Stroke is a result of problem with plumbing of nervous system. Like a building, our body has plumbing to carry blood to every part of the body. There are channels or vessels (arteries) for clean blood or blood full of oxygen, and there are vessels (veins) for not-clean blood or blood without oxygen. The major purpose of this plumbing system is to carry and provide oxygen and nutrients to every area of the body and carry toxic materials to their destinations. After traveling in different areas of the body and supplying oxygen and nutrients, blood travels back to the lungs, spleen, kidneys, and liver to be oxygenated, and cleaned.

Stroke is not a precise or clear-cut term, and it always needs further clarification depending upon the nature of problem with arteries or veins. Like plastic pipes, blood vessels can get blocked, slowly or suddenly, can get kinked, balloon up, or rupture. Anytime a significant problem with a brain blood vessel happens, an area of the brain is deprived of oxygen. Brain cells cannot survive more than a few minutes without sufficient oxygen supply and may start dying, which results in symptoms of stroke.

What is a Transient Ischemic Attack (TIA)?

If a blood vessel is blocked, patient may have symptoms due to the malfunction of the part of the brain this vessel is taking blood to. If the vessel never opens again, it is called a cerebral infarction. On the other hand, if this vessel opens up after a little while, the brain may get the blood supply again and start functioning. This is called a TIA. In my opinion, it is a misleading term. Almost every time a blood vessel is blocked in the brain, patient may have some damage to brain cells. This is because brain cells do not survive more than a few minutes without blood supply. Almost all so-called TIAs carry risk of damage to the brain; though many times the damage is so small that patient may not notice it. An MRI can help confirm this type of damage from a TIA.

What is a cerebral or brain infarction?

The term infarction implies damage due to lack of oxygen or nutrients. This term is used when an area of brain is permanently damaged due to lack of blood supply, as it happens in stroke.

What are the symptoms of stroke?

Stroke affects functioning of brain or the spinal cord, so one can lose any bodily function from stroke. Common symptoms are weakness (of face or arm or leg), numbness, difficulty speaking, difficulty swallowing, double vision, poor vision, difficulty walking, or difficulty remembering. Strokes that are from bleeding may also have headache, nausea and vomiting.

Can stroke cause pain?

Most strokes do not present with pain but some can cause a headache, especially the bleeding type. Rarely, a patient may develop a severe and very difficult to treat permanent pain from a stroke.

How do I know I am having a stroke?

If symptom(s) of stroke, described above, happen suddenly, and suddenly here is the key word; it may have happened from a stroke.

What should I do if I am having a stroke?

In case of sudden stroke-like symptoms, call 911, or call ambulance right away. If symptoms are there for more than a day, consider calling the primary care physician for further guidance instead of 911. Many times, a stroke can be reversed or treated when it is happening, but it is best done within first few hours after symptoms start.

What are different types of stroke?

The most common type of stroke is of ischemic type. The term ischemia means lack of blood supply due to blockage of blood vessel, and so lack of oxygen and nutrients. Blockage of a blood vessel leads to damage to brain from lack of oxygen and nutrients. The blockage can happen slowly over months to years, relatively quickly from injury to a blood vessel, or it can also happen abruptly from clogging. Clogging can happen by a piece of clotted blood, or by a broken piece of the inside of a blood vessel wall. In USA, almost 85% of strokes are of ischemic type.

Sometimes, instead of a blockage, a blood vessel can have a broken wall and suddenly blood starts leaking out of the vessel. The result is similar as with ischemic stroke but it can be more dramatic because of two problems: a. the area of brain getting oxygen and nutrients from this vessel gets affected, and b. the leaked blood outside the blood vessel puts pressure on the surrounding area of the brain. There are multiple reasons for a broken wall of a brain blood vessel, the most common being high blood pressure. One of the other causes includes an aneurysm formation.

What causes stroke?

Anything that can block, weaken, or break a blood vessel can cause a stroke. Risks of strokes are separated in two categories: the ones patient has no control on (non-modifiable) and the ones that can be changed (modifiable). In USA, generally speaking, being a male, African-American, Hispanic, or Native American, and older carry higher risk for strokes. The most common and important modifiable risk factor for stroke is high blood pressure, which directly impacts the heart and blood vessel of all sizes. Problem with lipid metabolism, many abnormalities of heart, tightening of large blood vessels in the neck and brain, some blood conditions, physical injury to the neck blood vessels, smoking cigarettes, drugs of abuse, and diabetes are other common modifiable risk factors.

