What is a stroke?

Brain cell function requires a constant delivery of oxygen and glucose from the bloodstream. A stroke, or cerebrovascular accident (CVA), occurs when blood supply to part of the brain is disrupted, causing brain cells to die. Blood flow can be compromised by a variety of mechanisms. Blockage of an artery
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Narrowing of the small arteries within the brain can cause a lacunar stroke, (lacune means "empty space"). Blockage of a single arteriole can affect a tiny area of brain causing that tissue to die (infarct). Hardening of the arteries (atherosclerosis) leading to the brain. There are four major blood vessels that supply the brain with blood. The anterior circulation of the brain that controls most motor activity, sensation, thought, speech, and emotion is supplied by the carotid arteries. The posterior circulation, which supplies the brainstem and the cerebellum, controlling the automatic parts of brain function and coordination, is supplied by the vertebrobasilar arteries.

If these arteries become narrow as a result of atherosclerosis, plaque or cholesterol, debris can break off and float downstream, clogging the blood supply to a part of the brain. As opposed to lacunar strokes, larger parts of the brain can lose blood supply, and this may produce more symptoms than a lacunar stroke.
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Embolism to the brain from the heart. In some instances blood clots can form within the heart and the potential exists for them to break off and travel (embolize) to the arteries in the brain and cause a stroke.

Rupture of an artery (hemorrhage)

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Cerebral hemorrhage (bleeding within the brain substance). The most common reason to have bleeding within the brain is uncontrolled high blood pressure. Other situations include aneurysms that leak or rupture or arteriovenous malformations (AVM) in which there is an abnormal collection of blood vessels that are fragile and can bleed.

What causes a stroke?

Blockage of an artery The blockage of an artery in the brain by a clot (thrombosis) is the most common cause of a stroke. The part of the brain that is supplied by the clotted blood vessel is then deprived of blood and oxygen. As a result of the deprived blood and oxygen, the cells of that part of the brain die and the part of the body that it controls stops working. Typically, a cholesterol plaque in a small blood vessel within the brain that has gradually caused blood vessel narrowing ruptures and starts the process of forming a small blood clot.

Risk factors for narrowed blood vessels in the brain are the same as those that cause narrowing blood vessels in the heart and heart attack (myocardial infarction). These risk factors include:
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high blood pressure (hypertension), high cholesterol, diabetes, and smoking.

Embolic stroke Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque (cholesterol and calcium deposits on the wall of the inside of the heart or artery) breaks loose, travels through the bloodstream and lodges in an artery in the brain. When blood flow stops, brain cells do not receive the oxygen and glucose they require to function and a stroke occurs. This type of stroke is referred to as an embolic stroke. For example, a blood clot might originally form in the heart chamber as a result of an irregular heart rhythm, such as occurs in atrial fibrillation. Usually, these clots remain attached to the inner lining of the heart, but occasionally they can break off, travel through the blood stream, form a plug (embolism) in a brain artery, and cause a stroke. An embolism can also originate in a large artery (for example, the carotid artery, a major artery in the neck that supplies blood to the brain) and then travel downstream to clog a small artery within the brain. Cerebral hemorrhage A cerebral hemorrhage occurs when a blood vessel in the brain ruptures and bleeds into the surrounding brain tissue. A cerebral hemorrhage (bleeding in the brain) causes stroke symptoms by depriving blood and oxygen to parts of the brain in a variety of ways. Blood flow is lost to some cells. As well, blood is very irritating and can cause swelling of brain tissue (cerebral edema). Edema and the accumulation of blood from a cerebral hemorrhage increases pressure within the skull and causes further damage by squeezing the brain against the bony skull further decreasing blood flow to brain tissue and cells. Subarachnoid hemorrhage In a subarachnoid hemorrhage, blood accumulates in the space beneath the arachnoid membrane that lines the brain. The blood originates from an abnormal blood vessel that leaks or ruptures. Often this is from an aneurysm (an abnormal ballooning out of the wall of the vessel). Subarachnoid hemorrhages usually cause a sudden, severe headache, nausea, vomiting, light intolerance, and a stiff neck. If not recognized and treated, major neurological consequences, such as coma, and brain death may occur. Vasculitis Another rare cause of stroke is vasculitis, a condition in which the blood vessels become inflamed causing decreased blood flow to brain tissue.

Migraine headache There appears to be a very slight increased occurrence of stroke in people with migraine headache. The mechanism for migraine or vascular headaches includes narrowing of the brain blood vessels. Some migraine headache episodes can even mimic stroke with loss of function of one side of the body or vision or speech problems. Usually, the symptoms resolve as the headache resolves.

What are the risk factors for stroke?

Overall, the most common risk factors for stroke are:
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high blood pressure, high cholesterol, smoking, diabetes and increasing age.

Heart rhythm disturbances like atrial fibrillation, patent foramen ovale, and heart valve disease can also be the cause. When strokes occur in younger individuals (less than 50 years old), less common risk factors to be considered include illicit drugs, such as cocaine or amphetamines, ruptured aneurysms, and inherited (genetic) predispositions to abnormal blood clotting. An example of a genetic predisposition to stroke occurs in a rare condition called homocystinuria, in which there are excessive levels of the chemical homocystine in the body. Scientists are trying to determine whether the non-hereditary occurrence of high levels of homocystine at any age can predispose to stroke.

What is a transient ischemic attack (TIA)?

