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BIOLOGICAL STRAND

Types of aphasia

Expressive aphasia. With expressive aphasia, the person knows what he or she wants to say yet has difficulty communicating it to others. It doesn't matter whether the person is trying to say or write what he or she is trying to communicate. Receptive aphasia. With receptive aphasia, the person can hear a voice or read the print, but may not understand the meaning of the message. Oftentimes, someone with receptive aphasia takes figurative language literally. Anomic aphasia. With anomic aphasia, the person has word-finding difficulties. This is called anomia. Because of the difficulties, the person struggles with an inability to find the right words for speaking and writing. Global aphasia. This is the most severe type of aphasia. It is often seen right after someone has a stroke. With global aphasia, the person has difficulty speaking and understanding words. In addition, the person is unable to read or write. Primary progressive aphasia. Primary progressive aphasia is a progressive disorder. With primary progressive aphasia, people lose their ability to talk, read, write, and comprehend what they hear in conversation over a period of time. With a stroke, aphasia may improve with proper therapy. There is, though, no treatment to reverse primary progressive aphasia. People with primary progressive aphasia are able to communicate in ways other than speech. For instance, they might use gestures. And many benefit from a combination of speech therapy and medications.

CLINICAL STRAND
Stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism, or due to a hemorrhage. Stroke is a medical emergency and can cause permanent neurological damage, complications and death if not promptly diagnosed and treated. Risk factors for stroke include advanced age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking, atrial fibrillation, the contraceptive pill, migraine with aura, and thrombophilia (a tendency to thrombosis), patent foramen ovale and several rarer disorders. High blood pressure is the most important modifiable risk factor of stroke. Strokes can be classified into two major categories: ischemic and hemorrhagic. Ischemia is due to interruption of the blood supply, while hemorrhage is due to rupture of a blood vessel or an abnormal vascular structure. 80% of strokes are due to ischemia; the remainder are due to hemorrhage. Ischemic stroke In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction and necrosis of the brain tissue in that area. There are four reasons why this might happen: thrombosis (obstruction of a blood vessel by a blood clot forming locally), embolism (idem due to a embolus from elsewhere in the body, see below), systemic hypoperfusion (general decrease in blood supply, e.g. in shock) and venous thrombosis. Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin). Thrombotic stroke In thrombotic stroke, a thrombus (blood clot) usually forms around atherosclerotic plaques. Since blockage of the artery is gradual, onset of symptomatic thrombotic strokes is slower. A thrombus itself (even if non-occluding) can lead to an embolic stroke if the thrombus breaks off, at which point it is called an "embolus". Thrombotic stroke can be divided into two types depending on the type of vessel the thrombus is formed on:

Large vessel disease involves the common and internal carotids, vertebral, and the Circle of Willis. Diseases that may form thrombi in the large vessels include (in descending incidence): atherosclerosis, vasoconstriction (tightening of the artery), aortic, carotid or vertebral artery dissection, various inflammatory diseases of the blood vessel wall (Takayasu arteritis, giant cell arteritis, vasculitis), noninflammatory vasculopathy, Moyamoya disease and fibromuscular dysplasia. Small vessel disease involves the smaller arteries inside the brain: branches of the circle of Willis, middle cerebral artery, stem, and arteries arising from the distal vertebral and basilar artery. Diseases that may form thrombi in the small vessels include (in descending incidence): lipohyalinosis (build-up of fatty hyaline matter in the blood vessel as a result of high blood pressure and aging) and fibrinoid degeneration (stroke involving these vessels are known as lacunar infarcts) and microatheroma (small atherosclerotic plaques). Sickle cell anemia, which can cause blood cells to clump up and block blood vessels, can also lead to stroke. Stroke is the second leading killer of people under 20 who suffer from sickle-cell anemia. Embolic stroke Embolic stroke refers to the blockage of an artery by an embolus, a traveling particle or debris in the arterial bloodstream originating from elsewhere. An embolus is most frequently a thrombus, but it can also be a number of other substances including fat (e.g. from bone marrow in a broken bone), air, cancer cells or clumps of bacteria (usually from infectious endocarditis). The source of the embolus must be identified. Because the embolic blockage is sudden in onset, symptoms usually are maximal at start. Also, symptoms may be transient as the embolus is partially resorbed and moves to a different location or dissipates altogether. Emboli most commonly arise from the heart (especially in atrial fibrillation) but may originate from elsewhere in the arterial tree. In paradoxical embolism, a deep vein thrombosis embolises through an atrial or ventricular septal defect in the heart into the brain. Cardiac causes can be distinguished between high- and low-risk: High risk: atrial fibrillation and paroxysmal atrial fibrillation, rheumatic disease of the mitral or aortic valve disease, artificial heart valves, known cardiac thrombus of the atrium or vertricle, sick sinus syndrome, sustained atrial flutter, recent myocardial infarction, chronic myocardial infarction together with ejection fraction <28 percent, symptomatic congestive heart failure with ejection fraction <30 percent, dilated cardiomyopathy, Libman-Sacks endocarditis, Marantic endocarditis, infective endocarditis, papillary fibroelastoma, left atrial myxoma and coronary artery bypass graft (CABG) surgery Low risk/potential: calcification of the annulus (ring) of the mitral valve, patent foramen ovale (PFO), atrial septal aneurysm, atrial septal aneurysm with patent foramen ovale, left ventricular aneurysm without thrombus, isolated left atrial "smoke" on echocardiography (no mitral stenosis or atrial fibrillation), complex atheroma in the ascending aorta or proximal arch Systemic hypoperfusion Systemic hypoperfusion is the reduction of blood flow to all parts of the body. It is most commonly due to cardiac pump failure from cardiac arrest or arrhythmias, or from reduced cardiac output as a result of myocardial infarction, pulmonary embolism, pericardial effusion, or bleeding. Hypoxemia (low blood oxygen content) may precipitate the hypoperfusion. Because the reduction in blood flow is global, all parts of the brain may be affected, especially "watershed" areas - border zone regions supplied by the major cerebral arteries. Blood flow to these areas does not necessarily stop, but instead it may lessen to the point where brain damage can occur. This phenomenon is also referred to as "last meadow" to point to the fact that in irrigation the last meadow receives the least amount of water. Venous thrombosis Cerebral venous sinus thrombosis leads to stroke due to locally increased venous pressure, which exceeds the pressure generated by the arteries. Infarcts are more likely to undergo hemorrhagic transformation (leaking of blood into the damaged area) than other types of ischemic stroke.

