Stroke and the Family a new guide pdf

A stroke is defined as permanent damage to an area of the brain caused by a blocked blood vessel or bleeding within the brain.. Because of the pressure created by the ing area of blood wi

sicians for specific information concerning their individual medical conditions The author has done his best to ensure that the infor- mation presented here is accurate up to the time of publication However, as research and development are ongoing, it is possible that new findings may supersede some of the data presented here This book contains references to actual cases the author has en- countered However, names and other identifying characteristics have been changed to protect the privacy of those involved Many of the designations used by manufacturers and sellers to distinguish their products are claimed as trademarks Where those designations appear in this book and Harvard University Press was aware of a trademark claim, then the designations have been printed in initial capital letters (for example, Coumadin).

Stroke and the Family

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

Stein, Joel.

Stroke and the family : a new guide / Joel Stein.

p cm.—(The Harvard University Press family health guides)

Includes bibliographical references and index.

ISBN 0-674-01513-4 (cloth : alk paper)—ISBN 0-674-01667-X (pbk : alk paper)

1 Cerebrovascular disease—Patients—Family relationships I Title II Series RC388.5.S785 2004

362.196 ′81–dc22 2004052291

Drawings by Arleen Frasca

To my children,

Daniel, Joshua, and Aliza, who bring joy to my life

Introduction 1

A stroke is actually a family illness.

McKenzie Buck, stroke survivor and psychologist

The diagnosis of stroke is a feared yet unfortunately common event.Despite its prevalence, however, both the lay public and medical profes-sionals harbor many misconceptions about it The very term “stroke”describes the way this disorder often occurs Frequently an active, inde-pendent person is literally “struck down.” Stroke is a sudden, life-alteringevent that often gives no warning of its approach

This book is about life after a stroke, with an emphasis on providinginformation and resources for the family members of a stroke survivor.Knowledge can help loved ones obtain needed services, advocate for thesurvivor, and cope with the stresses that stroke creates for the entire fam-ily Millions of stroke survivors and their families are living with a situa-tion they never anticipated and feel ill-equipped to manage It is easy tolose hope after a stroke, and society’s attitudes about this disorder canmake a difficult situation even worse Unfortunately, many people inboth the medical and the lay community believe that the useful, enjoy-able phase of life ends when a stroke occurs But there is good news:some stroke survivors are becoming more vocal about their experiences,sharing their stories and thus working to dispel these myths Althoughstroke affects many different people in many different ways, plenty of in-dividuals go on to live rich, satisfying lives after stroke, and they canserve as role models for the recently affected

A person’s response to stroke depends in substantial part on the vidual’s personality and character traits Some people are used to control-ling their own destiny, and so may react to a stroke by working vigorously

indi-to reestablish their independence and function Others are more passiveand may have a harder time mustering the resolve and determination toovercome the losses stroke imposes I never cease to be amazed at theachievements of some of my stroke patients, who surpass my every ex-pectation and achieve function I could not have reasonably expectedthem to attain I have learned from these patients not to be too certain in

my prognostications, and to always leave the door to hope ajar Patients,families, and healthcare providers can all create self-fulfilling prophe-cies—for better or for worse

There is a tendency among clinicians, patients, and families to focus

on the limitations experienced after stroke We all need to recognize thatdisability of one sort or another is pervasive in life Many people live withpain from arthritis, vision or hearing loss, or a host of other physical lim-itations People with disabilities cannot necessarily deny or change theirlimitations, but they can focus their attention on the many activities theycan accomplish and enjoy Indeed all of us, stroke survivors, families,and healthcare professionals, must focus our attention on stroke survi-vors’ abilities rather than on their disabilities The key to success afterstroke is working to minimize limitations, accepting what we cannotchange, and then moving on to the interesting and enjoyable parts of life

What Is a Stroke?

Roberta, a seventy-four-year-old grandmother and retired schoolteacher, ishaving coffee with her daughter one afternoon when she suddenly an-nounces, “I don’t feel well.” Her daughter notices that the right side ofRoberta’s face is drooping, and she is having a hard time swallowing hercoffee Over the course of a few minutes, Roberta begins to have troublespeaking and slumps over in her chair Her daughter calls 911, and Roberta

is rushed to a nearby emergency room There the emergency room cian tells Roberta and her daughter that it appears Roberta is having astroke The two women are scared and confused Is this really a stroke?Why wasn’t there any pain or other warning signs? How could this happen

physi-so suddenly? Will Roberta be ok?

