Ask a hundred people above the age of 60 what they fear, and you may be surprised by the responses. While we may assume peoples’ greatest fear is death, those who give it some thought will say “I fear being dependent on others, unable to care for myself”. The unspoken part of that response is the understood loss of dignity that accompanies it. One of the most dreaded consequences of cardiovascular disease is remaining alive but permanently injured, without use of an arm or a leg, unable to speak, unable to remember events in your past, unable to feed yourself, clothe yourself, or clean yourself. The loss of dignity, to a person who has been strong and independent all their life, can be crushing to their spirit and to their will to live. Two out of every three stroke survivors (those lucky enough to survive) will be left with permanent neurologic damage (ref: https://www.medicalnewstoday.com/articles/310769.php) This is the reality of someone who suffers a stroke.
A stroke is to the brain what a heart attack is to the heart. A stroke can occur when an artery in the brain bleeds, and the brain downstream from the bleed does not receive adequate oxygen. This is called a hemorrhagic stroke. A stroke can also occur if a particle, called an embolus, gets lodged in an artery in the brain, and obstructs blood flow downstream. This is called an embolic stroke, or ischemic stroke. Ischemia refers to deprivation of oxygen to living tissue. The embolus may be a blood clot, a piece of calcium that broke off from an artery wall, a piece of infected heart valve, a globule of fat, or even a bubble of air. 80-87% of strokes are ischemic strokes, and only 13-20% are hemorrhagic in nature (ref: https://www.uabmedicine.org/patient-care/conditions/stroke/utm_source=google&utm_medium=cpc&utm_content=stroke4&utm_campaign=UABmedneuro&gclid=Cj0KCQiAh9njBRCYARIsALJhQkH4rJBwfbeL_alQSclCCKNBFXjFV644f-9jdY9oRaFI8Q9m4pRHE5AaAnkUEALw_wcB )
Precious little is understood about the specific function of specific locations in the brain. We can speak in general terms, but no two individuals are the same, so the loss of specific functions cannot be predicted at the outset of a stroke. We also have limited tools at our disposal to treat a stroke. Since most emboli are blood clots, early treatment of strokes consisted of chewing aspirin and starting blood thinners. Prior to the use of blood thinners, a CT scan would be required to exclude the hemorrhagic variety of stroke, since giving blood thinners in that setting would make the bleeding worse.
As researched continued to evolve in treatment of stroke, protocols were developed to provide clot dissolving agents, if the stroke was discovered quickly enough and brought to medical attention within a certain window of time, less than 4.5 hours (ref: https://www.mayoclinic.org/diseases-conditions/stroke/diagnosis-treatment/drc-20350119 ).
While we consider American healthcare technology to be the most advanced in the world, it is humbling when we hear of doctors in another country performing delicate high risk procedures that we are not yet performing in the US! Nearly 20 years ago, the grandfather of one of the cardiology fellows in my training program underwent “embolectomy”, or removal of the clot, from inside an artery in his brain, by an interventional radiologist in Seoul, South Korea. In certain highly specialized centers in the United States, this technique may be performed, but the availability is limited to major metropolitan areas. The embolus retrieval is usually coupled with the use of clot dissolving medication.
Other research is focusing on the use of stem cells, delivered directly into the injured brain tissue, with the hope that the stem cells differentiate into viable brain tissue and replace the damaged tissue. In research studies performed thus far, the direct injection of Induced Pluripotent Stem Cells appear to show the greatest promise of a meaningful recovery following an ischemic stroke (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5808289/). Further research needs to be conducted in this field to fine tune the process and demonstrate in controlled clinical trials an improvement in neurologic function with minimal untoward effects, such as cell growth out of control, aka cancer.
Post-stroke care centers around physical therapy for gross motor loss (arm and leg strength loss), speech therapy (for slurred speech following stroke) occupational therapy (for fine hand movements such as using a writing instrument, using eating utencils, performing morning hygiene rituals, or regaining fine motor skills associated with occupations such as graphic design and performing surgical procedures). Since clinical depression is so common following a stroke, a psychiatrist may be involved in the health care team to address the symptoms of depression, which can include loss of motivation. A major thrust of this post-stroke care is to prevent recurrent stroke, which is where the patient must be motivated to participate. The next paragraph discusses how you can play an active role in preventing a stroke.
What Can You Do To Prevent a Stroke?
Control blood pressure – High blood pressure is the single biggest risk factor for stroke. There is a very close correlation to stroke risk and uncontrolled blood pressure. By cutting down on salt and caffeine intake, exercising more, and quitting smoking, you can help control your blood pressure, and can cut your stroke risk in half. (Redefining Blood-Pressure Targets--SPRINT Starts the Marathon. Perkovic V, Rodgers A N Engl J Med. 2015 Nov 26;373(22):2175-8 )
Treat atrial fibrillation – since atrial fibrillation increases risk of a stroke, it is important to follow the advice of your cardiologist, and participate in the discussion about blood thinners, rate control medication, and possibly converting the atrial fibrillation back to normal sinus rhythm with medications or with electric shock. The AFFIRM research trial showed that controlling the heart rate and thinning the blood was equally effective as a strategy that included cardioversion. And while blood thinners do carry bleeding risk, the stroke risk of not taking blood thinners is greater than the bleeding risk of the blood thinner. It is a trade-off that you need to understand. (https://www.nejm.org/doi/full/10.1056/NEJMoa021328 )
Lose weight – At first blush, this sounds like a strange idea, but weight loss will get blood pressure and blood sugar under better control, which will reduce your risk of a stroke. A low salt diet, along with a plant based diet that is less dependent on red meats will help you take great strides in achieving your ideal body weight, and cutting your risk.
Smoking cessation. A very important action for a stroke patient who smokes is to quit all tobacco products. Tobacco causes spasm of arteries, which can be sufficient to dislodge an embolus which can travel to your brain. There is a high correlation with smoking and stroke, and ongoing smoking with recurrent stroke.
Exercise – This has many cardiovascular benefits. Exercise lowers blood pressure, helps reduce weight, reduces stress on joints, increases cardiac and pulmonary exercise capacity, and promotes better heart health in addition to reducing risk of stroke. (https://www.health.harvard.edu/womens-health/8-things-you-can-do-to-prevent-a-stroke )
The National Stroke Association is trying to increase awareness of stroke symptoms by publicizing the mnemonic FAST. It stands for FACE – ARMS – SPEECH -TIME (https://www.stroke.org/ )
FACE – does one side of your face droop when you smile?
ARMS – Is one arm suddenly weaker than the other arm?
SPEECH – do you have new slurred speech?
TIME – Act quickly. If you have any of these symptoms, call 911 immediately.
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