Stroke IN THIS SECTION Neuraxpharm Psychiatric & Neurological Disorders Stroke There are two types of stroke: ischaemic and haemorrhagic. Find out what causes each type, the common symptoms, and how stroke is diagnosed and treated. What is stroke? A stroke (also known as a cerebral infarction) is a serious medical condition that needs urgent attention. A stroke happens if the brain doesn’t receive the blood supply it needs, which in turn restricts oxygen in the brain. When this happens, it is usually because either the blood supply to the brain is blocked or a blood vessel in the brain bursts. Without emergency treatment, clusters of cells in the brain can be damaged or die as a result of the lack of oxygen. This can lead to disability or even death. The sooner the right treatment is received, the better the chance of recovery. What are the main types of stroke? There are two main types of stroke: Ischaemic stroke: This is the most common form of stroke, making up around 80% of all cases. It is caused by a blood clot causing a blockage and cutting off the blood supply to the brain. Haemorrhagic stroke: This is when a blood vessel supplying the brain bursts, causing bleeding in or around the brain. Transient ischaemic attack (TIA) Some people experience a TIA before having a full stroke. The symptoms of a TIA are the same as a stroke, but they only last for a short time, which is why a TIA is often referred to as a ‘mini stroke’. Although the effects of a TIA aren’t as long lasting as a full stroke, it does indicate an increased risk of stroke in the near future. How many people have strokes? The 2020 Burden of Stroke in Europe report found that there were 1.2 million strokes in the European Union in 2017. It also projected that the number of people living with stroke in the next three decades (2017–2047) would increase by 27%, mainly due to an ageing population and increased survival rates. Symptoms The main symptoms of stroke affect the face, arms, and speech. But stroke is different for everyone and the symptoms will depend on which part of the brain has been affected and how badly the brain tissue is damaged. What are the symptoms of stroke? The three main areas of the body that are affected by stroke are: The face: It’s common for the face to droop on one side during a stroke. This can be more prominent when the person is smiling, so if you’re concerned about someone, ask them to smile to see if one side of their face droops. The arms: There is often a weakness or numbness in the arms. If someone is unable to lift and hold their arms up, it can be a sign of stroke. The speech: Garbled or slurred speech is often one of the first obvious symptoms. Sometimes speech is completely lost. Other possible symptoms may include: Paralysis on one side of the body Vision problems Difficulty understanding others Balance and coordination problems Dizziness Loss of consciousness Confusion What are the stages of stroke? There are no set stages associated with having a stroke; however, some people experience a transient ischaemic attack (TIA), which can be a warning sign that they may soon have a stroke. A TIA is sometimes called a ‘mini stroke’ because the symptoms are the same as those of a stroke but, because the blockage of blood to the brain is temporary, it only lasts for a short time. A TIA does not damage the brain cells or cause permanent disability, but it does indicate an increased risk of having a full stroke in the near future. Not everyone who has a stroke experiences a TIA first – but if they do, it’s important to get medical help immediately, as it could be a sign that a stroke is coming. In a study of stroke patients published in the medical journal Neurology, 2,416 people who had experienced an ischaemic stroke were examined. Of these, 549 experienced a TIA before their stroke, with the majority taking place within seven days of the stroke. Symptoms of TIA include: Feeling numb or weak on one side of the body Difficulty talking or understanding Vision problems Severe headaches Confusion Dizziness or loss of balance Long-term consequences of stroke In the long term there are a number of mental and physical issues that can arise as a result of having a stroke. These include: Mild, moderate or severe physical disability Problems with brain function, including memory and thinking skills Mental health problems, such as depression and anxiety What are the early signs of stroke? The ‘FAST’ test is often used to help identify a stroke. Look for the three main body areas affected: face, arms and speech, as described in the symptoms section. If any of these signs are present, it is time to call the emergency services for immediate medical attention. Remember the FAST acronym: Face: The face is drooping or numb, or the smile is lopsided. Arms: One arm is weak or numb, or it’s hard to keep the arms lifted. Speech: Speech is slurred or difficult to understand. Time: If you spot at least one of these symptoms, it’s time to call the emergency services. All strokes are different, and the three ‘FAST’ symptoms may be accompanied by one or more of the additional symptoms listed in the section ‘What are the stages of stroke?’