A transient ischemic attack (TIA, mini-stroke) is a short-lived stroke that gets better and resolves. It is a short-lived episode (less than 24 hours) of temporary impairment if brain function that is caused by a loss of blood supply. A TIA causes a loss of function in the area of the body that is controlled by the portion of the brain affected. The loss of blood supply to the brain is most often caused by a clot that spontaneously forms in a blood vessel within the brain (thrombosis). However, it can also result from a clot that forms elsewhere in the body, dislodges from that location, and travels to lodge in an artery of the brain (emboli). A spasm and, rarely, a bleed are other causes of a TIA. Many people refer to a TIA as a "mini-stroke." Some TIAs develop slowly, while others develop rapidly. By definition, all TIAs resolve within 24 hours. Strokes take longer to resolve than TIAs, and with strokes, complete function may never return and reflect a more permanent and serious problem. Although most TIAs often last only a few minutes, all TIAs should be evaluated with the same urgency as a stroke in an effort to prevent recurrences and/or strokes. TIAs can occur once, multiple times,

or precede a permanent stroke. A transient ischemic attack should be considered an emergency because there is no guarantee that the situation will resolve and function will return. A TIA from a clot in the blood vessel that supplies the retina of the eye can cause temporary visual loss (amaurosis fugax), which is often described as the sensation of a curtain coming down. A TIA that involves the carotid artery (the largest blood vessel supplying the brain) can produce problems with movement or sensation on one side of the body, which is the side opposite to the actual blockage. An affected patient may experience temporary double vision, What is the impact of strokes? In the United States, stroke is the third largest cause of death (behind heart disease and all forms of cancer). The cost of strokes is not just measured in the billions of dollars lost in work, hospitalization, and the care of survivors in nursing homes. The major cost or impact of a stroke is the loss of independence that occurs in 30% of the survivors. For some individuals, what was a self-sustaining and an enjoyable lifestyle prior to the stroke, many may lose most of their quality of life after a stroke. Family members and friends may have their lives altered as they find themselves in the new role as caregivers.

What are stroke symptoms?

When brain cells are deprived of oxygen, they cease to perform their usual tasks. The symptoms that follow a stroke depend on the area of the brain that has been affected and the amount of brain tissue damage. Small strokes may not cause any symptoms, but can still damage brain tissue. These strokes that do not cause symptoms are referred to as silent strokes. According to The U.S. National Institute of Neurological Disorders and Stroke (NINDS), these are the five major signs of stroke: 1. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. The loss of voluntary movement and/or sensation may be complete or partial. There may an associated tingling sensation in the affected area.

2. Sudden confusion or trouble speaking or understanding. Sometimes weakness in the muscles of the face can cause drooling.

3. Sudden trouble seeing in one or both eyes

4. Sudden trouble walking, dizziness, loss of balance or coordination

5. Sudden, severe headache with no known cause

dizziness (vertigo), loss of balance, one sided weakness or complete paralysis of the arm, leg, face, or one whole side of the body or be unable to speak or understand commands.

How is a stroke diagnosed?

A stroke is a medical emergency. Anyone suspected of having a stroke should be taken to a medical facility immediately for evaluation and treatment. Initially, the doctor takes a medical history from the patient if possible or from others familiar with the patient if they are available. Important questions include what the symptoms were, when they began, if they were getting better, worse or staying the same. Past medical history adds important information looking for risk factors for stroke and for medications that can cause bleeding (for example, warfarin [Coumadin], clopidogrel [Plavix], prasugrel [Effient]). Physical examination is key in confirming the parts of the body that have stopped functioning and may help determine what part of the brain has lost its blood supply. If available, a neurologist, a doctor specializing in disorders of the nervous system and diseases of the brain, can assist in the diagnosis and management of stroke patients. Just because a person has slurred speech or weakness on one side of the body does not necessarily signal the occurrence of a stroke. There are many other possibilities that can be responsible for these symptoms. Other conditions that can mimic a stroke include:
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brain tumors, brain abscess (a collection of pus in the brain caused by bacteria or a fungus), migraine headache, bleeding in the brain either spontaneously or from trauma, meningitis or encephalitis, an overdose of certain medications, or an electrolyte imbalance in the body. Abnormal concentrations (too high or too low) of sodium, calcium, or glucose in the body may also cause changes in the nervous system that can mimic a stroke.

In the acute stroke evaluation, many things will occur at the same time. As the physician is taking the history and performing the physical examination, nursing staff will begin monitoring the patient's vital signs, performing blood tests, and performing an electrocardiogram (EKG or ECG). Part of the physical examination that is becoming standardized is the use of a stroke scale. The American Heart Association has published a guide to the examination of the nervous system to help health care practitioners determine the severity of a stroke and whether aggressive intervention may be warranted. There is a narrow time frame to intervene in an acute stroke with medications to reverse the loss of blood supply to part of the brain (please see TPA below). The patient needs to be

