are also at risk.
  • Stroke is diagnosed by the patient's symptoms, history, and blood and imaging tests.
  • Depending on the situation, including the patient’s neurologic examination and severity of stroke, mechanical thrombectomy to remove a blood clot within a brain artery may occur up to 24 hours after onset of symptoms. This procedure is not available at all hospitals and not appropriate for all stroke patients.
  • You can prevent stroke by quitting smoking, controlling blood pressure, maintaining a healthy weight, eating a healthy diet, and exercising on a regular basis.
  • The prognosis and recovery for a person that has suffered a stroke depends upon the location of the injury to the brain.

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Thrombotic stroke

The blockage of an artery in the brain by a clot (thrombosis) is the most common cause of a stroke. The part of the brain that is supplied by the clotted blood vessel is then deprived of blood and oxygen. As a result of the deprived blood and oxygen, the cells of that part of the brain die and the part of the body that it controls stops working. Typically, a cholesterol plaque in one of the brain's small blood vessels ruptures and starts the clotting process.

Risk factors for narrowed blood vessels in the brain are the same as those that cause narrowing blood vessels in the heart and heart attack (myocardial infarction). These risk factors include:

  • high blood pressure (hypertension),
  • high cholesterol,
  • diabetes, and
  • smoking.

Embolic stroke

Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque (cholesterol and calcium deposits on the wall of the inside of the heart or artery) breaks loose, travels through the bloodstream, and lodges in an artery in the brain. When blood flow stops, brain cells do not receive the oxygen and glucose they require to function and a stroke occurs. This type of stroke is referred to as an embolic stroke. For example, a blood clot might originally form in the heart chamber as a result of an irregular heart rhythm, like atrial fibrillation. Usually, these clots remain attached to the inner lining of the heart, but occasionally they can break off, travel through the bloodstream (embolize), block a brain artery, and cause a stroke. An embolism, either plaque or clot, may also originate in a large artery (for example, the carotid artery, a major artery in the neck that supplies blood to the brain) and then travel downstream to clog a small artery within the brain.

Cerebral hemorrhage

A cerebral hemorrhage occurs when a blood vessel in the brain ruptures and bleeds into the surrounding brain tissue. A cerebral hemorrhage (bleeding in the brain) causes stroke symptoms by depriving blood and oxygen to parts of the brain in a variety of ways. Blood flow is lost to some cells. Additionally, blood is very irritating and can cause swelling of brain tissue (cerebral edema). Edema and the accumulation of blood from a cerebral hemorrhage increases pressure within the skull and causes further damage by squeezing the brain against the bony skull. This further decreases blood flow to brain tissue and its cells.

Subarachnoid hemorrhage

In a subarachnoid hemorrhage, blood accumulates in the space beneath the arachnoid membrane that lines the brain. The blood originates from an abnormal blood vessel that leaks or ruptures. Often this is from an aneurysm (an abnormal ballooning out of the blood vessel). Subarachnoid hemorrhages usually cause a sudden severe headache, nausea, vomiting, light intolerance, and stiff neck. If not recognized and treated, major neurological consequences, such as coma, and brain death may occur.

Vasculitis

Another rare cause of stroke is vasculitis, a condition in which the blood vessels become inflamed causing decreased blood flow to parts of the brain.

Migraine headache

There appears to be a very slight increased occurrence of stroke in people with migraine headache. The mechanism for migraine or vascular headaches includes narrowing of the brain blood vessels. Some migraine headache episodes can even mimic stroke with loss of function of one side of the body or vision or speech problems. Usually, the symptoms resolve as the headache resolves.

Many factors can increase your stroke risk. Some factors can also increase your chances of having a heart attack. Potentially treatable 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

  • Blood pressure readings higher than 120/80 millimeters of mercury (mm Hg)
  • Cigarette smoking or exposure to secondhand smoke
  • High cholesterol
  • Diabetes
  • Obstructive sleep apnea
  • 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.

Other factors associated with a higher risk of stroke include:

  • Age —People age 55 or older have a higher risk of stroke than do younger people.
  • Race — African-Americans have a higher risk of stroke than do people of other races.
  • Sex — Men have a higher risk of stroke than women. Women are usually older when they have strokes, and they're more likely to die of strokes than are men.
  • Hormones — use of birth control pills or hormone therapies that include estrogen, as well as increased estrogen levels from pregnancy and childbirth.

Symptoms of a stroke often appear without warning.

The main symptoms of stroke are:

  • confusion, including trouble with speaking and understanding
  • a headache, possibly with altered consciousness or vomiting
  • numbness or inability to move parts of the face, arm, or leg, particularly on one side of the body
  • vision problems in one or both eyes
  • trouble walking, including dizziness and lack of co-ordination

Strokes can lead to long-term health problems. Depending on how quickly it is diagnosed and treated, an individual can experience temporary or permanent disabilities in the aftermath of a stroke.

In addition to the persistence of the problems listed above, people may also experience the following:

  • bladder or bowel control problems
  • depression
  • pain in the hands and feet that gets worse with movement and temperature changes
  • paralysis or weakness on one or both sides of the body
  • trouble controlling or expressing emotions

Symptoms vary and may range in severity.

The acronym F.A.S.T. is a way to remember the signs of stroke, and can help identify the onset of stroke:

  • Face drooping: If the person tries to smile, does one side of the face droop?
  • Arm weakness: If the person tries to raise both their arms, does one arm drift downward?
  • Speech difficulty: If the person tries to repeat a simple phrase, is their speech slurred or strange?
  • Time to call 911: If any of these signs are observed, contact the emergency services.

