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DESCRIPTION
A stroke, or cerebrovascular accident (CVA) is a condition whereby a blood vessel to the brain is blocked resulting in a diminished blood supply to the brain or a blood vessel is ruptured, resulting in bleeding (hemorrhage) into the brain tissue. The brain tissue gets damaged because of lack of oxygen and glucose when it cannot be delivered to the brain. When that part of brain tissue dies the function of that brain tissue will be lost which alters the body function controlled by that area of the brain. If any part of the body, including the brain, is without a source of fresh blood and oxygen, the cells will be injured or may die. Although some cell injury is reversible, the death of brain cells is permanent, usually leaving lasting disability. Brain damage can begin within minutes, so it is important to know the symptoms of stroke and act fast. Quick treatment can help limit damage to the brain and increase the chance of a full recovery.
Stroke is a devastating illness causing severe disability in adults. The World Health Organization estimates that in 2001 there were over 20.5 million strokes worldwide, 5.5 million of these were fatal. A blockage of a blood vessel is the most frequent cause of stroke and is responsible for about 80 percent of the approximately 700,000 strokes in the United States each year. With nearly 150,000 stroke deaths each year, stroke ranks as the third leading killer in the United States after heart disease and all forms of cancer.
Stroke is the leading cause of adult disability in the United States with 2 million of the 3 million Americans who have survived a stroke sustaining some permanent disability. The overall cost of stroke to the nation is $40 billion a year. The cost of strokes is not just measured in the billions of dollars lost in work, hospitalization, and the care of survivors in nursing homes. The major cost or impact of a stroke is the loss of independence that occurs in 30 percent of the survivors. What was a self-sustaining and enjoyable lifestyle may lose most of its quality after a stroke and other family members can find themselves in a new role as caregivers.
TYPES OF STROKE
Blood flow can be compromised by a variety of mechanisms. CVA affects the vascular system and the nervous system. The complete or partial loss of blood flow to the brain tissue is frequently a complication of atherosclerosis or brain hemorrhage. There are three main types of stroke:
THROMBOTIC STROKE - BLOCKAGE OF AN ARTERY
A Thrombotic Stroke is the most common type of stroke, caused by a clot (thrombus) that is not able to pass through an artery that may already be obstructed by a buildup of plaque (fat) in the blood vessels (usually in the neck) and block the flow of blood.
Narrowing of the small arteries within the brain can cause a so-called lacunar stroke, (lacune means empty space). Blockage of a single arteriole can affect a tiny area of brain causing that tissue to die (infarct).
Hardening of the arteries (atherosclerosis) leading to the brain. There are four major blood vessels that supply the brain with blood. The anterior circulation of the brain that controls most motor, activity, sensation, thought, speech, and emotion is supplied by the carotid arteries. The posterior circulation, which supplies the brainstem and the cerebellum, controlling the automatic parts of brain function and coordination, is supplied by the vertebrobasilar arteries. If these arteries become narrow as a result of atherosclerosis, plaque or cholesterol, debris can break off and float downstream, clogging the blood supply to a part of the brain. As opposed to lacunar strokes, larger parts of the brain can lose blood supply, and this may produce more symptoms than a lacunar stroke.
MoonDragon's Health & Wellness: Atherosclerosis & Arteriosclerosis
EMBOLIC STROKE - EMBOLISM TO THE BRAIN FROM THE HEART
An Embolic Stroke is caused by a circulating piece of a clot or a piece of atherosclerotic plaque (emboli) (cholesterol and calcium deposits on the wall of the inside of the heart or artery) that breaks loose, travels through open arteries, and lodges in a blood vessel (artery) in the brain. When this happens, the flow of oxygen-rich blood to the brain is blocked and a stroke occurs. In situations in which blood clots form within the heart, the potential exists for small clots to break off and travel (embolize) to the arteries in the brain and cause a stroke.
The clot forms elsewhere in the body, usually in the heart, and moves freely until it reaches the small vessels in the brain and cannot move further. For example, a blood clot might originally form in the heart chamber as a result of an irregular heart rhythm, such as occurs in atrial fibrillation. Usually, these clots remain attached to the inner lining of the heart, but occasionally they can break off, travel through the blood stream, form a plug (embolism) in a brain artery, and cause a stroke. An embolism can 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.
HEMORRHAGIC STROKE - RUPTURE (HEMORRHAGE) OF AN ARTERY
A Hemorrhagic Stroke is a cerebral hemorrhage (intracranial bleeding within the brain substance). This may be caused by the rupture of a blood vessel, causing blood to accumulate in the brain. Those on the inside are caused by aneurysms, which are weak spots on the artery wall, or by head injury. Aneurysms are often caused by congenital defects or high blood pressure.
The most common reason to have bleeding within the brain is uncontrolled high blood pressure. Other situations include aneurysms that leak or rupture or arteriovenous malformations (AVM) in which there is an abnormal collection of blood vessels that are fragile and can bleed. Hemorrhagic strokes are the most severe and are often fatal. The chance of a full recovery is less than that for the other two types.
TRANSIENT ISCHEMIC ATTACK (TIA) - MINI STROKE
Most strokes are preceded by one or more mini-strokes (called transient ischemic attacks or TIA's) that should act as a warning to seek medical attention immediately. Some people call a transient ischemic attack (TIA) a mini-stroke, because the symptoms are like those of a stroke but do not last long. The most common symptoms of a stroke are:
- sudden numbness, weakness, or paralysis of the face, arm, or leg. Usually occurs on one side of the body.
- loss of speech or trouble talking or understanding what is said.
- sudden blurred vision, dizziness, loss of balance, or severe, unexplained headache.
A transient ischemic attack (TIA) is a short-lived episode (less than 24 hours) of temporary impairment to the brain that is caused by a loss of blood supply. A TIA happens when blood flow to part of the brain is blocked or reduced that causes a loss of function in the area of the body that is controlled by the portion of the brain affected. After a short time, blood flows again and the symptoms go away. With a stroke, the blood flow stays blocked, and the brain has permanent damage.
The loss of blood supply to the brain is most often caused by a clot that spontaneously forms in a blood vessel within the brain (thrombosis). However, it can also result from a clot that forms elsewhere in the body, dislodges from that location, and travels to lodge in an artery of the brain (emboli). A spasm and, rarely, a bleed are other causes of a TIA.
Some TIAs develop slowly, while others develop rapidly and may last from 2 minutes to 15 minutes or for as long as 24 hours. By definition, all TIAs resolve within 24 hours. Strokes take longer to resolve than TIAs, and with strokes, complete function may never return and reflect a more permanent and serious problem. Although most TIAs often last only a few minutes, all TIAs should be evaluated with the same urgency as a stroke in an effort to prevent recurrences and/or strokes. TIAs can occur once, multiple times, or precede a permanent stroke. A transient ischemic attack should be considered an emergency because there is no guarantee that the situation will resolve and function will return.
A TIA from a clot to the eye can cause temporary visual loss (amaurosis fugax), which is often described as the sensation of a curtain coming down. A TIA that involves the carotid artery (the largest blood vessel supplying the brain) can produce problems with movement or sensation on one side of the body, which is the side opposite to the actual blockage. An affected patient may experience paralysis of the arm, leg, and face, all on one side. Double vision, dizziness (vertigo), and loss of speech, understanding, and balance can also be symptoms depending on what part of the brain is lacking blood supply.
BE AWARE AND WATCH OUT FOR THESE TIA SYMPTOMS
Symptoms of a TIA come on suddenly.
- One side of your body may feel numb, tingly, or heavy.
- You may not be able to move your arm, your leg, or your face on one side of your body.
- Things may look blurry or dim. You may have double vision or not be able to see.
- It may be hard to speak. You may slur or mix up your words.
- It may be hard to understand words.
- You may feel unsteady, dizzy, or clumsy. You may have trouble walking.
A blood clot is the most common cause of a TIA. Blood clots can be the result of hardening of the arteries (atherosclerosis), heart attack, or abnormal heart rhythms. Brain cells are affected within seconds of the blockage. That causes symptoms in the parts of the body controlled by those cells. Once the clot dissolves, blood flow returns, and the symptoms go away.
Sometimes a TIA is caused by a sharp drop in blood pressure that reduces blood flow to the brain. This is called a "low-flow" TIA. It is not as common as other types.
DIAGNOSIS OF TIA
Your health care provider will do tests to look at your heart and blood vessels. You may need:
- Tests that show pictures of your brain and blood vessels, such as a CT scan, an MRI, a magnetic resonance angiogram (MRA), or an angiogram.
- A test that uses sound to check your blood flow (Doppler ultrasound).
- An echocardiogram (echo) to check your heart's shape and its blood flow.
- An electrocardiogram (EKG, ECG) to measure your heart rhythm.
Your health care provider will also check to see if something else is causing your symptoms.
TIA TREATMENT
Your health care provider will start you on medicines to help prevent a stroke. You may need to take several medicines. If tests show that the blood vessels (carotid arteries) in your neck are too narrow, you may need surgery to open them up (carotid endarterectomy). This can help prevent blood clots that block blood flow to your brain. Another type of surgery is carotid artery stenting. During this surgery, the practitioner puts a small tube called a stent inside your carotid artery. This helps keep the artery open. Carotid artery stenting is not as common as endarterectomy.
TIA PREVENTION
You can do a lot to reduce your chance of having another TIA or a stroke. Medicines can help, but you may need to make lifestyle changes too.
- Keep your blood pressure and cholesterol under control.
- If you have diabetes, keep your blood sugar as close to normal as possible.
- Take a daily aspirin or other medicines, if your health care provider advises it.
- Take your medicines just as your health care provider says to.
- Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil.
- Get some exercise on most, preferably all, days of the week.
- Stay at a healthy weight.
- If you smoke, quit. Avoid secondhand smoke too.
- Limit alcohol. Having more than 2 drinks a day raises the risk of stroke.
- Avoid getting sick from the flu. Consider getting a flu shot every year.
A TIA is a warning: It means you are likely to have a stroke in the future. If you think you are having a TIA, call 9-1-1 for emergency transport to the nearest medical facility. Early treatment can help prevent a stroke. If you think you have had a TIA but your symptoms have gone away, you still need to call your health care provider right away.
CAUSES OF STROKE
An ischemic stroke develops when a blood clot (thrombolic) or a piece of arterial plaque (embolic) blocks a blood vessel in the brain. The clot may form in the blood vessel or travel from somewhere else in the blood system. About 8 out of 10 strokes are ischemic strokes. They are the most common type of stroke in older adults. A hemorrhagic stroke develops when an artery in the brain leaks or bursts. This causes bleeding inside the brain or near the surface of the brain. Hemorrhagic strokes are less common but more deadly than ischemic strokes.
CAUSES OF ISCHEMIC STROKE (EMBOLIC & THROMBOLIC)
An ischemic stroke is caused by a blood clot (thrombosis) or plaque that blocks blood flow to the brain. A blood clot can develop in a narrowed artery that supplies the brain or can travel from the heart (or elsewhere in the body) to an artery that supplies the brain. Blood clots are usually the result of other problems in the body that affect the normal flow of blood, such as:
- Hardening of the arteries ( atherosclerosis). This is caused by high blood pressure, diabetes, high cholesterol, and smoking.
- Atrial fibrillation or other irregular heart rhythms.
- Certain heart valve problems, including having an artificial heart valve, a repaired heart valve, heart valve disease such as mitral valve prolapse, or narrowing (stenosis) of a heart valve.
- Infection of the heart valves (endocarditis).
- A patent foramen ovale, which is a congenital heart defect.
- Blood-clotting disorders.
- Inflammation of blood vessels (vasculitis).
- Heart attack.
- Heart failure.
- Low blood pressure (hypotension) may also cause an ischemic stroke, although less commonly. Low blood pressure results in reduced blood flow to the brain and may develop as a result of narrowed or diseased arteries, a heart attack, a large loss of blood, or a severe infection.
- Some surgeries (such as endarterectomy) or other procedures (such as angioplasty) that are used to treat narrowed carotid arteries may cause a blood clot to break loose, resulting in a stroke.
CAUSES OF HEMORRHAGIC STROKE
A hemorrhagic stroke is caused by bleeding inside the brain (called intracerebral hemorrhage) or bleeding in the space around the brain (called subarachnoid hemorrhage). Bleeding inside the brain may be a result of long-standing high blood pressure. Bleeding in the space around the brain may be caused by a ruptured aneurysm or uncontrolled high blood pressure.
Other causes of hemorrhagic stroke are less common but include:
- Inflammation in the blood vessels, which may develop from conditions such as syphilis, Lyme disease, vasculitis, or tuberculosis.
- Blood-clotting disorders, such as hemophilia.
- Head or neck injuries that result in damage to blood vessels in the head or neck.
- Radiation treatment for cancer in the neck or brain.
- Cerebral amyloid angiopathy (a degenerative blood vessel disorder).
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) can cause a stroke by depriving blood and oxygen to parts of the brain. Blood is also very irritating to the brain 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.
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 wall of the vessel). Subarachnoid hemorrhages usually cause a sudden, severe headache and stiff neck. If not recognized and treated, major neurological consequences, such as coma, and brain death will occur.
Vasculitis: Another rare cause of stroke is vasculitis, a condition in which the blood vessels become inflamed.
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.
SIGNS & SYMPTOMS
1. Headache.
2. Numbness or paralysis on one side of the body.
3. Dizziness.
4. Confusion.
5. Drooling.
6. Inability to speak.
7. Difficulty seeing.
8. Unequal pupil size.
9. Convulsions.
10. Respiratory arrest.
STROKE SYMPTOMS
A brain attack, also known as a stroke or cerebral vascular accident or CVA, occurs when there is interference with normal blood circulation to the brain. When brain cells are deprived of oxygen, they cease to perform their usual tasks. The symptoms that follow a stroke depend on the area of the brain that has been affected and the amount of brain tissue damage. Small strokes may not cause any symptoms, but can still damage brain tissue. These strokes that do not cause symptoms are referred to as silent strokes. Symptoms of stroke appear suddenly. According to The U.S. National Institute of Neurological Disorders and Stroke (NINDS), these are the five major signs of stroke:
- Sudden unexplained tingling and/or numbness or weakness or paralysis of the face, arm or leg, especially on one side of the body. The loss of voluntary movement and/or sensation may be complete or partial. There may also be an associated tingling sensation in the affected area.
- Sudden confusion or trouble speaking (slurred or garbled speech) or understanding speech. Sometimes weakness or paralysis in the muscles of the face can cause drooling. Difficulty swallowing may occur.
- Sudden trouble seeing (poor vision) in one or both eyes, such as dimness, blurring, double vision, or loss of vision.
- Sudden trouble walking, dizziness, loss of balance or coordination (feeling clumsy).
- Sudden, severe headache with no known or obvious cause.
If you have any of these symptoms, call 9-1-1 or other emergency services right away. See your health care provider if you have symptoms that seem like a stroke, even if they go away quickly. You may have had a transient ischemic attack (TIA), sometimes called a mini-stroke. A TIA is a warning that a stroke may happen soon. Getting early treatment for a TIA can help prevent a stroke.
SEVERE CVA / STROKE SYMPTOMS
The person with a severe CVA may experience:
- Experiences seizure activity.
- Loses consciousness.
- Experiences difficulty breathing, respiratory arrest.
- Develops paralysis on one side of the body and of the muscles on either side of the face.
- Have unequal pupil reaction when a light is focused on the pupil of the eye.
LESS SEVERE CVA / STROKE SYMPTOMS
The person with a less severe CVA may experience:
- Numbness, tingling in face, arm or leg.
- Disorientation, confusion.
- Dizziness.
- Difficulty seeing.
- Drooling.
- Incontinence.
- Headache.
- Slurred speech or inability to speak.
- Memory loss.
- Loss of consciousness.
A stoke patient may be conscious or unconscious and may or may not be able to speak. A stroke patient may be able to hear what you are saying even if he or she appears to be unconscious. Do not say anything that would increase the patient's anxiety. The patient may have a headache or suffer seizures. Treatment of the stoke patient will depend on the symptoms encountered.
AFFECTED BRAINS STRUCTURES & RELATED SYMPTOMS
The areas of the brain affected by stroke A stroke is the sudden damage or death of cells in a localized area of the brain, due to inadequate blood flow. A stroke occurs when blood flow is interrupted causing oxygen starvation. A hemorrhage or thrombosis in the main arteries of the brain can cause this oxygen starvation. The areas of the brain affected by the stroke depend on the particular artery that is affected:
- Middle cerebral artery (pink).
- Posterior cerebral artery (green).
- Anterior cerebral artery (blue).
Remember, most nerve pathways cross. Therefore, damage on one side of the brain results in signs and symptoms on the opposite side of the body. Symptoms vary depending on the extent of interference with the circulation and on the area and amount of tissue damaged. Patients with damage to the right side of the brain will exhibit:
- Paralysis on the left side of the body (left hemiplegia).
- Spatial-perceptual deficits. This means it is difficult to distinguish right from left and up from down. The world may appear "tilted" to the person with right-brain damage. The patient will have problems propelling a wheelchair, setting down items, and carrying out the activities of daily living.
