Stroke: A Perspective for the General Population

Shaveta Manchanda, M.B.B.S., M.P.H.

What is Stroke: Definitions?

Scientifically, a stroke is defined as “sudden development of a neurological defect, usually associated with the development of some degree of hemi paresis (weakness on one side of the body) and sometimes accompanied by unconsciousness.” ¹

A stroke can be a result of an interruption in blood supply to an area of the brain (ischemic) or it can be the result of a catastrophic event when a blood vessel in the brain bursts, spilling blood into the spaces surrounding the brain cells (hemorrhagic). ²⁴ It usually causes some kind of damage that is lasting -weakness, numbness, tingling, difficulty speaking, slurred speech, difficulty walking, paralysis, cognitive deficits, speech problems, emotional difficulties and daily living problems. ^5,6,11 Sometimes subtle abnormalities like difficulty dressing, recognizing faces, or copying simple figures, may be the result of a stroke. Rarely, a stroke may only cause personality changes, such that only very close associates of the patient can tell that the person is behaving out of character. But again, this kind of presentation attributable to a stroke is extremely rare.

The more common symptoms suggestive of a stroke are^{5, 6}:

· 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

Other Important but less Common Stroke Symptoms Include⁶:

· sudden nausea, fever and vomiting distinguished from a viral illness by the speed of onset (minutes or hours vs. several days)

· brief loss of consciousness or period of decreased consciousness (fainting, confusion, convulsions or coma

· sudden loss of vision in one eye

Stroke: Magnitude of the Problem

Stroke is the third leading cause of death in the United States.^8,9 Approximately 200, 000 deaths a year are caused by strokes.^2,3,4 In fact, someone dies from a stroke every 3.3 minutes^7. Women account for about 3 of every 5 deaths from stroke.^{4, 7}

Famous personalities such as Winston Churchill and Louis Pasteur have fallen prey to this devastating neurological emergency.⁴

The incidence of stroke actually increases with age, ^{2, 3} but by no means is stroke restricted only to the middle aged and elderly. Even children can fall prey to the devastating effects of a stroke.¹⁶

In recent years, the incidence of stroke has actually been decreasing, mainly because of better recognition and control of hypertension, one of the key risk factors for stroke.^{2, 3, 8, 9}

.

Prevention of Stroke:

A) Primary Prevention: Risk Factors and Their Reduction

The aim of primary prevention is to anticipate major adverse events to health.

As is true for any pathological condition, stroke prevention requires meticulous control of those factors that put an individual at risk for a stroke. These risk factors can mainly be divided into the factors that can be controlled, and the factors that cannot be changed.⁶

Stroke prevention is probably not an attainable goal in absolute terms, as some of the important risk factors such as age and heredity cannot be changed. But there are many controllable factors, all of which an individual can modify or manage, and very substantially reduce the chances of ever suffering a stroke.

The aim of primary prevention could be reached first by population education, i.e. by attempting to suppress the development of risk factors.

Risk of stroke is clearly influenced by lifestyle. Modification of lifestyle is the first line of work, and the targets to modify are poor diet, alcohol drinking, smoking and lack of physical activity. Clear recommendations must be given for weight reduction, decreased salt and animal fat intake, smoking cessation, increased exercise and how to drink alcohol in a ‘safe’ way.

The second step is an individual approach and aim to detect hypertension, high cholesterol, heart disease etc; and introduce specific individualized measures to manage these problems.

The Controllable Risk Factors for Stroke, and Their Management

1. A. High blood pressure:

The single most important controllable factor leading to stroke is uncontrolled, high blood pressure. ^2,3,6,8,9,10 Having high blood pressure, or hypertension, increases stroke risk four to six times.⁶ It has been seen that in the last 30 years, the incidence of stroke has been steadily decreasing because of, mainly, better blood pressure control.^{2, 3}

This point cannot be overemphasized that better BP control means greater protection from stroke.^2,3

High blood pressure is often called “the silent killer” because people can have it and not realize it, since it often has no symptoms. Hypertension is a common condition, affecting approximately 50 million Americans, or one-third of the adult population.⁶ Blood pressure is high if it is consistently more than 140/90 millimeters of mercury
(mmHg). Between 40 and 90 percent of all stroke patients had high blood pressure before their stroke. Hypertension puts stress on blood vessel walls and can lead to strokes from blood clots or hemorrhage.

1. B. Managing High Blood Pressure:

Blood pressure management begins with identifying people with unacceptably high readings. It is recommended that any person more than 18 years of age visiting a doctor’s office for any reason should get a B.P. check which should be recorded. Many public service ventures like free B.P. check camps at health fairs or in malls help detect people who have high blood pressure but are unaware of it. Since men are at greater risk of being hypertensive, after age 40 all men should get their B.P. checked at least once every 2 years.⁹ (United States Preventive Services Task Force).

Once high blood pressure is identified, the first step is to educate the patient that he or she may feel well but needs to take good care to prevent the possible complications.

Lifestyle modifications include decreased salt intake, regular exercise and healthy eating habits, and in mild cases, are enough by themselves to effectively lower B.P.

If lifestyle modifications do not sufficiently lower B.P., a doctor may prescribe medications such as water- pills or other medicines. Patients should be made aware of the catastrophic consequences high blood pressure may bring, and convinced that taking daily medication is an absolutely essential requirement even though they may feel perfectly well.

