April 2021
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A stroke or brain attack occurs when the blood supply to part of your brain is interrupted or reduced, preventing brain from getting oxygen and nutrients. Brain cell begin to die in minutes.

A stroke is a medical emergency and prompt treatment is crucial. Early action can reduce brain damage and other complications.

Symptoms: If you suspect yourself or someone with you might be having a stroke, pay particular attention to the time the symptoms began. Some treatment options are most effective when give soon after a stroke begins.

Signs & Symptoms of stroke include:

* Trouble speaking and understanding what others are saying. You may experience confusion or have difficulty in understanding speech.
*Paralysis or numbness of the face, arm or leg. You may develop sudden numbness, weakness or paralysisin your face, arm or leg. This often affects just one side of your body. Try to raise both your arms above your head at the same time. If one arm beginsto fall, you may be having a stroke. Also, one side of your mouth may droop when you try to smile.
*Problems seeing in one or both eyes. You may suddenly have blurred or blackened vision in one or both eyes, and you may see double.
*Headache. A sudden severe headache, which may be accompanied by vomiting, dizziness or altered consciousness might be an indication of stroke.
*Trouble walking. You may stumble or lose your balance. You might also have sudden vertigo or loss of coordination.

When to see a Doctor

Seek immediate medical attention if you notice any sign or symptom of stroke, even if they seem to come and go or they disappear completely. Think “FAST” 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 downwards? Or is the person unable to raise one arm?
*Speech. Ask the person to repeat a simple phrase. Is the person’s speech slurred or strange?
*Time. If you observe any of these signs, emergency medical help is needed immediately.

Do not wait to see if the symptoms stop. Every minute counts. The longer a stroke goes untreated, the greater the potential for brain damage and disability.

If you are with someone whom you suspect is having a stroke, watch the person carefully while waiting for emergency assistance.


There are two main causes of stroke: a blocked artery (ischaemic stroke) or leaking or bursting of a blood vessel (haemorrhagic stroke).
Some people may have only a temporary disruption of blood flow to the brain, known as a transient ischaemic attack (TIA), that doesn’t cause lasting symptoms.

Ischaemic stroke

This is the most common type of stroke. It happens when the brain’s blood vessels become narrowed or blocked, causing severely reduced blood flow (ischemia). Blocked or narrowed blood vessels are caused by fatty deposits that build up in blood vessels or by blood clots or other debris that travel through your bloodstream and lodge in the blood vessels in the brain.
Recent research shows that COVID-19 infection may be a possible cause of ischaemic stroke, but more study is needed.

Haemorrhagic stroke

Haemorrhagic stroke occurs when a blood vessel in the brain leaks or ruptures. Brain haemorrhages can result from many conditions that affect your blood vessels Factors related to haemorrhagic stroke include:

*Uncontrolled high blood pressure.
*Overtreatment with blood thinners (anti coagulants)
*Bulges at weak spots in your blood vessel walls (aneurysms)
*Trauma (such as a car accident)
*Protein deposits in blood vessel walls that lead to weakness in the vessel wall (cerebral amyloid angiopathy)
*A less common cause of bleeding an in the brain is the rupture of an abnormal tangle of thin-walled blood vessels (arteriovenous malformation).

Transient ischemic attack (TIA)

A transient ischemic attack (TIA) – sometimes known as a mini stroke) – is a temporary period of similar to those you’d have in a stroke. A TIA doesn’t cause permanent damage. They are caused by a temporary decrease in blood supply to part of the brain and which may last for as little as five minutes.

Like an ischemic stroke, a TIA occurs when a clot or debris reduces or blocks blood flow to part of the nervous system.

Seek emergency care even if you think you’ve had a TIA because your symptoms got improved. It’s not possible to tell if you’re having a stroke or TIA based only on your symptoms. If you’ve had a TIA, it means you may have a partially blocked or narrowed artery leading to your brain. Having a TIA increases your risk of having a full-blown stroke later.