Unfortunately, Roberta’s situation is very common It is estimatedthat each year in the United States alone, 600,000–700,000 people sufferstroke As a result, there are more than four million stroke survivors inthis country today Most adults, in fact, have family members or acquain-tances who have had a stroke Stroke is a leading cause of death in theUnited States and the number one cause of disability among adults De-spite its prevalence, however, many people have a very limited under-standing of what a stroke is and what can be done about it

A stroke is defined as permanent damage to an area of the brain caused

by a blocked blood vessel or bleeding within the brain There are a ber of different ways stroke can occur, and the type of stroke will deter-mine the appropriate treatment All strokes share a common feature,

num-however: they result in damage to one or more areas of the brain Thusthe aftereffects of stroke are primarily determined by the specific area(s)

of the brain affected, rather than by the specific cause of the stroke

Cerebral Infarction

The most common type of stroke is known as an “infarct,” and it occurswhen a portion of the brain loses its supply of blood This can happenwhen a blood clot lodges within a blood vessel and blocks it, or when

a blood vessel narrows to the point where blood can no longer flowthrough it When an area of the brain is not getting enough blood, it fails

to receive the oxygen and nutrients carried in the blood, and brain cellsdie from lack of these critical supplies A stroke is similar in many ways

to a heart attack, in which a portion of the heart loses its supply of blood,causing heart cells to die One important difference is that the heart has

an ample supply of nerves capable of providing pain sensation, whereasthe brain has little ability to feel pain As a result, many strokes are pain-less or have a relatively mild degree of pain The absence of pain oftenleads people who are having stroke symptoms to delay obtaining medicalcare

Cerebral Hemorrhage

Franklin is a sixty-three-year-old man with a history of prior polio and vere uncontrolled hypertension Despite the advice of his physicians, hecontinues to maintain a highly active role in an extraordinarily stressful po-sition One day he exclaims to a staff member, “I have a terrific pain in theback of my head.” He dies hours later of a massive cerebral hemorrhage

se-“Even His Family Unaware of Condition as Cerebral Stroke Brings Death to

Nation’s Leader at 63,” reports the New York Times on April 13, 1945, after

President Franklin D Roosevelt’s death

The second major category of strokes are due to bleeding in the brain.These strokes are known as cerebral hemorrhages, and they account forabout one-fifth of all strokes In a cerebral hemorrhage, the bleeding inthe brain puts pressure on the adjacent brain tissues and causes some

of these cells to die Because of the pressure created by the ing area of blood within the brain, these types of stroke are commonlymore painful than cerebral infarctions and may cause very sudden andsevere headaches Symptoms from cerebral hemorrhage are unpredict-able, however, and some individuals have painless neurological symp-toms indistinguishable from those of a cerebral infarction.

expand-Warning Signs before a Stroke:

Transient Ischemic Attacks (TIAs)

Jim is a sixty-four-year-old man with hypertension He is overweight, tary, and smokes At a business lunch with a client, he experiences somenumbness and sudden clumsiness when moving his left hand He contin-ues his business lunch and feels relieved when his symptoms go away ontheir own after about five minutes He almost forgets about the entire epi-sode, but his wife insists that he contact their primary care physician Sheread a magazine article that listed temporary clumsiness and numbness aspossible warning signs of stroke His physician finds that his exam is nor-mal but tells Jim that he has had a “TIA.” Jim is concerned—is he about tohave a stroke? Can he do anything to prevent a stroke?

seden-Transient ischemic attacks, or TIAs, are stroke-like episodes that solve spontaneously, usually within minutes TIAs result from tempo-rary blockages to blood flow Unlike in stroke, however, in a TIA the body

re-is able to dre-issolve the blockage and restore blood flow before any manent damage occurs TIAs have traditionally been defined as stroke-like neurological symptoms that completely resolve within twenty-fourhours With the availability of better imaging techniques (especiallymagnetic resonance imaging, or MRI scans), it has become clear thatsometimes events that appear to be TIAs are actually small strokes, withvery rapid recovery As a result, some physicians now consider TIAs

per-to be stroke-like sympper-toms that completely resolve without any graphic—that is, computerized tomography (CT) or MRI—evidence ofstroke

radio-The most important aspect of TIAs is that they provide a warning to

someone that a stroke may be imminent but is still preventable Theshort duration and spontaneous resolution of TIA symptoms lead manyindividuals to ignore these events and not seek medical attention In fact,people with TIAs are known to have a high risk of subsequent stroke andshould obtain immediate medical evaluation Treatment for TIAs varieswith the cause, and may include aspirin or other medications, or occa-sionally surgery.

Acute Management of Stroke

In the past, the medical profession considered stroke an untreatable dition When a person with stroke symptoms sought emergency care, hewas assigned a low priority and often had to wait to be evaluated andtreated This has changed substantially in the past few years with the de-velopment of “clot-busting” or thrombolytic medications These drugs,such as alteplase (TPA), can dissolve a blood clot that is causing a block-age The brain is a fragile organ that cannot survive for long without afresh blood supply bringing oxygen and other nutrients For this reason,these treatments need to be given as quickly as possible “Time is brain”

con-is a common saying among neurologcon-ists treating acute stroke, becauseevery minute counts In order to increase the awareness of stroke as atreatable emergency, organizations such as the American Stroke Associa-tion (a division of the American Heart Association) and the NationalStroke Association have established ongoing educational programs toalert people to the symptoms of stroke and the need to obtain promptmedical evaluation

Stroke is often painless Individuals suffering from the initial toms of stroke are sometimes inclined to “wait it out,” hoping that thesymptoms will resolve on their own Obtaining immediate medical at-tention is the best way to prevent or limit the damage to the brain whenstroke symptoms develop

symp-Stroke Symptoms

All stroke and TIA survivors and their families should be familiar withthe symptoms of a stroke It is important to recognize that stroke symp-

toms can vary substantially and may be mild Someone who has had astroke or TIA in the past may have very different symptoms with a newstroke If in doubt, seek prompt medical evaluation Some of the com-mon symptoms of stroke include:

• Weakness on one or both sides of the body

• Loss of sensation

• Difficulty speaking

• Confusion

• Visual changes

• Drooling or difficulty swallowing

• Difficulty walking or loss of balance

• Dizziness or room spins

Emergency management of stroke continues to evolve rapidly At ent, the most widely available emergency treatment for stroke is TPAgiven through a vein (“intravenous,” or “IV”) This treatment can be pro-vided in most emergency rooms with appropriate expertise and expe-rience Generally speaking, these “clot-busting” treatments need to bestarted within the first three hours after a stroke The earlier treatment isprovided, the better, and research has shown that people receiving thistreatment in the first 90 minutes after a stroke have greater benefits thanthose who receive treatment 90–180 minutes after a stroke A number ofimportant medical issues may prevent the use of thrombolytic medica-tions, including a prior recent stroke, any history of abnormal bleeding,severe elevations in blood pressure, and recent surgery, among others.Because of these limitations, only a relatively small percentage of peoplewho have a stroke actually receive this type of treatment

pres-Even when patients are carefully screened for administration of thisdrug, some can have bleeding in the brain as a complication from thispowerful clot-dissolving medication In other cases, the blockage ofblood flow is not successfully dissolved, and the damage from the stroke

is undiminished Even when all goes well, significant neurological age often still occurs even with treatment Despite these limitations,thrombolysis is an important and effective treatment, and a major ad-vance in the emergency management of stroke

dam-Some medical centers are currently studying the use of thrombolytictreatment given directly into the blocked arteries of the brain In thistreatment, a long, narrow tube known as a catheter is threaded throughthe blood vessels in the arm or leg into the neck, and the clot-dissolvingmedication is given right near the blood clot itself Although this treat-ment is quite promising, it requires a large team of physicians who areavailable at very short notice For this reason, its use is confined to a fewlarge hospitals at this time.

Heparin is another medication commonly used for the treatment ofacute stroke Heparin prevents blood clots from growing larger and fromforming new clots, but it does not actually dissolve existing clots Thegoal with this treatment is to prevent progression of the stroke to a moresevere stroke, or prevent a second stroke, but not to reverse the effects ofthe initial stroke Heparin is typically given intravenously It is com-monly used when an individual with a stroke is not appropriate for TPA(for example, too much time has elapsed, or the patient has had re-cent surgery), and as a preventative measure after strokes resulting fromblood-clot formation Although intravenous heparin is widely used, thereremains controversy about which specific subtypes of stroke are besttreated with the drug Research studies are ongoing

Aspirin has been found to be useful in the treatment of acute strokeand is commonly used when the other treatments outlined above are notappropriate

The medical management of acute stroke includes controlling any ver that develops, avoiding extremes of blood pressure (too high or toolow), and treating any elevations of blood sugar resulting from diabetes.These actions appear to help limit the extent of the damage caused by astroke

fe-In a small number of strokes, immediate surgery is beneficial Severebrain swelling can accompany some strokes and can create life-threaten-ing increases of pressure inside the skull Removal of a portion of theskull, sometimes coupled with removal of some of the dying brain tissue,can allow room for the swelling of the brain This drastic procedure ismost commonly used for younger stroke patients with large strokes Theportion of skull removed may be temporarily implanted underneath theskin in the abdomen for later replacement If the removed portion ofskull is unavailable, a plastic “plate” is used to reconstruct the skull in-

stead A hockey-type helmet is often used to protect the head until theskull can be reconstructed.

In cases of large hemorrhages within the brain, the blood clot is times surgically removed This treatment, too, is generally reserved forlife-threatening cases

some-Family Response to Stroke

The first few days after a stroke are often very difficult for family andfriends of the patient Information provided by the hospital staff may becouched in medical jargon and be difficult to assimilate Feelings of frus-tration and helplessness are common How can families work with themedical team as partners to achieve the best outcome for the stroke sur-vivor? Here are some practical suggestions:

Appoint a spokesperson Designating one family member (or friend) to

serve as the primary contact for the medical team will improve nication and clarify decision-making The spokesperson can then regu-larly update other family members and relay any questions to the phy-sician

commu-Establish daily contact with the physician The family spokesperson should

arrange for daily contact with the physician leading the team (commonlyknown as the “attending” physician), who can provide medical updatesand answer questions as they arise

Speak with the neurologist In some cases, the neurologist will be the

at-tending physician caring for the stroke survivor; in others, the gist will serve as a consultant to the attending physician In the lattercase, it is important to have direct contact with the neurologist, who is anexpert in determining the cause of the stroke and can provide the mostexperienced opinion regarding prognosis This contact need not be daily,but it should occur early after hospital admission, and then at least peri-odically during the hospital stay

neurolo-Contact the case manager Most hospitals employ nurses or social workers

as case managers to assist patients with discharge planning The case

manager plays a key role in determining the type and location of care thepatient will receive after discharge Since many stroke survivors require astay in a rehabilitation facility before returning home, and many othersrequire home services on discharge, the family should contact the casemanager early in the hospital stay This will allow the family to have earlyinput into the discussion of the discharge plan and help make the bestchoices for the stroke survivor.

