Stroke

• Diagnosis, Imaging, Screening
• General Information
• Guidelines
• Internet Sites
• Rehabilitation
• Risk Factors
• Risk Reduction
• Stroke Warning Signs
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Stroke

NIH - Stroke (Medical Encyclopedia) "The goal is to get the person to the emergency room immediately, determine if he or she is having a bleeding stroke or a stroke from a blood clot, and start therapy -- all within 3 hours of when the stroke began."

NIH - Stroke “A stroke is a medical emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. The other kind, called hemorrhagic stroke, is caused by a blood vessel that breaks and bleeds into the brain. "Mini-strokes" or transient ischemic attacks (TIAs), occur when the blood supply to the brain is briefly interrupted.”

NIH - Know Stroke: Know the Signs

NIH - Know Stroke: Know the Signs, Act in Time Video

NIH – Stroke (Medical Encyclopedia) “ISCHEMIC STROKE: This is the most common type of stroke. Usually this type of stroke results from clogged arteries, a condition called atherosclerosis. Fatty deposits collect on the wall of the arteries, forming a sticky substance called plaque. Over time, the plaque builds up. Often, the plaque causes the blood to flow abnormally, which can cause the blood to clot. There are two types of clots: • A clot that stays in place in the brain is called a cerebral thrombus. • A clot that breaks loose and moves through the bloodstream to the brain is called a cerebral embolism. Another important cause of cerebral embolisms is a type of arrhythmia called atrial fibrillation. Other causes of ischemic stroke include endocarditis, an abnormal heart valve, and having a mechanical heart valve. A clot can form on a heart valve, break off, and travel to the brain. For this reason, those with mechanical or abnormal heart valves often must take blood thinners. HEMORRHAGIC STROKE: A second major cause of stroke is bleeding in the brain hemorrhagic stroke. This can occur when small blood vessels in the brain become weak and burst. Some people have defects in the blood vessels of the brain that make this more likely. The flow of blood after the blood vessel ruptures damages brain cells. STROKE RISKS: High blood pressure is the number one reason that you might have a stroke. The risk of stroke is also increased by age, family history of stroke, smoking, diabetes, high cholesterol, and heart disease. Certain medications increase the chances of clot formation, and therefore your chances for a stroke. Birth control pills can cause blood clots, especially in woman who smoke and who are older than 35. Men have more strokes than women. But, women have a risk of stroke during pregnancy and the weeks immediately after pregnancy. Cocaine use, alcohol abuse, head injury, and bleeding disorders increase the risk of bleeding into the brain. … Symptoms: The symptoms of stroke depend on what part of the brain is damaged. In some cases, a person may not even be aware that he or she has had a stroke. Usually, a SUDDEN development of one or more of the following indicates a stroke: • Weakness or paralysis of an arm, leg, side of the face, or any part of the body • Numbness, tingling, decreased sensation • Vision changes • Slurred speech, inability to speak or understand speech, difficulty reading or writing • Swallowing difficulties or drooling • Loss of memory • Vertigo (spinning sensation) • Loss of balance or coordination • Personality changes • Mood changes (depression, apathy) • Drowsiness, lethargy, or loss of consciousness • Uncontrollable eye movements or eyelid drooping If one or more of these symptoms is present for less than 24 hours, it may be a transient ischemic attack (TIA). A TIA is a temporary loss of brain function and a warning sign for a possible future stroke. … IMMEDIATE TREATMENT Thrombolytic medicine, such as tPA, breaks up blood clots and can restore blood flow to the damaged area. People who receive this medicine are more likely to have less long-term impairment. However, there are strict criteria for who can receive thrombolytics. The most important is that the person be examined and treated by a specialized stroke team within 3 hours of when the symptoms start. If the stroke is caused by bleeding rather than clotting, this treatment can make the damage worse -- so care is needed to diagnose the cause before giving treatment. In other circumstances, blood thinners such as heparin and Coumadin are used to treat strokes. Aspirin may also be used. … Prevention To help prevent a stroke: • Get screened for high blood pressure at least every 2 years, especially if you have a family history of high blood pressure. • Have your cholesterol checked. If you are high risk, your LDL "bad" cholesterol should be lower than 70 mg/dL. • If you have high blood pressure, diabetes, high cholesterol, and heart disease, make sure you follow your doctor's treatment recommendations. • Follow a low-fat diet. • Quit smoking. • Exercise regularly -- 30 minutes a day if you are not overweight; 60 - 90 minutes a day if you are overweight. • Do not drink more than 1 to 2 alcoholic drinks a day. Aspirin therapy (81mg a day or 100mg every other day) is now recommended for stroke prevention in women under 65 as long as the benefits outweigh the risks. It should be considered for women over age 65 only if their blood pressure is controlled and the benefit is greater than the risk of gastrointestinal bleeding and brain hemorrhage. Ask your doctor if aspirin is right for you. Your doctor may also recommend that you take aspirin or another blood thinner if you have had a TIA or stroke in the past, or if you currently have a heart arrhythmia (like atrial fibrillation), mechanical heart valve, congestive heart failure, or risk factors for stroke.”

