Online Health Chat with Efrain Salgado, MD
May 22, 2014
Stroke is the leading cause of serious, long-term disability in the United States, with about 6.5 million stroke survivors alive today.
Each year, more than half a million Americans suffer from strokes. Stroke is the third leading cause of death in the United States according to the American Heart Association and American Stroke Association. A stroke, or “brain attack,” occurs when the blood supply is cut off from part of the brain. When this happens, the blood-deprived brain loses its supply of oxygen and nutrients. When the brain is deprived of blood for even a few minutes, it begins to die. Hence, the chances for survival and recovery improve when treatment begins within the first few hours of stroke warning signs.
Many factors increase the risk for stroke. Some factors can be controlled; others cannot. If you have been diagnosed as being at risk for a stroke, a stroke neurologist can help determine your best course of treatment. If you have suffered a stroke, there are advanced diagnostic examinations to detect abnormalities in the circulation of blood through the brain. This aids in assessing why a patient has suffered a stroke or transient ischemic attack (TIA) and helps determine the best therapies.
There are many factors that increase the risk of a stroke, but a stroke neurologist can help determine your best course of treatment to help prevent one from happening.
About the Speaker
Efrain Salgado, MD, is Director of the Cleveland Clinic Florida Stroke Center and Neurosonology Laboratory and Director of the Neurology Residency Training Program at Cleveland Clinic Florida. His specialty interests include cerebrovascular diseases (stroke), multiple sclerosis, headache and neuromuscular disease. He is board-certified in Neurology and Vascular Neurology by the American Board of Psychiatry and Neurology.
Dr. Salgado completed his fellowship in cerebrovascular disease, residency in neurology and internship in internal medicine at Cleveland Clinic. He graduated from medical school from Universidad Central del Caribe School of Medicine, in Bayamon, Puerto Rico.
Let’s Chat About Get the Facts About Stroke
Stroke: Signs and Symptoms, Migraine
george1958: Are there particular symptoms, say months or years, before an incident of stroke that would act as warning signs of increased probability of a stroke? Are they any different for predicting ischemic vs. hemorrhagic stroke?
Efrain_Salgado,_MD: Not really. A common precursor for stroke is a transient ischemic attack (TIA). Patients with TIA have symptoms similar to stroke symptoms, including sudden weakness or numbness involving one side of the body or the other, sudden difficulty speaking or understanding what is being said, sudden loss of vision in one eye or both eyes, sudden dizziness and loss of balance that may result in a fall, or sudden severe headache unlike any headache you have ever had before. However, with TIAs the symptoms typically resolve within minutes. This is a warning of a stroke, and the probability is that a stroke will occur shortly after these symptoms subside. Therefore, it is critical that anybody with these symptoms—even if transient—seek immediate medical assistance. The longer a person goes without having these symptoms after an initial occurrence, the less likely that a stroke will occur. The highest stroke risk is early, not much later such as months or years later.
mamas12: I was recently diagnosed as having had a transient ischemic attack (TIA). However, subsequent MRIs and CAT scans show no sign of damage in the brain, so they dismissed my symptoms as having been related to stroke. Are there any symptoms of TIA that remain and, if not, how do you know whether you really had a mini-stroke or not? Is there a risk that you will have an actual stroke if you had TIA symptoms?
Efrain_Salgado,_MD: By definition, no symptoms should remain if you have had a TIA. The diagnosis of TIA is a clinical one made by your doctor. There is no test that tells you whether you have had a TIA or not.
george1958: For those who experience a stroke, is there a prevalence of a history frequent headaches during their lifetime?
Efrain_Salgado,_MD: Not really. It is true that patients who suffer from migraine with aura are at a higher risk of having stroke, but the higher risk is not to such an extent that should cause these migraine patients to worry about it. As long as they control those risk factors I mentioned, they will do fine.
Ischemic vs. Hemorrhagic Stroke
douglas3361: I am confused about the difference between an ischemic stroke and a hemorrhagic stroke. Do they both have the same symptoms?
Efrain_Salgado,_MD: An ischemic stroke occurs when an artery that supplies the brain becomes blocked or obstructed leading to a lack of blood flow to a certain part of the brain destroying it. A hemorrhagic stroke occurs when a blood vessel in the brain ruptures and blood spills into the skull and brain. This also leads to a lack of blood flow in addition to increased pressure inside the skull, which—in and of itself—can cause damage as well because of the pressure build-up.
Branch Retinal Artery Occlusion (BRAO)
kahuna8: Eighteen months ago I had a branch retinal artery occlusion (BRAO) in my right eye. The BRAO has been evaluated and discussed with several physicians, including neurology, eye, internal medicine and cardiology. They are 50/50 whether my BRAO was actually a stroke. All medical histories and questionnaires ask “Did you have a stroke?" Did I have a stroke or a blood clot in my eye?
