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Stroke

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Stroke



Introduction 

A stroke is a serious, life-threatening medical condition that occurs when the blood supply to part of the brain is cut off.

Strokes are a medical emergency and urgent treatment is essential because the sooner a person receives treatment for a stroke, the less damage is likely to happen.

If you suspect that you or someone else is having a stroke, phone 999 immediately and ask for an ambulance.

Signs and symptoms

The main symptoms of stroke can be remembered with the word FAST: Face-Arms-Speech-Time.


Face – the face may have dropped on one side, the person may not be able to smile or their mouth or eye may have dropped.

Arms – the person with suspected stroke may not be able to lift both arms and keep them there because of arm weakness or numbness in one arm.

Speech – their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake.

Time – it is time to dial 999 immediately if you see any of these signs or symptoms.


Why do strokes happen?

Like all organs, the brain needs the oxygen and nutrients provided by blood to function properly. If the supply of blood is restricted or stopped, brain cells begin to die. This can lead to brain injury, disability and possibly death.

There are two main causes of strokes:


ischaemic – where the blood supply is stopped due to a blood clot (this accounts for 85% of all cases)

haemorrhagic – where a weakened blood vessel supplying the brain bursts


There is also a related condition known as a transient ischaemic attack (TIA), where the supply of blood to the brain is temporarily interrupted, causing a 'mini-stroke' often lasting between 30 minutes and several hours. TIAs should be treated seriously as they are often a warning sign that you are at risk of having a full stroke in the near future.

Who is at risk?

The brain injuries caused by strokes are a major cause of adult disability. Older people are most at risk of having strokes, although they can happen at any age – including in children.

If you are south Asian, African or Caribbean, your risk of stroke is higher. This is partly because of a predisposition (a natural tendency) to developing high blood pressure (hypertension), which can lead to strokes. Smoking, being overweight, lack of exercise and a poor diet are also risk factors for stroke, as are high cholesterol, atrial fibrillation anddiabetes.

How strokes are treated

Treatment depends on the type of stroke you have, including which part of the brain was affected and what caused it.

Most often, strokes are treated with medication. This generally includes medicines to prevent and remove blood clots, reduce blood pressure and reduce cholesterol levels.

In some cases, surgery may be required to treat brain swelling and reduce the risk of further bleeding in cases of haemorrhagic strokes.

Life after a stroke

Around one in every four people who has a stroke will die, and those who do survive are often left with long-term problems resulting from the injury to their brain.

Some people need to have a long period of rehabilitation before they can recover their former independence, while many will never fully recover and will need support adjusting to living with the effects of their stroke. Around half the people who have a stroke will be dependent on some form of care for help with their daily activities.

The process of rehabilitation will be specific to you, and will depend on your symptoms and how severe they are. A team of specialists are available to help, including physiotherapists, psychologists, occupational therapists, speech therapists and specialist nurses and doctors.

Can strokes be prevented?

You can significantly reduce your risk of having a stroke through a healthy lifestyle, such as eating a healthy diet, taking regular exercise, drinking alcohol in moderation and not smoking.

Lowering high blood pressure and cholesterol levels with medication also lowers the risk of stroke substantially, as does taking anticoagulant medication if you have an irregular heartbeat due to a condition called atrial fibrillation. If you have had a stroke or TIA in the past, these measures are particularly important because your risk of having another stroke in the future is greatly increased.

Symptoms and signs of stroke 

If you suspect that you or someone else is having a stroke, phone 112 immediately and ask for an ambulance.

Even if the symptoms of a stroke disappear while you are waiting for the ambulance to arrive, you or the person having the stroke should still go to hospital for an assessment.

Symptoms that disappear quickly (and in less than 24 hours) may mean you have had a transient ischaemic attack (TIA) and you could be at risk of having a full stroke in the near future.

After an initial assessment, you may need to be admitted to hospital to receive a more in-depth assessment and, if necessary, for specialist treatment to begin.

Recognising the signs of a stroke

The signs and symptoms of a stroke vary from person to person but usually begin suddenly. As different parts of your brain control different parts of your body, your symptoms will depend on the part of your brain affected and the extent of the damage.