Educate yourself Understanding the effects of stroke and the process of

recovery and rehabilitation will make you a more effective advocate foryour family member See the Appendix for a list of resources

Educate others Other loved ones and friends may have less information

than the most actively involved family members Share your knowledgewith them and encourage them to learn more about stroke The Ameri-can Stroke Association and National Stroke Association (see Appendix)provide short, easy-to-read pamphlets about stroke that may be helpfulfor family members

Accept uncertainty The first few days after a stroke are often filled with

uncertainty While the medical staff can provide their best estimates

of prognosis, the reality is that sometimes a period of time must elapsebefore the outcome of a stroke is clear Focusing on the immediate (forexample, medical) and near-term (post-hospital rehabilitation) issuesrather than on the long-term issues (for example, return to work, fi-nancial concerns) will allow time for the prognosis to become clearerand help prevent the stroke survivor’s family from becoming over-whelmed

Support the stroke survivor Depending on the severity and type of stroke,

the condition of the affected individual may range from fully awake andalert to, in severe cases, comatose with no ability to communicate at all.Even when it is uncertain if the stroke survivor is aware of your visits,providing comfort to an ill family member is important Sitting with thestroke survivor, holding her hand, or stroking her hair may not be proven

to help medically, but it provides emotional benefits for all involved

Take care of yourself Stroke is a crisis for all involved, and family

mem-bers can easily fail to attend to their own needs during the hospitalization

of the stroke survivor Twenty-four-hour-a-day vigils in the hospital lead

to exhaustion and exacerbate the emotional stress that family memberscommonly experience Taking time for adequate rest, sleep, eating right,and exercise are important if family members are to preserve their ownhealth and well-being

Finding the Cause of a Stroke

Nicholas is a sixty-five-year-old recently retired accountant on a vacationcruise with his wife when he wakes up one morning with mild left-sidedweakness He is brought by helicopter to a hospital, where he is diagnosedwith a cerebral infarction—a stroke Within the first forty-eight hours heundergoes a CT scan, an MRI, an echocardiogram, and carotid ultrasoundtests While in the hospital he quickly regains most of his strength on theleft side, but he wants to understand why all these tests were performedand what they show What caused his stroke? Is he likely to have anotherone? What can he do to prevent future strokes?

Cerebral infarcts all result from interruption of blood flow to a portion

of the brain, but they have a variety of specific causes Determining thecause is particularly important when selecting treatment(s) to preventanother stroke A number of tests are useful in determining the cause,though the actual selection of these tests will vary depending on the cir-cumstances and availability These tests include:

Computerized tomography (CT or CAT scan) of the brain CT is a special

computerized x-ray of the brain CT scans can show the location and size

of a stroke (see Figure 2.1) They can be performed quickly and are verygood at finding any bleeding in the brain (see Figure 2.2) Damage from

an infarct is not always visible when the scan is done soon after toms of a cerebral infarct develop, however

symp-Magnetic resonance imaging (MRI scan) of the brain MRI provides very

de-tailed pictures of the brain and does not involve any radiation MRI scanstypically take longer to perform than CT scans, but they may be better

figure 2.1 Cerebral infarction.

This CT of the brain shows a large infarct in the patient’s left frontal andparietal lobes The stroke appears darker than the surrounding brain There

is a small amount of bleeding within the stroke, visible as small areas thatare lighter than the surrounding stroke

figure 2.2 Cerebral hemorrhage.

This CT of the brain shows a large hemorrhage in the patient’s right basalganglia The blood appears brighter than the surrounding brain tissue A rim

of edema (swelling) is seen around the blood and is darker than both theblood and the surrounding brain

[To view this image, refer to the print version of this title.]

[To view this image, refer to the print version of this title.]

able to detect a stroke (especially an infarct) very early after symptoms velop Certain people cannot undergo MRI, including those with pace-makers or other metallic objects in their body.

de-Magnetic resonance and computerized tomographic angiography These

techniques are used to provide pictures of the blood vessels supplyingthe brain They are noninvasive and safe, and frequently provide suf-ficient information to direct treatment In some circumstances conven-tional angiography is needed to provide even more detailed images

Conventional angiography In this procedure, detailed pictures of the blood

vessels to the brain are taken by injecting a dye into the blood vessels via

a special catheter (long, flexible tube) This is a more invasive procedurethan MR or CT angiography and may carry some risk of adverse side ef-fects, including stroke in rare cases

Echocardiogram In an echocardiogram, an ultrasound machine takes

pic-tures of the heart using sound waves These sound waves are at a highfrequency and are beyond the range of human hearing The sound wavesbounce off the internal organs and are used to create a picture of theheart There are two types of echocardiogram—a conventional or “trans-thoracic” echocardiogram, in which the recording head of the ultrasoundmachine is placed on the outside of the chest wall, and a “transesoph-ageal” echocardiogram, in which the recording head of the ultrasound isswallowed and pictures are obtained from within the esophagus (thetube connecting the mouth with the stomach) Transesophageal echo-cardiograms provide more detailed pictures, and may be needed in cer-tain circumstances to determine the cause of a stroke