appropriately evaluated and stabilized before any clot-busting drugs can be potentially utilized. Computerized tomography: In order to help determine the cause of a suspected stroke, a special X-ray test called a CT scan of the brain is often performed. A CT scan is used to look for bleeding or masses within the brain that may cause symptoms that mimic a stroke, but are not treated with thrombolytic therapy with TPA. MRI scan: Magnetic resonance imaging (MRI) uses magnetic waves rather than X-rays to image the brain. The MRI images are much more detailed than those from CT, but due to the length of time to do the test and lack of availability of the machines in many hospitals, is not a first line test in stroke. While a CT scan may be completed within a few minutes, an MRI may take more than an hour to complete. An MRI may be performed later in the course of patient care if finer details are required for further medical decision making. People with certain medical devices (for example, pacemakers) or other metals within their body, cannot be subjected to the powerful magnetic field of an MRI. Other methods of MRI technology: An MRI scan can also be used to specifically view the blood vessels non-invasively (without using tubes or injections), a procedure called an MRA (magnetic resonance angiogram). Another MRI method called diffusion weighted imaging (DWI) is being offered in some medical centers. This technique can detect the area of abnormality minutes after the blood flow to a part of the brain has ceased, whereas a conventional MRI may not detect a stroke until up to six hours after it has started, and a CT scan sometimes cannot detect it until it is 12 to 24 hours old. Again, this is not a first line test in the evaluation of a stroke patient, when time is of the essence. Computerized tomography with angiography: Using dye that is injected into a vein in the arm, images of the blood vessels in the brain can give information regarding aneurysms or arteriovenous malformations. Moreover, other abnormalities of brain blood flow may be evaluated. With faster machines and better technology, CT angiography may be done at the same time as the initial CT scan to look for a blood clot within an artery in the brain. CT and MRI images often require a radiologist to interpret their results. Conventional angiogram: An angiogram is another test that is sometimes used to view the blood vessels. A long catheter tube is inserted into an artery in the groin or arm and threaded into the arteries of the brain. Dye is injected while X-rays are taken and information can be obtained about blood flow in the brain. The decision to perform CT angiography versus conventional angiography depends upon a patient's specific situation and the technical capabilities of the hospital. Carotid Doppler ultrasound: A carotid Doppler ultrasound is a non-invasive test that uses sound waves to look for narrowing or stenosis and decreased blood flow in the carotid arteries (the major arteries in the front of the neck that supply blood to the brain). Heart tests: Certain tests to evaluate heart function are often performed in stroke patients to search for the source of an embolism. Electrocardiograms (EKG or ECG) may be used to detect abnormal heart rhythms like atrial fibrillation that are associated with embolic stroke.

Ambulatory rhythm monitoring may be considered if the patient complains of palpitations or passing out episodes (syncope) and the doctor cannot find reason for it on the EKG. The patient can wear a Holter monitor for 1-2 days and sometimes longer looking fro a potential electrical conduction problem with the heart. Echocardiograms or ultrasounds of the heart can help evaluate the structure and function of the heart including the heart muscle, valves and the motion of the heart chamber when the heart beats. As well, specifically for stroke patients, this test may be able to find blood clots within the heart and the presence of a patent foramen ovale, both potential causes of stroke. Blood tests: In the acute situation, when the patient is in the midst of a stroke, blood tests are done to check for anemia, kidney and liver function, electrolyte abnormalities and blood clotting function. In other situations, when time is not of the essence, similar blood tests may be done. In addition, screening test for inflammation may be considered including an ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein). These are non specific tests that may give direction to medical care.

What is the treatment of a stroke?

Tissue plasminogen activator (TPA) There is opportunity to use alteplase (TPA) as a clot-buster drug to dissolve the blood clot that is causing the stroke. There is a narrow window of opportunity to use this drug. The earlier that it is given, the better the result and the less potential for the complication of bleeding into the brain. Present American Heart Association guidelines recommend that if used, TPA must be given within 4 1/2 hours after the onset of symptoms. for patients who waken from sleep with symptoms of stroke, the clock starts when they were last seen in a normal state. TPA is injected into a vein in the arm but, the time frame for its use may be extended to six hours if it is dripped directly into the blood vessel that is blocked requiring angiography, which is performed by an interventional radiologist. Not all hospitals have access to this technology. TPA may reverse stroke symptoms in more than one-third of patients, but may also cause bleeding in 6% patients, potentially making the stroke worse. For posterior circulation strokes that involve the vertebrobasilar system, the time frame for treatment with TPA may be extended even further to 18 hours. Heparin and aspirin Drugs to thin the blood (anticoagulation; for example, heparin) are also sometimes used in treating stroke patients in the hopes of improving the patient's recovery. It is unclear, however, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes (see below). In certain patients, aspirin given after

the onset of a stroke does have a small, but measurable effect on recovery. The treating doctor will determine the medications to be used based upon a patient's specific needs. Managing other Medical Problems Blood pressure will be tightly controlled often using intravenous medication to prevent stroke symptoms from progressing. This is true whether the stroke is ischemic or hemorrhagic. Supplemental oxygen is often provided. In patients with diabetes, the blood sugar (glucose) level is often elevated after a stroke. Controlling the glucose level in these patients may minimize the size of a stroke. Patients who have suffered a transient ischemic attacks, the patient may be discharged with blood pressure and cholesterol medications even if the blood pressure and cholesterol levels are within acceptable levels. Smoking cessation is mandatory. Rehabilitation When a patient is no longer acutely ill after a stroke, the health care staff focuses on maximizing the individuals functional abilities. This is most often done in an inpatient rehabilitation hospital or in a special area of a general hospital. Rehabilitation can also take place at a nursing facility. The rehabilitation process can include some or all of the following: 1. speech therapy to relearn talking and swallowing; 2. occupational therapy to regain as much function dexterity in the arms and hands as possible; 3. physical therapy to improve strength and walking; and 4. family education to orient them in caring for their loved one at home and the challenges they will face. The goal is for the patient to resume as many, if not all, of their pre-stroke activities and functions. Since a stroke involves the permanent loss of brain cells, a total return to the patient's pre-stroke status is not necessarily a realistic goal in many cases. However, many stroke patients can return to vibrant independent lives. Depending upon the severity of the stroke, some patients are transferred from the acute care hospital setting to a skilled nursing facility to be monitored and continue physical and occupational therapy. Many times, home health providers can assess the home living situation and make recommendations to ease the transition home. Unfortunately, some stroke patients have such significant nursing needs that they cannot be met by relatives and friends and long-term nursing home care may be required.

