Neurologist Robert Brown, M.D., answers the most frequently asked questions about strokes.
Hi, I'm Dr. Robert Brown, a neurologist at Mayo Clinic. And I'm here to answer some of the important question you may have about strokes.
The fast acronym, F.A.S.T., is a good way of remembering stroke symptoms and what to do if you or a friend or loved one experiences those symptoms. F for facial weakness, A for arm weakness, S for speech slurring, and T for time. Time to call 911 should those symptoms occur. Sometimes stroke symptoms may be temporary, lasting only several minutes or hours, and this is called a transient ischemic attack. The symptoms should not be ignored even if they are temporary. The risk of stroke is markedly increased in the days and weeks after those symptoms occur, so seek emergency evaluation to clarify why the symptoms occurred and how best to prevent a future stroke.
An aneurysm is a small saccular-shaped or berry-shaped out-pouching off of an artery in the brain. About two to three percent of the population has a brain aneurysm, and most never cause any symptoms. But on occasion, that aneurysm can rupture, leading to bleeding into and surrounding the brain, a bleeding type of stroke called a subarachnoid hemorrhage. People with that type of hemorrhage typically present with a sudden onset of a very severe headache, unlike anything they've ever experienced before, and they should seek emergency medical care.
The brain cells are affected very quickly after a stroke occurs. In the most common type of stroke, called an ischemic stroke, or cerebral infarction, there's a lack of blood flow to an area of the brain leading the brain cells to begin to die off due to a lack of oxygen and other nutrients. Emergency treatments can sometimes be used to restore the blood flow. Stroke treatments are most effective if they can be used early after stroke symptoms occur.
Most strokes are preventable. And stroke prevention is far more effective than trying to treat a stroke after it has occurred. There are both non-modifiable risk factors, those things we cannot change, and modifiable risk factors, those things that can be changed. Non-modifiable risk factors include age, race, gender, and family history of stroke. Modifiable risk factors include high blood pressure, high cholesterol levels, cigarette smoking, diabetes, obstructive sleep apnea, lack of regular exercise, obesity, heavy alcohol use, recreational drug use, and some types of heart disease.
Every stroke is a little bit different because any area of the brain can be affected by a stroke. Some strokes lead to only mild symptoms, and others are more severe and have a major impact on speech, strength, swallowing, walking, and vision. The patient with a stroke will typically start therapies very early after a stroke, including physical therapy, occupational therapy, and speech therapy. A person can continue to recover from a stroke for many months after a stroke up to a year or even longer. This recovery is a very gradual process. But don't give up. Celebrate the gains from week to week and month to month.
If you have any stroke risk factors, partner with your medical team to control them. If stroke symptoms occur, seek emergency care. Work with your medical team to arrange for the appropriate evaluation to clarify why the stroke happened, and institute strategies to prevent another stroke from occurring in the future. Take your medications as advised. Your medical team will also institute therapies to help you with any deficit that you might have related to your stroke so that you can live your life to the fullest after a stroke occurs. Thank you for your time and we wish you well.
Things will move quickly once you get to the hospital, as your emergency team tries to determine what type of stroke you're having. That means you'll have a CT scan or other imaging test soon after arrival. Doctors also need to rule out other possible causes of your symptoms, such as a brain tumor or a drug reaction.
Stroke consultation at Mayo Clinic
CT scan of brain tissue damaged by stroke
CT scan of brain tissue damaged by stroke
CT scan showing brain tissue damaged by stroke
A cerebral angiogram showing a carotid aneurysm associated with stroke
Some of the tests you may have include:
- A physical exam. Your doctor will do a number of tests you're familiar with, such as listening to the heart and checking the blood pressure. You'll also have a neurological exam to see how a potential stroke is affecting your nervous system.
- Blood tests. You may have several blood tests, including tests to check how fast the blood clots, whether the blood sugar is too high or low, and whether you have an infection.
- Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show bleeding in the brain, an ischemic stroke, a tumor or other conditions. Doctors may inject a dye into your bloodstream to view the blood vessels in the neck and brain in greater detail (computerized tomography angiography).
- Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and a magnetic field to create a detailed view of the brain. An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. Your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography or magnetic resonance venography).
- Carotid ultrasound. In this test, sound waves create detailed images of the inside of the carotid arteries in the neck. This test shows buildup of fatty deposits (plaques) and blood flow in the carotid arteries.
- Cerebral angiogram. In this uncommonly used test, your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in the groin, and guides it through the major arteries and into the carotid or vertebral artery. Then your doctor injects a dye into the blood vessels to make them visible under X-ray imaging. This procedure gives a detailed view of arteries in the brain and neck.
