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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 – 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
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Stroke Warning Signs
General Information 2000 - 2010(News, Articles, Journal Articles, Guidelines, Internet Sites)
Arrival method, slow response often delay stroke care “Study highlights: • In a study that analyzed data on more than 15,000 stroke patients only 23 percent arrived at the hospital within two hours of symptom onset and were suitable for evaluation to receive tPA. • Those who arrived by ambulance were more than twice as likely to receive timely CT scans as those who “walked in” on their own. • Researchers said it’s important for people to recognize the symptoms of stroke and promptly call 9-1-1. Arriving at a hospital by ambulance could lead to faster stroke diagnosis and speed treatment.”
Do You Know You're Having A Stroke? “"Time is crucial in treating stroke," says Latha Stead, M.D., emergency medicine specialist and lead author of the study. "Each individual's medical background differs and affects recovery, but in general the sooner a patient experiencing a stroke reaches emergency care, the more likely the stroke can be limited and the condition managed to prevent further damage and improve recovery." The researchers say their findings clearly indicate that better public understanding of stroke symptoms will lead to a faster response and better outcomes.”
Most Stroke Patients Do Not Recognize Symptoms, Delay Seeking Treatment “About 70% of patients who suffer a minor stroke or transient ischemic attack (TIA) do not correctly recognize their symptoms, and 30% delay seeking medical attention for more than 24 hours, a new study concludes.”
Need For Speed: Two New Studies On Stroke "No matter what kind of stroke or mini-strokes patients have, the best course of action in all cases is to call 911, so that an ambulance or other emergency medical team can arrive and transport the patient to the hospital. Driving to the hospital oneself, or being driven by a friend or loved one, is less ideal because of delays that can occur en route or upon arrival at the hospital. Even at major hospitals with dedicated 24-hour stroke teams, such as U-M, it can take an hour or more to use diagnostic tests to assess what type of stroke a patient is having and to start tPA treatment. At smaller hospitals, it can be more than an hour -- and intra-arterial tPA, which can be given up to six hours after the start of a stroke, may not be available. So, a person experiencing a stroke really needs to get to a hospital within two hours of the start of a stroke to have the best chance of receiving tPA ... "
One-Fifth of Hospitals Give Bad Emergency Advice on Stroke: Too often, personnel do not tell callers to phone 911, study finds "Americans who think they're having a stroke face better than a one-in-five chance of getting the wrong -- and potentially fatal -- advice when they call local hospital personnel, a new study shows. Although experts say the best thing to do when suspected stroke symptoms appear is to immediately call emergency 911, in 22 percent of cases, hospital personnel who answered the phone advised that patients call their family doctor. … There are two messages in the new study, Schwamm said. "The first is that if you or someone you see is having a stroke, call 911, and say, 'I think I'm having a stroke,' " he said. "The second is to find out [beforehand], by calling hospitals in your area, if a hospital has an acute stroke team, if it is equipped to care for a stroke. The education message needs to go to everyone involved." "
Stroke Symptoms Common But Often Unreported "Many Americans suffer a stroke and don't know it or don't do anything about it, a new study finds. Researchers say that as many 18 percent of adults with no history of stroke had experienced at least one stroke symptom in the past."
Stroke victims pay neavily for delays "STROKE victims are robbing themselves of critical minutes by calling a relative or friend instead of an ambulance, new research shows."
The Claim: A Stroke Can Be Diagnosed in Three Steps "... an email message ... claims that an untrained bystander can tell whether people have suffered a stroke by asking them to smile, raise both arms slowly and recite a simple sentence. But because the symptoms of a stroke vary widely, the three-step test can detect some victims but will miss many others ... Some of the more common symptoms of a stroke, for example, are problems seeing, an unusual headache, sudden numbness and trouble with coordination or walking - all of which the three-step test overlooks."