What complications can occur after a stroke?

A stroke can become worse despite an early arrival at the hospital and appropriate medical treatment. Progression of symptoms may be due to brain swelling or bleeding into the brain tissue. It is not unusual for a stroke and a heart attack to occur at the same time or in very close proximity to each other. During the acute illness, swallowing may be affected. The weakness that affects the arm, leg, and side of the face can also impact the muscles of swallowing. A stroke that causes slurred speech seems to predispose the patient to abnormal swallowing mechanics. Should food and saliva enter the trachea instead of the esophagus when eating or swallowing, pneumonia or a lung infection can occur. Abnormal swallowing can also occur independently of slurred speech. Because a stroke often results in immobility, blood clots can develop in a leg vein (deep vein thrombosis). This poses a risk for a clot to travel upwards to and lodge in the lungs - a potentially life-threatening situation (pulmonary embolism). There are a number of ways in which the treating physician can help prevent these leg vein clots. Prolonged immobility can also lead to pressure sores (a breakdown of the skin, called decubitus ulcers), which can be prevented by frequent repositioning of the patient by the nurse or other caretakers. Stroke patients often have some problem with depression as part of the recovery process, which needs to be recognized and treated. The prognosis following a stroke is related to the severity of the stroke and how much of the brain has been damaged. Some patients return to a near-normal condition with minimal awkwardness or speech defects. Many stroke patients are left with permanent problems such as hemiplegia (weakness on one side of the body), aphasia (difficulty or the inability to speak), or incontinence of the bowel and/or bladder. A significant number of persons become unconscious and die following a major stroke. If a stroke has been massive or devastating to a person's ability to think or function, the family is left with some very difficult decisions. In these cases, it is sometimes advisable to limit further medical intervention. It is often appropriate for the doctor and the patient's family to discuss and implement orders to not resuscitate the patient in the case of a cardiac arrest, since the quality of life for the patient would be so poor. In many cases, this decision is made somewhat easier if the patient has had a discussion with family or loved ones before an illness has occurred.

What can be done to prevent a stroke?

Risk factor reduction High blood pressure: The possibility of suffering a stroke can be markedly decreased by controlling the risk factors. The most important risk factor for stroke is high blood pressure. When a person's blood pressure is persistently too high, roughly greater than 130/85, the risk of a stroke increases in proportion to the degree by which the blood pressure is elevated.

Managing high blood pressure so that it is well controlled and in the normal range decreases the chances of a stroke. Smoking: An important stroke risk factor is cigarette smoking or other tobacco use. Chemicals in cigarettes are associated with developing atherosclerosis or narrowing of the arteries in the body. This narrowing can involve the large carotid arteries as well as smaller arteries within the brain. Smoking is also a major risk factor in heart disease and artery disease. Diabetes: Diabetes causes the small vessels to close prematurely. When these blood vessels close in the brain, small (lacunar) strokes may occur. Good control of blood sugar is important in decreasing the risk of stroke in people with diabetes. High cholesterol: Elevated cholesterol and/or triglycerides in the bloodstream are risk factors for a stroke due to the eventual blockage of blood vessels (atherosclerosis) and plaque formation. A healthy diet and medications can help normalize an elevated blood cholesterol level. Blood thinner/warfarin: An irregular heart beat called atrial fibrillation whereby the upper chambers of the heart do not beat in a coordinated fashion can cause blood clots to form inside the heart. These can break off and travel or embolize to blood vessels in the brain blocking blood flow and causing a stroke. Warfarin (Coumadin) is a blood "thinner" that prevents the blood from clotting. This medication is often used in patients with atrial fibrillation to decrease this risk. Warfarin is also sometimes used to prevent the recurrence of a stroke in other situations, such as with certain other heart conditions and conditions in which the blood has a tendency to clot on its own (hypercoagulable states). Warfarin dosing is monitored by periodic blood tests to measure INR (international normalized ration) which assess how quickly the patient's blood clots. Aspirin may also be considered for anticoagulation in atrial fibrillation. Antiplatelet therapy: Many TIA and stroke patients may benefit from "antiplatelet" drugs that can decrease clotting risk and potentially reduce their risk of suffering another cerebrovascular event. These medicines act on platelets to decrease their stickiness and reduce the tendency to clot blood. The side effect is an increased risk of bleeding. Aspirin is the most commonly prescribed medication in this group. If the patient develops TIA or stroke symptoms while taking aspirin, other anti-platelet medications may be considered including clopidogrel (Plavix), prasugrel (Effient), and dipyridamole (Persantine). Carotid endarterectomy: In many cases, a person may suffer a TIA or a stroke that is caused by the narrowing or of the carotid arteries (the major arteries in the neck that supply blood to the brain). If left untreated, patients with these conditions have a higher risk of experiencing a major stroke in the future. An operation that cleans out the carotid artery and restores normal blood flow is known as a carotid endarterectomy. This procedure has been shown to markedly reduce the incidence of a subsequent stroke. In patients who have a narrowed carotid artery, but no symptoms, this operation may be indicated in order to prevent the occurrence of a first stroke.