- Change in personality. The individual with right brain damage becomes very quick and impulsive.
If the left side of the brain is damaged, you will note:
- Paralysis on the right side of the body (right hemiplegia).
- Aphasia - an inability to express or understand speech.
- Change in personality. The individual becomes very cautious, anxious, and slow to complete tasks.
Other symptoms may be present with either right- or left-brain damage. These may include:
- Sensory-perceptual deficits.
- Loss of position sense. The person cannot tell, for example, where an affected foot is or what position it is in without looking at it.
- The inability to identify common objects such as a comb, a fork, a pencil, or a glass.
- The inability to use common objects. The patient may know what an item is, such as a fork, but he will be unable to pick it up and use it. This is not a result of paralysis, but is due to brain damage.
- Unilateral neglect. The patient ignores the paralyzed side of the body. For example, the affected arm may hang over the side of the wheelchair without the patient realizing where the arm is.
- Hemianopsia. This is impaired vision. Both eyes have only half vision. For example, if the patient has left hemiplegia, the left half of both eyes is blind.
- Emotional lability. Patients who have had a stroke may start to cry or laugh for no apparent reason. They have very little control over this and may be embarrassed.
- Cognitive impairments. There may be changes in the patient's intellectual function. This may affect memory, judgment, and problem-solving abilities.
APHASIA
Stoke victims often suffer from aphasia or language impairment. They have difficulty forming thoughts or expressing them in coherent ways. This is extremely frustrating and frightening for the patient and family.
- Receptive Aphasia: Means that the person cannot comprehend communication.
- Expressive Aphasia: Means that the person cannot properly form thoughts or express them coherently.
- Global Aphasia: Means that the person has lost all language abilities.
STROKE RISK FACTORS
MEDICAL CONDITIONS THAT INCREASE YOUR STROKE RISK
Overall, the most common risk factors for stroke are:
- Previous stroke or "mini-stroke" (transient ischemic attack, TIA). Depending on the most likely cause of your stroke, your health care provider may prescribe specific medication or consider surgery to remove fatty deposits in your carotid artery.
- High blood pressure. Hypertension is one of the leading risks for heart disease and stroke. Your health care provider may advise dietary or lifestyle changes, or specific medications to lower your blood pressure.
- High cholesterol.
- Smoking.
- Diabetes. High blood sugar can increase your risk, so you should work closely with your health care provider to manage it.
- Increasing age.
- Heart disease, congestive heart failure, or recent heart attack. Heart rhythm disturbances (heart beat irregularities) such as atrial fibrillation, patent foramen ovale, and heart valve disease can also be the cause. If you have one of these conditions, your health care provider may prescribe medications to thin your blood and/or reduce your cholesterol level.
When strokes occur in younger individuals (less than 50 years old), less common risk factors are considered including:
- Illicit drugs, such as cocaine or amphetamines.
- Ruptured aneurysms.
- Inherited (genetic) predispositions to blood clotting
An example of a genetic predisposition to stroke occurs in a rare condition called homocystinuria, in which there are excessive levels of the chemical homocystine in the body. Scientists are trying to determine whether the non-hereditary occurrence of high levels of homocystine at any age can predispose to stroke.
STROKE RISK FACTORS THAT CANNOT BE CONTROLLED
Risks factors for getting stroke that cannot be controlled are:
- Age: Stroke is more common in people over 60. The older you are, especially above 65, you are at higher risk to get stroke.
- Gender: Men and women both have strokes, although stroke is more common at younger ages in men. Men are at slightly higher risk to get stroke than women.
- Family History, Heredity & Ethnicity: A higher risk exists if you or your family has had a stroke or minor stroke (transient ischemic attack). Stroke is more common in people whose close relatives have had stroke at an early age. African-Americans and Hispanic Americans are at higher risk than white Americans. This may be due in part to high blood pressure and dietary differences.
STROKE RISK FACTORS THAT CAN BE CONTROLLED
The factors that increase your risk of getting stroke that can be controlled with proper lifestyles, diet, and conventional medical measures and appropriate medications are:
- High blood pressure.
- Diabetes.
- High blood cholesterol level (elevated cholesterol, and elevated lipids). Reducing your dietary intake of saturated fats and cholesterol may help reduce your risk of a stroke.
- Smoking. Tobacco use is a major preventable risk factor for stroke and heart disease. Even if you have smoked for years, you can still reduce your risk by quitting now.
- Overweight and obesity.
- Physical inactivity. A sedentary lifestyle void of regular exercise can contribute to heart disease which may lead to stroke.
- Stress.
- Diet - Low fiber and high fat dietary habits.
- Excessive alcohol use and/or abuse (heavy drinking).
- Illegal drug use.
REDUCING YOUR RISK OF STROKE
If you have ever had a stroke (or stroke warning signs), it is very important that you work with your health care provider to determine the most likely cause of the problem and the best course of treatment for you. Certain medical conditions greatly increase your likelihood of having a stroke (or another stroke). Working with your practitioner, you may need to begin specific medical treatment to control these risk factors.
STROKE PREVENTION
You can help prevent a stroke if you control risk factors and treat other medical conditions that can lead to a stroke. And if you have already had a stroke or a transient ischemic attack (TIA), you can prevent another stroke in the same way, by controlling risk factors and treating medical conditions that can lead to stroke. A transient ischemic attack (TIA) is a warning sign that a stroke may soon occur. Prompt medical attention for a TIA may help prevent a stroke. Seek emergency medical help immediately if you have symptoms of a TIA, which are similar to those of a stroke. Symptoms include problems with vision, speech, behavior, and thought processes. A TIA may cause loss of consciousness, seizure, dizziness (vertigo), and weakness or numbness on one side of the body. Symptoms of a TIA, however, are temporary and usually disappear after 10 to 20 minutes, although they may last longer. Treating other medical conditions can help prevent a stroke.
- Hardened arteries. If you have been told that you have hardening of the arteries (atherosclerosis), check with your health care provider about whether you should take an aspirin each day and/or a medicine to lower your cholesterol. Taking an aspirin daily can also reduce the risk of stroke in a person who has already had an ischemic stroke, a TIA, or carotid endarterectomy surgery.
- Blocked carotid artery. If your health care provider hears a swishing sound (a bruit) when listening to blood flow through the large blood vessels in your neck (carotid arteries), ask whether you need further testing (usually carotid ultrasound). Aspirin or surgery to reopen a blocked carotid artery may be appropriate.
A relatively new procedure called carotid artery stenting is another option for some people at high risk for stroke. This procedure is much like coronary angioplasty, which is commonly used to open blocked arteries in the heart. During this procedure, a practitioner inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque. The practitioner may use a stent that is coated with medicine to help prevent future blockage. For more about this procedure, see under "Treatment" further down on this page.
STROKE PREVENTION GUIDELINES
Having regular medical checkups. Work closely with your health care provider. Go to all your appointments, and take your medications as prescribed by your health care provider.
Manage your stress levels.
Controlling your high blood pressure by working with your health care provider.
If you have diabetes, keeping your blood sugar levels as close to normal as possible.
Controlling high cholesterol, heart disease (especially atrial fibrillation), diabetes, or disorders that affect your blood vessels, such as coronary artery disease. Take cholesterol-lowering medicines called statins if you have high cholesterol or have had a heart attack, TIA, or stroke.
Taking aspirin if you have had a heart attack, if your health care provider recommends it. Taking anticoagulants, as prescribed by your practitioner, if you have atrial fibrillation or have had a heart attack with other complications.
Not smoking and avoiding secondhand smoke. If you do smoke, quit. Daily cigarette smoking increases the risk of stroke by more than 2 times.
Limiting alcohol. Low to moderate alcohol consumption may decrease the risk of ischemic stroke. Moderate drinking is 2 drinks a day for men, and 1 drink a day for women. Excessive use of alcohol (more than 2 drinks a day) can raise your risk of stroke.
Becoming more active. Try to do activities that raise your heart rate. Exercise for at least 30 minutes on most, preferably all, days of the week. A large study showed that physical activity lowers your risk of stroke, partly by reducing the two greatest risk factors for stroke: high blood pressure and heart disease. The more physically active you are, the lower your risk. Moderately active people had a 20 percent lower risk of stroke than inactive people. Highly active people had about a 30 percent reduction of risk. Exercise can also help raise HDL ("good") cholesterol levels in your body, which also lowers the risk of stroke. Check with your health care provider before starting any new exercise program, especially if you have been sedentary for quite some time. He or she can suggest a safe level of exercise for you.
Eating a nutritious, balanced diet that is low in cholesterol, saturated fats, and salt. Foods high in saturated fat and cholesterol can make hardening of the arteries worse. Eat plenty of fruits and vegetables to increase your intake of potassium and vitamins B, C, E, and riboflavin and add olive oil to your diet. Add high-fiber whole grains and breads to your diet: one study showed whole grains reduced the risk of ischemic stroke in women. Eating fish one or more times a month may also reduce your risk of stroke. Limit the amount of salt you eat too.
Maintaining a healthy weight. Being overweight increases your risk of developing high blood pressure, heart problems, and diabetes, which are risk factors for TIA and stroke. Safely take of the extra pounds with a healthy, balanced diet. Avoid crash dieting.
Avoiding illegal drugs (such as a stimulant, like cocaine). Cocaine can increase blood pressure and cause the heart to beat more rapidly, thereby increasing your risk of stroke.
Avoiding birth control pills if you have other risk factors. If you smoke or have high cholesterol or a history of blood clots, taking birth control pills increases your risk of having a stroke.
Avoiding hormone replacement therapy. In women who have gone through menopause, hormone replacement therapy has been shown to slightly increase the risk of stroke.
Avoid getting sick from the flu. Consider getting a flu shot every year.
RISK FACTOR REDUCTION
High blood pressure: The possibility of suffering a stroke can be markedly decreased by controlling the risk factors. The most important risk factor for stroke is high blood pressure. When a person's blood pressure is persistently too high, roughly greater than 130/85, the risk of a stroke increases in proportion to the degree by which the blood pressure is elevated. Controlling blood pressure in the normal range decreases the chances of a stroke.
Smoking: Another important risk factor is cigarette or other tobacco use. Cigarettes cause the carotid arteries to develop severe atherosclerosis, which can lead to their closure and block the blood flow to the brain. Atherosclerosis in general, including involvement of the arteries that supply blood to the heart, is accelerated by smoking. So, when an individual smokes, the main question becomes - which will occur first; a stroke, heart attack, or lung cancer?
Diabetes: Another risk factor for developing a stroke is diabetes mellitus. Diabetes causes the small vessels to close prematurely. When these blood vessels close in the brain, small (lacunar) strokes may occur. Good control of blood sugar is important in decreasing the risk of stroke in diabetic patients. An elevated level of blood cholesterol is also a risk factor for a stroke due to the eventual blockage of blood vessels (atherosclerosis). A healthy diet and medications can help normalize an elevated blood cholesterol level.
Blood thinner/warfarin: An irregular heart beat (atrial fibrillation in particular) is associated with an increased risk of an embolic stroke, in which the blood clot travels from the heart, through the bloodstream, and into the brain. Warfarin (Coumadin) is a blood "thinner" that prevents the blood from clotting. This medication is often used in patients with atrial fibrillation to decrease this risk. Warfarin is also sometimes used to prevent the recurrence of a stroke in other situations, such as with certain other heart conditions and conditions in which the blood has a tendency to clot on its own (hypercoagulable states). Patients taking warfarin need to have periodic blood checks to make sure that their current dose is producing the desired effect. Patients on warfarin also need to know that they are at increased risk for bleeding, either externally or internally.
Aspirin and other antiplatelet therapy: Many stroke patients who do not require warfarin can use another class of medicines called "antiplatelet" drugs to reduce their risk of suffering another stroke. These medicines reduce the tendency of the blood to clot (clog) in the arteries. As a side effect, patients on these medicines usually have a higher likelihood of bleeding, but this risk is less than when taking an anticoagulant like warfarin. The most commonly prescribed first-choice antiplatelet agent for preventing a stroke recurrence is aspirin. If the patient has an adverse reaction to aspirin or has a stroke despite being on aspirin, newer antiplatelet preparations can be used [clopidogrel (Plavix), dipyridamole (Persantine)].
Carotid endarterectomy: In many cases, a person may suffer a TIA or a stroke that is caused by the narrowing or ulceration (sores) of the carotid arteries (the major arteries in the neck that supply blood to the brain). If left untreated, patients with these conditions have a high risk of experiencing a major stroke in the future. An operation that cleans out the carotid artery and restores normal blood flow is known as a carotid endarterectomy. This procedure has been shown to markedly reduce the incidence of a subsequent stroke. In patients who have a narrowed carotid artery, but no symptoms, this operation may be indicated in order to prevent the occurrence of a first stroke.
EMERGENCY PROCEDURES - IF YOU SUSPECT YOU OR SOMEONE ELSE IS HAVING A STROKE
If any of the symptoms mentioned above suddenly appear, emergency medical attention should be sought. Therefore, the first action should be to call 9-1-1 (or whatever number activates the emergency medical response in your area). The family health care provider and/or neurologist should also be contacted. However, the first priority is ensuring that the ambulance arrives as soon as possible.
INITIAL EMERGENCY CARE
The affected person should lie flat to promote an optimal blood flow to the brain. Placing the person into the "recovery position" is recommended if drowsiness, unresponsiveness, or nausea is present. This position is also called the "rescue position" and is used to prevent choking should vomiting occur.
Although aspirin plays a major role in stroke prevention (see below), once the symptoms of a stroke begin, it is generally recommended that additional aspirin not be taken until the patient receives medical attention. If stroke is of the bleeding type, aspirin could theoretically make matters worse.
According to a study by the University of North Carolina, three commands may be used to assess whether a person may be experiencing a stroke. Lay persons can command a potential stroke victim to:
- Smile.
- Raise both arms.
- Speak a simple sentence.
The three commands, known as the Cincinnati Prehospital Stroke Scale (CPSS), are used by health professionals as a simple first step in the assessment process for signs of stroke. If a person has trouble with any of these simple commands, emergency services (9-1-1) should be called immediately with a description of the situation, noting that you suspect the individual is having a stroke.
F-A-S-T STROKE ASSESSMENT
Only a health professional can determine if someone is having a stroke. However, you might be able to provide information that saves your loved one's life. A stroke usually occurs when a blood clot blocks the flow of blood to the brain. It can also happen if a blood vessel breaks. Stroke is a medical emergency and fast action is needed. The faster treatment begins the less risk of permanent damage.
The American Stroke Association encourages you to Think F-A-S-T. Look for the following signs and symptoms:
F A S T
- Sudden loss of vision.
- Loss of balance with dizziness, or sudden severe headache.)
F-A-S-T is based on Cincinnati Prehospital Stroke Scale (CPSS). This 3-item scale developed by the University of Cincinnati Medical Center was designed for use by paramedics and emergency medical personnel to speed their identification of possible strokes. There is no research to support the use of the scale by someone not trained in medicine. However, the American Stroke Association believes that F-A-S-T will make it easier for people to remember the warning signs of stroke and to call 9-1-1.
Unfortunately, most people with stroke symptoms do not get to the hospital in time to receive the full range of possible treatments. If the stroke is the result of a clot, there is a drug that can break up the clot. However, the drug must be given within three hours of the start of symptoms. Health providers will need time to determine the cause of the stroke before treatment can begin. Getting to the hospital quickly is important.
As a concerned family member or friend, you play an important role in helping a stroke victim get needed care. People who are alone when symptoms occur are more likely to delay going to the emergency room. They may not recognize the signs of a stroke, they cannot believe this is happening to them, the stroke may be interfering with their ability to act, or they are afraid of feeling "stupid" if they are wrong. People who are with others when they suffer a stroke frequently get care more quickly. As a family member or friend, here are some specific things you can do.
Become familiar with stroke warning signs. Think F-A-S-T.
Call 9-1-1 or your local Emergency Medical Service if even only one warning sign is present. Let the health professionals determine if it is a stroke or not.
When you call 9-1-1 tell the dispatcher what warning signs are present and when the symptoms first occurred. If you do not know when the symptoms first began, the dispatcher needs to know that as well. The information you provide can make a difference in the kind of treatment that can be safely provided.
Call 9-1-1 or EMS rather than drive your family member or friend to the hospital. The dispatcher can help you assess the symptoms and tell you which hospital in your area is best equipped to treat strokes. The dispatcher can also let the hospital know that you are coming. If you are quite a distance from the hospital, you may work out a plan with the dispatcher to meet an ambulance in route to the hospital in order to get your family member there as quickly as possible. Getting treatment quickly is the goal.
Think F-A-S-T. Time lost is brain lost. If you suspect someone is having a stroke, call 9-1-1 or EMS. A stroke is a medical emergency.
This information is being provided for educational purposes. Your health care provider can make recommendations specific to your situation. Follow your health care provider's advice.
