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Stroke - FAST, Symptoms, Causes, Types, Treatment, Prevention
Stroke - FAST, Symptoms, Causes, Types, Treatment, Prevention
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A stroke occurs when part of the brain loses its blood supply and stops working. This
causes the part of the body that the injured brain controls to stop working.
Transient ischemic attack, TIA, or mini-stroke (The stroke symptoms resolve within
minutes, but may take up to 24 hours on their own without treatment. This is a
drugs (thrombolytics) to try to restore blood supply to the affected part of the brain.
Face drooping
Arm weakness
Speech difficulty
the brain.
People at risk for stroke include those who have high blood pressure, high
cholesterol, diabetes, and those who smoke. People with heart rhythm disturbances,
Stroke is diagnosed by the patient's symptoms, history, and blood and imaging tests.
artery may occur up to 24 hours after onset of symptoms. This procedure is not
available at all hospitals and not appropriate for all stroke patients.
You can prevent stroke by quitting smoking, controlling blood pressure, maintaining
The prognosis and recovery for a person that has suffered a stroke depends upon the
What is a stroke?
A stroke, also known as a cerebrovascular accident or CVA is when part of the brain loses its
A stroke, also known as a cerebrovascular accident or CVA is when part of the brain loses its
blood supply and the part of the body that the blood-deprived brain cells control stops
working. This loss of blood supply can be ischemic because of lack of blood flow, or
because strokes can lead to death or permanent disability. There are opportunities to treat
ischemic strokes but that treatment needs to be started in the first few hours after the signs
of a stroke begin. The patient, family, or bystanders, should call 9-1-1 and activate
A transient ischemic attack (TIA or mini-stroke) describes an ischemic stroke that is short-
lived where the symptoms resolve spontaneously. This situation also requires emergency
assessment to try to minimize the risk of a future stroke. By definition, a stroke would be
QUESTION
What is a stroke?
See Answer
Thrombotic stroke
The blockage of an artery in the brain by a clot (thrombosis) is the most common cause of a
stroke. The part of the brain that is supplied by the clotted blood vessel is then deprived of
blood and oxygen. As a result of the deprived blood and oxygen, the cells of that part of the
brain die and the part of the body that it controls stops working. Typically, a cholesterol
plaque in one of the brain's small blood vessels ruptures and starts the clotting process.
Risk factors for narrowed blood vessels in the brain are the same as those that cause
narrowing blood vessels in the heart and heart attack (myocardial infarction). These risk
factors include:
high cholesterol,
diabetes, and
smoking.
Embolic stroke
Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque
(cholesterol and calcium deposits on the wall of the inside of the heart or artery) breaks
loose, travels through the bloodstream, and lodges in an artery in the brain. When blood flow
stops, brain cells do not receive the oxygen and glucose they require to function and a stroke
occurs. This type of stroke is referred to as an embolic stroke. For example, a blood clot
might originally form in the heart chamber as a result of an irregular heart rhythm, like atrial
fibrillation. Usually, these clots remain attached to the inner lining of the heart, but
occasionally they can break off, travel through the bloodstream (embolize), block a brain
artery, and cause a stroke. An embolism, either plaque or clot, may also originate in a large
artery (for example, the carotid artery, a major artery in the neck that supplies blood to the
brain) and then travel downstream to clog a small artery within the brain.
Cerebral hemorrhage
A cerebral hemorrhage occurs when a blood vessel in the brain ruptures and bleeds into the
surrounding brain tissue. A cerebral hemorrhage (bleeding in the brain) causes stroke
symptoms by depriving blood and oxygen to parts of the brain in a variety of ways Blood
symptoms by depriving blood and oxygen to parts of the brain in a variety of ways. Blood
flow is lost to some cells. Additionally, blood is very irritating and can cause swelling of brain
tissue (cerebral edema). Edema and the accumulation of blood from a cerebral hemorrhage
increases pressure within the skull and causes further damage by squeezing the brain
against the bony skull. This further decreases blood flow to brain tissue and its cells.
