A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and food. Within minutes, brain cells begin to die.
A stroke is a medical emergency. Prompt treatment is crucial. Early action can minimize brain damage and potential complications.
The good news is that strokes can be treated and prevented, and many fewer Americans now die of stroke than was the case even 15 years ago. Better control of major stroke risk factors — high blood pressure, smoking and high cholesterol — is likely responsible for the decline.
Watch for these signs and symptoms if you think you or someone else may be having a stroke. Note when signs and symptoms begin, because the length of time they have been present may guide treatment decisions.
* Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination.
* Trouble with speaking and understanding. You may experience confusion. You may slur your words or be unable to find the right words to explain what is happening to you (aphasia). Try to repeat a simple sentence. If you can't, you may be having a stroke.
* Paralysis or numbness on one side of your body or face. You may develop sudden numbness, weakness or paralysis on one side of your body. Try to raise both your arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your mouth may droop when you try to smile.
* Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision, or you may see double.
* Headache. A sudden, severe "bolt out of the blue" headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke.
When to see a doctor
Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear. Call 911 or your local emergency number right away. Every minute counts. Don't wait to see if symptoms go away. The longer a stroke goes untreated, the greater the potential for brain damage and disability. To maximize the effectiveness of evaluation and treatment, it's best that you get to the emergency room within 60 minutes of your first symptoms.
If you're with someone you suspect is having a stroke, watch the person carefully while waiting for emergency assistance. You may need to:
* Begin mouth-to-mouth resuscitation if the person stops breathing
* Turn the person's head to the side if vomiting occurs, which can prevent choking
* Keep the person from eating or drinking
A stroke disrupts the flow of blood through your brain and damages brain tissue. There are two chief types of stroke. The most common type — ischemic stroke — results from blockage in an artery. The other type — hemorrhagic stroke — occurs when a blood vessel leaks or bursts. A transient ischemic attack (TIA) — sometimes called a ministroke — temporarily disrupts blood flow through your brain.
Almost 90 percent of strokes are ischemic strokes. They occur when the arteries to your brain are narrowed or blocked, causing severely reduced blood flow (ischemia). Lack of blood flow deprives your brain cells of oxygen and nutrients, and cells may begin to die within minutes. The most common ischemic strokes are:
* Thrombotic stroke. This type of stroke occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot usually forms in areas damaged by atherosclerosis — a disease in which the arteries are clogged by fatty deposits (plaques). This process can occur within one of the two carotid (kuh-ROT-id) arteries of your neck that carry blood to your brain, as well as in other arteries of the neck or brain.
* Embolic stroke. An embolic stroke occurs when a blood clot or other debris forms in a blood vessel away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of blood clot is called an embolus. It's often caused by irregular beating in the heart's two upper chambers (atrial fibrillation). This abnormal heart rhythm can lead to pooling of blood in the heart and the formation of blood clots that travel elsewhere in the body.
Hemorrhage is the medical term for bleeding. Hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures. Brain hemorrhages can result from a number of conditions that affect your blood vessels, including uncontrolled high blood pressure (hypertension) and weak spots in your blood vessel walls (aneurysms). A less common cause of hemorrhage is the rupture of an arteriovenous malformation (AVM) — an abnormal tangle of thin-walled blood vessels, present at birth. There are two types of hemorrhagic stroke:
* Intracerebral hemorrhage. In this type of stroke, a blood vessel in the brain bursts and spills into the surrounding brain tissue, damaging cells. Brain cells beyond the leak are deprived of blood and are also damaged. High blood pressure is the most common cause of this type of hemorrhagic stroke. Over time, high blood pressure can cause small arteries inside your brain to become brittle and susceptible to cracking and rupture.
* Subarachnoid hemorrhage. In this type of stroke, bleeding starts in an artery on or near the surface of the brain and spills into the space between the surface of your brain and your skull. This bleeding is often signaled by a sudden, severe "thunderclap" headache. This type of stroke is commonly caused by the rupture of an aneurysm, which can develop with age or be present from birth. After the hemorrhage, the blood vessels in your brain may widen and narrow erratically (vasospasm), causing brain cell damage by further limiting blood flow to parts of your brain.