Detailed information can be obtained from the following official source:

National High Blood Pressure Education Program
c/o NHLBI Information Center
P.O. Box 30105
Bethesda, Maryland 20824-0105
301-592-8573
http://www.nhlbi.nih.gov
NHLBIInfo@rover.nhlbi.nih.gov

Other useful web sites for learning more about this major killer are:

2. http://www.bloodpressure.com/

3. http://www.ishib.org/main/patient_info_cardio.htm

4. http://www.mco.edu/org/whl/pat.html

5. http://www.cdc.gov/nchs/fastats/hypertens.htm

2. A. Previous prtens.stroke or “mini-stroke” (transient ischemic attack, TIA)

People, who have already had a stroke or TIA (transient ischemic attack), are at high risk for having another. ^{6, 7}

After suffering a stroke, men have a 42 percent chance of recurrent stroke within five years, and women have a 24 percent chance of having another stroke.⁶ Altogether, about 35 percent of those who experience TIAs have a stroke within five years.⁶
Most TIAs are caused by cholesterol deposits which have formed plaques on the walls of the carotids, the vessels that supply blood to the brain. These cholesterol plaques are often the culprits, throwing up minor pieces of themselves called “emboli” which lodge in one of the branching vessels of the brain, shutting off the blood supply to that area and causing a stroke.

2. B. Management of Patients with stroke or “mini-stroke”.

It is essential that people with previous strokes or mini strokes (TIAs) be aware of their

heightened risk and adopt healthy lifestyles, with meticulous control of any factors which may increase this risk, like high blood pressure or cholesterol.

Fortunately, it is possible for physicians to start people who have had TIAs on protective medication like aspirin or other drugs, and sometimes-corrective carotid surgery may be indicated. The surgery aims at removing cholesterol plaques from the carotids that supply the head and neck area. This aspect is more fully discussed under “secondary prevention”

More information regarding TIAs and their prevention can be obtained from various web sites:

1. http://www.agingwell.state.ny.us/prevention/tia.htm

2. http://www.postgradmed.com/issues/2002/03_02/pn_tia.htm

3. http://www.aafp.org/afp/991115ap/2329.html

4. http://familydoctor.org/

5. http://www.well-net.com/stroke/stroke4.html

3. A. Heart Disease:

Heart disease such as atrial fibrillation increases stroke risk six times.^{6, 13}

About 15 percent of all people who have a stroke have a heart disease called atrial fibrillation, or AF, which affects more than 1 million Americans.⁶ AF is caused when the two upper chambers of the heart, the so called 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 that can then be carried to the brain, causing a stroke. Some other kinds of conditions causing irregular heartbeat may also lead to stroke, although much less frequently than atrial fibrillation.

Congestive heart failure or recent heart attack, and diseases of the heart valves, also may lead to a stroke.⁵

3. B. Management of Heart Disease:

It is possible through the use of drugs, surgery and techniques called radio-frequency ablation to rectify an irregular heartbeat caused by atrial fibrillation or other reasons.

Congestive heart failure management needs life style modifications.

Dietary salt should be minimized and bakery products, ketchups, preserved foods, etc; that is, all foods with high salt content should be minimized in the diet. A regular routine of physical exercise, which has been approved by the physician, should be followed, and medications regularly used.

A recent heart attack also predisposes to stroke, and especially, the medications used for acute care of a heart attack patient may actually lead to a stroke. The physician should always carefully weigh the risk benefit ratio of administering the medication. After a patient has been discharged from the hospital, regular follow up is necessary, and as is always true, maintaining a physician approved healthy lifestyle with appropriate diet and exercise is very essential.

Some useful websites for learning more about heart disease are:

1. http://www.americanheart.org/

2. http://heartdisease.about.com/

3. http://www.cdc.gov/cvh/womensatlas/index.htm

4. http://www.health-heart.org/

5. http://www.noah-health.org/english/illness/heart_disease/heartdisease.html

4. A. High Cholesterol:

High cholesterol can directly and indirectly increase stroke risk by clogging blood vessels and putting people at greater risk of coronary heart disease, another important stroke risk factor. ^{13, 16}

A cholesterol level of more than 200 is considered “high.” 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 blood stream can lead to the buildup of plaque on the inside of arteries, which can clog them and cause heart or brain attack.^{6, 7,9,10}

It is now a well-known scientific fact that there are different “kinds” of cholesterol in the body. The “good cholesterol” is called HDL (High Density Lipoprotein) in medical jargon, and one of the “bad cholesterols” is termed LDL (Low Density Lipoprotein). There are also other “bad lipids” such as triglycerides. The aim of all interventions is not to just lower cholesterol, but to increase HDL, the “good cholesterol” and decrease all kinds of “bad cholesterol”, especially LDL.

4. B. Managing High Cholesterol:

As is true for high blood pressure, people with high cholesterol, and especially, high LDL, may be totally unaware of their problem. The first step is to screen the population most at risk. It is recommended that all patients with heart disease or diseases related to vessels be screened for high cholesterol, since these individuals are at a greater risk of stroke if their cholesterol also turns out to be high. Also, the American College of Physicians recommends screening of all adult males above the age of 35 and all women above 45 years for high cholesterol. Some authorities such as the National Cholesterol Education Program (NCEP) even recommend that all adults above age 20 years be screened for high cholesterol levels. Screening may be done by measuring total cholesterol, or by measuring all different kinds of cholesterol after an overnight fast in the morning, in the fasting state.