Hemorrhagic stroke Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the brain). Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system). The main types of extra-axial hemorrhage are epidural hematoma (bleeding between the dura mater and the skull), subdural hematoma (in the subdural space) and subarachnoid hemorrhage (between the arachnoid mater and pia mater). Most of the hemorrhagic stroke syndromes have specific symptoms (e.g. headache, previous head injury). Intracerebral hemorrhage (ICH) is bleeding directly into the brain tissue, forming a gradually enlarging hematoma (pooling of blood). It generally occurs in small arteries or arterioles and is commonly due to hypertension, trauma, bleeding disorders, amyloid angiopathy, illicit drug use (e.g. amphetamines or cocaine), and vascular malformations. The hematoma enlarges until pressure from surrounding tissue limits its growth, or until it decompresses by emptying into the ventricular system, CSF or the pial surface. A third of intracerebral bleed is into the brain's ventricles. ICH has a mortality rate of 44 percent after 30 days, higher than ischemic stroke or even the very deadly subarachnoid hemorrhage. Pathophysiology Ischemic stroke occurs due to a loss of blood supply to part of the brain, initiating the ischemic cascade. Brain tissue ceases to function if deprived of oxygen for more than 60 to 90 seconds and after a few hours will suffer irreversible injury possibly leading to death of the tissue, i.e., infarction. Atherosclerosis may disrupt the blood supply by narrowing the lumen of blood vessels leading to a reduction of blood flow, by causing the formation of blood clots within the vessel, or by releasing showers of small emboli through the disintegration of atherosclerotic plaques. Embolic infarction occurs when emboli formed elsewhere in the circulatory system, typically in the heart as a consequence of atria fibriliation, or in the carotid arteries. These break off, enter the cerebral circulation, then lodge in and occlude brain blood vessels. Due to collateral circulation, within the region of brain tissue affected by ischemia there is a spectrum of severity. Thus, part of the tissue may immediately die while other parts may only be injured and could potentially recover. The ischemia area where tissue might recover is referred to as the ischemic penumbra. As oxygen or glucose becomes depleted in ischemic brain tissue, the production of high energy phosphate compounds such as adenosine triphosphate (ATP) fails leading to failure of energy dependent processes (such as ion pumping) necessary for tissue cell survival. This sets off a series of interrelated events that result in cellular injury and death. A major cause of neuronal injury is release of the excitatory neurotransmitter glutamate. The concentration of glutamate outside the cells of the nervous system is normally kept low by so-called uptake carriers, which are powered by the concentration gradients of ions (mainly Na+) across the cell membrane. However, stroke cuts off the supply of oxygen and glucose which powers the ion pumps maintaining these gradients. As a result the transmembrane ion gradients run down, and glutamate transporters reverse their direction, releasing glutamate into the extracellular space. Glutamate acts on receptors in nerve cells (especially NMDA receptors), producing an influx of calcium which activates enzymes that digest the cells' proteins, lipids and nuclear material. Calcium influx can also lead to the failure of mitochondria, which can lead further toward energy depletion and may trigger cell death due to apoptosis. Ischaemia also induces production of oxygen free radicals and other reactive oxygen species. These react with and damage a number of cellular and extracellular elements. Damage to the blood vessel lining or endothelium is particularly important. In fact, many antioxidant neuroprotectants such as uric acid and NXY-059 work at the level of the endothelium and not in the brain per se. Free radicals also directly initiate elements of the apoptosis cascade by means of redox signaling . These processes are the same for any type of ischemic tissue and are referred to collectively as the ischemic cascade. However, brain tissue is especially vulnerable to ischemia since it has little respiratory reserve and is completely dependent on aerobic metabolism, unlike most other organs. Brain tissue survival can be improved to some extent if one or more of these processes is inhibited. Drugs that scavenge Reactive oxygen species, inhibit apoptosis, or inhibit excitotoxic neurotransmitters, for example, have