Stroke is a largely preventable condition. Many of the key risk factors can be reduced by making lifestyle changes. There are some risk factors for stroke that cannot be changed, including:
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age: you are more likely to have a stroke if you are over 65 years old. However, about a quarter of strokes happen in younger people. family history: if a close relative (parent, grandparent, brother or sister) has had a stroke, your risk is likely to be higher ethnicity: if you are south Asian, African or Caribbean, your risk of stroke is higher, partly because rates of diabetes and high blood pressure are higher in these groups your medical history: if you have previously had a stroke, TIA or heart attack, your risk of stroke is higher

Ischaemic strokes
Ischaemic strokes occur when blood clots block the flow of blood to the brain. Blood clots typically form in areas where the arteries have been narrowed or blocked by fatty cholesterolcontaining deposits known as plaques. This narrowing of the arteries is caused by atherosclerosis. As we get older our arteries become narrower but certain risk factors can dangerously accelerate the process. Risk factors include:
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smoking high blood pressure (hypertension) obesity high cholesterol levels (often caused by a high-fat diet, but can result from inherited factors) a family history of heart disease or diabetes excessive alcohol intake (which can also make obesity and high blood pressure worse, as well as causing heart damage and an irregular heart beat)

Diabetes is also a risk factor, particularly if it is poorly controlled, as the excess glucose in the blood can damage the arteries. Another possible cause of ischaemic stroke is an irregular heartbeat (atrial fibrillation), which can cause blood clots that become lodged in the brain. Atrial fibrillation can be caused by:
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high blood pressure coronary artery disease mitral valve disease (disease of the heart valve) cardiomyopathy (wasting of the heart muscle) pericarditis (inflammation of the bag surrounding the heart) hyperthyroidism (overactive thyroid gland) excessive alcohol intake drinking lots of caffeine; for example, tea, coffee and energy drinks

Haemorrhagic strokes

Haemorrhagic strokes (also known as cerebral haemorrhages or intracranial haemorrhages) usually occur when a blood vessel in the brain bursts and bleeds into the substance of the brain (intracerebral haemorrhage). In about 5% of cases, the bleeding occurs on the surface of the brain (subarachnoid haemorrhage). The main cause of haemorrhagic stroke is high blood pressure (hypertension), which can weaken the arteries in the brain and make them prone to split or rupture. The risk factors for high blood pressure include:
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being overweight drinking excessive amounts of alcohol smoking a lack of exercise stress, which may cause a temporary rise in blood pressure

Another important risk factor for haemorrhagic stroke is treatment with medicines given to prevent blood clots, for example, warfarin. Haemorrhagic stroke can also occur from rupture of an aneurysm (a balloon-like expansion of a blood vessel) and cerebral blood vessel malformations. A traumatic head injury can also cause bleeding into the brain. In most cases, the cause is obvious but bleeding into the lining of the brain (subdural haematoma) can occur without any obvious signs of trauma, especially in the elderly. The symptoms and signs can then mimic stroke.

Other causes
Less than 1% of strokes are caused by a blood clot (thrombosis) in the veins of the brain (the cerebral veins). Abnormalities of clotting increase the risk of this type of stroke. If you suspect that you or someone else is having a stroke, phone 999 immediately and ask for an ambulance. Even if the symptoms of a stroke disappear while you are waiting for the ambulance to arrive, you or the person having the stroke should still go to hospital for an assessment. Symptoms that disappear may mean you have had a transient ischaemic attack (TIA) and you could be at risk of having a full stroke at a later stage. After an initial assessment, you may need to be admitted to hospital to receive a more indepth assessment and, if necessary, for specialist treatment to begin.

Recognising the signs and symptoms of a stroke

The signs and symptoms of a stroke vary from person to person but they usually begin suddenly. As different parts of your brain control different parts of your body, your symptoms will depend upon the part of your brain that has been affected and the extent of the damage.

The main stroke symptoms can be remembered with the word FAST: Face-Arms-SpeechTime.
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Face: the face may have dropped on one side, the person may not be able to smile or their mouth or eye may have drooped Arms: the person with suspected stroke may not be able to lift one or both arms and keep them there because of arm weakness or numbness Speech: their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake Time: it is time to dial 999 immediately if you see any of these signs or symptoms

It is important for everyone to be aware of these signs and symptoms. If you live with or care for somebody in a high-risk group, such as someone who is elderly or has diabetes or high blood pressure, being aware of the symptoms is even more important. Symptoms in the FAST test identify about nine out of 10 strokes. Other signs and symptoms may include:
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numbness or weakness resulting in complete paralysis of one side of the body sudden loss of vision dizziness communication problems, difficulty talking and understanding what others are saying problems with balance and coordination difficulty swallowing sudden and severe headache, unlike any the person has had before, especially if associated with neck stiffness blacking out (in severe cases)

Want to know more?