Once high cholesterol levels are identified, several measures should be taken:

a) Rigorous dietary measures should be instituted which include cutting back total fat in diet, changing to mono unsaturated fats such as olive or canola oil, eating generous helpings of fresh vegetables and fruit, including rich sources of fiber such as oat meal in the diet.

b) Graded exercise programs designed to lose weight if an individual is obese, or just to “burn fat” and maintain healthy body proportions, should be followed.

c) Individual response to diet and exercise regimens varies considerably. So, if after a period of 4weeks, no changes or a worsening in the cholesterol level is noted, medication to lower cholesterol should be started under a physician’s guidance.

d) Meticulous control of such factors as diabetes, which leads to, increased levels of the "bad cholesterol" fractions.

More can be learned about cholesterol, what is "good and "bad" about it, and how to control its levels at these informative web-sites:

1. http://www.americanheart.org/

2. http://www.nhlbi.nih.gov/chd/

3. http://www.nlm.nih.gov/medlineplus/cholesterol.html

4. http://science.howstuffworks.com/cholesterol.htm

5.http://directory.google.com/Top/Health/Conditions_and_Diseases/Cardiovascular_Disorders/Heart_Disease/

5. A. Diabetes:

Many studies have repeatedly shown that diabetics are more prone to stroke. This may be a direct result of diabetes itself. It has been seen that people who have inappropriately high blood sugars most of the time, that is, those with uncontrolled and poorly controlled diabetes, are very likely to have permanent changes in their small and large blood vessels. In the brain, these changes lead to irreversible decrease in blood flow to various areas of the brain, predisposing to stroke. ^{5, 6,14,15,18}

The effect of diabetes could also be indirect. Diabetics are also more likely to suffer from lipid abnormalities like high cholesterol, especially the unhealthy fraction of lipids called triglycerides. Heart disease is also more prevalent in this population. As already discussed, these factors, especially in conjunction with underlying diabetes, are very likely to increase the risk of stroke.

5. B. Managing Diabetes:

Just like high blood pressure and cholesterol, diabetes can go unnoticed for a long time unless actively looked for. Again, there is a primary role for screening individuals at risk. While no standard recommendation on who to screen are available, in practice, all pregnant ladies (pregnancy is associated with diabetes much more commonly than the general healthy population) should be screened for what is called “gestational diabetes”.

In addition, people who have family history of diabetes should get their blood sugar checked periodically, and anyone suffering from any problem even remotely suggestive of underlying diabetes, such as excessive urination, thirst, unexplained weight loss in spite of increased appetite, a non healing wound, excessive tiredness etc; should get his or her blood sugar checked.

Health fairs and routine tests help to identify many diabetics in early stages of their disease and help considerably in improving their health by early intervention.

Once diabetes is detected, meticulous blood sugar control alone is not enough to prevent serious morbidity such as stroke. Adequate attention must also be paid to managing high blood pressure, cholesterol and heart disease because the destructive potential of these problems is magnified many-folds by the presence of underlying diabetes.

All diabetics should be encouraged to make lifestyle changes, which include not only proper diet and exercise, but also quitting smoking and consuming alcohol only in moderation. Needless to say, all medications and general instructions should be followed as directed by the physician.

Some useful web sites to help know more about diabetes are:

1. http://www.niddk.nih.gov/

2. http://www.diabetesnet.com/

3. http://www.childrenwithdiabetes.com/index_cwd.htm

4. http://www.joslin.harvard.edu/jboston/classes.shtml

5. http://www.diabetes.org/main/application/commercewf

6. A. Life Style Choices:

Certain ways of life predispose an individual to a stroke.

Foremost among these are:

a) Smoking: Tobaccos smoke contains more than 1200 known carcinogens, and substantially increases the risk of many diseases and catastrophes like stroke.

b) Physical Inactivity.

Physical inactivity, not surprisingly, contributes to an increased risk of stroke. This is mainly because people who are physically inactive are also typically negligent of their health in other areas. ⁵
They are likely to be obese, have high cholesterol and are at increased risk of heart disease, which, as discussed, is itself a risk factor for stroke.

c) Alcohol:

Excessive alcohol intake is also likely to increase the risk of stroke substantially. It has been shown that heavy drinkers are much more likely to suffer from the type of stroke called hemorrhagic stroke than the general population.

d) Illegal drug use:

Illicit drugs, especially cocaine, substantially increase the risk of stroke. Cocaine is a powerful chemical which causes blood vessels to constrict, cutting off blood supply to vital organs, causing stroke sin the brain and infarctions (“heart attacks”) in the

heart. ^{4, 5, 18}

Many other illicit drugs are very potent and harmful, and a little overdose can, oftentimes, be fatal.

6. B. Life Style Choices; Choosing a Healthy life-style:

a) Smoking:

The most important choice to make is to quit smoking, especially if attendant risks such as diabetes and heart disease are already present. The good news about smoking is that no matter how long one has smoked, the risk of stroke can be substantially reduced by quitting to smoke, ^{5, 6}although the risk may remain elevated as compared to nonsmokers for a few years even after one stops.

Since nicotine is a highly addictive substance, quitting smoking is usually a very daunting task. It should be emphasized again and again to the smoker that few people have succeed in quitting smoking in their first attempt, but most smokers are able to give up finally when they persist long enough. With proper encouragement, guidance and medical help such as nicotine patches and gums, this is a very achievable and highly desirable goal not only for those at risk for stroke, but for all smokers.

b) Exercise:

Regular exercise has been shown to not only help lose weight and acquire an attractive body countenance, but also step up the body's metabolism, activate the body's defense mechanisms, regulate blood pressure and blood sugar levels, as well as help lower "bad cholesterol". The benefits of exercise continue beyond the time actually spent exercising, and help reduce the incidence of many medical conditions including stroke.

c) Alcohol: Modest alcohol consumption and "social drinking" have not been shown to increase stroke incidence, but heavy drinking should be cut back on. Support groups such as Alcoholics Anonymous (AA), de -addiction treatment, psychiatric counseling and a warm, supportive home atmosphere, all go a long way in achieving this rather difficult goal.

d) Illicit drug use needs to be stopped as soon as possible, and usually requires expert help. Mass campaigns as well as individual counseling to adolescents and young adults should be aggressively pursued to educate young minds regarding the hazards of illicit drug use so that the least number of people are tempted to try them out of curiosity and/ or due to peer pressure.