Risk factors

Many factors can increase your stroke risk. Potentially treatable stroke risk factors include:

Lifestyle risk factors

*Being overweight or obese
*Physical inactivity
*Heavy or binge drinking
*Use of illegal drugs such as cocaine and methamphetamine

Medical risk factors
*Blood pressure
*Cigarette smoking or smoke exposure (Passive smoking)
*High cholesterol
*Obstructive sleep apnea
*Cardiovascular disease, including heart failure, heart defects, heart infection or abnormal heart rhythm such as atrial fibrillation
*Personal or family history of stroke, heart attack or TIA
*COVID-19 infection

Other factors associated with a higher risk of stroke include:
*Age – People aged 55 or older have higher risk of stroke than do younger people
*Sex – Men have higher risk of stroke than women. Women are generally older when they have strokes, and they are more likely to die of stroke than are men
*Hormones – Use of birth control pills or hormone therapies that include estrogen increase the risk


Things will move quickly once you get to the hospital, as the emergency team tries to determine what type of stroke you’re having. That means you will have a CT scan or other imaging test soon after arrival. Doctors also need to rule out other possible causes of your symptoms such as a brain tumour or a drug reaction.
Some of the tests you may have include:

*A physical exam. Your Doctor will do several tests you’re familiar with, such as listening to your heart and checking your blood pressure. You’ll also have a neurological exam to see how a potential stroke is affecting your nervous system.
*Blood tests. You may have several blood tests, including tests to check blood sugar, whether your blood sugar is too high or low, and whether you have an infection or electrolyte dysfunction.
*Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of the brain. A CT scan can show bleeding in the brain, an ischemic stroke, a tumour or other conditions. Doctors may inject a dye into the bloodstream to view the blood vessels in the neck and brain in greater detail (computerized tomography angiography).
*Magnetic resonance imaging (MRI). A MRI uses powerful radio waves and magnets to create adetailed view of the brain. MRI can detect brain tissue damaged by an ischemic stroke and brain haemorrhages. Your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography or magnetic resonance venography).
*Carotid ultrasound. In this test, sound waves create detailed images of the inside of the carotid arteries in your neck. This test shows build-up of fatty deposits (Plaques) and blood flow in your carotid arteries.
*Echocardiogram. An echocardiogram uses sound waves to create detailed images of the heart. This can find the source of clots in the heart which may have travelled from your heart to the brain and caused the stroke.


Emergency treatment for stroke depends on whether you’re having an ischemic stroke or a stroke that involves bleeding into the brain (haemorrhagic).

Ischemic stroke
To treat an ischemic stroke, doctors must quickly restore blood flow to the brain. This may be done with:

*Emergency IV medication. Therapy with drugs that can break up a clot has to be given within 4-5 hours from when the symptoms first started if given intravenously. The sooner these drugs are given, the better. Quick treatment not only improves the chances of survival, but also may reduce complications.
An IV injection of recombinant tissue plasminogen activator (tPA)-also called alteplase (Activase)-is the gold standard treatment for ischemic stroke. 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 started.
This drug restores blood flow by dissolving the blood clot which caused the stroke. The Doctor will consider certain risks, such as potential bleeding in the brain, to determine if tPA is appropriate for the patient.

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

*Removing the clot with a stent retriever.Doctors can use a device attached to a catheter to directly remove the clot from the blocked blood vessel in the brain. This procedure is particularly beneficial for people with large clots that cant be completely dissolved with tPA. This procedure is often performed in combination with injected tPA.

The time window when these procedures can be considered has been expanding due to newer technology. Doctors may order perfusion imaging tests (done with CT or MRI) to help determine how likely it is that someone can benefit from endovascular therapy.