NHS - Understanding stroke and TIA (UK) “There are some risk factors for stroke that cannot be changed, including: • Age You’re more likely to have a stroke if you're over the age of 65. However, about a quarter of strokes happen in younger people. • Family history If a close relative (parent, grandparent, brother or sister) has had a stroke, your risk is likely to be higher. • Ethnicity If you’re South Asian, African or Caribbean, your risk of stroke is higher, partly because rates of diabetes and high blood pressure are higher in these groups. • Your medical history If you’ve previously had a stroke, TIA or heart attack, your risk of stroke is higher. However, many of the major risk factors for stroke can be reduced by making lifestyle changes or taking the right medication. These risks include: • Hypertension (high blood pressure). This is the major, treatable risk factor for stroke. • Smoking. • High blood cholesterol. • An inactive lifestyle. • Diabetes. • Being overweight or obese. • Atrial fibrillation. • Drinking more than the recommended amounts of alcohol. Rarer risk factors are normally related to genetic problems, blood disorders, antibody abnormalities, migraine and other diseases of the heart and blood vessels. … Patients with a suspected stroke should have a scan of their brain to determine: • If the stroke has been caused by a blocked artery or a burst blood vessel. • Which part of the brain has been affected. • How severe the stroke is. The brain scan should be carried out as soon as possible after the symptoms of stroke start, so that the correct treatment can begin. The sooner treatment is started the greater the chance of survival and recovery. Minutes really do matter. There are some treatments, including aspirin, which cannot be given to patients with a haemorrhagic stroke as these may increase the damage to the brain. The brain scan is required in order to confirm the causes and type of stroke. For TIA, rapid diagnosis allows steps to be taken to reduce the risk of a second and potentially major stroke. … Stroke experts have set out standards which define good stroke care, including: • A rapid response to a 999 call for suspected stroke. • Prompt transfer to a hospital providing specialist care. • An urgent brain scan (for example, CT or MRI) undertaken as soon as possible. • Immediate access to a high quality stroke unit. • Early multidisciplinary assessment, including swallowing screening. • Stroke specialised rehabilitation. • Planned transfer of care from hospital to community and longer term support. “

Highlighted Articles

Transient ischemic attack: diagnostic evaluation. (Ann Emerg Med. 2008) “At a minimum, the following tests are recommended: fingerstick glucose level, electrolyte levels, CBC count, urinalysis, and coagulation studies; noncontrast computed tomography (CT) of the head; electrocardiography; and continuous telemetry monitoring. Vascular imaging studies, such as carotid ultrasonography, CT angiography, or magnetic resonance angiography, should be performed on an urgent basis and prioritized according to the patient's risk stratification for disease. Consideration should be given for echocardiography if no large vessel abnormality is identified.”