The main stroke symptoms can be remembered with the word FAST: Face-Arms-Speech-Time.


Face – the face may have dropped on one side, the person may not be able to smile or their mouth or eye may have drooped.

Arms – the person with suspected stroke may not be able to lift both arms and keep them there because of arm weakness or numbness in one arm.

Speech – their speech may be slurred or garbled, or the person may not be able to talk at all despite appearing to be awake.

Time – it is time to dial 999 immediately if you notice any of these signs or symptoms.


It is important for everyone to be aware of these signs and symptoms. If you live with or care for somebody in a high-risk group, such as someone who is elderly or has diabetes or high blood pressure, being aware of the symptoms is even more important.

Other possible symptoms 

Symptoms in the FAST test identify most strokes, but occasionally a stroke can cause different symptoms.

Other symptoms and signs may include:


complete paralysis of one side of the body

sudden loss or blurring of vision 

dizziness

confusion

difficulty understanding what others are saying

problems with balance and co-ordination 

difficulty swallowing (dysphagia)

a sudden and very severe headache resulting in a blinding pain unlike anything experienced before

loss of consciousness


However, there are usually other causes for these symptoms.

'Mini-stroke' or transient ischaemic attack (TIA)

The symptoms of a TIA are the same as a stroke, but they tend to only last between a few minutes and a few hours before disappearing completely.

Although the symptoms do improve, a TIA should never be ignored as it is a serious warning sign there is a problem with the blood supply to your brain and means you are at an increased risk of having a stroke in the near future. If you have had a TIA, you should contact your GP, local hospital orout-of-hours service, as soon as possible.

Causes of stroke 

There are two main types of stroke – ischaemic strokes and haemorrhagic strokes – which affect the brain in different ways and can have different causes. 

Ischaemic strokes

Ischaemic strokes are the most common type of stroke. They occur when a blood clot blocks the flow of blood and oxygen to the brain.

These blood clots typically form in areas where the arteries have been narrowed or blocked over time by fatty deposits known as plaques. This process is known as atherosclerosis.

As you get older, the arteries can naturally narrow, but certain things can dangerously accelerate the process. These include:


smoking 

high blood pressure (hypertension) 

obesity

high cholesterol levels

diabetes

an excessive alcohol intake


Another possible cause of ischaemic stroke is a type of irregular heartbeat called atrial fibrillation, which can cause blood clots in the heart that break up and escape from the heart and become lodged in the blood vessels supplying the brain. Atrial fibrillation can have a number of different causes, including lung disease, heart valve disease, excessive alcohol intake, coronary heart disease, and an overactive thyroid gland 

Haemorrhagic strokes

Haemorrhagic strokes (also known as cerebral haemorrhages or intracranial haemorrhages) are less common than ischaemic strokes. They occur when a blood vessel within the skull bursts and bleeds into and around the brain. The main cause of haemorrhagic stroke is high blood pressure, which can weaken the arteries in the brain and make them prone to split or rupture.

Things that increase the risk of high blood pressure include:


being overweight or obese

drinking excessive amounts of alcohol 

smoking

a lack of exercise 

stress, which may cause a temporary rise in blood pressure


Haemorrhagic strokes can also occur as the result of the rupture of a balloon-like expansion of a blood vessel (brain aneurysm) and badly-formed blood vessels in the brain.

Can I reduce my risk?

It's not possible to completely prevent strokes because some things that increase your risk of the condition cannot be changed, including:


age – you are more likely to have a stroke if you are over 65 years old, although about a quarter of strokes happen in younger people

family history– if a close relative (parent, grandparent, brother or sister) has had a stroke, your risk is likely to be higher

ethnicity – if you are south Asian, African or Caribbean, your risk of stroke is higher, partly because rates of diabetes and high blood pressure are higher in these groups

your medical history – if you have previously had a stroke,transient ischaemic attack (TIA) or heart attack, your risk of stroke is higher


However, in most cases it is possible to significantly reduce your risk of having a stroke by making lifestyle changes to avoid problems such as atherosclerosis and high blood pressure. This includes things such as having a healthy diet, exercising regularly, stopping smoking if you smoke and cutting down on the amount of alcohol you drink.

