Dr. Jyh-Haur Lu, MD



What is a stroke?
A stroke or "brain attack" occurs when a blood clot blocks an artery (a blood vessel that carries blood from the heart to the body) or a blood vessel (a tube through which the blood moves through the body) breaks, interrupting blood flow to an area of the brain. When either of these things happen, brain cells begin to die and brain damage occurs.

When brain cells die during a stroke, abilities controlled by that area of the brain are lost. These abilities include speech, movement and memory. How a stroke patient is affected depends on where the stroke occurs in the brain and how much the brain is damaged.

For example, someone who has a small stroke may experience only minor problems such as weakness of an arm or leg. People who have larger strokes may be paralyzed on one side or lose their ability to speak. Some people recover completely from strokes, but more than 2/3 of survivors will have some type of disability.

Stroke symptoms include:
• Sudden numbness or weakness of face, arm or leg - especially 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.

If you have experienced any of these symptoms, you may have had a TIA or mini-stroke.

If you think someone may be having a stroke, act F.A.S.T. and do this simple test:

Act F.A.S.T
FACE Ask the person to smile.
Does one side of the face droop?
ARMS Ask the person to raise both arms.
Does one arm drift downward?
SPEECH Ask the person to repeat a simple sentence.
Are the words slurred? Can he/she repeat the sentence correctly?
TIME If the person shows any of these symptoms, time is important.
Call 911 or get to the hospital fast. Brain cells are dying.


Types of stroke
There are two main ways "brain attacks" can happen: ischemic and hemorrhagic strokes. In ischemic strokes, a blood clot blocks or "plugs" a blood vessel in the brain. In hemorrhagic strokes, a blood vessel in the brain breaks or ruptures.

Ischemic stroke: In everyday life, blood clotting is beneficial. When you are bleeding from a wound, blood clots work to slow and eventually stop the bleeding. In the case of stroke, however, blood clots are dangerous because they can block arteries and cut off blood flow, a process called ischemia. An ischemic stroke can occur in two ways: embolic and thrombotic strokes.

Embolic stroke: In an embolic stroke, a blood clot forms somewhere in the body (usually the heart) and travels through the bloodstream to your brain. Once in your brain, the clot eventually travels to a blood vessel small enough to block its passage. The clot lodges there, blocking the blood vessel and causing a stroke. The medical word for this type of blood clot is embolus.

Thrombotic stroke: In the second type of blood-clot stroke, blood flow is impaired because of a blockage to one or more of the arteries supplying blood to the brain. The process leading to this blockage is known as thrombosis. Strokes caused in this way are called thrombotic strokes. That's because the medical word for a clot that forms on a blood-vessel deposit is thrombus.

Blood-clot strokes can also happen as the result of unhealthy blood vessels clogged with a buildup of fatty deposits and cholesterol. Your body regards these buildups as multiple, tiny and repeated injuries to the blood vessel wall. So your body reacts to these injuries just as it would if you were bleeding from a wound; it responds by forming clots.

Two types of thrombosis can cause stroke large vessel thrombosis and small vessel disease (or lacunar infarction).

Large vessel thrombosis: Thrombotic stroke occurs most often in the large arteries, so large vessel thrombosis is the most common and best understood type of thrombotic stroke. Most large vessel thrombosis is caused by a combination of long-term atherosclerosis followed by rapid blood clot formation. Thrombotic stroke patients are also likely to have coronary artery disease, and heart attack is a frequent cause of death in patients who have suffered this type of brain attack.

Small vessel disease/Lacunar infarction: Small vessel disease, or lacunar infarction, occurs when blood flow is blocked to a very small arterial vessel. The term's origin is from the Latin word lacuna which means hole, and describes the small cavity remaining after the products of deep infarct have been removed by other cells in the body. Little is known about the causes of small vessel disease, but it is closely linked to hypertension (high blood pressure).