Transient ischemic attack overview: defining the challenges for improving outcomes. (Ann Emerg Med. 2008) “Transient ischemic attacks are reversible neurologic events that herald potentially catastrophic strokes. Well designed studies have documented that approximately 10% of patients who have a transient ischemic attack will have a stroke within the succeeding 90 days; half of these strokes occur within 48 hours of the transient ischemic attack.”

Transient ischemic attack: definitions and clinical presentations. (Ann Emerg Med. 2008) “Correct diagnosis depends on an accurate medical history and physical examination, combined with the appropriate neuroimaging. It is uncommon that syndromes such as syncope, isolated dizziness, drop attacks, or global amnesia are caused by cerebral ischemia or transient ischemic attack. With the careful evaluation of symptoms according to this definition of transient ischemic attack, a clinician can determine whether a transient ischemic attack has occurred and thus propose treatment that may decrease the likelihood of a subsequent stroke.”

Transient Ischemic Attack: A Dangerous Harbinger and an Opportunity to Intervene. (Semin Neurol. 2005) Transient ischemic attack (TIA) and ischemic stroke are both characterized by sudden onset of neurological symptoms due to focal cerebral ischemia, but they are distinguished by the duration of neurological symptoms, with TIA traditionally defined by resolution of symptoms within 24 hours and stroke reserved for symptoms of longer duration. ... The short-term risk of ischemic stroke after TIA is very high ..."

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Stroke

General Information

NEWS:

Doctors Re-Examine Blood Thinners to Prevent Strokes “But, ironically, as use of warfarin has risen in recent years, so has the number of another type of stroke called hemorrhagic stroke, which occurs when a blood vessel ruptures in the brain. … For patients taking warfarin for atrial fibrillation, the heart association recommends following a checklist that includes telling your doctor immediately about unusual bleeding or bruising, alerting other doctors and your dentist about your warfarin use, and keeping in close contact with your doctor. Flaherty also recommended that people taking warfarin routinely undergo a test that measures the blood's ability to clot. It's all about measuring the benefits with the risks, he said.”

Frequency of Ischemic Stroke Climbs Steeply After the Age of 40 Years

General and Abdominal Adiposity and Risk of Stroke in Chinese Women. (Stroke. 2009) “CONCLUSIONS: Increasing levels of general or abdominal adiposity consistently predict increased risk of stroke in predominantly nonobese Chinese women.”

Men's Stroke Risk Rises Dramatically in Mid-40s “"Silent strokes" -- which have no obvious symptoms but can cause residual damage -- are also common in this younger group of men, researchers reported Feb. 26 in the journal Stroke. "The risk factors are most of the ones we start thinking about in older people -- mostly cholesterol, but also smoking, high blood pressure and diabetes. So that's something we need to start looking at, at a younger age," said Dr. Michael Palm, assistant professor of neuroscience and experimental therapeutics and internal medicine at the Texas A&M Health Science Center College of Medicine. "If we wait till 50, many of these risk factors are already fairly well established and causing problems," he said. Since many of these risk factors are modifiable, "there is a need for developing aggressive primary prevention strategies," added Dr. Jukka Putaala, lead author of the new study. "The optimal target group for primary prevention interventions [especially among men] could perhaps be 35 to 44 years." “

Mini-Strokes May Cause Vision Loss “A study of people who suffer the mini-strokes called silent cerebral infarcts could help explain the medical mystery of normal-tension glaucoma, Hong Kong ophthalmologists report. Glaucoma is the progressive loss of vision caused by deterioration of the optic nerves, which carry signals from the eyes to the brain. It is customarily attributed to abnormally high pressure of the fluid in the eye. But glaucoma can occur in some people who have normal intraocular pressure, a phenomenon that puzzles eye doctors. The Hong Kong study of 286 people with normal-tension glaucoma found a high incidence of silent cerebral infarcts among those whose loss of vision progressed more rapidly. The finding is in the July issue of Ophthalmology. "We feel that our study does cast light on the pathogenesis of normal-tension glaucoma," said the study's lead author, Dr. Dexter Y.L. Leung, deputy coordinator of the glaucoma service at Hong Kong Eye Hospital. "We postulate that vascular [blood vessel] risk factors may be interacting with intraocular pressure in causing glaucoma optic neuropathy." “