FURTHER EMERGENCY CARE UNTIL HELP ARRIVES
The first priority is to maintain an open airway. If oxygen is available and you have been trained to use it, administer oxygen at moderate flow rates. If the patient is having convulsions, try to prevent further injury from occurring but do not completely restrain the patient during the seizure. Never insert your fingers into the mouth of a patient having a seizure. (For more information about seizures and what to do, see the following link below.)
If you must move a patient who is suffering from paralysis or numbness, do so carefully. A person who has numbness or paralysis may have another injury that he or she cannot feel. Examine the patient carefully during your patient assessment to locate any suspected fractures or other injuries that may have resulted from the stroke.
Other than airway maintenance and administration of oxygen (if available), your treatment should consist of giving psychological support by talking to and touching the patient, and preventing further injury from occurring.
Keep the patient warm, maintaining normal body temperature.
If a patient's throat muscles are paralyzed, the patient may not be able to swallow. Place an unconscious person in the recovery position (see above) to help keep the airway open and to allow any secretions to drain from the mouth.
Keep the person quiet until help arrives or transportation to a medical facility can be arranged.
In cases of severe stroke, the patient may stop breathing. If this occurs, begin rescue breathing (mouth to mouth or mask to mouth breathing) or full CPR (cardiopulmonary resuscitation), if necessary. (Note: Everyone is encouraged to go through CPR training by a qualified teacher to be trained as a first responder. CPR should only be performed by someone trained in the procedure.)
Any patient you think has suffered a stroke should be transported by ambulance to a medical facility for treatment as quickly as possible.
References:
Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. "Cincinnati Prehospital Stroke Scale: reproducibility and validity." Ann Emerg Med 1999 Apr;33(4):373-8. Liferidge AT, Brice JH, Overby BA, Everson KR. (2004) Ability of laypersons to use the Cincinnati Prehospital Stroke Scale. Prehospital Emergency Care, Oct-Dec; 8 (4)384-7. American Stroke Association. What is Stroke? (Learn about Stroke): www.strokeassociation.org. National Stroke Association. Reducing Risk and Recognizing Symptoms Fact Sheet: www.stroke.org/site/PageNavigator/HOME.
STROKE DIAGNOSIS
A stroke is a medical emergency. Anyone suspected of having a stroke should be taken to a medical facility immediately for evaluation and treatment.
MEDICAL HISTORY
The first step in understanding and diagnosing your problem is to obtain a careful medical history. The health care provider takes a medical history by asking questions about the situation from the patient, if he/she is alert. If the patient cannot communicate, a family member or friend familiar with the patient, if they are available, will be asked to provide this information. The practitioner will ask about the symptoms the patient is currently experiencing and any symptoms experienced in the past, previous medical problems or surgeries, any illnesses which run in the family, and about any prescription and non-prescription medications and supplements the patient is taking. It is helpful if a current list of medications and supplements are available for medical review. If the symptoms lasted only a while, the practitioner may also want to talk with someone else who was with the patient at the time.
PHYSICAL EXAMINATION
The next step is to perform a thorough physical examination. The practitioner will check the patient's pulse and blood pressure and examine the rest of the body (heart, lungs, etc). The neurologic examination includes detailed tests of your muscles and nerves. The health care provider will check for strength, sensation, coordination and reflexes. In addition, the patient will be asked questions to check his or her memory, speech and thinking.
If a person has been seeing a particular practitioner, it would be ideal for that health care provider to participate in the assessment. Previous knowledge of the patient can improve the accuracy of the evaluation. A neurologist, a practitioner specializing in disorders of the nervous system and diseases of the brain, will often assist in the diagnosis and management of stroke patients.
Depending on the results of the evaluation, the practitioner may need additional tests to fully understand the patient's problem. Detailed information about each of these tests can be found below. The patient may also be referred to a medical specialist in brain disorders (neurologist), brain surgery (neurosurgery) or another area.
Be patient. Sometimes it takes a while to discover the cause of stroke symptoms, and sometimes the cause of a stroke cannot be determined. Be sure to discuss any questions or concerns with your health care provider.
STROKE MIMICS
Just because a person has slurred speech or weakness on one side of the body does not necessarily signal the occurrence of a stroke. There are many other possibilities that can be responsible for these symptoms. Other conditions that can mimic a stroke include:
- Brain tumors.
- A brain abscess (a collection of pus in the brain caused by bacteria or a fungus).
- Migraine headache.
- Bleeding in the brain either spontaneously or from trauma.
- Meningitis or encephalitis.
- An overdose of certain medications.
- An imbalance of sodium, calcium, or glucose in the body can also cause changes in the nervous system that can mimic a stroke.
In the acute stroke evaluation, many things will occur at the same time. As the practitioner is taking the history and performing the physical examination, nursing staff will begin monitoring the patient's vital signs, getting blood tests, and performing an electrocardiogram (EKG or ECG).
Part of the physical examination that is becoming standardized is the use of a stroke scale. The American Heart Association has published a guide to the examination of the nervous system to help care providers determine the severity of a stroke and whether aggressive intervention may be warranted.
There is a narrow time frame to intervene in an acute stroke with medications to reverse the loss of blood supply to part of the brain (please see TPA below). The patient needs to be appropriately evaluated and stabilized before any clot-busting drugs can be potentially utilized.
Guidelines recommend that risk factors for heart disease also be assessed after a stroke to prevent disability or death from a future heart problem. This is because many people who have had a stroke also have coronary artery disease.
DIAGNOSTIC TESTS & PROCEDURES
Time is critical when diagnosing a stroke. A quick diagnosis within the first 3 hours may enable the patient's health care provider to use medicines that can lead to a better recovery.
The first priority will be to determine whether you are having an ischemic or hemorrhagic stroke. This distinction is critical because the medicine given for an ischemic stroke (caused by a blood clot) could be life-threatening if the stroke is hemorrhagic (caused by bleeding). The health care provider will also want to rule out other conditions that have symptoms similar to a stroke and to check for complications.
To find out what kind of stroke it is, the practitioner will do a type of X-ray called a CT scan of the brain, which can show if there is bleeding. The practitioner may order other tests to find the location of the clot or bleeding, check for the amount of brain damage, and check for other conditions that can cause symptoms similar to a stroke.
If you have had a stroke or stroke warning signs, your health care provider may need additional information to fully understand your problem or plan the best treatment. In addition to blood tests, you may need to schedule special tests or procedures to examine your brain, heart or blood vessels. Here are the tests health care providers use most often in stroke diagnosis.
COMPUTERIZED TOMOGRAPHY (CT SCAN)
CT Scan is also know as a CAT Scan or computed axial tomography. In order to help determine the cause of a suspected stroke, a special x-ray test called CT scan of the brain is typically the first test performed after a stroke, particularly during an acute stroke in the emergency room. A CT scan is a series of X-rays of the skull and brain used to look for bleeding or masses within the brain or other problems of the brain and brainstem. This test will help the health care provider to diagnose whether the stroke is ischemic or hemorrhagic. Magnetic resonance imaging (MRI) (see below) may also be done to determine the amount of damage to the brain and help predict recovery.
This test can show areas of abnormalities in the brain, and can help to determine if these areas are caused by insufficient blood flow (ischemic stroke), a ruptured blood vessel (hemorrhage), or a different kind of a problem. CT scans can be obtained on any part of the body, but the information here applies only to CT scans of the head.
The patient lies in a tunnel-like machine. The inside of the machine rotates and takes x-rays of the head from different angles, which are later used by computers to make an image of a "slice" (or cross-section) of the brain. Unlike other techniques, CT scans (and MRI scans) can show the inside of the head, including soft tissue, bones, brains and blood vessels. CT scans can often show the size and locations of brain abnormalities caused by tumors, blood vessel defects, blood clots, and other problems.
A CT scan may not always be able to diagnose the problem. Even if you are having a stroke, it might not be seen on CT scan for several reasons. In many cases, the involved area of the brain does not appear abnormal for the first several hours after the onset of stroke. Also, the stroke region may be too small to be seen on CT scan, or it may be in a part of the brain (brainstem or cerebellum) which the CT scan does not image well. Depending on the results of the CT scan, the practitioner may wish to obtain additional testing, including an MRI scan. MRI can be more accurate for stroke and other conditions, but it takes longer and is often not available under emergency conditions.
The Procedure
The patient will remove any metallic objects which could diminish the quality of the images (this includes jewelry, glasses, dentures, and hairclips). The patient may also be asked remove their clothing and put on a patient gown. A technologist will help the patient to lie face up on the scanner table, with the patient's head toward the "donut hole" of the CT scanner. The technologist will position the patient on the table, and a device to hold the patient's head in place may be used. Then the technologist leaves the exam room and goes to the control room, where the patient can still communicate by intercom. An intravenous dye (contrast dye) may be given, through injection. This can help to highlight any areas of abnormality in the scan.
While CT images are being taken, it is important for the patient to lie still on the table, which will be moving very slowly in order to image the brain. It is normal for the CT scanner to make a whirring noise during the exam, so the patient should not be alarmed. The table will be moving a few millimeters at a time in order to obtain images of small slices of the brain, until the exam is finished. The procedure usually takes between 20 minutes and an hour.
CT is based on the same principles as regular X-ray. The X-rays are absorbed differently by the different parts of the body. Bone absorbs the most X-rays, so the skull appears white on the image. Water (in the cerebral ventricles, fluid-filled cavities in the middle of the brain) absorbs little, and appears black. The brain has intermediate density and appears grey. Most ischemic strokes are less dense (darker) than normal brain, whereas blood in hemorrhage is denser and looks white on CT.
In brain CT imaging, a fan beam of X-rays is sent out through the skull, and a device on the other side of the scanner picks up the different strengths of the X-rays. After the X-ray tube and detector have made one 360° rotation, the image of one cross-section (a few millimeters in width) has been taken. During this rotation, hundreds of snapshots are taken, which are later used by a computer to make the final image.
CT Scan Risks
The test is painless and there are few side effects. The CAT scan uses very little x-ray radiation. If the patient receives contrast dye, there is a chance of an allergic reaction. This reaction can be serious, and may require treatment with appropriate medication. If the patient has allergies to any foods or medicines, particularly seafood or iodine, it is important to inform the technologist before the procedure. The patient should also tell the technologist if they could be pregnant.
MAGNETIC RESONANCE IMAGING (MRI SCAN)
Magnetic resonance imaging (MRI) is also known as an MRI scan or MR. MR uses magnetic waves rather than x-rays to image the brain. The MRI images are much more detailed than those from CT, but this is not a first line test in stroke. While a CT scan may be completed within a few minutes, an MRI may take more than an hour to complete. An MRI may be performed later in the course of patient care if finer details are required for further medical decision making. People with certain medical devices (for example, pacemakers) or other metals within their body, cannot be subjected to the powerful magnetic field of an MRI.
MR uses magnetic fields to produce a 3-dimensional image of your head. The MR scan shows the brain and spinal cord in more detail than CT. MRI is a test that produces very accurate pictures of the brain and its arteries without x-rays or dyes. This test is useful for detecting a wide variety of brain and blood vessel abnormalities, and can usually determine the area of the brain that is damaged by an ischemic stroke. During this painless test, the patient lies on a table that moves into the opening of the MRI machine. The machine creates a magnetic field which briefly alters the water molecules in the patient's brain cells. The response to this magnetic field is then detected and used to create an image of the brain. Although MRI scans can be used on any part of the body, the following description applies only to MRI of the head. can be used to diagnose ischemic stroke, hemorrhagic stroke, and other problems involving the brain, brainstem, and spinal cord.
The Procedure
Before the test, the patient will be asked a number of questions about previous operations or the presence of any metallic objects in their body. If the patient has artificial joints, a pacemaker, aneurysm clips, or other metal in their body, they should consult their health care provider before having an MRI. The patient will be asked to remove all jewelry and metallic objects, and may be asked to change into a patient gown. The technologist will help the patient to lie down on the scanner table. After the patient is in the proper place, the patient's head will be put in position and a special radio antenna (called a surface coil) will be placed around the head. The technologist will leave the exam room and go to the control room, where the patient can still communicate with him or her by intercom. The patient may have the option of listening to music during the test. While the MR images are being taken, it is important for the patient to lie still on the table, which will be moving very slowly to image the brain. It is normal for the MRI machine to make a loud knocking noise during the exam, so the patient should not be alarmed. The table will be moving a few millimeters at a time to obtain images of each "slice" of the brain, until the exam is finished. The test takes between 30 and 90 minutes to complete. A dye (contrast medium) may be given, through intravenous injection, to highlight the area being studied.
During the exam, a radio signal is turned on in bursts, and the energy is absorbed differently by the different atoms in the body. This energy is reflected out of the body and detected by the MRI scanner. A digital computer constructs these reflections into a picture of the brain. The switching on and off of the device that measures the reflected MR signals (called the gradient coils) produces the knocking sound heard during the exam.
MRI is useful for imaging soft tissues such as the brain because it shows great detail. It can detect minute differences, even between areas that are similar (unlike CAT scans, which are useful in imaging bone and soft tissue, but with less detail). MRI can often demonstrate brain abnormalities which are too small or located in regions of the brain that cannot be seen well by CAT scans. Another benefit of MRI is that it can be performed without x-rays or dyes (although many times, an intravenous dye called gadolinium is used to image the brain and its blood vessels). Brain MRI is commonly used to detect and diagnose many kinds of abnormalities of the skull, brain, and spinal cord. In addition to stroke, MRI is used to diagnose abnormal growths such as tumors, blood vessel abnormalities, infections, or disorders such as multiple sclerosis. MRI can provide direct views of the body from almost any direction, while CAT scans only provide images in an axial orientation. Medical images taken of the human body are usually displayed in three orientations:
- Coronal orientation: in a slice dividing the head into front and back halves.
- Sagittal orientation: in a slice dividing the head into left and right halves.
- Axial orientation: in a slice dividing the head into upper and lower halves.
There are several different kinds of MRI scan (called image sequences). Each sequence highlights different aspects of brain tissue, and may be used to answer specific questions. Some sequences (for example, diffusion-weighted MR) are particularly useful for detecting abnormalities in the first few hours after ischemic stroke. MRI can also be used to obtain an image of the blood vessels which supply the brain (magnetic resonance angiography or MRA).
MRI Risks
The MRI does not involve X-rays and there are no side effects. However, if the patient has any metallic objects in their body, the magnetic field can cause dangerous interactions. It is essential that the patient tells their health care provider or the technologist about any previous surgery, implanted devices such as pacemakers, bullets or shrapnel wounds. The patient will have to lie flat within a relatively small space for as long as an hour. If the patient thinks this may be a problem for them (for example, if the patient is claustrophobic), they should discuss this with their health care provider before scheduling the test. If the MRI test involves contrast dye, the patient will have an injection by vein (usually in their arm).
Other Methods of MRI Technology
An MRI scan can also be used to specifically view the blood vessels non-invasively (without using tubes or injections), a procedure called an MRA (magnetic resonance angiogram). Another MRI method called diffusion weighted imaging (DWI) is being offered in some medical centers. This technique can detect the area of abnormality minutes after the blood flow to a part of the brain has ceased, whereas a conventional MRI may not detect a stroke until up to six hours after it has started, and a CT scan sometimes cannot detect it until it is 12 to 24 hours old. Again, this is not a first line test in the evaluation of a stroke patient, when time is of the essence.
MAGNETIC RESONANCE ANGIOGRAM (MRA)
Magnetic resonance angiogram, also known as a MRA, is a special type of MRI scan (see above) which can be used to see the blood vessels in your neck or brain.
CAROTID DOPPLER ULTRASOUND
A carotid Doppler ultrasound is also known as a carotid doppler, carotid duplex, or as a carotid ultrasound. This is a non-invasive (without injections or placing tubes) method that uses sound waves to screen for narrowings and decreased blood flow in the carotid artery (the major artery in the neck that supplies blood to the brain), as well as how much blood flows and how fast it travels through the vessels. If the health care provider suspects or other tests indicate narrowing of a carotid artery, he or she may want the patient to have a carotid ultrasound/Doppler scan to evaluate blood flow through the artery. The health care provider may also request magnetic resonance angiogram (MRA), CT angiogram, or carotid angiogram.
Health care providers often use carotid ultrasound on patients who have had a stroke or who might be at high risk for a stroke. Narrowing of the carotid arteries (often caused by cholesterol deposits) and blood clots can be detected using this procedure. These conditions can cause problems with the blood flow to the brain and lead to a stroke. The actual blood flow through the carotid arteries can also be imaged by this test.
Painless ultrasound waves (the same ones used in imaging the fetus in a pregnant woman) are used to take a picture of the carotid arteries in your neck, and to show the blood flowing to your brain. This test can show if your carotid artery has an abnormality, is narrowed or blocked by arteriosclerosis (cholesterol deposition) that can lead to stroke. This test can be used to investigate the carotid arteries for several reasons, but the information here applies only to stroke evaluation.
The Procedure
The patient will be asked to lie down on an examination table. The technician (or health care practitioner) will place a clear gel on the area of the neck where the carotid artery is located. The gel is simply a lubricant that allows the transducer (a device that both puts out and detects ultrasound signals) to slide around easily on your skin. When the transducer is placed against the skin, an image of the artery is shown on a video screen. To view the arteries from many different angles, the practitioner will re-position the transducer several times. Because blood is flowing through the artery, a sound similar to the patient's heartbeat will be heard. The procedure is repeated for the carotid artery on the other side of the neck.