Some useful web sites to learn more about healthy living are as follows:

1. http://www.americanheart.org/

2. http://www.healthylivingscotland.gov.uk/publications.cfm

3. http://www.healthylife.org

4. http://www.globallifestyle.net/

5. http://www.ivillage.com/topics/health/

Uncontrollable Risk Factors:

There are many factors that cannot be modified, and do increase the risk of stroke significantly. But what should always be remembered and also communicated clearly to the community, is that these factors in themselves are seldom enough to cause a stroke, and meticulous management of all risk factors which are controllable with a little self-discipline and medications, would still substantially reduce the risk of a stroke even in the presence of these factors.

1. Age:

Perhaps the most important of the uncontrollable factors, the incidence of stroke substantially increases with increasing age. Stroke is more common in people over 60, and the risk increases exponentially with increase in age beyond 60.^5,6,17

It is proven that with age, the arteries harden, and the likelihood of cholesterol plaques having formed on their surface is increased. The hardening of the arterial wall makes it less flexible and unable to expand if faced with a sudden pressure surge, which may occur for a number of reasons, some of them even physiological. As a result, the arterial wall may rupture, causing what would technically be called a hemorrhagic stoke. The formation of plaques leads to the problem of ‘emboli’, as already discussed. The emboli effectively cut off blood supply causing the classic “ischemic” stroke. The hardening and plaque deposition together may lead to such a narrowing of blood vessels that the meager blood supply is eventually too little even to sustain the viability of the brain tissue, leading again to an ischemic stroke.

Not only is age in itself an important factor, but also what compounds the problem is that the elderly are also more likely to be suffering from the controllable risk factors enumerated above. Although it is obvious that age is not something amenable to modification, it should be realized even more acutely in the case of the elderly that the controllable factors require very meticulous management. The high blood pressure, cholesterol, heart disease etc; need to be aggressively monitored and the importance of these factors should be explained in detail to all elderly people.

2. Male sex:

Men of all ages are more prone to stroke as compared with similar-age women. Especially at younger ages, this difference is even more pronounced.

3. Races and Heredity:

It has been seen that relatives of people who have suffered a stroke are more likely to

suffer from a stroke themselves. The closer the blood relation, the higher the chance that a stroke would occur.

Similarly, race also predisposes or alleviates the risk of a stroke. In Ohio, Blacks experienced the highest stroke death rate, whereas Hispanics experienced the lowest rate.

No doubt, some of these observations could be linked to similar lifestyle patterns and dietary habits within a family, and the more frequent occurrence of the most significant risk factor, hypertension, in African Americans and Hispanics.⁶

B) Secondary Prevention: Organizing for Rapid Treatment.

The word “stroke” evokes a feeling of intense fear and a sense of being out of control to the general population. Most people know this term and they have someone, either in their family, or a friend, who’s had a stroke. Since the beginning of the recorded history of the condition, stroke or brain attack has been viewed as unpreventable and untreatable.
Even today, these misperceptions are firmly entrenched, both among the public and among health care providers. Believing that stroke is untreatable, the public fails to respond to symptoms. As a result, the average stroke patient waits more than 12 hours before presenting at the emergency room. Believing that stroke is unpreventable, health care providers fail to be assertive and diligent about potential preventive measures. Believing that stroke is untreatable, health care providers take an attitude of “watchful waiting” instead of treating stroke (brain attack) as a medical emergency. These outdated attitudes serve as the largest obstacle to the effective treatment of stroke.

The Most Important Factor Determining Successful Treatment:

The time gap between the onset of symptoms and seeking expert help is the most important determinant of outcome. Recent studies have found that ^{5, 6, 7}

· 42% presented within 24 hours of onset. (Alberts et al)

· 13 hours was median time from onset to presentation (Feldman et al)

· Nationally, only 26 percent of the general public can name the most commonly recognized warning signs.

· Transport systems have been slow to change how they transport stroke patients to acute care facilities.

· Medical professionals are sometimes reluctant to use the acute care treatment, a novel treatment for acute stroke, tissue plasminogen activator (t-PA) because they may lack adequate experience with it and because of attendant risks like bleeding into the brain.

· The primary factor correlating with early presentation and hence, successful treatment was patient recognition of symptoms (Feldman et al)^{, 6, 7} and the realization that the symptoms require emergency treatment.

