STROKE AWARENESS

Information about Stroke

from the Stanford Stroke Center
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STANFORD STROKE CENTER

(650) 723-4448
http://strokecenter.stanford.edu

Physician_____________________________
M ore than 750,000 Americans are
expected to suffer a stroke this
year. Stroke is the number one cause of
adult disability in the United States.
These statistics, however, can and should
be lower. The risk of stroke can be re-
duced through heightened awareness of
stroke risk factors and warning signs.
Medical, surgical and neuroradiolo-
gic therapies are now available to treat
and prevent stroke in many high-risk
patients. In addition, new approaches
are available for the emergency treat-
ment of stroke. These therapies have the
potential to significantly reduce perma-
nent disability from stroke; however, to
do so they must be administered within
the first few hours after the appearance
of stroke symptoms.
2 TABLE OF CONTENTS
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
The Stanford Stroke Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Part I: Understanding Stroke
WHAT IS A STROKE? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Ischemic Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Thrombotic Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Embolic Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Hemorrhagic Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Subarachnoid Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Intracerebral Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Aneurysms and CVMs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
THE WARNING SIGNS OF STROKE . . . . . . . . . . . . . . . . . . . . . . . . . 8
Transient Ischemic Attacks (TIAs) . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Seek Help Promptly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
STROKE PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
How to Reduce Your Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Regular Medical Check-ups . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Control Blood Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Stop Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Treat Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Improve Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Maintain a Healthy Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Exercise Regularly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Treat Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Reduce Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Use of Oral Contraceptives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Post-Menopausal Estrogen Use . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Risk Factors That Cannot be Changed . . . . . . . . . . . . . . . . . . . . . . . . . 14
Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Family or Individual History . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
New Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Stroke and Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Part II: New Diagnosis and Treatment Options
HOW TO DIAGNOSE STROKE AND STROKE RISK. . . . . . . . . . . . . . . . . 16
Computerized Tomography (CT) Scan . . . . . . . . . . . . . . . . . . . . . . . 16
Magnetic Resonance Imaging (MRI) . . . . . . . . . . . . . . . . . . . . . . . . 16
Magnetic Resonance Angiography (MRA) . . . . . . . . . . . . . . . . . . . . . 17
 CT Angiography (CTA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Introduction
3
Transcranial Doppler (TCD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Xenon CT Scanning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Carotid Duplex Scanning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Radionuclide SPECT Scanning . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Cerebral Angiography (Angiogram) . . . . . . . . . . . . . . . . . . . . . . . . 17
Transesophageal Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . 17
NEW DRUGS FOR STROKE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Emergency Treatment of Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Thrombolytic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Neuroprotective Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Stroke Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Antiplatelet Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ADVANCED SURGICAL TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . 19
Carotid Endarterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Stereotactic Microsurgery for Cerebral Vascular Malformations and Aneurysms . . . . . 20
CyberKnife, Stereotactic Radiosurgery for Cerebral Vascular Malformations . . . . . . . 20
Revascularization of the Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . 21
Intraoperative Adjuncts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Neurotransplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
INTERVENTIONAL NEURORADIOLOGY TECHNIQUES . . . . . . . . . . . . . . 21
Endovascular Treatment of Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . 22
Mechanical Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Endovascular Treatment of Cerebral Vascular Malformations . . . . . . . . . . . . . . 22
Angioplasty and Stenting of Vessels in the Neck and Brain. . . . . . . . . . . . . . . 22
Intra-Arterial Thrombolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
THE STANFORD NEUROCRITICAL CARE PROGRAM . . . . . . . . . . . . . . . 23
PATIENT CARE AT STANFORD . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Registered Nurses/Licensed Vocational Nurses . . . . . . . . . . . . . . . . . . . . 24
Nursing Assistants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Physical, Occupational and Speech Therapists. . . . . . . . . . . . . . . . . . . . 24
Medical Social Worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Chaplaincy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Dietitian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Rehabilitation Services at Stanford . . . . . . . . . . . . . . . . . . . . . . . . . . 25
REHABILITATION FOLLOWING STROKE . . . . . . . . . . . . . . . . . . . . . 25
Stroke Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Support Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4 INTRODUCTION
Introduction
The Stanford Stroke Center
The Stanford Stroke Center — one of the
first centers of its kind in the United States —
is pioneering new approaches to the diagnosis
and treatment of stroke that can significantly
improve patient chances for an optimal recov-
ery. New drugs, advanced surgical techniques
and innovative interventional neuroradiology
procedures are among the effective new med-
ical options now available for stroke patients.
The Center, which includes both a patient
care and a research component, was founded
in 1992 and has cared for over 14,000 stroke
patients. The Center brings together the
expertise of specialists in many different areas
to provide our patients with the benefit of a
collaborative team approach. The team
includes neurologists, neurosurgeons, neurora-
