Stroke
A medical emergency requiring immediate treatment to minimize brain damage
Table of Contents
Overview
A stroke occurs when the blood supply to part of your brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Brain cells begin to die within minutes. A stroke is a medical emergency, and prompt treatment is crucial. Early action can reduce brain damage and other complications.
Stroke is the fifth leading cause of death in the United States and a leading cause of adult disability. Each year, approximately 795,000 people in the United States have a stroke. About 610,000 of these are first or new strokes, while 185,000 are recurrent strokes. Nearly 3 in 4 strokes occur in people over the age of 65, but strokes can and do occur at any age.
The good news is that many strokes can be prevented, and treatments have improved dramatically over the years. Strokes can be treated and prevented, and many fewer Americans die of stroke now than in the past. Quick treatment not only saves lives but can also greatly reduce the lasting effects of stroke.
Types of Stroke
Ischemic Stroke (87% of strokes)
Occurs when a blood clot blocks or narrows an artery leading to the brain. This is the most common type of stroke. Subtypes include:
- Thrombotic stroke: A blood clot forms in an artery that supplies blood to the brain
- Embolic stroke: A blood clot forms elsewhere and travels to the brain
Hemorrhagic Stroke (13% of strokes)
Occurs when a blood vessel in the brain ruptures and bleeds into surrounding brain tissue. Types include:
- Intracerebral hemorrhage: Bleeding within the brain tissue
- Subarachnoid hemorrhage: Bleeding in the space between the brain and skull
Transient Ischemic Attack (TIA)
Sometimes called a "mini-stroke," a TIA is a temporary blockage of blood flow to the brain. Symptoms are similar to stroke but last only a few minutes to hours. TIAs are warning signs - about 1 in 3 people who have a TIA will eventually have a stroke.
Cryptogenic Stroke
A stroke of unknown origin, where the cause cannot be determined despite extensive testing. This accounts for about 25-30% of ischemic strokes.
Symptoms - Act F.A.S.T.
Recognizing stroke symptoms and acting quickly is crucial. Use the F.A.S.T. acronym to remember warning signs:
F.A.S.T. Warning Signs
- F - Face Drooping: Does one side of the face droop or is it numb? Ask the person to smile.
- A - Arm Weakness: Is one arm weak or numb? Ask the person to raise both arms.
- S - Speech Difficulty: Is speech slurred or strange? Ask the person to repeat a simple phrase.
- T - Time to Call 911: If you see any of these signs, call 911 immediately.
Common Stroke Symptoms
Additional Warning Signs
- Vision problems: Sudden trouble seeing in one or both eyes
- Walking difficulty: Sudden trouble walking, loss of balance or coordination
- Confusion: Sudden confusion or trouble understanding
- Numbness: Sudden numbness of face, arm, or leg, especially on one side
- Seizures: May occur in some types of stroke
Gender Differences
Women may experience unique stroke symptoms including:
- Sudden face and limb pain
- Sudden hiccups
- Sudden nausea
- Sudden general weakness
- Sudden chest pain
- Sudden shortness of breath
- Sudden palpitations
Causes and Risk Factors
Different types of stroke have different causes, but many risk factors are similar:
Causes of Ischemic Stroke
- Atherosclerosis: Buildup of plaque in arteries
- Blood clots: From the heart (atrial fibrillation) or other sources
- Small vessel disease: Damage to small arteries in the brain
- Arterial dissection: Tear in artery wall
Causes of Hemorrhagic Stroke
- High blood pressure: The leading cause
- Aneurysms: Weak spots in blood vessel walls
- Arteriovenous malformations (AVMs): Abnormal blood vessel tangles
- Blood-thinning medications: Can increase bleeding risk
- Head trauma: Can cause bleeding in the brain
Major Risk Factors
Medical Conditions
- High blood pressure (most important modifiable risk factor)
- Diabetes
- High cholesterol
- Atrial fibrillation and other heart diseases
- Previous stroke or TIA
- Sickle cell disease
- Sleep apnea
Lifestyle Factors
- Smoking
- Physical inactivity
- Obesity
- Heavy alcohol use
- Illegal drug use (cocaine, methamphetamines)
- Poor diet high in sodium and saturated fats
Non-Modifiable Risk Factors
- Age: Risk doubles each decade after age 55
- Gender: Men have higher risk, but more women die from stroke
- Race: African Americans have nearly twice the risk
- Family history: Genetic factors play a role
- Previous stroke: 1 in 4 strokes are recurrent
Diagnosis
Quick and accurate diagnosis is critical for effective stroke treatment. Emergency medical teams will:
Initial Assessment
- Physical examination: Checking vital signs, neurological function
- Medical history: When symptoms started, medications, risk factors
- Neurological exam: Testing reflexes, strength, sensation, coordination
- NIH Stroke Scale: Standardized assessment of stroke severity
Imaging Tests
CT Scan (Computed Tomography)
Usually the first test performed. Can quickly show if stroke is ischemic or hemorrhagic and rule out other conditions.
MRI (Magnetic Resonance Imaging)
More detailed than CT, can detect brain tissue damaged by ischemic stroke and brain hemorrhages.
CT or MR Angiography
Shows blood vessels in the brain and neck, helping identify blockages or aneurysms.