Electrocardiogram (ECG) Electrocardiogram, or ECG, is a routine

record-ing of the heart’s electrical activity This is a simple and useful test foridentifying damage to the heart, or an abnormal heart rhythm that may

be responsible for a stroke

Carotid ultrasound/transcranial doppler This is another form of ultrasound

that provides pictures and other information about the structure andfunctioning of the major blood vessels in the head and neck

Holter monitor Similar to an electrocardiogram, but obtained over a

longer period of time (usually twenty-four hours), this test involves a cial tape recorder that is carried by the patient It can be useful in detect-ing abnormal heart rhythms that are intermittent and can cause stroke

spe-Blood tests for blood clotting These tests check for abnormalities of blood

clotting that can lead to stroke

Lipid profile This blood test, generally obtained after the patient has been

fasting, provides information about fatty components of the blood, such

as cholesterol and triglycerides, which can contribute to the risk ofstroke This test determines levels of high-density lipoprotein (HDL), the

“good cholesterol” associated with a reduced risk of stroke, and sity lipoprotein (LDL), the “bad cholesterol” that increases the risk ofstroke and heart disease

low-den-Types of Stroke

On the basis of the information obtained from these tests, physicians canusually identify the type and cause of the stroke Ischemic strokes areoften divided into several categories, depending on how the stroke oc-curs Certain medical conditions may predispose individuals to particu-lar types of stroke

Embolic Stroke

Embolic stroke is caused by a clump of material traveling through thebloodstream and blocking a blood vessel in the brain The substancecausing an embolic stroke is most commonly a blood clot, though thereare other substances that can “embolize” and cause stroke in rare cases,including pieces of cholesterol, fat from the middle of bones after a se-vere fracture, and even air Blood clots can originate in a number of ar-eas, as described below

atrial fibrillation

A particularly common cause of blood clots forming in the heart is a dition known as “atrial fibrillation.” In atrial fibrillation, the two smaller

con-chambers of the heart, known as the atria, do not beat regularly and socannot empty out all the blood they contain Instead, the individual heartcells contract in an uncoordinated fashion, leading to inefficient pump-ing of the blood This causes the blood to stagnate in the heart, allowingthe formation of blood clots within the left atrium These clots can breakoff and travel to the brain, causing a stroke Warfarin (best known byits brand name, Coumadin) is the usual treatment for this condition,though aspirin is often used for individuals at low risk for stroke, and

is a useful alternative for those unable to take Coumadin for medicalreasons

cardioembolic stroke

Blood clots can originate in other parts of the heart, including the leftventricle, the main pumping chamber of the heart This usually occurswhen there is substantial heart disease and the heart is not pumping nor-mally In this case blood may have a chance to form a clot within theheart, resulting in a stroke if a piece of the clot breaks off and ends up in

a blood vessel supplying the brain The standard treatment is lation with Coumadin (warfarin) to prevent further clot development

anticoagu-aortic arch emboli

In recent years a relationship has been demonstrated between sclerosis (fatty deposits in the blood vessel wall) of a portion of the aorta,the main blood vessel carrying blood from the heart, and stroke It is sus-pected that atherosclerosis in this area leads to an irregular surface in-side the aorta, which allows clots to form and subsequently break off.These clots can then block a blood vessel in the brain and cause a stroke.Treatment typically involves Coumadin (warfarin) or aspirin to preventanother stroke

athero-paradoxical emboli

Before birth, there is normally an opening between the two smallerchambers of the heart (known as the atria) In most individuals thisopening closes at birth, but it may remain open in some people through-out adulthood This condition is usually asymptomatic The opening isknown as the “foramen ovale,” and when it remains open after infancy, it

is known as a “patent foramen ovale,” sometimes abbreviated as PFO Inindividuals with normal heart anatomy, the blood coming back from thebody travels through the lungs before being pumped back to the headand body The small blood vessels in the lungs function as a sort of filter,

“catching” any blood clots that may be present This filtering functionprevents any of these clots from traveling to the brain and causing astroke In individuals with a PFO, however, some of the blood returningfrom the body bypasses the lungs and is pumped directly back to thebrain and body If there is a blood clot contained in this blood, it may becarried to the brain and cause a stroke Fortunately, blood clots traveling

in the blood are a relatively uncommon event, so individuals with a PFOmay never have any symptoms Nonetheless, PFO is increasingly recog-nized as a cause of stroke, particularly in young people without otherknown causes for stroke Treatment for a PFO may include anticoagu-lation (Coumadin) or closure of the opening This closure can now beperformed in some centers via a catheter, thus preventing open-heartsurgery

Atherothrombotic Stroke

Atherothrombotic strokes are those that occur as a result of a blockage ofthe blood vessels supplying blood to the brain These are often dividedinto two distinct subgroups: blockages of the small blood vessels withinthe brain (“lacunar strokes”) and blockages of the large vessels supplyingthe brain

to severe weakness of an entire side of the body This type of stroke isstrongly associated with hypertension Blood pressure control and anti-platelet medications (such as aspirin) are the main preventative mea-sures

carotid artery narrowing and blockage

Blockage (“stenosis”) of the large blood vessels in the neck, the carotid teries, can cause stroke (see Figure 2.3) These blockages often developgradually over a long period of time and can be detected through ultra-sound testing Surgical treatment for these blockages is known as an

ar-“endarterectomy” and consists of removal of the inner layers of the bloodvessel creating the blockage This surgery is effective in preventing fu-ture strokes but does carry some risk of stroke at the time of surgery.Having the surgery performed by an experienced surgeon at a center thatdoes a large number of these procedures appears to be the best approachfor minimizing this risk Complete blockage of one of these blood ves-sels (known as a carotid “occlusion”) is generally not amenable to sur-gery, and in such cases medications are used to reduce the risk of futurestroke