diologists, neuroscientists, neuroanesthesiolo-
Dr. Gregory Albers, Director of the Stanford
Stroke Center, leads a team of dedicated, experi-
enced physicians.
gists, neuropsychologists, emergency medicine
and rehabilitation specialists, and a dedicated
nursing staff.
Starting in 2004, a national program for
stroke center certification was launched by
the Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO). Goals of
the JCAHO program include improving
stroke care nationwide and ensuring that
stroke patients cared for at certified stroke
center receive optimal stroke treatment. The
Stanford Stroke Center was one of the 1st
academic medical centers in the country to
receive certification from JCAHO.
We have prepared this handbook to provide
you with some important information about
stroke. The first part of the booklet explains
the different types of stroke, describes the
warning signs and risk factors for stroke, and
recommends steps you can take to reduce your
risk for stroke. The second section provides an
overview of the advanced techniques for diag-
nosis and treatment available at the Stanford
Stroke Center.
As you’ll learn in this handbook, the best
thing that you can do to improve your odds
against stroke is to familiarize yourself with the
warning signs and risk factors, and then take
the appropriate steps to change the risk factors
within your control. And most importantly,
if you or someone you know should experi-
ence symptoms of stroke, seek emergency help
immediately — call 911 — do not wait.
If you have any questions after reading
this handbook, please feel free to call us at the
Stanford Stroke Center: (650) 723-4448.
 PART I
UNDERSTANDING
STROKE
6 WHAT IS A
Part 1: Understanding Stroke
STROKE?
A stroke occurs when blood vessels carry-
ing oxygen and other nutrients to a specific
part of the brain suddenly burst or become
blocked. When blood fails to get through
to the affected parts of the brain the oxygen
supply is cut off and brain cells begin
to die.
Diagram of blood supply to the brain.
Carotid Bifurcation
Right Common
Carotid Artery
Right Subclavian
Artery
Innominate Artery
The blood supply to the brain is very
important. Brain cells must have a continuous
supply of oxygen and other nutrients from the
blood in order to function. To meet this
demand, blood is pumped continuously from
the heart to the brain via several artery groups.
Within the brain, these arteries (known as
cerebral arteries) branch into smaller and
smaller arteries, and eventually into tiny ves-
sels called capillaries. These thin-walled ves-
sels supply the nutrients to millions of nerve
Vertebral Arteries
Left Common
Carotid Artery
Left Subclavian
Artery
Aortic Arch
cells within the brain. When this continuous
blood supply is disrupted, a stroke results.
Strokes fall into several major categories,
based on whether the disrupted blood supply
is caused by a blocked blood vessel (also
known as an ischemic stroke) or a hemor-
rhage. Since each type of stroke has a differ-
ent type of treatment, it is very important for
the physician to determine the cause of the
stroke, as well as the location, as quickly as
possible.
Ischemic Stroke
Ischemic stroke results from a blocked blood
vessel, and includes both thrombotic and
embolic stroke.
Thrombotic Stroke
Artery Wall
Atherosclerotic
Plaque
Thrombus
■ Thrombotic Stroke (or cerebral thrombosis)
is the most common type of stroke. In this
type of stroke, a blood clot (thrombus)
forms inside an artery in the brain or one of
the neck (carotid or vertebral) arteries that
transport blood from the heart to the brain.
Blood clots form most often in arteries dam-
aged by atherosclerosis, a disease in which
rough, fatty deposits build up in the walls of 7
the arteries and project into the blood-
Part 1: Understanding Stroke
stream. These deposits gradually narrow the
passageway, causing the blood flow to slow
down and, sometimes, to completely
occlude (block) the artery.
■ Embolic Stroke (or cerebral embolism)
occurs when a piece of clot (an embolus)
breaks loose from the heart or from a blood
vessel in the neck and is carried by the
blood stream to the brain. Traveling
through the arteries as they branch into
smaller vessels, the clot reaches a point
where it can go no further and plugs the
vessel, cutting off the blood supply. This
sudden blockage is called an embolism.
Embolic Stroke
Artery Wall
Embolus
You may also hear the term cerebral infarc-
tion in connection with these two types of
stroke. An infarct is an area of necrosis, or tis-
sue death, due to obstruction of a blood vessel
by a thrombus or embolus. Thrombotic and
embolic strokes are the two types of strokes
that cause cerebral infarction.
8 Hemorrhagic Stroke
The other main category of stroke, hemor-
Part 1: Understanding Stroke
rhagic stroke, occurs when a blood vessel
in or around the brain ruptures, spilling blood
into the brain or the area surrounding the
brain. When this occurs, the cells nourished
by the artery fail to get their normal supply of
nutrients and cease to function properly. Fur-
thermore, the accumulated blood from the
ruptured artery soon clots, displacing normal
brain tissue and disrupting brain function.
Cerebral hemorrhage is most likely to occur in
people who suffer from a combination of ath-
erosclerosis and high blood pressure.
There are two main types of hemorrhagic
strokes: subarachnoid hemorrhage and intracere-
bral hemorrhage, which refer to the parts of the
brain affected by the bleeding.
■ In Subarachnoid Hemorrhage, the bleed-
ing occurs in the space between the brain
and the skull.
■ Intracerebral Hemorrhage is caused when
an abnormal artery within the brain bursts,
flooding the surrounding brain tissue with
blood.
Aneurysms and Cerebral Vascular
Malformations
Hemorrhagic strokes are frequently caused by
the bursting of an aneurysm (an abnormal
“bulging” of a blood vessel in the brain) or a
cerebral vascular malformation, a cluster of
abnormal blood vessels. In the case of an
aneurysm, the weak spot in the vessel wall can
be stretched out over the years, often by high
blood pressure, which ultimately causes it to
rupture. While aneurysms may not cause any
symptoms until they burst (sometimes causing
people to liken them to “time bombs” in the
brain), cerebral vascular malformations may
have many associated symptoms, including
seizures, progressive neurologic problems and
severe headaches that are unresponsive even
to strong medications.
Until recently, some aneurysms and cere-
bral vascular malformations were virtually
impossible to treat without high risk to the
patient. New diagnostic and surgical advances
pioneered at the Stanford Stroke Center have
made it possible to treat these important
causes of stroke and offer patients the likeli-
hood of a cure. Some of these new treatments
will be explored further in the section on sur-
gical techniques.
THE WARNING SIGNS
OF STROKE
Your physician may identify certain signs that
indicate you are at risk for stroke. Or, your
body may warn you by the appearance of one
or more of the symptoms listed on the follow-
ing page. Familiarize yourself with the follow-
ing important warnings.
 9