Only 1 in 8 Strokes Heralded by TIA “A new population-based study shows that transient ischemic attack (TIA) precedes an acute stroke in only 12.4% of cases, ranging up to about 20% for large artery strokes. The results suggest more resources for primary prevention strategies should be considered over urgent-care TIA clinics that will prevent only "a small but significant fraction of the current stroke burden," write the researchers, with lead author Daniel G. Hackam, MD, PhD, from the University of Western Ontario in London, Canada. "Of course we should always intervene if someone has had a warning event, and try to sort out whether it's heralding a stroke to come or something else," Dr. Hackam told Medscape Neurology. "But we'll get more bang for our buck, and be able to prevent more strokes, if we were to devote more resources to primary prevention and actually trying to develop better tools to predict who will and who will not have a stroke in the future." “

Outcomes after stroke: risk of recurrent ischemic stroke and other events. (Am J Med. 2009) “Patients who have had a stroke are likely at high enough risk for subsequent events to warrant the same aggressive treatment, including statins and antihypertensive drugs, as would be given to patients with other forms of cardiovascular disease. Future clinical trials will better define the optimal management of patients after stroke.”

Physically Active Patients Have Better Stroke Outcomes

Silent Strokes More Common in Younger People Than Thought “These so-called silent strokes are "really not silent," said lead study author Dr. Jose Rafael Romero, an assistant professor of neurology at Boston University School of Medicine. "What we saw is that the [brain] damage caused by the silent stroke can be seen by the MRI." "We don't really have a way of ordinarily recognizing this sort of thing, but if it's part of the brain that's not directly involved with motion or our speech, it could impact memory or the mood of the person," added one expert, Dr. Norman Kaplan, clinical professor at the University of Texas Southwestern Medical Center in Dallas. "There are all sorts of parts of the brain that are not so obvious in what they reflect but nevertheless make up who a person really is." Indeed, stroke researchers point out that those who suffer from silent strokes appear more likely to experience other health problems. "By nature, the [strokes are] very small. But if they happen to occur in a specific part of the brain, then they can produce symptoms that may make somebody suspect," Kaplan said. “

The evaluation of delirium post-stroke. (Int J Geriatr Psychiatry. 2009) “CONCLUSIONS: Delirium is a common complication post-stroke. The CAM is equivalent to the DRS in the acute stroke setting when used by a trained non-psychiatrist. A low MMSE score may have a small benefit in identifying patients that are at risk of having delirium.”

Where Fast Food Joints Abound, So Do Strokes “Stroke risk is linked to the number of fast food restaurants in a given area, a new study suggests. Researchers zeroed in on a region of Texas, analyzed neighborhoods for the number of fast food restaurants, and found a 13% elevated risk of ischemic stroke in neighborhoods with the highest number of fast food restaurants. Ischemic strokes are caused by blood clots. For every fast food restaurant in a designated neighborhood, the relative stroke risk increased 1%, according to research presented at the American Stroke Association’s International Stroke Conference 2009. “

ARTICLES:

Make Strokes Less Deadly with This Vitamin “More research is needed to confirm the link, but a Finnish study that followed about 6,000 people for more than 25 years showed that those with the highest D intake were significantly less likely to die of either stroke or heart disease, compared with the people with the lowest D intake.”

What Is A Mini-Stroke? What Is A Transient Ischemic Attack (TIA)?