Subarachnoid hemorrhage
membrane that lines the brain. The blood originates from an abnormal blood vessel that
leaks or ruptures. Often this is from an aneurysm (an abnormal ballooning out of the blood
vomiting, light intolerance, and stiff neck. If not recognized and treated, major neurological
Vasculitis
Another rare cause of stroke is vasculitis, a condition in which the blood vessels become
Migraine headache
There appears to be a very slight increased occurrence of stroke in people with migraine
headache. The mechanism for migraine or vascular headaches includes narrowing of the
brain blood vessels. Some migraine headache episodes can even mimic stroke with loss of
function of one side of the body or vision or speech problems. Usually, the symptoms resolve
Strokes are usually classified by what mechanism caused the loss of the blood supply, either
ischemic or hemorrhagic. A stroke may also be described by what part of the brain was
affected (for example, a right temporal stroke) and what part of the body stopped working
Ischemic stroke
preventing oxygen-rich blood from being delivered to brain cells. The artery can be blocked
in a couple of ways. In a thrombotic stroke, an artery can narrow over time because of
cholesterol buildup, called plaque. If that plaque ruptures, a clot is formed at the site and
prevents blood from passing to brain cells downstream, which are then deprived of oxygen.
In an embolic stroke, the artery is blocked because of debris or a clot that travels from the
heart or another blood vessel. An embolus or embolism is a clot, a piece of fatty material or
other object that travels within the bloodstream that lodges in a blood vessel to cause an
obstruction.
Blood clots that embolize usually arise from the heart. The most common cause of these
blood clots is a heart arrhythmia called atrial fibrillation, where the upper chambers of the
heart, the atria, do not beat in an organized rhythm. Instead, the chaotic electrical rhythm
causes the atria to jiggle like a bowl of Jell-O. While blood still flows to the ventricles (the
heart's lower chambers) to be pumped to the body, some blood along the inner walls of the
atrium can form small blood clots. If a clot breaks off, it can travel or embolize to the brain,
where it can block blood flow to a part of the brain and cause a stroke.
The carotid arteries are two large blood vessels that provide the brain with blood supply.
These arteries can narrow, or develop stenosis, with cholesterol plaque that may build up
over time. The surface of the plaque is irregular and bits of debris can break off and embolize
to the brain to block blood vessels downstream and deprive brain cells of oxygen-rich blood.
Hemorrhagic stroke
When a blood vessel leaks and spills blood into brain tissue, those brain cells stop working.
The bleeding or hemorrhage is often due to poorly controlled high blood pressure that
weakens the wall of an artery over time. Blood may also leak from an aneurysm, a congenital
congenital abnormality where an artery and vein connect incorrectly. The bleeding can form
a hematoma that directly damages brain cells and may also cause swelling that puts further
There are four major arteries that supply the brain with blood.
The right and left carotid artery are located in the front of the neck and their pulse
The right and left vertebral arteries are encased in bone as they run through the
vertebrae in the neck. As the two enter the brain, they join to form the basilar artery.
The carotid arteries and the vertebrobasilar arteries join to form the Circle of Willis at
the base of the brain and from this circle, arteries branch off to supply the brain with
blood.
The left side of the brain controls the right side of the body and vice versa. Speech tends to
The anterior and middle cerebral arteries provide blood supply to the front two-thirds of the
brain, including the frontal, parietal, and temporal lobes. These parts of the brain control
voluntary body movement, sensation, speech and thought, personality, and behavior.
The vertebral and basilar arteries are considered the posterior circulation and supply the
occipital lobe where vision is located, the cerebellum that controls coordination and balance,
and the brainstem that is responsible for the unconscious brain functions that include blood
Strokes may be described based upon the function of the body that is lost and by the area of
the brain that is affected. Most commonly in strokes that involve the brain, the symptoms
the brain that is affected. Most commonly in strokes that involve the brain, the symptoms
involve either the right or left side of the body. In strokes that affect the brainstem or the
Strokes may affect motor function or the ability for the body to move. Part of the body may
be affected, like the face, a hand, or an arm. An entire side of the body may be affected (for
example, the left part of the face, left arm, and left leg). Weakness on one side of the body is
called hemiparesis (hemi = half + paresis = weak) and paralysis is hemiplegia (hemi = half +
plegia = paralysis).
Similarly, sensory function -- the ability to feel -- can affect the face, hand, arm, trunk, or a
combination of these.
Other symptoms like speech, vision, balance, and coordination help locate the part of the
brain that has stopped working and helps the health care professional make the clinical
diagnosis of stroke. This is an important concept since not all loss of neurologic function is
due to stroke and if the anatomy and physiology do not match the loss of body function,
other diagnoses may be considered that can affect both brain and body.