The transducer emits high-frequency, ultrasound waves that pass into the body and bounce off the carotid arteries and the red blood cells moving through them. The sound waves are reflected differently by different parts of the body. The transducer detects the different reflections of the sound waves, which are then measured and converted by a computer into live pictures of the arteries and the blood flow.
A carotid ultrasound usually only takes 15 to 30 minutes to complete and the results are immediately known by the practitioner.
Carotid ultrasound Risks
Since the procedure is done without entering the body and does not use dyes or x-rays, there is no risk or pain involved in having a carotid ultrasound.
TRANSCRANIAL DOPPLER (TCD)
Transcranial doppler, also known as TCD, are ultrasound waves are used to measure blood flow in some of the arteries in the brain.
COMPUTERIZED TOMOGRAPHY WITH ANGIOGRAPHY
Computerized tomography with angiography: Using dye that is injected into a vein in the arm, images of the blood vessels in the brain can give information regarding aneurysms or arteriovenous malformations. As well, other abnormalities of brain blood flow may be evaluated. With increasingly sophisticated technology, CT angiography has supplanted conventional angiograms. CONVENTIONAL ANGIOGRAM
Conventional angiogram is another test that is sometimes used to view the blood vessels. A long catheter tube is inserted into an artery (usually in the groin area) and dye is injected while x-rays are simultaneously taken. While an angiogram delivers some of the most detailed images of the blood vessel anatomy, it is also an invasive procedure and is used only when absolutely necessary. For example, an angiogram is done after a hemorrhage when the precise source of bleeding needs to be identified. It also is sometimes performed to accurately evaluate the condition of a carotid artery when surgery to unblock that blood vessel is contemplated. CEREBRAL ARTERIOGRAM / CEREBRAL ANGIOGRAPHY
Cerebral arteriogram, is also known as a cerebral angiogram, cerebral angiography, Digital subtraction angiography, or DSA. Cerebral angiography is used to image the blood vessels of the brain and the blood flowing through them. Antiography involves inserting a catheter in an artery in the patient's arm or leg, and a special dye (contrast medium) is injected into the blood vessels (carotid arteries) leading to the patient's brain. Then regular X-ray images are used to show or detect any abnormalities of the brain's blood vessels, including narrowing, blockage, or malformations (such as aneurysms or arterio-venous malformations). Cerebral arteriogram is a more difficult test than carotid doppler or MRA, but the results are the most accurate. Although cerebral angiography can be used to investigate many abnormalities, only its relevance to stroke is discussed here.
Cerebral angiography is usually done after another test (such as a CT scan) has already detected an abnormality. Angiography is useful in detecting and diagnosing acute stroke and is especially beneficial since the images taken through cerebral angiography cannot be taken through other techniques.
The Procedure
The patient will be asked to remove all clothing and jewelry and wear a patient gown before undergoing the procedure. While the patient is lying on an x-ray table, a local anesthetic is given, usually in the thigh, where an incision is made. The catheter (a long, narrow flexible tube) is put into the patient's body through the incision navigated to the carotid arteries, where the dye is injected. After the patient is properly placed on the exam table, the patient's head is positioned in the desired field of view, and regular x-ray is used to take pictures of the blood vessels in the brain. While the procedure is being done, both the technologist and radiologist remain by your side. Although the patient is awake during the procedure, a medication may be given to help him or her relax. The entire procedure can take from one to two hours to complete.
The basic principle behind cerebral angiography is the same as that of regular x-ray imaging. As the x-rays pass through the body, they are absorbed at different levels. The absorption of the x-rays by the injected dye allows the blood vessels in the brain to be imaged. The differences in absorption become one of many images detected by a camera, which finally become a "movie" of the blood flow (and the flow of the intravenous dye) through the vessels.
Cerebral Angiography Risks
The use of a catheter in cerebral angiography may cause the patient some discomfort or pain, although an anesthetic is usually given to help alleviate most discomfort. There is also a risk of stroke caused by the catheter. While being navigated through the carotid arteries the catheter could break off a plaque that could block a smaller blood vessel in the brain and lead to stroke.
HEART TESTS
Certain tests, such as the electrocardiogram (ECG, EKG), are to evaluate heart function. These tests are often performed in stroke patients to search for the source of an embolism. An echocardiogram is a sound wave test that is done by placing a microphone device on the chest or down the esophagus (transesophageal echocardiogram) in order to view the heart chambers. A Holter monitor is similar to a regular electrocardiogram (EKG), but the electrode stickers remain on the chest for 24 hours or longer in order to identify a faulty heart rhythm.
Electrocardiogram (ECG, EKG) is used to check for heart problems, including arrhythmias and atrial fibrillation. If the health practitioner believes the stroke may have been caused by a problem with the patient's heart, an echocardiogram or Holter monitoring or telemetry test may be done.
ELECTROCARDIOGRAM (EKG, ECG)
The electrocardiogram, also known as EKG or ECG, is a standard test to show the pattern of electrical activity in your heart. 3-10 electrical leads are attached to your chest, arms and legs. Sometimes the EKG is recorded continuously over days, with the signals sent to a portable recorder (Holter monitor) or by radio to a hospital monitoring station (telemetry).
The ECG is done so often and routinely that most people do not even consider it a special test. However, a lot can be learned from an ECG about the regularity (or irregularity) of the heartbeat. The fact that irregularities in the rhythm of the heartbeat can lead to stroke makes it an important tool in stroke evaluation.
An ECG is a painless test that is used to get information about the electrical activity of the heart, such as the rate and regularity of the heartbeat. The size and position of the heart chambers as well as any damage to the heart can also be obtained through an ECG. If the patient uses an implanted device, like a pacemaker, its effect on the heart can also be studied through the results of this test.
ECG is sometimes the only method of detecting irregularities in heart rhythm - such as atrial fibrillation - that can lead to the forming of blood clots that can later get flow to the brain. These blood clots can cause stroke by forming in the heart, coming loose and then getting lodged in a small artery of the brain. ECG is performed on every stroke patient as part of the routine evaluation. However, the test shows only a "snapshot" of the electrical activity of the heart (about 5 minutes), and other devices may be used to find irregularities that occur less frequently.
The Procedure
The patient will be asked to lie down while the sites where the sticky electrodes will be attached are cleaned and shaven, if necessary. About 12 electrodes are attached to various parts of the patient's body, six of which will be attached to the chest. The other six (called limb leads) will be attached accordingly: one on each arm, one on each leg, and two on the abdomen. The patient must usually lie still during the test, while holding their breath for short periods at a time. The test requires ten to 15 minutes to complete.
The electrodes contain wires that can detect the electrical signals of the heart through the skin. These wires are connected to a machine that traces the heart rhythm on graph paper. Because the results are immediately known, the health care provider will instantly know the basic vital signs of the patient's heart.
ECG Risks
Since ECG is done without entering the body and does not use dyes or x-rays, there is no pain or risk associated with having an ECG.
ECHOCARDIOGRAM
Echocardiogram, also known as 2-d echo, Cardiac echo, TTE, and TEE, are painless ultrasound waves are used to take a picture of your heart and the circulating blood. The ultrasound probe may be placed on your chest (trans-thoracic echocardiogram, TTE) or deep in your throat (trans-esophageal echocardiogram, TEE).
An echocardiogram can be used to find out if there is an abnormality of the heart that could lead to stroke. There are two types of echocardiograms: one that examines the heart through the chest (called transthoracic echocardiogram, or TTE), and one that examines the heart through the throat (called transesophageal echocardiogram, or TEE). The information that follows applies only to the use of these procedures in a stroke evaluation.
- Transthoracic echocardiogram (TTE) is most commonly performed, and it is a test that gives information about the size of the heart chamber, the motion of the heart walls, the movements of the heart valves and changes in structure in and around the heart. Ultrasound waves (the same ones used in imaging the fetus in a pregnant woman) are used to make an image of the heart's walls and valves.
- Transesophageal echocardiogram (TEE) provides images of the internal structures of the heart and its blood vessels using the same ultrasound technology.
Health care providers often use TTE on patients in whom they suspect blood clotting (called cardiac embolus), since clots that form in the heart can be detected using this procedure. Blood clots are a leading cause of stroke, as 80 percent of all clots in the heart eventually come loose and travel to the brain. An echocardiogram can help determine how to treat or prevent a stroke (if a blood clot is found in the heart, a blood-thinner such as Warfarin may be prescribed). TTE is performed routinely after heart attack and as part of a stroke evaluation.
Transesophageal echocardiogram (TEE) is usually prescribed after an abnormality is found in the results of a TTE. The images from TEE can provide more information about the condition of the heart because they have better resolution and are taken from the inside of the body rather than the outside.
The Procedure
In TTE, a clear gel is placed on the area of the chest where the heart is located. This lubricating gel allows a device that both puts out and detects ultrasound signals (called an ultrasound transducer) to slide around easily on the skin. When the transducer is placed against the skin, a picture of the area is shown on a video screen. Depending on how the transducer is positioned, the heart can be viewed from several different angles. Due to blood flowing through the heart, a sound similar to patient's heartbeat will be heard. A dye, called agitated saline, may be injected to find any leaking between the chambers of the heart. The images, stored as a 15-minute recording, will be viewed later by the practitioner. TTE requires about 45 minutes to complete.
TEE, unlike TTE, requires preparation before the test can be done. The patient will be asked not eat or drink anything except water during the eight hours before the test. The patient should also not smoke for six hours before the test is done. The patient should be sure to ask their health care provider about how they should adjust their daily medications, such as insulin if they are diabetic. During the actual procedure, the patient will be sedated intravenously to make it less uncomfortable. The practitioner will then ask the patient to swallow a thin, flexible tube with a special tip (called a probe). The patient may be asked to gargle an anesthetic that will numb the throat and tongue so that they can swallow the probe more easily. The test takes 60-90 minutes to complete, but the patient may have to stay for one or two hours so that the sedative can wear off.
The transducer, or probe, emits high-frequency ultrasound waves that pass into the body and bounce off the valves of the heart and the muscles of the heart walls. The sound waves are reflected differently by different parts of the body. The transducer detects the different reflections of the sound waves, which are then measured and converted into live pictures of the heart by a computer. These images are recorded on video tape and later viewed by the health care provider.
Echocardiogram Risks
Since TTE is done without entering the body and does not use dyes, there is no risk or pain in having a TTE.
In TEE, the swallowing of the probe may cause some discomfort or pain. However, anesthetics are usually given to make the procedure less uncomfortable.
CHEST X-RAY (CXR)
An x-ray of the heart and lungs is a standard test for patients with acute medical problems. Abnormalities may alert the patient's health care provider to important problems such as pneumonia or heart failure.
ELECTROENCEPHALOGRAM (EEG)
The EEG measures the patient's brain waves through several electrical leads painlessly attached to the head. EEG is not routinely used for stroke diagnosis, but would be ordered if the patient's health care provider thinks that the patient may have had a seizure.
LUMBAR PUNCTURE (LP)
The lumbar puncture, also known as LP or a spinal tap, may be performed to check for abnormalities in the spinal fluid. A needle is inserted in the patient's lower back to obtain a sample of the fluid (cerebrospinal fluid, CSF) which surrounds the brain and spinal cord. LP is not routinely used for diagnosis of ischemic stroke. However, LP is often required if subarachnoid hemorrhage (bleeding from a cerebral aneurysm) is suspected. LP may also be needed if the patient's health care provider suspects a nervous system infection (such as meningitis) or inflammation.
ELECTROMYOGRAM (EMG)
The electromyogram is also known as an EMG or nerve conduction test (NCV). This test records the electrical activity of the nerves and muscles. EMG is not used for stroke diagnosis, but might be needed if the patient's health care provider suspects a problem with the nerves in the patient's arms or legs.
BRAIN BIOPSY
A brain biopsy is a surgical procedure in which a small piece of the brain is removed for microscopic examination. Biopsy is used to diagnose lesions (such as tumors) which cannot be identified by CT or MRI scan. It is very rarely used for stroke diagnosis, when cerebral vasculitis is suspected.
BLOOD TESTS
If a patient is being evaluated for stroke, it is likely that their health care provider will order some blood tests. Stroke cannot be diagnosed by a blood test alone. However, these tests can provide information about stroke risk factors and other medical problems which may be important.
Blood tests such as a sedimentation rate and C-reactive protein are done to look for signs of inflammation that can suggest inflamed arteries. Certain blood proteins that can increase the chance of stroke by thickening the blood are measured. These tests are performed to identify treatable causes of a stroke or to help prevent further injury. Screening blood tests looking for potential infection, anemia, kidney function, and electrolyte abnormalities may also be considered.
Blood tests, such as a complete blood count (CBC), blood sugar, electrolytes, liver and kidney function, and prothrombin time (a test that measures how long it takes your blood to clot). These tests are done to help the patient's practitioner make choices about their treatment and to check for conditions that may cause symptoms similar to a stroke.
Please note that the first set of tests are commonly used for routine or emergency evaluation of stroke, while the others are used only in very specific situations. Unless otherwise noted, each of these tests require just one tube of blood (a few teaspoons) drawn from a vein.
CBC (COMPLETE BLOOD COUNT)
This is a routine test to determine the number of red blood cells, white blood cells, and platelets in your blood. Hematocrit and hemoglobin are measures of the number of red blood cells. A complete blood count might be used to diagnose anemia (too little blood) or infection (shown by too many white blood cells).
COAGULATION TESTS
- PT (Prothrombin time).
- PTT (Partial thromboplastin time).
- INR (International normalized ratio).
These tests measure how quickly the blood clots. An abnormality could result in excessive bleeding or excessive clotting (which is difficult to measure). If a patient has been prescribed a blood-thinning medicine such as warfarin (Coumadin or similar drugs), the INR is used to be sure that the patient receives the correct dose. It is very important that the patient obtains regular checks. If the patient is taking heparin, the PTT (or aPTT) test is used to determine the correct dose.
BLOOD CHEMISTRY TESTS
Blood chemistry tests measure the levels of normal chemical substances in the patient's blood. The most important test in emergency stroke evaluation is glucose (or blood sugar), because levels of blood glucose which are too high or too low can cause symptoms which may be mistaken for stroke. A fasting blood glucose is used to help in the diagnosis of diabetes, which is a risk factor for stroke. Other blood chemistry tests measure serum electrolytes, the normal ions in patient's blood (sodium, potassium, calcium) or check the function of the liver or kidneys.
BLOOD LIPID TESTS
- Cholesterol.
- Total lipids.
- HDL.
- LDL.
Elevated cholesterol (particularly "bad" cholesterol, or LDL) is a risk factor for heart disease and stroke. For more information about high cholesterol, see the following link:
BLOOD TESTS FOR SPECIFIC SITUATIONS
This is a partial list of less common blood tests sometimes ordered for specific stroke situations, or where the cause of stroke is unclear (for example, in a young person without known stroke risk factors). Abnormal results may suggest a cause for the stroke.
- Antinuclear antibodies (ANA).
- Antiphospholipid antibodies (APL).
- Anticardiolipin antibodies (ACL).
- Lupus anticoagulant (LA).
- Blood culture.
- Cardiac enzymes:
- Troponin.
- Creatine kinase (CPK, CK).
- LDH isoenzymes.
- Coagulation factors:
- Antithrombin III.
- Protein C.
- Protein S.
- Factor VIII.
- Activated Protein C resistance (Factor V Leiden).
- Erythrocyte sedimentation rate (ESR).
- Hemoglobin electrophoresis.
- Homocysteine.
- Syphilis serology (VDRL, FTA, others).
- Toxicology screen (serum or urine).
Please note that this chart applies only to the use of these tests for stroke diagnosis. The patient should be sure to discuss any questions or concerns with their health care provider.
URINALYSIS (UA)
A urine sample is often obtained to screen for bladder infection or kidney problems. If infection is suggested, a urine culture test may be required.
PULSE OXIMETRY
Pulse oximetry (blood oxygen) is a painless test is sometimes done in the emergency room or hospital to determine if the patient's blood is receiving enough oxygen from the lungs. A small probe with a red light is usually attached to one finger.
TREATMENT OF STROKE
Treatment of stroke depends on the areas affected and the damage done. With strokes caused by blood clots, use of "clot busting" drugs (as used in treating heart attacks) can be helpful in the early stages of a stroke. Often, anticonvulsant drugs are used in conjunction with other therapies. It is important that anyone with sudden onset of symptoms suggestive of a stroke seek medical attention as soon as possible.
For an ischemic stroke, treatment focuses on restoring blood flow to the brain. If less than 3 hours have passed since your symptoms began, health care providers may use a medicine that dissolves blood clots. Research shows that this medicine can improve recovery from a stroke, especially if given within 90 minutes of the first symptoms. Other medicines may be given to prevent blood clots and control symptoms.
A hemorrhagic stroke can be hard to treat. Health care providers may do surgery or other treatments to stop bleeding or reduce pressure on the brain. Medicines may be used to control blood pressure, brain swelling, and other problems.