Part 1: Understanding Stroke

THE WARNING SIGNS OF STROKE
■ Sudden weakness, numbness, or paralysis of the face, arm or
leg (especially on one side of the body)
■ Loss of speech or trouble talking or understanding language
■ Sudden loss of vision, particularly in only one eye
■ Sudden, severe headache with no apparent cause
■ Unexplained dizziness, loss of balance or coordination
(especially if associated with any of the above symptoms)

Transient Ischemic Attacks (TIAs)
About one-third of all strokes are preceded by
one or more “mini-strokes,” known as tran-
sient ischemic attacks (TIAs). TIAs can occur
days, weeks or even months before a stroke.
TIAs are caused by temporary interrup-
tions in the blood supply to the brain. The
symptoms occur rapidly and last a relatively
short time, usually from a few minutes to sev-
eral hours. For instance, if you experience
a sudden loss of vision, or weakness in an arm
or leg that disappears, you might be having
a TIA.
Because TIAs are temporary and the body
soon returns to normal, it is easy to ignore
them or to believe that the problem has disap-
peared. However, it is dangerous to ignore
TIAs, because the underlying problem that
caused the TIA continues to exist. TIAs are
often early warning signs of a more serious
and debilitating stroke in the future.
Seek Help Promptly
If you or someone you know experiences any
of the warning signs listed above, it is ex-
tremely important to seek emergency help
right away. Call your 911 immediately even if
you think that you are getting better or if the
symptoms seem to disappear. If the symptoms
last for more than 10 to 15 minutes, appear
frequently or seem to get worse, ask the
emergency responders for urgent transporta-
tion to the nearest appropriate emergency
medical facility.
Unfortunately, patients often do not seek
help for a day or more after the first symptoms
appear. By that time, it is usually too late for
10
“Ideally, stroke patients should
Part 1: Understanding Stroke
receive emergency medical care
within the first two hours after
symptoms begin.”
– Gregory Albers, M.D.
Director, Stanford Stroke Center
new treatments to be effective. Recognizing
and responding to the warning signs of stroke
— as soon as they appear — gives the patient
the best chance for an optimal recovery.
Remember, stroke is an emergency!
STROKE PREVENTION
There are many positive steps that you can
take now to reduce your risk of stroke. The
most common risk factors for stroke are listed
below. These include some conditions that
can be changed by lifestyle modification or
medical treatment, and some, such as heredi-
tary factors, that cannot be changed.
How to Reduce Your Risk
Most of the controllable risk factors for stroke
relate to cardiovascular fitness. Because stroke
is a form of cardiovascular disease, it makes
sense that keeping your heart and blood ves-
sels as healthy as possible will reduce your risk
of stroke. The following are the most impor-
tant measures you can take to control your
stroke risk. These include changing risk fac-
tors by medical treatment as well as by posi-
tive lifestyle modifications.
■ Regular Medical Check-ups — Risk factors
such as heart disease, high blood pressure,
and elevated blood cholesterol must be
monitored by your physician on a regular
basis. These risk factors can be changed or,
at minimum, controlled by proper medical
treatment and appropriate diet and lifestyle
modifications.
■ Control Blood Pressure — High blood
pressure (hypertension) is the single most
important risk factor for stroke. Even mild
hypertension, if not adequately treated,
increases stroke risk. In general, an ideal
blood pressure is 120/80 or below. Elevated
blood pressure promotes atherosclerosis and
puts abnormal pressure on blood vessel
walls, which can cause a rupture at a weak
spot. Hypertension is often called the
“silent killer” because there may be no
obvious symptoms. It is important to check
your blood pressure regularly. Controlling
blood pressure, whether by a low-sodium
diet, weight control, regular exercise, stress
management and/or medication will reduce
your risk of stroke. Remember: medication to
control hypertension is effective only if taken on
a regular basis, so it is important to follow your
physician’s instructions.
Treatment of hypertension in older adults
is also important. However, in elderly indi-
viduals, an abrupt fall in blood pressure may
actually cause a stroke. Therefore, treat-
 ment of high blood pressure in the elderly dramatically within a few years of stopping 11
may need to start with small doses of med- smoking.

Part 1: Understanding Stroke

ication, so that blood pressure is reduced
gradually.
■ Stop Smoking — Studies confirm that
smokers have a higher risk of stroke, regard-
less of other factors such as age, high blood
pressure, or heart disease. The risk declines
■ Treat Heart Disease — A variety of heart
conditions, including irregular heart
rhythms (atrial fibrillation), heart attacks
and heart valve disorders, can cause stroke.
Treatment of these disorders can reduce
stroke risk.

