Illustration of the effects of a stroke on the brain Bay Area Medical Information (BAMI.us)
Stroke and TIAs
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Signs & Symptoms |
ABCDs to Determine Stroke Risk | Causes | TIAs | Treatment | Prevention

If you have symptoms of a stroke, it is a medical emergency. Brain tissue dies quickly when deprived of oxygen. Early treatment can minimize brain damage and potential disability or even mean the difference between life and death.

“Every minute you wait, hoping your symptoms will go away, you lose almost 2 million brain cells. Don’t try to tough it out, and don’t waste time trying to get in touch with your primary physician or neurologist. You need emergency help,” said Jeffrey L. Saver, M.D., professor of neurology at the University of California, Los Angeles. American Stroke Assn

It is a common misconception that stroke is an "old person’s disease"--in fact, thousands of strokes occur in people under the age of 65. The third-leading cause of death in the United States, stroke is also the leading cause of adult disability and is the #1 cause for nursing home admissions.

Fewer Americans now die of strokes than was the case 20 or 30 years ago. Improvement in the control of major risk factors — smoking, high blood pressure and high cholesterol — is likely responsible for the decline.

Know the Signs and Symptoms:

Frequently a stroke gives no warning and the symptoms are sudden in onset. Multiple symptoms generally arise simultaneously. Symptoms of a stroke vary greatly from person to person, but most common symptoms include:

  • Numbness, weakness, or paralysis of the face, arm or leg — usually on one side of the body

  • Loss of the ability to speak or understand written or oral communication (aphasia)

  • Blurred, double or decreased vision

  • Dizziness, loss of balance or loss of coordination

  • A sudden, severe "bolt out of the blue" headache or an unusual headache, which may be accompanied by a stiff neck, facial pain, pain between the eyes, vomiting or altered consciousness

  • Confusion, or problems with memory, spatial orientation or perception
Symptoms of a stroke vary from person to person depending on a number of factors:
1) The location of the stroke in the brain,
2) Whether the stroke is ischemic or hemorrhagic, and
3) The extent of brain damage.

Symptoms of an ischemic stroke usually occur in the side of the body opposite from the side of the brain where the clot occurred. For example, an ischemic stroke in the right side of the brain affects the left side of the body.

Symptoms of a hemorrhagic stroke can be similar to those of an ischemic stroke but may additionally have symptoms relating to higher pressure in the brain, such as severe headache, nausea and vomiting, neck stiffness, dizziness, seizures, irritability, confusion, and possibly unconsciousness.

ABCDs to Determining Stroke Risk after a TIA (or mini-stroke)
A new scoring system predicts who is at highest risk of a stroke after a transient ischemic attack (TIA), or mini-stroke.

During an episode of tempororary symptoms, which of the following were present?
Factor Score
Age > 60
1
Raised blood pressure
1
Symptoms:
-weakness on one side
2
-speech difficulty w/no weakness
1
-neither
0
Duration of symptoms:
>60 min.
2
10-59 min.
1
<10 min.
0
Results: Risk of stroke within
seven days of a TIA:
Score
Risk
1-3
0.0%
4
1.1
5
12.1
6
31.4
A team of British researchers has devised a simple and useful way of estimating who is at imminent risk of having a stroke in the days after an episode of temporary symptoms known as a transient ischemic attack (TIA), or mini-stroke. (See table on left). Their findings were published online in the journal of the Lancet.

The estimate, which can be performed in a few minutes, will help physicians identify patients needing immediate treatment and may give people a clearer picture of what constellation of symptoms should be considered a medical emergency, even if it goes away.

This risk-scoring system can help health care providers identify those patients at highest risk -- and estimate the magnitude of that risk as well. The British team calls its scoring system ABCD for "age, blood pressure, clinical features and duration of symptoms." Note: This system should not be viewed as foolproof and should not take the place of a visit to the physician.

 

Causes and Pathology of Stroke

The blood supply of the brainA stroke is an interruption, or severe reduction, of the blood supply to any part of the brain. This results in deprivation of vital oxygen and nutrients to brain tissue and within a few minutes to a few hours, brain cells begin to die. As a result, the part of the body controlled by the damaged section of the brain does not function properly. (Image to the left, courtesy of 3dScience.com, illustrates the blood supply of the brain.)

There are two main types of stroke and it is critical to know which type before treatment begins:

1) Ischemic When blood flow to the brain becomes blocked, or severely reduced, by a blood clot or atherosclerotic plaque. Within minutes of the interrupted blood supply, the nerve cells in that area of the brain become damaged, and they may die within a few hours. About 80% of all strokes are ischemic. Ischemic Strokes can be thrombotic or embolic. A Thrombotic stroke occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to the brain. This usually occurs in areas damaged by atherosclerosis. This process can occur within one of the two carotid arteries of the neck that carry blood to the brain, as well as in other arteries. An ischemic stroke may also be caused by plaques that completely clog or markedly narrow an artery. An Embolic stroke occurs when a blood clot or atherosclerotic plaque forms in a blood vessel away from the brain, (often the heart) but it breaks away and is swept through the bloodstream to lodge in a narrower artery supplying the brain. This is called an embolus. Atrial fibrillation, an abnormal heart rhythm, is a common source of an embolic stroke caused by a blood clot that has formed in the heart.

