Introduction

Cleveland_Clinic_Host: Welcome to our Online Health Chat with a specialty trained Cleveland Clinic physician and an expert in the evaluation and treatment of stroke and transient ischemic attacks. Today we will answer common questions regarding stroke management and treatment options.

Stroke Basics

Cleveland_Clinic_Host: Each year, more than half a million Americans suffer from strokes. A stroke, or brain attack, occurs when the blood supply is cut off from part of the brain. The chances for survival and recovery improve when treatment begins within the first few hours of stroke warning signs. Let’s start with some basic questions about stroke.

kidatheart: What are the different types of stroke? Is one type worse than another?

Cleveland Clinic Physician: Strokes are categorized into ischemic and hemorrhagic. Ischemic stroke occurs due to a lack of blood flow to a portion of the brain either due to a clot that has obstructed flow or due to a narrowing of the blood vessel. Hemorrhagic stroke is a bleed in the brain due to a rupture of an aneurysm, blood vessel or due to blood thinning medication.

since21107: Why are they now calling stroke a ‘brain attack’?

Cleveland Clinic Physician: The term “brain attack” is to mimic “heart attack” as a stroke is quite similar to a heart attack. Strokes are not painful and thus are often ignored, but carry a more substantial disability. It is crucial to seek medical attention as soon as possible if you suspect a stroke as there are therapies available to reduce the disability of a stroke but must be administered within a very short time period from the time the stroke began.

brainchild: Is a brain aneurysm a type of stroke?

Cleveland Clinic Physician: A ruptured brain aneurysm is a type of stroke called subarachnoid hemorrhage. If you develop symptoms of the 'worst headache of your life' this may be a sign of an aneurysm bleed.

Non-ruptured aneurysms typically do not cause symptoms, but should be evaluated for possible preventative treatment options.

newtonm: What is a ‘Silent Stroke?’

Cleveland Clinic Physician: A Silent Stroke occurs when a patient has a MRI or CT scan of the brain showing a stroke but without clinical symptoms associated with the event. This may be a marker of risk factors for stroke and heart disease.

Stroke Symptoms

bunkerhill: What are the symptoms of a stroke? Do symptoms differ in men & women?

Cleveland Clinic Physician: Symptoms of a stroke typically include numbness of half your body, slurring of speech, and weakness of half your body, trouble with vision, and trouble with balance. The symptoms are the same in men and women.

Stroke Risk Factors

punkdbill: What are the risk factors associated with stroke?

Cleveland Clinic Physician: The following risk factors are associated with stroke. Patients with hypertension, high cholesterol, diabetes mellitus and older age are risk factors for developing plaque build up in arteries that can cause stroke. Additionally an irregular hear rhythm called atrial fibrillation places patients at a higher risk for stroke. Typically patients are evaluated for blockages of their arteries as well as the heart rhythm.

dillond: Can stroke be related to Atrial Fibrillation?

Cleveland Clinic Physician: Atrial fibrillation is a risk factor for stroke. The risk of a stroke from atrial fibrillation is 5-6% per year without blood thinning medication. Often times Warfarin (a potent blood thinner) is recommended for patients with atrial fibrillation.

alwayswondered: If a woman has had a stroke or even if there is a history of stroke in the family, should she take estrogen replacement therapy?

Cleveland Clinic Physician: Patients on estrogen replacement therapy are at an increased risk for stroke or other clotting disorders. If you have suffered a stroke, estrogen replacement therapy may put you at a higher risk for a subsequent stroke. This should be discussed with your physician as to the indications for the estrogen replacement therapy.

brandlee: What is the etiology of a person having multiple mini strokes and being unaware of the occurrence until later years, when they may have a brain scan and it is discovered? Please explain.

Cleveland Clinic Physician: The etiology of this is likely due to the same risk factors associated with stroke and heart disease. These include: elevated cholesterol, high blood pressure, diabetes, smoking, weight, genetics and age.

Stroke and Cholesterol

Charlie: Does cholesterol create plaque?

Cleveland Clinic Physician: Yes. Cholesterol has been associated with plaque accumulation in arterial blood vessels. Controlling cholesterol with diet and exercise can lead to a reduced risk of plaque build-up. If your cholesterol still remains elevated, then medications may be indicated.

Charlie: Having a clean Doppler of heart and carotids, echo cardiogram and CAT scan with only a MRI showing a minimal deposit of "?", assumed to be plaque in the speech area of the brain, where might the deposit have come from?

Charlie: As I must assume, plaque will always be present in a 67 year old man. What preventative measures can be taken to lessen chances of plaque breaking away and traveling to the brain whose weight is under control, has a total cholesterol 202, exercises and is a non-drinker or smoker?