The faster a person with suspected stroke receives medical attention, the better their prognosis will be, and the less likely they will be to experience permanent damage or death.

Strokes onset rapidly and will often occur before an individual can be seen by a doctor for a proper diagnosis.

For a person experiencing a stroke to get the best diagnosis and treatment possible, they should be treated at a hospital within 3 hours of their symptoms first appearing.

There are several different types of diagnostic tests that doctors can use to determine which type of stroke has occurred:

  • Physical examination: A doctor will ask about symptoms and medical history. They may check blood pressure, listen to the carotid arteries in the neck, and examine the blood vessels at the back of the eyes to check for indications of clotting.
  • Blood tests: A doctor may perform blood tests to find out how quickly the clots occur, the levels of particular substances in the blood, including clotting factors and whether or not an infection is present.
  • CT scan: A series of X-rays can show hemorrhages, strokes, tumors, and other conditions within the brain.
  • MRI scan: Radio waves and magnets create an image of the brain to detect damaged brain tissue.
  • Carotid ultrasound: An ultrasound scan to check the blood flow in the carotid arteries and to see if there is any plaque present.
  • Cerebral angiogram: Dyes are injected into the brain's blood vessels to make them visible under X-ray. This gives a detailed view of the brain and the blood vessels in the neck.
  • Echocardiogram: This creates a detailed image of the heart to check for any sources of clots that could have traveled to the brain to cause a stroke.

It is only possible to confirm the type of stroke someone has had by giving them a brain scan in a hospital environment.

As ischemic and hemorrhagic strokes have different causes, both require different forms of treatment.

It is not only important that the type of stroke is diagnosed quickly to reduce the damage done to the brain, but also because a treatment suitable for one type of stroke may be harmful when treating different type.

Ischemic stroke

Ischemic strokes are caused by arteries being blocked or narrowed, and so treatment focuses on restoring an adequate flow of blood to the brain.

Treatment starts with drugs that break down clots and prevent others from forming. Aspirin can be given, as can an injection of tissue plasminogen activator (TPA). TPA is very effective at dissolving clots but needs to be injected within 4.5 hours of stroke symptoms starting.

Emergency procedures include administering TPA directly into an artery in the brain or using a catheter to physically remove the clot. Research is still ongoing as to the benefit of these procedures.

There are other procedures that can be carried out to decrease the risk of strokes or TIAs. A carotid endarterectomy involves a surgeon opening the carotid artery and removing any plaque that might be blocking it.

Alternatively, an angioplasty involves a surgeon inflating a small balloon in a narrowed artery via catheter and then inserting a mesh tube called a stent into the opening. This prevents the artery from narrowing again.

Hemorrhagic stroke

Hemorrhagic strokes are caused by blood leaking into the brain, so treatment focuses on controlling the bleeding and reducing the pressure on the brain.

Treatment can begin with drugs given to reduce the pressure in the brain, control overall blood pressure, prevent seizures and prevent sudden constrictions of blood vessels.

If an individual is taking blood-thinning anticoagulants or an antiplatelet medication like warfarin or clopidogrel, they can be given drugs to counter the effects of the medication or blood transfusions to make up for blood loss.

Surgery can be used to repair any problems with blood vessels that have led or could lead to hemorrhagic strokes. Surgeons can place small clamps at the base of aneurysms or fill them with detachable coils to stop blood flow and prevent rupture.

If the hemorrhage is caused by arteriovenous malformations (AVMs), surgery can also be used to remove them if they are not too big and not too deep in the brain. AVMs are tangled connections between arteries and veins that are weaker and burst more easily than other normal blood vessels.


Rehabilitation: Strokes are life-changing events that can affect a person both physically and emotionally. After a stroke, successful recovery will often involve specific therapies and support, such as:

Speech therapy: This helps with any problems producing or understanding speech. Practice, relaxation, and changing communication style can all help.

Physical therapy: This can help a person relearn movement and co-ordination. It is important to stay active, even if it is difficult at first.

Occupational therapy: This is used to help a person to improve their ability to carry out routine daily activities, such as bathing, cooking, dressing, eating, reading, and writing.

Support groups: These help with common mental health problems such as depression that can occur after a stroke. Many find it useful to share common experiences and exchange information.

Support from friends and family: The people closest to a person should offer practical support and comfort after a stroke. Letting friends and family know what can be done to help is very important.

Rehabilitation is an important and ongoing part of treatment. With the right assistance and the support of loved ones, rehabilitation to a normal quality of life is possible, depending on the severity of the stroke.

The best way to prevent a stroke is to address the underlying causes. This is best achieved through lifestyle changes, including:

  • eating a healthy diet
  • maintaining a healthy weight
  • exercising regularly
  • not smoking tobacco
  • avoiding alcohol or drinking moderately

Eating a nutritious diet means including plenty of fruits, vegetables, and healthy whole grains, nuts, seeds, and legumes. Be sure to eat little or no red or processed meat and limit intake of cholesteroland saturated fats. Minimize salt intake to support healthy blood pressure.

Other measures taken to help reduce the risk of stroke include:

  • keeping blood pressure under control
  • managing diabetes
  • treating obstructive sleep apnea

As well as these lifestyle changes, a doctor can help to reduce the risk of future ischemic strokes through prescribing anticoagulant or antiplatelet medication.

In addition, arterial surgery can also be used to lower the risk of repeat strokes, as well as some other surgical options still being studied.

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