Transient ischemic attack (TIA)
A transient ischemic attack (TIA) — sometimes called a ministroke — is a brief episode of symptoms similar to those you'd have in a stroke. The cause of a transient ischemic attack is a temporary decrease in blood supply to part of your brain. Many TIAs last less than five minutes.
Like an ischemic stroke, a TIA occurs when a clot or debris blocks blood flow to part of your brain. But unlike a stroke, which involves a more prolonged lack of blood supply and causes permanent tissue damage, a TIA doesn't leave lasting effects because the blockage is temporary.
Seek emergency care even if your symptoms seem to clear up. If you've had a TIA, it means there's likely a partially blocked or narrowed artery leading to your brain, putting you at a greater risk of a full-blown stroke that could cause permanent damage later. And it's not possible to tell if you're having a stroke or a TIA based only on your symptoms. Up to half of those whose symptoms appear to go away are actually having a stroke that's causing brain damage.
Many factors can increase your risk of a stroke. A number of these factors can also increase your chances of having a heart attack. Stroke risk factors include:
* Personal or family history of stroke, heart attack or TIA.
* Being age 55 or older.
* High blood pressure — risk of stroke begins to increase at blood pressure readings higher than 115/75 millimeters of mercury (mm Hg). Your doctor will help you decide on a target blood pressure based on your age, whether you have diabetes and other factors.
* High cholesterol — a total cholesterol level above 200 milligrams per deciliter (mg/dL), or 5.2 millimoles per liter (mmol/L).
* Cigarette smoking or exposure to secondhand smoke.
* Being overweight (body mass index of 25 to 29) or obese (body mass index of 30 or higher).
* Physical inactivity.
* Cardiovascular disease, including heart failure, a heart defect, heart infection, or abnormal heart rhythm.
* Use of birth control pills or hormone therapies that include estrogen.
* Heavy or binge drinking.
* Use of illicit drugs such as cocaine and methamphetamines.
Because the risk of stroke increases with age, and women tend to live longer than men, more women than men have strokes and die of them each year. Blacks are more likely to have strokes than are people of other races.
A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain suffers a lack of blood flow and which part was affected. Complications may include:
* Paralysis or loss of muscle movement. Sometimes a lack of blood flow to the brain can cause a person to become paralyzed on one side of the body, or lose control of certain muscles, such as those on one side of the face. With physical therapy, you may see improvement in muscle movement or paralysis.
* Difficulty talking or swallowing. A stroke may cause a person to have less control over the way the muscles in the mouth and throat move, making it difficult to talk, swallow or eat. A person may also have a hard time speaking because a stroke has caused aphasia, a condition in which a person has difficulty expressing thoughts through language. Therapy with a speech and language pathologist may improve this disability.
* Memory loss or trouble with understanding. It's common that people who've had a stroke experience some memory loss. Others may develop difficulty making judgments, reasoning and understanding concepts. These complications may improve with rehabilitation therapies.
* Pain. Some people who have a stroke may have pain, numbness or other strange sensations in parts of their bodies affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm. You may also be sensitive to temperature changes, especially extreme cold. This is called central stroke pain or central pain syndrome (CPS). This complication generally develops several weeks after a stroke, and it may improve as more time passes. But because the pain is caused by a problem in the brain instead of a physical injury, there are few medications to treat CPS.
* Changes in behavior and self-care. People who have a stroke may become more withdrawn and less social or more impulsive. They may lose the ability to care for themselves and may need a caretaker to help them with their grooming needs and daily chores.
As with any brain injury, the success of treating these complications will vary from person to person.
Preparing for your appointment
A stroke in progress is usually diagnosed in a hospital emergency room. If you're having a stroke, your care will focus on minimizing brain damage and helping you recover and avoid another stroke in the future. If you haven't yet had a stroke but are worried about your future risk, you can discuss your concerns with your doctor at your next scheduled appointment.