In fact, herein lays the importance of public education. A very good case study in public education and stroke outcomes is illustrated by The University of Cincinnati researchers working on a clinical trial of a stroke medication called t-PA (tissue plasminogen activator). ⁷
Investigators required patients to present within 90 and 180 minutes from the time of symptom onset. It soon became apparent that to maximize the percentage of stroke patients presenting within this narrow treatment window, community-wide efforts would have to be made involving all hospitals, emergency medical technicians and public information sources. The challenge was to change the way Cincinnati residents viewed stroke and the way the medical and emergency response community responded to and treated stroke.
In a unique cooperative effort, the 11 Cincinnati hospitals collaborated to form an urgent stroke response system incorporating rapid identification and transport by EMS personnel and streamlined, top-priority, in-hospital stat procedures for stroke.
Following these fundamental changes in approach, the improvement in presentation times was impressive:

· 39% presented within 90 minutes

· 59% presented within 3 hours

· 66% presented within 6 hours

Use of EMS services as a patient’s first contact was a major factor in improving time to presentation.^{6, 7}

Recommendations of the Experts:

The American Stroke Association, a panel of nationwide experts, has launched an initiative called “Operation Stroke”. ⁷ The association encourages the general public to call 9-1-1 when they or someone around them experiences the warning signs of stroke. They urge patients to not try and diagnose the problem by them, and never to wait and see if the symptoms go away on their own. Even if the symptoms pass quickly, they could be an important warning that requires prompt medical attention

The association strongly recommends the following “Stroke Chain of Survival”. ⁷ chains, which includes:

1. Rapid recognition and reaction to stroke warning signs. The association urges people to note the time when the symptoms first occur, and then, without losing any time, to call 9-1-1 immediately. The caller should tell the operator that he/she or the person they are with is having stroke-warning signs.

2. Rapid start of pre-hospital care. The victim can receive early assessments and pre-hospital care by Emergency Medical Personnel.

3. Rapid EMS (Emergency Medical Personnel) gets the victim to an appropriate hospital quickly via ambulance and personnel notify the emergency room.

4. Rapid diagnosis and treatment at the hospital. Prompt evaluation of medical data and treatment to restore blood flow to the brain or other treatments as appropriate by a properly staffed and equipped hospital is immediately started on arrival.

By educating and motivating emergency medicine professionals and raising public awareness of stroke symptoms, the programs of Operation Stroke have the potential to substantially reduce crucial delays in stroke treatment.

Treatment of Stroke:

Our notions about stroke and its treatment are being revolutionized. ^{12, 14, 18.} The new stroke interventionalists (neurologists, neuroradiologists, emergency medicine physicians and their colleagues) are dedicated to emergent stroke treatment.

How Physicians Identify Stroke and its Cause: ^{20, 21}

The first step in understanding the problem is to obtain a careful medical history.^{20, 21} The doctor or health care provider asks questions about the situation. If the patient cannot communicate, a family member or friend is asked to provide this information. The next step is a thorough physical examination. The doctor checks pulse and blood pressure, and examines the rest of the body (heart, lungs, etc). The neurological examination includes detailed tests of the muscles and nerves. The doctor checks strength, sensation, coordination and reflexes. In addition, questions to check memory, speech and thinking are also asked.

The physician, depending on the patient’s situation and the doctor’s discretion, then uses a whole array of modern investigative tools to visualize the stroke. The most common of these are the following:

1. CT scan ((CAT scan, Computed axial tomography): CT scan uses x-rays to produce a 3-dimensional image of the head. It is the most common technique employed initially as it rapidly answers the vital question of whether a stroke is present, and whether the stroke is hemorrhagic. In the case of a hemorrhagic stroke, the latest medication called t-PA would be very harmful as opposed to the scenario of an ischemic stroke where rapid administration of t-PA can save life or limb. MRI can also diagnose hemorrhagic stroke, but a CT can do this as well, and at lesser cost and most importantly in much shorter time.

2. MRI scan (Magnetic resonance imaging, MRI): MR uses magnetic fields to produce a 3-dimensional image of the head. The MR scan shows the brain and spinal cord in more detail than CT. MR can be used to diagnose ischemic stroke and other problems involving the brain, brainstem, and spinal cord.

3. Carotid Doppler (Carotid duplex, Carotid ultrasound): Painless ultrasound waves are used to take a picture of the carotid arteries in the neck, and to show the blood flowing to the brain. This test can show if the carotid artery is narrowed by arteriosclerosis (cholesterol deposition).

4. MRA (Magnetic resonance angiogram): This is a special type of MRI scan (see above), which can be used to see the blood vessels in the neck or brain.

5. Tran cranial Doppler (TCD): Ultrasound waves are used to measure blood flow in some of the arteries in the brain

6. Cerebral arteriogram (Cerebral angiogram, Digital subtraction angiography, [DSA]): A catheter is inserted in an artery in the arm or leg, and a special dye is injected into the blood vessels leading to the brain. X-ray images show any abnormalities of the blood vessels, including narrowing, blockage, or malformations (such as aneurysms or arterio-venous malformations). Cerebral arteriogram is a more difficult test than carotid Doppler or MRA, but the results are the most accurate.

Usually, heart test are also conducted to see if an underlying heart problem is at the root of the present stroke. These tests include:

1. Electrocardiogram (EKG, ECG): This is a standard test to show the pattern of electrical activity in the heart. 3-10 electrical leads are attached to the chest, arms and legs.

2. Echocardiogram (2-d echo, Cardiac echo, TTE, TEE): Painless ultrasound waves are used to take a picture of the heart and the circulating blood. The ultrasound probe may be placed on the chest (trans-thoracic echocardiogram, TTE) or deep in the throat (trans-esophageal echocardiogram, TEE).

Routine Screening Tests:

Many other supportive tests, such as tests of the blood measuring cholesterol levels etc; are also ordered to get a complete picture of the patient’s health condition.

The Latest Medications:

Much of the damage caused by a thrombotic or embolic stroke occurs in the first six hours. The primary areas of research have focused on the development of new clot-dissolving drugs and medications that make the brain more resistant to stroke (neuroprotective agents).