Efrain_Salgado,_MD: Branch retinal artery occlusion typically leads to permanent damage of part of the retina due to a lack of blood flow. The retina is actually part of the central nervous system which includes the brain. Stroke was officially redefined last year as follows: An episode of neurological dysfunction (in your case this may have been partial loss or impaired vision) caused by focal cerebral, spinal, or retinal infarction (permanent damage from lack of blood flow). Therefore, the retinal infarction from branch retinal artery occlusion is indeed a stroke. A blood clot in the eye, as you mentioned is a common cause of stroke.
kahuna8: I have low platelets. My last test read 110. I would assume this is favorable as to clotting predisposition.
Efrain_Salgado,_MD: I believe it would be reasonable to assume that.
Vertebral Artery Dissection
Dancia: I was 34 years old when I had my first stroke leaving me with hemianopia. Six months later I had another stroke with no bad effects. After an MRI and MRA, I was told the cause of both were vertebral artery dissection. My neurologist said he thinks I probably have fibromuscular dysplasia (FMD.) He decided not to test me as treatment for this is the same as I am already on. I take Plavix® (clopidogrel bisulfate). Should I be tested? I know very little about this and am putting my faith in my doctor. I am now 38 years old and have other health issues, including autoimmune disorder, sarcoidosis, Raynaud phenomenon and Graves disease. My most troublesome health problem is migraine.
Efrain_Salgado,_MD: Fibromuscular dysplasia is just one of many risk factors associated with vertebral artery dissection. It is one of the rarer ones. Other risk factors are more frequent. The evaluation done for vertebral artery dissection will typically provide information that would suggest that diagnosis. Your doctor should be able to tell you whether the evaluation that was done at the time of the stroke revealed evidence to suggest fibromuscular dysplasia. If not, this conclusion is purely speculative, and there is probably no reason to excessively worry about pure speculation. There is no specific treatment for fibromuscular dysplasia, and your doctor is correct in that it would not change your present treatment.
Moderator: You may be interested in joining the FMD video chat June 19th at 12 noon with Heather Gornik, MD, a vascular medicine specialist and leader of the Fibromuscular Dysplasia Clinic at Cleveland Clinic and Pamela Mace, RN, president of the Fibromuscular Dysplasia Society of America (FMDSA) and an FMD patient.
Stroke and Dementia
Globro: Recently, I heard of microscopic brain strokes and that they can't be detected on an MRI. Is this true? Can this type of stroke cause dementia? Can a patient completely recover after this type of stroke?
Efrain_Salgado,_MD: While this is possible, it is highly unlikely. If patients have no stroke symptoms and no strokes can be seen with MRI, it is highly unlikely that they would cause dementia.
Stroke Risk Factors
jacks1947: Would you please discuss the risk factors for stroke? Is it true that pre-hypertension is now considered a risk factor?
Efrain_Salgado,_MD: There are multiple risk factors for stroke, the most important being poorly controlled high blood pressure, diabetes, cholesterol, smoking, excessive alcohol consumption, atrial fibrillation, and obstructive sleep apnea. These risk factors lead to hardening of the arteries (atherosclerosis) which is the most common cause of stroke. This is why we say that up to 80 percent of strokes are preventable if we can optimally control all of the above. There are still some questions as to whether or not pre-hypertension is actually a risk factor for stroke.
Moderator: Interested in learning more about risk factors? Try our Stroke Calculator.
enidsto: What are the risk factors for stroke? Which ones can be controlled and which cannot?
Efrain_Salgado,_MD: The first question I already answered with respect to the risk factors that can be controlled—the so-called modifiable risk factors. You are absolutely correct in that there are some that cannot be controlled. The main risk factor that cannot be controlled is age, and indeed this is the most important risk factor for stroke. In other words if you are 80 years old, you are more likely to have a stroke than someone who is 20 years old even if the 80 year old does not have any other risk factors. The most important modifiable risk factor for stroke is hypertension.
addam: Does having a stroke increase the risk of a recurrence? What can I do to prevent having another stroke?
Efrain_Salgado,_MD: Yes, having a stroke increases your risk of another. However, there is much you can do to lower that risk by making sure that all of your risk factors are well controlled and by the use of medications such as aspirin, Plavix® (clopidogrel bisulfate), aspirin and extended-release Persantine® (dipyridamole)—or in some cases medications such as Coumadin® (warfarin) depending on your particular needs. Indeed your stroke risk is lowered by 30 to 40 percent just by making sure your blood pressure is well controlled.
Genetic Causes of Stroke
Bnster: Is there a genetic factor to strokes?
Efrain_Salgado,_MD: Yes. There are genetic factors. There are some people that are born with certain genes that predispose them to stroke. One such condition would be CADASIL (cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy). If you are interested, I am sure you can learn more about this condition from the Web. Some people are born with genetic conditions that predispose them to clotting. This in turn may increase their stroke risk. Finally, if you have a strong family history of high blood pressure, diabetes, high cholesterol or any of the major modifiable risk factors for stroke, you may also be at higher risk because of this. However, these particular conditions are very much treatable and you certainly can do something about them to lower your risk.
george1958: Is stroke an arterial or venous phenomenon? I have been genotyped as factor V Leiden homozygous recessive, which significantly increases my chances of experiencing blood clots. I was told that this type of clots is of the venous type whereby it is developed in the veins of the leg and travels to the lungs. Aspirin is not a remedy for this type of clotting. Does this genotype increase the risk of intracranial stroke?