What to expect from your doctor
In the emergency room, you may see an emergency medicine specialist or a neurologist as well as nurses and medical technicians. Your emergency team's first priority will be to stabilize your symptoms and overall medical condition. Then your care will focus on determining if you are having a stroke and, if so, which type. There are different treatments for ischemic strokes caused by artery blockage and hemorrhagic strokes caused by blood vessel rupture.
If you are seeking your doctor's advice during a scheduled appointment, your doctor will evaluate your risk factors for stroke and heart disease. Your discussion will focus on quitting smoking if you are a smoker and on lifestyle strategies or medications to control high blood pressure, cholesterol, and other risk factors. In some cases, your doctor may recommend certain tests and procedures to better understand your risk or to treat underlying conditions that raise risk.
Tests and diagnosis
To determine the best treatment for your stroke, your emergency team must figure out what type of stroke you're having and what parts of your brain it's affecting. Other possible causes of your symptoms, such as a brain tumor or a drug reaction, also need to be ruled out. Your doctor may also use some of these tests to determine your risk of stroke.
* Physical examination. Your doctor will ask you or a family member what symptoms you've been having, when they started, and what you were doing when they began, and then will evaluate whether these symptoms are still present. The doctor will want to know what medications you take, and whether you have experienced any head injury. The doctor will also ask about your personal and family history of heart disease, TIA or stroke. Your doctor will check your blood pressure and use a stethoscope to listen to your heart and to listen for a whooshing sound (bruit) over your carotid (neck) arteries, which may indicate atherosclerosis. Your doctor may also use an ophthalmoscope to check for signs of tiny cholesterol crystals or clots in the blood vessels at the back of your eyes.
* Blood tests. Various blood tests give your care team such important information as how fast your blood clots and whether your blood sugar is abnormally high or low, whether critical blood chemicals are out of balance, or whether you may have an infection. Your blood's clotting time and levels of sugar and key chemicals must be managed as part of your stroke care. Infections must also be treated.
* Computerized tomography (CT). Brain imaging plays a key role in determining if you are having a stroke and what type. Computerized tomography angiography (CTA) is a specialized CT exam in which a dye is injected into your vein and X-ray beams create a 3-D image of the blood vessels in your neck and brain. Doctors use CTA to look for aneurysms or arteriovenous malformations and to evaluate arteries for narrowing. CT scanning, which is done without dye, can provide images of your brain and show hemorrhages, but provides less detailed information about the blood vessels.
* Magnetic resonance imaging (MRI). In this type of imaging, a strong magnetic field and radio waves generate a 3-D view of your brain. An MRI can detect brain tissue damaged by an ischemic stroke. Magnetic resonance angiography (MRA) uses a magnetic field, radio waves and a dye injected into your veins to evaluate arteries in your neck and brain.
* Carotid ultrasound. This procedure can show narrowing or clotting in your carotid arteries. A wand-like device (transducer) painlessly sends high-frequency sound waves into your neck. The sound waves pass through tissue and then return, creating on-screen images.
* Arteriography. This procedure gives a view of arteries in your brain not normally seen in X-rays. Your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in your groin. The catheter is manipulated through your major arteries and into your carotid or vertebral artery. Then your doctor injects a dye through the catheter to provide X-ray images of your arteries.
* Echocardiography. This ultrasound technology creates images of your heart, enabling your doctor to see if a clot (embolus) from your heart has traveled to your brain and caused your stroke. Your doctor may need to use transesophageal echocardiography (TEE) to see your heart clearly. During this procedure, you swallow a flexible probe with a transducer built into it. From there, the probe travels to your esophagus — the tube that connects the back of your mouth to your stomach. Because your esophagus is directly behind your heart, very clear, detailed ultrasound images can be created, allowing a better view of blood clots that might not be seen clearly in a traditional echocardiography exam.
Treatments and drugs
Emergency treatment for stroke depends on whether you are having an ischemic stroke blocking an artery — the most common kind — or a hemorrhagic stroke involving bleeding into the brain.