been shown experimentally to reduce tissue injury due to ischemia. Agents that work in this way are referred to as being neuroprotective. In addition to injurious effects on brain cells, ischemia and infarction can result in loss of structural integrity of brain tissue and blood vessels, partly through the release of matrix metalloproteases, which are zinc- and calciumdependent enzymes that break down collagen, hyaluronic acid, and other elements of connective tissue. Other proteases also contribute to this process. The loss of vascular structural integrity results in a breakdown of the protective blood brain barrier that contributes to cerebral edema, which can cause secondary progression of the brain injury. As is the case with any type of brain injury, the immune system is activated by cerebral infarction and may under some circumstances exacerbate the injury caused by the infarction. Inhibition of the inflammatory response has been shown experimentally to reduce tissue injury due to cerebral infarction, but this has not proved out in clinical studies. Hemorrhagic strokes result in tissue injury by causing compression of tissue from an expanding hematoma or hematomas. This can distort and injure tissue. In addition, the pressure may lead to a loss of blood supply to affected tissue with resulting infarction, and the blood released by brain hemorrhage appears to have direct toxic effects on brain tissue and vasculature. Causes A stroke is sometimes called a brain attack. The problem is with the amount of blood in your brain. The cause of one type of stroke ischemic stroke is too little blood in the brain. The cause of the other main type of stroke hemorrhagic stroke is too much blood within the skull. Ischemic stroke About 80 percent of strokes are ischemic strokes. They occur when blood clots or other particles block arteries to your brain and cause severely reduced blood flow (ischemia). This deprives your brain cells of oxygen and nutrients, and cells may begin to die within minutes. The most common ischemic strokes are: Thrombotic stroke. This type of stroke occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot usually forms in areas damaged by atherosclerosis a disease in which the arteries are clogged by an accumulation of cholesterol-containing fatty deposits (plaques). This process can occur within one of the two carotid (kuh-ROT-id) arteries of your neck that carry blood to your brain, as well as in other arteries. An ischemic stroke may also be caused by plaques that completely clog or markedly narrow an artery. This narrowing is called stenosis. Embolic stroke. An embolic stroke occurs when a blood clot or other particle forms in a blood vessel away from your brain commonly in your heart and is swept through your bloodstream to lodge in narrower brain arteries. This type of blood clot is called an embolus. It's often caused by irregular beating in the heart's two upper chambers (atrial fibrillation). This abnormal heart rhythm can lead to poor blood flow and the formation of a blood clot. Hemorrhagic stroke "Hemorrhage" is the medical word for bleeding. Hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures. Hemorrhages can result from a number of conditions that affect your blood vessels, including uncontrolled high blood pressure (hypertension) and weak spots in your blood vessel walls (aneurysms). A less common cause of hemorrhage is the rupture of an arteriovenous malformation (AVM) a malformed tangle of thin-walled blood vessels, present at birth. There are two types of hemorrhagic stroke: Intracerebral hemorrhage. In this type of stroke, a blood vessel in the brain bursts and spills into the surrounding brain tissue, damaging cells. Brain cells beyond the leak are deprived of blood and are also damaged. High blood pressure is the most common cause of this type of hemorrhagic stroke. High blood pressure can cause small arteries inside your brain to become brittle and susceptible to cracking and rupture. Subarachnoid hemorrhage. In this type of stroke, bleeding starts in a large artery on or near the membrane surrounding the brain and spills into the space between the surface of your brain and your skull. A subarachnoid hemorrhage is often signaled by a sudden, severe "thunderclap" headache. This type of stroke is commonly caused by the rupture of an aneurysm, which can develop with age or result from a genetic predisposition. After a

subarachnoid hemorrhage, vessels may go into vasospasm, a condition in which arteries near the hemorrhage constrict erratically, causing brain cell damage by further restricting or blocking blood flow to portions of the brain. Signs and symptoms Stroke symptoms typically develop rapidly (seconds to minutes). The symptoms of a stroke are related to the anatomical location of the damage; nature and severity of the symptoms can therefore vary widely. Ischemic strokes usually only affect regional areas of the brain perfused by the blocked artery. Hemorrhagic strokes can affect local areas, but often can also cause more global symptoms due to bleeding and increased intracranial pressure. Face - look to see if there is any drooping or loss of muscle tone on the face Arm - ask the patient to close their eyes and hold both arms out straight for 30 seconds - in a patient with a stroke, you might see one arm tending to slowly move down Speech - listen to see if you can hear any slurring of the speech not otherwise explained (e.g. alcohol) and see if they can answer simple questions If the area of the brain affected contains one of the three prominent Central nervous system pathwaysthe spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include: hemiplegia and muscle weakness of the face numbness reduction in sensory or vibratory sensation In most cases, the symptoms affect only one side of the body (unilateral). The defect in the brain is usually on the opposite side of the body (depending on which part of the brain is affected). However, the presence of any one of these symptoms does not necessarily suggest a stroke, since these pathways also travel in the spinal cord and any lesion there can also produce these symptoms. In addition to the above CNS pathways, the brainstem also consists of the 12 cranial nerves. A stroke affecting the brainstem therefore can produce symptoms relating to deficits in these cranial nerves: altered smell, taste, hearing, or vision (total or partial) drooping of eyelid (ptosis) and weakness of ocular muscles decreased reflexes: gag, swallow, pupil reactivity to light decreased sensation and muscle weakness of the face balance problems and nystagmus altered breathing and heart rate weakness in sternocleidomastoid muscle with inability to turn head to one side weakness in tongue (inability to protrude and/or move from side to side) If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the following symptoms: aphasia (inability to speak or understand language from involvement of Broca's or Wernicke's area) apraxia (altered voluntary movements) visual field defect memory deficits (involvement of temporal lobe) hemineglect (involvement of parietal lobe) disorganized thinking, confusion, hypersexual gestures (with involvement of frontal lobe) anosognosia (persistent denial of the existence of a, usually stroke-related, deficit) If the cerebellum is involved, the patient may have the following: trouble walking altered movement coordination vertigo and or disequilibrium

