Stroke is the second leading cause of death worldwide. It is the third leading
cause of death in the US, and a major cause of neurological disability. An
estimated 750,000 strokes occur every year in the United States while roughly
4 million who survive strokes live with neurological sequali widely ranging
in severity. The financial burden on the nation for the annual health care
expenditure for strokes including direct and indirect is greater than $4 billion.
Although stroke can be prevented, its incidence has been increasing as is the
prevalence of cardiovascular risk factors. Prevention of stroke requires identification
of effect management of the associated major risk factors.
What is a stroke?
A stroke happens when blood flow to the brain stops. There are two different
types of stroke. The most common is ischemic stroke caused by a blood clot
that blocks a blood vessel or artery in the brain. The other less common
is a hemorrhagic stroke caused when a blood vessel in the brain ruptures
and spills blood into the surrounding tissue. Brain cells in the area begin
to die either because they stop getting the oxygen or the nutrients needed
to function or are killed by the ruptured vessel and suddenly spill off blood.
The symptoms of stroke happen immediately. They include:
Loss of ambulation
Numbness or weakness of the arms, face, or legs especially on one side of the
body
Confusion, difficulty speaking or understanding speech
Vision disturbance in one or both eyes
Dizziness, trouble walking, loss of balance or coordination
Severe headache with unknown cause
If you or someone else has these symptoms, seek immediate medical attention.
The longer blood flow is cut off to the brain the greater the potential for
permanent damage.
The prevention of the first stroke
The stroke is well suited for preventive interventions and the recommendations
for treatment of risk factors associated with stroke include:
Hypertension which is the most prevalent and notable modifier risk factor for stroke.
Treatment of hypertension substantially decreases the risk of stroke. A
decrease of 5-6 mm of HG in diastolic blood pressure reduces the stroke by
42%. Treatment of isolated systolic hypertension reduces the stroke by 36%.
Myocardial Infarction
The incidence of stroke after MI is approximately 1-2% per year. It is the
greatest during the first month after MI (31%).
Stroke strategies
Stroke treatment strategies include anti-platelet agents, anticoagulation’s,
and lipid lowering agents.
Atrial Fibrillation (AF)
Nonvalvular atrial fibrillation, which affects 2 million in the US, increases
the incidence of stroke and risk of stroke by 6 times. Preventive treatments
include anticoagulation and antiplatelet agents.
Diabetes Type I and II
Well-established risk factors for stroke. Increased blood sugar at the time
of presentation of a stroke increases with more stroke morbidity and death.
Blood lipids
Patients with high lipids and risk for coronary artery disease are recommended
to maintain lipid lower agents and cholesterol lowering diet.
Asymptomatic carotid artery disease
If there is a hardening of the carotid artery with a narrowing of 60% or
more carotid surgery may be warranted. This depends on the individual’s
risk factors and surgical expertise available.
Lifestyle changes
Cigarette smoking increases the risk of stroke by a factor of 1.5. Alcohol
can increase the risk for hemorrhagic strokes. Regular exercise may decrease
the risk of stroke as well as heart disease.
Stroke prevention after TIA or stroke
Stroke recurrence is the highest during the first 30 days after the initial
event. Patients with a TIA tend to return to the ER with a stroke within
90 days and reoccurring within 2 days. If a patient has symptoms of a stroke
and seeks immediate attention the patient might be a candidate for a clot
buster called TPA. This dissolves a clot or clots and keeps the blood flowing
to the brain. But this has to be administered within 3 hours of the onset
of the symptoms. The patient needs to come for immediate medical attention
and has to have a work-up including a CT scan to make sure there is no hemorrhage
before this clot buster can be administered. Once the stroke has occurred
and there is damage to the brain, treatment can be initiated to prevent another
stroke happening with starting either antiplatelet agents (aspirin, Plavix,
Aggrenox, or Ticlid) or anti-coagulation (Warfarin or Heparin) as well as
treating the underlying risk factors such as hypertension, diabetes, atrial
fibrillation, elevated cholesterol, or carotid stenosis. There should also
be life-style changes such as stopping smoking, decreasing alcohol intake,
and increased exercise. If the patient has paralysis resulting in gait difficulty,
intensive physical therapy or if there is paralysis or difficulty with upper
extremity use then occupational therapy. If there is speech difficulty, then
with speech therapy. Sometimes this can be performed in an inpatient setting,
such as inpatient rehab, in order for the patient to recover sufficiently
for the patient to go home.
Risk factors shortly after a stroke
Risk factors include recurrent stroke, developing clots in the legs such as
DVTs and then can cause clots into the lungs. This could be prevented by
early mobilization using stockings as well as anticoagulation such Heparin
or Lovenox. There is increased risk of pneumonia initially after a stroke
especially if there is difficulty with swallowing. If the patient is mobilized
early, there is risk of skin breakthrough if there is significant paralysis
with the stroke. This is very common after a stroke and this needs to be
treated. If there is significant spasticity on one side, this could be treated
with medications, range of motion, and intensive therapy. If these fail,
potentionally isolated muscles can be treated with Botox.
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