Stroke Education

Any of the following can be a sign of stroke – and they do not all have to happen at once:

• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body.
• Sudden confusion, trouble speaking or understanding speech.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble walking, dizziness, loss of balance or coordination.
• Sudden severe headache with unknown cause.

If any of these signs happen, call 911 as soon as possible. The ambulance team will call the hospital and tell them your signs. The stroke team will be ready to care for you when you arrive.

If you see any of these signs, BE FAST:

• B – Balance off /dizziness – Ask the person if they are experiencing sudden loss of balance or coordination.
• E – Eyes not focusing – Ask the person if they have experienced sudden blurred vision, double vision or sudden, persistent vision trouble.
• F – Face drooping – Ask the person to smile. If the face droops on one side, that is a sign of a stroke.
• A – Arm weakness – Ask the person to raise both arms. If they cannot hold one arm up, that is a sign of a stroke.
• S – Speech difficulty – Ask the person to say a few easy words. If they talk like they are drunk (slurred speech) or you cannot understand what they are trying to say, that is a sign of a stroke.
• T – Time to call 911 –Time is very important. The sooner you get to the hospital, the better your chances are for improving or getting better. If you wait too long, you may get worse or may not get better.

There are three main types of stroke: transient ischemic attack, ischemic stroke and hemorrhagic stroke.

Transient ischemic attack
A transient ischemic attack or TIA (“mini stroke”) is a temporary blockage of blood flow to the brain. TIAs usually last only a few minutes. Although symptoms may go away soon, a TIA is a warning sign that a stroke may occur in the near future. About one-third of people who have a TIA go on to have a severe stroke within the first year. Steps should be taken immediately to prevent a stroke. Diagnostic workup for TIA is the same as for ischemic stroke.

Ischemic stroke
An ischemic (iss-KEE-mik) stroke is the most common type of stroke and makes up 87 percent of all strokes. Ischemic stroke occurs when there is a blockage in a vessel that supplies blood to the brain. If an ischemic stroke is caught early enough, debilitating effects may be reversed with treatment.

Hemorrhagic stroke
Hemorrhagic (bleeding) strokes account for about 13 percent of strokes. Hemorrhagic stroke occurs when a weakened blood vessel ruptures, allowing blood to leak into the brain. This leakage will cause that part of the brain not to function properly.

Ask your doctor—What type of stroke did I have?

When you show symptoms of a stroke, the emergency team will need to evaluate the type of stroke you are having and the areas of your brain affected by the stroke. Your doctor may use several tests to determine your risk of stroke, including:

• A review of medical history.
• Physical and neurological examination.
• Laboratory (blood) tests.
• Diagnostic tests (radiologic).

Diagnostic tests are used to examine how the brain looks, works and obtains its blood supply. They can outline the injured area of the brain and sometimes determine the cause of the stroke. Diagnostic tests that may be ordered include:

CT (computerized tomography) scan is a test that uses radiation to create a picture of the brain. It is ordered first when diagnosing a stroke.
CTA (CT angiography) uses intravenous contrast dye to show major arteries supplying the brain blood and detect the type and location of a stroke.
CTP (CT perfusion) is a specialized CT test used to evaluate blood flow to brain tissue when an ischemic stroke is suspected.
MRI (magnetic resonance imaging) is a test that uses a large magnetic field to create detailed image of the brain. The image produced by MRI is sharper and more detailed than a CT scan and can be used to diagnose small, deep injuries.
MRA (MR angiography) uses intravenous contrast dye to view the blood flow of the head and neck. The MRA allows the doctor to look at smaller blood vessels to detect the type and location of a stroke.
Cerebral angiogram (arteriogram) is the most definitive way to view the blood vessels of the brain and provides the highest level of detail. In addition to providing high-resolution images, an angiogram also provides information about the blood flow in your brain. For the procedure, a small catheter is placed through an artery in the wrist or groin and carefully moved up through the main blood vessels in the chest and neck. Contrast dye then is injected and X-ray images are taken to construct a 3D view of your vessels.
Echocardiogram is a test that uses sound waves to create a moving picture of the heart. It can provide pictures of the heart’s valves and chambers and help evaluate the pumping action of the heart.
TEE (transesophageal echocardiogram) is a test that uses sound waves from a transducer that is placed in the esophagus to produce a very detailed picture of the heart, especially the back of the heart.
EEG (electroencephalogram) is a diagnostic test that uses small metal discs placed on the scalp to pick up electrical impulses. These electrical impulses can show areas of the brain injury and may help identify seizure activity.
Carotid ultrasound (Doppler testing) is a blood flow test that uses ultrasound to provide detailed information about the condition of the carotid and vertebral arteries that supply blood to the brain.

Treatment of an acute ischemic stroke: Time is brain
Timing is everything and will affect what treatments are used. Treatment choices can include medications to break up the blood clot or surgery to remove the blood clot.

• Medication – Alteplase is a clot-busting drug that can be given to dissolve the clot, but this medication must be administered within 4.5 hours of the time last known to be well, when stroke signs start. Because the benefit of Alteplase is time dependent, it is critical to treat with this medication as quickly as possible.
• Surgery – Mechanical thrombectomy is a procedure in which attempts are made to surgically remove a blockage. Thrombectomy is indicated for patients with acute ischemic stroke due to a large vessel occlusion, and guidelines support treatment in eligible patients up to 24 hours after the last known to be well time.