Too Many Ignore Symptoms of Mini-Stroke " 'Anyone feeling the symptoms of a TIA should go directly to an emergency room,' she advised. 'If you call your family doctor, you're wasting time,' she said. 'If you call your primary-care physician you'll be told to go to an emergency room anyway. Immediate action is necessary, Brooks said, because after a TIA, 'you are at increased risk especially over the next 90 days, but also of having a major stroke in the next 48 hours to seven days.' "
Treating mini-strokes rapidly cuts later risk "Treating patients quickly for mini-strokes could dramatically cut the risk of a major stroke later, report two studies that could change standard treatment and potentially save millions of people from stroke’s damaging effects. In research published Tuesday, British and French doctors found that patients treated within 24 hours of having a mini-stroke cut their chances by 80 percent of having a more serious stroke in the next three months. … In the U.K., most patients who have small strokes are referred by their doctors to specialist clinics. Many wait several weeks before being treated. In the United States too, many people are sent home within a day if their symptoms seem to resolve. … Doctors increasingly say that small strokes should be seen as warning signals for a more dangerous stroke later on, in the same way that chest pain can be a red flag for an imminent heart attack."
"Weekend effect" raises risk of stroke mortality " … patients should remember: 'Time is brain,' lead investigator Dr. Gustavo Saposnik said in an American Heart Association press release, 'so the sooner the patient seeks medical attention, the higher the chance of better outcome, no matter the day, time or living area.'"
Having a stroke? Make 911 your first call "People who think they're having a stroke, and their loved ones, often call others for advice before calling an ambulance, hints a study conducted in Australia. This could lead to delays in the administration of potentially life-saving treatment. Half of stroke patients or the people with them at the time of the stroke consulted a third-party, who frequently came to the patient's home before calling an ambulance, Dr. Ian Mosley of the National Stroke Research Institute in Heidelberg Heights, Victoria and colleagues report."
Learn To Recognize A Stroke "Stroke is a medical emergency. Know these warning signs of stroke and teach them to others. Every second counts: - Sudden numbness or weakness of the face, arm or leg, especially on one side of the body - Sudden confusion, trouble speaking or understanding - Sudden trouble seeing in one or both eyes - Sudden trouble walking, dizziness, loss of balance or coordination - Sudden, severe headache with no known cause Call 9-1-1 immediately if you experience symptoms! Time lost is brain lost!"
TIA Linked to Substantial Risk for Major Stroke Within a Week "New research suggests that patients who experience a transient ischemic attack (TIA) are at a substantially increased risk of having a major stroke within 1 week — a finding that, researchers say, warrants treating TIA as a medical emergency."
Timing of TIAs preceding stroke: time window for prevention is very short. (Neurology. 2005) "CONCLUSION: In patients presenting with ischemic stroke, TIAs occur most often during the hours and days immediately preceding the stroke."
What is a "TIA" and how would I know if I was having this type of attack? "With a TIA all symptoms return to normal with no residual deficit in less than 24 hours; it may be as brief as a few minutes. If these symptoms occur call your doctor immediately or call 911 and go to the nearest emergency room."
Adult Stroke (Circulation 2005)
Awareness of stroke warning signs--17 states and the U.S. Virgin Islands, 2001. (MMWR Morb Mortal Wkly Rep. 2004)
Cerebral infarct presenting with thunderclap headache (The Journal of Headache and Pain 2009)
Clinical Characteristics of Patients With Early Hospital Arrival After Stroke Symptom Onset (Journal of Stroke and Cerebrovascular Diseases 2005)
Diagnostic challenge - Is this really a stroke? (Aust Fam Physician. 2006)
Early CT Findings in Unknown-Onset and Wake-Up Strokes. (Cerebrovasc Dis. 2006) "Background: Approximately one quarter of the acute ischemic stroke patients notice the event at awakening. Such patients with stroke at awakening are usually excluded from thrombolysis, since the time of stroke onset cannot be definitely identified. We compared the hyperacute CT findings of awakening stroke patients with those of stroke patients with known onset to assess whether the time of stroke onset is shortly before awakening. ... Conclusion: Based on our CT findings, stroke at awakening seems to be developing shortly before in a large subset of patients, making them potential candidates for acute stroke therapies."