. Causes, risk factors and life expectancy Strokes can be ischaemic (when the blood supply to the brain is cut off) or haemorrhagic (when there is bleeding in or around the brain). The chance of having a stroke increases with age, and older people have a lower chance of survival. What causes strokes? Strokes are caused by a restriction in blood supply to the brain, which happens in different ways depending on the type of stroke. Ischaemic stroke In ischaemic strokes, a blockage cuts off the blood supply to the brain. This can be caused by a blood clot forming either in an artery that leads to the brain or in a small blood vessel deep inside the brain. It can also be the result of a clot moving through the bloodstream to the brain from another part of the body. Haemorrhagic stroke A haemorrhagic stroke is also referred to as a brain haemorrhage or a brain bleed, as it is caused by bleeding in or around the brain. This can happen in two ways: Intracerebral haemorrhage: A blood vessel inside the brain bursts and causes bleeding in the brain. Subarachnoid haemorrhage: A blood vessel on the surface of the brain bursts, causing bleeding in between the brain and the skull. Are strokes hereditary? The chance of stroke is higher for people with a family history of strokes, but it is thought that it is the risk factors for stroke that are hereditary (such as high blood pressure and diabetes), rather than stroke itself. Who gets strokes? The risk of having a stroke is affected by factors which are either ‘non-modifiable’, meaning they cannot be changed, or ‘modifiable’, meaning behaviour and choices can influence them. The two non-modifiable factors – those that relate to who a person is – that can affect the risk of having a stroke are: Older age: The risk of stroke increases with age and doubles every decade after the age of 55. Gender: On average, men experience strokes about four years earlier than women, and stroke incidence in men is 33% higher. However, women are more likely to experience severe stroke than men. Modifiable risk factors – those that can be influenced or controlled – include: Drinking alcohol to excess: Drinking too much alcohol raises blood pressure, which is one of the biggest risk factors for stroke. Smoking: Smoking increases the risk of all types of stroke for both men and women. Obesity: Being overweight raises the risk of high blood pressure, heart disease, and type 2 diabetes, which can all increase the risk of a stroke. Diabetes: Research shows that people with type 2 diabetes are more likely to have a stroke. High blood pressure: This is one of the biggest risk factors for stroke and is closely related to drinking, smoking, and being overweight. Blood pressure of 140/90 or above can damage the blood vessels that supply blood to the brain. Heart disease is also a significant risk factor in having a stroke, and is a major cause of death after experiencing a stroke. If the heart disease is hereditary, this may be a non-modifiable risk factor, but some people may be able to modify their behaviour to influence their risk of heart disease, and therefore the risk of stroke. How long can you live with stroke? When it comes to survival rates after a stroke, age is one of the most influential factors, with research showing that the risk of death from a stroke approximately doubles with every decade of age. Another significant factor is the length of time since the stroke. One study associated stroke with an almost fivefold increase in the risk of death between four weeks and one year after a stroke, compared with the general population, and a two-fold increase after one year. However, survival rates have greatly improved over the last decade thanks to new stroke treatments and improved stroke care. Prompt treatment helps to increase the chance of survival and reduce the risk of long-term effects. Diagnosis To give the best chance of recovery, doctors need to confirm the diagnosis of a stroke as quickly as possible. How is stroke diagnosed? Diagnosis is made by carrying out a range of tests to help identify any health conditions that can cause a stroke (such as high blood pressure) and performing brain scans to give a better picture of what is happening inside the brain. Test to diagnose stroke If doctors suspect a stroke, they will try to carry out one of the following types of brain scan within an hour of arrival at hospital: Computed tomography (CT) scan: Multiple images are used to create a 3D picture of the brain. CT scans are usually quicker than MRI scans, allowing treatment to start sooner, and they are effective at showing the difference between ischaemic and haemorrhagic strokes. Magnetic resonance imaging (MRI) scan: Magnetic fields and radio waves are used to give a detailed picture of the inside of the brain. This type of scan will be used if someone has recovered from a TIA. It is able to show brain tissue in detail and identify smaller areas that have been affected by a stroke. Other tests that can be helpful in diagnosing a stroke include: Blood tests: To check cholesterol and blood sugar levels Blood pressure: If this is high, medication may be needed to reduce