To treat an ischemic stroke, doctors must quickly restore blood flow to your brain.
Emergency treatment with medications. Therapy with clot-busting drugs must start within 4.5 hours — and the sooner, the better. Quick treatment not only improves your chances of survival, but may also reduce the complications from your stroke. You may be given:
Aspirin. Aspirin is the best-proven immediate treatment after an ischemic stroke to reduce the likelihood of having another stroke. In the emergency room, it's likely you'll be given a dose of aspirin. The dose may vary, but if you already take a daily aspirin for its blood-thinning effect, you may want to make a note of that on an emergency medical card so that the doctors will know if you've already had some aspirin.
Other blood-thinning drugs, such as warfarin (Coumadin), heparin and clopidogrel (Plavix) also may be given, but they aren't used as commonly as aspirin for emergency treatment.
* Intravenous injection of tissue plasminogen activator (TPA). Some people who are having an ischemic stroke can benefit from an injection of tissue plasminogen activator (TPA), usually given through a vein in the arm. TPA is a potent clot-busting drug that helps some people who have had a stroke recover more fully. However, intravenous TPA can be given only within a 4.5-hour window of the stroke occurring. TPA involves certain risks that your doctors will consider in assessing whether it's the right treatment for you. TPA cannot be given to people who are having a hemorrhagic stroke.
Emergency procedures. Doctors sometimes treat ischemic strokes with procedures that must be performed as soon as possible.
* TPA delivered directly to the brain. Doctors may thread a catheter through an artery in your groin up to your brain, and then release TPA directly into the area where the stroke is under way. The time window for this treatment is somewhat longer than for intravenous TPA but still limited.
* Mechanical clot removal. Doctors may also use a catheter to maneuver a tiny device into your brain to physically grab and remove the clot.
Other procedures. To decrease your risk of having another stroke or TIA, your doctor may recommend a procedure to open up an artery that's moderately to severely narrowed by plaques. Doctors also sometimes recommend these procedures to prevent a stroke. Options may include:
* Carotid endarterectomy. In this procedure, a surgeon removes plaques blocking the carotid arteries that run up both sides of your neck to your brain. The blocked artery is opened, the plaques are removed and your surgeon closes the artery. The procedure may reduce your risk of ischemic stroke. However, in addition to the usual risks associated with any surgery, a carotid endarterectomy itself can also trigger a stroke or heart attack by releasing a blood clot or fatty debris. Surgeons attempt to reduce this risk by placing filters (distal protection devices) at strategic points in your bloodstream to "catch" any material that may break free during the procedure.
* Angioplasty and stents. Angioplasty is another technique that can widen the inside of a plaque-coated artery leading to your brain, usually the carotid artery. In this procedure, a balloon-tipped catheter is maneuvered into the obstructed area of your artery. The balloon is inflated, compressing the plaques against your artery walls. A metallic mesh tube (stent) is usually left in the artery to prevent recurrent narrowing. Inserting a stent in a brain artery (intracranial stenting) is similar to stenting the carotid arteries. Using a small incision in the groin, doctors thread a catheter through the arteries and into the brain. Sometimes they use angioplasty to widen the affected area first; in other cases, angioplasty is not used before stent placement.
Emergency treatment of hemorrhagic stroke focuses on controlling bleeding and reducing pressure in your brain. Surgery may also be used to help control future risk.
Emergency measures. If you take warfarin (Coumadin) or antiplatelet drugs such as clopidogrel (Plavix) to prevent blood clots, you may be given drugs or transfusions of blood products to counteract their effects. You may also be given drugs to lower your blood pressure, prevent seizures or reduce your brain's reaction to the bleeding (vasospasm). People having a hemorrhagic stroke can't be given clot-busters such as aspirin and TPA because these drugs may worsen bleeding.
Once the bleeding in your brain stops, treatment usually involves bed rest and supportive medical care while your body absorbs the blood. Healing is similar to what happens while a bad bruise goes away. If the area of bleeding is large, surgery may be used in certain cases to remove the blood and relieve pressure on the brain.