- Echocardiogram. An echocardiogram uses sound waves to create detailed images of the heart. An echocardiogram can find a source of clots in the heart that may have traveled from the heart to the brain and caused a stroke.
Emergency treatment for stroke depends on whether you're having an ischemic stroke or a stroke that involves bleeding into the brain (hemorrhagic).
To treat an ischemic stroke, doctors must quickly restore blood flow to the brain. This may be done with:
Emergency IV medication. Therapy with drugs that can break up a clot has to be given within 4.5 hours from when symptoms first started if given intravenously. The sooner these drugs are given, the better. Quick treatment not only improves your chances of survival but also may reduce complications.
An IV injection of recombinant tissue plasminogen activator (TPA) — also called alteplase (Activase) or tenecteplase (TNKase) — is the gold standard treatment for ischemic stroke. An injection of TPA is usually given through a vein in the arm within the first three hours. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started.
This drug restores blood flow by dissolving the blood clot causing the stroke. By quickly removing the cause of the stroke, it may help people recover more fully from a stroke. Your doctor will consider certain risks, such as potential bleeding in the brain, to determine whether TPA is appropriate for you.
- Emergency endovascular procedures. Doctors sometimes treat ischemic strokes directly inside the blocked blood vessel. Endovascular therapy has been shown to significantly improve outcomes and reduce long-term disability after ischemic stroke. These procedures must be performed as soon as possible:
- Medications delivered directly to the brain. Doctors insert a long, thin tube (catheter) through an artery in the groin and thread it to the brain to deliver TPA directly where the stroke is happening. The time window for this treatment is somewhat longer than for injected TPA but is still limited.
- Removing the clot with a stent retriever. Doctors can use a device attached to a catheter to directly remove the clot from the blocked blood vessel in the brain. This procedure is particularly beneficial for people with large clots that can't be completely dissolved with TPA. This procedure is often performed in combination with injected TPA.
The time window when these procedures can be considered has been expanding due to newer imaging technology. Doctors may order perfusion imaging tests (done with CT or MRI) to help determine how likely it is that someone can benefit from endovascular therapy.
To decrease your risk of having another stroke or transient ischemic attack, your doctor may recommend a procedure to open up an artery that's narrowed by plaque. Options vary depending on the situation, but include:
- Carotid endarterectomy. Carotid arteries are the blood vessels that run along each side of the neck, supplying the brain (carotid arteries) with blood. This surgery removes the plaque blocking a carotid artery and may reduce the risk of ischemic stroke. A carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.
- Angioplasty and stents. In an angioplasty, a surgeon threads a catheter to the carotid arteries through an artery in the groin. A balloon is then inflated to expand the narrowed artery. Then a stent can be inserted to support the opened artery.
Emergency treatment of hemorrhagic stroke focuses on controlling the bleeding and reducing pressure in the brain caused by the excess fluid. Treatment options include:
- Emergency measures. If you take blood-thinning medications to prevent blood clots, you may be given drugs or transfusions of blood products to counteract the blood thinners' effects. You may also be given drugs to lower the pressure in the brain (intracranial pressure), lower blood pressure, prevent spasms of the blood vessels and prevent seizures.
- Surgery. If the area of bleeding is large, your doctor may perform surgery to remove the blood and relieve pressure on the brain. Surgery may also be used to repair blood vessel problems associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if an aneurysm, arteriovenous malformation (AVM) or other type of blood vessel problem caused the hemorrhagic stroke.
- Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm to stop blood flow to it. This clamp can keep the aneurysm from bursting, or it can keep an aneurysm that has recently hemorrhaged from bleeding again.
- Coiling (endovascular embolization). Using a catheter inserted into an artery in the groin and guided to the brain, the surgeon will place tiny detachable coils into the aneurysm to fill it. This blocks blood flow into the aneurysm and causes blood to clot.
- Surgical AVM removal. Surgeons may remove a smaller AVM if it's located in an accessible area of the brain. This eliminates the risk of rupture and lowers the risk of hemorrhagic stroke. However, it's not always possible to remove an AVM if it's located deep within the brain, it's large, or its removal would cause too much of an impact on brain function.
- Stereotactic radiosurgery. Using multiple beams of highly focused radiation, stereotactic radiosurgery is an advanced minimally invasive treatment used to repair blood vessel malformations.