RISK FACTORS THAT CAN BE CHANGED

■ hypertension (high blood pressure)
■ smoking
■ heart disease
■ high cholesterol level
■ excess alcohol intake
■ obesity
■ sedentary lifestyle
■ diabetes
■ elevated hematocrit (increase in red blood cells)
■ use of oral contraceptives (especially for women who smoke)
■ stress

RISK FACTORS THAT CANNOT BE CHANGED

■ age
■ sex
■ race
■ family or individual history of stroke or TIA
12
Part 1: Understanding Stroke
Regular exercise can reduce the risk of stroke.
■ Improve Diet — Consumption of foods
high in fat, cholesterol and salt increases
the risk for stroke. The following recom-
mendations are among the most important
for stroke prevention. Ask your doctor for
more help in identifying dietary culprits and
making appropriate substitutions.
1) Avoid excess fat: High intakes of fat,
particularly saturated fat, and cholesterol
may contribute to atherosclerosis, which is
associated with stroke. Dietary fat and cho-
lesterol may be reduced by limiting fat or oil
added in cooking, trimming fat and skin
from meats and poultry, using low-fat or
non-fat dairy products, broiling and baking
 foods rather than frying, and limiting eggs
to no more than three a week.
2) Avoid excess sodium: Excess sodium in
the diet is linked to hypertension. Table
salt is the primary source of dietary sodium.
There is also “hidden” salt in most processed
and canned foods. Disodium phosphate,
monosodium glutamate, sodium nitrate, or
any similar compounds in the list of ingre-
dients indicate a high sodium content. Try
to eat fresh food whenever possible.
3) Limit alcohol intake: Individuals who
drink alcoholic beverages (more than two
drinks per day) have an increased risk of
stroke. For heavy drinkers, the risk of stroke
increases further. Healthy young adults are
just as susceptible to the risk of stroke in-
curred by heavy alcohol consumption as are
older persons.
■ Maintain a Healthy Weight — Being over-
weight strains the heart and blood vessels
and is associated with high blood pressure.
Obesity also predisposes a person to heart
disease and diabetes, both of which increase
the risk for stroke. Keeping your weight to
recommended levels for your height and
build is a prudent preventive measure.
■ Exercise Regularly — The percentage of
fat in our bodies tends to increase with age.
Regular exercise helps keep this increase to
a minimum. There appears to be an inverse
relationship between exercise and athero-
sclerosis, i.e., more exercise is linked to
lower levels of atherosclerosis.
If you have not exercised regularly and 13
would like to start an exercise program, or if
Part 1: Understanding Stroke
you have medical problems or family history
of serious disease, consult your physician
before beginning an exercise program.
Select an exercise program that is most suit-
able for you. Experts recommend at least 20
to 30 minutes of aerobic exercise three to
four times a week in order to achieve and
maintain an improved level of fitness.
■ Treat Diabetes — The association between
diabetes and increased stroke risk seems to
be related to the circulatory problems
caused by diabetes. Good control of dia-
betes appears to reduce the cardiovascular
complications of the disease.
■ Reduce Stress — Because stress may
increase blood pressure, it is linked indi-
rectly to stroke risk. A one-time stressful
event rarely causes a stroke, but long-term
unresolved stress can contribute to high
blood pressure. Stress management, includ-
ing relaxation techniques, biofeedback,
exercise and counseling, appear to be useful
in the treatment of high blood pressure,
thus lowering the risk of stroke.
■ Use of Oral Contraceptives — Oral con-
traceptives, especially those with high
estrogen content, appear to increase the
risk of blood clots, including clots that
cause stroke, especially in women over age
30. The risk is even higher in women who
smoke. Consult your physician for advice
regarding alternative methods of birth con-
14 trol if you have stroke risk factors and are
currently using oral contraceptives.
Part 1: Understanding Stroke
■ Post-menopausal estrogen use — Recent
studies have shown that post-menopausal
estrogen replacement is associated with a
small increase in the risk of stroke.
Risk Factors That Cannot be Changed
■ Age — The chance of having a stroke
increases with age. Two-thirds of strokes
occur in persons over the age of 65.
■ Gender — For reasons that are not yet
clear, stroke is 25 percent more common in
men than in women.
■ Race — The incidence of stroke varies
among races for reasons that are probably
related to genetic factors. Social factors,
such as lifestyle and environment, can also
play a part. African-Americans have a
higher incidence of hypertension than Cau-
casians, and also a higher rate of stroke.
Furthermore, they are more likely to suffer
strokes at an earlier age.
■ Family or Individual History — A history
of cerebrovascular disease in a family ap-
pears to be a contributing factor to stroke.
While you have no control over your family
history, you can take steps to decrease your
risk through diet, exercise and other means
discussed in this handbook. If you have
experienced a stroke or TIA in the past,
you are at increased risk for having a stroke
in the future. Therefore, all the preventive
measures discussed in this section are of
particular importance.
New Risk Factors
The Stanford Stroke Center is participating
in clinical trials that are evaluating some
recently described stroke risk factors. These
risk factors may predispose to atherosclerosis
or blood clot formation and appear to be
treatable.
■ Stroke and Migraine — Migraine head-
aches are not considered a traditional risk
factor for stroke. However, several epidemi-
ological studies have reported that people
with migraine may be at a slightly increased
risk for stroke, as compared to people who
do not have migraine headaches. This
appears to be particularly true of people
who carry additional stroke risk factors such
as smoking, elevated cholesterol, or use of
birth control pills.
People who experience migraine with
aura may have symptoms that very much
resemble stroke-like symptoms. The aura
symptoms of migraine are typically visual
symptoms, but sometimes speech difficul-
ties, numbness and tingling or weakness on
one side of the body may occur. Migraine
auras are oftentimes followed by severe
headaches, but rarely the aura symptoms
can occur without the headaches. In some
instances it can be difficult to determine if
aura symptoms represent the warning symp-
toms of stroke or migrainous phenomena.
Therefore, if in doubt it is important to seek
an urgent medical evaluation.
 PART II
NEW DIAGNOSIS
AND TREATMENT
OPTIONS
16 HOW TO DIAGNOSE distinguish between an ischemic or hemor-
rhagic stroke. The test involves the use of
Part I1: New Diagnosis and Treatment Options

STROKE AND STROKE low-dose x-rays to visualize the brain.

