Everything You Need to Know About Stroke

According to the World Health Organization, stroke, also known as cerebrovascular accident, is the 2nd leading cause of death and the third leading cause of disability globally.

And according to the American Heart Association, stroke is the 5th biggest killer and the number one cause of disability in the US.

What Is a Stroke?

A stroke is a medical emergency when the blood supply to the brain is blocked or reduced.

When this happens, your brain tissue doesn’t get the oxygen and nutrients it needs, so your brain cells die within minutes.

It’s, therefore, crucial that a person exhibiting signs of stroke receive prompt treatment.

A speedy response can reduce brain damage and other complications. Early action can also mean the difference between life and death.

Stroke Symptoms

Use FAST as a mnemonic to recognize stroke signs and know when to call 911.

• F for facial droop. Does one side of the person’s face appear drooped? Can the person smile? Is the smile uneven or lopsided?
• A for arm weakness. Can the person raise both arms? Is one arm drifting downward or unable to rise?
• S for speech problems. Ask the person to repeat a simple sentence. Can you understand what the person is saying? Is their speech slurred or slowed? Or is the person unable to speak entirely?
• T for time to call 911. If you observe any of the above symptoms, call 911 immediately and seek immediate medical attention, even if the symptoms disappear.

Other additional symptoms of cerebrovascular accident include:-

• Sudden confusion and difficulty speaking and understanding speech.
• Sudden weakness, numbness, or paralysis of the face, arm, or leg, usually affecting one side of the body.
• Sudden trouble walking. A person may experience loss of balance, dizziness, or coordination. They may also have difficulty walking and may even stumble.
• Sudden vision problems. One may have trouble seeing in one or both eyes or experience double vision.
• Sudden unexplained severe headache. The person may also experience vomiting and dizziness.

Types of Stroke and Causes

Stroke can result from various reasons and have many effects. The following are different types of cerebrovascular accidents and their causes.

1. Ischemic stroke

Ischemic stroke is the most common type, accounting for about 87% of all strokes.

It occurs when a blood vessel supplying blood to the brain becomes narrowed or obstructed, often due to atherosclerosis, i.e., the buildup of fatty deposits in and on vessel walls.

Atherosclerosis can cause two types of stroke:

• A thrombotic: occurs when a blood clot (thrombus) forms within an artery that supplies blood to your brain, blocking it and severely reducing blood flow to a part of the brain.
• Embolic: this type of ischemic stroke happens when a blood clot or other debris (embolus) that develops elsewhere in the body, usually the heart, enters the bloodstream and travels to your brain. Once in your brain, the embolus becomes lodged in a brain artery too small to pass, blocking blood flow to the brain.

2. Hemorrhagic stroke

Hemorrhagic strokes constitute approximately 13% of all events. This type of stroke occurs when a weakened blood vessel, usually an aneurysm or arteriovenous malformation (AVM), in your brain ruptures.

As a result, a brain hemorrhage or brain bleed occurs, resulting in reduced blood flow to your brain. Your brain cells then become starved of nutrients, causing them to die.

There are two types of hemorrhagic, namely:

• Intracerebral hemorrhage: bleeding occurs within the brain.
• Subarachnoid hemorrhage: bleeding happens on the brain’s surface, specifically in the subarachnoid space, i.e., the space between the arachnoid and pia mater.

Factors that increase your risk include:

• Uncontrolled hypertension
• Ischemic stroke
• Physical trauma
• Overtreatment with anticoagulants (blood thinners)
• Heavy alcohol use
• Abusing cocaine and amphetamines

3. Transient ischaemic attack (TIA)

A transient ischaemic attack, which some call a mini-stroke, is short-lived, where blood flow to the brain is temporarily interrupted.

It causes temporary symptoms such as double vision, speech problems, paralysis of one side of the body, and vertigo, which disappear within 24 hours.

A TIA occurs when a clot or debris temporarily reduces or blocks the blood supply to part of your brain. Usually, an embolus dissolves on its own or gets dislodged.

Although mini-strokes don’t cause permanent damage, they may be a sign of a full-blown stroke in the future. One study found that nearly 12% of people who suffer a TIA die within a year.

Risk Factors for Stroke

We’ll categorize risk factors for stroke into those you can control and those not within your control.

Risk factors within your control

• High blood pressure, also known as hypertension: know your blood pressure numbers and take measures to lower and manage them.
• Cigarette smoking or secondhand smoke exposure: nicotine and carbon monoxide affect the function of your cardiovascular system, increasing your risk of stroke. Quit smoking.
• Diabetes: control your blood sugar levels if you have type 1 or type 2 diabetes. In the US, more than 25% of the population aged 65 years and older have diabetes. An estimated 16% of these will succumb to stroke.
• Obesity: lose weight if you’re overweight (BMI of 25 and 29.9) or obese (BMI of 30 or higher). Losing as little as five to ten pounds can significantly reduce your risk of diabetes, high blood pressure, and cardiovascular disease.
• Diet: eat a heart-healthy diet. Diets high in cholesterol and saturated and trans fats raise your blood cholesterol levels. Those high in calories contribute to obesity, while those high in sodium can increase your blood pressure.
• Physical inactivity: aim for at least 150 minutes of moderate aerobic activity a week. A sedentary lifestyle increases your risk of stroke, heart disease, high blood pressure, diabetes, obesity, and high blood cholesterol.
• High blood cholesterol: high cholesterol increases your risk of arteriosclerosis, which, in turn, increases your risk of stroke. You can help improve your cholesterol levels by eating healthy, exercising regularly, losing weight, and quitting smoking.
• Atrial fibrillation (AFib or AF): AFiB is an irregular heartbeat that can cause blood clots, increasing your risk of stroke. Getting treatment can help reduce your risks.
• Obstructive sleep apnea (OSA): OSA is linked to various stroke risk factors but is an independent risk factor for stroke. Treatment consists of lifestyle changes, such as weight loss.

