Stroke

Symptoms

It's important to be able to spot the symptoms of a stroke. If you or someone you're with may be having a stroke, try to note the time the symptoms begin. Tell this time to emergency responders. Some treatments are most effective when given soon after a stroke begins.

Symptoms of stroke include:

• Trouble speaking and understanding what others are saying. A person having a stroke may be confused, slur words or may not be able to understand speech.
• Numbness, weakness or paralysis in the face, arm or leg. This often affects just one side of the body. When trying to raise both arms overhead, one arm may fall. Also, one side of the mouth may droop when trying to smile.
• Problems seeing in one or both eyes. A stroke can cause blurry or blackened vision in one or both eyes. It also can cause double vision.
• Headache. A sudden, severe headache may be a symptom of a stroke. Vomiting, dizziness and a change in consciousness may occur with the headache.
• Trouble walking. Someone having a stroke may stumble or lose balance or coordination.

When to see a doctor

Seek medical attention right away if you notice any symptoms of a stroke, even if they seem to come and go or if they go away completely. Think F.A.S.T. and do the following:

• Face. Ask the person to smile. Does one side of the face droop?
• Arms. Ask the person to raise both arms. Does one arm drift downward? Or is one arm not able to rise?
• Speech. Ask the person to repeat a simple phrase. Is the person's speech slurred or different from usual?
• Time. If you see any of these signs, call 911 or emergency medical help right away.

It's essential to call 911 or your local emergency number right away. Don't wait to see if symptoms stop. Every minute counts. The longer a stroke is not treated, the greater the chance of brain damage and disability.

If you're with someone you think is having a stroke, watch the person carefully while waiting for emergency assistance.

Risk factors

Many factors can increase the risk of stroke. Potentially treatable stroke risk factors include:

Lifestyle risk factors

• Physical inactivity.
• Cigarette smoking or secondhand smoke exposure.
• Heavy or binge drinking.
• Use of illegal drugs, such as cocaine and methamphetamine.

Medical risk factors

• Having obesity.
• High blood pressure.
• High cholesterol.
• Diabetes.
• Obstructive sleep apnea.
• Cardiovascular disease, including heart failure, heart defects, heart infection or irregular heart rhythm, such as atrial fibrillation.
• Personal or family history of stroke, heart attack or transient ischemic attack.
• COVID-19 infection.

Other risk factors

Other factors associated with a higher risk of stroke include:

• Being age 55 or older.
• Being of African American or Hispanic descent.
• Being assigned male at birth.
• Taking hormone therapy that includes estrogen.

Prevention

You can take steps to prevent a stroke. It's important to know your stroke risk factors and follow the advice of your healthcare professional about healthy lifestyle strategies. If you've had a stroke, these measures might help prevent another stroke. If you have had a transient ischemic attack (TIA), these steps can help lower your risk of a stroke. The follow-up care you receive in the hospital and afterward also may play a role.

Many stroke prevention strategies are the same as strategies to prevent heart disease. In general, healthy lifestyle recommendations include:

• Control high blood pressure, known as hypertension. This is one of the most important things you can do to reduce your stroke risk. If you've had a stroke, lowering your blood pressure can help prevent a TIA or stroke in the future. Healthy lifestyle changes and medicines often are used to treat high blood pressure.
• Lower the amount of cholesterol and saturated fat in your diet. Eating less cholesterol and fat, especially saturated fats and trans fats, may reduce buildup in the arteries. If you can't control your cholesterol through dietary changes alone, you may need a cholesterol-lowering medicine.
• Manage diabetes. Diet, exercise and losing weight can help you keep your blood sugar in a healthy range. If lifestyle factors aren't enough to control blood sugar, you may be prescribed diabetes medicine.
• Maintain a healthy weight. Being overweight contributes to other stroke risk factors, such as high blood pressure, cardiovascular disease and diabetes.
• Eat a diet rich in fruits and vegetables. Eating five or more servings of fruits or vegetables every day may reduce the risk of stroke. The Mediterranean diet, which emphasizes olive oil, fruit, nuts, vegetables and whole grains, may be helpful.
• Exercise regularly. Aerobic exercise reduces the risk of stroke in many ways. Exercise can lower blood pressure, increase the levels of good cholesterol, and improve the overall health of the blood vessels and heart. It also can help you lose weight, control diabetes and reduce stress. Gradually work up to at least 30 minutes of moderate physical activity on most or all days of the week. The American Heart Association recommends getting 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity a week. Moderate-intensity activities can include walking, jogging, swimming and bicycling.
• Treat obstructive sleep apnea (OSA). OSA is a sleep disorder that causes you to stop breathing for short periods several times during sleep. Your healthcare professional may recommend a sleep study if you have symptoms of OSA. Treatment includes a device that delivers positive airway pressure through a mask to keep the airway open while you sleep.

