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Stroke

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Introduction

If you’re like most of us, you plan for your future. When you take a job, you examine its benefit plan. When you buy a home, you consider its location and condition so that your investment is safe. Today, more and more people are protecting their most important asset–their health. Are you?
Stroke ranks as the third leading killer in the United States. A stroke can be devastating to individuals and their families, robbing them of their independence. It is the most common cause of adult disability. Each year more than 700,000 Americans have a stroke, with about 160,000 dying from stroke-related causes.

What is a stroke?

A stroke, or “brain attack,” occurs when blood circulation to the brain fails. Brain cells can die from decreased blood flow and the resulting lack of oxygen. There are two broad categories of stroke: those caused by a blockage of blood flow and those caused by bleeding. While not usually fatal, a blockage of a blood vessel in the brain or neck, called an ischemic stroke, is the most frequent cause of stroke and is responsible for about 80 percent of strokes. These blockages stem from three conditions: the formation of a clot within a blood vessel of the brain or neck, called thrombosis; the movement of a clot from another part of the body such as the heart to the neck or brain, called embolism; or a severe narrowing of an artery in or leading to the brain, called stenosis. Bleeding into the brain or the spaces surrounding the brain causes the second type of stroke, called hemorrhagic stroke.

Two key steps you can take will lower your risk of death or disability from stroke: know stroke’s warning signs and control stroke’s risk factors. Scientific research has identified warning signs and a large number of risk factors.

What are warnings signs of a stroke?

Warning signs are clues your body sends that your brain is not receiving enough oxygen. If you observe one or more of these signs of a stroke or “brain attack,” don’t wait, call a doctor or 911 right away!

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

Other danger signs that may occur include double vision, drowsiness, and nausea or vomiting. Sometimes the warning signs may last only a few moments and then disappear. These brief episodes, known as transient ischemic attacks or TIAs, are sometimes called “mini-strokes.” Although brief, they identify an underlying serious condition that isn’t going away without medical help. Unfortunately, since they clear up, many people ignore them. Don’t. Heeding them can save your life.

What are the risk factors of a stroke?

A risk factor is a condition or behavior that occurs more frequently in those who have, or are at greater risk of getting, a disease than in those who don’t. Having a risk factor for stroke doesn’t mean you’ll have a stroke. On the other hand, not having a risk factor doesn’t mean you’ll avoid a stroke. But your risk of stroke grows as the number and severity of risk factors increases.
Stroke occurs in all age groups, in both sexes, and in all races in every country. It can even occur before birth, when the fetus is still in the womb. In African-Americans, stroke is more common and more deadly–even in young and middle-aged adults–than for any ethnic or other racial group in the United States. Scientists have found more and more severe risk factors in some minority groups and continue to look for patterns of stroke in these groups.
What are the Treatable Risk Factors?
Some of the most important treatable risk factors for stroke are:

  • High blood pressure. Also called hypertension, this is by far the most potent risk factor for stroke. If your blood pressure is high, you and your doctor need to work out an individual strategy to bring it down to the normal range. Some ways that work: Maintain proper weight. Avoid drugs known to raise blood pressure. Cut down on salt. Eat fruits and vegetables to increase potassium in your diet. Exercise more. Your doctor may prescribe medicines that help lower blood pressure. Controlling blood pressure will also help you avoid heart disease, diabetes, and kidney failure.
  • Cigarette smoking. Cigarette smoking has been linked to the buildup of fatty substances in the carotid artery, the main neck artery supplying blood to the brain. Blockage of this artery is the leading cause of stroke in Americans. Also, nicotine raises blood pressure; carbon monoxide reduces the amount of oxygen your blood can carry to the brain; and cigarette smoke makes your blood thicker and more likely to clot. Your doctor can recommend programs and medications that may help you quit smoking. By quitting, at any age, you also reduce your risk of lung disease, heart disease, and a number of cancers including lung cancer.
  • Heart disease. Common heart disorders such as coronary artery disease, valve defects, irregular heart beat, and enlargement of one of the heart’s chambers can result in blood clots that may break loose and block vessels in or leading to the brain. The most common blood vessel disease, caused by the buildup of fatty deposits in the arteries, is called atherosclerosis. Your doctor will treat your heart disease and may also prescribe medication, such as aspirin, to help prevent the formation of clots. Your doctor may recommend surgery to clean out a clogged neck artery if you match a particular risk profile. If you are over 50, NINDS scientists believe you and your doctor should make a decision about aspirin therapy. A doctor can evaluate your risk factors and help you decide if you will benefit from aspirin or other blood-thinning therapy.
  • Warning signs or history of stroke. If you experience a TIA, get help at once. Many communities encourage those with stroke’s warning signs to dial 911 for emergency medical assistance. If you have had a stroke in the past, it’s important to reduce your risk of a second stroke. Your brain helps you recover from a stroke by drawing on body systems that now do double duty. That means a second stroke can be twice as bad.
  • Diabetes. You may think this disorder affects only the body’s ability to use sugar, or glucose. But it also causes destructive changes in the blood vessels throughout the body, including the brain. Also, if blood glucose levels are high at the time of a stroke, then brain damage is usually more severe and extensive than when blood glucose is well-controlled. Treating diabetes can delay the onset of complications that increase the risk of stroke.

Do you know your stroke risk?

Some of the most important risk factors for stroke can be determined during a physical exam at your doctor’s office. If you are over 55 years old, a worksheet in a pamphlet available from the NINDS can help you estimate your risk of stroke and show the benefit of risk-factor control. Ask your doctor about this.
Many risk factors for stroke can be managed, some very successfully. Although risk is never zero at any age, by starting early and controlling your risk factors you can lower your risk of death or disability from stroke. With good control, the risk of stroke in most age groups can be kept below that for accidental injury or death.
Americans have shown that stroke is preventable and treatable. In recent years, a better understanding of the causes of stroke has helped Americans make lifestyle changes that have cut the stroke death rate nearly in half.
Scientists predict that, with continued attention to reducing the risks of stroke and by using currently available therapies and developing new ones, Americans should be able to prevent 80 percent of all strokes.

What stroke therapies are available?

Physicians have a wide range of therapies to choose from when determining a stroke patient’s best therapeutic plan. The type of stroke therapy a patient should receive depends upon the stage of disease. Generally there are three treatment stages for stroke: prevention, therapy immediately after stroke, and post-stroke rehabilitation. Therapies to prevent a first or recurrent stroke are based on treating an individual’s underlying risk factors for stroke, such as hypertension, atrial fibrillation, and diabetes, or preventing the widespread formation of blood clots that can cause ischemic stroke in everyone, whether or not risk factors are present. Acute stroke therapies try to stop a stroke while it is happening by quickly dissolving a blood clot causing the stroke or by stopping the bleeding of a hemorrhagic stroke. The purpose of post-stroke rehabilitation is to overcome disabilities that result from stroke damage.
Therapies for stroke include medications, surgery, or rehabilitation.