Drugs that dissolve clots are known as thrombolytic agents. Experimental data and pilot clinical studies suggest that if given within the first few hours after stroke onset, these drugs may dramatically minimize stroke damage.

The only drug that has received FDA approval for acute ischemic stroke treatment is a recombinant form of t-PA (tissue plasminogen activator), a naturally occurring “clot buster” in the body which lyses small clots continuously in the physiologic state. ^{5, 6,9,10} A recombinant form (a form made in the laboratory) retains the original clot bursting quality and in fact, is more potent than the naturally occurring substance. Since the nature of t-PA is to burst clots, the natural side effect is a risk of lysing clots where they were needed, i.e. a risk of inappropriate bleeding. This risk is especially high in the brain, and it is ironical that the wonder drug for ischemic stroke has the potential adverse effect of causing a hemorrhagic stroke.
Although t-PA works very well if given within a small window period of 3 hours in the case of ischemic stroke, it is still not a panacea. Given the multi-dimensional nature of ischemic brain cell injury, stroke experts predict that no single drug will be able to completely protect the brain during stroke; more likely, a combination of agents will be necessary for full recovery potential.

Many new drugs are being intensively studied, and it is very likely that in the near future, novel agents to treat stroke more effectively will be available. Several of these new drugs are being evaluated in clinical trials²¹ for example; Citicoline is a substance that may have direct neuroprotective effects as well as help in cell repair. ^{12, 20, 21} Lubeluzole and BFGF are names of other neuroprotective agents being studied.^{20, 21}

Measures To Prevent A Recurrence of Stroke:

Medications

The unfortunate individuals, who have already had a stroke or TIAs, are at extremely high risk of a repeat event, and secondary prevention using drugs or other means should be strongly recommended. Two major drug groups are the cornerstones of secondary prevention. These groups are:

Anticoagulants: may be given orally or intravenously. These drugs work by thinning the blood and preventing clotting. They are also used for deep vein thromboses and pulmonary emboli.

Antiplatelet Agents: work by preventing or reducing the occurrence in the blood stream of a phenomenon known as platelet aggregation. When there is damage or injury to a blood vessel, platelets (one type of blood particle) migrate to the scene to initiate a healing process. Large numbers of platelets clump together (aggregation) and form what is essentially a plug. This aggregation can sometimes result in formation of a thrombus (blood clot) that may totally block the artery or break loose and block a smaller artery. By preventing this from occurring, antiplatelet agents can reduce the risk of stroke in patients who have had TIAs or prior ischemic strokes.

Surgical Techniques:

Surgery is an accepted way of preventing stroke for patients with certain conditions. There are a number of conventional surgical techniques that have been in use for some time, including “clipping” aneurysms (abnormal dilatations of vessels) to avoid their bursting.

1. Carotid Endarterectomy is a procedure used to remove atherosclerotic (cholesterol) plaques from the carotid artery when this vessel is blocked. It has recently been proven that for certain patients with minor strokes or TIAs, carotid endarterectomy is highly beneficial in preventing future strokes. This procedure is also beneficial for some patients with blockage of the carotid arteries who have not had previous symptoms.

2. Stereotactic microsurgery is one of the most dramatic new surgical procedures for certain aneurysms that were once considered untreatable. It employs sophisticated computer technology. This technique allows neurosurgeons to locate the abnormality in blood vessels within one or two millimeters so they can operate, using microscope-enhanced methods and delicate instruments, without affecting normal brain tissue.

3. Stereotactic radio surgery is a minimally invasive, relatively low-risk procedure that uses the same basic techniques as stereotactic microsurgery to pinpoint precise locations and then obliterating abnormal vessel dilatations by focusing a beam of radiation. Due to the precision of this technique, normal brain tissue usually is not affected. This procedure is generally performed on an outpatient basis.

In addition to new medications and surgical techniques, a number of new interventional radiology procedures called endovascular procedures are used to prevent stroke in patients with aneurysms, and partially blocked arteries. These procedures are performed within the blood vessel.

Some other interesting new developments in the field of stroke treatment are:

1. Hypothermia:

During surgical treatment of abnormal blood vessels, there is a certain inherent risk that the patient may have a stroke while on the operating table. Physicians are using a technique known as hypothermia (cooling of the body), to prevent stroke during surgical treatment of giant and complex aneurysms.

2. Revascularization of the Blood Supply:

Revascularization is a surgical technique for treating aneurysms or blocked cerebral arteries. The technique essentially provides a new route of blood to the brain by grafting another vessel to a cerebral artery or providing a new source of blood flow to the brain. Cerebral angioplasty is similar to a widely used cardiology procedure, and is used to open partially blocked vertebral and carotid arteries in the neck.

Tertiary Prevention: Rehabilitation After a Stroke: ^{21, 22}

Tertiary prevention consists in patient rehabilitation after stroke, in order to recover partial or complete independence and to improve quality of life. Recovery from stroke is seldom complete and it is estimated that 40% of patients living at home after stroke need help in daily living.²⁴

Facing life after a stroke can be a challenge. Special rehabilitation centers can go a long way in helping to regain a sense of control over one’s life. Children can also suffer from stroke, although mercifully such an event is rare. Children who have had a stroke may be seen at a facility that specializes in pediatric rehabilitation.

At any rehabilitation center, the focus is on the functional challenges the stroke created. Before beginning treatment, the person is assessed by an interdisciplinary team.

The usual team consists of any or all of the following professionals:

· A physical therapist to help learn gross motor control

· An occupational therapist to learn fine motor control

· A speech therapist to overcome language problems

· Social work to help the person and his or her family cope with disability and recovery.