Hemorrhagic stroke: Strokes caused by the breakage or "blowout" of a blood vessel in the brain are called hemorrhagic strokes. The medical word for this type of breakage is hemorrhage. Hemorrhages can be caused by a number of disorders which affect the blood vessels, including long-standing high blood pressure and cerebral aneurysms. An aneurysm is a weak or thin spot on a blood vessel wall. These weak spots are usually present at birth. Aneurysms develop over a number of years and usually don't cause detectable problems until they break. There are two types of hemorrhagic stroke: subarachnoid and intracerebral.

In an intracerebral hemorrhage, bleeding occurs from vessels within the brain itself. Hypertension is the primary cause of this type of hemorrhage.

In a subarachnoid hemorrhage (SAH), an aneurysm bursts in a large artery on or near the thin, delicate membrane surrounding the brain. Blood spills into the area around the brain which is filled with a protective fluid, causing the brain to be surrounded by blood-contaminated fluid.

The FDA recently issued a voluntary recall of non-prescription medications containing PPA (phenylpropanolamine) after they were linked to an increased risk of hemorrhagic stroke in women.

Stroke myths

Stroke is unpreventable Stroke is largely preventable
Stroke cannot be treated Stroke requires emergency treatment
Stroke only strikes the elderly Stroke can happen to anyone
Stroke happens to the heart Stroke is a "Brain Attack"
Stroke recovery only happens for a few months following a stroke Stroke recovery continues throughout life


Am I at risk for a stroke?
Anyone can have a stroke. But your chances for having a stroke increase if you meet certain criteria. Some of these criteria, called risk factors, are beyond your control -- such as being over age 55, being male, being African American, Hispanic or Asian/Pacific Islander, or having a family history of stroke. Other stroke risk factors are controllable.

Risk reduction through lifestyle modification
• Controlling high blood pressure
- a low-salt diet
- other methods
• Controlling heart disease
- diet
- exercise
- other methods
• Controlling smoking
• Controlling alcohol consumption
• Controlling weight
• Nutrition and stroke risk reduction

Risk reduction - medical management
• Antihypertensive medication
• Controlling heart disease
- atrial fibrillation
- cholesterol reducing medication for coronary heart disease

Risk reduction through surgery
• Carotid endarterectomy
• Arterial bypass surgery

Controllable stroke risk factors
Many of the things that increase your stroke risk can be controlled. The diseases that increase risk can be treated. Lifestyle choices such as eating and exercise habits can be changed.

Treatable diseases that increase stroke risk:
High blood pressure (hypertension): Blood pressure is the force of your blood pushing against the walls of your arteries. If you have high blood pressure, your heart is pumping harder to move blood through the body. This can weaken blood vessels and damage major organs such as the brain. Left untreated, high blood pressure can lead to stroke.

Blood pressure guidelines:
- A blood pressure reading below 120/80 is considered normal. In general, the lower the blood pressure, the better.
- A blood pressure reading of 120-39/80-89 is considered pre-hypertension. People with pre-hypertension are at an increased risk for high blood pressure, or hypertension.
- A blood pressure reading of 140/90 or above is considered high blood pressure, or hypertension.

- High blood pressure is a common condition, affecting 65 million Americans - 1 in 3 adults
- High blood pressure increases stroke risk 4-6 times
- High blood pressure is the most common cause of stroke
- High blood pressure usually has no signs or symptoms

Atrial fibrillation (AF): Atrial Fibrillation (AF) is caused when the two upper chambers of the heart (atria) beat rapidly and unpredictably, producing an irregular heartbeat. AF raises stroke risk because it allows blood to pool in the heart. When blood pools, it tends to form clots which can then be carried to the brain, causing a stroke. Long-term untreated AF can also weaken the heart, leading to heart failure.

- AF affects approximately 2.2 million Americans
- AF increases stroke risk up to 6 times
- About 15% of all people who have a stroke have AF
- AF is most often found in people over the age of 65 and in people who have heart disease or thyroid disorders

High cholesterol: Cholesterol is a fatty substance in the blood that our bodies make on their own, but we also get it from fat in the foods we eat. Certain foods (such as egg yolks, liver or foods fried in animal fat or tropical oils) contain cholesterol. High levels of cholesterol in the bloodstream can clog arteries and cause a stroke or heart attack. It can also increase stroke risk by putting you at greater risk for heart disease -- another important stroke risk factor.