As atrial fibrillation can also significantly increase your risk of having a stroke, it is also important to seek medical advice if you think you may have an irregular heartbeat. If you are diagnosed with the condition, you should talk to your doctor about the option of taking anticoagulant medications to lower your stroke risk.

Diagnosing stroke 

Strokes are usually diagnosed by carrying out physical tests andstudying images of the brain produced during a scan.

A number of tests can then be carried out to help confirm the diagnosis and determine the cause of the stroke.

This may include blood tests to determine your cholesterol and blood sugar levels, checking your pulse for an irregular heartbeat and taking a blood pressure measurement.

Brain scans

Even if the physical symptoms of a stroke are obvious, brain scans should also be carried out to determine:


if the stroke has been caused by a blocked artery (ischaemic stroke) or burst blood vessel (haemorrhagic stroke)

which part of the brain has been affected

how severe the stroke is


Different treatment is required for the different types of stroke, so a rapid diagnosis will make treatment more straightforward.

Everyone with suspected stroke should receive a brain scan within 24 hours and some people should be scanned within an hour of the onset of symptoms, especially those who:


might benefit from clot-busting drugs (thrombolysis) such as alteplase or early anticoagulant treatment

are already on anticoagulant treatments

have a lower level of consciousness


This is why a stroke is a medical emergency and why 999 should be dialled when a stroke is suspected – there isn’t time to wait for a GP appointment.

The two main types of scan used to assess the brain in people who have had a suspected stroke are a computerised tomography (CT) scan and a magnetic resonance imaging (MRI) scan. The type of scan you may have largely depends on your symptoms.

CT scans

A CT scan is like an X-ray, but uses multiple images to build up a more detailed, three-dimensional picture of your brain to help your doctor identify any problem areas.

During the scan, you may be given an injection of a special dye into one of the veins in your arm to help improve the clarity of the CT image and look at the blood vessels that supply the brain.

If it is suspected you are experiencing a major stroke, a CT scan is usually able to show whether you have had an ischaemic stroke or a haemorrhagic stroke. It's generally quicker than an MRI scan and can mean you are able to receive appropriate treatment sooner.

MRI scans

An MRI scan uses a strong magnetic field and radio waves to produce a detailed picture of the inside of your body.

For people with more complex symptoms, where the extent or location of the damage is unknown – and in people who have recovered from atransient ischaemic attack (TIA) – an MRI scan is more appropriate. This will provide greater detail of brain tissue, allowing smaller, or more unusually located areas affected by a stroke to be identified.

As with a CT scan, special dye can be used to improve MRI scan images.

Swallow tests

A swallow test is essential for anybody who has had a stroke, as swallowing ability is commonly affected early after a stroke.

When a person cannot swallow properly, there is a risk that food and drink may get into the windpipe and then into the lungs (called aspiration), which can lead to chest infections such as pneumonia. The test is simple. The person is given a few teaspoons of water to drink. If they can swallow this without choking and coughing they will be asked to swallow half a glass of water. If they have any difficulty swallowing, they will be referred to the speech and language therapist for a more detailed assessment.

They will usually not be allowed to eat or drink normally until they have seen the therapist and may therefore need to have fluids or food given directly into an arm vein (intravenously) or through a tube inserted into their stomach via their nose.

Heart and blood vessel tests 

Further tests on the heart and blood vessels might be carried out later to confirm what caused your stroke. Some of the tests that may be carried out are described below.

Carotid ultrasound

A carotid ultrasound scan can help show if there is any narrowing or blockages in the neck arteries leading to your brain.

An ultrasound scan involves using a small probe (transducer) to send high-frequency sound waves into your body. When these sound waves bounce back, they can be used to create an image of the inside of your body. When carotid ultrasonography is needed, it should happen within 48 hours.

Echocardiography

In some cases another type of ultrasound scan called an echocardiogram may be carried out to produce images of your heart and check for any problem with it that could be related to your stroke. This will normally involve using an ultrasound probe moved across your chest (transthoracic echocardiogram). In some cases, an alternative type of echocardiogram called transoesophageal echocardiography (TOE) may also be used.