RISK ■ Magnetic Resonance Imaging (MRI) is an

advanced diagnostic tool that provides a
The ability to pinpoint quickly the precise high level of anatomic detail for precisely
location of a stroke and determine the extent locating the stroke and determining the
of damage is of critical importance in making extent of damage. Due to its high level of
treatment decisions during a stroke emer- sensitivity, MRI is considered especially
gency. For instance, the physician must be able useful when the stroke involves small blood
to quickly determine whether the stroke is an vessels. The technology involves use of a
ischemic event (arising from a blocked blood strong magnetic field, and is performed in a
vessel) or a hemorrhagic event (bleeding special room free of metallic equipment.
caused by bursting of a blood vessel) before Recently, there have been major advances
the appropriate medical therapy can begin. in the early detection of stroke using diffu-
The Stanford Stroke Center is one of the sion (DWI) and perfusion (PWI) weighted
few places in the country that has more than a imaging. These modalities allow both early
dozen state-of-the-art brain diagnostic devices and more accurate detection of acute stroke,
available to obtain in-depth information improving our ability to treat patients with
about a patient’s status. These highly sensitive cerebrovascular problems. Stanford has been
tools are of critical importance in diagnosing a leader in the development of this technique.
abnormalities that place a patient at high risk
CT scans help distinguish the type of stroke.
for stroke, such as a blocked blood vessel or
the presence of an aneurysm or cerebral vascu-
lar malformations
To obtain complete diagnostic information,
it is likely that several (but not all) of the fol-
lowing diagnostic studies will be performed
during an evaluation for stroke or stroke risk.
■ Computerized Tomography (CT) Scan is
generally the first diagnostic test done after
a patient with a suspected stroke arrives in
the emergency room. It is used to quickly

Dr. David Tong directs the Stroke Center's
Neurosonology Laboratory. He is shown here
performing an ultrasound examination.
■ Magnetic Resonance Angiography (MRA)
is a noninvasive technology for imaging the
neck and cerebral blood vessels, which
yields valuable information regarding blood
supply and vascular anomalies of the brain.
The use of intravenous contrast agents
(MFAST technique) has provided tremen-
dous improvement in the resolution of this
test for accurately viewing blood vessels in
the neck and brain.
■ CT Angiography (CTA) is a non invasive
study that demonstrates three-dimensional
anatomical views of cerebral blood vessels
and complex aneurysms.
■ Transcranial Doppler (TCD) is a new, 17
noninvasive ultrasound procedure that
Part I1: New Diagnosis and Treatment Options
allows the assessment of blood flow through
the cerebral vessels via a small probe placed
against the skull. TCD is a portable test,
which can be performed frequently at the
patient’s bedside to follow the progress of
medical treatment for stroke.
■ Xenon CT Scanning is another non-inva-
sive imaging method that uses the inhala-
tion of the inert gas Xenon to measure
blood flow in various brain regions.
■ Carotid Duplex Scanning is a noninvasive
study to diagnose blockage in the carotid
arteries. This technology involves recording
sound waves that reflect the velocity of
blood flow.
■ Radionuclide SPECT Scanning provides
data on relative blood flow using the
radionuclide Technetium99.
■ Cerebral Angiography (angiogram) is a
diagnostic study that requires injection of a
contrast dye through a major artery (usually
the femoral artery in the thigh) for evalua-
tion of blood flow to the brain and for diag-
nosis of cerebral aneurysms and vascular
malformations. This procedure is completed
in Stanford’s Cath/Angio lab. The proce-
dure time is approximately two to three
hours; bed rest for six hours is required after
the procedure.
■ Transesophageal Echocardiography in-
volves placing a flexible tube in the esopha-
18 gus (tube to stomach) to directly image the during the critical early stages of stroke.
heart. Patients must have no food in their Early administration of tPA after a stroke
Part I1: New Diagnosis and Treatment Options