Stroke recovery and rehabilitation
Brain hemisphere connections
Brain hemisphere connections
After emergency treatment, you'll be closely monitored for at least a day. After that, stroke care focuses on helping you recover as much function as possible and return to independent living. The impact of the stroke depends on the area of the brain involved and the amount of tissue damaged.
If the stroke affected the right side of the brain, your movement and sensation on the left side of the body may be affected. If the stroke damaged the brain tissue on the left side of the brain, your movement and sensation on the right side of the body may be affected. Brain damage to the left side of the brain may cause speech and language disorders.
Most stroke survivors go to a rehabilitation program. Your doctor will recommend the most rigorous therapy program you can handle based on your age, overall health and degree of disability from the stroke. Your doctor will take into consideration your lifestyle, interests and priorities, and the availability of family members or other caregivers.
Rehabilitation may begin before you leave the hospital. After discharge, you might continue your program in a rehabilitation unit of the same hospital, another rehabilitation unit or skilled nursing facility, as an outpatient, or at home.
Every person's stroke recovery is different. Depending on your condition, your treatment team may include:
- Doctor trained in brain conditions (neurologist)
- Rehabilitation doctor (physiatrist)
- Rehabilitation nurse
- Physical therapist
- Occupational therapist
- Recreational therapist
- Speech pathologist
- Social worker or case manager
- Psychologist or psychiatrist
Speech therapy is often a part of stroke rehabilitation.
One way to evaluate the care of patients diagnosed with stroke is to look at the percentage of patients receiving the timely and effective care measures that are appropriate. The goal is 100 percent.
The graphs below display the percentage of eligible Mayo Clinic patients diagnosed with stroke receiving all of the appropriate care measures.
Stroke Core Measure
See related graph.
Carotid Endarterectomy Mortality
See related graph.
Carotid Stenting Mortality
See related graph.
Comprehensive Stroke Measure
See related graph.
Comprehensive Stroke – Arrival Time to Skin Puncture
See related graph.
Comprehensive Stroke – Post Thrombolysis Revascularization Rate
See related graph.
Comprehensive Stroke – Timeliness of IV t-PA Therapy
See related graph.
For additional information and data visit Medicare Hospital Compare.
For additional information about quality at Mayo Clinic visit Quality Measures.
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Coping and support
A stroke is a life-changing event that can affect your emotional well-being as much as your physical function. You may sometimes feel helpless, frustrated, depressed and apathetic. You may also have mood changes and a lower sex drive.
Maintaining your self-esteem, connections to others and interest in the world are essential parts of your recovery. Several strategies may help you and your caregivers, including:
- Don't be hard on yourself. Accept that physical and emotional recovery will involve tough work and that it will take time. Aim for a "new normal," and celebrate your progress. Allow time for rest.
- Join a support group. Meeting with others who are coping with a stroke lets you get out and share experiences, exchange information and build new friendships.
- Let friends and family know what you need. People may want to help, but they may not know what to do. Let them know how they can help, such as by bringing over a meal and staying to eat with you and talk, or attending social events or religious activities with you.
Problems with speech and language can be especially frustrating. Here are some tips to help you and your caregivers cope with communication challenges:
- Practice. Try to have a conversation at least once a day. It will help you learn what works best for you. It will also help you feel connected and help rebuild your confidence.
- Relax and take your time. Talking may be easiest and most enjoyable in a relaxing situation when you're not rushed. Some stroke survivors find that after dinner is a good time.
- Say it your way. When you're recovering from a stroke, you may need to use fewer words, rely on gestures or use your tone of voice to communicate.
- Use props and communication aids. You may find it helpful to use cue cards showing frequently used words or pictures of close friends and family members, a favorite television show, the bathroom, or other regular wants and needs.
Preparing for your appointment
A stroke in progress is usually diagnosed in a hospital. If you're having a stroke, your immediate care will focus on minimizing brain damage. If you haven't yet had a stroke but you're worried about your future risk, you can discuss your concerns with your doctor at your next scheduled appointment.
What to expect from your doctor
In the emergency room, you may see an emergency medicine specialist or a doctor trained in brain conditions (neurologist), as well as nurses and medical technicians.
Your emergency team's first priority will be to stabilize your symptoms and overall medical condition. Then the team will determine if you're having a stroke. Doctors will try to find the cause of the stroke to determine the most appropriate treatment.
If you're seeking your doctor's advice during a scheduled appointment, your doctor will evaluate your risk factors for stroke and heart disease. Your discussion will focus on avoiding these risk factors, such as not smoking or using illegal drugs. Your doctor will also discuss lifestyle strategies or medications to control high blood pressure, cholesterol and other stroke risk factors.
Jan. 20, 2022