These steps are also important for lowering the risk of stroke:

• Quit tobacco use. Smoking and exposure to secondhand smoke raises the risk of stroke. Quitting lowers this risk.
• Drink alcohol in moderation, if at all. Drinking large amounts of alcohol increases the risk of high blood pressure, ischemic strokes and hemorrhagic strokes. Alcohol also may interact with other medicines you're taking. But drinking small to moderate amounts of alcohol may help prevent ischemic stroke and decrease the blood's clotting tendency. A small to moderate amount is about one drink a day. Talk to your healthcare professional about what's right for you.
• Don't use illicit drugs. Certain illicit drugs such as cocaine and methamphetamine are known risk factors for a TIA or a stroke.

Preventive medicines

If you have had an ischemic stroke, you may need medicines to help lower your risk of having another stroke. If you have had a TIA, medicines can lower your risk of having a stroke in the future. These medicines may include:

• Antiplatelet drugs. Platelets are cells in the blood that form clots. Antiplatelet medicines make these cells less sticky and less likely to clot. The most common antiplatelet medicine is aspirin. Your healthcare professional can recommend the right dose of aspirin for you.

  If you've had a TIA or minor stroke, you may take both an aspirin and an antiplatelet medicine such as clopidogrel (Plavix). These medicines may be prescribed for a period of time to reduce the risk of another stroke. If you can't take aspirin, you may be prescribed clopidogrel alone. Ticagrelor (Brilinta) is another antiplatelet medicine that can be used for stroke prevention.

• Blooding-thinning medicines, known as anticoagulants. These medicines reduce blood clotting. Heparin is a fast-acting anticoagulant that may be used short-term in the hospital.

  Slower acting warfarin (Jantoven) may be used over a longer term. Warfarin is a powerful blood-thinning medicine, so you need to take it exactly as directed and watch for side effects. You also need regular blood tests to monitor warfarin's effects.

  Several newer blood-thinning medicines are available to prevent strokes in people who have a high risk. These medicines include dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa). They work faster than warfarin and usually don't require regular blood tests or monitoring by your healthcare professional. These medicines also are associated with a lower risk of bleeding complications compared with warfarin.

Treatment

The type of emergency treatment you need depends on whether you're having an ischemic stroke or a hemorrhagic stroke. During an ischemic stroke, blood vessels in the brain are blocked or narrowed. During a hemorrhagic stroke, there's bleeding into the brain.

Ischemic stroke

To treat an ischemic stroke, blood flow to the brain must be restored quickly. This may be done with emergency medicine or procedures.

• Emergency IV medicine. An IV medicine that can break up a clot has to be given within 4.5 hours from when symptoms began. The sooner the medicine is given, the better. Quick treatment improves your chances of survival and may reduce complications.

  An IV injection of recombinant tissue plasminogen activator (TPA) is the gold standard treatment for ischemic stroke. The two types of TPA are alteplase (Activase) and tenecteplase (TNKase). An injection of TPA is usually given through a vein in the arm within the first three hours. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms start.

  This medicine restores blood flow by dissolving the blood clot causing the stroke. Quickly removing the cause of the stroke may help you recover more fully. Your healthcare professional considers certain risks, such as potential bleeding in the brain, to determine whether TPA is appropriate for you.

• Emergency endovascular procedures. Healthcare professionals sometimes treat ischemic strokes directly inside the blocked blood vessel. Endovascular therapy has been shown to improve outcomes and reduce long-term disability after ischemic stroke. These procedures must be performed as soon as possible:

  • Medicines delivered directly to the brain. During this procedure, a long, thin tube called a catheter is inserted through an artery in the groin. The catheter is moved through the arteries to the brain to deliver TPA directly where the stroke is happening. The time window for this treatment is somewhat longer than for injected TPA but is still limited.
  • Removing the clot with a stent retriever. A device attached to a catheter can directly remove the clot from the blocked blood vessel in the brain. This procedure is especially helpful for people with large clots that can't be completely dissolved with TPA. This procedure often is performed in combination with injected TPA.

The time window when these procedures can be considered is expanding due to newer imaging technology. Perfusion imaging tests done with CT or MRI help determine whether someone may benefit from endovascular procedures.

Other procedures to treat ischemic stroke

Your healthcare professional may recommend a procedure to open up an artery that is narrowed by plaque. This type of procedure is done to lower your risk of having another stroke or transient ischemic attack. Options vary, but include:

• Carotid endarterectomy. Carotid arteries are blood vessels that run along each side of the neck, supplying the brain with blood. This surgery removes the plaque blocking a carotid artery and may reduce the risk of ischemic stroke. A carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.
• Angioplasty and stents. In an angioplasty, a surgeon threads a catheter to the carotid arteries through an artery in the groin. A balloon is inflated to expand the narrowed artery. Then a stent can be inserted to support the opened artery.