- Combined HDL and LDL cholesterol should fall below 200 mg/dL.
- Nearly 107 million American adults have a total blood cholesterol of 200 or higher.

Diabetes: In people with diabetes, the body either doesn't produce enough insulin or the cells ignore the insulin. Without insulin, the body can't process sugar, which is the basic fuel for the cells in the body. In addition to their diebetes, most diabetics have other health problems such as high blood pressure, high cholesterol and obesity/excess weight. These problems increase their risk of stroke even more.

- According to the American Diabetes Association, there are 20.8 million Americans with diabetes
- 2 out of 3 people with diabetes die from stroke or heart disease
- Diabetes increases stroke risk 2-4 times

Lifestyle choices that increase stroke risk
Tobacco use/smoking: Among other things, smoking damages blood vessel walls, speeds up the clogging of arteries, raises blood pressure and makes the heart work harder. Smoking doubles the risk of stroke. Smoking women have special concerns. If a woman smokes, has a history of migraines, and takes oral contraceptives, her stroke risk is increased as much as 34 times.

Alcohol use: Drinking lots of alcohol has been linked to stroke in some studies. Drinking more than 2 drinks per day may increase stroke risk by 50%.

Obesity/excessive weight: Excess weight puts a strain on the entire ciculatory system. It also makes people more likely to have high cholesterol, high blood pressure and diabetes -- all of which can increase your risk for stroke.

Uncontrollable stroke risk factors
Some risk factors are controllable while others are not. The following are the things you can't control but that do increase your risk for stroke:

Age: A stroke can happen to anyone, but your risk of stroke increases with age. After the age of 55, your stroke risk doubles for every decade.

Gender: Stroke is more common in men than women. But more women than men die from stroke.

Race: If you are African American, your risk is twice the rate for whites. If you are Hispanic or Asian/Pacific Islander, your stroke risk is also higher than Caucasions.

Family history: If someone in your family has had a stroke, you have a higher risk of stroke yourself.

Previous stroke or TIA: If you have already had a stroke or a transient ischemic attack (ministroke), you have a 25-40% chance of having another stroke in the next 5 years.

Having one or more of these risk factors does not mean you will automatically have a stroke. But because your stroke risk is higher, it's even more important that you ask your doctor about changes you can make to prevent a stroke. Remember, 80% of strokes are preventable. Which means that every year, up to 600,000 Americans could have prevented their strokes. You can prevent a stroke!

Secondary (recurrent) risk
After experiencing a stroke, survivors and their families usually concentrate their efforts on rehabilitation and recovery. However, preventing another (or recurring) stroke from happening is also a critical consideration. Of the estimated 750,000 Americans who experience a stroke each year, 5 to 14 percent will have an additional stroke within one year. Within the next five years, stroke will recur in 24 percent of women and 42 percent of men.

Stroke prevention is also important to those who have experienced transient ischemic attacks (TIAs or mini-strokes). TIAs are brief episodes of stroke-like symptoms that can last from a few minutes to 24 hours, but usually cause no permanent damage or disability. TIAs are serious warning signs of an impending stroke. Up to 35 percent of people who experience a TIA are expected to have a stroke. However, many recurrent strokes and TIAs can be prevented through lifestyle changes, surgery, medication, or a combination of all three methods.

Stroke prevention guidelines
The Stroke Prevention Guidelines were established by National Stroke Association's Stroke Prevention Advisory Board, an elite group of the nation's leading experts on stroke prevention. They were first published in a 1999 issue of Journal of the American Medical Association (JAMA) and have been updated to reflect current medical standards.

National Stroke Association suggests you ask your doctor for advice on how to best use these guidelines.

(1) Know your blood pressure
• Have it checked at least annually. If it is elevated, work with your doctor to keep it under control.
• High blood pressure (hypertension) is a leading cause of stroke.
• You can check your blood pressure at your doctor's office, at health fairs, at home with an automatic blood pressure machine, or at your local pharmacy or supermarket.
• If the higher number (your systolic blood pressure) is consistently above 135 or if the lower number (your diastolic blood pressure) is consistently over 80, consult your doctor.
• If your doctor decides that you have high blood pressure, s/he may recommend some combination of changes in your diet, regular exercise, and medicine.
• Blood pressure drugs have improved. Once you and your doctor find the right medicine for you, it will almost never cause side effects or interfere with your quality of life.