Medications

Medication or drug therapy is the most common treatment for stroke. The most popular classes of drugs used to prevent or treat stroke are antithrombotics (antiplatelet agents and anticoagulants), thrombolytics, and neuroprotective agents.
Antithrombotics prevent the formation of blood clots that can become lodged in a cerebral artery and cause strokes. Antiplatelet drugs prevent clotting by decreasing the activity of platelets, blood cells that contribute to the clotting property of blood. These drugs reduce the risk of blood-clot formation, thus reducing the risk of ischemic stroke. In the context of stroke, physicians prescribe antiplatelet drugs mainly for prevention. The most widely known and used antiplatelet drug is aspirin. Other antiplatelet drugs include clopidogrel and ticlopidine.
Anticoagulants reduce stroke risk by reducing the clotting property of the blood. The most commonly used anticoagulants include warfarin (also known as Coumadin® ) and heparin.
Thrombolytic agents are used to treat an ongoing, acute ischemic stroke caused by an artery blockage. These drugs halt the stroke by dissolving the blood clot that is blocking blood flow to the brain. Recombinant tissue plasminogen activator (rt-PA) is a genetically engineered form of t-PA, a thombolytic substance made naturally by the body. It can be effective if given intravenously within 3 hours of stroke symptom onset, but it should be used only after a physician has confirmed that the patient has suffered an ischemic stroke. Thrombolytic agents can increase bleeding and therefore must be used only after careful patient screening.
Neuroprotectants are medications that protect the brain from secondary injury caused by stroke Although only a few neuroprotectants are FDA-approved for use at this time, many are in clinical trials. There are several different classes of neuroprotectants that show promise for future therapy, including calcium antagonists, glutamate antagonists, opiate antagonists, antioxidants, apoptosis inhibitors, and many others. One of the calcium antagonists, nimodipine, also called a calcium channel blocker, has been shown to decrease the risk of the neurological damage that results from subarachnoid hemorrhage. Calcium channel blockers, such as nimodipine, act by reducing the risk of cerebral vasospasm, a dangerous side effect of subarachnoid hemorrhage in which the blood vessels in the subarachnoid space constrict erratically, cutting off blood flow.

Surgery

Surgery can be used to prevent stroke, to treat acute stroke, or to repair vascular damage or malformations in and around the brain. There are two prominent types of surgery for stroke prevention and treatment: carotid endarterectomy and extracranial/intracranial (EC/IC) bypass.
Carotid endarterectomy is a surgical procedure in which a doctor removes fatty deposits (plaque) from the inside of one of the carotid arteries, which are located in the neck and are the main suppliers of blood to the brain. As mentioned earlier, the disease atherosclerosis is characterized by the buildup of plaque on the inside of large arteries, and the blockage of an artery by this fatty material is called stenosis.
Currently, the NINDS is sponsoring the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST), a large clinical trial designed to test the effectiveness of carotid endarterectomy versus a newer surgical procedure for carotid stenosis called stenting. The procedure involves inserting a long, thin catheter tube into an artery in the leg and threading the catheter through the vascular system into the narrow stenosis of the carotid artery in the neck. Once the catheter is in place in the carotid artery, the radiologist expands the stent with a balloon on the tip of the catheter. The CREST trial will test the effectiveness of the new surgical technique versus the established standard technique of carotid endarterectomy surgery.
EC/IC bypass surgery is a procedure that restores blood flow to a blood-deprived area of brain tissue by rerouting a healthy artery in the scalp to the area of brain tissue affected by a blocked artery.

Rehabilitation therapy

Stroke is the number one cause of serious adult disability in the United States. Stroke disability is devastating to the stroke patient and family, but therapies are available to help rehabilitate post-stroke patients.
For most stroke patients, physical therapy (PT) is the cornerstone of the rehabilitation process. A physical therapist uses training, exercises, and physical manipulation of the stroke patient’s body with the intent of restoring movement, balance, and coordination. The aim of PT is to have the stroke patient relearn simple motor activities such as walking, sitting, standing, lying down, and the process of switching from one type of movement to another.
Another type of therapy involving relearning daily activities is occupational therapy (OT). OT also involves exercise and training to help the stroke patient relearn everyday activities such as eating, drinking and swallowing, dressing, bathing, cooking, reading and writing, and toileting. The goal of OT is to help the patient become independent or semi-independent.
Speech and language problems arise when brain damage occurs in the language centers of the brain. Due to the brain’s great ability to learn and change (called brain plasticity), other areas can adapt to take over some of the lost functions. Speech therapy helps stroke patients relearn language and speaking skills, or learn other forms of communication. Speech therapy is appropriate for patients who have no deficits in cognition or thinking, but have problems understanding speech or written words, or problems forming speech. A speech therapist helps stroke patients help themselves by working to improve language skills, develop alternative ways of communicating, and develop coping skills to deal with the frustration of not being able to communicate fully. With time and patience, a stroke survivor should be able to regain some, and sometimes all, language and speaking abilities.
Many stroke patients require psychological or psychiatric help after a stroke. Psychological problems, such as depression, anxiety, frustration, and anger, are common post-stroke disabilities. Talk therapy, along with appropriate medication, can help alleviate some of the mental and emotional problems that result from stroke. Sometimes it is also beneficial for family members of the stroke patient to seek psychological help as well.