Surgical blood vessel repair. Surgery may be used to repair certain blood vessel abnormalities associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if you're at high risk of spontaneous aneurysm or arteriovenous malformation (AVM) rupture:
* Aneurysm clipping. A tiny clamp is placed at the base of the aneurysm, isolating it from the circulation of the artery to which it's attached. This can keep the aneurysm from bursting, or it can prevent re-bleeding of an aneurysm that has recently hemorrhaged. The clip will stay in place permanently.
* Coiling (aneurysm embolization). This procedure offers an alternative to clipping for certain aneurysms. Surgeons use a catheter to maneuver a tiny coil into the aneurysm. The coil provides a scaffolding where a blood clot can form and seal off the aneurysm from connecting arteries.
* Surgical AVM removal. It's not always possible to remove an AVM if it's too large or if it's located deep within the brain. Surgical removal of a smaller AVM from a more accessible portion of the brain, though, can eliminate the risk of rupture, lowering the overall risk of hemorrhagic stroke.
Stroke recovery and rehabilitation
Following emergency treatment, stroke care focuses on helping you regain your strength, recover as much function as possible and return to independent living. The impact of your stroke depends on the area of the brain involved and the amount of tissue damaged. Harm to the right side of your brain may affect movement and sensation on the left side of your body. Damage to brain tissue on the left side may affect movement on the right side; this damage may also cause speech and language disorders. In addition, if you've had a stroke, you may have problems with breathing, swallowing, balancing and hearing. You may also experience loss of vision and loss of bladder or bowel function.
Most stroke survivors receive treatment in a rehabilitation program. Your doctor will recommend the most rigorous program you can handle based on your age, overall health and your degree of disability from your stroke. The recommendation will also take into account your lifestyle, interests and priorities, and availability of family members or other caregivers.
Your rehabilitation program may begin before you leave the hospital. It may continue in a rehabilitation unit of the same hospital, another rehabilitation unit or skilled nursing facility, an outpatient unit, or your home.
Every person's stroke recovery is different. Depending on your complications, the team of people who help in your recovery could include these professionals:
* Rehabilitation doctor (physiatrist)
* Physical therapist
* Occupational therapist
* Recreational therapist
* Speech therapist
* Social worker
* Case manager
* Psychologist or psychiatrist
Coping and support
A stroke is a life-changing event that can affect your emotional well-being as much as your physical function. Feelings of helplessness, frustration, depression and apathy aren't unusual. Diminished sex drive and mood changes also are common.
Maintaining your self-esteem, connections to others and interest in the world are an essential part of your recovery. These strategies may help both you and your caregivers:
* Don't be hard on yourself. Accept that physical and emotional recovery will involve tough work and take time. Aim for a "new normal," and celebrate all your progress. Allow time for rest.
* Get out of the house even if it's hard. Try not to be discouraged or self-conscious if you move slowly and need a cane, walker or wheelchair to get around. Getting out is good for you.
* Join a support group. Meeting with others who are coping with a stroke lets you get out and share experiences, exchange information and forge new friendships.
* Let friends and family know what you need. People may want to help but not be sure how. Let them know that you would like them to bring over a meal and stay to eat with you and talk, or to help you get out to lunch or attend social events or church activities.
* Know that you are not alone. Nearly 800,000 Americans have a stroke every year. About 6.5 million are living with stroke today.
One of the most frustrating effects of stroke is that it can affect speech and language. Here are some tips to help both stroke survivors and caregivers cope with communication challenges:
* Practice will help. Try to have a conversation at least once a day. It will help you learn what works best for you, help you feel connected and rebuild your confidence.
* Relax and take your time. Talking may be easiest and most enjoyable in a relaxing situation when you have plenty of time. Some stroke survivors find that after dinner is a good time.
* Say it your way. When you're recovering from a stroke, you may need to use fewer words, or to rely on gestures or your tone of voice to get an idea across.
* Use props and communication aids. You may find it helpful to use cue cards showing frequently used words, pictures of close friends and family members, and daily activities such as a favorite television show or the bathroom.