· Medicine (one or more physicians). When a person has had a stroke; the physician may be a neurologist or an internist.

Other professionals may also join the rehabilitation team. These include:

· A recreation therapist, who will help the person with recreational activities in the community; and

· Psychologist who specializes in education and learning, to help the child with any learning problems in case of children. Also, if the child is an infant, the team will work to help the child do as well as possible in achieving developmental milestones such as learning to roll over, sit up, walk, handle toys, speak, etc. With older children, the therapists may visit schools and community settings to assess how well the child is doing in different aspects of life. The goal will be to help the child function as well as possible in school, at home and in the community.

Types of Rehabilitation:

There are three primary means of rehabilitation:

1) Physical therapy (PT) helps restore physical functioning and skills like walking and range of movement. Major problems after a stroke that is best helped by PT are partial or one-sided paralysis, faulty balance and foot drop. PT Basically helps with gross motor functions such as walking or mobility.

2) Occupational therapy (OT) involves relearning the skills needed for everyday living such as eating, toileting, dressing and taking care of oneself. The focus here is on helping with fine motor activities such as holding objects. The daily functioning of an individual may be severely hampered by a stroke. A good OT trainer can not only make life easier physically but also restore much needed confidence and a sense of independence in the unfortunate victim.

3) Speech therapy is another form of a major rehabilitative therapy. Some stroke survivors are left with an impairment of language and speaking skills in which the stroke survivor can continue to think and process his or her thoughts normally, but develops the frustrating problem of an inability to get the right words out through speech, or inability to process words heard. These language problems are called "aphasias" in scientific jargon. Aphasia is usually caused by a stroke on the left side of the brain. Speech language therapists can teach the aphasic stroke survivor and his or her family members methods for coping with this wearisome impairment. Speech language pathologists also work to help the stroke survivor cope with memory loss and other “thought” problems caused by the stroke.

The rehabilitation process is a long one and people need to see it as a process, which may take years of recovery assisted by various professionals. For children, is important that parents be continuously involved in the process. The effects of each stroke are different, so it is difficult to generalize about recovery. It is thought that children’s brains tend to have more plasticity than those of adults (plasticity is the ability to make positive changes to improve functional capacity). This may give children’s brains a greater potential for recovery. However, a significant injury to the brain can have life-long effects.

Life At Home after a Stroke for Victims and Care-givers:

After a stroke, both the stroke survivor and the family often are apprehensive about being on their own at home. Among the common concerns are fears:

· that a stroke might happen again

· that the stroke survivor may be unable to accept the disabilities

· that the survivor might be placed in a nursing home

· that the caregiver may not be prepared to face the responsibility of caring for the stroke survivor

· that friends and family will abandon them.

The rehabilitation team can make a huge difference in helping the patient and the families dispel all of these fears, and restore a sense of control over their lives. The concern over suffering a stroke again should be specifically addressed by a physician, and medicines or surgical procedures should be appropriately used as indicated. A supportive family and expert help can put a stroke victim back in charge of his or her life with full acceptance of the misfortune and a wish to get along with their lives in the future.

Some common problems faced at home are as follows:

Daily Task Difficulties:

Stroke survivors will find that completing simple tasks around the house, which they took for granted before the stroke, are now extremely difficult or impossible. Many adaptive devices and techniques have been designed especially for stroke survivors to help them retain their independence and function safely and easily. The home usually can be modified so that narrow doorways, stairs and bathtubs do not interfere with the stroke survivor’s ability to care for personal needs.
Helpful bathroom devices include grab bars, a raised toilet seat, a tub bench, a hand-held showerhead, no-slip pads, a long-handled brush, a washing mitt with pockets for soap, soap-on-a-rope, an electric toothbrush and an electric razor. There are many small electric appliances and kitchen modifications, which also make it possible for the stroke survivor to participate in meal preparation.

Dressing and Grooming:

Dependence on someone else for dressing oneself is a major blow to the sense of independence and self-esteem of a stroke victim. Being neatly and attractively dressed without assistance or minimal help enhances a stroke survivor’s self-image. There are many ways to eliminate the difficulties in getting dressed. Stroke survivors should avoid tight-fitting sleeves, armholes, pant legs and waistlines; as well as clothes, which must be put on over the head. Clothes should fasten in front. Velcro fasteners should replace buttons, zippers and shoelaces. Devices which can aid in dressing and grooming include a mirror which hangs around the neck, a long-handled shoehorn and a device to help pull on stockings.

Diet, Nutrition and Eating:

A low-salt, low-fat, low-cholesterol diet can help prevent a recurrent stroke. People with high blood pressure should limit the amount of salt they eat. Those with high cholesterol or hardening of the arteries should avoid foods containing high levels of saturated fats (i.e., animal fats). People with diabetes need to follow their doctor’s advice on diet. These diet controls can enhance the benefits of the drugs, which may have been prescribed for control of a specific condition.

Weight control is also important. Inactive people can easily become overweight from eating more than a sedentary lifestyle requires. Obesity can also make it difficult for someone with a stroke-related disability to move around and exercise.

Some stroke survivors may have a reduced appetite. Ill-fitting dentures or a reduced sense of taste or smell can make food unappealing. The stroke survivor who lives alone might even skip meals because of the effort involved in buying groceries and preparing food. Soft foods and foods with stronger flavors may tempt stroke survivors who are not eating enough. Nutrition programs, such as Meals on Wheels, or hot lunches offered through community centers have been established to serve the elderly and the chronically ill.