This involves passing an ultrasound probe down your gullet (oesophagus), usually under sedation. As this allows the probe to be placed directly behind the heart, it produces a clear image of blood clots and other abnormalities that may not get picked up by a transthoracic echocardiogram.

Treating stroke 

Effective treatment of stroke can prevent long-term disability and save lives.

The specific treatments recommended depend on whether a stroke is caused by a blood clot obstructing the flow of blood to the brain (ischaemic stroke) or by bleeding in or around the brain (haemorrhagic stroke). Treatment will usually involve taking one or more different medications, although some people may also need surgery.

The main treatment strategies for the two types of stroke are outlined below.




Treating ischaemic strokes  



If you have had an ischaemic stroke, a combination of medications to treat the condition and prevent it from happening again will usually be recommended. Some of these medications will need to be taken immediately and only for a short time, while others may only be started once the stroke has been treated and may need to be taken in the long-term.

Thrombolysis

Ischaemic strokes can often be treated using injections of a medication called alteplase that dissolves blood clots and restores the flow of blood to the brain. This use of 'clot-busting' medication is known as thrombolysis.

Alteplase is most effective if started as soon as possible after the stroke occurs and is not generally recommended if more than four and a half hours have passed because it's not clear how beneficial it is when used after this time.

However, before alteplase can be used, it is very important that a brain scan to confirm a diagnosis of an ischaemic stroke is carried out because the medication can make the bleeding that occurs in haemorrhagic strokes worse.

Antiplatelets

Most people will also be offered a regular dose of aspirin which – as well as being a painkiller – makes the cells in your blood called platelets less sticky, reducing the chances of another clot forming. In addition to aspirin, other antiplatelet medicines such asclopidogrel and dipyridamole are also available.

Anticoagulants

Some people may also be offered an additional medication called an anticoagulant to help reduce their risk of developing further blood clots in the future.

Anticoagulants prevent blood clots by changing the chemical composition of the blood in a way that prevents clots from occurring. Warfarin, rivaroxaban, dabigatran and apixaban are examples of anticoagulants for long term use. There are also a number of anticoagulants called heparins that can only be given by injection and are used in the short-term.  

Anticoagulants may be offered if you:


have a type of irregular heartbeat called atrial fibrillation that can cause blood clots

have a history of blood clots

are at risk of developing clots in your leg veins – known asdeep vein thrombosis (DVT) – because a stroke has left you unable to move one of your legs


Antihypertensives

If your blood pressure is too high, you may be offered medicines to lower it. Medicines that are commonly used include:


thiazide diuretics

angiotensin-converting enzyme (ACE) inhibitors

calcium channel blockers

beta-blockers

alpha-blockers


Statins

If the level of cholesterol in your blood is too high, you will be advised to take a medicine known as a statin. Statins reduce the level of cholesterol in your blood by blocking an enzyme (chemical) in the liver that produces cholesterol. You may be offered a statin even if your cholesterol level is not particularly high, because a statin may help reduce your risk of stroke whatever your cholesterol level is.

Carotid endarterectomy

Some ischaemic strokes are caused by narrowing of an artery in the neck called the carotid artery, which carries blood to the brain. The narrowing, known as carotid stenosis, is caused by a build-up of fatty plaques.

If the carotid stenosis is particularly severe, surgery may be offered to unblock the artery. This is done using a surgical technique called a carotid endarterectomy. It involves the surgeon making an incision in your neck to open up the carotid artery and remove the fatty deposits.

Recovering after a stroke 

The injury to the brain caused by a stroke can lead to widespread and long-lasting problems.

Although some people may recover quite quickly, many people who have a stroke will need long-term support to help them manage any difficulties they have and regain as much independence as possible.

This process of rehabilitation will be specific to you, and will depend on your symptoms and their severity. It will often start while you are still in hospital and will continue at home or at a local clinic in your community once you are well enough to leave.

A team of specialists are available to help with your rehabilitation, including physiotherapists, psychologists, occupational therapists, speech therapists and specialist nurses and doctors.