stomach when this test is performed. can reduce neurological damage signifi-
cantly. These medications are most effec-
tive when administered within the first 3
NEW DRUGS FOR hours of stroke onset.
Recent data suggest that the time win-
STROKE dow for effective administration of throm-
bolytic agents may be as long as 6 hours for
Drug therapy is a relatively recent approach to
selected stroke patients.
the treatment of stroke, and a tremendous
■ Neuroprotective Agents — Medications
amount of research is under way to find effec-
that make the brain less susceptible to the
tive new drugs that can minimize stroke
damaging effects of a stroke are called neu-
damage.
roprotective agents. These new drugs are
The Stanford Stroke Center is participating
being evaluated in clinical trials at Stanford.
in FDA-approved clinical trials of a number
It is not yet known which stroke patients
of new drugs, showing promise for both emer-
are the best candidates for these neuropro-
gency treatment of stroke as well as stroke
tective drugs or whether the drugs will be
prevention.
consistently effective. The medications are
Emergency Treatment of Stroke investigational and authorized by the FDA
for use only in randomized clinical trials.
Much of the damage caused by a thrombotic
■ Hypothermia — In experimental models,
or embolic stroke occurs in the first few hours.
cooling of the body is one of the most effec-
The primary focus of acute stroke research has
tive therapies for stroke. Currently a num-
been the development of new clot-dissolving
ber of clinical trials of acute hypothermia
drugs and medications that make the brain
are in progress. Stanford is also participating
more resistant to stroke (neuroprotective
in an investigational study of this treatment
agents).
modality for patients with severe strokes.
Drugs that dissolve clots are known as
thrombolytic agents. These drugs can dramat-
Stroke Prevention
ically minimize stroke damage.
A number of medications that help prevent
■ Thrombolytic Agents (tissue plasminogen
stroke in high-risk patients, particularly
activator [tPA]), widely used to dissolve
those who have had a previous TIA or minor
clots that cause heart attacks, are also able
to dissolve artery-blocking clots in the brain
stroke, are under investigation at the Stanford ■ Antiplatelet Agents work by preventing or 19
Stroke Center. These drugs fall into two reducing the occurrence in the blood-

Part I1: New Diagnosis and Treatment Options

major categories: anticoagulants (such
as heparin, warfarin and ximelagatran) and
antiplatelet agents (such as aspirin, dipyri-
damole, and clopidogrel).
■ Anticoagulants may be given orally, intra-
venously or subcutaneously. These drugs
work by preventing blood clotting. They
are also used for deep vein thromboses and
pulmonary emboli and are very effective for
preventing stroke in patients with atrial fib-
rillation.
Dr. Gary Steinberg, Co-Director of the Stanford
Stroke Center, has pioneered several new surgical
techniques for patients with AVMs and aneurysms.
stream of a phenomenon known as platelet
aggregation. When there is damage or
injury to a blood vessel, platelets (one type
of blood particle) migrate to the scene to
initiate a healing process. Large numbers of
platelets clump together (aggregation) and
form what is essentially a plug. This aggre-
gation can sometimes result in formation of
a thrombus (blood clot) that may totally
block the artery or break loose and block a
smaller artery. By preventing this from
occurring, antiplatelet agents can reduce
the risk of stroke in patients who have had
TIAs or prior ischemic strokes. Antiplatelet
studies are under way at Stanford to deter-
mine the most effective ways to administer
these agents.

ADVANCED SURGICAL
TECHNIQUES
Surgery is an accepted way of preventing
stroke for patients with certain conditions.
There are a number of conventional surgical
techniques that have been in use for some
time, including “clipping” aneurysms to pre-
vent further bleeding and removing cerebral
vascular malformations.
The Stanford Stroke Center is pioneering
several new surgical techniques for patients
20 with cerebral vascular malformations or
aneurysms once considered impossible to treat
Part I1: New Diagnosis and Treatment Options

because of their location or size.

Carotid Endarterectomy
Carotid endarterectomy is a procedure used to
remove atherosclerotic plaque from the carotid
artery when this vessel is blocked. For certain
patients with minor strokes or TIAs, carotid
endarterectomy is highly beneficial in pre-
venting future strokes. This procedure is also
beneficial for some patients with blockage of
the carotid arteries who have not had previ-
ous symptoms.