Recently, experimental devices have been developed to keep these teries open without surgery These devices, known as “stents,” are placedinside the blood vessel through a nonsurgical procedure in which a long,thin, flexible tube (catheter) is threaded through the blood vessels start-ing in the arm or groin area The stent, a tubular, expandable wire meshdevice, is then placed in the area of blockage using the catheter, and ex-panded to hold the blood vessel open This treatment remains experi-mental and is being studied at a number of centers It is not suitable forall blockages, depending on the specific anatomical issues in each case.Medical treatment with Coumadin (warfarin) or antiplatelet medicationssuch as aspirin or clopidogrel (Plavix) is sometimes used for lesser de-grees of blockage, while the patient awaits surgery, or in individuals whoare unable to undergo surgery Surgery remains the most common treat-ment at present for moderate to severe blockages

ar-vertebrobasilar stenosis

In addition to the two large carotid arteries on each side of the neck,there is a third major artery supplying blood to the brain—the basilar ar-tery The basilar artery receives its blood from two arteries in the neckknown as the vertebral arteries Like the carotid arteries, any or all ofthese arteries may become blocked over time Unfortunately, because oftheir location, these arteries are not presently amenable to surgical treat-

ment Medical treatment (with aspirin, for example) is the usual proach As with carotid artery blockages, research on the use of stents tohold the artery open is ongoing.

sur-cryptogenic stroke

“Cryptogenic” is an elegant way of saying “unknown cause,” and genic strokes are those for which no cause can be determined Despitethe extensive diagnostic tests undertaken, a cause remains unidentifiedfor a significant number of strokes Treatment of these strokes generallyinvolves antiplatelet medications, such as aspirin or Plavix (clopidogrel),

crypto-or Coumadin (warfarin)

figure 2.3 Carotid stenosis.

The carotid arteries are shown in black in this angiogram The narrowing(stenosis) of the internal carotid artery is visible at the arrow

[To view this image, refer to the print version of this title.]

Other Types of Stroke

watershed infarcts and anoxic encephalopathy

Any condition that leads to severely reduced blood pressure and bloodflow can result in a stroke or brain damage Examples of this include afall in blood pressure that occurs during surgery, or temporary loss ofblood flow during a cardiac arrest When blood flow is substantially re-duced, the strokes that result commonly occur in the boundaries be-tween areas of the brain supplied by different arteries, rather than beingcentered in the area supplied by a specific artery These strokes are oftenreferred to as “watershed” infarcts, because they occur at the boundarybetween two areas of blood circulation, or “watersheds.” In some cases,such as cardiac arrest, blood flow to the entire brain is compromised si-multaneously In these cases, damage is more diffuse throughout thebrain, with some areas more sensitive to the injury than others Failure

of blood or oxygen flow to the entire brain is known as an “anoxic” injury(meaning lack of oxygen) Memory problems are often very prominent inthese type of injuries and may be the major long-term effect

arterial dissection

Blockage of a blood vessel leading to a stroke can be caused by a tion that forms between the inner layer of a blood vessel and the outerlayers, resulting in a blockage in the artery This is known as an arterialdissection This is a cause of stroke in otherwise young, healthy individu-als who do not have the usual risk factors for stroke Arterial dissectionoften occurs after a minor injury, often one involving twisting or bending

separa-of the neck, though sometimes no injury can be identified Chiropracticmanipulation of the neck has been found to result in arterial dissection

in a small number of people Some individuals appear to have a geneticpredisposition to this type of stroke, but the exact reason a dissection oc-curs often remains unknown Treatment involves anticoagulation withheparin and then Coumadin (warfarin) for a period of time

asymptomatic In a minority of individuals, however, this increased dency to form clots can lead to a stroke Some hypercoagulable states de-velop as the result of an acquired condition rather than a genetic one.These include antiphospholipid antibody syndrome, in which the bodyforms antibodies against itself, and the hypercoagulable state frequentlypresent in people with cancer Treatment for hypercoagulable conditionsvaries according to the severity and type of disorder and often involvesanticoagulants such as Coumadin (warfarin).

ten-The use of oral contraceptives can increase the risk of clotting what and is implicated as a cause of stroke in some young women Forthis reason, the use of oral contraceptives may be inadvisable in youngwomen who have suffered a stroke, even if they were not using thesemedications at the time of their stroke The combination of smoking andolder age (for example, being in your forties versus your twenties) ap-pears to increase the risk of stroke associated with oral contraceptives

some-migrainous strokes

Migraine headaches are very common, affecting millions of Americans

In a very small number of cases, migraine headaches can be associatedwith stroke in a young adult This is believed to be caused by severespasm of the blood vessels, leading to a blockage of blood supply to a por-tion of the brain The use of oral contraceptives in young women withmigraine headaches seems to increase the risk of this type of stroke

strokes caused by illicit drug use

Certain illicit drugs, most notably cocaine and amphetamines, areknown to cause ischemic strokes or hemorrhagic strokes in a small num-ber of people

cerebral venous thrombosis

This relatively rare type of stroke involves not the blood vessels bringingthe blood to the brain (arteries) but rather the blood vessels that drain the