High-risk mini strokes (Bandolier Journal ) "A transient ischaemic attack (TIA) is usually defined as causing symptoms for less than 24 hours, but it is unlikely that brain or eye is actually ischaemic for more than a few minutes. What we observe is the clinical effects of reversible impairment of neuronal function resulting from a short period of ischaemia. The risk of stroke after a TIA is about 12% in the first year and then about 7% a year thereafter, with risk of stroke, heart attack or vascular death being about 10% a year. This is about seven times the risk in the background population. But there is also a high risk of stroke in the seven days after a TIA, possibly as high as 10%. ... The likelihood of chance associations related to TIA and subsequent seven-day stroke was eliminated by using only factors previously significantly found to be independent predictors of stroke in the three months after a TIA. These were age, clinical features characterised (motor weakness and speech disturbance), duration of symptoms, diabetes, and hypertension. ..."
[How to diagnose acute stroke?] (Tidsskr Nor Laegeforen. 2007) "RESULTS AND INTERPRETATION: The diagnosis depends on rapidly developing symptoms or new symptoms on awakening. Symptoms associated with a high probability of stroke are acute unilateral paresis, lateralisation of symptoms to one hemisphere, high neurological score on NIH and symptoms corresponding to a certain vascular territory. Simple screening tools increase the pre-hospital probability of stroke. In hospital a definite diagnosis is based upon CT or MRI findings. Diffusion-weighted MRI is highly sensitive in acute ischemic stroke."
Is the ABCD Score Useful for Risk Stratification of Patients With Acute Transient Ischemic Attack? (Stroke. 2006) "BACKGROUND AND PURPOSE: A 6-point scoring system (ABCD) was described recently for stratifying risk after transient ischemic attack (TIA). This score incorporates age (A), blood pressure (B), clinical features (C), and duration (D) of TIA. A score <4 reportedly indicates minimal short-term stroke risk. ... CONCLUSIONS: Although the ABCD score has some predictive value, patients with a score <4 still have a substantial probability of having a high-risk cause of cerebral ischemia or radiographic evidence of acute infarction despite transient symptoms."
Low public recognition of major stroke symptoms. (Am J Prev Med. 2003)
[Knowledge about stroke in patients admitted in a French Stroke Unit] (Rev Neurol (Paris). 2004)
Level of Physical Activity in the Week Preceding an Ischemic Stroke (Cerebrovascular Diseases 2007) "Conclusion: Stroke patients are less physically active in the week preceding an ischemic stroke when compared to age- and sex-matched controls."
Mortality of stroke patients treated with thrombolysis: Analysis of nationwide inpatient sample (Neurology 2006) "US community experience in the use of thrombolysis has higher rates of complications and mortality than in controlled clinical trials."
Patient Recognition of and Response to Symptoms of TIA or Stroke. (Neuroepidemiology. 2006) "Results: The median delay time from symptom onset to admission to hospital was 4.5 h. While 41% of participants delayed less than 3 h, more than 45% delayed greater than 6 h. Independent predictors of delay time included mode of arrival at hospital with those taking an ambulance having a median delay time of 2.7 h vs. 15.4 h for those arriving by private car (p = 0.04). Gender also predicted delay with women delaying longer (p = 0.001). The first response of others was also an independent predictor of delay time (p = 0.003) with those who called the emergency services number or took the patient to hospital resulting in the shortest patient delays. Finally, if the patient appraised their symptoms as serious they had a shorter delay time (p = 0.02)."
Posterior headache as a warning symptom of vertebral dissection: a case report. (J Headache Pain. 2005)
Stroke Among Patients With Dizziness, Vertigo, and Imbalance in the Emergency Department. A Population-Based Study. (Stroke. 2006) "BACKGROUND AND PURPOSE: Dizziness, vertigo, and imbalance are common presenting symptoms in the emergency department. Stroke is a leading concern even when these symptoms occur in isolation. The objective of the present study was to determine the "real-world" proportion of stroke among patients presenting to the emergency department with these dizziness symptoms (DS). ... CONCLUSIONS: The proportion of cerebrovascular events in patients presenting with dizziness, vertigo, or imbalance is very low. Isolated dizziness, vertigo, or imbalance strongly predicts a noncerebrovascular cause. The symptom of imbalance is a predictor of stroke/TIA."