What disabilities can result from a stroke?

Although stroke is a disease of the brain, it can affect the entire body. Some of the disabilities that can result from a stroke include paralysis, cognitive deficits, speech problems, emotional difficulties, daily living problems, and pain.

Paralysis

A common disability that results from stroke is paralysis on one side of the body, called hemiplegia. A related disability that is not as debilitating as paralysis is one-sided weakness or hemiparesis. The paralysis or weakness may affect only the face, an arm, or a leg or may affect one entire side of the body and face. A person who suffers a stroke in the left hemisphere of the brain will show right-sided paralysis or paresis. Conversely, a person with a stroke in the right hemisphere of the brain will show deficits on the left side of the body. A stroke patient may have problems with the simplest of daily activities, such as walking, dressing, eating, and using the bathroom. Motor deficits can result from damage to the motor cortex in the frontal lobes of the brain or from damage to the lower parts of the brain, such as the cerebellum, which controls balance and coordination. Some stroke patients also have trouble eating and swallowing, called dysphagia.

Cognitive Deficits

Stroke may cause problems with thinking, awareness, attention, learning, judgment, and memory. If the cognitive problems are severe, the stroke patient may be said to have apraxiaagnosia, or “neglect.” In the context of stroke, neglect means that a stroke patient has no knowledge of one side of his or her body, or one side of the visual field, and is unaware of the deficit. A stroke patient may be unaware of his or her surroundings, or may be unaware of the mental deficits that resulted from the stroke.

Language Deficits

Stroke victims often have problems understanding or forming speech. A deficit in understanding speech is called aphasia. Trouble speaking or forming words is called dysarthria. Language problems usually result from damage to the left temporal and parietal lobes of the brain.

Emotional Deficits

A stroke can lead to emotional problems. Stroke patients may have difficulty controlling their emotions or may express inappropriate emotions in certain situations. One common disability that occurs with many stroke patients is depression. Post-stroke depression may be more than a general sadness resulting from the stroke incident. It is a clinical behavioral problem that can hamper recovery and rehabilitation and may even lead to suicide. Post-stroke depression is treated as any depression is treated, with antidepressant medications and therapy.

Pain

Stroke patients may experience pain, uncomfortable numbness, or strange sensations after a stroke. These sensations may be due to many factors including damage to the sensory regions of the brain, stiff joints, or a disabled limb. An uncommon type of pain resulting from stroke is called central stroke pain or central pain syndrome (CPS). CPS results from damage to an area in the mid-brain called the thalamus. The pain is a mixture of sensations, including heat and cold, burning, tingling, numbness, and sharp stabbing and underlying aching pain. The pain is often worse in the extremities – the hands and feet – and is made worse by movement and temperature changes, especially cold temperatures. Unfortunately, since most pain medications provide little relief from these sensations, very few treatments or therapies exist to combat CPS.

What special risks do women face?