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The Stroke Association: common symptoms

'Mini-stroke' or transient ischaemic attack (TIA)

The symptoms of a transient ischaemic attack (TIA) are the same as for a stroke but only last from between a few minutes to a few hours, then completely disappear. However, never ignore a TIA as it is a serious warning sign that there is a problem with the blood supply to your brain. There is about a one in 10 chance that those who have a TIA will experience a full stroke during the four weeks following the TIA. If you have had a TIA, you should contact your GP, local hospital or out-of-hours service, as soon as possible.

Diagnosing stroke
Strokes are usually diagnosed by studying images of the brain (brain imaging). This can also be helpful in determining the risk of a transient ischaemic attack (TIA). Even if the physical symptoms of a stroke are obvious, brain imaging should be carried out to determine:
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if the stroke has been caused by a blocked artery or a burst blood vessel which part of the brain has been affected how severe the stroke is

Different treatment is required for each type of stroke so a rapid diagnosis will make treatment more straightforward.

CT and MRI scans

Two common methods used for brain imaging are a computer tomography (CT) scan and a magnetic resonance imaging (MRI) scan. A CT scan is like an X-ray but it uses multiple images to build up a more detailed, threedimensional (3D) picture of your brain. An MRI scan uses a strong magnetic field and radio waves to produce a detailed picture of the inside of your body. The type of scan you may have in hospital depends on the type of symptoms. In people with suspected major stroke, a CT scan is sufficient to identify whether the stroke is due to bleeding or clotting. It's quicker than an MRI scan and improves the chances of rapidly delivering treatments such as clot-busting (thrombolysis) that might be used in appropriate cases but which are time-limited and require the results of the scan before the treatment can be given safely. For people with more complex symptoms, where the extent or location of the damage is unknown, and in patients who have recovered from a transient ischaemic attack, an MRI scan is more appropriate. This will provide greater detail of brain tissue, allowing smaller, or more unusually located strokes to be identified. All patients with suspected stroke should receive a brain scan within 24 hours. Some patients should be scanned within the hour, especially those who:
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have had a suspected thrombotic stroke and might benefit from clot-busting drugs (thrombolysis) such as alteplase or early anticoagulant treatment are already on anticoagulant treatments have a lower level of consciousness

After the injection of a dye into an arm vein, both CT and MRI can be used to take pictures of the blood vessels in the brain, as well as the blood vessels in the neck that take blood to the brain from the heart. This is known as a CT or MR angiogram and is often done immediately after taking picture of the brain itself. Want to know more?

The Royal College of Radiologists: virtual departments

Swallow tests
A swallow test is essential for anybody who has had a stroke. Swallowing problems affect over a third of people after a stroke. When a person cannot swallow properly, there is a risk that food and drink may get into the windpipe and then into the lungs (called aspiration), which can lead to chest infections and pneumonia. The test is simple. The person is given a few teaspoons of water to drink. If they can swallow this without choking and coughing they will be asked to swallow half a glass of water. If they have any difficulty swallowing, they will be referred to the speech and language therapist for a more detailed assessment. They will usually be kept nil by mouth until they have seen the therapist and may therefore need to have fluids or food given by an intravenous drip or nasogastric tube.

Heart and blood vessel tests

Further tests on the heart and blood vessels might be carried out later to confirm what caused the stroke. These may include:
Ultrasound (carotid ultrasonography)

An ultrasound scan uses high frequency sound waves to produce an image of the inside of your body. Your doctor may use a wand-like probe (transducer) to send high-frequency sound waves into your neck. These pass through the tissue creating images on a screen that will show if there is any narrowing or clotting in the arteries leading to your brain. This type of ultrasound scan is sometimes known as a doppler scan or a duplex scan. Where carotid ultrasonography is needed, it should happen within 48 hours.
Catheter angiography (arteriography)

Dye is injected into your carotid or vertebral artery via a catheter. This gives a detailed view of your arteries than can be obtained using ultrasound, CT angiography or MR angiography.
Echocardiogram

In some cases an echocardiogram may be used to produce images of your heart using an ultrasound probe placed on your chest (transthoracic echocardiogram). In addition, transoesophageal echocardiography (TOE) may also be used. This involves an ultrasonic probe which is passed down the foodpipe (oesophagus), usually under sedation. Because it's directly behind the heart, it produces a clear image of blood clots and other abnormalities that may not get picked up by the transthoracic echocardiogram.

Physical examination

Your doctor may check for risk factors of stroke by taking blood tests, checking your pulse and blood pressure and using a stethoscope to listen to the sound of blood in the neck arteries.

Treating stroke

What is good stroke care?

Effective treatment of stroke has been found to prevent long-term disability and save lives. The National Stroke Strategy was published in December 2007, and provides a guide to high quality health and social care for those affected by stroke. Stroke experts have set out standards which define good stroke care, including:
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a rapid response to a 999 call for suspected stroke prompt transfer to a hospital providing specialist care an urgent brain scan (for example, computerised tomography [CT] or magnetic resonance imaging [MRI]) undertaken as soon as possible immediate access to a high quality stroke unit early multidisciplinary assessment, including swallowing screening stroke specialised rehabilitation planned transfer of care from hospital to community and longer term support

The National Institute for Health and Clinical Excellence (NICE) has produced a quality standard for stroke that describes the level of care that the NHS is working towards. If you are concerned about the standard of care provided, speak to your stroke specialist or a member of the stroke team. Want to know more?
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NICE: Early assessment and treatment of people who have had a stroke or transient ischaemic attack (TIA) (PDF, 520kb) NICE: stroke quality standard

Ischaemic strokes hide

Ischaemic strokes can be treated using a 'clot-busting' medicine called alteplase, which dissolves blood clots (thrombolysis). However, alteplase is only effective if started during the first four and a half hours after the onset of the stroke. After that time, the medicine has not been shown to have beneficial effects. Even within this narrow time frame, the quicker alteplase can be started the better the chance of recovery. However, not all patients are suitable for thrombolysis treatment. You will also be given a regular dose of aspirin (an anti-platelet medication), as this makes the cells in your blood, known as platelets, less sticky, reducing the chances of further blood clots occurring. If you are allergic to aspirin, other anti-platelet medicines are available.