(2) Find out if you have atrial fibrillation
• Atrial fibrillation (AF) is an irregular heart beat that changes heart function and allows blood to collect in the chambers of your heart.
• This blood, which is not moving through your body, tends to clot.
• The beating of your heart can move one of these blood clots into your blood stream, and can cause a stroke.
• Your doctor can diagnose AF by carefully evaluating your pulse.
• AF can be confirmed or ruled out with an electrocardiogram (ECG) (a recording of the electrical activity of the heart) which can probably be done in your doctor's office.
• If you have AF, your doctor may choose to lower your risk for stroke by prescribing medicine blood thinners. Aspirin and warfarin (CoumadinR) are the most commonly prescribed treatments.

(3) If you smoke, stop
• Smoking doubles the risk for stroke.
• If you stop smoking today, your risk for stroke will immediately begin to drop.
• Quitting smoking today can significantly reduce your risk of stroke from this factor.

(4) If you drink alcohol, do so in moderation
Studies now show that drinking up to two drinks per day can reduce your risk for stroke by about half. More alcohol than this each day can increase your risk for stroke by as much as three times and also can lead to liver disease, accidents and more. If you drink, we recommend that you limit yourself to no more than two drinks each day, and if you don't drink, don't start!

Remember that alcohol is a drug and it can interact with some medications. It's a good idea to ask your doctor or pharmacist if any of the medications you are taking could interact with alcohol.

(5) Find out if you have high cholesterol
• Know your cholesterol number.
• If your total cholesterol level (LDL and HDL) is over 200, talk to your doctor. You may be at increased risk for stroke. LDL, known as the "bad" cholesterol, is the form that builds up and causes plaque which may narrow arteries and limit or stop blood flow. LDL can be inherited from your family members or be a result of your body chemistry. It can also be the result of a diet high in saturated fats, lack of exercise, or diabetes. HDL is the "good" cholesterol that sweeps the blood and removes plaque.Lowering your cholesterol (if elevated) may reduce your risk for stroke.
• High cholesterol can be controlled in many individuals with diet and exercise.
• Some individuals with elevated cholesterol may require medication.

(6) If you are diabetic
• Follow your doctor's advice carefully to control your diabetes.
• Often, diabetes may be controlled through careful attention to what you eat.
• Work with your doctor and your dietitian (a health care professional who helps promote good health through proper eating) to develop a nutrition program that fits your needs and your lifestyle.
• Your doctor can prescribe lifestyle changes and medicine that can help control your diabetes.
• Having diabetes puts you at an increased risk for stroke; by controlling your diabetes, you may lower your risk for stroke.

(7) Exercise
• Include exercise in your daily activities.
• A brisk walk for as little as 30 minutes a day can improve your health in many ways, and may reduce your risk for stroke.
• Try walking with a friend; this will make it more likely that you'll make it a habit.
• If you don't enjoy walking, choose another exercise or activity that you do enjoy, such as biking, swimming, golf, tennis, dance, or aerobics.
• Make time each day to take care of yourself by exercising.

(8) Enjoy a lower sodium (salt), lower fat diet
• By cutting down on sodium and fat in your diet, you may be able to lower your blood pressure and, most importantly, lower your risk for stroke.
• Work towards a balanced diet each day with plenty of fruits, vegetables, grains, and a moderate amount of protein (meat, fish, eggs, milk, nuts, tofu, and some beans).
• Adding fiber, such as whole grain bread and cereal products, raw, unpeeled fruits and vegetables and dried beans, to the diet can reduce cholesterol levels by 6 to 19 percent.