Carotid Ultrasound
Shows buildup of plaque and blood flow in carotid arteries.
Other Tests
- Blood tests: Clotting time, blood sugar, infection markers
- Echocardiogram: Checks for blood clots from the heart
- Cerebral angiogram: Detailed view of brain and neck arteries
- ECG: Detects heart rhythm problems like atrial fibrillation
Treatment
Stroke treatment depends on the type of stroke and how quickly treatment begins. Time is critical - brain cells die rapidly without oxygen.
Emergency Treatment for Ischemic Stroke
IV tPA (Tissue Plasminogen Activator)
The gold standard treatment, must be given within 4.5 hours of symptom onset. This clot-busting drug can significantly improve outcomes if given quickly.
Mechanical Thrombectomy
A procedure to physically remove the clot using a catheter. Can be performed up to 24 hours after stroke in selected patients with large vessel blockages.
Antiplatelet Medications
Aspirin is often given within 48 hours to prevent additional clots. Other antiplatelets like clopidogrel may also be used.
Emergency Treatment for Hemorrhagic Stroke
Blood Pressure Control
Medications to lower blood pressure and reduce bleeding. Careful monitoring is essential.
Surgical Interventions
- Surgical clipping: Placing a clip at the base of an aneurysm
- Coiling: Inserting coils into aneurysm to prevent rupture
- Surgical AVM removal: For arteriovenous malformations
- Craniotomy: Removing blood and relieving pressure
Medications for Stroke Prevention
- Anticoagulants: Warfarin, DOACs for atrial fibrillation
- Antiplatelets: Aspirin, clopidogrel, dipyridamole
- Statins: To lower cholesterol
- Blood pressure medications: ACE inhibitors, beta-blockers, diuretics
Stroke Unit Care
Specialized stroke units provide:
- Continuous monitoring
- Specialized nursing care
- Early rehabilitation
- Coordinated team approach
- Prevention of complications
Recovery and Rehabilitation
Stroke recovery is a long-term process that begins in the hospital and continues for months or years. The goal is to help survivors become as independent as possible.
Rehabilitation Team
- Physiatrist: Rehabilitation medicine specialist
- Physical therapist: Helps with movement and balance
- Occupational therapist: Assists with daily activities
- Speech-language pathologist: Addresses communication and swallowing
- Neuropsychologist: Helps with cognitive and emotional issues
- Social worker: Coordinates care and resources
Types of Rehabilitation
Physical Therapy
- Strengthening exercises
- Coordination and balance training
- Range of motion exercises
- Learning to use assistive devices
- Constraint-induced movement therapy
Occupational Therapy
- Relearning daily activities
- Fine motor skill exercises
- Home safety assessment
- Adaptive equipment training
- Cognitive rehabilitation
Speech and Language Therapy
- Speech exercises for aphasia
- Swallowing therapy for dysphagia
- Communication strategies
- Cognitive-communication therapy
- Alternative communication methods
Recovery Timeline
- First few days: Stabilization and preventing complications
- First weeks: Beginning rehabilitation, often in hospital
- 1-3 months: Most rapid recovery period
- 3-6 months: Continued improvement with therapy
- 6 months - 2 years: Slower but continued progress possible
- Beyond 2 years: Gains still possible with continued effort
Prevention
Up to 80% of strokes can be prevented through lifestyle changes and medical management:
Lifestyle Modifications
- Control blood pressure: Keep below 120/80 mmHg
- Quit smoking: Reduces risk by 50% within 1 year
- Exercise regularly: At least 150 minutes moderate activity weekly
- Healthy diet: Mediterranean or DASH diet patterns
- Maintain healthy weight: BMI under 25
- Limit alcohol: No more than 1-2 drinks daily
- Manage stress: Through relaxation techniques, exercise
Medical Management
- Treat atrial fibrillation: With anticoagulation
- Control diabetes: Keep A1C below 7%
- Manage cholesterol: With statins if needed
- Take prescribed medications: As directed
- Regular check-ups: Monitor risk factors
Know Your Numbers
- Blood pressure: Check regularly
- Cholesterol levels: Test every 4-6 years
- Blood sugar: Screen for diabetes
- BMI: Calculate and monitor
- Atrial fibrillation: Be aware of irregular heartbeat
Complications
Stroke can cause temporary or permanent disabilities, depending on how long the brain lacks blood flow and which part was affected:
Physical Complications
- Paralysis or weakness on one side of the body
- Problems with balance and coordination
- Difficulty swallowing (dysphagia)
- Chronic pain and unusual sensations
- Fatigue and reduced endurance
- Seizures (in about 10% of survivors)
Cognitive and Communication Issues
- Aphasia (difficulty speaking or understanding)
- Memory problems
- Difficulty with thinking and reasoning
- Problems with attention and concentration
- Apraxia (difficulty with learned movements)
Emotional and Behavioral Changes
- Depression (affects 30-50% of survivors)
- Anxiety disorders
- Emotional lability (uncontrolled emotions)
- Personality changes
- Apathy or lack of motivation
Medical Complications
- Deep vein thrombosis
- Pulmonary embolism
- Pneumonia
- Urinary tract infections
- Pressure sores
- Falls and fractures