Stroke Awareness & Prevention -- March 16, 2009 -- Dr. Michael Kaminski - NewsChannel5.com | Nashville News, Weather & Sports

Stroke Awareness & Prevention -- March 16, 2009 -- Dr. Michael Kaminski

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Medical Mondays
Stroke: Awareness & Prevention
Michael Kaminski, MD, neurologist
Saint Thomas Neurology
Monday, March 16, 2009

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What is a stroke?

A stroke occurs when a blood vessel in the brain is blocked or bursts. Without blood and the oxygen it carries, part of the brain starts to die. The part of the body controlled by the damaged area of the brain can't work properly.

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.

What are the symptoms?

Symptoms of a stroke happen quickly. A stroke may cause sudden:

  • Numbness, weakness, or paralysis of the face, arm, or leg, especially on one side of the body.
  • Trouble seeing in one or both eyes. You may have double vision, or things may look dim or blurry.
  • Confusion or trouble understanding.
  • Slurred or garbled speech.
  • Trouble walking. You may feel unsteady, dizzy, or clumsy.
  • Severe headache.

If you have any of these symptoms, call911or other emergency services right away.

See your doctor 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.

What causes a stroke?

There are two types of stroke:

  • An ischemic stroke develops when a blood clot 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 (say "iss-KEE-mick") 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 (say "heh-muh-RAH-jick") strokes are less common but more deadly than ischemic strokes.

How is a stroke diagnosed?

Seeing a doctor right away is very important. If a stroke is diagnosed quickly-within the first 3 hours of when symptoms start-doctors may be able to use medicines that can lead to a better recovery.

The first thing the doctor needs to find out is what kind of stroke it is: ischemic or hemorrhagic. This is important because the medicine given to treat a stroke caused by a blood clot could be deadly if used for a stroke caused by bleeding in the brain.

To find out what kind of stroke it is, the doctor will do a type of X-ray called a CT scan of the brain, which can show if there is bleeding. The doctor 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.

How is it treated?

For an ischemic stroke, treatment focuses on restoring blood flow to the brain. If less than 3 hours have passed since your symptoms began, doctors 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.1 Other medicines may be given to prevent blood clots and control symptoms.

A hemorrhagic stroke can be hard to treat. Doctors 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.

After your condition is stable, treatment shifts to preventing other problems and future strokes. You 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).

The best way to get better after a stroke is to start stroke rehab. The goal of stroke rehab is to help you regain skills you lost or to make the most of your remaining abilities. Stroke rehab can also help you take steps to prevent future strokes. You have 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.

Can you prevent a stroke?

After you have had a stroke, you are at risk for having another one. You can make some important lifestyle changes that can reduce your risk of stroke and improve your overall health.

  • Don't smoke. Smoking can more than double your risk of stroke.2 Avoid secondhand smoke too.
  • Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil. Eat less salt too.
  • Get exercise on most, preferably all, days of the week. Your doctor can suggest a safe level of exercise for you.
  • Stay at a healthy weight.
  • Control your cholesterol and blood pressure.
  • If you have diabetes, keep your blood sugar as close to normal as possible.
  • Limit alcohol. Having more than 2 drinks a day increases the risk of stroke.
  • Take a daily aspirin or other medicines if your doctor advises it.
  • Avoid getting sick from the flu. Get a flu shot every year.

Work closely with your doctor. Go to all your appointments, and take your medicines just the way your doctor says to.

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 doctor 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 doctor hears a swishing sound-a bruit (say "broo-E")-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. For more information on this surgery, see:

Should I have carotid endarterectomy?

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 doctor inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque. The doctor may use a stent that is coated with medicine to help prevent future blockage.

Control your risk factors for stroke by:

  • Having regular medical checkups.
  • Controlling your high blood pressure by working with your doctor.
  • 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.
  • Taking cholesterol-lowering medicines called statins if you have high cholesterol or have had a heart attack, TIA, or stroke.9
  • Not smoking and avoiding secondhand smoke. If you do smoke, quit. (For tips, see the topic Quitting Tobacco Use.) Daily cigarette smoking increases the risk of stroke by more than 2 times.2
  • 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.
  • 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.
  • 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% lower risk of stroke than inactive people. Highly active people had about a 30% reduction of risk.10Exercise can also help raise HDL ("good") cholesterol levels in your body, which also lowers the risk of stroke.

Lower your risk for stroke by:

  • Taking aspirin if you have had a heart attack.2 For more information, see:

Should I take daily aspirin to prevent a heart attack or a stroke?

  • Taking anticoagulants, as prescribed by your doctor, if you have atrial fibrillation or have had a heart attack with other complications.2
  • 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 more fruits and vegetables to increase your intake of potassium and vitamins B, C, E, and riboflavin. Add whole grains to your diet: one study showed whole grains reduced the risk of ischemic stroke in women.11 Eating fish one or more times a month may also reduce your risk of stroke.12 Limit the amount of salt you eat too. For more information, see:

Heart disease: Eating a heart-healthy diet.

  • 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.7
  • Avoid getting sick from the flu. Get a flu shot every year.