Special utensils can help people with physically impaired arms and hands at the table. These include flatware with built-up handles, which are easier to grasp, rocker knives for cutting food with one hand and attachable rings, which keep food from being, pushed off the plate accidentally.

Stroke survivors who have trouble swallowing need to be observed while eating so that they do not choke on their food. The same is true of those with memory loss who may forget to chew or to swallow. Tougher foods should be cut into small pieces.

Skin Care:

Decubitus ulcers (sometimes called bed sores) can be a serious problem for stroke survivors who spend a good deal of time in bed or who use a wheelchair. The sores usually appear on the elbows, buttocks or heels.

To prevent bedsores, caregivers should make sure the stroke survivor does not sit or lie in the same position for long periods of time. Pillows should be used to support the impaired arm or leg. The feet can hang over the end of the mattress so that the heels don’t rest on the sheet, or pillows can be put under the knees to prop them so that the soles of the feet rest flat on the bed. Sometimes, a piece of sheepskin placed under the elbows, buttocks or heels can be helpful. Special mattresses or cushions reduce pressure and help prevent decubitus ulcers.

Pain:

A stroke survivor may suffer pain for many reasons. The weight of a paralyzed arm can cause pain in the shoulder. Improperly fitted braces, slings or special shoes can cause discomfort. Often the source of pain can be traced to nerve damage, bedsores or an immobilized joint. Lying or sitting in one position too long causes the body and joints to stiffen and ache.

Behavioral Alterations after a Stroke:

Depression:

Depression is natural and nearly universal among people who have had a stroke. It can be crushing, affecting the spirit and confidence of everyone involved. A depressed person may refuse or neglect to take medications, may not be motivated to perform exercises which will improve mobility or may be irritable with others. This makes the stroke victim less likely to receive help, as the family may not understand this behavior as a manifestation of depression, and may lose enthusiasm for helping with recovery. It also deprives the stroke survivor of the social contacts, which could help dispel depression, and creates a vicious cycle. It is possible that as time goes by and a stroke survivor’s deficits improve, the depression may lift by itself. Family can help by trying to stimulate interest in other people, encouraging leisure activities and providing opportunities to participate in spiritual activities. If necessary, chronic depression can be treated with individual counseling, group therapy or antidepressant drugs.

Neglect and Apathy:

Some stroke victims may neglect personal hygiene, be socially withdrawn and be generally apathetic. The apathetic stroke survivor should not live in a world so quiet and simple that there is little to react to. The caregiver needs to be aware of the reasons for the stroke survivor’s behavior, without overlooking the fact that he or she may also be depressed. A strange symptom seen in some stroke survivors is left-sided neglect. Some stroke survivors do not perceive what is on their left side as a result of damage to vital areas on the right side of the brain. For example, the stroke survivor with left-sided neglect may ignore the left side of the face when washing or not eat food on the left side of the plate. If the stroke survivor’s head is moved to the left, neglected objects may become apparent. If the plate is turned around, he or she will finish eating the meal.

Emotional Instability:

Sudden laughing or crying for no apparent reason and difficulty controlling emotional responses, known as emotional liability, affects many stroke survivors. There may be no happiness or sadness involved, and the emotional display will end as quickly as it started.
It may be the result of the stroke itself, with irreversible damage to certain brain areas controlling emotions. Sometimes, as the stroke victim recovers, the emotional liability may improve.

Memory Loss and Intellectual Impairment:

Some stroke victims may suffer damage to areas controlling memory, intellect, reasoning, abstract thinking etc; , the so-called "higher centers" of the brain Some changes in behavior, such as memory loss, can be so subtle the family may not notice them at first. A stroke survivor may be anxious and cautious, needing a reminder to finish a sentence or know what to do next. Some stroke survivors have difficulty with numbers and calculating. A common complication resulting from stroke is loss of cognitive function, or intellectual abilities, technically called vascular dementia.

Communication Problems- "Aphasias":

As outlined in rehabilitation, these problems are termed aphasias. If a stroke causes damage to the language center in the brain, there will be language difficulties. Some stroke survivors do not understand spoken words, and do not make sense when they speak in response. This is termed a sensory aphasia. Others cannot speak at all, and are said to have an expressive aphasia. Some can no longer read or write. Many have difficulty pronouncing words. Communication problems are among the most frightening after-effects of stroke for both the survivor and the family, often requiring professional help.

Sexuality:

The quality of a couple’s sexual relationship following a stroke does change, but not all find this to be a problem. The closeness that a couple shares before a stroke is the best indicator of how their relationship will evolve after the stroke. It is important to remember that sexual satisfaction, both giving and receiving, can be accomplished in many ways. Whatever is comfortable and acceptable between partners is normal sexual activity.

Conclusion:

Stroke remains a problem of major public health concern, but many of the factors leading to a stroke are preventable or manageable. Although some factors leading to a stroke are not controllable and cannot be changed, definitely, better control of the manageable factors does lead to a significantly reduced risk. The recent encouraging trend of decreased incidence of stroke is mainly attributable to a better control of one of the major risk factors, hypertension.

The most important factor that decides a stroke victim's fate is how soon expert help was sought. No time should be lost in dialing 911 and activating the rescue system, and no efforts at self-help should be made if the victim or family suspects stroke.

Effective therapy exists only for certain types of stroke, and the best hope in secondary prevention lies with prescribing effective medication or surgical procedures to avoid a recurrence of stroke.

Lastly, life after a stroke is a challenge for the victim and the family, but expert help and a supportive, encouraging and underst