The person with a stroke will need to be admitted to hospital to know the cause of the stroke and how much the brain has been damaged. They will be treated with medications and surgery is sometimes necessary to stop bleeding or remove blood clot.
After the patient's condition is stable, treatment shifts to preventing other problems and future strokes. The patient may need to take a number of medicines to control conditions that put you at risk for stroke, such as high blood pressure, high cholesterol, and diabetes. Some people need to have a surgery to remove plaque buildup from the blood vessels that supply the brain (carotid arteries).
TISSUE PLASMINOGEN ACTIVATOR (TPA)
There is opportunity to use alteplase (TPA) as a clot-buster drug to dissolve the blood clot that is causing the stroke. There is a narrow window of opportunity to use this drug. The earlier that it is given, the better the result and the less potential for the complication of bleeding into the brain. Present American Heart Association guidelines recommend that if used, TPA must be given within three hours after the onset of symptoms. Normally, TPA is injected into a vein in he arm. The time frame for use can be extended to six hours if it is dripped directly into the blood vessel that is blocked. This is usually performed by an interventional radiologist, and not all hospitals have access to this technology. For posterior circulation strokes that involve the vertebrobasilar system, the time frame for treatment with TPA may be extended even further to 18 hours.
HEPARIN & ASPIRIN
Drugs to thin the blood (anticoagulation; for example, heparin) are also sometimes used in treating stroke patients in the hopes of improving the patient's recovery. It is unclear, however, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes. In certain patients, aspirin given after the onset of a stroke does have a small, but measurable effect on recovery. The treating practitioner will determine the medications to be used based upon a patient's specific needs.
MANAGING OTHER MEDICAL PROBLEMS
Blood pressure and cholesterol control are key to prevention of future stroke events. In transient ischemic attacks, the patient may be discharged with medications even if the blood pressure and cholesterol levels are acceptable. In an acute stroke, blood pressure will be tightly controlled to prevent further damage.
In patients with diabetes, the blood sugar (glucose) level is often elevated after a stroke. Controlling the glucose level in these patients may minimize the size of a stroke. Finally, oxygen may administered to stroke patients when necessary.
AFTER THE HOSPITAL
After hospital treatment, the patient will be started on a rehabilitation program as soon as possible, such as exercises to build up his strength, speech training and lessons on how to carry out his daily activities. Advice will be given about maintaining a healthy diet.
The best way to get better after a stroke is to start stroke rehab. The goal of stroke rehab is to help the patient regain skills they have lost or to make the most of their remaining abilities. Stroke rehab can also help a patient take steps to prevent future strokes. The patient has the greatest chance of regaining abilities during the first few months after a stroke. So it is important to start rehab soon after a stroke and do a little every day.
REHABILITATION
When a patient is no longer acutely ill after a stroke, the health care team focuses on maximizing the patient's functional abilities. This is most often done in an inpatient rehabilitation hospital or in a special area of a general hospital. Rehabilitation can also take place at a nursing facility. The rehabilitation process can include some or all of the following:
- Speech therapy to relearn talking and swallowing.
- Occupational therapy to regain dexterity in the arms and hands.
- Physical therapy to improve strength and walking.
- Family education to orient them in caring for their loved one at home and the challenges they will face.
The goal is for the patient to resume as many, if not all, of their pre-stroke activities and functions. Since a stroke involves the permanent loss of brain cells, a total return to the patient's pre-stroke status is unfortunately, not a realistic goal in many cases. When a stroke patient is ready to go home, a home-visiting professional (usually a nurse) may come to the home for a period of time until the family is familiar with caring for the patient and the procedures for giving various medications. Physical therapy may continue at home. Eventually, the patient is usually left at home with one or more caregivers, who now find their lives have changed in major ways. Caring for the stroke patient at home may be easy or very nearly impossible. At times, it becomes apparent that the patient must be placed in a board and care home or a skilled nursing facility because adequate care cannot be given at home despite the good intentions of the family.
CAROTID ENDARTERECTOMY
A carotid endarterectomy is a surgical procedure in which a practitioner removes fatty deposits from one of the carotid arteries, two main arteries in the neck supplying blood to the brain. Carotid artery problems become more common as people age. The disease process that causes the buildup of fat and other material on the artery walls is called atherosclerosis, popularly known as "hardening of the arteries." The fatty deposit is called plaque and the narrowing of the artery is called stenosis. The degree of stenosis is usually expressed as a percentage of the normal diameter of the opening.
Carotid endarterectomies are performed to prevent stroke. Two large clinical trials supported by the National Institute of Neurological Disorders and Stroke (NINDS) have identified specific individuals for whom the surgery is highly beneficial when performed by surgeons and in institutions that can match the standards set in those studies. The surgery has been found highly beneficial for persons who have already had a stroke or experienced the warning signs of a stroke and have a severe stenosis of 70 percent to 99 percent. In this group, surgery reduces the estimated 2-year risk of stroke by more than 80 percent, from greater than 1 in 4 to less than 1 in 10.
Surgery reduces the 5-year risk of stroke by 6.5 percent for patients with 50 to 69 percent stenosis, compared to an 80 percent risk reduction for patients with greater than 70 percent stenosis. Patients with 50 percent stenosis or lower do not show enough benefit from endartarectomy to outweigh the risks of the procedure. With the completion of the NASCET trial, patients with moderate stenosis will be better able to decide whether to risk surgery in order to prevent possible future strokes. The point at which surgery begins to confer a significant benefit seems to be around the time that the artery is 50 percent blocked.
In another trial, the procedure has also been found highly beneficial for persons who are symptom-free but have a severe stenosis of 60 percent to 99 percent. In this group, the surgery reduces the estimated 5-year risk of stroke by more than one-half, from about 1 in 10 to less than 1 in 20.
In 1995, the most recent year for which statistics are available from the National Hospital Discharge Survey, there were about 132,000 carotid endarterectomies performed in the United States. The procedure has a 40-year history. It was first described in the mid-1950s. It began to be used increasingly as a stroke prevention measure in the 1960s and 1970s. Its use peaked in the mid-1980s when more than 100,000 operations were performed each year. At that time, several authorities began to question the trend and the risk-benefit ratio for some groups, and the use of the procedure dropped precipitously. The NINDS-supported North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the NINDS-supported Asymptomatic Carotid Atherosclerosis Study (ACAS) were launched in the mid-1980s to identify the specific groups of people with carotid artery disease who would clearly benefit from the procedure.
The total average cost for the diagnostic tests, surgical procedure, hospitalization and followup care is about $15,000 (or more).
Risk Factors & Surgical Risks
Important risk factors in addition to the degree of stenosis include, gender, diabetes, the type of stroke symptoms (whether in the brain or in the eye), blockage of the carotid artery on the opposite side, and the use of aspirin immediately prior to the surgery. Without other complicating illnesses, age alone is not a worrisome risk factor. Risk factors can affect patients in two ways. They can, particularly in combination, greatly increase a person's risk of having a stroke. In addition, these risk factors can increase the likelihood of surgical complications.
Disease Detection
In most cases, the disease can be detected during a normal checkup with a health care provider. Some of the tests a practitioner can use or order include history and physical exam, doppler ultrasound imaging, oculoplethysmography (OPG), computed tomography (CT), arteriography and digital subtraction angiography (DSA), magnetic resonance angiography (MRA). Frequently these procedures are carried out in a stepwise fashion: from a practitioner's evaluation of signs and symptoms to ultrasound, with arteriography, DSA or MRA reserved for difficult diagnoses.
A practitioner will ask about symptoms of a stroke such as numbness or muscle weakness, speech or vision difficulties, or lightheadedness. Using a stethoscope, a health care provider may hear a rushing sound, called a bruit, in the carotid artery. Unfortunately, dangerous levels of disease sometimes fail to make a sound, and some blockages with a low risk can make a sound. Tests related to this procedure include:
- Doppler ultrasound imaging. This is a painless, non-invasive test in which sound waves above the range of human hearing are sent into the neck. Echoes bounce off the moving blood and the tissue in the artery and can be formed into an image. Ultrasound is fast, risk-free, relatively inexpensive and painless. Unfortunately, there is a small possibility of error in an ultrasound study. A stenosis with a high level of risk will occasionally be incorrectly reported as a low-risk finding. Conversely, a stenosis with a low level of risk will sometimes be reported as a high level of risk. In carefully calibrated ultrasound laboratories, ultrasound studies can be up to 95 percent accurate and offer visualization of the anatomy, evaluation of the blood flow rate and turbulence, and characterization of the plaque. Performing an ultrasound study requires a great deal of skill which is not always available.
- Oculoplethysmography (OPG). This procedure measures the pulsation of the arteries in the back of the eye. It is used as an indirect check for blockages in the carotid arteries.
- Computed Tomography (CT). This test produces a series of cross-sectional X-rays of the head and brain. It cannot detect carotid artery disease but may be ordered by a practitioner to investigate other possible causes of symptoms. The test is also called a CAT scan, for computer assisted tomography.
- Arteriography and Digital Subtraction Angiography (DSA). Arteriography is an X-ray of the carotid artery taken when a special dye is injected into another artery in the leg or arm. A burning sensation may be felt when the dye is injected. DSA is also an X-ray study of the carotid artery. It is similar to arteriography except that less dye is used. A person having a DSA must remain still during the test. These invasive procedures are more expensive and carry their own small risk of causing a stroke.
- Magnetic Resonance Angiography (MRA). This is a very new imaging technique that is more accurate than ultrasound yet avoids the risks associated with X-rays and dye injection. An MRA is a type of magnetic resonance image that uses special software to create an image of the arteries in the brain. A magnetic resonance image uses harmless but powerful magnetic fields to create a highly detailed image of the body's tissues.
The mainstay of stroke prevention is risk factor management: smoking cessation, treatment of high blood pressure and heart disease and control of blood sugar levels among persons with diabetes. Additionally, practitioners may prescribe aspirin, warfarin, or ticlopidine.
STROKE MEDICATIONS
It is very important to seek emergency medical attention for stroke symptoms. If you are having an ischemic stroke, which is caused by a blood clot, you may be given medicines that get rid of the clot. If you are having a hemorrhagic stroke, which is caused by bleeding in the brain, you will not be given medicines.
If you are having an ischemic stroke, you may be able to receive tissue plasminogen activator (t-PA), a clot-dissolving medicine. This medicine is strongly recommended, but it is most effective if given within 3 hours of the onset of stroke symptoms. If you receive t-PA within this 3-hour window, it may improve your recovery. Evidence shows that there may be some benefit in giving t-PA even beyond 3 hours. However, t-PA can be life-threatening because it can cause bleeding in the brain. It is not used to treat hemorrhagic stroke.
Blood clots cause most strokes, so medicines that prevent the formation of blood clots are used to prevent additional ischemic strokes. These medicines are usually given after the initial treatment for stroke. They are not recommended in the first 24 hours after t-PA has been given. The two types of medicines used to prevent clotting are:
- Antiplatelet medicines, which prevent the smallest cells in blood (platelets) from sticking together. Aspirin is the antiplatelet medicine most commonly used to prevent strokes. Two large studies showed that taking aspirin within 48 hours of a stroke may reduce the chance of another stroke and prevent death. People who cannot take aspirin or who have transient ischemic attacks (TIAs) or a stroke while taking aspirin are sometimes given other antiplatelet medicines, such as clopidogrel (Plavix). Another medicine that can prevent ischemic stroke is Aggrenox, which is aspirin combined with extended-release dipyridamole. Aspirin is not recommended within the first 24 hours of giving t-PA.
- Anticoagulants, which prevent the production of proteins needed for blood to clot normally. Anticoagulants (particularly warfarin) are the best method of preventing blood clots that form in the heart because of atrial fibrillation, heart attack, heart valve problems, or heart failure. Anticoagulants are not given as emergency treatment for stroke.
For people with coronary artery disease, treatment with cholesterol-lowering drugs called statins can slow the development of atherosclerosis in the carotid arteries and may also reduce the chance of having a TIA or stroke. Studies have shown a reduced risk of stroke in people taking statins.
MEDICATION CHOICES
Medicine used in the emergency treatment of stroke caused by a clot (ischemic stroke) includes tissue plasminogen activator (t-PA), a medicine that breaks up clots.
After emergency treatment for a stroke, the focus will turn to preventing future transient ischemic attacks (TIAs) or another stroke. Your doctor will decide which medicines to use based on the risks and possible side effects of the medicines. These medicines are not usually given until at least 24 hours after treatment with t-PA.
COMMONLY USED MEDICATIONS
Platelets are blood cells that are help the blood clot (stick together) and prevent bleeding. When the body has a cut, scratch, bruise or bleed, platelets go into action and begin to work. They can be thought of as materials (like bricks or blocks) that aggregate (link together or stack up) to form this clot. These platelet cells need thromoxane A2 and adenosine; vitamin K specific clotting factors (chemicals produced by the body) to make them stick together. These chemicals are essentially the glue that holds the blocks together to make the clot. However, in patients who have had a TIA or stroke, the blocks do not need to stick together as much because this causes the blood to be too thick (like adding flour to milk when making a cake batter) and possibly form a clot that cannot fit through the vessels. Antiplatelets decrease blood clot formation by preventing the smallest blood cells (platelets) from sticking together and forming blood clots. Health care providers often place stroke and TIA patients on blood thinners to decrease the possibility of the body forming another clot in the blood, which may lead to another stroke and TIA.
Aspirin with extended-release dipyridamole (Aggrenox) is used for the prevention of ischemic stroke. Aspirin is an antiplatelet medicine often used for a first TIA or ischemic stroke or if you have atherosclerosis. Talk with your health care provider before you start taking aspirin to prevent a stroke. Clopidogrel (Plavix) may be used if you have had a TIA or ischemic stroke and cannot take aspirin. Antiplatelet medicines include the following:
DRUG NAME OTHER NAMES USED FOR DRUG TYPE Aspirin Acetylsalicylic Acid
ASAStroke Prevention Antiplatelet
ASPIRIN (Acetylsalicylic Acid, ASA)
Besides relieving pain, fever and inflammation, aspirin has many other uses. Aspirin is also used as an antiplatelet/platelet aggregation inhibitor (to keep the blood from sticking together) in patients who have had a TIA or stroke. It can also reduce the risk of having another TIA or stroke. Different doses are used for this purpose, ranging from 50 mg to 325 mg per day, depending on the patient's condition and the health care provider's decision.
The idea that "if one is good for me, two or three must be better" is wrong. Do not adjust the dose without first talking to the pharmacist or health care provider that dispensed or prescribed the medication. The dose is not the same for everyone. The usual dose for stroke/TIA prevention is 30-325 mg daily. Take the medication the way the practitioner instructs you to. So, even though you may be taking an 81 mg (baby aspirin) a day, someone else who had a stroke may be taking 325 mg of aspirin a day or may be on a different medicine for stroke prevention. So do not rely on what you hear from other stroke patients, and do not take more or less of the drug without first talking to the health care provider who prescribed it.
Since aspirin can irritate the stomach, it is best to take it with food or a full glass of water or milk to help avoid or lessen possible stomach problems.
This medication will help prevent platelets (glue like particles) from making the blood too thick, thereby risking a clot. Therefore, it will lessen your body's ability to stop bleeding when you are cut, scratched, or bruised. Your health care provider wants the aspirin to thin the blood (decrease the body's ability to form a clot) just enough to help prevent a future TIA or stroke. Watch for blood in the urine, stools, or around the gums when eating and brushing teeth; bleeding from the nose; or easy bruising. If you notice abnormal or excessive bleeding, let your pharmacist and health care provider know, and talk with them before you change or take any new medicines.
Abdominal (stomach area) pain that will not go away and ringing in the ears are other signs that there might be a problem with the medication. Let the pharmacist or health care provider know if you have any of these warning signs.
Talk with your pharmacist or health care provider before taking any other aspirin products, anti-inflammatory agents (Aleve, Naprosyn, Ibuprofen, etc) or any other medications.
Aspirin Web Page: Bayer U.S. - www.wonderdrug.com
Aspirin In Heart Attack & Stroke Prevention: American Heart Association
DRUG NAME OTHER NAMES USED FOR DRUG TYPE Clopidogrel Plavix Stroke Prevention Antiplatelet
CLOPIDOGREL (Plavix)
Clopidogrel (Plavix®) is an antiplatelet/platelet aggregation inhibitor drug that is used to help prevent another stroke. It does this by decreasing the blood's ability to clot (clump together). This means that when you get a cut or scratch it will take a little longer to stop bleeding. Watch for blood in the urine, blood in the stools, bleeding around the gums when eating and brushing teeth, bleeding from the nose, or bruising easily. If you notice abnormal or excessive bleeding, let your pharmacist and health care provider know, and talk with them before you change or take any new medicines.
You will take one 75 mg tablet once a day in the morning (can be taken with or without food), or when and how your pharmacist and health care provider tell you. Do not adjust the dose without first talking to the pharmacist or practitioner that dispensed or prescribed the mediation, and be sure to talk with your pharmacist or practitioner before taking any other medications.