Treatment Overview

Prompt treatment of stroke and medical problems related to stroke, such as high blood sugar and pressure on the brain, may minimize brain damage and improve the chances of survival. Starting a rehabilitation program as soon as possible after a stroke increases your chances of recovering some of the abilities you lost.

Initial treatment for stroke

Initial treatment for a stroke varies depending on whether it's caused by a blood clot (ischemic) or bleeding in the brain (hemorrhagic). Before starting treatment, your doctor will use a computed tomography (CT) scan of your head and possibly magnetic resonance imaging (MRI) to diagnose the type of stroke you've had. Further tests may be done to determine the location of the clot or bleeding and to assess the amount of brain damage. While treatment options are being determined, your blood pressure and breathing ability will be closely monitored, and you may receive oxygen.

Initial treatment focuses on restoring blood flow for an ischemic stroke or controlling bleeding for a hemorrhagic stroke. As with a heart attack, permanent damage from a stroke often occurs within the first few hours. The quicker you receive treatment, the less damage will occur.

Ischemic stroke

Emergency treatment for an ischemic stroke depends on the location and cause of the clot. Measures will be taken to stabilize your vital signs, including giving you medicines.

  • If your stroke is diagnosed within 3 hours of the start of symptoms, you may be given a clot-dissolving medicine called tissue plasminogen activator (t-PA), which can increase your chances of survival and recovery. However, t-PA is not safe for everyone. If you have had a hemorrhagic stroke, use of t-PA would be life-threatening. Your eligibility for t-PA will be quickly assessed in the emergency room.
  • You may also receive aspirin or aspirin combined with another antiplatelet medicine. However, aspirin is not recommended within 24 hours of treatment with t-PA.1 Other medicines may be given to control blood sugar levels, fever, and seizures. In general, high blood pressure won't be treated immediately unless systolic pressure is over 220 millimeters of mercury (mm Hg) and diastolic is more than 120 mm Hg (220/120, which is also called 220 over 120).1

Hemorrhagic stroke

Initial treatment for hemorrhagic stroke is difficult. Efforts are made to control bleeding, reduce pressure in the brain, and stabilize vital signs, especially blood pressure.

  • There are few medicines available to treat hemorrhagic stroke. In some cases, medicines may be given to control blood pressure, brain swelling, blood sugar levels, fever, and seizures. You will be closely monitored for signs of increased pressure on the brain, such as restlessness, confusion, difficulty following commands, and headache. Other measures will be taken to keep you from straining from excessive coughing, vomiting, or lifting, or straining to pass stool or change position.
  • Surgery generally is not used to control mild to moderate bleeding resulting from a hemorrhagic stroke. However, if a large amount of bleeding has occurred and the person is rapidly getting worse, surgery may be needed to remove the blood that has built up inside the brain and to lower pressure inside the head.
  • If the bleeding is due to a ruptured brain aneurysm, surgery to repair the aneurysm may be done. Repair may include:
  • o Using a metal clip to clamp off the aneurysm to prevent renewed bleeding.
  • o Endovascular coil embolization, a procedure which involves inserting a small coil into the aneurysm to block it off.

Whether these surgeries can be done depends on the location of the aneurysm and your condition following the stroke.

After emergency treatment for stroke, and when your condition has stabilized, treatment focuses on rehabilitation and preventing another stroke. It will be important to control your risk factors for stroke, such as high blood pressure, atrial fibrillation, high cholesterol, or diabetes.

Your doctor will probably want you to take aspirin or other antiplatelet medicines. If you had an ischemic stroke (caused by a blood clot), you may need to take anticoagulants to prevent another stroke. You may also need to take medicines, such as statins, to lower high cholesterol or medicines to control your blood pressure. Medicines to lower high blood pressure include:

Your doctor may also recommend carotid endarterectomy surgery to remove plaque buildup in the carotid arteries. For more information on this decision, see:

Should I have carotid endarterectomy?

A relatively new procedure called carotid artery stenting is another option for some people who are at high risk of stroke. This procedure is much like coronary angioplasty, which is commonly used to open blocked arteries in the heart. During this procedure, a doctor inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque. The doctor may use a stent that is coated with medicine to help prevent future blockage.

Early aggressive rehabilitation may allow you to regain some normal functioning. Your rehabilitation will be based on the physical abilities that were lost, your general health before the stroke, and your ability to participate. Rehabilitation begins with helping you resume activities of daily living, such as eating, bathing, and dressing. For more information, see the topic Stroke Rehabilitation.

Changes in lifestyle may also be an important part of your ongoing treatment to reduce your risk of having another stroke. It will be important for you to exercise to the extent possible, eat a balanced diet, and quit smoking, if you smoke. Your doctor may suggest that you follow the Dietary Approaches to Stop Hypertension (DASH) diet if you have high blood pressure. If you have high cholesterol, you may need to follow the Therapeutic Lifestyle Changes (TLC) diet. These eating plans stress a diet that is low in fat (especially saturated fat) and contains more whole grains, fruits, vegetables, and low-fat dairy products.

If you take warfarin (such as Coumadin), see:

Anticoagulants: Vitamin K and your diet.

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