Stroke Education for Patients and Families

Every 45 seconds, someone in America has a stroke. A stroke occurs when the blood flow to the brain stops or when blood leaks into or around the brain tissue. Normally, the blood vessels carry blood and oxygen to the brain to nourish brain cells. When the blood supply is interrupted, the brain cells die and the parts of the body controlled by the affected area of the brain may not be able to function properly and signs and symptoms of a stroke appear.

Warning Signs of a Stroke

Stroke is a medical emergency. If you have any of the following warning signs, call 9-1-1 immediately:

•  Sudden numbness, weakness, or paralysis of the face, arm or leg, mainly 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.

Recognizing a stroke is the first important step in getting the right treatment. The National Stroke Association recommends act “FAST” to recognize and respond to a stroke.

F = Face – Ask the person to smile: does one side of the face droop?

A = Arm – Ask the person to raise his/her arms: does one arm drop downward?

S = Speech – Ask the person to repeat a phrase: does his/her speech sound slurred or strange?

T = Time – If any of the above is true, remember “TIME IS BRAIN” and CALL 9-1-1!

What is a Stroke?

A stroke occurs when blood flow to the brain stops or when blood leaks into or around the brain tissue. There are two different kinds of stroke:

• An ischemic stroke is the most common type of stroke. It occurs when a blood vessel supplying blood to the brain is obstructed or blocked. When the blood vessel is blocked, oxygen in the blood no longer reaches the brain tissue and the tissue begins to die.Ischemic strokes may be caused by hardening of the arteries (known as
  atherosclerosis); narrowing of one of the main arteries in the neck (carotid artery disease); small vessel disease; infection or inflammation of the brain arteries; irregular heartbeat (atrial fibrillation); heart attack (myocardial infarction or MI); a small hole in one of the heart chambers (atrial septal defect); or blood clotting disorder.
• A hemorrhagic stroke is the second type of stroke. It occurs when a blood vessel in the brain ruptures or breaks open. Warning signs of a hemorrhagic
  stroke include:
  • Sudden start of a bad headache, often expressed as “the worst headache of my life”.
  • Feeling nauseated, with or without vomiting, with a severe headache. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body.
  • Loss of consciousness or confusion, especially with a severe headache.
• There are four types of hemorrhagic stroke:
  • An intracerebral hemorrhage is the most common type of hemorrhagic stroke. This type of stroke occurs when a small artery breaks and spills blood into the brain’s tissue. Brains cells in the area of the blood spill are damaged. High blood pressure is usually the cause of this type of hemorrhagic stroke.
  • A subarachnoid hemorrhage occurs when a large artery on the surface of the brain becomes weak and stretches out like a balloon. This stretched out blood vessel is called an aneurysm. When an aneurysm bursts, blood spills into the space between the brain tissue and the membrane that covers it and begins to push on the brain tissue. Treatment may include clipping or coiling of the aneurysm.
  • Arterial Venous Malformation (AVM) is an abnormal connection between arteries and veins in the brain. This happens before birth and results in the tangling of blood vessels in a region of the brain. Over time, the AVM can break apart and blood leaks into the brain tissue.
  • Cerebral Amyloid Angiopathy occurs in older persons when small blood vessels in the brain are damaged by an abnormal layer of protein. The arteries become weak and break and blood leaks into the brain tissue.
• Though not a stroke, it is important to describe Transient Ischemic Attacks or TIAs. A TIA occurs when blood flow to the brain becomes blocked for a brief period of time. This temporary lack of blood supply to the brain can produce signs and symptoms of a stroke. These symptoms are short and do go away. A TIA does not cause any permanent damage to the brain, but it is a very serious warning sign that a stroke may soon occur. TIAs should never be ignored: it is important to get help right away.

Stroke Treatment 

Emergency Stroke Treatment

Once a stroke patient gets to the emergency room, sudden onset stroke treatments are started in an attempt to try to stop a stroke from getting worse. Ischemic strokes (strokes caused by a blood clot blocking a blood vessel) can be treated quickly by giving a “clot buster” medicine known as tissue plasminogen activator or tPA. This medicine can dissolve the blood clot that is blocking the blood vessel and causing the stroke. TPA can be very effective in reversing a stroke but is only considered if the stroke patient gets to the emergency room within three (3) hours of the first stroke symptom. Only the patients who get to the emergency department in time receive this medicine.

It is very important to come to the emergency room immediately when you realize you or a loved one may have symptoms of a stroke.

