Stroke – Diagnosis, Symptoms, and Treatment

What is a Stroke?

A stroke is damage to the brain due to a lack of blood flow. You may hear strokes referred to as cerebrovascular accidents (CVA’s) this is the medical term for stroke and is often used by physicians. 

The damage to the brain tissue caused by stroke can have any number of effects, classically long-term symptoms such as paralysis, trouble swallowing, difficulty speaking, and loss of vision occur.  Stroke is one of the leading causes of death in the United States and is closely associated with heart disease which is another leading cause of death. 

Early recognition of the signs and symptoms of stroke and rapid emergency treatment can mean the difference between significant recovery and severe lifelong disability. For this reason understanding what leads to strokes, theri symptoms, and their primary treatments is critical. 

What Causes a Stroke?

A stroke is often caused by a significant reduction in the blood supply to an area of the brain. The most common cause of stroke is the rupture of a fatty plaque within the larger arteries of the brain, this is known as an ischemic stroke. This is the same mechanism by which most heart attacks occur and is more common in individuals with high blood pressure, high cholesterol, and diabetes. 

Some ischemic strokes are caused by a blood clot from elsewhere in the body traveling to the brain and getting stuck in one of the blood vessels. This is most common in patients with atrial fibrillation, an abnormal rhythm of the heart that is very common in older patients with heart disease. 

The rarest form of stroke is a hemorrhagic stroke, in these strokes a blood vessel bursts this both reduces blood flow to the affected area of the brain and spills blood into the brain tissue, which leads to death of even more brain tissue. This form of stroke is most common in those with uncontrolled high blood pressure. 

The risk of stroke is not equal in all patients, the most common risk factors for stroke are:

• High blood pressure (hypertension)
• Elevated cholesterol (hyperlipidemia)
• Diabetes mellitus
• Smoking
• Advanced age
• History of minor or major heart attack or stroke
• History of atrial fibrillation

How Common are Strokes?

Strokes are exceedingly common and are one of the leading causes of death and disability in the United States and around the world. The United States Centers for Disease Control and Prevention state that 1 in every 20 deaths is due to stroke. Stroke is the 5th leading cause of death in the U.S. with an estimated 150,000 deaths per year. 

Strokes do not always kill, 3.1% of American adults (7.8 million people) have experienced a stroke and are living with the after-effects. 

Signs and Symptoms of Stroke 

Strokes have a massive number of potential symptoms, the system that is used to remember some of these symptoms is F.A.S.T. These are the classic symptoms of stroke and should result in immediate medical attention. 

• F: Facial drooping

• A: Arm weakness

• S: Speech difficulties

• T: Time

Drooping of one side of the face,  an inability to hold both arms steady in front of the chest, and slurring of speech are the classic stroke signs and symptoms that are in the FAST acronym. Time refers to the idea that time is critical, and getting an individual with these symptoms to medical care as fast as possible is critical. 

There are other common symptoms that present in individuals with stroke, the most common of these are:

• Paralysis – one-sided weakness, trouble swallowing/speaking
• Double vision or loss of vision
• Confusion
• One-sided numbness or loss of sensation
• Headache

Stroke is most feared for its long term complications. Even with rapid and ideal treatment patients that have had a stroke may present with many of the following: 

• Permanent disability
• Inability to walk or perform daily activities
• Pneumonia - due to problems swallowing leading to aspiration (choking on food)
• Memory loss (dementia)
• Changes in behavior – depression, anxiety, or personality changes
• Death

Diagnosis

The diagnosis of stroke begins with a description of your symptoms, a doctor will then complete a detailed neurological examination that helps to record those symptoms and how they change over time. 

All patients with a suspected stroke will receive a CT scan or MRI, this will be done as soon as possible if the stroke occurred within the past few hours. If symptoms have been going on for 24 hours of longer this test may be done at a later date.

Your doctor will also likely order blood tests such as a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and coagulation studies (PT/INR, PTT).  They will also check your cholesterol levels and screen for diabetes.

Another important test is an ECG (electrocardiogram), ultrasound of the neck, and ultrasound of the heart (echocardiogram). These tests are done to look for conditions that may lead to stroke and could predict the occurrence of another stroke.

Treatment of Stroke 

The treatment of stroke is based on three things, what is causing the stroke, how severe your symptoms are, and the time since your symptoms began. 

What is causing the stroke is the first consideration, hemorrhagic strokes are more difficult to treat, only surgery can revolve a bleed within the brain. If this type of stroke is occurring your doctor will seek to optimize your blood pressure and prepare you for surgery if indicated. Ischemic strokes can be treated by a wide variety of clot busting and anticoagulant medications. 

The severity of symptoms is the second consideration, a test known as the NIH Stroke Scale is used to determine if your symptoms are severe enough that the benefits of using powerful clot busting medications outweighs the risks of severe bleeding. This determination may change if your symptoms change. 

Third, the time since the stroke occured is critical. The shorter the time between the stroke and presenting to the hospital the more brain tissue can be saved in the case of ischemic stroke. 3 hours from your first symptom is ideal timing but this will vary based on your age and the proposed intervention.

After a CT scan of the head is obtained to rule out a brain bleed, most patients with a recent (within 3 hours) ischemic stroke typically receive a medication called Alteplase (tissue plasminogen activator) that rapidly thins the blood and opens up the artery to your brain. This medication has a risk of causing serious bleeding which your doctor will discuss with you or your family members. The longer the time since the stroke occurred the less benefit will be seen from this medication.

There are many other medications that are used in the treatment of stroke, the majority of these medications are used in patients that are at significant risk of stroke or have had a stroke and are seeking to prevent another. The most commonly prescribed and their purpose is as follows.

• Antiplatelet agents: these medications are very effective at preventing the formation of new clots in patients at risk for ischemic stroke. Aspirin is also given when a stroke occurs as it has been shown to increase survival rates.
  • Aspirin 
  • Plavix (Clopidogrel)
• Cholesterol-lowering therapy: These medications treat high cholesterol and reduce the risk of stroke in nearly all patients. 
  • Lipitor (Atorvastatin)
  • Pravachol (Pravastatin)
• Antihypertensive agents: These medications are given daily to control blood pressure which may help prevent hemorrhagic strokes. 
  • Angiotensin converting enzyme (ACE) inhibitors - Zestril (Lisinopril) 
  • Angiotensin receptor blockers (ARBs) - Cozaar (Losartan)

Patients with atrial fibrillation will require an anticoagulant, a medication that thins the blood and prevents clots. This is because the abnormal heart rhythm in atrial fibrillation may lead to the formation of blood clots in the heart that can break off and cause a stroke. 

• Coumadin (Warfarin)
• Xarelto (Rivaroxaban)
• Eliquis (Apixaban) 
• Pradaxa (Dabigatran)

Patients with an ischemic stroke are monitored very closely in the hospital because they may develop seizures, brain swelling, and even bleeding into the brain.  As we mentioned, stroke is frequently associated with heart attacks, which is another reason patients are closely monitored.

After leaving the hospital, patients frequently require physical therapy at a skilled nursing facility. They may also need speech and swallow therapy to help prevent choking on food (aspiration).  Their diet may need to be modified to reduce the risk of aspiration. 

Many patients with disabilities following stroke improve over time. Taking your medications regularly is a key part of recovery as it will help to prevent repeat strokes and further disability. Many patients leave the hospital with multiple medications and the price of these new prescriptions can be overwhelming. At PriceProPharmacy.com our pharmacists can help to find equally effective medications that are available at a low monthly cost.