How does high blood pressure cause stroke?

High blood pressure may cause stroke in multiple ways, and the most common is its impact on blood vessel walls. Even mildly high blood pressure for a longer period may lead to narrowing of blood vessels and stroke. Depending upon the level of high blood pressure, its impact on blood vessel wall can be relatively quick It can damage the inside of the wall resulting in scarring and narrowing of the vessel, or it can break the vessel wall altogether leading to bleeding type of stroke. High blood pressure also affects other organs such as kidneys and heart, which may indirectly lead to stroke.

High blood pressure may selectively impact small blood vessels resulting in numerous silent strokes. It can practically impact blood vessels of all sizes and can cause stroke of all times, from blockage of an artery to it rupture.

How does heart cause stroke?

There are multiple conditions or diseases of the heart that can cause stroke. Conditions affecting the muscles of the heart, its blood vessels, or its electrical system, all may lead to a stroke. Coronary artery disease (problem with the blood vessels of the heart), or exposure to certain chemicals like too much alcohol or certain drugs may weaken the heart muscle, a condition called cardiomyopathy. A heart with cardiomyopathy has difficulty pumping all the blood coming to it and the blood may start clotting inside its chambers. The clotted blood inside the heart may go into a brain’s blood vessel causing stroke.

Atrial fibrillation is a type of abnormal heart rhythm due to damage to its electrical system. In this condition, one chamber of the heart may not contract, leading to clotting of blood and then stroke (blood can clot if not in proper motion).

Another problem of the heart leading to stroke is a malfunction of one of its separation-wall between the chambers. Heart keeps unclean blood (in its right side) separate from the clean (in its left side.) In some people there is a hole between two sides where non-clean blood can come to the cleaner left side. In normal situation, non-clean blood from the body when it reaches the right side of the heart may carry small blood clots, formed during its travels in the slowly flowing veins of the body. These clots get filtered away in the lungs or spleen before it reaches back to the left side of heart. In patients with a “hole” in the heart, a condition called PFO or Patent Foramen Ovale, unclean blood with blood clots can move to the left side. Once it is in the left side, it may be pumped to any area of the body including brain where it can cause a stroke.

Hearts valves and some other parts of its chambers are rugged structures and are prone to developing blood clots, especially if there is an additional problem with blood itself making it thicker than its normal consistency. This is yet another way heart may cause stroke. Very rarely, a patient may have a tumor, usually a benign one, inside a heart’s chamber resulting in clot formation and stroke.

How does carotid artery disease cause stroke?

Carotids are two large arteries in front of the neck, one on each side going inside the head and supplying blood to a large part of brain. Strokes commonly happen in the areas covered by these arteries. One common problem with carotid artery is its blockage, or stenosis. It usually is a chronic process developing in years, but sometimes, if its wall gets damaged, it can happen much more quickly. If the stenosis reaches a critical level, a blood clot can form at that point, or a small piece of the inner vessel wall can breakup; in either case becoming a material that should not be there. It can travel north and get stuck in a brain blood vessel causing stroke.

This process can happen in the carotid arteries in the neck before they enter in the skull, while they are passing through the skull, or inside the skull. Similar process can also affect large branches of carotid arteries inside the skull and close to or inside the brain. There are some differences in how this process affects different ethnicities. Caucasians seems to have this problem in the part of the carotids in the neck before it enters the skull, while African Americans, Hispanic, and Asians get more disease in the part of carotids inside the skull.

How do problems with blood cause stroke?

Other than the reasons within the heart or blood vessels, blood clot can also form due to a problem with the blood itself. There are many conditions making blood thicker than its normal consistency, usually genetic in origin. Not all of them have been identified but many are well known. Some conditions causing blood thickness are not genetic and are due to multiple other factors.