Stereotactic Microsurgery for

Cerebral Vascular Malformations
and Aneurysms
Stereotactic microsurgery using intraoperative
surgical navigation is one of the most dra-
matic new surgical procedures for cerebral
vascular malformations and certain aneurysms
that were once considered untreatable. It
employs sophisticated computer technology
and geometric principles to pinpoint the
precise location of the cerebral vascular mal-
formation. During the procedure, markers are
painlessly placed on the patient’s head and
three-dimensional reference points are estab-
lished using MRI or CT. This technique
allows neurosurgeons to locate the cerebral
vascular malformation within one or two mil-
Dr. Midori Yenari researches novel stroke
treatments, and also provides care for patients at
the Stanford Stroke Center.
limeters so they can operate in deep or elo-
quent brain areas, using microscope-enhanced
methods and delicate instruments, without
affecting normal brain tissue.
CyberKnife, Stereotactic Radiosurgery
for Cerebral Vascular Malformations
Stereotactic radiosurgery with the frameless
CyberKnife System developed at Stanford, is a
minimally invasive, relatively low-risk proce-
dure, that uses the same basic techniques as
stereotactic microsurgery to pinpoint the pre-
cise location of the cerebral vascular malfor-
mation. Once located, the cerebral vascular
malformation can be obliterated by focusing a
beam of radiation that causes it to clot and
then disappear. Due to the precision of this
technique, normal brain tissue usually is not
affected. This procedure is generally per-
formed on an outpatient basis.
Revascularization of the Blood Supply
Revascularization is a surgical technique for
treating aneurysms or blocked cerebral arteries
associated with atherosclerosis or moyamoya
disease. The technique essentially provides a
new route of blood to the brain by grafting
another vessel to a cerebral artery or provid-
ing a new source of blood flow to the brain.
Stanford has been at the forefront of advances
in revascularization techniques.
Intraoperative Adjuncts
Several specialized procedures are performed
in the operating room during cerebrovascular
surgery to decrease the risk of stroke. These
include continuous electrophysiological moni-
toring of brain waves reflecting important
neurologic functions, as well as intraoperative
mapping of critical motor, sensory and lan-
guage brain regions. Cerebral blood flow mea-
surements and angiography are also performed
during surgery to prevent neurologic injury.
Hypothermia
During surgical treatment of aneurysms and
cerebral vascular malformations, there is a
certain inherent risk that the patient may 21
have a stroke while on the operating table.
Part I1: New Diagnosis and Treatment Options
Stanford physicians are using a technique
known as hypothermia (cooling of the body),
to prevent stroke during surgical treatment of
giant and complex aneurysms or difficult cere-
bral vascular malformations. Dropping the
brain temperature gives the surgeon the nec-
essary time to operate with minimal risk of
surgery-induced stroke. Special equipment
known as a cardiopulmonary bypass machine
is occasionally used to completely shunt blood
flow away from the brain while the body is
placed under deep hypothermia.
Neurotransplantation
Stanford Stroke Center has developed an
innovative program in neurotransplantation
for stroke patients who have neurologic defects.
This includes experimental studies transplant-
ing neuronal progenitor cells or stem cells to
repair damaged brain tissue and restore neuro-
logic function.
INTERVENTIONAL
NEURORADIOLOGY
TECHNIQUES
In addition to new medications and surgical
techniques, The Stanford Stroke Center is
pioneering a number of new interventional
radiology procedures to prevent stroke in
22 A B
Part I1: New Diagnosis and Treatment Options
(A) A large aneurysm of the internal carotid
artery (arrow). (B) The aneurysm after place-
ment of coils to help thrombose the aneurysm.
Coiled aneurysm is indicated by arrow.
patients with selected high-risk cerebral
vascular malformations, aneurysms, and par-
tially blocked arteries. These endovascular
procedures are performed within the blood
vessel.
Endovascular Treatment
of Aneurysms
Endovascular treatment of aneurysms is a new
interventional neuroradiologic technique,
which greatly benefits patients with serious
medical conditions who are unable to sustain
the stress of surgery. Platinum coils developed
at Stanford are guided into the aneurysm via
a catheter, creating a clot that effectively
closes the aneurysm off from the surrounding
circulation, preventing the risk of hemor-
rhagic stroke in the future.
Mechanical Devices
Stanford has substantial experience using
mechanical devices that can physically
remove blood clots that are blocking blood
vessels within the brain. One of the devices,
the MERCI Retrieval System, was recently
approved by the FDA. The device works like
a corkscrew to pull a clot out of blood vessels.
The Stanford Stroke Center is one of only 25
medical centers in the country with experi-
ence using this device. For selected patients,
devices such as the MERCI retriever can
effectively treat stroke even up to 8 hours
after symptom onset.
Endovascular Treatment of Cerebral
Vascular Malformations
Endovascular treatment of cerebral vascular
malformations is also available at Stanford.
One innovative form of treatment involves
use of a “super glue” substance introduced via
a tiny catheter to reduce the size of the cere-
bral vascular malformations and facilitate fur-
ther microsurgical or radiation treatment. In
some cases, it is possible to completely block
off and cure the cerebral vascular malforma-
tions with endovascular treatment alone.
Angioplasty and Stenting of Vessels in
the Neck and Brain
Angioplasty and stenting of vessels in the
neck and brain are other new endovascular
procedures available at only a few institutions
nationwide. Cerebral angioplasty is similar to
a widely used cardiology procedure, and is intensive care unit. The Neurocritical Care 23
used to open partially blocked vertebral and Program also focuses on specific severe stroke

Part I1: New Diagnosis and Treatment Options

carotid arteries in the neck, as well as blood subtypes, including: very large strokes which
vessels within the brain. Stenting of carotid or may cause swelling of the brain and raised
vertebral arteries and large cerebral veins pressure within the skull, intracerebral hemor-
involves use of a fine, tubular wire mesh to rhage, and subarachnoid hemorrhage. In
hold the vessel open. addition to stroke patients, the Neurocritical
Care Program incorporates the care of criti-
Intra-Arterial Thrombolysis cally ill neurologic patients that do not have a
Stanford has used this innovative technique stroke, such as uncontrolled seizures, brain
for treatment of selected stroke patients for infections, head trauma, severe muscle weak-
more than 10 years. A small catheter (tube) is ness, and brain injury due to cardiac arrest.
threaded into the brain during cerebral Under guidance of the neurocritical care pro-
angiography (see section “How to Diagnose gram Stanford University Medical Center has
Stroke and Stroke Risk”) and clot dissolving adopted a routine hypothermia protocol for
medications are delivered directly into the
blocked blood vessel. Dr. Christine Wijman directs the Stanford
Neurocritical Care Program, focusing on the care
of stroke patients who require intensive care
monitoring.
THE STANFORD
NEUROCRITICAL CARE
PROGRAM
The Neurocritical Care Program at Stanford
was established in 2001 under the direction of
Dr. Christine Wijman. This program focuses
on the care of critically-ill stroke patients who
require management in the intensive care
unit in order to closely monitor their neuro-
logic, respiratory, or circulatory function.
Patients who receive thrombolytic therapy or
who undergo neuro-interventional procedures
are often monitored for 12-24 hours in the
24 patients who remain comatose after cardiac
arrest. This therapy has been shown in two
Part I1: New Diagnosis and Treatment Options
independent studies to improve neurologic
outcome in these patients.
The Stanford Neurocritical Care Program
also conducts a number of clinical studies,
including investigating a new technique to
remove blood from the chambers of the brain
that block off the pathways of the spinal fluid
in patients with hemorrhagic stroke. Other
studies include evaluating the effects of
hypothermia in patients with stroke within
the first six hours of symptom onset as well as
the safety and feasibility of selective cerebral
hypothermia (cooling the brain without cool-
ing the entire body) by means of a cooling
helmet.
PATIENT CARE AT
STANFORD
In addition to the diagnostic and therapeutic
services offered by the Stanford Stroke Cen-
ter, a full spectrum of allied patient care ser-
vices is available. To ensure that emergency
care is administered as expeditiously as possi-
ble in the case of stroke victims, Stanford
offers 24-hour emergency helicopter and
fixed-wing transport through its Life Flight
program. The Emergency Department staff
provide an early and essential communica-
tions link in the identification and treatment
of stroke patients.
After care in the Emergency Room or the
Intensive Care Unit (ICU), stroke patients
are generally admitted to the Inpatient Neu-
rology or Neurosurgery Unit for continued
observation, treatment and eventual rehabili-
tation. During their hospital stay, patients will
receive care from a dedicated, interdiscipli-
nary team.
The team includes:
■ Physicians — including the patient’s pri-
mary care physician, as well as physicians
on the neurology, neurosurgery, neuroradi-
ology and neuroanesthesiology services
■ Registered Nurses/Licensed Vocational
Nurses — assess and coordinate patient
needs, administer treatment, provide
patient/family instruction
■ Nursing Assistants — provide personal
care and hygiene
■ Physical, Occupational and Speech
Therapists — provide individualized reha-
bilitation treatment
■ Medical Social Worker — offers support to
patient and family, works to coordinate any
appropriate community resources
■ Chaplaincy — offers spiritual support to
patient and family
■ Case Management — oversees hospitaliza-
tion and coordinates with insurance payors,
works to insure follow-up arrangements
such as home care
■ Dietitian — assists with proper design of
nutritional and caloric intake
Rehabilitation Services at Stanford 25
Stanford offers a wide variety of rehabilitation