JOURNAL ARTICLES:

Causes of Death and Predictors of 5-Year Mortality in Young Adults After First-Ever Ischemic Stroke. The Helsinki Young Stroke Registry. (Stroke. 2009)

Cognitive Impairment Predicts Poststroke Death In Long-Term Follow Up (J Neurol Neurosurg Psychiatry 2009)

Elderly women have lower rates of stroke, cardiovascular events, and mortality after hospitalization for transient ischemic attack. (Stroke. 2009)

High Prevalence of Peripheral Arterial Disease in Patients with Acute Ischaemic Stroke. (Cerebrovasc Dis. 2010)

Intracerebral Hemorrhage Volume Predicts Poor Neurologic Outcome in Children. (Stroke. 2009)

Medical complications after stroke (The Lancet Neurology 2009)

Mortality and Predictors of Death 1 Month and 3 Years after First-Ever Ischemic Stroke: Data from the First National Acute Stroke Israeli Survey (NASIS 2004) (Neuroepidemiology 2009)

Population-based study of risk and predictors of stroke in the first few hours after a TIA (NEUROLOGY 2009) “Conclusion: That about half of all recurrent strokes during the 7 days after a TIA occur in the first 24 hours highlights the need for emergency assessment. That the ABCD2 score is reliable in the hyperacute phase shows that appropriately triaged emergency assessment and treatment are feasible.”

Recurrent cerebral ischemia in medically treated patent foramen ovale: a meta-analysis. (Neurology. 2009) “CONCLUSIONS: In medically treated patients with prior cryptogenic stroke, while the absolute rate of recurrent events is variable, available evidence does not support an increased relative risk of recurrent ischemic events in those with vs without a patent foramen ovale. Patent foramen ovale closure in these patients cannot be recommended until the results of ongoing clinical trials are reported.”

[Seizures and epilepsies after stroke.] (Nervenarzt. 2009) “Epilepsies after stroke represent 20% of all adult-onset epilepsies and exhibit special characteristics with respect to diagnosis, treatment, and prognosis. Patients are frequently amnestic for their seizures the signs of which can be very subtle. Postictal pareses and confusional states can last for days, which further complicate diagnosis. Single seizures after stroke were reported in 2% to 10% of cases, and community-based studies found epilepsies in 3% to 4% of stroke patients. Analyses of subgroups identified epilepsy risks of 3% after ischemic infarction, 6% to 10% after intracerebral hemorrhage, and 9% after subarachnoid hemorrhage. Status epilepticus developed in less than 1% of stroke patients.”

Significance of Aphasia after First-Ever Acute Stroke: Impact on Early and Late Outcomes (Neuroepidemiology 2009) “Conclusions: Increasing age, atrial fibrillation and severity of stroke were associated with the risk of aphasia after stroke. Severity of aphasia is a strong predictor of long-term mortality and dependence of post-stroke patients.”

Stroke: roles of B vitamins, homocysteine and antioxidants (Nutrition Research Reviews (2009)) “Hence, poor dietary intake of folate, vitamin B6 and vitamin B12 are associated with increased risk of stroke. Elevated consumption of fruits and vegetables appears to protect against stroke. Antioxidant nutrients have important roles in cell function and have been implicated in processes associated with ageing, including vascular, inflammatory and neurological damage. Plasma vitamin E and C concentrations may serve as a biological marker of lifestyle or other factors associated with reduced stroke risk and may be useful in identifying those at high risk of stroke. After reviewing the observational and intervention studies, there is an incomplete understanding of mechanisms and some conflicting findings; therefore the available evidence is insufficient to recommend the routine use of B vitamins, vitamin E and vitamin C for the prevention of stroke. A better understanding of mechanisms, along with well-designed controlled clinical trials will allow further progress in this area.”

Stroke-Associated Infection Is an Independent Risk Factor for Poor Outcome after Acute Ischemic Stroke: Data from the Netherlands Stroke Survey. (Cerebrovasc Dis. 2009) “Conclusions: This study suggests that stroke-associated infection, in particular pneumonia, is independently associated with poor functional outcome after ischemic stroke.”

Swallowing Disturbance Pattern Relates to Brain Lesion Location in Acute Stroke Patients. (Stroke. 2009)

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