Other procedures

To decrease the risk of having another stroke or transient ischemic attack, your doctor may recommend a procedure to open up an artery that is narrowed by plaque. Options vary depending on the patient’s situation, but include:

*Carotid endarterectomy. Carotid arteries are blood vessels that run along each side of your neck, supplying your brain with blood. This surgery removes the plaque blocking a carotid artery, and may reduce your 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 your carotid arteries through an artery in your groin. A balloon is then inflated to expand the narrowed artery. Then a stent can be inserted to support the opened artery.

Haemorrhagic stroke

Emergency treatment of haemorrhagic stroke focuses on controlling the bleeding and reducing pressure in the brain caused by the excess blood collection.
Treatment options include:
Emergency measures. If you take blood-thinning medications to prevent blood clots, you may have to stop the offending drug. You may also be given drugs to lower the pressure in the brain (intracranial pressure), lower your blood pressure, prevent spasms of your blood vessels and prevent seizures.

*Surgery. If the area of bleeding is large,surgery may be performed to remove the blood and relieve pressure on your brain. Surgery may also be used to repair blood vessel problems associated with haemorrhagic stroke. The Doctor may recommend one of these procedures after a stroke or if an aneurysm, arteriovenous malformation (AVM) or other type of blood vessel problem caused the haemorrhagic stroke.

*Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm, to stop blood flow to it. This clamp can keep the aneurysm from bursting, or it can keep an aneurysm that has recently haemorrhaged from bleeding again.

*Coiling (endovascular embolization). Using a catheter inserted into an artery in your groin and guided to your brain, the surgeon would place tiny detachable coils into the aneurysm and causes blood to clot.

*Surgical AVM removal.Surgeons may remove a smaller AVM if it is located in an accessible area of the brain. This eliminates the risk of rupture and lowers the risk of haemorrhagic stroke. However, it is not always possible to remove an AVM if it is located deep within the brain, it’s large, or it’s removal would cause too much of an impact on brain function.

*Stereotactic radiosurgery. Using multiple beams of highly focused radiation, stereotactic radiosurgery is an advanced minimally invasive treatment used to repair blood vessel malformations.

Stroke recovery and rehabilitation

After emergency treatment, you will be closely monitored for at least a day. After that, stroke care focuses onhelping you recover as much function as possible and 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, the movement and sensation on the left side of the body may be affected. If the stroke damaged the brain tissue on the left side of the brain, the movement and sensation on the right side of the body may be affected. Brain damage to the left side of the brain may cause speech and language disorders.

Most stroke survivors go to a rehabilitation program. The doctor will recommend the most rigorous therapy program you can handle based on your age, overall health and degree of disability from your stroke. The doctor will take into consideration your lifestyle, interests and priorities and the availability of family members or other caregivers.

Rehabilitation may begin before you leave the hospital. After discharge, you might continue your program in a rehabilitation unit or skilled nursing facility, as an outpatient, or at home.

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

*Doctor trained inbrain conditions (Neurologist)
*Rehabilitation doctor
*Physical therapist/Occupational therapist
*Speech pathologist
*Psychologist or Psychiatrist


A stroke can sometimes produce temporary or permanent disabilities, depending on how long the brain lacks blood flow and which part was affected.
Complications may include:
*Paralysis or loss of muscle movement. You may become paralyzed on one side of your body, or lose control of certain muscles, such as those on one side of your face or one arm.

*Difficulty in talking or swallowing.A stroke might affect control of the muscles in your mouth and throat, making it difficult to talk clearly, swallow or eat. You may also have difficulty with language, including speaking or understanding speech, reading or writing.
*Memory loss or thinking difficulties. Many people who have had strokes experience some memory loss. Others may have difficulty thinking, reasoning, making judgements and understanding concepts.
*Emotional problems. People who have had strokes may have more difficulty controlling their emotions, or they may develop depression.
*Pain. Pain, numbness or other unusual sensations may occur in the parts of the body affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm.
*Changes in behaviour and self-care ability. People who have had strokes may become more withdrawn. They may need help with grooming and daily chores.


