Stroke

Stroke
Stroke is the second leading cause of death worldwide, 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 and there are roughly 4 million people who have survived strokes living with neurological impairment widely ranging in severity. 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 and effective management of the associated major risk factors.

What is a stroke?

A stroke happens when blood flow to the brain is interrupted. 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 type of stroke is a hemorrhagic stroke which is 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 and nutrients needed to function or are killed by the ruptured vessel and sudden spill of blood.

The symptoms of stroke happen immediately. They include:

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
Hypertension 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%.

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
Increased blood sugar at the time of presentation of a stroke increases the rate of stroke morbidity and death. Preventive treatment includes good control of blood sugar levels through diet control and medications.

Blood lipids
Patients with high lipids and risk for coronary artery disease are recommended to maintain lipid lower agents and cholesterol lowering diet. Preventive treatment includes good control of their lipids.

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.

Obstructive Sleep Apnea
Major studies have shown that sleep apnea significantly increases the risk of stroke. For males, mild sleep apnea doubles the risk, whereas moderate to severe sleep apnea can triple the risk. For females, severe sleep apnea results in a significant increase in stroke. Effective treatment with CPAP results in a significant decrease in risk of stroke from sleep apnea.

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. If a patient has symptoms of a stroke and seeks immediate attention, the patient may be a candidate for a "clot buster" called TPA. This medication dissolves a clot (or clots) and keeps the blood flowing to the brain. However, this has to be administered within 3 hours of the onset of the symptoms. The patient needs to come for immediate medical attention and will require a work-up including a CT scan to make sure there is no hemorrhage before the TPA can be administered. Recent studies have shown that patients who do not respond to IV-TPA may still be candidates for further intracranial intervention at a tertiary stroke center. Once the stroke has occurred and there is damage to the brain, treatment can be initiated to prevent another stroke from happening. This is done by starting the patient on 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, or difficulty with upper extremity use then intensive physical and/or occupational therapy may be necessary and helpful. If there is speech difficulty, then with speech therapy. Sometimes these therapies must 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 after a stroke include: developing clots in the legs such as DVTs that then can cause clots into the lungs. This could be prevented by early mobilization using stockings as well as with anticoagulation such Heparin or Lovenox. There is increased risk of pneumonia initially after a stroke especially if the patient has difficulty with swallowing as a result of the stroke. If the patient is not mobilized early, there is risk of skin breakdown, especially if there is significant paralysis with the stroke. This is very common after a stroke and this needs to be treated immediately. If there is significant spasticity on one side, it can be treated with medications, range of motion exercises, and intensive therapy. If these fail, isolated muscles can be treated with Botox.

Tour our Neuro-Orthopedic Center

  • The internal entrance to the rehab clinic.
  • Rehabilitation exercise equipment in the neuro-orthopedic center.
  • Model kitchen in the rehabilitation center.
  • Wood and carpeted stairs in the rehabilitation clinic.
  • Practice car and ramp in the rehab clinic.
  • Grocery store in the rehab clinic.