You will be encouraged to actively participate in the rehabilitation process and will work with your care team to set goals you want to achieve during your recovery.

The different treatment and rehabilitation methods for some of the main problems caused by strokes are outlined below.

Want to know more?


The Stroke Association: common problems after stroke

Healthtalkonline: real stories about living with stroke

NICE: stroke rehabilitation



Psychological impact  



Two of the most common psychological problems that can affect people after a stroke are:


depression – many people experience intense bouts of crying and feel hopeless and withdrawn from social activities 

anxiety – where people experience general feelings of fear and anxiety, sometimes punctuated by intense, uncontrolled feelings of anxiety (anxiety attacks)


Feelings of anger, frustration and bewilderment are also common.

You will receive a psychological assessment from a member of your healthcare team soon after your stroke to check if you are experiencing any emotional problems.

Advice should be given to help deal with the psychological impact of stroke. This includes the impact on relationships with other family members and any sexual relationship. There should also be a regular review of any problems of depression and anxiety, and psychological and emotional symptoms generally.

These problems may settle down over time but if they are severe or last a long time, GPs can refer people for expert healthcare from a psychiatrist or clinical psychologist.

For some people, medicines and psychological therapies, such as counselling or cognitive behavioural therapy (CBT) can help. CBT is a therapy that aims to change the way you think about things to produce a more positive state of mind.

Want to know more?


The Stroke Association: emotional changes after stroke (PDF, 347kb)

The Stroke Association: Stroke Helpline



Preventing strokes 

The best way to help prevent a stroke is to eat a healthy diet, exercise regularly and avoid smoking and drinking too much alcohol.

These lifestyle changes can reduce your risk of problems such as atherosclerosis (where arteries become clogged up by fatty substances), high blood pressure and high cholesterol levels, all of which are important risk factors for strokes.

If you have already had a stroke, making these changes can help reduce your risk of having another one in the future.

Diet

An unhealthy diet can increase your chances of having a stroke because it may lead to an increase in your blood pressure and cholesterol levels.

Therefore, a low-fat, high-fibre diet is usually recommended, including plenty of fresh fruit and vegetables (five portions a day) and whole grains.

Ensuring a balance in your diet is important. Don’t eat too much of any single food – particularly foods that are high in salt and processed foods.

You should limit the amount of salt you eat to no more than 6g (0.2oz) a day because too much salt will increase your blood pressure. Six grams of salt is about one teaspoonful.

Exercise

Combining a healthy diet with regular exercise is the best way to maintain a healthy weight, and regular exercise can also help lower your cholesterol level and keep your blood pressure at a healthy level.

For most people, at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week is recommended.

If you are recovering from a stroke, you should discuss possible exercise plans with the members of your rehabilitation team. Regular exercise may not be possible in the first weeks or months following a stroke but you should be able to begin exercising once your rehabilitation has progressed.

Stop smoking

Smoking significantly increases your risk of having a stroke. This is because it narrows your arteries and makes your blood more likely to clot.

If you stop smoking, you can reduce your risk of having a stroke. Not smoking will also improve your general health and reduce your risk of developing other serious conditions, such as lung cancer and heart disease.

Cut down on alcohol

Excessive alcohol consumption can lead to high blood pressure and trigger irregular heartbeat (atrial fibrillation), both of which can increase your risk of having a stroke.

Because alcoholic drinks are high in calories they also cause weight gain. Heavy drinking multiplies the risk of stroke by more than three times.

If you choose to drink alcohol and have fully recovered, you should aim not to exceed the recommended limits. These are:


men should not regularly drink more than 3-4 units of alcohol a day

women should not regularly drink more than 2-3 units a day


If you have not fully recovered from your stroke, you may find that you will have become particularly sensitive to alcohol and even the recommended safe limits as above for the general population may be too much for you. 

Managing underlying conditions

If you have been diagnosed with a condition known to increase your risk of stroke – such as high cholesterol, high blood pressure, atrial fibrillation, diabetes or a transient ischaemic attack (TIA) – ensuring the condition is well controlled is also important in helping prevent strokes.

The lifestyle changes mentioned above can help control these conditions to a large degree, but you may also need to take regular medication.