TPA can also be given during a procedure to picture the blood vessels of the brain called a cerebral arteriogram. The doctor gives the clot-buster medicine through a small plastic tube placed in your artery (femoral artery in your groin) straight into the clot causing the stroke in your head (intra-arterial tPA). This can only be given by doctors and specially trained staff.

The treatment for hemorrhagic stroke (a stroke caused by bursting of a blood vessel with bleeding) may require surgery. For example, if a cerebral aneurysm (a bulging or weak spot in a blood vessel) bursts, a surgeon may place a metal clip at the base of the abnormal vessel to stop the bleeding. If the hemorrhagic stroke is caused by an abnormal clump of blood vessels called an arterial venous
malformation, these blood vessels can be removed. If the stroke is caused by uncontrolled high blood pressure, medicines can be given to lower your pressure.

Stroke Medical Treatment

After emergency treatment for a stroke, medical treatment in the hospital is needed to prevent a stroke from getting worse and to prevent other problems that can happen as a result of a stroke. During the hospital stay, the doctor monitors the stroke patient closely and may order more tests. These tests are called diagnostic tests and help the doctor decide what caused the stroke and how to prevent another one. Diagnostic tests for a stroke may include X-ray(s), heart monitoring, ultrasound, computer-assisted imaging (CT), and magnetic resonance imaging (MRI).

Medicines are also a very vital part of stroke treatment, and may include blood pressure medicines to lower your blood pressure; drugs to lower cholesterol or the fatty stuff in your blood; drugs to keep blood clots from forming (anticoagulants, such as Coumadin® or Warfarin®); a drug to keep blood clots from forming or getting bigger (Heparin®); drugs that keep blood from sticking together to prevent blood clots that could cause a stroke (antiplatelet agents, such as Aspirin® or Plavix®). Aspirin® can also be used to decrease blood vessel irritation in the risk of stroke.

Stroke Surgical Treatment

Some stroke patients may be helped by surgery. For example, strokes caused by a blood clot may result in brain swelling. Life-saving surgery may be necessary to remove the clot and brain tissue that has died from lack of oxygen.

A blockage can also occur in the brain when a blood vessel is narrowed by harmful fatty deposits called plaques. Sometimes clots form in these narrowed vessels and block them. A procedure called angioplasty can open the narrowed blood vessels. During this procedure, a tiny balloon is pushed through the artery to the blockage. When the balloon is inflated, it opens the artery and a mesh tube, called a stent, is placed to keep the blood vessel open.

The main arteries of the neck, known as the carotid arteries, supply the brain with blood. When patients have a serious blockage in these arteries, surgery may be done to prevent another stroke or TIA. This operation is called a carotid endarterectomy. During this procedure, the surgeon cleans out and opens up the narrowed blood vessel.

Surgical treatment can also be considered for patients who have suffered strokes from bleeding or hemorrhagic strokes. The bleeding may occur when a weakened blood vessel leaks or bursts (aneurysm). There are several types of surgery to repair aneurysms. A clip may be placed across the neck of the aneurysm to stop the bleeding or a coil can be placed in it to fill the space and seal off the bleeding.

The Human Brain

The human brain controls many of the actions and functions of our bodies. The brain is divided into many different regions: each region is responsible for an area of the body and controls how that area of the body moves, feels and responds.

The left side of the brain controls movement and feeling of the right side of the body. It helps us with problem-solving, in understanding what we read or hear and with reasoning. Left-sided stroke survivors may have weakness or paralysis (no movement) of the right side of the body. They may also have difficulty with speaking and understanding written or spoken words (aphasia). Left stroke survivors may have a hard time remembering things or retaining new information.

The right side of the brain controls the movement and feelings of the left side of the body. This side of the brain decides our creative and artistic skills. Right-sided stroke survivors may have weakness or paralysis (no movement) of the left side of the body. They may have trouble with judging distances and space, so these stroke survivors may be more likely to fall or bump into things.

There are many other general symptoms that a stroke survivor may go through. Sometimes stroke survivors have trouble controlling their emotions or behaviors. They may also have problems with judgment, and may not realize that they can no longer complete tasks safely, such as driving. A stroke survivor may also have difficulty with movement, sensation, swallowing, eating or vision.

Risk Factors for a Stroke

A risk factor is anything that increases the chance of illness or an event. Health-related risk factors may include medical history, hereditary make-up, personal habits, lifestyle, and certain characteristics of the environment.

There are a number of risk factors that increase the chance of having a stroke. Some stroke risk factors can be controlled or eliminated: these are called controllable or modifiable risk factors. Some stroke risk factors cannot be controlled: these are known as uncontrollable or non-modifiable risk factors.