Blood can get thick in case of an infection anywhere in the body, if there are excessive amount of red blood cells, in dehydration, in some conditions with high level of special antibodies in the blood, with many types of cancer, or with abnormal shapes or configuration of blood cells. Clotted blood, for whatever reason is a risk factor for stroke, especially if it happens on the cleaner side of the body, i.e., the left side of heart and arteries. Sometimes it gets sticky enough just to block tiny blood vessels, and sometime bigger clots block larger arteries.

What are some of the emergency treatments of stroke?

For Ischemic Stroke:

A: Blood pressure control: Sometimes patient has severe high blood pressure that has to be treated urgently to avoid further damage to brain blood vessels.

B: Clot-busting drugs: If patient comes to the emergency room within first few hours of stroke, there are drugs that can be used to break the blood clot causing stroke.
C: Removing blood clot by using a catheter: For many patients, this treatment is used by inserting a catheter through a leg or the arm’s blood vessel and taking it to the brain and removing the clot.

D: Rarely brain surgery

For Stroke with bleeding:

A: Blood pressure control.

B: Medicine to reverse clotting disorder, if that is the issue.

C: Sometimes emergency procedure with a catheter to prevent further bleeding.

D: Rarely brain surgery

Should I take an aspirin right-away if I have stroke like symptoms?

This is not a prudent approach. Though many patients having stroke can be helped by taking an aspirin, without brain imaging with a CAT scan or an MRI, it is not possible to tell what type of stroke it might be? One shall not take aspirin if it is a bleeding type of stroke. The best approach is to call 911, and come to emergency room to figure it out and have appropriate treatment.

What is a venous infarct or a venous stroke?

Most stroke happen from a problem with an artery, but sometimes similar blockage can occur in a vein, causing a venous stroke or a venous infarct. Venous infarcts may be somewhat difficult to diagnose in initial stages. Sometimes historical facts help to think about them. Young women after labor are at risk for this condition.

What Can I do to prevent stroke?

The answer to this question can be different for different people, based upon their underlying conditions and risks. In general, the most important risk factor for stroke is high blood pressure. High blood pressure is a silent offender; it causes a lot of problems in the body, especially in the heart and brain, without a person noticing any symptoms. In a person with mildly elevated blood pressure, it is not uncommon to find many small strokes on MRI of brain, without history of any particular symptoms of stroke.

If there is family history of high blood pressure, one has to be extra careful. Nowadays, blood pressure is routinely checked for even a minor medical visit. If it is high, follow it up. Be proactive and follow through with your doctor. Many times it is possible to bring the blood pressure down by some measures other than medicines. In case of extra weight, losing it can help. Regular exercise can help. If there is Obstructive Sleep Apnea, treating it can help. Avoiding regular or too much alcohol drinking, and treatment of anxiety, if present, can also help.

If blood pressure is mildly high, one may try all the non-medicinal measures for a few months. If they do not work, take medicine because the risk is too high. If taking medicine for blood pressure control, one has to make sure they are working. Now and then check blood pressure. Some patients take one; most two, and many take more than two blood pressure medicines to bring it to the normal level. In case of side effects from a medicine, talk to the doctor, there are many other medicines to choose from. In one-way or other, blood pressure has to come down. High blood pressure injures blood vessels all over the body but especially in kidneys, heart, eyes, and brain.

Maintain healthy lifestyle with normal weight, regular physical activity or exercise, healthier diet plan, not smoking, quitting or minimizing alcohol. Finally, there may be many other specific personal or familial risk factors unique to a person, which should also be attended to and managed.

How long it takes for stroke symptoms to resolve?

Stroke is the leading cause of disability in USA. During recent years, many effective treatments are discovered and used to resolve symptoms of strokes when it happens. Unfortunately, for multiple reasons, many patients do not get this treatment or some do not respond to it. They are left with disabling symptoms of stroke. It is difficult to say, if a person with stroke ever goes back to completely normal or his/her baseline. But significant improvement does happen. Improvement varies based upon many factors including age, size and location of the stroke, and underlying medical conditions. Most of the improvement happens during first year after the stroke.

What can I do to improve my situation after a stroke?

