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Stroke or Cerebrovascular Accident

Understanding Stroke

A stroke (cerebrovascular accident) occurs when blood flow to part of the brain is blocked or when a blood vessel in the brain bursts. Without blood and oxygen, brain cells begin to die within minutes. A stroke can be fatal and requires immediate treatment.

What is a Stroke?
A stroke occurs when blood flow to part of the brain is blocked or when a blood vessel in the brain bursts. Without blood and oxygen, brain cells begin to die within minutes. Strokes are the second leading cause of death worldwide.

Common Symptoms

  • Face drooping
  • Arm weakness
  • Speech difficulty (trouble speaking or complete loss of speech)
  • Sudden severe headache
  • Vision problems or dizziness
  • Confusion or agitation
  • BE FAST acronym: balance, eyes (vision problems), face (droop), arm (weakness), speech, time (call 911 immediately)

TIAs and Types of strokes

  • Transient Ischemic Attack (TIA): often called a mini stroke but this is not a completely accurate term.
  • TIAs mean that there is a transient interruption to blood flow to the brain.
  • Although TIAs are not true strokes they increase your risk of future strokes and you should be evaluated immediately.
  • Ischemic: typically caused by blood clot blocking a blood vessel that supplies part of the brain.
  • Some causes of ischemic stroke include: atherosclerosis (plaque buildup and hardening of arteries), atrial fibrillation (arrhythmia), clotting disorders, microvascular ischemic disease (narrowing of the small blood vessels in the brain due to thickened walls and buildup of plaque), heart defects (atrial septal defects or ventricular septal defects, which cause holes between the chambers of the heart through which clots can travel)
  • Hemorrhagic: rupture of blood vessel and bleeding in the brain
  • Some causes of hemorrhagic stroke include aneurysms, brain tumors, uncontrolled high blood pressure

Risk Factors for Stroke

  • Hypertension
  • History of TIA or stroke
  • Carotid stenosis (narrowing of the carotid arteries)
  • Diabetes
  • High cholesterol
  • Heart Failure
  • Tobacco use
  • Alcohol consumption
  • Oral contraceptive use
  • Obesity
  • Genetic predisposition
  • Age

Diagnosis Testing and Workup

  • Blood work
  • CT scan (initially done to differentiate between ischemic and hemorrhagic stroke)
  • If suspicion for hemorrhage is high, a lumbar puncture (spinal tap) is done
  • Emergent vascular imaging (CT angiography with or without perfusion scanning) may be indicated to look for occlusion of large vessels
  • MRI
  • MRA may also be needed to evaluate large arteries and veins
  • Carotid dopplers may be needed to look for narrowing of carotid arteries
  • Echo to look for clots in the heart, vegetations on heart valves (a growth or deposit on the valve, which can be due to infection), valvular defects or a hole in the heart (evaluated with a bubble study)

Treatments

  • Ischemic: Clot-busting drugs (tPA) or endovascular thrombectomy (physical removal of clot) if within time window
  • Hemorrhagic: Surgery to stop bleeding and relieve pressure in brain from blood
  • Cardiac telemetry (to monitor for arrhythmias)
  • Permissive hypertension initially (allowing higher blood pressures initially to promote blood flow to the brain)
  • Keeping head of bed flat initially to promote blood flow to brain
  • Rehabilitation (physical, speech, occupational therapy)
  • Medications to prevent future strokes

Medications for Prevention of Future Strokes

  • Recommended medications depend on type of stroke and underlying cause
  • Antiplatelet agents: aspirin is typically started and a second antiplatelet agent may be recommended for a certain amount of time (usually clopidogrel/plavix)
  • If cardiac arrhythmia is identified, anticoagulation is recommended (i.e. apixaban/eliquis or rivaroxaban/xarelto)
  • Medications for controlling blood pressure and blood sugar
  • Cholesterol medications (statins if tolerated and LDL is not at goal)
  • If at risk for seizures, a preventative medication for seizures is recommended
Preventing Future Strokes

Prevention

  • Treatment of underlying cause
  • Management of blood pressure, blood sugar, diabetes
  • Smoking cessation and regular exercise
During Your Hospital Stay

What to Expect

  • Frequent neurological assessments
  • Monitoring for complications
  • Testing to evaluate for underlying cause of stroke
  • Early mobilization when safe
  • Evaluations by speech therapy, physical therapy, and occupational therapy