Anticoagulants

You may also be given an additional medication called an anticoagulant. Like aspirin, anticoagulants prevent blood clots by changing the chemical composition of the blood in a way that prevents clots from occurring. Heparin and warfarin are two anticoagulants that are commonly used. Anticoagulants are often prescribed for people who have an irregular heartbeat that can cause blood clots.

Blood pressure
If your blood pressure is too high, you may be given medicines to lower it. Two medicines that are commonly used are:
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thiazide diuretic: this reduces the amount of water in your body and widens the blood vessels, which decreases blood pressure angiotensin converting enzyme (ACE) inhibitors: these widen the blood vessels and reduce blood pressure

Statins
If the level of cholesterol in your blood is too high, you will be given a medicine known as a statin. Statins reduce the level of cholesterol in your blood by blocking an enzyme (chemical) in the liver that produces cholesterol.

Carotid stenosis
Some ischaemic strokes are caused by a narrowing in the carotid artery, which is an artery in the neck, which takes blood to the brain. The narrowing, known as carotid stenosis, is caused by a build-up of fatty plaques. If the carotid stenosis is particularly bad, surgery may be used to unblock the artery. This is done using a surgical technique called a carotid endarterectomy. It involves the surgeon making an incision in your neck in order to open up the carotid artery and remove the fatty deposits.

Recovering from stroke

The damage caused by a stroke can be widespread and long-lasting. Many people need to have a long period of rehabilitation before they can recover their former independence. The process of rehabilitation will be specific to you, and will depend on your symptoms and their severity. A team of specialists are available to help, including physiotherapists, psychologists, occupational therapists, speech therapists and specialist nurses and doctors. The damage that a stroke causes to your brain can impact on many aspects of your life and wellbeing, and depending on your individual circumstances, you may require a number of different treatment and rehabilitation methods. These are discussed in more detail below. Want to know more?

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The Stroke Association: stroke rehabilitation Healthtalkonline: real stories about living with stroke Your health, your way: What is self-care?

Psychological impact hide

The two most common psychological conditions found in people after a stroke are:
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depression: many people experience intense bouts of crying and feel hopeless and withdrawn from social activities anxiety disorder: where people experience general feelings of fear and anxiety, often punctuated by intense, uncontrolled feelings of anxiety (anxiety attack)

You will receive a psychological assessment from a member of your healthcare team within the first month after your stroke. Feelings of anger, anxiety, depression, frustration and bewilderment are all common, although they may fade over time. Your healthcare team, family, friends and organisations such as the Stroke Association can all provide you with support and care you need. The person with stroke and their relatives and carers should be given some advice and help about dealing with the psychological impact of stroke. This includes the impact on relationships with other family members and any sexual relationship. There should also be a regular review of any problems of depression and anxiety, and psychological and emotional symptoms generally. These symptoms tend to settle down over time but if symptoms are severe or last a long time, GPs can refer people for expert healthcare from a psychiatrist or clinical psychologist. For some people, medicines and psychological therapies, such as counselling or cognitive behavioural therapy (CBT) can help. CBT is a therapy that aims to change the way you think about things in order to produce a more positive state of mind. Want to know more?
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The Stroke Association: Stroke Helpline

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Cognitive impact show

Cognitive is a term used by scientists to describe the many processes and functions our brain uses to process information. One or more cognitive functions can be disrupted by a stroke. Cognitive functions include:
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communication: both verbal and written spatial awareness: having a natural awareness of where your body is in relation to your immediate environment memory

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concentration executive function: the ability to plan, solve problems and reason about situations praxis: the ability to carry out skilled physical activities, such as getting dressed or making a cup of tea

As part of your treatment, each one of your cognitive functions will be assessed and a treatment and rehabilitation plan will be created. You can be taught a wide range of techniques that can help you re-learn disrupted cognitive functions, such as recovering communication skills through speech therapy. There are also many methods to compensate for any loss of cognitive function, such as using memory aids or a wall planner to help plan daily tasks. Most cognitive functions will return after time and rehabilitation but you may find that they do not return to their former levels. The damage that a stroke causes to your brain also increases the risk of developing vascular dementia. The dementia may happen immediately after a stroke or it may develop some time after the stroke occurred.
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Physical impact show

Strokes can cause weakness or paralysis in one side of the body. Also, many people have problems with coordination and balance. Many people suffer from extreme tiredness (fatigue) in the first few weeks after a stroke, and may also have difficulty sleeping, making them even more tired. As part of your rehabilitation you should be seen by a physiotherapist, who will assess the extent of any physical disability before drawing up a treatment plan. Treatment will normally begin as soon as your medical condition has stabilised. At first, your physiotherapist will work with you to improve your posture and balance. After this, you will have short sessions of physiotherapy that last a few minutes. The sessions will then increase in duration as you start to regain muscle strength and control. The physiotherapist will work with you by setting goals. At first, these may be simple goals like picking up an object. As your condition improves, more demanding long-term goals, such as standing or walking, will be set. An paid careworker or an unpaid careworker, such as a member of your family, will be encouraged to become involved in your physiotherapy. The physiotherapist can teach you both simple exercises that you can carry out at home. Sometimes, physiotherapy can last months or even years. The treatment is stopped when it is no longer producing any marked improvement to your condition. Want to know more?