Hemorrhagic stroke

Emergency treatment of hemorrhagic stroke focuses on controlling the bleeding and reducing pressure in the brain caused by excess fluid.

Emergency measures

If you take blood-thinning medicines to prevent blood clots, you may be given treatment to counteract the blood thinners' effects. These treatments include medicines or a transfusion of blood products. Medicines also can lower the pressure in your brain, lower blood pressure, prevent spasms of the blood vessels and prevent seizures.

Surgery

If the area of bleeding is large, you may need surgery to remove the blood and relieve pressure on your brain. Surgery also may be used to repair blood vessel damage linked to hemorrhagic strokes.

Your healthcare professional may recommend one of these procedures if an aneurysm, arteriovenous malformation (AVM) or other blood vessel condition caused the stroke.

• Surgical clipping. A surgeon places a tiny clamp at the base of an aneurysm to stop blood flow to it. An aneurysm is a bulge at a weak spot in a blood vessel. The clamp can keep the aneurysm from bursting. Or the clamp can keep an aneurysm that has recently burst from bleeding again.
• Coiling, also known as endovascular embolization. A catheter is inserted into an artery in the groin and guided to the brain. Using the catheter, a surgeon places tiny coils into the aneurysm to fill it. This blocks blood flow into the aneurysm and causes blood to clot.
• Surgical removal of a tangle of thin-walled blood vessels, known as an AVM. Surgeons may remove a smaller AVM if it's in an area of the brain that's easy to access. This removes the risk of rupture and lowers the risk of hemorrhagic stroke. However, it's not always possible to remove an AVM if it's deep within the brain or if it's large. It also may not be possible to remove if the procedure would impact brain function.
• Stereotactic radiosurgery. This procedure uses multiple beams of highly focused radiation to repair blood vessel malformations. Stereotactic radiosurgery is an advanced treatment that's not as invasive as other procedures.

Stroke recovery and rehabilitation

After emergency treatment, you're closely monitored for at least a day. After that, stroke care focuses on helping you recover as much function as possible and to return to independent living. The impact of the stroke depends on the area of the brain involved and the amount of tissue damaged.

If the stroke affected the right side of the brain, movement and feeling on the left side of your body may be affected. If the stroke damaged the left side of the brain, movement and feeling on the right side of your body may be affected. Brain damage to the left side of the brain also may affect your speech and language skills.

Most people who have had a stroke go to a rehabilitation program. Your healthcare professional can recommend a therapy program based on your age, overall health and degree of disability from the stroke. Your lifestyle, interests, priorities, and whether you have help from family members or caregivers are considered.

Rehabilitation may begin before you leave the hospital. After discharge, you may continue the program in a rehabilitation unit of the same hospital. Or you may go to another rehabilitation unit or to a skilled nursing facility as an outpatient. You also may have rehabilitation at home.

Every person's stroke recovery is different. Depending on your condition, your treatment team may include:

• Doctor trained in brain conditions, known as a neurologist.
• Rehabilitation doctor, known as a physiatrist, and rehabilitation nurse.
• Dietitian.
• Physical therapist, occupational therapist, recreational therapist and speech pathologist.
• Social worker or case manager.
• Psychologist or psychiatrist.
• Chaplain.

Outcomes

Early treatment of stroke is linked to less disability, fewer complications and lower risk of having another stroke. People treated in an emergency department within three hours of their first stroke symptom have less disability three months later. Starting rehabilitation soon after a stroke also leads to better outcomes.

Preparing for an appointment

A stroke in progress is usually diagnosed in a hospital. If you're having a stroke, your immediate care focuses on reducing brain damage. If you haven't had a stroke but you're worried about your risk, talk to your healthcare professional at your next appointment.

What to expect from your doctor

In the emergency room, you may see an emergency medicine specialist or a doctor trained in brain conditions, known as a neurologist. Nurses and medical technicians also are likely to be involved in your care.

Your emergency team's first priority is to stabilize your symptoms and overall medical condition. Then the team determines if you're having a stroke. Healthcare professionals try to find the cause of the stroke to determine the proper treatment.

If you're seeking medical advice during a scheduled appointment, your healthcare professional considers your risk factors for stroke and heart disease. Your healthcare professional can offer advice on how to lower your risk. This may include lifestyle strategies, stopping smoking or not using illicit drugs. Your healthcare professional also may consider if you need medicines to control high blood pressure, cholesterol and other stroke risk factors.