Plavix Patient Information: Bristol-Myers Squibb - www.plavix.com
DRUG NAME OTHER NAMES USED FOR DRUG TYPE Dipyridamole Aggrenox
Persantine
OthersStroke Prevention Antiplatelet
DIPYRIDAMOLE (Aggrenox, Persantine, & Others)
Aggrenox is the combination of, aspirin (25 mg) and extended release dipyridamole (200 mg), two antiplatelet/platelet aggregation inhibitors. Each of these medications work together in similar way (but on separate chemicals in the blood) to help prevent a future TIA or stroke. Do not adjust the dose without first talking to the pharmacist or health care provider that dispensed or prescribed the medication. The aspirin portion of the combination works in the same way as above, but the dirpyridamole helps prevent platelets, blood cells and the vessels from using adenosine (another chemical that helps the bricks and glue form a clot). Dipyridamole also has the potential to vasodilate the vessels that carry the blood to allow a more blood and particles to flow through (like a water hose expanding in the summer sun).
The combination capsule Aggrenox® (aspirin and dipyridamole) cannot be substituted by taking each drug separately. Taking the two separately does not have the desired effect as the combination capsule does. Take one capsule in the morning (with or without food) and take one capsule in the evening (with or without food) for a total of two capsules a day. Swallow the capsule. Do not chew it or crush it. It must be swallowed whole. Take the medication the way the pharmacist and health care provider told you.
Many patients starting on Aggrenox® develop a severe headache due to the vessels in the brain vasodialating (expanding). This headache tends to decrease and go away as the body gets use to the medicine. In the mean time use an over-the-counter pain reliever and call the pharmacist or practitioner to inform them of the headache.
The combination of aspirin and dipyridamole is a stronger blood thinner than either drug alone. So, watch for blood in the urine, blood in the stools, bleeding around the gums when eating and brushing teeth, bleeding from the nose, or bruising easily. If you notice abnormal or excessive bleeding, let your pharmacist and health care provider know, and talk with them before you change or take any new medicines.
Talk with your pharmacist or health care provider before taking any other aspirin products, anti-inflammatory agents (Aleve, Naprosyn, Ibuprofen, etc) or any other medications.
Aggrenox Patient Information: Boehringer Ingelheim Pharmaceuticals
DRUG NAME OTHER NAMES USED FOR DRUG TYPE Ticlopidine Ticlid Stroke Prevention Antiplatelet
TICLOPIDINE (Ticlid)
Ticlid® is used to help prevent another stroke. You will take a 250 mg tablet two times a day (one in the morning and one in the evening) with food. Take the medicines like the pharmacist and health care provider told you, and do not adjust the dose without first talking to the pharmacist or practitioner that dispensed or prescribed the mediations. Be especially observant of any excessive bleeding such as blood in the urine, blood in the stools, bleeding around the gums when eating and brushing teeth, bleeding from the nose, or bruising easily. If you notice abnormal or excessive bleeding, let your pharmacist and health care provider know, and talk with them before you change or take any new medicines.
You will have to have lab work done every two weeks for the first three months of treatment to check your blood levels. Talk with your pharmacist or health care provider before taking any other aspirin products, anti-inflammatory agents (Aleve, Naprosyn, Ibuprofen, etc) or any other medications.
Ticlid Patient Information: Roche Pharmaceuticals - Ticlid
Thrombolytic therapy is the use of drugs to break-up the clot that is causing the disruption in blood flow to the brain. It is crucial, imperative, and very important that you immediately go to the hospital when you first notice the warning signs of a stroke. The length of time between the first warning signs and the time you get to a hospital may be the difference between a good or poor outcome. Patients who present to the hospital within 3 hours of the first sign of a stroke have the possibility to receive alteplase (tPa, Activase®). Alteplase is a clot-buster. It breaks-up the clot to restore blood flow to the area of the stroke. There are many factors that determine whether or not a patient is able to receive thrombolytic therapy. One of these factors, that you have control of, is the amount of time between the onset of symptoms and presentation to the hospital. If you get to the hospital within the 3 hour time frame and the health care provider determines you are able to receive this clot-buster, you may have a better recovery.
DRUG NAME OTHER NAMES USED FOR DRUG TYPE Tissue Plasminogen Activator tPA
ActivaseAcute Stroke Treatment Thrombolytic
TISSUE PLASMINOGEN ACTIVATOR (tPA, Activase)
Tissue plasminogen activator is a thrombolytic drug (a "clot-buster"). It can reduce the severity of ischemic stroke if it is given within three hours of stroke onset. This drug can be given intravenously or by arterial catheter, but not by mouth.
Activase Information: Genentech, Inc.
Anticoagulants (warfarin and heparin) are often used instead of or in combination with antiplatelets, such as aspirin or clopidogrel.
Anticoagulants are a class of drugs commonly used to prevent the blood from forming dangerous clots that could result in a stroke. Often called "blood thinners," anticoagulants are often the first medication prescribed by health care providers following a stroke. By reducing the ability of the blood to clot - and thereby reducing the likelihood of coronary or vascular emboli - anticoagulants are frequently used in patients that are already at high-risk for stroke. Below is information on specific types of anticoagulants used for stroke prevention.
DRUG NAME OTHER NAMES USED FOR DRUG TYPE Heparin Calciparine
LiquaeminStroke Prevention Anticoagulant
HEPARIN
Heparin is an anticoagulant drug ("blood thinner"). It can be given intravenously or sub-cutaneously, but not by mouth. Heparin is sometimes used to reduce acute stroke damage or stroke risk in hospitalized patients. In addition, heparin may be used in hospitalized stroke patients to reduce the risk of blood clots forming in leg veins.
DRUG NAME OTHER NAMES USED FOR DRUG TYPE Warfarin Coumadin
OthersStroke Prevention Anticoagulant
WARFARIN (Coumadin & Others)
Warfarin is an anticoagulant drug ("blood thinner") which is taken by mouth. Daily use of warfarin can reduce the risk of stroke in certain patients. The American College of Physicians recommends Warfarin for people who are at risk for stroke because of abnormal heart rhythms (atrial fibrillation - heart irregularity) or blood clots that form in the heart or another place in the body. Warfarin is usually given to people age 65 and older. Use of warfarin requires careful monitoring, and you should closely follow your health care provider's recommendations, including regular blood tests. Let your practitioner know if you are taking any other medications.
Your health care provider will start you on a low dose of Coumadin and will have you see him or someone else to check your blood weekly. You want your blood levels to be within a certain range (think of it as keeping your car between the yellow line on the left side of the road and the white line on the right side of the road). The health care provider wants you to be right in the middle, so you will have you blood drawn and the practitioner will increase or decrease your dose based on the blood values and where he or she wants you to be.
Patients receiving Coumadin® also need to be very careful about their diet and activities to prevent problems while taking the medication. The levels of the drug in the body can be affected by the amount of vitamin K in your diet. Foods high in vitamin K include: leafy green vegetables, green teas, as well as pork and beef liver. Patients should avoid large amounts of alfalfa, broccoli, asparagus, Brussels sprouts, cauliflower, cabbage, kale, spinach, watercress, lettuce and turnip greens. You can still eat these items, but eat the same amount regularly. For example, do not eat a plate-full of turnips every day for a week and then decide to stop eating them the next week. Keep the relatively the same diet foods high in vitamin K. Large changes in the amount you eat can cause problems with your treatment.
Also, since Coumadin is a fairly strong blood thinner, you have a chance of bleeding more than usual with common cut, scrapes and falls. Use caution walking and with activities that place you at risk to fall or get hurt. Be careful while shaving, because a common cut may take longer to stop bleeding. Watch for blood in the urine, in the stools, or around the gums when eating and brushing teeth; bleeding from the nose; or bruising easily. If you notice abnormal or excessive bleeding, let your pharmacist and health care provider know, and talk with them before you change or take any new medicines. Lastly, get an identification bracelet or necklace to let people, health care providers and dentist know you are taking Coumadin.
Coumadin Consumer Information: Bristol_Myers Squibb
If you have high blood pressure, your health care provider may want you to take medicines to lower it. Blood pressure medicines include:
- Angiotensin-converting enzyme (ACE) inhibitors.
- Angiotensin II receptor blockers (ARBs).
- Beta-blockers.
- Diuretics.
- Calcium channel blockers.
MEDICATION CONSIDERATIONS
Choosing which medicine to use to prevent stroke is based on evaluation of your risks and the benefits of taking that medicine.
The American College of Cardiology and the American Heart Association recommend that short-acting dipyridamole alone not be used by people who have chronic stable angina (an indicator of coronary artery disease) because dipyridamole may reduce blood flow to portions of the heart (ischemia) during exercise. Extended-release formulations, such as Aggrenox, do not appear to have this risk and may be safe for people with angina. Talk to your health care provider if you are considering taking a medicine that contains dipyridamole.
Medicines used to treat depression and pain may be prescribed after a stroke.
The medications on the listed here are among the most commonly prescribed for stroke treatment and prevention. US trade-names have been provided, but these drugs may have different names in other countries. The web sites listed under each medication name provide complete information.
In addition to the medications shown here, many stroke patients also receive medications to treat high blood pressure, diabetes, or high cholesterol.
The choice of medication for stroke depends on your individual condition. Remember: if you have questions about your medications, ask your health care provider.
LASER THERAPY FOR STROKE TREATMENT
LASER LIGHT FOR STROKE TREATMENT
PhotoThera, a company out of Carlsbad, California, is currently conducting clinical trials of their experimental laser system for the treatment of strokes. Using a near-infrared laser that is capable of reaching the brain through the scalp, it is thought that the light can help reinvigorate cells in the ischemic milieu.
LASER TREATMENT OFFERS HOPE AFTER STROKES
Article By John Fauber of the Journal Sentinel
Tuesday, January 15, 2008
It was 4 a.m. on a snowy Christmas Eve as Linda Quire lay in her hospital room with her head shaved. She and a doctor wore special goggles to protect their eyes as the physician aimed an experimental laser device through her scalp and skull into her brain. Quire's treatment at the University of Wisconsin Hospital in Madison last month was part of a clinical trial to test a novel method for protecting brain cells hours after a stroke. Doctors say such therapies are desperately needed because most stroke victims don't get to a hospital soon enough.
As the device beeped every second, Quire dozed off, tired from the 24-hour medical ordeal that had landed her at UW Hospital.
Nearly a day earlier, Quire, 54, had been in the kitchen of her home in Browntown, about 45 miles south of Madison. As she stood at the sink, her right arm suddenly felt like it was floating. Her face drooped. Emergency medical personnel quickly arrived and took her to Monroe Hospital, a few minutes away. As tests were being done, her symptoms subsided, and doctors decided she would spend the night there. "But then I started to get worse," she said. "I couldn't remember, and it was harder to speak."
Now doctors needed to quickly get her to UW Hospital. The drive in the snow took nearly an hour and a half. The snow also would slow Justin Sattin, the UW neurologist who was called in the middle of the night. "My car was snowed in, so I took the bus to the hospital," said Sattin, medical director of the UW Hospital stroke program.
When Quire arrived in Madison, she was long past the therapeutic window for t-PA, the only approved clot-busting drug, which usually must be administered within three hours of the onset of symptoms. Because most patients don't recognize they are having a stroke early enough and because some hospitals still don't offer t-PA, the vast majority of people who have strokes don't get the drug, said Harold Adams, a professor of medicine and director of the stroke program at the University of Iowa.
As the night wore on into the early morning, doctors talked to Quire and her family about one last experimental option: a near-infrared laser that could penetrate into her brain and activate a substance inside her brain cells.
UW is one of several sites around the country testing the treatment. Nationally, researchers hope to treat 660 stroke patients. So far, UW, the only hospital in the state offering the treatment, has treated five people. The trial is being funded by PhotoThera Inc., the Carlsbad, Calif., company that makes the device. "This (the laser treatment) would be a new type of protection," said Adams, who is not a part of the study. "It's kind of unorthodox." If further testing shows it is effective, it could substantially extend the window of treatment, he said.
For Quire, the laser would be too late for the brain cells that already had died. But in the blood-starved area surrounding the clot, an untold numbers of neurons likely were in danger of dying and in dire need of nutrition. During a typical stroke, tens of millions of neurons die every hour. In Quire's case, the laser might be able to save them and in doing so preserve valuable brain function for her. "The dying brain is a process," Sattin said. "It doesn't happen instantly." Quire's stroke was moderate in size and occurred on the left side of her brain, he said.
As part of the protocol of the study, Sattin used a hand-held device that looks like a hair dryer to deliver two minutes of laser light to each of 20 silver-dollar-sized spots all over her head. "It (the laser) does in fact get into the brain," he said. "Once it's in the brain, the million-dollar question is what does it do?" In neurology, doctors refer to this stressed but still viable region of brain tissue as the penumbra, an allusion to an astronomy term for the gray, partial shadow that forms between complete darkness and complete illumination during an eclipse.
Chances of Success
To prevent Quire's penumbra from going over to the dark side, two things had to occur. First, the laser treatment would have to work. Although animal studies and limited human research suggest it might be effective, the treatment still is in the experimental stage and its value has yet to be proved. Second, Quire would have to get the actual laser treatment. Under the protocol of the clinical trial, half the patients get the treatment and half get a sham treatment. Neither the doctor nor the patients know who is getting treated. Essentially, Quire had a 50-50 chance of receiving an iffy treatment.
Still, there is reason to believe the laser treatment, which can be given up to 24 hours after the onset of symptoms, might be beneficial. An earlier trial involving 120 patients found that 70 percent who got the laser treatment had a successful outcome, such as complete recovery from their stroke, compared with 51 percent for those who got a sham treatment. "The prospects are very good," said Harry Whelan, a neurologist who practices at Children's Hospital of Wisconsin and Froedtert Hospital.
Energy Use Is Key
Whelan, who has done extensive research on so-called photo therapy, said that when infrared laser light reaches brain cells, it improves energy metabolism in those cells, which can be starved of glucose and other energy sources when the blood supply is inhibited. The laser light activates an enzyme that controls production of an energy source known as ATP. "There is a large area (of brain cells) fighting for survival," said Whelan, a professor of neurology at the Medical College of Wisconsin who was not a part of the study.
Indeed, using laser light might be beneficial in other neurological disorders, said Whelan, who is researching whether it might help in the treatment of Parkinson's disease and diabetic retinopathy.
For Quire, it could be another year before the study is unblinded and she learns whether she got the laser treatment or the sham. But she said she has recovered extremely well from the stroke after initially having some problems with language. "Each day it was amazing how much better I got," she said. "I don't know if it (the laser) is what helped. Maybe it was. Normally people don't recover from a stroke as fast as I did."
COMPLICATIONS OF STROKE
A stroke can become worse despite an early arrival at the hospital and appropriate medical treatment. It is not unusual for a stroke and a heart attack to occur at the same time or in very close proximity to each other.
During the acute illness, swallowing may be affected. The weakness that affects the arm, leg, and side of the face can also impact the muscles of swallowing. A stroke that causes slurred speech seems to predispose the patient to abnormal swallowing mechanics. Should food and saliva enter the trachea instead of the esophagus when eating or swallowing, pneumonia or a lung infection can occur. Abnormal swallowing can also occur independently of slurred speech.
Because a stroke often results in immobility, blood clots can develop in a leg vein (deep vein thrombosis). This poses a risk for a clot to travel upwards to and lodge in the lungs - a potentially life-threatening situation (pulmonary embolism). There are a number of ways in which the treating practitioner can help prevent these leg vein clots. Prolonged immobility can also lead to pressure sores (a breakdown of the skin, called decubitus ulcers), which can be prevented by frequent repositioning of the patient by the nurse or other caretakers.
Stroke patients often have some problem with depression as part of the recovery process, which needs to be recognized and treated.
The prognosis following a stroke is related to the severity of the stroke and how much of the brain has been damaged. Some patients return to a near-normal condition with minimal awkwardness or speech defects. Many stroke patients are left with permanent problems such as hemiplegia (weakness on one side of the body), aphasia (difficulty or the inability to speak), or incontinence of the bowel and/or bladder. A significant number of persons become unconscious and die following a major stroke.
If a stroke has been massive or devastating to a person's ability to think or function, the family is left with some very difficult decisions. In these cases, it is sometimes advisable to limit further medical intervention. It is often appropriate for the health care provider and the patient's family to discuss and implement orders to not resuscitate the patient in the case of a cardiac arrest, since the quality of life for the patient would be so poor. In many cases, this decision is made somewhat easier if the patient has made such a request when well.
EFFECT ON DAILY LIVING AND ACTIVITIES
A person who has had a stroke may have problems with the simplest of daily activities such as walking, dressing, eating and using the bathroom. Unless the stroke is so severe as to cause death within a few days, a degree of recovery from the initial severe restrictions can be expected. Most of this recovery occurs within the first 6 months. After one year from the stroke further recovery is likely to be limited. Recovery and the effectiveness of rehabilitation depend upon many factors. These include the size and site of the brain damage and whether any other impairment is present.