(9) Circulation problems
• Ask your doctor if you have circulation problems which increase your risk for stroke.
• Strokes can be caused by problems with your heart (pump), arteries and veins (tubes), or the blood which flows through them. Together, they are your circulation. Your doctor can check to see if you have problems in the circulation supplying blood to your brain.
• Fatty deposits - caused by atherosclerosis (a hardening or buildup of cholesterol plaque and other fatty deposits in the arteries) or other diseases - can block the arteries which carry blood from your heart to your brain. These arteries, located on each side of your neck, are called carotid and vertebral arteries. This kind of blockage, if left untreated, can cause stroke. You can be tested for this problem by your doctor. Your doctor can listen to your arteries just as s/he listens to your heart, or look at ultrasound or MRI images.
• If you have blood problems such as sickle cell disease, severe anemia (lower than normal number of red blood cells), or other diseases, work with your doctor to manage these problems. Left untreated, these can cause stroke.
• Circulation problems can usually be treated with medications. If your doctor prescribes aspirin, warfarin (CoumadinR), ticlopidine (TiclidR), clopidogrel (PlavixR), dipyridamole (AggrenoxR), or other medicine for circulation problems, take it exactly as prescribed.
• Occasionally, surgery is necessary to correct circulation problems such as a blocked artery.

(10) Symptoms
If you have any stroke symptoms, seek immediate medical attention.
These include:
• Sudden numbness or weakness of face, arm or leg - especially 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.

If you have experienced any of these symptoms, you may have had a TIA or mini-stroke. Ask your doctor if you can lower your risk for stroke by taking aspirin, or by other means.

Effects of stroke
The ability to define the world and our place in it distinguishes our humanity. Stroke or brain attack forever alters this world-making capacity. The stroke patient's world, once comprehensible and manageable, is transformed into a confusing, intimidating and hostile environment. The skills of intellect, sensation, perception and movement, which are honed over the course of a lifetime and which so characterize our humanity are the very abilities most compromised by stroke. Stroke can rob people of the most basic methods of interacting with the world.

The specific abilities that will be lost or affected by stroke depend on the extent of the brain damage and most importantly where in the brain the stroke occurred. The brain is an incredibly complex organ, and each area within the brain has responsibility for a particular function or ability. The brain is divided into four primary parts: the right hemisphere (or half), the left hemisphere, the cerebellum and the brain stem.

Recovery & rehabilitation
Current statistics indicate that there are over 4 million people in the United States who have survived a stroke or brain attack and are living with the after-effects. These numbers do not reflect the scope of the problem and do not count the millions of husbands, wives and children who live with and care for stroke survivors and who are, because of their own altered lifestyle, greatly affected by stroke.

The very word "stroke" indicates that no one is ever prepared for this sudden, often catastrophic event. Stroke survivors and their families can find workable solutions to most difficult situations by approaching every problem with patience, ingenuity, perseverance and creativity.

Early recovery: There's still so much we don't know about how the brain compensates for the damage caused by stroke or brain attack. Some brain cells may be only temporarily damaged, not killed, and may resume functioning. In some cases, the brain can reorganize its own functioning. Sometimes, a region of the brain "takes over" for a region damaged by the stroke. Stroke survivors sometimes experience remarkable and unanticipated recoveries that can't be explained. General recovery guidelines show:

• 10 percent of stroke survivors recover almost completely
• 25 percent recover with minor impairments
• 40 percent experience moderate to severe impairments requiring special care
• 10 percent require care in a nursing home or other long-term care facility
• 15 percent die shortly after the stroke

Rehabilitation: Rehabilitation actually starts in the hospital as soon as possible after the stroke. In patients who are stable, rehabilitation may begin within two days after the stroke has occurred, and should be continued as necessary after release from the hospital.

Depending on the severity of the stroke, rehabilitation options include:
• A rehabilitation unit in the hospital
• A subacute care unit
• A rehabilitation hospital
• Home therapy
• Home with outpatient therapy
• A long-term care facility that provides therapy and skilled nursing care

The goal in rehabilitation is to improve function so that the stroke survivor can become as independent as possible. This must be accomplished in a way that preserves dignity and motivates the survivor to relearn basic skills that the stroke may have taken away - skills like eating, dressing and walking.

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