Treatments of hemorrhagic stroke

• Cerebral angiogram – This test may be used to look for the cause of your bleed. In emergencies, a cerebral angiogram may reveal an abnormality in a vessel that needs to be treated to stop the bleeding and/or to prevent further bleeding. In this case, treatment may be performed at the same time or very shortly after. Procedures to treat abnormal blood vessels include embolization (endovascular treatment) and surgical intervention with craniotomy.
• Craniotomy – This procedure is more invasive and involves opening, and sometimes removal (craniectomy), of a portion of the skull. This may be necessary when aneurysms or arteriovenous malformations (AVM) cannot be embolized effectively. A craniotomy may be performed for resection (removal) of an AVM or a surgical clipping of an aneurysm.
• Arteriovenous malformation resection (removal of an AVM) – Sometimes an embolization is performed before this procedure to reduce the risk of bleeding.
• Surgical clipping – This procedure is performed by doing a craniotomy and placing a clip on the aneurysm to eliminate blood flow into the aneurysm.
• Embolization – This procedure is minimally invasive and does not require cutting into the skull. Using the same technique used for a cerebral angiogram, a catheter is guided to the target vessel and an attempt is made to minimize blood flow to the affected area. This is also called endovascular treatment. Embolization can be performed using multiple techniques: coiling, intrasaccular flow disruptor, stenting, flow diverter and onyx.
  • Coiling – This treatment is performed to fill an aneurysm from inside of the vessel. The coils induce clotting within the aneurysm and prevent blood from flowing into it. This is the most common treatment for ruptured aneurysms and does not require blood-thinning medication. Sometimes, coils may compact over time, causing a recurrence of the aneurysm.
  • Intrasaccular flow disruptor – With this treatment, a meshed device is placed within the aneurysm to prevent blood flow inside it. An example of this is a WEB embolization. Aspirin may be prescribed following this procedure.
  • Stenting – Stents may be used alone or in combination with coils. Stents are placed across the vessel where the aneurysm is to redirect blood flow straight through the vessel instead of into the aneurysm. When used with coils, stents can help hold coils in place and serve as an additional “barrier” for blood flow into the aneurysm. Because blood can stick to the stent, antiplatelet medications will be prescribed following the procedure.
  • Flow diversion – This treatment uses certain types of stents called flow diverters, which are made with smaller grid patterns. The tighter grid allows less blood to move across the stent wall, which redirects the blood flow through the main vessel and away from the aneurysm, helping the artery heal from inside. As with stenting procedures, flow diverters require the use of antiplatelet medications.
  • Onyx – This glue-like substance is used to seal off a vessel. This is most commonly used to treat AVMs, either alone or before a resection.

Risk factors are traits and lifestyle habits that increase the risk of disease. The more risk factors you have, the higher your chances of having a stroke. The best way to prevent a stroke is to reduce your stroke risk factors. A healthcare provider can help you change factors that result from lifestyle or environment.

Modifiable risk factors (start managing):

• Atrial fibrillation (AFib) – AFib increases your risk of stroke because the irregular and often rapid heart rate can cause blood clots to develop and travel to your brain. Medications can be taken to help reduce the risk of blood clots and prevent existing blood clots from getting bigger.
• Diabetes – Carefully monitor your blood sugar, follow up with your primary care provider and take your medications regularly. Having diabetes can put you at an increased risk for stroke.
• Diet – Cutting down on salt and fat can help you lower your blood pressure and cholesterol levels.
• High blood cholesterol – Monitoring your cholesterol levels regularly, eating a healthy diet and taking medications can decrease your risk for stroke. Your HDL “good” cholesterol should be greater than 40mg/dLx–60mg/dL, and your LDL “bad” cholesterol should be between 50–70mg/dL.
• High blood pressure – Optimal blood pressure is less than 120mmHg/80mmHg. Checking your blood pressure regularly and taking medications could decrease your risk for stroke.
• Obesity – Manage your weight through diet and exercise.
• Obstructive sleep apnea – In this disorder, you stop breathing in your sleep for 10 seconds or more. Symptoms may include loud snoring, disruptive sleep and excessive daytime sleepiness. An overnight sleep study will need to be conducted to diagnosis obstructive sleep apnea.
• Carotid disease – Carotid arteries in your neck supply blood to your brain. A carotid artery narrowed by fatty deposits from atherosclerosis (buildup of plaque in the artery wall) may become blocked by a blood clot. Carotid artery disease also is called carotid artery stenosis.
• Peripheral artery disease – This condition is caused by the narrowing of vessels carrying blood to the leg and arm muscles. The blood vessels narrow because fatty plaque builds up in artery walls.
• Sickle cell disease – In this genetic disorder, sickle-shaped red blood cells are less able to carry oxygen to the body’s tissues and organs. They tend to stick to blood vessel walls, blocking arteries to the brain and causing a stroke.

Modifiable risk factors (stop!):

• Drinking too much alcohol
• Using illegal drugs
• Being inactive
• Smoking or being exposed to secondhand smoke

Non-modifiable risk factors:

• Increasing age – People of all ages can have a stroke, but the older you are the more your risk increases for stroke.
• Sex (gender) – Stroke is more common in men than in women. In most age groups, more men than women have stroke in a given year. However, women account for more than half of all stroke deaths. Women who are pregnant, take birth control pills and smoke, or have high blood pressure are all at an increased risk for stroke.
• Heredity (family history) and race – Your risk of stroke or aneurysm (including rupture) is greater if a parent, grandparent, sister or brother has had a stroke or aneurysm. African Americans have a much higher risk of death from a stroke or aneurysm rupture than Caucasians. Stroke is the fourth leading cause of death for Hispanics living in the United States, and Hispanics have different risk factors for stroke. Compared to Caucasians, Hispanics have strokes at younger ages.
• Prior stroke or heart attack – Previous strokes (including those from ruptured aneurysms) or heart attacks increase the risk of having another stroke.