Risk Factors Out of Your Control

• Age: stroke is more prevalent among older people, with the likelihood of cerebrovascular accidents increasing with age for both men and women.
• Family history: you may be at a higher risk of stroke if your grandparent, parent, or sibling has had a stroke, particularly before the age of 65. It can also occur due to a genetic disorder (e.g., CADASIL) that obstructs blood flow in the brain.
• Race: African Americans are at a greater risk of death from a stroke than Caucasians, partially because they have a higher risk of diabetes, obesity, and high blood pressure. Additionally, a new study found that African Americans who smoke more than double their risk.
• Gender: Women suffer more strokes than men, and more women than men die from cerebrovascular accident. We have discussed this in detail in the sections below.
• A history of stroke, TIA, or heart attack: if you have previously suffered a stroke or heart attack, you are at a higher risk. Both conditions often result from plaque buildup that reduces or blocks blood flow to part of the heart muscle or brain, respectively. In addition, if you had one or more transient ischemic attacks, your risk is ten times higher than someone your age and sex who hasn’t suffered a TIA.

Women and Stroke

In the US, stroke is the fourth leading cause of death in women, killing over 80,000 women a year.

One in five women has a stroke, with black women at a higher risk. Moreover, it kills more women than it does men.

Risk factors in women include:

• Pregnancy. A pregnant woman is three times more likely to have a stroke than an unpregnant woman her age. The risk increases during the third trimester and postpartum.
• Preeclampsia. High blood pressure during pregnancy doubles a woman’s risk of stroke in the future.
• Birth control pills. Oral contraceptives can double your risk of stroke, especially in women with risk factors such as high blood pressure and smoking.
• Atrial fibrillation. This type of heart arrhythmia (irregular heartbeat) can increase your risk of stroke up to five times. In women over 75, atrial fibrillation increases risk by 20%.
• Migraines with aura. Younger women who experience migraines with aura are at a higher risk of ischemic stroke, especially if they smoke or use birth control pills.

Men and Stroke

Stroke is the No. 5 cause of death in men and the leading cause of long-term disability.

Stroke risk factors in men include (listed below are statistics for the US):

• High blood pressure. Four in five men with high blood pressure aren’t managing their blood pressure, further increasing their risk for stroke.
• Smoking. About one out of six men smoke, and generally, more men than women use tobacco.
• Overweight or obese. Nearly three in four men are overweight or obese.
• Diabetes. About one out of nine men have diabetes.
• Excessive alcohol consumption. Men are almost twice as likely to binge drink than women.

Diagnosing Cerebrovascular Accident

As soon as you arrive in the hospital, your doctor will gather information about your symptoms and past medical history and do several tests to confirm a stroke diagnosis and determine the cause. Examples of tests you may undergo include:

• Physical and neurological examinations: your doctor assesses your vital signs, such as pulse rate and blood pressure. He/she also performs a neurological exam to evaluate your nervous system and quantify the impairment a stroke may have caused.
• Blood tests: your doctor will run blood tests to check for various things, including cholesterol and blood sugar levels, how long it takes for blood to clot, red blood cell and platelet count, and infection.
• Computerized tomography (CT) scan: uses a series of X-rays to produce detailed images of your brain. A CT scan shows an ischemic stroke, hemorrhagic stroke, masses, or other conditions in the brain.
• Magnetic resonance imaging (MRI): uses strong radio waves and magnetic fields to create detailed brain images. An MRI produces sharper images than a CT scan. It can detect brain tissue damage from ischemic stroke and brain hemorrhage. MRIs can also help distinguish ischemic lesions from stroke mimics, such as seizure and brain tumors.
• Electroencephalogram (EEG): an EEG is used to evaluate your brain’s electrical activity. Small metal discs called electrodes are placed on your scalp to pick up electrical impulses. These electrical signals appear as brain waves on an EEG recording.
• Carotid ultrasound: this is a type of blood flow test. It uses sound waves to generate images of the inside of your carotid arteries, i.e., the neck arteries that supply blood to your brain. Carotid ultrasound shows if they are narrowed or clogged and the size and location of the blockages. It also helps assess blood flow through your carotid arteries.

Stroke Treatment

Stroke treatment depends on the type of stroke you’re having.