Some risk factors for stroke apply only to women. Primary among these are pregnancy, childbirth, and menopause. These risk factors are tied to hormonal fluctuations and changes that affect a woman in different stages of life. Research in the past few decades has shown that high-dose oral contraceptives, the kind used in the 1960s and 1970s, can increase the risk of stroke in women. Fortunately, oral contraceptives with high doses of estrogen are no longer used and have been replaced with safer and more effective oral contraceptives with lower doses of estrogen. Some studies have shown the newer low-dose oral contraceptives may not significantly increase the risk of stroke in women.
Other studies have demonstrated that pregnancy and childbirth can put a woman at an increased risk for stroke. Pregnancy increases the risk of stroke as much as three to 13 times. Of course, the risk of stroke in young women of childbearing years is very small to begin with, so a moderate increase in risk during pregnancy is still a relatively small risk. Pregnancy and childbirth cause strokes in approximately eight in 100,000 women. Unfortunately, 25 percent of strokes during pregnancy end in death, and hemorrhagic strokes, although rare, are still the leading cause of maternal death in the United States. Subarachnoid hemorrhage, in particular, causes one to five maternal deaths per 10,000 pregnancies.
A study sponsored by the NINDS showed that the risk of stroke during pregnancy is greatest in the post-partum period – the 6 weeks following childbirth. The risk of ischemic stroke after pregnancy is about nine times higher and the risk of hemorrhagic stroke is more than 28 times higher for post-partum women than for women who are not pregnant or post-partum. The cause is unknown.
In the same way that the hormonal changes during pregnancy and childbirth are associated with increased risk of stroke, hormonal changes at the end of the childbearing years can increase the risk of stroke. Several studies have shown that menopause, the end of a woman’s reproductive ability marked by the termination of her menstrual cycle, can increase a woman’s risk of stroke. Fortunately, some studies have suggested that hormone replacement therapy can reduce some of the effects of menopause and decrease stroke risk. Currently, the NINDS is sponsoring the Women’s Estrogen for Stroke Trial (WEST), a randomized, placebo-controlled, double-blind trial, to determine whether estrogen therapy can reduce the risk of death or recurrent stroke in postmenopausal women who have a history of a recent TIA or non-disabling stroke. The mechanism by which estrogen can prove beneficial to postmenopausal women could include its role in cholesterol control. Studies have shown that estrogen acts to increase levels of HDL while decreasing LDL levels.

Are children at risk for stroke?

The young have several risk factors unique to them. Young people seem to suffer from hemorrhagic strokes more than ischemic strokes, a significant difference from older age groups where ischemic strokes make up the majority of stroke cases. Hemorrhagic strokes represent 20 percent of all strokes in the United States and young people account for many of these.
Clinicians often separate the “young” into two categories: those younger than 15 years of age, and those 15 to 44 years of age. People 15 to 44 years of age are generally considered young adults and have many of the risk factors mentioned above, such as drug use, alcohol abuse, pregnancy, head and neck injuries, heart disease or heart malformations, and infections. Some other causes of stroke in the young are linked to genetic diseases.
Medical complications that can lead to stroke in children include intracranial infection, brain injury, vascular malformations such as moyamoya syndrome, occlusive vascular disease, and genetic disorders such as sickle cell anemia, tuberous sclerosis, and Marfan’s syndrome.
The symptoms of stroke in children are different from those in adults and young adults. A child experiencing a stroke may have seizures, a sudden loss of speech, a loss of expressive language (including body language and gestures), hemiparesis (weakness on one side of the body), hemiplegia (paralysis on one side of the body), dysarthria (impairment of speech), convulsions, headache, or fever. It is a medical emergency when a child shows any of these symptoms.
In children with stroke the underlying conditions that led to the stroke should be determined and managed to prevent future strokes. For example, a recent clinical study sponsored by the National Heart, Lung, and Blood Institute found that giving blood transfusions to young children with sickle cell anemia greatly reduces the risk of stroke. The Institute even suggests attempting to prevent stroke in high-risk children by giving them blood transfusions before they experience a stroke.
Most children who experience a stroke will do better than most adults after treatment and rehabilitation. This is due in part to the immature brain’s great plasticity, the ability to adapt to deficits and injury. Children who experience seizures along with stroke do not recover as well as children who do not have seizures. Some children may experience residual hemiplegia, though most will eventually learn how to walk.

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