Stroke is one of the most preventable of all life-threatening health problems. Learning how to control risk factors is one of the most effective ways to prevent a stroke. By controlling risk factors, one can greatly reduce the chance of having a stroke.

Non-Controllable Stroke Risk Factors

Non-modifiable (non-controllable) stroke risk factors or stroke risk factors that cannot be changed. Please have your healthcare provider or nurse select those risk factors that apply to you. Non-modifiable risk factors for stroke are:

• Age
  • For every ten years lived, the risk of having a stroke increases. Sixty six percent (66%) of strokes occur in people over the age of 65
• Gender
  • Men have two times more risk for stroke than women, but more women than men die of a stroke.
• Race
  • African-Americans have a two times higher risk of stroke than other races. Hispanics and Asians have the greatest risk of ruptured blood vessels in the head, a type of hemorrhagic stroke.
• Family History
  • Stroke risk climbs when heart attack, stroke, or TIAs run throughout the family history.
• Personal History of Diabetes
  • High blood sugar levels lead to blood flow problems that may cause a stroke. A stroke is likely to be more serious if blood sugar levels are high the time a stroke occurs. People with diabetes have a higher risk of stroke even when their blood sugars are well controlled.

Controllable Stroke Risk Factors

Modifiable (controllable) stroke risk factors or stroke risk factors that can be
changed. Please have your healthcare provider or nurse select those risk factors that apply to you and you can change or modify. Modifiable risk factors for stroke are:

• Smoking
  • If you smoke, stop. Smoking doubles the risk of stroke. The risk of stroke starts to drop the day you stop smoking. After 5-15 years of being smoke-free, your risk for stroke is the same as a person who never smoked.
  • Smoking causes blood to clot more easily. It increases the build-up of
    cholesterol or plaque in the arteries. Arteries narrow and blood pressure increases every time a cigarette is smoked as a result of the nicotine.
• High Blood Pressure (Hypertension)
  • High blood pressure is the number one risk factor for stroke: it increases your risk for stroke four to six times. Many people who have high blood pressure do not realize it as they have no warning signs of it.
  • When you control your blood pressure, you can greatly reduce your risk of stroke. Talk to your doctor to learn what your blood pressure should be. Have your blood pressure checked at least twice per year to make sure your blood pressure is at a safe level or near 120/80. Limit the amount of salt in your diet by not adding salt to any foods you cook: also limit the amount of processed food you eat as most of it has a high salt content. Other important lifestyle changes that improve blood pressure are regular exercise, not smoking, and weight loss. Follow your doctor’s advice about diet, exercise, and medicines.
• High Cholesterol
  • Unhealthy cholesterol may lead to fat deposits in the arteries. These fat deposits are called plaque. Plaque narrows the arteries and can lead to stroke. Follow your doctor’s advice for regular cholesterol testing. It is important to learn your personal cholesterol numbers. Your total cholesterol should be lower than 200. Your good cholesterol (HDL) should be higher than 60. Your bad cholesterol (LDL) should be lower than 129 (based on health history), and your triglycerides (another type of fat) should be below 150.
  • To reach your cholesterol goals, you may need diet, exercise, and
    medicine. It is very important to work very hard to control your
    cholesterol to prevent a stroke or recurrent stroke. Eat a diet full of
    vegetables, lean meats, whole grains, and fruits. Exercise at least 30
    minutes a day, for at least three days per week, to strengthen your heart and reduce your risk of building up cholesterol in your blood vessels. Follow your doctor’s advice for cholesterol control.
• Carotid Artery Disease
  • The carotid arteries are the two main arteries that carry blood to the brain. When cholesterol build-up narrows the arteries, carotid disease results. Medicine or surgery to clean out plaque in the arteries can reduce the risk of stroke, so if your doctor suggests these treatments, follow them exactly.