The Stroke Association: physiotherapy after stroke (PDF, 66kb)

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Communication problems show

After having a stroke, many people experience problems with speaking and understanding, as well as with reading and writing. This is called aphasia and is sometimes also known as dysphasia. Aphasia can be caused by damage to the parts of the brain that are responsible for language, or be due to the muscles that are involved in speech being affected. You should see a speech and language therapist as soon as possible for an assessment, and to start therapy to help you with your communication skills. Want to know more?
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The Stroke Association: speech and language therapy (PDF, 68kb) Connect Speakability

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Visual problems show

Stroke can sometimes damage the parts of the brain that receive, process and interpret information sent by the eyes. Some people may have double vision, or lose half of their field of vision in one eye. This means that they are able to see everything that is on one side of the eye, but are blind on the other side. Want to know more?
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The Stroke Assoication: visual problems after stroke (PDF, 76kb)

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Sex after stroke show

Even if you have been left with a severe disability, it is important to experiment with different positions and find new ways of being intimate with your partner. Having sex will not put you at higher risk of having a stroke. There is no guarantee you will not have another stroke but there is no reason why it should happen while you are having sex. Be aware that some drugs can reduce your libido (sex drive), so make sure your doctor knows if you have a problem, there may be other medicines which can help.
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Bladder and bowel control show

Some strokes damage the part of the brain that controls bladder and bowel movements. This can result in urinary incontinence and difficulty with bowel control. Most people who have had a stroke regain control in a week or so. If there are still problems when they leave hospital after a stroke, there is help in the community available from the hospital, GP or community continence nurse. Want to know more?
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Bladder and Bowel Foundation

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Driving show
If you have had a stroke, you cannot drive for one month. Whether you can return to driving depends on what long-term disabilities you may have and the type of vehicle that you drive. Your GP can advise you about whether you can start driving again a month after your stroke or whether you need to have a further assessment at a mobility centre. Want to know more?
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The Stroke Association: driving after stroke (PDF, 83kb) Directgov: stroke and driving

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Caring for someone show

There are many ways that you can provide support to a friend or relative who has had a stroke in order to speed up their rehabilitation process. These include:
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helping to practice physiotherapy exercises in between their sessions with the physiotherapist providing emotional support and reassurance that their condition will improve with time helping to motivate the person to reach their long-term goals adapting to any needs they may have, such as speaking slowly if they have communication problems

Caring for somebody after a stroke can be a frustrating and sometimes a lonely experience. The advice outlined below may help.
Be prepared for changed behaviour

Someone who has had a stroke can often seem as though they have had a change in personality and appear to act irrationally at times. This is due to the psychological and cognitive impact of a stroke. They may become angry or resentful towards you. Upsetting as it may be, try not to take it personally. It is important to remember that a person will return to their old self as their rehabilitation progresses.

Try to remain patient and positive

Rehabilitation can be a slow and frustrating process, and there will be periods of time when it appears that little progress has been made. Encouraging and praising any progress, no matter how small it may appear, can help motivate someone who has had a stroke to achieve their long-term goals.
Make time for yourself

If you are caring for someone who has had a stroke, it is important not to neglect your own physical and psychological wellbeing. Socialising with friends or pursuing leisure interests will help you cope better with the situation.
Ask for help

There are a wide range of support services and resources available for people who are recovering from strokes, and for their families and carers. This ranges from equipment that can help with mobility, to psychological support for carers and families. The hospital staff involved with the rehabilitation process can provide advice and relevant contact information. Want to know more?
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Live Well: support and advice for stroke carers Carers Direct

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Will I be able to lead a normal life again? sho

Preventing stroke

Fibre-rich foods can help prevent a stroke

The best way to prevent a stroke is to eat a healthy diet, exercise regularly and avoid smoking and excessive consumption of alcohol.

Diet
A poor diet is a major risk factor for a stroke. High-fat foods can lead to the build-up of fatty plaques in your arteries and being overweight can lead to high blood pressure. A low-fat, high-fibre diet is recommended, including plenty of fresh fruit and vegetables (five portions a day) and whole grains. You should limit the amount of salt that you eat to no more than 6g (0.2oz) a day because too much salt will increase your blood pressure. Six grams of salt is about one teaspoonful. There are two types of fat: saturated and unsaturated. You should avoid food containing saturated fats because these will increase your cholesterol levels. Foods high in saturated fat include:
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meat pies sausages and fatty cuts of meat butter ghee: a type of butter that is often used in Indian cooking lard cream hard cheese cakes and biscuits foods that contain coconut or palm oil.

However, a balanced diet should include a small amount of unsaturated fat, which will help reduce your cholesterol levels. Foods high in unsaturated fat include:
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oily fish avocados nuts and seeds sunflower, rapeseed, olive and vegetable oils

Want to know more?

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Live Well: healthy eating Live Well: lose weight