A lacunar stroke describes the blockage of a single tiny penetrating artery branch in the
brain. The area of the involved brain is small but can still cause significant neurologic deficits,
just like a stroke involving a larger blood vessel and more brain tissue. In some cases,
however, the stroke is silent, meaning that no obvious body function is lost and an old
lacunar stroke can be seen as an incidental finding on a CT or MRI scan of the head that
might be done for other reasons. The term lacune means empty space and a tiny empty
space of an old lacunar stroke can be seen on imaging where brain tissue has been lost.
SLIDESHOW
A transient ischemic attack (TIA, mini-stroke) is a short-lived stroke that gets better and
impairment of brain function that is caused by a loss of blood supply. A TIA causes a loss of
function in the area of the body that is controlled by the portion of the brain affected. The
loss of blood supply to the brain is most often caused by a clot that spontaneously forms in a
blood vessel within the brain (thrombosis). However, it can also result from a clot that forms
elsewhere in the body, dislodges from that location, and travels to lodge in an artery of the
brain (emboli). Arterial spasm and, rarely, a bleed into brain tissue are other causes of a TIA.
Some TIAs develop slowly, while others develop rapidly. By definition, all TIAs resolve within
24 hours. Strokes take longer to resolve than TIAs, and with strokes, complete function may
never return and reflect a more permanent and serious problem. Although most TIAs often
last only a few minutes, all TIAs should be evaluated with the same urgency as a stroke in an
effort to prevent recurrences and/or strokes. TIAs can occur once, multiple times, or precede
because there is no guarantee that the situation will resolve itself and function will return
A TIA from a clot in the blood vessel that supplies the retina of the eye can cause temporary
visual loss (amaurosis fugax), which is often described as the sensation of a black, dark
curtain coming down. A TIA that involves the carotid artery (the largest blood vessel
supplying the brain) can produce problems with movement or sensation on one side of the
body, which is the side opposite to the actual blockage. An affected patient may experience
complete paralysis of the arm, leg, face, or one whole side of the body; or be unable to
complete paralysis of the arm, leg, face, or one whole side of the body; or be unable to
high cholesterol,
smoking,
diabetes, and
increasing age.
Heart conditions like atrial fibrillation, patent foramen ovale (hole in the heart), and heart
When stroke occurs in younger individuals (less than 50 years old), less common risk factors
homocystinuria, in which there are excessive levels of the chemical homocystine in the body.
Scientists are trying to determine whether the non-hereditary occurrence of high levels of
There may be no warning signs of a stroke until it occurs. It is why high blood pressure
(hypertension), one of the risk factors for stroke, is called the silent killer.
Some patients may experience transient ischemic attack (TIA) that can be thought of as a
stroke that has resolved itself. The symptoms may be mild or dramatic and can mimic a
stroke with weakness, numbness, facial droop, and speech difficulties, but these symptoms
may only last a few minutes. TIAs should not be ignored since they may offer an opportunity
guarantee that the symptoms of stroke will resolve on their own. For that reason, a TIA
Amaurosis fugax describes the temporary loss of vision in one eye that occurs because of an
embolus of blood clot or debris to the artery that supplies the eye. While it only involves
Symptoms of stroke depend upon what area of the brain has stopped working due to loss of
its blood supply. Often, the patient may present with multiple symptoms including the
following:
Double vision
The symptoms of ischemic and hemorrhagic stroke may be the same, but patients with
Stroke care involves many health care professionals as the patient travels through the care
process.
Care for a stroke patient may begin with prehospital providers (first responders, EMTs,
Emergency physicians begin the evaluation and may help make the decision to administer
decision to treat the stroke patient with tPA or clot retrieval, if the latter is an option at the
hospital.
Critical care specialists help stabilize the patient after tPA is given. Patients who are not
Rehabilitation physicians, physical therapists and occupational therapists are involved after
Finally, the primary care provider would look after the patient long-term.
Time is of the essence since the longer a stroke remains unrecognized and untreated, the
longer brain cells are deprived of oxygen-rich blood and the greater number of brain cells
The American Heart Association and the American Stroke Association recommend
First responders, EMTs and paramedics may use the Cincinnati Prehospital Stroke
Scale to recognize a stroke and alert the emergency department to prepare for their
arrival. This scale addresses the same three components as the FAST: speech, arm
In the emergency department, nurses and doctors may use the National Institute of
examination.