Stroke Symptoms and the Decision to Call for an Ambulance (Stroke. 2007) " Conclusions— Stroke was reported as the problem (unprompted) by <50% of callers. Fewer than half the calls were made within 1 hour from symptom onset. Interventions are needed to more strongly link stroke recognition to immediate action and increase the number of stroke patients eligible for acute treatment."
Stroke-related headache: a clinical study in lacunar infarction. (Headache. 2005)
Subarachnoid haemorrhage. (Lancet. 2007) " Subarachnoid haemorrhage accounts for only 5% of strokes, but occurs at a fairly young age. Sudden headache is the cardinal feature, but patients might not report the mode of onset. CT brain scanning is normal in most patients with sudden headache, but to exclude subarachnoid haemorrhage or other serious disorders, a carefully planned lumbar puncture is also needed. Aneurysms are the cause of subarachnoid haemorrhage in 85% of cases. The case fatality after aneurysmal haemorrhage is 50%; one in eight patients with subarachnoid haemorrhage dies outside hospital. Rebleeding is the most imminent danger; a first aim is therefore occlusion of the aneurysm."
Sudden deafness as a sign of stroke with normal diffusion-weighted brain MRI. (Acta Otolaryngol. 2005)
Time is brain--quantified. (Stroke. 2006) "CONCLUSIONS: Quantitative estimates of the pace of neural circuitry loss in human ischemic stroke emphasize the time urgency of stroke care. The typical patient loses 1.9 million neurons each minute in which stroke is untreated."
Transient Ischemic Attack: A Dangerous Harbinger and an Opportunity to Intervene. (Semin Neurol. 2005)
Stroke-related headache: a clinical study in lacunar infarction. (Headache. 2005) "Conclusions.-Headache at the onset of a lacunar infarction is uncommon. Mesencephalic topography, nausea and vomiting, female sex, diabetes, and age were independent variables significantly associated with lacunar infarction with headache."
Transient Ischemic Attacks: Part I. Diagnosis and Evaluation (Am Fam Physician 2004) "Transient ischemic attack is no longer considered a benign event but, rather, a critical harbinger of impending stroke. Failure to quickly recognize and evaluate this warning sign could mean missing an opportunity to prevent permanent disability or death. The 90-day risk of stroke after a transient ischemic attack has been estimated to be approximately 10 percent, with one half of strokes occurring within the first two days of the attack."
Warning Headache of Subarachnoid Hemorrhage and Infarction due to Vertebrobasilar Artery Dissection. (Clinical Journal of Pain 2006) "Objectives: The authors describe the clinical features of headache in patients with vertebrobasilar artery dissection (VBAD) and emphasize the importance of recognition of warning headaches preceding subarachnoid hemorrhage. ... Conclusions: The present study confirms a high frequency of headache in patients with VBAD. Sudden severe occipital and nuchal pain, even without subarachnoid hemorrhage or any neurologic deficit, should be considered as a warning sign of subarachnoid hemorrhage. Computed tomography, magnetic resonance imaging, and magnetic resonance angiography should be performed urgently for screening of patients with a warning headache to prevent resultant life-threatening major vascular events."
Warning Signs and Symptoms of Subarachnoid Hemorrhage (Southern Medical Journal 2009) “Results: Overall, 28 cases of spontaneous SAH were identified during the study period. A history of headache as the most frequent warning symptom was present in 64.3% of the cases. Transient loss of consciousness (42.8%), difficulty in walking (21.4%), hemiparesis (14.2%), ocular signs (14.2%) and seizure (3.6%) were the next most frequent symptoms. Hypertension and smoking, the most frequent risk factors for SAH, were found in 39.3 and 32.1% of the cases, respectively. … An atypical headache of abrupt onset should be recognized as an important warning symptom for spontaneous subarachnoid hemorrhage.”
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