“used” blood away from the brain (veins) In cerebral venous thrombosis,

a clot develops within these veins, causing the blood to “back up” withinthe brain This results in a stroke, which can develop superimposedbleeding in some cases (see “Hemorrhagic Conversion”) The treatmentfor this type of stroke is anticoagulants such as heparin and Coumadin

Cerebral Hemorrhage

Cerebral hemorrhage, or bleeding in the brain, has several causes though the effects of cerebral hemorrhage resemble ischemic stroke inmany ways, their causes are quite distinct

Al-hypertensive hemorrhage

Elevated blood pressure can cause rupture of a blood vessel within thebrain, known as a hypertensive hemorrhage The worse the hyperten-sion, the higher the likelihood of such a hemorrhage occurring In afamous example, Franklin D Roosevelt died in office of a cerebral hem-orrhage caused by uncontrolled hypertension Fortunately, many medi-cations to control high blood pressure are now available, allowing ef-fective blood pressure control in the vast majority of individuals withhypertension

cerebral amyloid angiopathy

In some older individuals, an abnormal protein is deposited in the walls

of the blood vessels in the brain, causing the blood vessels to becomefragile This can result in rupture of the blood vessels and cerebral hem-orrhage This condition, known as cerebral amyloid angiopathy (CAA),can be difficult to diagnose with certainty in some cases Unfortunately,there is no effective treatment for this disorder at the present time, andrecurrent hemorrhages are possible Avoiding medications known to in-crease the risk of bleeding, such as aspirin or Coumadin (warfarin), aswell as alcohol is advised Good control of hypertension, if present, isalso advisable, since elevated blood pressure may increase the risk of ahemorrhage due to cerebral amyloid angiopathy Research on possibletreatments for this condition is ongoing (see Appendix)

aneurysms

There are several types of malformations of the blood vessels that cancause a hemorrhagic stroke One of the more common types is an aneu-rysm, which is an out-pouching of one of the larger arteries in the brain(see Figure 2.4) Aneurysms tend to run in families and can be asymp-tomatic for many years Larger aneurysms have a greater risk of burstingand typically cause bleeding around the brain rather than inside it This

type of bleeding is known as a subarachnoid hemorrhage The effects of

a ruptured aneurysm vary widely, ranging from severe headache withoutany other neurological problems to coma and even death Surgery to

“clip” the aneurysm or catheter placement of small detachable wire coils

to clot off the aneurysm are the usual treatments In some cases, thebleeding around the brain irritates the blood vessels of the brain, whichcan spasm so severely that blood supply to an area of the brain is inter-rupted, and a stroke occurs Medications such as nimodipine (Nimotop)are used to prevent this complication of subarachnoid hemorrhage,though they are not always effective

arteriovenous malformations (avms)

Another type of blood vessel malformation is an arteriovenous mation, or AVM (see Figure 2.5) An AVM is a complicated tangle of ab-normal arteries and veins in the brain that may grow over time Some-times the growth of the AVM can cause symptoms by itself, withoutactually bleeding Commonly, however, these malformations bleed intothe brain owing to the fragility of the abnormal blood vessels contained

malfor-in the AVM If the hemorrhage is large and the AVM was not previouslyidentified, it may be difficult to find the AVM on the initial scans of thebrain, since the blood may obscure it If AVM is suspected, follow-up

AneurysmIntracranial artery

figure 2.4 Cerebral aneurysm.

This diagram shows an outpouching of the blood vessel (aneurysm), whichcan rupture and lead to bleeding around the brain

scans are often advised in order to examine the brain after the rhage has been reabsorbed Treatment for AVMs also involves the use ofcatheter-delivered coils to reduce the size of the AVM or block off the ma-jor blood vessel “feeding” (providing blood to) the AVM Surgery mayalso be used to remove all or part of the AVM Finally, radiation therapycan be used to shrink the AVM A combination of these techniques issometimes used, with coils or radiation used to reduce the size, followed

hemor-by surgery to remove the remaining AVM

hemorrhagic conversion

In some cases, a stroke can start out as an infarct, but then bleedingoccurs into the area of the stroke This is known as a “hemorrhagic con-version” of the stroke The superimposed hemorrhage may be large or

Vein

Arteriovenousmalformation (AVM)

Artery

figure 2.5 Arteriovenous malformation (AVM).