Efrain_Salgado,_MD: Stroke can be either arterial or venous. There are veins in the brain as well that can clot and produce stroke. Conditions that make you prone to clotting such as the factor V Leiden condition you describe can also increase your risk of a brain stroke since it can affect the veins in your brain.
george1958: Is it recommended to have annual brain scans for those who are predisposed to a stroke and over the age of 50 years old? What type of diagnostics scan should it be?
Efrain_Salgado,_MD: No, it is not recommended that you have annual brain scans for this purpose. The best diagnostic testing that you should have is your regular visits with your doctor for an exam and to monitor those risk factors that I mentioned before, making sure that they are well controlled.
Medications and Stroke
greatdame14: I am on Coumadin® (warfarin) to alleviate strokes. Do I have to take it the rest of my life? I attribute some of my problems to that medication. I have swollen ankles and feet and dizziness all the time when I walk. I drive, but I am not dizzy when sitting. If I could get off Coumadin®, I think these problems would cease. What do you think?
Efrain_Salgado,_MD: Coumadin does not alleviate strokes. However, it can significantly lower the probability that you will have a stroke provided you have a condition for which Coumadin® is indicated, such as nonvalvular atrial fibrillation. Your doctor should be able to tell you what specific condition you have that requires Coumadin® therapy.
JonCas: I had a transient ischemic attack in 2001, but none since. I also have atrial fibrillation. I am 72 years old. Do I need to take Coumadin® (warfarin) forever?
Moderator: The month of May is considered Stroke Awareness Month. It is important to have as much information as possible for yourself, a loved one or a friend. Please visit: my.clevelandclinic.org/campaigns/stroke-awareness.aspx.
Clara: I have been on Plavix® (clopidogrel bisulfate) and aspirin for five years because of eight stents. My mother died of bleeding in the brain in her 50s. She used aspirin a lot. Is there a danger of bleeding being on two blood thinners for so long?
Efrain_Salgado,_MD: There is a risk of bleeding complications when you take two blood thinners. However, your doctor needs to decide whether the risk of complications from not being on two blood thinners outweighs the potential side effects. If this is the case, then he will recommend that you take both. You should discuss this with your doctor.
F94jL63: Could surgical interventions be considered reasonable (practical) alternatives to life-long anti-coagulation medications for persons diagnosed with atrial fibrillation?
Efrain_Salgado,_MD: Not at this point in time.
jwsbug2: I am 64 years old, and I get around with a cane. I have issues with my carotid arteries. What exercises do you recommend?
Efrain_Salgado,_MD: Only your doctor, who knows your medical condition well, can recommend an appropriate exercise program for you.
Primary Stroke Center
KLeeigh: What does a “primary stroke center” mean and why is it important?
Efrain_Salgado,_MD: Primary Stroke Center is a designation of quality provided by a governmental or national regulating agency that assures that hospitals are providing the best evidenced-based (high quality) care for stroke patients.
Moderator: I am sorry to say that our time with Dr. Efrain Salgado from Cleveland Clinic Florida is now over. Thank you for sharing your expertise and time to answer questions today.
To make an appointment with Dr. Efrain Salgado at Cleveland Clinic Florida, please call 877.463.2010. You may also visit clevelandclinicflorida.org/stroke.
To make an appointment with another other stroke specialist in the Cerebrovascular Center at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at www.clevelandclinic.org/cerebrovascular.
For More Information
On Cleveland Clinic
The Cerebrovascular Center at Cleveland Clinic’s Neurological Institute integrates a multidisciplinary team of neurologists, neurosurgeons, neuroradiologists, neurointensivists and rehabilitation specialists who provide expert diagnosis and medical, endovascular, and surgical management of all cerebrovascular conditions. Cleveland Clinic is a designated Primary Stroke Center.
A Primary Stroke Center is usually housed in a hospital where a group of medical professionals who specialize in stroke work together to diagnose, treat, and provide early rehabilitation to stroke patients. The Joint Commission’s Certificate of Distinction for Primary Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care. The Cleveland Clinic Primary Stroke Center provides services that have critical elements to achieve long-term success in improving outcomes, providing quality care and effectively managing the unique and specialized needs of stroke patients.
Cleveland Clinic Florida is currently designated as an AHCA Primary Stroke Center. The emergency room performs a rapid evaluation of patients with acute stroke and offers medications that may dissolve clots and reverse the damage done by the stroke. For the past 5 years (2008-2013), Cleveland Clinic Florida has been the recipient of the American Heart Association/American Stroke Association’s Get With The Guidelines® Stroke Gold Plus Performance Achievement Award for our commitment to implementing excellent care for stroke patients, according to evidence-based guidelines.
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