Part I1: New Diagnosis and Treatment Options

services for stroke patients, ranging from inpa-
tient services on the Comprehensive Inpa-
tient Rehabilitation Unit, as well as several
types of outpatient therapies. The program
features an interdisciplinary team approach,
including physical, occupational and recre-
ational therapists; speech/language patholo-
gists; neuropsychologists; clinical social work-
ers/case managers; dietitians; physicians and
rehabilitation nurses.

REHABILITATION
FOLLOWING STROKE
Because of the tremendous advances in stroke
treatment, along with the ever-increasing
sophistication of rehabilitation techniques,
the outlook for stroke patients has never been Rehabilitation is an important part of stroke
more hopeful. therapy.
The ultimate goal of rehabilitation is to
may be mild or severe, ranging from dizziness
return the patient to as independent a lifestyle
and confusion, to sensory loss, to paralysis
as possible. Successful stroke rehabilitation is
and even death. Patients with mild strokes or
dependent on many factors, including the
those who obtained successful medical ther-
severity of brain damage and the cooperation
apy may need little or no rehabilitation.
of family and friends. Not surprisingly, the
After a stroke, other blood vessels may
attitude of the patient is a key factor in speed
be able to take over for the damaged blood
and degree of recovery. A positive outlook
vessel. This allows some cells to recover,
and high level of determination may facilitate
although others may still die. If the blood sup-
recovery.
ply is cut off due to a clot, the body works to
Depending on the area of the brain affected
by the stroke, physical and mental damage
26 dissolve the clot. This means that the dam- Support Groups
aged part of the brain can sometimes improve Support Groups for patients and their families
Part I1: New Diagnosis and Treatment Options

or return to normal without rehabilitation. are available. Participants have the opportu-
Most stroke patients, however, will benefit nity to increase their knowledge of diagnostic
from some type of rehabilitation. and treatment options, and develop problem
solving and coping skills.
Stroke Disabilities The support group is intended to be a forum
Different areas of the brain control different where patients and their families can share ex-
bodily functions. When certain brain cells periences and concerns about rehabilitation,
are not able to function due to stroke, the depression, and other daily concerns. All
parts of the body controlled by those cells are patients, at any stage of treatment, are en-
also unable to function. For instance, if the couraged to participate.
left hemisphere of the brain is damaged, most
of the effects will occur on the right side of
the body. It’s also important to note that most
areas of the brain will continue to function
normally, despite substantial damage in other
areas.
Some of the most common results of a
stroke are hemiparesis (paralysis on one side
of the body), aphasia (the loss of ability to
speak or to understand language), spatial-per-
ceptual deficits, learning difficulties, memory
loss, behavioral/emotional changes, and loss
of motor skills.
If someone you know has suffered some of
these disabilities as a result of stroke, there
are many community resources available that
can help you cope with the situation and
learn how to provide the proper support and
encouragement. The Stanford Stroke Center
can provide you with an up-to-date list of
community resources.
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 FOR A STROKE EMERGENCY, CALL

911
IMMEDIATELY – DO NOT WAIT

FOR MORE INFORMATION

CHECK OUR WEB SITES

http://strokecenter.stanford.edu
http://stroke.stanfordhospital.com
http://fightstroke.com

If you have any questions

after reading this handbook, please feel free to
call us at the Stanford Stroke Center:
(650) 723-4448.

You can also send e-mail to

strokecenter@med.stanford.edu

(Please note that no individual

patient advice will be given by e-mail)

300 Pasteur Drive, Stanford, California 94305

9/04 10K