Even if an upper limb remains without useful function, the use of technical aids may enable the person to manage alone. If the dominant arm is affected, full independence may be more difficult to achieve. The need for help with daily living activities is likely to be restricted to short but necessary periods in relation to specific tasks, such as dressing, washing and cutting up food.
Many younger people who have had a stroke without other complications are likely to achieve a considerable degree of independence. Most will be likely to learn to walk again although some will require assistance from mechanical aids such as a walking frame, tripod or stick. Such persons are likely to be independently mobile within the house, but when out of doors they may be restricted in terms of distance and speed. If the cerebellum has been affected then walking may be adversely affected by balance problems (ataxia) and disturbances of gait. Following a less severe stroke, other areas of the brain may take over the function of the damaged part. This may result in considerable functional improvement.
A homonymous hemianopia (a loss of one half of the visual field) or aphasia or dysarthria are likely to make communication very difficult. If these problems are present then considerable help will normally be required. Additionally, homonymous hemianopia is often associated with "neglect" syndrome reducing still further the person's ability to care for themselves and get around.
REHABITATION FOR STROKE PATIENTS
The effect of a small stroke can be overcome, but in other cases, the disabilities are severe and permanent. So, support and understanding from family, friends, and intensive rehabilitation from health care professionals, can always improve stroke patients quality of life. The health care professionals who can help are :
- Speech therapist to maintain or improve speech and communication and assess swallowing difficulties.
- Occupational therapist to teach coping strategies and new skills and help adapt the family home to better cater for the need of a stroke patient.
- Physiotherapist to maintain or improve the movement and functioning of the body.
NURSING CARE GUIDELINES FOR POST-STROKE PATIENTS
1. Maintaining the skills and abilities that the patient has left.
2. Preventing complications cause by immobility.
- Contractures.
- Pressure ulcers.
- Pneumonia.
- Blood clots.
3. Helping the patient regain functional abilities.
- Activities of daily living.
- Bowel and bladder control.
- Mobility.
- Communication skills.
DURING RECOVERY
Recovery from a stroke is often a very frustrating experience for the patient. Caregivers must be patient. If you are a caregiver for a stroke patient, remember two things:1. The patient has more than enough frustration for the two of you, so be careful not to let yours show. The last thing the patient needs is your silent reinforcement of his helplessness.
2. It is well known that the degree and speed of recovery are directly related, in most cases, to the patience and encouragement of the caregivers with whom the patient has close contact.
Other interventions during recovery include:
- Physical therapy to increase independent mobility; bed movements, getting to the side of the bed, standing by the side of the bed, transferring out of bed and into a chair, and ambulation.
- Occupational therapy to regain the ability to perform the activities of daily living, such as bathing, grooming, dressing, and eating, with little or not assistance.
- Speech therapy to regain or to learn different methods of communication.
- Nursing care to:
- Implement bowel and bladder training programs or providing catheter care if necessary.
- Implement pressure ulcer prevention programs.
- Reinforce the programs provided by the therapists.
- Care to prevent contractures by:
- Positioning the patient appropriately and changing positions at least every 2 hours.
- performing passive range-of-motion exercises as directed.
- Applying splints or braces as ordered.
All caregiver staff can help with rehabilitation efforts by:
- Encouraging the patient to communicate.
- Maintaining a positive and supportive attitude at all times.
- Providing only the assistance that the patients needs.
- Following approaches consistently as outlined in the patient's care plan.
Convalescence is often long. The nursing care is demanding, requiring much patience and understanding.
COMMUNICATING WITH PATIENTS WITH APHASIA
Patients who have had a stroke or brain damage due to an injury may have aphasia. Aphasia means the person cannot understand spoken or written language, or cannot express spoken or written language, or both. Trying to communicate with patients with aphasia can be frustrating to both the patient and the caregiver.
1. Face the patient and make eye contact before speaking.
2. Say the patient's name and give a social greeting before asking questions or giving instructions.
3. Speak slowly and clearly. Use short, complete sentences.
4. Pause between sentences to allow the patient time to comprehend and interpret what you said.
5. Check the patient's comprehension before you proceed. Ask a question based on information you just gave the patient.
6. Use non-verbal cues to augment spoken communication. Use gestures, facial expressions, or pictures.
7. Ask questions that require only short responses or ones that can be answered non-verbally.
8. Repeat what the patient just said to help him or her keep focused on the conversation.
9. Find out if the speech therapist has devised methods of non-verbal communications, such as communication boards or picture books.
10. Do not avoid talking to a person with aphasia. Do not shout to try to make him or her understand.
11. If you sense frustration, let the patient know that you are aware of the frustration. Suggest that you talk about something else for a while and then try again.
NUTRITION AND STROKE PREVENTION
A healthy diet can reduce your risk for acquiring medical conditions such as hypertension (high blood pressure), diabetes, high lipid levels, coronary artery disease and obesity. All of these conditions can increase your chance of getting a stroke. Your age, sex, current weight, distribution of body fat, eating habits and fitness level also influence your risk.
Factors that tend to increase blood pressure:
- Being overweight.
- Lack of exercise.
- Stress.
- Smoking.
- Low intake of some minerals, such as calcium and potassium.
- High intake of sodium.
To lower your risk of stroke, follow these guidelines:
- Eat a variety of foods.
- Balance the foods you eat with physical activity. Maintain or improve your weight.
- Choose more whole grains, vegetables and fruits.
- Choose foods low in fat, saturated fat and cholesterol.
- Choose foods with moderate amounts of added sugar.
- Choose foods with moderate amounts of salt and sodium.
- If you drink alcoholic beverages, do so in moderation.
Practical tips for getting started on a healthier diet and lifestyle:
- Be realistic: Make one or two small changes every month and stick to them.
- Be adventurous: Expand your tastes and try a greater variety of foods.
- Be flexible: Balance what you eat and your physical activity over several days.
- Be sensible: Enjoy all foods; just do not overdo it.
- Be active: Walk the dog; do not just watch the dog walk!
Seek assistance from a registered dietitian (R.D.) to help guide you in making these significant lifestyle changes toward healthier eating.
HOW STROKE CAN AFFECT EATING AND NUTRITION
Stroke can devastate a person's nutritional health because it may limit his or her ability to perform daily activities associated with eating, such as grocery shopping, preparing meals and feeding oneself.
Stroke can also impair a person's ability to swallow. Swallowing problems may result from weakening of the tongue or loss of coordination of tongue movements. Food can become pocketed between the cheek and teeth and drooling may occur because of an inability to seal the lips.
The person may also:
- Choke and cough during and after meals.
- Be unable to suck from a straw.
- Lack a gag reflex.
- Suffer from chronic upper respiratory infection.
If calorie and nutritional needs cannot be met, the person may become malnourished, a condition characterized by weight loss and a poor appetite.
Diet modifications need to be individualized according to the type and extent of these impairments. A registered dietitian (R.D.) can develop a plan of care that will provide a satisfying and nutritionally adequate diet.
Tips for eating well with swallowing problems:
- Liquids of thicker consistency are easier to swallow.
- Drink eight cups of liquid each day to meet fluid needs.
- Very warm and well-chilled foods make swallowing easier.
- Eat small meals frequently throughout the day to meet nutrient needs.
- Eat moist foods, such as casseroles and foods with sauces.
STROKE SUPPLEMENTS & PRODUCTS
Information, products and supplements for stroke, a loss or change in bodily function that is caused from an insufficient supply of blood to a part of the brain. Consult with your health care provider if you are on medications to make sure there is no medication-supplement incompatibility.
BENEFICIAL DIETARY SUPPLEMENTS
Vitamin E improves circulation.
Vitamin A guards against heart disease and stroke and lowers cholesterol levels.
Flaxseed Oil decreases inflammation that can lead to heart attack, stroke and atherosclerosis.
Selenium protects against heart disease and stroke.
Folic Acid and Vitamin B-12 can help decrease the risk of stroke and heart disease.
Evening Primrose Oil and Lecithin prevents blood clots from forming.
Vitamin C with Bioflavonoids improves the strength of blood vessels.
Ginkgo Biloba increases blood flow to the brain when taken in tea form.
Garlic decreases cholesterol and improves circulation. CARDIO-NUTRITIONAL SUPPLEMENTS
The following nutrients are important for healing once appropriate conventional treatment has been administered. These supplement are for prevention and healing after a cardiac-related incident and are not to be taken in place of appropriate medical therapy.
Unless otherwise specified, the following recommended doses are for those over the age of 18. For a child between 12 and 17 years old, reduce the dose to 3/4 the recommended amount. For a child between 6 and 12 years old, use 1/2 the recommended dose, and for a child under 6, use 1/4 the recommended amount.
NUTRIENTS Supplement Suggested Dosage Comments Essential Coenzyme Q-10 50-100 mg daily. Increases oxygenation of heart tissue. Has been shown to prevent recurrences in individuals who have had a heart attack.
CoQ10, Vegetarian Coenzyme, NOW Foods, 30 mg, 60 VCaps,
CoQ10, Now Foods, 400 mg, 60 SoftgelsCoenzyme A As directed on label. Can streamline metabolism, increase energy, support adrenal glands, process fats, remove toxins from the body, boost the immune system, and improve overall physical and mental processes.
Pantethine (Coenzyme A Precursor), Highly Active Form of Vitamin B-5, 300 mg, NOW Foods, 60 SoftgelsKyolic EPA As directed on label. Reduces triglyceride levels in the blood.
Essential Fatty Acids
(Flaxseed Oil, Black Currant Seed Oil, MaxEPA, Primrose Oil, and Salmon Oil are all good sources.)As directed on label. Helps prevent hardening of the arteries. If you use a fish oil, use a product with vitamin E added to prevent rancidity.
Ultimate Oil, Essential Fatty Acids Supplement, Nature's Secret, 90 SoftGels,
Barlean's Flax Oil, 100% Highest Lignan Content, Organic, Pesticide & Herbicide Free, 16 fl. oz.,
Barlean's Flax Oil, Highest Lignan, 1000 mg, 250 Caps,
Black Currant Oil, 500 mg, NOW Foods, 100 SoftGels,
Barlean's Primrose Oil, With Gamma Linolenic Acid (GLA), 1300 mg, 120 SoftGels,
Wild Salmon Oil, 2000 mg, 120 EPA/ 80 DHA, NOW Foods, 250 SoftGelsL-Arginine As directed on label. Take with carbohydrates rather than protein, which inhibits absorption. Improves blood flow.
L-Arginine, Pharmaceutical Grade, Free Form, NOW Foods, 500 mg, 100 Caps,
L-Arginine, Pharmaceutical Grade, Vegetarian, NOW Foods, 1000 mg, 120 TabsVitamin C With Bioflavonoids 1,000 mg 3 times daily. Extremely important in treating cardiovascular disease.
Vitamin C Liquid w/ Rose Hips & Bioflavonoids, Kosher, Natural Citrus Flavor, Dynamic Health, 1000 mg, 16 fl. oz.,
Ester C With Bioflavonoids, Nature's Way, 1000 mg, 90 Tabs,
Vitamin C 1000 With Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 VCaps,
The Right C, Nature's Way, 1000 mg, 120 TabsVery Important Bio-Cardiozyme Forte As directed on label. A complex that strengthens the heart muscle. Heart Science
From Source Naturals1 Tablet 3 times daily. Contains antioxidants, cholesterol fighters, herbs, and vitamins that work together to protect the heart and promote cardiovascular function. Calcium 1,500-2,000 mg daily, in divided doses, after meals and at bedtime. Important in the proper functioning of the cardiac muscle. Use chelate forms.
Calcium Ionic Mineral Supplement, Fully Absorbable, 700 +/- ppm, 16 fl. oz.,
Liquid Calcium W/ConcenTrace, Orange Vanilla, Trace Minerals, 1000 mg, 32 fl. oz.,
Cal-Mag Pre-Chelated Calcium & Magnesium, Vital Earth, 240 GelcapsMagnesium 750-1,000 mg daily, in divided doses, after meals and at bedtime. Vital for a health heart. Connected to over 300 enzyme actions controlling glucose, proteins, and fats.
Magnesium Ionic Mineral Supplement, Fully Absorbable, 350 +/- ppm, 16 fl. oz.,
Just An Ounce Calcium & Magnesium Liquid, Almond Flavor, 16 fl. oz.,
Calcium & Magnesium Mineral Complex, 100% Natural, Nature's Way, 500 mg / 250 mg, 250 CapsCardio Logic
From WakunagaAs directed on label. Increases the oxygenation of heart tissue. L-Carnitine 500 mg twice daily. Helps to strengthen the heart muscle and to promote circulation by transporting long fatty acid chains. Reduces fat and triglyceride levels in the blood. Increases oxygen uptake and stress tolerance.
Shark Liver Oil With Vitamin A, NOW Foods, 40 mg / 10,000 IU, 120 SoftGels,
L-Carnitine Liquid, Double Strength, NOW Foods, 16 fl. oz.,
L-Carnitine, Stable Tartrate Form, NOW Foods, 500 mg, 60 CapsLecithin Granules
Or
Capsules1 tablespoon 3 times daily, before meals.
2,400 mg 3 times daily, with meals. Take with vitamin E (below).Emulsifies (breaks up) fats.
Lecithin Vegetarian Granules, NOW Foods, 97% Phosphatides, Identity Preserved Non-GE, 1 lb,
Lecithin Liquid, NOW Foods, Vegetarian, 16 fl. oz.,
Lecithin Concentrate, Nature's Way, 400 mg, 100 SoftGelsLiquid Kyolic
(Take with B-1 & B-12)As directed on label. Lowers blood pressure and thins the blood.
Kyolic Liquid Aged Garlic Extract, Cardiovascular, Vegetarian, Wakunaga Kyolic, 4 fl. oz.,
Or
"Green Drinks"
Fresh Wheatgrass Juice
Such as Kyo-Green from WakunagaAs directed on label. Concentrated barley and wheatgrass juice; contains nutrients needed for healing and prevention of heart disease. Use liquid or tablet form. Also prepare fresh "green drinks" from green leafy vegetables.
Wheatgrass Supplements & ProductsLycopene
Plus
LuteinAs directed on label. Carotenoids that lower LDL (bad) cholesterol.
Lycopene, Double Strength, NOW Foods, 20 mg, 50 SoftGels,
Lycopene, Super Antioxidant Supplement, Nature's Way, 5 mg, 60 SoftGels,
Lutein Supplement, Nature's Way, 20 mg, 60 SoftGelsGarlic (Kyolic) 2 capsules 3 times daily, with meals. Lowers blood pressure and helps to strengthen the heart muscle. Thins the blood.
Garlic Oil Tincture, Alcohol Free, Nature's Way, 1 fl. oz.,
Garlic Bulb Cloves, Garlic Supplement, Nature's Way, 580 mg, 100 Caps,
Odorless Garlic Supplement, NOW Foods, 50 mg, 250 SoftGels,
Garlic Supplement, Kwai, Triple Concentrated, 180 Tabs,
Every Day Garlic Supplement, Kwai, 30 Tabs,
Garlic Tincture, 100% Organic, 2 fl. oz.,
Aged Garlic Extract, Cardiovascular Formula 100, Wakunaga Kyolic Supplements, 300 Caps,
Kyolic Liquid Aged Garlic Extract, Cardiovascular, Vegetarian, Wakunaga Kyolic, 4 fl. oz.,
Kyolic Aged Garlic Extract, One-A-Day, Vegetarian, 1000 mg, Wakunaga Kyolic, 30 Caps,
Aged Garlic Extract, Cholesterol Formula 104, Wakunaga Kyolic, 200 CapsPantothine As directed on label. A derivative of pantothenic acid that reduces LDL cholesterol.
Pantothine (CoEnzyme A Precursor), Highly Active Form of Vitamin B-5, 300 mg, 60 SoftGelsPhosphatidyl Choline As directed on label. Reduces fat and triglyceride levels in the blood.
Choline Supplement, 100% Natural, Nature's Way, 500 mg, 100 TabsOr
Lipotropic FactorsAs directed on label. Reduces fat and triglyceride levels in the blood. Pycnogenol As directed on label. Found to be more effective than aspirin in reducing buildup of platelets in the arteries, a major risk factor in heart disease.
Pycnogenol W/ Vitamin E, 100% Natural, Nature's Way, 50 mg, 30 TabsImportant Aerobic Heart
From Aerobic Life Industries
Or
Kyolic Homocysteine
From WakunagaAs directed on label. Contains vitamins B-6 & B-12, folic acid, and trimethylglycine.
Contains aged garlic extract with vitamin B-6 & vitamin B-12, folic acid, and betaine to support healthy homocysteine levels.Chitosan As directed on label. A polysaccharide derived from shellfish that has been shown to reduce blood cholesterol levels.
Chitosan Fat Blocker, NOW Foods, 500 mg, 120 CapsDimethylglycine (DMG) 50 mg 4 times daily. Promotes the utilization of oxygen.
DMG Supplement N,N Dimethyl Glycine, NOW Foods, 125 mg, 100 CapsPotassium 99 mg daily. Needed for electrolyte balance, especially if taking cortisone or blood pressure medication.