2) Hemorrhagic Stroke occurs when a blood vessel breaks and bleeds into or around the brain. Hemorrhagic stroke is less common but more frequently fatal than ischemic stroke. About 20% of all strokes are hemorrhagic.

TIAs (transient ischemic attacks)
For most people, a stroke gives no warning. One possible sign of an impending stroke, however, is a transient ischemic attack (TIA). As opposed to a stroke, a TIA is only a temporary interruption of blood flow to a part of your brain. The signs and symptoms of TIA are the same as for a stroke, but they last for a shorter period of time — several minutes to 24 hoursand then completely resolve. Some people have more than one TIA, and the recurrent signs and symptoms may be similar or different. A TIA indicates a serious underlying risk that a full-blown stroke may follow. People who have had a TIA are nine times more likely to have a stroke as are those who have never had a TIA.

Emergency Treatment
If you have symptoms of a stroke, it is a medical emergency

Brain tissue dies quickly when deprived of oxygen. Early treatment can minimize brain damage and potential disability or even mean the difference between life and death. But do not try to treat yourself by taking aspirin. If the stroke is hemorrhagic, aspirin could make it worse, even fatal. If you are having symptoms of a stroke, you must get to a professional medical facility, such as an emergency room, as soon as possible. Usually the best way to do this is to call 911.

Treatment depends on whether or not the stroke is ischemic or hemorrhagic. To determine this, the most widely used imaging procedure is the computed tomography (CT) scan. Also known as a CAT scan. CT scan can quickly rule out a hemorrhage, can occasionally show a tumor that might mimic a stroke, and may even show evidence of early infarction. Infarctions generally show up on a CT scan about 6 to 8 hours after the start of stroke symptoms.

If a stroke is caused by hemorrhage, a CT can show evidence of bleeding into the brain almost immediately after stroke symptoms appear. Hemorrhage is the primary reason for avoiding certain drug treatments for stroke, such as thrombolytic therapy, the only proven acute stroke therapy for ischemic stroke. Thrombolytic therapy cannot be used until the doctor can confidently diagnose the patient as suffering from an ischemic stroke because this treatment might increase bleeding and could make a hemorrhagic stroke worse.

1) For an ischemic stroke, immediate treatment is needed to d
issolve the clot. Therapy with clot-busting drugs must start within three hours, if given intravenously. Quick treatment not only improves chances of survival, but may also reduce the amount of disability resulting from the stroke. However, only a small proportion of Americans who have had a stroke receive this thrombolytic therapy. Reasons for this include the limited time window of three hours as well as other contraindications of this type of therapy in certain people. These drugs are only given in carefully selected patients.

2) Hemorrhagic stroke Surgery may be used to treat a hemorrhagic stroke or prevent another one. The most common procedures — aneurysm clipping and arteriovenous malformation (AVM) removal — carry some risks.

Prevention of Ischemic Strokes (Not Hemorrhagic)
Preventive medications: If you've had an ischemic stroke, it's important to determine why the stroke occurred and to prevent another. Your doctor may recommend medications to help reduce your risk of having a TIA or stroke. These include:

Anti-platelet drugs: Platelets are cells in the blood that initiate clots. Anti-platelet drugs make your platelets less sticky and less likely to clot.

  • Aspirin: The most frequently used anti-platelet medication.
  • Aggrenox: A combination of low-dose aspirin and the anti-platelet drug dipyridamole, to reduce blood clotting.
  • Plavix: Might be prescribed if aspirin doesn't prevent your TIA or stroke or if you can't take aspirin.

Anticoagulants: Affect the clotting system differently than do anti-platelet medications. These drugs have a profound effect on blood clotting and require frequent bloodwork and close monitoring by a doctor. These drugs may also be prescribed for people who have certain blood-clotting disorders, certain arterial abnormalities, an abnormal heart rhythm such as atrial fibrillation, or other cardiac problems.

  • Heparin: Fast acting and is used over the short term in the hospital.
  • Warfarin (Coumadin): Slower acting warfarin is used over a longer term.

Additional preventive measures :

Rehabilitative Services
A stroke team is an essential part of an optimal recovery. Therapy is best started as soon as the patient is stable and can tolerate activity. The team may consist of:
  • Rehabilitation doctor
  • Nurse
  • Dietitian
  • Physical therapist
  • Occupational therapist
  • Recreational therapist
  • Speech therapist
  • Social worker
  • Psychologist or psychiatrist

Video Tutorials on stroke

Preventing Strokes from Medline Plus, a service of the National Library of Medicine and the National Institute of Health

Stroke Rehabilitation from Medline Plus, a service of the National Library of Medicine and the National Institute of Health

Internet References

--Written by N Thompson, ARNP in collaboration with M Thompson, MD, Internal Medicine last updated June 2010

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