The clinical diagnosis of stroke is usually made after the health-care professional performs a
history and physical examination. While speed is important in making the diagnosis, it is also
important to learn about the circumstances that brought the patient to be seen. For example,
the patient just started slurring words about an hour ago versus the patient has been slurring
There is urgency to make the diagnosis and determine whether treatment with thrombolytic
medications (clot-busting drugs) to “reverse” the stroke is a possibility. The time frame to
intervene is narrow and may be as short as 3 to 4 ½ hours after onset of symptoms. For that
History may include asking about what symptoms are present, when they began, and if they
are improving, progressing, or remaining the same. Past medical history will look for stroke
risk factors, medications, allergies, and any recent illnesses or surgeries. Medication history
is very important, especially when the patient is taking anticoagulants (examples include
enoxaparin [Lovenox]).
Physical examination includes assessing vital signs and patient wakefulness. A neurologic
examination is performed, usually using the standardized stroke scale. Heart, lungs, and
If an acute stroke is still a consideration, blood tests and CT of the head are indicated.
However, the tests are not used to make the diagnosis, but are used to help plan treatment.
The CT is used to look for bleeding or masses in the brain and potentially how much brain
A CT perfusion scan may also be done to see how much brain is at risk by using injected dye
An MRI of the brain may be possibly indicated, but not all hospitals have this technology
readily available.
Blood tests may include a complete blood count (CBC), to measure red blood cell count
and platelets, electrolytes, blood glucose, and kidney function and blood tests to measure
blood clotting function, international normalized ratio (INR), prothrombin time (PT) and partial
thromboplastin time (PTT). Other blood tests may be indicated based upon the patient's
specific situation.
An EKG may be performed to check the heart's rate and rhythm. The patient is usually
Not all strokes affect the brain equally, and stroke symptoms and signs depend upon the part
For example, most people’s speech center is located in the left half of the brain so a
stroke affecting the left side of the brain would affect speech and comprehension. It
also would be associated with weakness of the right side of the body.
A right brain stroke would make the left side of the body weak. And depending on
where in the brain the injury occurred, the weakness could be the face, arm, leg or a
The NIH Stroke Scale tries to score how severe a stroke might be. It also monitors whether
the person's stroke is improving or worsening as time passes as the patient is re-examined.
There are 11 categories that are scored and include whether the patient is awake; can follow
commands; can see; can move face, arms and legs; has normal body sensations or feelings;
As in many emergencies, the first consideration are the CABs (Circulation, Airway, and
Breathing, according to the new CPR guidelines) to make certain that the patient has blood
pumping, no airway blockage and can breathe, and then has adequate blood pressure
control. In severe strokes, especially those that involve the brainstem, the brain's ability to
Patients will have intravenous lines established, oxygen administered, appropriate blood
tests, and noncontrast CT scans performed. At the same time, the health care professional
performs an assessment to make the clinical diagnosis of stroke and decides whether
thrombolytic therapy (tPA, a clot busting medication) or clot retrieval (mechanically removing
the clot through catheters that are threaded into the blocked artery) is an option to treat the
stroke.
If the diagnosis of ischemic stroke has been made, there is a window of time when
thrombolytic therapy using tPA (tissue plasminogen activator) may be an option. tPA
dissolves the clot that is blocking an artery in the brain and restores blood supply. For many
patients, that time window is 3 hours after the onset of symptoms. In a select group of
patients, that period may be extended to 4.5 hours. During that 3-to-4½ hours, the patient or
family needs to recognize the stroke symptoms, get the patient to a hospital (call 9-1-1), have
the patient assessed by the health care professional, who performs a CT scan to look for
other causes of stroke (including hemorrhage or tumor), consults with a neurologist, and
stabilizes the patient’s blood pressure and breathing. Only then can it be time to administer
the tPA or call an interventional radiologist or neurosurgeon to try to remove the clot
(mechanical thrombectomy).
(neurosurgeon) immediately to help determine whether any treatment options are available
thrombolytic agents, as these could worsen bleeding, make the symptoms of hemorrhagic
Hospital ER doctors and nurses are trained to act quickly in caring for stroke patients. The
most common delay that prevents tPA from being administered is patient delay in seeking
medical attention. Health care professionals perform an urgent CT scan of the head to help
distinguish an ischemic from a hemorrhagic stroke. This may also cause a delay in a few
instances.
Some smaller hospitals may use telemedicine to virtually consult neurology specialists, who
can help make the diagnosis of stroke, review the CT scan, and help decide whether tPA is a
reasonable option. They may administer the thrombolytic drug and transfer the patient to a
The decision to administer tPA in the appropriate patient (there are many reasons that the
drug is not indicated even if the patient arrives in time) is one that health care professionals
discuss with the patient and family, since there is risk of bleeding in the brain with the use of
tPA. While there is potential great benefit, because the blood vessels are fragile, there is a 6%
risk that an ischemic stroke can turn into a hemorrhagic stroke with bleeding into the brain.