First is to follow medical advice to prevent any further stroke. For the symptoms present after the stroke, depending upon symptoms, seek help of a physical therapist and/or occupational therapist. Many times help of a speech therapist is also needed. They usually provide services for a few days to a few weeks to months. During that time, learn all exercises and activities and continue doing them on your own. Stay active, as much as possible, and avoid steps that can cause further stroke. More specific problems are addressed on individual basis.

What are some other symptoms that affect people after a stroke?

Other than the obvious symptoms of stroke that bring patient to medical attention, a patient after a stroke may have number of other issues. Some are listed here:

a. Fatigue and lethargy
b. Difficulty sleeping or insomnia
c. Other sleep disorder like obstructive sleep apnea
d. Depression
e. Anxiety
f. Anger and agitation
g. Erectile difficulties
h. Decreased libido
i. Pain
j. Difficulty controlling urination
k. Cognitive impairment
l. Dementia

Many of these symptoms can be temporary and may disappear after a few weeks to month. If they persist, many of them have available treatment options.

Is stroke a genetic disorder?

Most of the time, not necessarily; but if same risk factors are present the risk is similar. If blood pressure runs in the family, everyone affected by it is at risk. There are some rare stroke conditions with genetic basis, e.g., CADASIL.

Can a child have a stroke?

Though relatively rare, children can also suffer from stroke. In fact, even an unborn child in uterus can have a stroke too. Reasons and risk factors for stroke in fetus or in children are somewhat different than stroke in adults.

Is there any surgical treatment for stroke?

Stroke leads to dying of an area of brain. There is no surgical treatment to bring that brain back. But some surgical procedures are used during treatment of acute stroke. For example, if someone has a very large stroke, or a bleed in the head, sometimes surgery is done to save life. Many times patients have bleeding outside the brain and inside the skull, and surgery is done to remove that blood clot.

What is subdural hemorrhage (SDH)?

This is bleeding inside the skull but outside the brain, under one of the coverings of the brain (under dura mater). It typically happens from falling and hitting head on hard object. Brain gets jolted inside the head and some veins are injured resulting in leaking of blood. It is seen more commonly in elderly, because, compared to young people, they have relatively more space in the skull and brain can easily jolt. Extra space is from shrinking of brain in old age.

How is subdural hemorrhage (SDH) treated?

Small subdural bleeds do not need any treatment and blood gets absorbed on its own. Larger ones may put pressure on the brain and are surgically removed.

What is epidural hemorrhage?

This is a different type of bleed inside the skull and outside the brain, under the skull and outside the coverings of the brain. Unlike subdural hemorrhage where the leak is from a vein, this is a leak in an artery. In some patients, with time, it can get bigger and bigger and put a lot of pressure on the brain. In that case it becomes a neurosurgical emergency.

The cause usually is trauma to the head, like a significant concussion. In this type of bleed a patient may be ok after the trauma, but may suddenly get worse a few hours later. This is one main reason that patients after a after a concussion are observed for a few hours to look for any change in their mental or physical state. If that happens, an emergency CT scan is required to make the diagnosis. If it is found, an emergency neurosurgery is required. It is a relatively rare type of bleed.

What is intracerebral hemorrhage (ICH)?

ICH is bleeding inside the brain. This usually happens from a leaking small blood vessel, caused by high blood pressure. Sustained moderately high blood pressure may weaken small blood vessels to the point that they may start leaking.

What causes intracerebral hemorrhage (ICH)?

High blood pressure is its most common cause. In elderly, it may also be from a gunk like material build-up in blood vessel walls, called amyloid. Other causes may include trauma, an AVM (discussed later), infection, or a tumor.

How is intracerebral hemorrhage (ICH) treated?

Small bleeds may not need any treatment, other than blood pressure control. Rarely a surgical procedure is done to remove blood clot and to minimize disability and save life. But surgery does not work for most cases of ICH. Most patients are admitted in a hospital, and cared for a few days before the clot is resolved. No specific treatment is available. Depending upon its size and location, ICH may cause significant disability.

What is subarachnoid hemorrhage (SAH)?

This is another bleed inside the head and outside the brain, under one of the coverings of the brain called arachnoid mater. It is usually from a leaking aneurysm, and rarely from trauma. If it is from a leaking aneurysm, it presents with a sudden very severe (worst in life) headache, which many times is associated with nausea, vomiting, or confusion. In more severe cases, patient may just become comatose. It is a neurological emergency and patient should be brought to ER right away.