Cleveland Clinic Physician: Due to age, you do have risk of a stroke, but the best strategy to reduce your risk is to target your blood pressure of less than 140/90 and your LDL cholesterol to less than 100.

Charlie: Any recommended diets for cholesterol reduction?

Cleveland Clinic Physician: Regarding cholesterol information, there are several documents that can be found on the Cleveland Clinic Health Information website. Go to my.clevelandclinic.org/healthy_living/Cholesterol/hic_Cholesterol.aspx

Stroke Prevention

newtonm: Can strokes be prevented, especially if there is a family history?

Cleveland Clinic Physician: Prevention is an important strategy. Currently the focus is on controlling modifiable risk factors which will reduce the risk of stroke and heart disease. It is important to work towards control of blood pressure, cholesterol and blood sugars if you are diabetic. Additionally healthy food choices and exercise will reduce your stroke risk.

Charlie: Would exercise contribute to the risk of plaque somewhere in the body breaking loose and going to the brain?

Cleveland Clinic Physician: No. Exercise has been linked to improved vascular health. It is an important part of healthy living.

jackinthebox: Are there medications to prevent stroke? How about taking a baby aspirin?

Cleveland Clinic Physician: Patients who have suffered a TIA, stroke or heart attack are candidates for blood thinning medications to prevent a stroke. Typically your physician will prescribe Aspirin, Plavix, Coumadin or Aggrenox for the secondary prevention of stroke depending on the cause of the stroke. It is important to remember that reducing the risk factors with control of blood pressure, cholesterol and blood sugars have a large impact on secondary prevention.

Stroke Diagnosis and Tests

oldguy: What tests are done to determine if you are having a stroke? I was told an MRI is used, but I have a pacemaker and therefore cannot have an MRI.

Cleveland Clinic Physician: The diagnosis of a stroke is a clinical one. It can be made through an examination by a vascular neurologist. A MRI is helpful in understanding the extent of the stroke, but a CT scan can often provide sufficient information with a good clinical evaluation.

Charlie: Can a stroke be mistakenly diagnosed.

Cleveland Clinic Physician: Yes - a stroke can be mistakenly diagnosed. There are other diseases that mimic stroke but tend to occur in younger patients. Examples of these are migraine headaches with associated stroke like symptoms. Also metabolic disorders in children may manifest with stroke like symptoms.

Stroke: When to Seek Immediate Care

dillond: What is the most important thing to remember if you suspect a stroke?

Cleveland Clinic Physician: If you or a loved one is suffering a stroke it is crucial to call 911 and go to the nearest hospital in order to be evaluated for acute stroke treatments. Currently under 3 hours a medicine called tPA (tissue plasminogen activator), can be administered to help “breakup” the clot that may be causing the stroke. Additional therapies are available beyond three hours but are under investigation. Rapid evaluation and treatment will help to reduce the disability associated with a stroke. Because strokes are not painful many patients wait too long to seek medical help.

worrieddaughter: If you think someone is having a stroke, besides calling 911 what should you do? Will the ambulance transport to the nearest hospital with a stroke team or should you drive the person there?

Cleveland Clinic Physician: Besides calling 911 assess the patient for difficulty with breathing or choking. Do not allow the patient to move as they may injure themselves. Wait for the EMS team to arrive and upon arrival you may request the patient be transferred to a certified stroke center that is closest to your area.

glasshalffull: I have had time delays for treatment as a walk-in patient in Emergency Rooms. How do you identify yourself as a stroke victim so that you can get immediate treatment within the critical 3 hour window?

Cleveland Clinic Physician: If you think you are having a stroke, you should notify the emergency room triage person that you believe your symptoms are related to a stroke. They will assess the severity and duration of your symptoms and decide upon the appropriate next step.

Stroke Treatment

silverandgold: What is tPA and why is it so important to give in within 3 hours of having a stroke?

Cleveland Clinic Physician: Tissue plasminogen activator (tPA) is a medication that has been dubbed the 'clot buster'. It is important to administer this drug within 3 hours as there is a risk of bleeding beyond this time window.

Within 3 hours there is greater benefit to being treated with this medication as it can potentially reverse disability related to a stroke.

nystrom: Are there treatment options beyond the 3 hour time window for acute stroke?

Cleveland Clinic Physician: There are currently catheter based treatment options beyond 3 hours where tPA can be given directly to the clot.