This risk is minimized the earlier the drug is given and if the appropriate patient is selected.
In certain stroke situations, the treatment period may be extended to 4.5 hours. If tPA is given,
the patient will need to be admitted to an intensive care bed for monitoring. As well,
Some stroke patients are candidates for mechanical thrombectomy, where a thin catheter is
threaded into the blocked artery in the neck or brain, and the clot is sucked out. Depending
upon the patient, the size of the stroke, the location of the blockage in the brain and brain
symptoms. Mechanical thrombectomy is not available at all hospitals and may not be
appropriate for all patients. These procedures require the skill of a specially trained
In those patients where tPA and other interventions are not possible or are not indicated, the
patient is usually admitted to the hospital for observation, supportive care, and referral for
rehabilitation.
Stroke remains a major killer in the United States and worldwide. In the U.S., 20% of stroke
patients will die within a year. However, with the ability to intervene with thrombolytic therapy
to reverse the stroke and with more aggressive rehabilitation, the goal is to increase patient
Specialized stroke centers -- hospitals that have the doctors, equipment, and resources to
intervene quickly and treat strokes aggressively -- have shown to increase stroke survival as
well as patient function and recovery. These hospitals are certified by The Joint Commission,
the American Stroke Association, and the health departments of some states. It is to your
advantage to know which hospitals in your area are designated stroke centers because they
will have the specialists and equipment needed to minimize diagnosis-to-treatment times.
Many complications can develop in stroke patients, some of whom may not be able to return
decreased body function, mentally with decreased cognition, and emotionally with
The return to function depends upon the severity of the stroke, what parts of the brain and
body have stopped working, and what complications develop. Patients who lose their ability
to swallow may develop aspiration pneumonia when they inhale food or saliva into the
lungs, causing infection. Patients who have difficulty moving can develop pressure sores and
Seizures may be a complication in up to 10% of patients. The more severe the stroke, the
I ft t k ibl ?
Is recovery after a stroke possible?
Prompt intervention in the acute stroke and restored blood supply to brain tissue increase
the likelihood that stroke patients can be rescued and brain damage minimized.
In patients who have physical, mental, and emotional deficits because of the stroke,
rehabilitation offers hope of increased function and return to the level of activity that they
Again, the best treatment for stroke is prevention and minimizing risk factors for not only
stroke but for heart attack and peripheral vascular disease (PAD).
The purpose of rehabilitation is to return the stroke patient to the life and level of function
that existed before the stroke. The success of that goal depends upon the underlying health
Rehabilitation may take weeks or months and usually requires a team approach for success.
Physical therapists, occupational therapists, and speech pathologists will coordinate care
with the primary doctor and physical medicine and rehabilitation specialists.
Some of the treatments are directed to prevent life-threatening complications. For example,
speech pathologists may help with swallowing to prevent aspiration pneumonia. Physical
therapists may concentrate on strength and balance to prevent falls. Occupational therapists
may find ways to allow the patient to perform daily activities from personal hygiene to
Many patients with significant stroke deficits may require admission to a rehabilitation
hospital and/or longer term nursing facility prior to returning home. Unfortunately, some
patients will have had too severe a stroke to be offered that opportunity.
Prevention is always the best treatment, especially when the illness can be life-threatening
artery disease) and peripheral vascular disease. These include high blood pressure, high
cholesterol, diabetes, and smoking. Stopping smoking and keeping the other three under
Patients who have had a transient ischemic attack (TIA) are often prescribed medications to
decrease their risk of a subsequent stroke. These include medications to lower blood
cholesterol levels and control blood pressure. In addition, antiplatelet medications may be
prescribed to make platelets less likely to promote blood clot formation. These include
Patients with a TIA are usually evaluated for carotid stenosis or narrowing of the carotid
artery. Surgery to open critically narrowed carotid arteries (termed endarterectomy) may
Lifelong control of high blood pressure decreases the risk of hemorrhagic stroke.
Atrial fibrillation is the most common cause of embolic stroke. Ideally the heart rhythm can
be converted to normal sinus rhythm but in those patients whose hearts are chronically in
atrial fibrillation, anticoagulation or “blood thinning” minimizes the risk of blood clot formation
in the heart and subsequent embolization and stroke. The drug that is prescribed depends
upon the specific patient and individual situation. Patients who are prescribed apixaban