Loss of consciousness, headache, and vomiting usually occurs more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing on the brain. If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke. Screening and diagnosis If you've had a previous stroke or TIA or think you're at risk of stroke, talk with your doctor about screening and diagnostic tests. Before treating a stroke, your doctor must diagnose the type of stroke and its location. Other possible causes of your symptoms, such as a tumor, also need to be excluded. The following are most often used as screening tools to determine your risk, but they may also be used as diagnostic tools if you're having a stroke: Physical examination and tests. Your doctor may check for risk factors of stroke, including high blood pressure, high cholesterol levels, diabetes and elevated levels of the amino acid homocysteine. Your doctor may also use a stethoscope to listen for a whooshing sound (bruit) over your arteries that may indicate atherosclerosis. Carotid ultrasonography. In this procedure, a wand-like device (transducer) sends high-frequency sound waves into your neck. The sound waves pass through tissue and then return, creating on-screen images that delineate any narrowing or clotting in your carotid arteries. Arteriography. This procedure gives a view of arteries in your brain not normally seen in X-rays. Your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in your groin. The catheter is manipulated through your major arteries and into your carotid or vertebral artery. Then your doctor injects a dye through the catheter to provide X-ray images of your arteries. Computerized tomography (CT). In computerized tomographic angiography (CTA), a dye is injected into your vein and X-ray beams create a three-dimensional image of the blood vessels in your neck and brain. Doctors use CTA to look for aneurysms or arteriovenous malformations and to evaluate arteries for narrowing. CT scanning, which is done without dye, can provide images of your brain and show hemorrhages, but without as much detailed information about the blood vessels. Magnetic resonance imaging (MRI). Using a strong magnetic field, an MRI can generate a three-dimensional view of your brain. This test is sensitive for detecting an area of brain tissue damaged by an ischemic stroke. Magnetic resonance angiography (MRA) uses this magnetic field and a dye injected into your veins to evaluate arteries in your neck and brain. Echocardiography. Your doctor can use this ultrasound technology to compose images of your heart. He or she may also use transesophageal echocardiography (TEE). During this procedure, a flexible probe with a transducer built into it is placed in your esophagus the tube that connects the back of your mouth to your stomach. Because your esophagus is directly behind your heart, very clear, detailed ultrasound images can be created, allowing a better view of some things, such as blood clots, that might not be seen clearly in a traditional echocardiography exam. Treatment Ischemic stroke To treat an ischemic stroke, doctors must remove any obstruction and restore blood flow to your brain. Emergency treatment. Therapy with clot-busting drugs must start within three hours. Quick treatment not only improves your chances of survival, but may also reduce the amount of disability resulting from the stroke. Injection of a clot-busting (thrombolytic) drug such as a tissue plasminogen activator (TPA) into your veins to dissolve a blood clot may be more effective in increasing your chances of a full recovery, compared with other treatment methods. Currently, though, only a small proportion of Americans who have had a stroke receive thrombolytic therapy. Reasons for this include: A limited time window. Three hours has long been considered the window within which clot-busting drugs should be administered intravenously. Whether people can still gain some benefit from receiving clot-busting drugs beyond three hours is uncertain. After too much time has passed, the risks of bleeding or other complications from this type of therapy begin to outweigh the potential benefits.