the risk of another stroke Pulse measurement: To check for irregular heartbeats Electrocardiogram (ECG): To show if an irregular heartbeat may have caused the stroke Treatment and medication Rehabilitation and recovery after a stroke take time. The process is different for everyone, and usually involves a team of specialists setting goals to work towards. It’s important to stay actively engaged in the rehabilitation plan for the best possible chance of recovery. How is stroke treated? Every stroke is different, so treatment and recovery vary greatly between individuals. Recovery often takes months and can take years for some stroke survivors. It starts in hospital and often involves a range of specialists who will help set goals to work towards as part of recovery. This may involve further tests to help doctors understand what is needed. Tests could include: Swallowing test: It’s common to experience difficulties with swallowing after a stroke, so doctors may do tests to check someone can eat and drink safely. Mobility assessment: This will show the extent of the physical impact from the stroke, and identify what help is needed. Communication and cognitive assessments: A stroke can affect the brain’s ability to understand, organise, and store information. Initial cognitive tests are taken in hospital and there may be further ongoing assessments to see how the stroke has affected the brain in the longer term. Nutritional status and hydration tests: These will highlight any nutritional deficiencies and check for dehydration. Continence assessment: Bladder and bowel problems can be one of the less welcome side effects of stroke, but these can usually be improved with the right advice. A continence assessment will enable doctors to provide the best advice and treatment. Medication A range of medication can be used to treat strokes. Different options may be chosen depending on the type of stroke. Medication for ischaemic stroke In an emergency situation, medication called thrombolysis, or ‘clot-busting’ medication, is usually used. It works by dissolving blood clots and allowing blood to flow back into the brain, and can have a positive effect on reducing stroke damage if it is given within a few hours of the onset of a stroke. Other treatments which may be used later to help prevent any further strokes include: Anti-platelet agents:These are used to help prevent further clots forming in the blood. Anti-coagulants:These change the chemical make-up of the blood to reduce the chance of further clots forming. Blood pressure medication:This may be offered if someone has high blood pressure, to help reduce the risk of further strokes. Statins: These help to lower cholesterol levels and may be offered to reduce the risk of further strokes, whether cholesterol levels are high or not. Medication for haemorrhagic strokes If someone has had a haemorrhagic stroke, doctors may recommend that they take blood pressure medication to help reduce the risk of further strokes. If they were already taking anticoagulants, they will need treatment to reverse their effects and lower the chance of further bleeding. Therapy The long-term effects of stroke can be wide-ranging, and a number of therapies can have a significant impact on the recovery and rehabilitation process. Everyone recovers differently, requiring support from a variety of specialists. These may include: Physiotherapists: The ongoing physical effects of stroke can include balance and coordination problems, muscle weakness, and paralysis on one side of the body. A physiotherapist can help by setting regular exercises and providing goals to work towards. Psychologists: It’s very normal for people to experience stress, anxiety, depression, or anger after a stroke. Regular counselling sessions can help patients to address these feelings and also help them cope with the impact on close relationships. Occupational therapists: Many daily activities can become challenging after a stroke. An occupational therapist can offer advice on how to adapt the home or use specialist equipment to allow people to maintain their independence. Speech and language therapists:Many people experience communication difficulties after a stroke. A speech and language therapist can help to teach the brain how to communicate again. Other specialists:Therapy after a stroke may also include help from other specialists such as a dietician or an ophthalmologist. Intervention A number of surgical procedures can be used to treat stroke. The appropriate procedure will depend on what caused the stroke. Intervention for ischaemic stroke Thrombectomy: This is sometimes used for severe ischaemic stroke caused by a blood clot in a large artery in the brain. It is an emergency procedure which takes place very soon after the stroke. A catheter is inserted into an artery, and a small device is used to remove the blood clot that caused the stroke. Carotid endarterectomy: This surgery can be used in some ischaemic strokes that were caused by a narrowing of the carotid artery in the neck, which carries blood to the brain. It involves making a cut in the neck and unblocking the fatty deposits in the artery. Intervention