Knowing your risk factors, following your doctor’s advice and adopting a healthy lifestyle are the best steps you can take to prevent a stroke.If you’ve had a stroke or a transient ischemic attack (TIA), these measures might help prevent another stroke.
Many stroke prevention strategies are the same as for heart disease.
In general, healthy lifestyle recommendations include:
*Controlling high blood pressure. This is one of the most important things you can do to reduce stroke risk. If you’ve had a stroke, lowering your blood pressure can help prevent a subsequent Tia or stroke. Healthy lifestyle changes and medications are often used to treat high blood pressure.
*Lowering the amount of cholesterol and saturated fat in diet. Eating less cholesterol and fat, especially saturated fat and trans fats may reduce the build-up in your arteries. If you can’t control your cholesterol through dietary changes alone, you may be prescribed a cholesterol-lowering medication.
*Quitting tobacco use. Smoking raises the risk of stroke for smokers and non-smokers exposed to second-hand smoke. Quitting tobacco use reduces your risk of stroke.
*Managing diabetes. Diet exercise and losing weight can help you keep your blood sugar in healthy range. If lifestyle factors do not seem to be enough to control diabetes, medication may be prescribed.
*Maintaining a healthy weight. Being overweight contributes to other stroke risk factors, such as high blood pressure, cardiovascular disease and diabetes.
*Eating a diet rich in fruit and vegetables. A diet containing fruits or vegetables may reduce your risk of stroke. A diet which emphasizes fruits, nuts, vegetables and whole grains, may be helpful.
*Exercising regularly. Aerobic exercise reduces your risk of stroke in many ways. Exercise can lower your blood pressure, increase your levels of good cholesterol, and improve the overall health of you blood vessels and heart. It also helps you to lose weight, control diabetes and reduce stress. Gradually work upto at least 30 minutes of moderate physical activity such as walking, jogging, swimming or bicycling on most, if not all, days of the week.
*Drinking alcohol. Heavy alcohol consumption increases your risk of high blood pressure, ischemic strokes and haemorrhagic strokes. Alcohol may also interact with other drugs. The doctor would recommend what’s appropriate for you.
*Treating obstructive sleep apnea (OSA). A sleep study may be recommended if you have symptoms of OSA – a sleep disorder that causes you to stop breathing for short periods repeatedly during sleep. Treatment of OSA includes a device that delivers positive airway pressure through a mask to keep your airway open while you sleep.
*Avoiding illegal drugs. Certain street drugs are established risk factors for a TIA or a stroke.

Preventive medications

If you’ve had an ischemic stroke or TIA your doctor may recommend medications to help reduce your risk of having another stroke.
These include:

*Anti-platelet drugs. Platelets are cells in your blood that form clots. Anti-platelet drugs make these cells less sticky and less likely to clot. The most common anti-platelet medications are aspirin and clopidogrel. After a TIA or minor stroke, you may be given aspirin and an anti-platelet drug such as clopidogrel (Plavix) for a period of time to reduce the risk of another sroke. If you can’t take aspirin, you may be prescribed clopidogrel alone.

*Anticoagulants. These drugs reduce blood clotting. Heparin is fast acting and may be used short-term in the hospital. Slower-acting warfarin may be used over a longer term. Warfarin is a powerful blood-thinning drug, so you’ll need to take it exactly as directed and watch for side effects. Regular blood tests are also needed to monitor warfarin’s effects.
Several newer blood-thinning medications (anticoagulants) are available for preventing strokes in people who have a high risk. These medications include dabigatran, rivaoxaban, apixaban(Eliquis). They are shorter acting than warfarin and usually don’t require regular blood tests or monitoring by the doctor. These drugs are also associated with a lower risk of bleeding complications.

An Overview by Dr Manorama Devi K Rajan, Hon.Senior Consultant, Department of Neurology, KIMSHEALTH.

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