A limited group of people who benefit from this therapy. TPA-type therapy doesn't treat hemorrhagic stroke. In fact, it may dramatically worsen a hemorrhagic stroke. Also, not everyone who has had an ischemic stroke is an ideal candidate for thrombolytic therapy. The ability of TPA-type agents to dissolve blood clots carries with it a risk of brain hemorrhage and bleeding elsewhere. With the diagnosis of an acute stroke, you and your doctor can work together to weigh the risks versus benefits of thrombolytic therapy in your individual case. Your doctor may not give you clot-busting medications if your blood pressure isn't controllable at the time when the TPA is being considered. Surgical and other procedures. Your doctor may recommend a procedure to open up an artery that's moderately to severely narrowed by plaques. This may include: Carotid endarterectomy. Your surgeon makes an incision in your neck to expose your carotid artery. The artery is opened, the plaques are removed, and your surgeon closes the artery. In people with marked blockages in the carotid artery who are candidates for the surgery, the procedure may reduce the risk of ischemic stroke. However, in addition to the usual risks associated with any surgery, a carotid endarterectomy itself can also trigger a stroke or heart attack by releasing a blood clot or fatty debris, although surgeons now place filters (distal protection devices) at strategic points in your bloodstream to "catch" any material that may break free during the procedure. Angioplasty. Used less commonly than carotid endarterectomy, angioplasty can widen the inside of an artery leading to your brain, usually the carotid artery. In this procedure, a balloon-tipped catheter is maneuvered into the obstructed area of your artery. The balloon is inflated, compressing the plaques against your artery walls. A metallic mesh tube (stent) is usually left in the artery to prevent recurrent narrowing. Distal protection devices also may be used with angioplasty. Other techniques. Doctors are also exploring new ways to remove clots. In a catheter embolectomy, a catheter is threaded into one of the arteries that lead to the brain and used to remove clots. You may also receive thrombolytic drugs directly into these arteries, via a catheter. Preventive medications. If you've had an ischemic stroke, it's important to determine why the stroke occurred and to prevent another. Your doctor may recommend medications to help reduce your risk of having a TIA or stroke. These include: Anti-platelet drugs. Platelets are cells in your blood that initiate clots. Anti-platelet drugs make your platelets less sticky and less likely to clot. The most frequently used anti-platelet medication is aspirin. Your doctor may also consider prescribing Aggrenox, a combination of low-dose aspirin and the anti-platelet drug dipyridamole, to reduce blood clotting. If aspirin doesn't prevent your TIA or stroke or if you can't take aspirin, your doctor may instead prescribe an anti-platelet drug such as clopidogrel (Plavix) or ticlopidine (Ticlid). Anticoagulants. These drugs include heparin and warfarin (Coumadin). They affect the clotting mechanism in a different manner than do anti-platelet medications. Heparin is fast acting and is used over the short term in the hospital. Slower acting warfarin is used over a longer term. These drugs have a profound effect on blood clotting and require that you work with your doctor to monitor them closely. Your doctor may prescribe these drugs if you have certain blood-clotting disorders, certain arterial abnormalities, an abnormal heart rhythm, such as atrial fibrillation, or other heart problems. Hemorrhagic stroke Surgery may be used to treat a hemorrhagic stroke or prevent another one. The most common procedures aneurysm clipping and arteriovenous malformation (AVM) removal carry some risks. Your doctor may recommend one of these procedures if you're at high risk of spontaneous aneurysm or AVM rupture: Aneurysm clipping. A tiny clamp is placed at the base of the aneurysm, isolating it from the circulation of the artery to which it's attached. This can keep the aneurysm from bursting, or it can prevent re-bleeding of an aneurysm that has recently hemorrhaged. Coiling (aneurysm embolization). In an embolization procedure, a catheter is maneuvered into the aneurysm. A tiny platinum coil is pushed through the catheter and positioned inside the aneurysm. The coil fills the aneurysm, causing clotting and sealing the aneurysm off from connecting arteries. Surgical AVM removal. It's not always possible to remove an AVM if it's too large or if it's located deep within the brain. Surgical removal of a smaller AVM from a more accessible portion of the brain, though, can eliminate the risk of rupture, lowering the overall risk of hemorrhagic stroke. Other treatment options for AVMs include