Knowing your stroke risk factors, following your doctor's recommendations and adopting a healthy lifestyle are the best steps you can take to prevent a stroke. If you've had a stroke or a TIA, these measures may also help you avoid having another one. Many stroke prevention strategies are the same as for preventing heart disease. In general, a healthy lifestyle means that you:
* Control high blood pressure (hypertension). One of the most important things you can do to reduce your stroke risk is to keep your blood pressure under control. If you've had a stroke, lowering your blood pressure can help prevent a subsequent transient ischemic attack or stroke. Exercising, managing stress, maintaining a healthy weight, and limiting the amount of sodium and alcohol you eat and drink are all ways to keep high blood pressure in check. Adding more potassium to your diet may also help. In addition to recommendations for lifestyle changes, your doctor may prescribe medications to treat high blood pressure, such as diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers.
* Lower the amount of cholesterol and saturated fat in your diet. Eating less cholesterol and fat, especially saturated fat and trans fats, may reduce the plaques in your arteries. If you can't control your cholesterol through dietary changes alone, your doctor may prescribe a statin such as simvastatin (Zocor) or atorvastatin (Lipitor) or another type of cholesterol-lowering medication.
* Don't smoke. Smoking raises the risk of stroke for both the smoker and nonsmokers exposed to secondhand smoke. Quitting smoking reduces your risk — several years after quitting, a former smoker's risk of stroke is the same as that of a nonsmoker.
* Control diabetes. You can manage diabetes with diet, exercise, weight control and medication.
* Maintain a healthy weight. Being overweight contributes to other risk factors for stroke, such as high blood pressure, cardiovascular disease and diabetes. Weight loss of as little as 10 pounds may lower your blood pressure and improve your cholesterol levels.
* Eat a diet rich in fruits and vegetables. A diet containing five or more daily servings of fruits or vegetables may reduce your risk of stroke.
* Exercise regularly. Aerobic exercise reduces your risk of stroke in many ways. Exercise can lower your blood pressure, increase your level of high-density lipoprotein (HDL, or "good") cholesterol, and improve the overall health of your blood vessels and heart. It also helps you lose weight, control diabetes and reduce stress. Gradually work up to 30 minutes of activity — such as walking, jogging, swimming or bicycling — on most, if not all, days of the week.
* Drink alcohol in moderation, if at all. Alcohol can be both a risk factor and a preventive measure for stroke. Binge drinking and heavy alcohol consumption increase your risk of high blood pressure and of ischemic and hemorrhagic strokes. However, drinking small to moderate amounts of alcohol can increase your HDL cholesterol and decrease your blood's clotting tendency. Both factors can contribute to a reduced risk of ischemic stroke.
* Don't use illicit drugs. Certain street drugs, such as cocaine and methamphetamines, are established risk factors for a TIA or a stroke.
If you've had an ischemic stroke or TIA, your doctor may recommend medications to help reduce your risk of having another. These include:
Anti-platelet drugs. Platelets are cells in your blood that initiate clots. Anti-platelet drugs make these cells less sticky and less likely to clot. The most frequently used anti-platelet medication is aspirin. Your doctor can help you determine the right dose of aspirin for you.
Your doctor may also consider prescribing Aggrenox, a combination of low-dose aspirin and the anti-platelet drug dipyridamole, to reduce blood clotting. If aspirin doesn't prevent your TIA or stroke or if you can't take aspirin, your doctor may instead prescribe an anti-platelet drug such as clopidogrel (Plavix) or ticlopidine (Ticlid).
Anticoagulants. These drugs include heparin and warfarin (Coumadin). They affect the clotting mechanism in a different manner than do anti-platelet medications. Heparin is fast acting and is used over the short term in the hospital. Slower acting warfarin is used over a longer term.
Warfarin is a powerful blood-thinning drug, so you'll need to take it exactly as directed and watch for side effects. Your doctor may prescribe these drugs if you have certain blood-clotting disorders; certain arterial abnormalities; an abnormal heart rhythm, such as atrial fibrillation: or other heart problems.