Additionally, there are FDA approved mechanical devices to remove the clot from the arteries in the brain. Typically, these therapies can be employed up to 8 hours from symptoms onset. It is imperative not to delay seeking medical help when you suspect a stroke as such therapies may potentially reduce disability.

dand: Is surgery for carotid artery stenosis more safe for persons over 80 years than putting in a stent? What percentage of blockage demands surgery in a person over 80 years old? (carotid blockage)

Cleveland Clinic Physician: If an 80 yr. old patient has had a stroke or TIA referable to the carotid artery lesion, then treatment with a stent is felt to be a reasonable option.

In certain instances, carotid endarterectomy is a better option if the anatomy precludes safe placement of a stent.

In patients with asymptomatic carotid disease with a life expectancy of more than 5 years, treatment with surgery or stenting can be considered if the lesion is greater than 80%.

kendp: What direction is advised for a 48 year old male who suffered a massive stroke at age 47? Paralysis in right side, loss of speech. Any new research for us? Who should we see next?

Cleveland Clinic Physician: Currently, there are no treatments several months after a stroke has occurred. In the future the use of stem cells or neurostimulators may be treatment options but they are currently in the infancy stage of development. More research is required to ensure the efficacy of these therapies.

TIA (Transient Ischemic Attack)

abc1234: What is a TIA (transient ischemic attack?) Can you have a TIA and not be aware that you had one?

Cleveland Clinic Physician: A TIA has also been termed “mini stroke” and can be a warning sign. TIA’s present with stroke like symptoms but TIA’s are shorter in duration typically lasting minutes and resolving. Patients with TIA’s are at risk for an ischemic stroke and need to be rapidly evaluated.

kpn1018: Is an episode of “double vision” always a TIA? What if one eye temporarily goes dark and it lasts about 30 seconds?

Cleveland Clinic Physician: “Double vision” or diplopia is not always a TIA but may be a TIA. Depending on the clinical circumstance this would require an evaluation to understand the etiology of the symptom. If one eye goes dark for a brief episode this would be concerning for a TIA.

cpp111: Is there a way to tell the difference between a TIA and a migraine headache when the symptoms are temporary partial vision loss and headache?

Cleveland Clinic Physician: It is difficult to distinguish between the two when it occurs for the first time. Typically with migraines patients are younger without risk factors for stroke and the events occur multiple times.

In contrast, strokes with headache symptoms are noted in patients with risk factors. If it is the first time these symptoms occur, you should seek immediate medical attention to assess for stroke.

Stroke: Thalamic Pain Syndrome

sk123: My mother had a thalamic stroke December 7th and is now having pain and numbness and hypersensitivity on the affected side. This seems to shift and change day to day. What is the treatment, if any, and what is the chance this will go away over time?

Cleveland Clinic Physician: This is called a 'Thalamic Pain Syndrome.' This is common after a stroke in this location. There are several medications that may potentially help reduce the sensitivity on the affected side. These include: Tegretol, Neurotin, Keppra and Lyrica. These are medicines typically used for seizures, but can also help with this condition and should be prescribed by a physician.

Stroke Research

abc1234: What research is being done in regards to stroke?

Cleveland Clinic Physician: There are ongoing trials considering secondary prevention strategies including the assessment of insulin resistance in non-diabetic patients. Additionally there are new blood thinning agents being tested in the hopes of reducing stroke risk.

For patients with acute stroke, there are catheter based treatment options being studied to expand the time window beyond 3 hours.

newton: Once brain cells are dead and damage is done by a massive stroke hemorrhage, can the brain regenerate at all?

Cleveland Clinic Physician: Currently there is no therapeutic intervention to restore irreversibly injured brain cells.

Shortly after a stroke, rehabilitation has been shown to improve outcomes. There is ongoing research on the use of stem cells and neurostimulators to restore function to injured brain tissue. These treatments are still investigational.

Cleveland Clinic Cerebrovascular Center

George: What services are available for stroke patients at Cleveland Clinic?

Cleveland Clinic Physician: Cleveland Clinic’s Cerebrovascular Center is a Joint Commission-certified Primary Stroke Center treating more than 3,200 patients annually, one of the highest stroke-related patient volumes in the nation.

Our multidisciplinary staff offers expert diagnosis and medical, surgical and endovascular treatment for all cerebrovascular conditions, including stroke, brain aneurysms, brain and spinal vascular malformations, carotid stenosis and intracranial atherosclerosis. For more information on the services we offer, please visit our web site at www.clevelandclinic.org/cerebrovascular.

Closing

Cleveland_Clinic_Host: I'm sorry to say that our time is now over.

More Information

• Cleveland_Clinic_Host: If you would like more information regarding the management and treatment of Acute Ischemic Stroke, the Cerebrovascular Center at Cleveland Clinic’s Neurological Institute, please call 216.636.5860 or toll free 866.588.2264. You may also visit the web site at www.clevelandclinic.org/cerebrovascular. 
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.