What is a cerebral aneurysm?

Aneurysm is ballooning of a part of an artery. It can affect many arteries in our body, including the ones supplying the brain. Brain aneurysms are more common in women, and typically start causing trouble in middle age. Sometimes aneurysms are familial, affecting multiple family members.

Problems from aneurysm depend upon its size and location. Tiny aneurysms, less than 3-4mm, seldom cause any trouble. Larger aneurysms, larger than 7-8mm are usually treated before they cause any trouble. The medium ones are sometimes treated and sometimes not depending upon many factors. Aneurysms are best treated before they cause trouble.

Many times aneurysm is an incidental finding on an MRI or CT of brain done for some other reason. If it is small and has not caused any trouble, usually repeating another scan in 6-12 months is recommended. If any significant increase in size is noted, it can be treated.

The main problem with brain aneurysm is that it can start leaking blood, sometimes profusely. Bleeding from an aneurysm is a life-threatening emergency. It presents with sudden onset of very severe headache that patient may describe as the “worst headache of life.” It is different from someone having a very severe migraine that may start mild and gets severe. With headache, patient may also have nausea, vomiting, confusion, seizure, or any other stroke like symptom.

Patient with a leaking aneurysm has to be treated right away to save life and disability. Nowadays aneurysms are treated by a procedure called coiling, and surgery is rarely needed.

Should everyone in the family be checked for aneurysm, if a family member is diagnosed with it?

First relatives of a patient with aneurysm (children, siblings, parents) have somewhat higher risk of having an aneurysm and performing a scan is reasonable and recommended. The risk for other relatives is not that high compared to anyone else and a routine examination is not recommended, and many times not covered by insurance.

What should I do if I am diagnosed with an aneurysm?

If it is discovered incidentally on a scan and it has not caused any trouble, it is not an emergency; do not panic. See a neurologist or a neurosurgeon for consultation. Nowadays, most patients with aneurysms do not really need surgery; in fact most aneurysms do not need any urgent treatment. The decision about how to manage an aneurysm depends upon its size and location, which can be discussed with the neurologist or the neurosurgeon.

What can I do to keep my aneurysm from getting larger or leak?

A: Control blood pressure
B: No smoking
C: Minimize or quit alcohol
D: Avoid stress, and treat anxiety disorder if that is a problem
E: Lose weight if overweight
F: Diagnose and treat sleep apnea if that is a problem
G: No street drugs
H: Avoid too much aspirin or ibuprofen type of medicines

What is an AVM?

The term AVM, or Arterio-venous Malformation, means an abnormality of blood vessels. A blood vessel could be very tortuous (making too many turns or loops), abnormally large, or may be joined to a wrong blood vessel. AVMs are of many types, depending upon the type of blood vessels involved: arteries, veins, or capillaries (very small blood vessels), or a combination of one or more.

What causes an AVM?

AVM have genetic basis, but they do not behave like cerebral aneurysm. Most of them are incidentally discovered on a scan done for some other reason.

What are the risks of AVM?

Common examples of problem from an AVM are stroke, in brain or the spinal cord, or seizure disorder. Most AVMs do not need any direct treatment, but some require emergency treatment. Consult a neurologist or a neurosurgeon for further guidance.

What are silent strokes?

This is an arbitrary term to describe strokes noted on a CT scan or an MRI with patient never reporting any symptoms of stroke. This kind of strokes are usually ischemic (from blockage of an artery), are usually associated with untreated high blood pressure, and if not stopped from happening may cause problem with balance, gait, and cognitive functions.

What is small-vessel disease of brain?

It is a condition affecting primarily small blood vessels of brain. It is commonly seen in patients with untreated high blood pressure. Some genetic diseases may also cause it. The end-result usually is numerous ischemic type of strokes resulting in physical and mental disability.

Where can I get more information about stroke?

American Academy of Neurology, AAN
American Heart Association, AHA
National Stroke Association, ASA
Center for Disease Control and Prevention, CDC
Local stroke support group