Ischemic stroke treatment

Emergency treatment for ischemic stroke focuses on clot removal to restore blood flow to your brain. Doctors can achieve this with the following:

1. IV Medication

The gold standard treatment for ischemic stroke is tissue plasminogen activator (tPA), also called alteplase. tPA is an intravenous medicine, so it’s administered through a vein in the arm.

It works by dissolving the blood clot causing your stroke and improving blood flow to the part of the brain starved of oxygen and nutrients.

tPA treatment is most effective when administered as soon as possible. Quick treatment can save your life and reduce long-term complications of strokes.

Usually, patients are given an injection of tPA within a 3 to 4.5-hour time window after the onset of symptoms.

Before administering alteplase, an ischemic stroke diagnosis must be confirmed. The reason is tPA can cause worsened bleeding in the brain in a hemorrhagic stroke.

2. Mechanical thrombectomy

A mechanical thrombectomy is a strongly recommended treatment for large vessel occlusions (LVOs). An LVO is an ischemic stroke caused by a clot in a major artery in the brain.

The procedure uses a stent retriever attached to a catheter. The device is guided to the blocked artery in the brain through an artery in your groin.

The stent retriever opens and retrieves the clot, directly unblocking the blood vessel.

A suction technique can also be applied to remove the clot. Your doctor may perform a mechanical thrombectomy with tPA IV treatment if appropriate for you.

3. Other medication

Your doctor may also prescribe the medications below to decrease your risk of another stroke or transient ischemic attack.

• Antiplatelets: help stop clots from forming in the future. They include Aspirin, Clopidogrel (Plavix), Dipyridamole (Persantine), and Prasugrel (Effient).
• Anticoagulants (blood thinners): reduce the blood’s ability to clot. Examples include Apixaban (Eliquis), Heparin, and Warfarin (Coumadin).
• Statins: these are medications used to lower LDL “bad” cholesterol. Your doctor may recommend taking statins even with a cholesterol level that’s not unusually high.
• Blood pressure medication: these medicines help lower your blood pressure. They include diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers.

Hemorrhagic stroke treatment

Emergency treatment for hemorrhagic stroke involves controlling bleeding and reducing pressure on the brain by draining excess fluid and blood around the brain.

Differentiating between ischemic and hemorrhagic strokes is crucial because thrombolytic agents used to treat ischemic stroke can worsen bleeding in hemorrhagic stroke, even causing death. Treatments for brain hemorrhage include:

• Medication: if you take anticoagulants, you may be given drugs or undergo a blood transfusion to counteract their effects. You may also receive medication to lower blood pressure, reduce increased intracranial pressure, prevent cerebral vasospasm, and prevent seizures.
• Surgery: you may have emergency surgery to remove excess fluid in the brain, relieving pressure. Or to repair damaged blood vessels.
• Coiling (endovascular embolization): a surgeon places detachable coils into the aneurysm using a catheter. The catheter is inserted into an artery, often in the groin, and passed to your brain. Coiling blocks blood flow into the aneurysm, which causes blood to clot.
• Surgical clipping: this procedure also blocks blood flow to the aneurysm by placing a tiny clamp at its base. Aneurysm clipping prevents the aneurysm from rupturing or a ruptured aneurysm from bleeding further.

Recovery and Rehabilitation

Suffering a stroke can result in various complications. The impact of your stroke will depend on what area of the brain it affects and the amount of tissue damaged. Changes a stroke patient may have include:

• Physical changes: these include weakness or paralysis of one side of the body, seizures, spasticity, fatigue, vision problems, incontinence, swallowing difficulty (dysphagia), and balance problems.
• Communication changes: examples include aphasia, which is a language disorder that affects your ability to speak, write, and understand spoken or written language; dysarthria, which is a speech disorder characterized by slowed or slurred speech; and apraxia, which is a neurological disorder where a person has difficulty making skilled movements and gesture despite their willingness.
• Memory and cognitive challenges: for example, short memory span, mixing up details of an event, and difficulty absorbing new information.
• Emotional and behavioral changes: includes depression, anxiety, pathological laughter, and crying.

A rehabilitation program can significantly influence a patient’s health outcome and recovery.

You may have rehabilitation in an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF), a long-term acute care facility, a nursing home, an outpatient clinic, or at home.

Depending on your condition, your rehabilitation team may include the following:

• Neurologist
• Psychiatrist or psychologist
• Nurse
• Speech pathologist
• Physical therapist
• Occupational therapist
• Recreation therapist
• Nutritionist
• Social worker
• Chaplain

How to Prevent Stroke

If you’ve had a stroke or TIA, knowing the underlying cause is crucial to preventing another event.

If you’ve never suffered a stroke, knowing your risk factors, following your physician’s recommendations, and making lifestyle changes are effective preventative measures. A healthy lifestyle involves:

• Managing your blood pressure and cholesterol levels
• Eating a heart-healthy diet
• Quitting smoking
• Losing and maintaining a healthy weight
• Exercising regularly
• Quitting drinking alcohol or drinking in moderation
• Managing diabetes
• Managing depression
• Treating obstructive sleep apnea (OSA)
• Managing atrial fibrillation (AFib)
• Staying clear of illegal drugs like cocaine
• Taking preventative medication, namely antiplatelets and anticoagulants