for haemorrhagic stroke Craniotomy:: This surgery involves removing blood from the brain and repairing any burst blood vessels. Shunt surgery: This is a surgical procedure which is used when the stroke causes fluid to build up in the brain’s cavities (a condition known as hydrocephalus). The fluid is drained from the brain using a tube called a shunt. Diet Eating a healthy diet is crucial after a stroke. Diet can play a key role in recovery by helping to control blood pressure and cholesterol levels and helping maintain a healthy body weight. This will also reduce the risk of having another stroke. Stroke survivors should aim to eat a diet rich in grains, vegetables and fruit, as well as healthy dairy and protein sources such as yoghurt, lean meat, fish, pulses, nuts, and seeds. They should also reduce their intake of processed foods, saturated fats, and trans fats. Too much salt can lead to an increase in blood pressure. Salt intake can be reduced by avoiding processed food (which is often high in salt) and resisting the urge to add salt to food. Exercices There are many benefits to staying active after having a stroke. These include: Boosting confidence and wellbeing Improving muscle strength and coordination Keeping the heart and arteries healthy Reducing blood pressure Stabilising blood sugar levels Lowering cholesterol in the blood Helping maintain a healthy weight It can be nerve-racking to get active again after a stroke, especially when the body isn’t as strong as it used to be. Taking small steps can be the best approach, and a physiotherapist can offer advice on how to start slowly and build up over time. Prevention There are many simple lifestyle changes that can help reduce the risk of stroke: Stop smoking: Studies show that giving up smoking lowers the chance of having a stroke. And it’s never too late to give up – research shows that those who continue to smoke after experiencing a stroke increase their risk of a recurrence. Reduce alcohol intake: Excessive drinking can increase the risk of stroke, so limit alcohol intake and spread the units over the course of the week. Eat a healthy diet: A healthy diet will help to keep other risk factors (such as obesity and high blood pressure) in check. Take regular exercise: Not only does exercise help maintain a healthy body weight, research suggests that regular physical activity is associated with a 25–30% risk reduction for stroke. Have regular check-ups: Medical conditions such as diabetes, high blood pressure, and high cholesterol can cause the arteries to harden and narrow, increasing the chance of them becoming blocked, which can lead to a stroke. Regular check-ups can help maintain control of these risk factors. Scientific studies A raft of research is being done to develop new and more effective treatments for stroke, and scientists are especially keen to discover ways to restore blood flow to the brain and protect brain cells from dying after a stroke. Other areas of interest in the field of treatment include looking at ways to improve rehabilitation and post-stroke recovery. When it comes to stroke prevention, researchers are looking to understand more about the risk factors for stroke. Imaging techniques are also being used in an effort to learn more about how stroke affects the brain. Referenced sources Donkor ES. Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life. Stroke Res Treat. 2018;2018:3238165. doi:10.1155/2018/3238165 Wafa HA, Wolfe CDA, Emmett E, Roth GA, Johnson CO, Wang Y. Burden of stroke in Europe – thirty-year projections of incidence, prevalence, deaths, and disability-adjusted life years. 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Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500 000 men and women in China. Lancet. 2019;393(10183):1831-1842. doi:10.1016/S0140-6736(18)31772-0 Pan B, Jin X, Jun L, Qiu S, Zheng Q, Pan M. The relationship between smoking and stroke. Medicine (Baltimore). 2019;98(12):e14872. doi:10.1097/MD.0000000000014872 Chen R, Ovbiagele B, Feng W. Diabetes and stroke: epidemiology, pathophysiology, pharmaceuticals and outcomes. Am J Med Sci. 2016;351(4):380-386. doi:10.1016/j.amjms.2016.01.011 Shavelle R, Brooks J, Strauss D, Towfighi A. Long-term survival prognosis after stroke. A practical guide for clinicians. Practical Neurology. Published February 2020. Accessed February 2021. https://practicalneurology.com/articles/2020-feb/long-term-survival-prognosis-after-stroke Brønnum-Hansen H, Davidsen M, Thorvaldsen P. Long-term survival and causes of death after stroke. Stroke. 2001;32(9):2131-2136. doi:10.1161/hs0901.094253 Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults BMJ 2019; 365 doi:10.1136/bmj.l1778 Pan B, Jin X, Jun L, Qiu S, Zheng Q, Pan M. The relationship between smoking and stroke. Medicine (Baltimore). 2019;98(12):e14872. doi:10.1097/MD.0000000000014872 Chen J, Li S, Zheng K et al. Impact of smoking status on stroke recurrence. J Am Heart Assoc. 2019;8(8):e011696. doi:10.1161/JAHA.118.011696 Gallanagh S, Quinn TJ, Alexander J, Walters MR. Physical activity in the prevention and treatment of stroke. 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