• Heart Disease

  • Atrial Fibrillation
    • Atrial fibrillation is an irregular heartbeat and a common cause of
      stroke. It can lead to blood clots forming in your heart that may
      travel to your brain. You can have atrial fibrillation and not know it. If you think your heart rate is irregular, call your doctor.
    • If you have atrial fibrillation, follow your doctor’s plan for control of it very carefully. These plans may include special medicine(s), diet, blood testing orders and treatments to help your heart return to a normal rhythm.
  • Heart Attack
    • A heart attack occurs when the blood supply to the heart is greatly reduced or stopped. This can result in damage to the heart muscle. Another name for a heart attack is “myocardial infarction”. Three percent (3%) of people who have a heart attack will also have a stroke.
  • Congestive Heart Failure
    • Congestive heart failure is a weakening of the heart muscle. The heart becomes less able to pump the amount of blood the body needs to perform normal activities. Congestive heart failure is a risk factor for stroke and getting treatment for this condition helps reduce the risk of stroke.
  • Valve Disease
    • Valve disease prevents the heart valves from working properly. Blood clots can result from heart disease. The blood clots may travel through the arteries to the brain and cause a stroke. Medicine and sometimes surgery can help reduce the stroke risk from valve disease
  • Diabetes
    • Diabetes greatly increases the risk of ischemic stroke. Diabetes causes plaque to build up in the arteries at a faster rate. People also tend to gain weight with diabetes, which can lead to high blood pressure and high cholesterol, both risk factors for stroke. When sugar (glucose) levels are high, damage from a stroke can be even worse. Good control of diabetes can reduce your risk of stroke. For good control, it is important to monitor and control blood glucose levels, follow your diet plan, and exercise.
  • Obesity
    • Excess weight increases your risk of stroke. People who have a stroke or heart disease often have excess body fat around their lower belly or abdomen. This is sometimes called an “apple shape.” Obesity can bring other risk factors with it, such as high blood pressure, high cholesterol, and diabetes. Weight control and exercise improve your circulation and help reduce other risk factors.
  • Lack of Physical Activity 
    • Exercise is important to help control weight, blood pressure, cholesterol, and diabetes, all risk factors for stroke.
  • Alcohol and Drug Use
    • Heavy alcohol use increases the risk of stroke. The use of street drugs, especially cocaine and amphetamines, is a major stroke risk for young adults. Steroid use for body-building increases the risk of stroke.
  • Poor Nutrition
    • A diet high in fat, sugar, and salt puts you at risk for stroke. Studies show that eating 5 servings of fruits and vegetables a day will reduce your risk of stroke by 30%.
  • Stress
    • Studies show a link between mental stress and the narrowing of the carotid arteries. Learning about stress and practicing ways to reduce it may help to reduce your stroke risk.
  • Estrogen
    • Birth control pills and hormone replacement therapy (HRT) contain estrogen. The hormone estrogen may change the blood’s clotting ability. Blood clots may then form, which can cause a stroke.

Stroke Recovery and Rehabilitation

Rehabilitation starts in the hospital as soon as possible after the stroke. Depending on the severity of the stroke, rehabilitation may continue after you leave the hospital. Your rehabilitation team may include:

• Neurologists– doctors skilled in finding the cause and deciding the treatment for diseases of the central nervous system, including the brain, nerves, and spinal cord.
• Rehabilitation physicians– doctors skilled in the assessment, planning, and care of patients requiring rehabilitation services.
• Nurses– professionals who coordinate the day-to-day care of the stroke survivor and help to make rehabilitation a part of the stroke survivor’s routine.
• Physical Therapists– help stroke survivors restore the physical acts and skills they need for daily living, such as getting in and out of bed, transferring from a bed to a chair, balance, coordination, and walking.
• Occupational Therapists– help stroke survivors relearn the skills they need for everyday life, such as eating, going to the bathroom, dressing, and taking care of oneself.
• Speech and Language Pathologists– assist stroke survivors who are experiencing difficulty understanding or speaking written or spoken words
  (aphasia). Stroke survivors can have receptive aphasia (difficulty processing words coming in) or expressive aphasia (difficulty with getting words out).
  Speech therapists can also assist stroke survivors and caregivers with swallowing and diet concerns. They can also teach the stroke survivor and caregiver many ways to cope with all of the problems above.
• Social workers and case managers– provide counseling and support services for stroke survivors and their families. They assist caregivers in finding the best possible solutions for the stroke survivor’s rehabilitation and recovery needs.

References & Stroke-Related Pages

American Occupational Therapy Association (AOTA) http://www.aota.org
American Physical Therapy Association (APTA) http://www.apta.org
American Speech-Language-Hearing Association (ASHA) http://www.asha.org
American Stroke Association (ASA)-A Division of the American Heart Association
http://www.strokeassociation.org

National Institute of Health Stroke Webpage http://stroke.nih.gov/
National Stroke Association http://www.stroke.org

This information is not intended to be used as a substitute for professional medical advice, diagnosis or treatment. You should not rely entirely on this information for your health care needs. Ask your doctor or healthcare provider any specific medical questions that you have.