Potassium Ionic Mineral Supplement, Fully Absorbable, 340 +/- ppm, 16 fl. oz.,
Potassium Chelate, 100% Natural, Nature's Way, 99 mg, 100 Caps,
Potassium Chloride Powder, NOW Foods, Vegetarian, 8 oz.Red Yeast Rice As directed on label. Contains lovastatin, which has been proven to reduce cholesterol levels (synthetic lovastatin is often prescribed for this purpose).
Red Yeast Rice, By Hi-Tech Pharmaceuticals, 90 Tabs,
Red Yeast Rice Extract, Vegetarian, NOW Foods, 600 mg, 120 VCaps,
Red Yeast Rice Powder, NOW Foods, 4 oz.Selenium 200 mcg daily. Do not exceed a total daily intake of 800 mcg daily from all sources, including diet. If you are pregnant, do not exceed 40 mcg daily. Deficiency has been linked with heart disease. Destroys free radicals in the heart. Caution: Do not take supplemental selenium if you are pregnant or have heart, kidney, or liver disease.
Selenium Supplement, Yeast Free, NOW Foods, 200 mcg, 180 Caps,
Selenium Ionic Mineral Supplement, Fully Absorbable, 50 +/- ppm, 16 fl. oz.,
Ionic Selenium, Trace Minerals, 300 mcg, 2 fl. oz.,
Selenium, 100% Natural, Nature's way, 200 mcg, 100 CapsSuperoxide Dismutase (SOD) As directed on label. A powerful antioxidant.
GliSODin Antioxidant Catalyst, NOW Foods, 100 mg, 90 VCaps,Taurine Plus
From American Biologics1,000 mg daily. Take with 50 mg Vitamin B-6 and 100 mg Vitamin C for better absorption. Helps stabilize the heartbeat and correct cardiac arrhythmias. An important antioxidant and immune regulator, necessary for white blood cell activation and neurological function. Use the sublingual form.
Taurine, Free Form, NOW Foods, 500 mg, 100 Caps,
Taurine, Double Strength, Free Form Amino Acid, NOW Foods, 1000 mg, 100 Caps,
Chromium Picolinate As directed on label. Lower LDL cholesterol.
Chromium Picolinate, NOW Foods, 200 mcg, 100 Caps,
Ionic Chromium Supplement, Trace Minerals, 550 mcg, 2 fl. oz.,
Chromium Ionic Mineral Supplement, Fully Absorbable, 50 +/- ppm, 16 fl. oz.Vitamin E Start with 100-200 IU daily and increase slowly, adding 100 IU each week until the dosage is 800-1,000 IU daily. Consult your health care provider if you are taking anticoagulant medication. Strengthens the immune system and heart muscle, improves circulation, and destroys free radicals. Use d-alpha-tocopherol form. Caution: Use this supplement only under the supervision of a health care provider.
Ester E Natural Vitamin E, California Natural, 400 IU, 60 Softgels,
Vitamin E, 400 IU, 100% Natural, NOW Foods, 100 Gels,
Vitamin E-1000, NOW Foods, 1000 IU, 100 Gels,
Vitamin E, d-alpha-tocopherol, 400 IU, 100 Softgels
Helpful Copper 3 mg daily or as directed by health care provider. Needed to balance with zinc. A deficiency may be linked to some heart problems.
Copper Ionic Mineral Supplement, Fully Absorbable, 50 +/- ppm, 16 fl. oz.,Kelp
Or
Seaweed1,000-1,500 mg daily with meals.
As directed on label.A rich source of important vitamins, minerals, and trace elements.
Kelp Supplement, Nature's Way, Certified, 650 mg, 100 Caps,
Kelp Seaweed, Norwegian, NOW Foods, 100% Natural, 550 mg, 250 Caps,
Kelp Seaweed, Norwegian Powder, 4 oz. BulkMelatonin 2-3 mg daily, taken 2 hours or less before bedtime. A powerful antioxidant that may help prevent stroke and also aids sleep.
Melatonin Supplement, Time Released, NOW Foods, 1 mg, 100 Tabs,
Sublingual Melatonin Supplement, Nature's Way, 2.5 mg, 100 Lozenges,
Melatonin, Pharmaceutical Grade, NOW Foods, 3 mg, 60 CapsMulti-Enzyme Complex As directed on label. Take between meals. To aid digestion and circulation and enhance oxygen use in all body tissues. Caution: Do not give this supplement to a child.
Plant Enzymes, NOW Foods, Vegetarian, 120 VCaps,
Enzymes, All Complete, 250 mg, 90 Caps,
MetabolicZyme (Hypoallergenic), Allergy Research Group / Nutricology, 900 Tabs,Plus
Bromelain300 mg daily. For digestion.
Bromelain 2000 GDU Supplement, NOW Foods, 500 mg, 90 TabsCitrin As directed on label. Inhibits synthesis of fatty acids in liver, thus helping to prevent an accumulation of potentially dangerous fats in the body.
Vitamin C Complex Powder, NOW Foods, Vegetarian Formula, 8 oz.,Octacosanol
And/Or
Wheat GermAs directed on label.
As directed on label.Improves endurance; relieves muscle pain.
Octacosanol, NOW Foods, 5000 mcg, 100 Caps,
Wheat Germ Oil, Expeller Pressed, Vegetarian, NOW Foods, 16 fl. oz.Sea Mussel As directed on label. A source of protein that aids in the functioning of the cardiovascular system.
Sea Mussel Extract, NOW Foods, 500 mg, 100 CapsTrimethylglycine (TMG) As directed on label. TMG converts homocysteine into methionine. SAMe is a by-product of this conversion.
TMG (Trimethylglycine) Powder, NOW Foods, 3.5 oz.,
Extra Strength TMG (Trimethylglycine) Powder, NOW Foods, 1000 mg, 100 TabsVitamin B Complex 50 mg of each B vitamin daily, with meals 3 times daily (amounts of individual vitamins in a complex will vary). B vitamins work best when taken together.
Ultimate B (Vitamin B Complex), Nature's Secret, 60 Tabs,
Vitamin B-100 Complex, w/ Coenzyme B-2, Nature's Way, 631 mg, 100 CapsPlus Extra
Vitamin B-1 (Thiamine)50 mg daily. B vitamins work best when taken together. Deficiency in the heart muscle leads to heart disease. Lowers cholesterol and improves circulation.
Vitamin B-1 / Thiamine HCl (Hydrochloric Acid), 100% Natural, Nature's Way, 100 mg, 100 CapsVitamin B-3 (Niacin) 50 mg daily. Do not exceed a total of 200 mg daily if you have a history of rheumatic heart disease or other valvular heart disease. B vitamins work best when taken together. Lowers cholesterol and improves circulation. Caution: Do not take niacin if you have a liver disorder, gout, or high blood pressure.
Niacin Supplement (Vitamin B-3), 100% Natural, Nature's Way, 100 mg, 100 CapsAnd
Vitamin B-6 (Pyridoxine)50 mg daily. Deficiency has been linked to heart disease. Extremely important for formation of red blood cells and neurotransmitters.
Vitamin B-6 / Pyridoxine, Nature's Way, 100 mg, 100 CapsAnd
Folic Acid400 mcg daily. Needed for the formation of oxygen-carrying red blood cells. Studies have shown that deficiencies of B-6 and Folic acid may lead to an increase in levels of homocysteine levels, an amino acid that has been linked to heart disease.
Vitamin B-9 (Folic Acid), 100% Natural, Nature's Way, 800 mcg, 100 Caps
Alive! Whole Food Energizer, Multi-Vitamin With Mineral, Nature's Way, 18 mg of Iron Added, 90 Tabs
Nature's Way Alive multi-vitamin with mineral is better absorbed into your blood stream because its tablets disintegrate up to 5X faster than other leading brands. No other supplement contains more life-giving nutrients than Alive, which is just the way it will make you feel.Barlean's Flax Oil, 100% Highest Lignan Content, Organic, Pesticide & Herbicide Free, 16 fl. oz.
Barlean's Flax Oil contains 25% more lignan bearing flax particulate than competing brands. Barlean's Flax Oil is one of the Nation's Top-10 Best Selling Health Products.B-Stress Vitamin Complex With Siberian Eleuthrero (Siberian Ginseng), Nature's Way, 100 Caps
If you are looking for herbal stress relief, you will find B-Stress Vitamin Complex with Siberian Eleuthero, formerly Siberian Ginseng Root to be just what you are looking for.Cellfood Liquid Multi-Vitamin, 100% RDA Spray, 1 fl. oz.
Cellfood Liquid Multi-Vitamin has an absorption and assimilation rate of almost 20 times more than vitamin pill supplementation.Cholesterol Guard Herbal Tea, 20 Tea Bags
A caffeine free Herbal Tea designed to disperse stagnant blood, soften and dilate blood vessels, to maintain healthy cholesterol level and normal blood pressure.Coronary Ease For Heart Health, TCM Formula, Danshen Shuxion, 500 mg, 60 Caps
Made of extracts from red sage root, notoginseng root with rosewood oil, this well-known formula is used in traditional Chinese medicine to maintain regular heart beat and coronary health.Evening Primrose Oil, Cold Pressed, Nature's Way, 500 mg, 250 Softgels
Nature's Way EFA Gold is the highest quality Evening Primrose Oil - guaranteed to contain 10% gamma-linolenic acid (GLA).Folic Acid (Vitamin B-9), 100% Natural, Nature's Way, 800 mcg, 100 Caps
Nature's Way Folic Acid is 100% natural and contains no artificial ingredients or preservatives.Garlic Oil Tincture, Alcohol Free, Nature's Way, 1 fl. oz.
Garlic oil is often used to soothe the ear and as an antibiotic but most often used as a food and herb and also to lower serum cholesterol and blood pressure and to improve circulation as well as possibly inhibiting the growth of ulcer causing bacteria.Ginkgold, Ginkgo Biloba Extract, Nature's Way, Vegetarian Standardized, 60 mg, 150 Tabs
Nature's Way Ginkgold ginkgo biloba extract has been proven to support healthy circulation to the brain as well as the extremities.Heart Formula With Hawthorn CoQ10 & Vitamin E, Nature's Way, 60 Caps
Heart Formula with Hawthorn CoQ10 & Vitamin E represents the powerful synergy of current scientific research and traditional herbal medicine. Key ingredients include Hawthorn Extract, CoQ10, and Natural Vitamin E.Lecithin Concentrate, Nature's Way, 400 mg, 100 Softgels
Nature's Way Lecithin Supplement is 100% natural from soy oil and it contains no artificial ingredients or preservatives.Nattokinase for Circulatory Health, Vegetarian, NOW Foods, 100 mg, 60 VCaps
Natto has been consumed safely for thousands of years for its numerous health benefits. More recently, both clinical and non-clinical studies have demonstrated that Nattokinase supports heart health and promotes healthy circulation.PlasminPlus Thrombolytic, 250 mg, 36 Caps
In China, Plasmin Plus Thrombolytic is used for stroke victims that have suffered paralysis or brain damage, blood clots in the legs and brain, poor circulation, clogged arteries, and to prevent thrombosis associated with airline travel.Selenium, 100% Natural, 200 mcg, 100 Caps
Selenium is an essential component of glutathione, the body's most potent natural antioxidant system. It is a popular choice in many antioxidant regimens.Vitamin A, Nature's Way, 100% Natural, 10,000 IU, 100 Softgels
Nature's Way vitamin A is 100% natural from fish liver oil. It contains no artificial ingredients or preservatives.Vitamin B-100 Complex With Coenzyme B-2, Nature's Way, 631 mg, 100 Caps
A complete Vitamin B complex of 8 essential vitamins. B Vitamins are precursors of coenzymes involved in the conversion of cellular energy, manufacture of hormones and proteins, and repair and maintenance of nerve structures.Vitamin B-12 Complex Liquid, NOW Foods, 2 fl. oz.
Vitamin B-12 Helps to maintain a healthy nervous system, and helps in the prevention of pernicious anemia. Folic Acid should be taken by all females of child bearing age to help prevent neuro-tube birth defects. Folic acid is also linked to heart health.Vitamin C 500 With Bioflavonoids, Nature's Way, 100% Natural, 500 mg, 250 Caps
Vitamin C 500 With Bioflavonoids provides antioxidant protection for many of the body's important enzyme systems.Vitamin C 1000 With Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 VCaps
Nature's Way Vitamin C with Bioflavonoids provides antioxidant protection for many of the body's important enzyme systems.Vitamin E (D-Alpha-Tocopheryl Acetate), 100% Natural, NOW Foods, 400 IU, 250 Softgels
Vitamin E is a major antioxidant and the primary defense against lipid peroxidation. It is particularly important in protecting the body's cells from free radical/oxidative damage.
Herbal Remedies: Stroke Information
Herbal Remedies: Stroke Supplements & Products
Herbal Remedies: Heart Attack / Myocardial Infarction Supplements & Products
Herbal Remedies: Heart Disease / Cardiovascular Disease Supplements & Products
STROKE TREATMENT RESEARCH
Currently, studies are being done on additional drugs that dissolve clots. These drugs are administered either in the veins (like TPA) or directly into the clogged artery. The goal of these studies is to determine which stroke patients might benefit from this new and aggressive form of treatment.
New medications are also being tested that help slow the degeneration of the nerve cells that are deprived of oxygen during a stroke. These drugs are referred to as "neuroprotective" agents, an example of which is sipatrigine. Another example is chlormethiazole, which works by modifying the expression of genes within the brain. (Genes produce proteins that determine an individual's makeup.)
Finally, stem cells, which have the potential to develop into a variety of different organs, are being used to try to replace brain cells damaged by a previous stroke. In many academic medical centers, some of these experimental agents may be offered in the setting of a clinical trial. While new therapies for the treatment of patients after a stroke are on the horizon, they are not yet perfect and may not restore complete function to a stroke victim.
CONTACTING MEDICAL CARE
Call 9-1-1 or other emergency services immediately if:
- Signs of a stroke develop suddenly. These may include:
- Numbness, weakness, or inability to move the face, arm, or leg, especially on one side of the body.
- Vision problems in one or both eyes, such as dimness, blurring, double vision, or loss of vision.
- Confusion, trouble understanding.
- Slurred or garbled speech.
- Trouble walking, dizziness, loss of balance or coordination.
- Severe headache with no known cause.
- You have signs of a transient ischemic attack (TIA). Symptoms are similar to those of a stroke, except the loss of vision is usually described as a sensation that a shade is being pulled down over one eye.
- TIA symptoms typically disappear after 10 to 20 minutes but may last longer. There is no way to tell whether the symptoms are caused by a stroke or by TIA, so emergency medical care is needed for both conditions.
Call your health care provider immediately if you have:
- Had recent symptoms of a TIA or stroke, even if the symptoms have disappeared.
- Had a TIA or stroke and are taking aspirin or other medicines that prevent blood clotting and you notice any signs of bleeding.
- Had a stroke and have a choking episode from food going down your windpipe.
- Had a stroke and have signs of a blood clot in a deep blood vessel, which include redness, warmth, and pain in a specific area of your arm or leg.
Call your health care provider for an appointment if you:
- Think you have had a TIA in the past and have not talked with your health care provider about it.
- Have had a stroke and have a pressure sore. Pressure sores, which usually develop along the elbows, ankles, heels, knees, buttocks, and tailbone and on the back along the spine, are caused by staying in one position too long. The first sign of a pressure sore is a reddened area that does not go away with rubbing or massaging.
- Have had a stroke and notice that your affected arm or leg is becoming increasingly stiff or you are not able to straighten it (spasticity).
- Have had a stroke and notice signs of a urinary tract infection. Signs may include fever, pain with urination, blood in urine, and low back (flank) pain.
- Have had a stroke and you are having trouble keeping your balance.
WATCHFUL WAITING
Watchful waiting is not appropriate if you have signs of a stroke. Emergency medical care is needed to prevent or treat any complications that may be life-threatening. Prompt treatment may prevent extensive damage to the brain, decreasing permanent disabilities from the stroke.
If the stroke is caused by a blood clot, early care by a health care provider in the emergency room or hospital is critical. If you seek help within 3 hours, you can sometimes receive a medicine (tissue plasminogen activator, or t-PA) that dissolves clots, but this medicine should be given within the first 3 hours after symptoms begin. Not everyone can safely receive this medicine.
WHO TO SEE
Health care providers who can diagnose and treat stroke include:
- Emergency medicine specialists.
- Family medicine practitioners.
- Internists.
- Neurologists.
If you need surgery or have other health problems, other specialists may be consulted, such as a:
- Neurosurgeon.
- Cardiologist.
- Vascular surgeon.
Some hospitals have a stroke team made up of many different health professionals, such as a physical therapist, an occupational therapist, a speech therapist, a rehabilitation practitioner (physiatrist), a nurse, and a social worker.
RELATED LINKS
This valuable and informative booklet details the post-stroke rehabilitation process by offering practical advice and information on a wide range of topics. Its purpose is to assist stroke survivors in getting the most out of rehabilitation.
Description and several articles about diagnosing, treatment and recovery from stroke.
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