This diagram shows a tangle of abnormal fragile blood vessels connecting anartery with a vein in the brain

small Small hemorrhages are often of little significance, since they are

in the middle of an area of brain tissue that has already been irreparablydamaged In larger hemorrhagic conversions, however, the hemorrhagemay cause as much or more damage than the original stroke Hemor-rhagic conversion usually occurs in larger strokes and may be related insome cases to the use of anticoagulants (heparin or Coumadin) Often nospecific treatment is needed, though anticoagulants are commonly dis-continued when hemorrhagic conversion occurs The risk of hemor-rhagic conversion exists primarily within the first few weeks after strokeand is uncommon afterward

Stroke-Like Conditions

A number of conditions affect the brain and can cause symptoms similar

to those seen after stroke These include any condition that results in

a localized injury to the brain Brain tumors, both benign (such as ameningioma—a tumor of the lining of the brain) and malignant (arising

in the brain, or coming from another part of the body) frequently causestroke-like problems These most commonly have a more gradual on-set—weakness that gets worse over a period of weeks, for example—rather than the sudden onset more typical of stroke Multiple sclerosiscan produce symptoms that are similar to those resulting from stroke.Trauma to the brain (for example, from a car accident) often producesmore diffuse damage to the brain than stroke does, and tends to result in

a different though overlapping set of problems A detailed discussion oftraumatic brain injury is beyond the scope of this book (see Appendix forresources)

brain abscess

Like any other organ of the body, the brain can develop infections A lection of pus can develop in severe brain infections, known as a brainabscess Brain abscesses can result from dental infections, heart valveand bloodstream infections, or other infections elsewhere in the body.Headache and fever are common, and symptoms often develop moregradually than in a stroke Treatment includes surgical drainage of theinfection and intravenous antibiotics Once the brain abscess is treated,the aftereffects are often very similar to those of stroke

col-Most stroke-like conditions can be distinguished fairly easily fromstroke by the medical history and by CT or MRI images From the per-spective of patients and their families, stroke-like conditions presentmany of the same challenges as stroke and may pose some additionalchallenges as well In the case of brain tumors, there may be a need for

figure 2.6 Subdural hematoma.

The collection of blood between the brain and the skull (subdural

hematoma) in this CT scan appears as a lighter-colored crescent-shaped area

on the left

[To view this image, refer to the print version of this title.]

surgery, followed by radiation and/or chemotherapy in some instances.

In cases where these conditions are not curable (unfortunately, still acommon situation), the likelihood of progression of the cancer creates avery different and complex set of issues beyond those caused by the neu-rological damage itself

Stroke Prevention

Roberta, whom we met in the first chapter, is found to have a stroke caused

by a blockage affecting her left middle cerebral artery Further evaluation veals that she has an irregular heartbeat, known as atrial fibrillation Afterdiscussing the risks and benefits of treatment with Roberta and her family,her doctor starts her on Coumadin (warfarin) to reduce the risk of any fu-ture strokes Is this the best treatment for stroke prevention? What else canRoberta do to reduce her risk of another stroke?

re-Prevention of Ischemic Stroke

Medications

Stroke prevention through the use of medication is a rapidly evolvingarea, and new data are becoming available all the time This discussion isintended to provide general information rather than a guide to specificcare Several broad classes of treatment are currently available and will

be discussed as categories

antiplatelet medications

Platelets are small particles that circulate in the bloodstream and helpform blood clots to prevent or stop bleeding Since blood clots are an im-portant factor in causing strokes, medications that interfere with plateletfunction can be useful in preventing stroke A number of medicationshave been developed for this purpose, including aspirin, an aspirin/dipyridamole combination (Aggrenox), clopidogrel (Plavix), and ticlopi-dine (Ticlid) All these medications have been found to be effective in re-

ducing the risk of a second stroke and are also useful in individuals athigh risk of a first stroke (for example, people who have had TIAs) Whilegenerally well tolerated, aspirin (and Aggrenox, which contains aspirin)can cause stomach upset or even ulcers in some people Ticlopidine, andless frequently Plavix, can cause blood abnormalities in some people Aswith any medication intended to interfere with blood clotting, antiplate-let medications do increase the risk of abnormal bleeding somewhat Butthey are less risky in this regard than certain other medications, such asCoumadin (warfarin) Antiplatelet medications are generally the drugs ofchoice for prevention of lacunar strokes (those resulting from blockage

of the small blood vessels) and strokes without a clear cause Overall,these are effective, important, and well-tolerated medications for the pre-vention of stroke

warfarin (coumadin)

Warfarin, commonly referred to by its brand name, Coumadin, is a erful anticoagulant (sometimes known as a “blood thinner,” a mislead-ing term) that interferes with blood-clot formation Coumadin requirescareful adjustment, as too small a dose is ineffective, whereas too large adose can be quite dangerous Individual dose requirements vary widelyand dosing must be individualized Blood must be tested frequently—of-ten weekly until a stable dose is achieved This blood test, known as a

pow-“Protime,” measures the time required for a component of blood clots toform and is usually reported as an International Normalized Ratio, orINR INR target values vary with the cause of the stroke and may be indi-vidualized to some extent Physicians prescribing Coumadin determinethis range on the basis of the diagnosis, and take into consideration theincreased risk of bleeding at higher INR values, as well as the risk of in-sufficient protection against stroke at lower INR values

The Coumadin dosage required to keep the INR at the right level mayvary over time Changes in diet and other medications can require sig-nificant changes in Coumadin dose For this reason, periodic monitoringthrough blood tests is required as long as someone is taking Coumadin.Changes in dosage are commonly required

Coumadin is the preferred preventative treatment for strokes that arecaused by blood clots forming in the heart, such as atrial fibrillation It isoften used for other types of stroke as well, though controversy persists