focused radiation or embolization, in which the small arteries supplying the blood to the AVM are blocked, shrinking the AVM Initial treatment for stroke Initial treatment for a stroke varies depending on whether it's caused by a blood clot (ischemic) or by bleeding in the brain (hemorrhagic). Before starting treatment, your doctor will use a computed tomography (CT) scan of your head and possibly magnetic resonance imaging (MRI) to diagnose the type of stroke you've had. Further tests may be done to find the location of the clot or bleeding and to assess the amount of brain damage. While treatment options are being determined, your blood pressure and breathing ability will be closely monitored, and you may receive oxygen. Initial treatment focuses on restoring blood flow for an ischemic stroke or controlling bleeding for a hemorrhagic stroke. As with a heart attack, permanent damage from a stroke often occurs within the first few hours. The quicker you receive treatment, the less damage will occur. Ischemic stroke Emergency treatment for an ischemic stroke depends on the location and cause of the clot. Measures will be taken to stabilize your vital signs, including giving you medicines.

If your stroke is diagnosed soon enough after the start of symptoms, you may be given a clot-dissolving medicine called tissue plasminogen activator (t-PA), which can increase your chances of survival and recovery. But t-PA is not safe for everyone. If you have had a hemorrhagic stroke, use of t-PA would be life-threatening. Your eligibility for t-PA will be quickly assessed in the emergency room. You may also receive aspirin or aspirin combined with another antiplatelet medicine. But aspirin is not recommended within 24 hours of treatment with t-PA. Other medicines may be given to control blood sugar levels, fever, and seizures. In general, high blood pressure won't be treated immediately unless systolic pressure is over 220 millimeters of mercury (mm Hg) and diastolic is more than 120 mm Hg (220/120, which is also called 220 over 120).

Hemorrhagic stroke Initial treatment for hemorrhagic stroke is difficult. Efforts are made to control bleeding, reduce pressure in the brain, and stabilize vital signs, especially blood pressure. There are few medicines available to treat hemorrhagic stroke. In some cases, medicines may be given to control blood pressure, brain swelling, blood sugar levels, fever, and seizures. You will be closely monitored for signs of increased pressure on the brain, such as restlessness, confusion, difficulty following commands, and headache. Other measures will be taken to keep you from straining from excessive coughing, vomiting, or lifting, or straining to pass stool or change position. Surgery generally is not used to control mild to moderate bleeding resulting from a hemorrhagic stroke. But if a large amount of bleeding has occurred and the person is rapidly getting worse, surgery may be needed to remove the blood that has built up inside the brain and to lower pressure inside the head. If the bleeding is due to a ruptured brain aneurysm, surgery to repair the aneurysm may be done. Repair may include: o Using a metal clip to clamp off the aneurysm to prevent renewed bleeding. o Endovascular coil embolization, a procedure which involves inserting a small coil into the aneurysm to block it off.

Whether these surgeries can be done depends on the location of the aneurysm and your condition following the stroke. Surgery

When surgery is being considered after a stroke, your age, prior overall health, and current condition are major factors in the decision. Surgery is not recommended as part of the initial or emergency treatment for ischemic stroke. Surgery for ischemic stroke Carotid endarterectomy. Carotid endarterectomy is surgery to remove plaque buildup in the carotid arteries in people with moderate to severe narrowing of the carotid arteries. This surgery can help prevent additional strokes. For more information, see: If a stroke has occurred because of a narrowed carotid artery, a carotid endarterectomy may help lower the risk of a future stroke. You are most likely to benefit from surgery if you have had a TIA or mild stroke in the past 6 months and have 70% or greater narrowing in one of your carotid arteries. Carotid endarterectomy may be appropriate if your carotid arteries are moderately or severely blocked (50% to 69% narrowing) and you have had one or more TIAs or mild strokes.10 Talk to your doctor about whether a carotid endarterectomy is right for you. Carotid endarterectomies are most successful when they are performed by a surgeon who is experienced in the procedure. Ask your doctor about his or her rate of complications. Surgery for hemorrhagic stroke Surgeries for hemorrhagic stroke include:

Surgery to drain or remove blood in or around the brain that was caused by a bleeding blood vessel (hemorrhagic stroke). A procedure (endovascular coil embolization) to repair a brain aneurysm that is the cause of a hemorrhagic stroke. A small coil is inserted into the aneurysm to block it off. Whether this surgery can be done depends on the location of the aneurysm, its size, and whether you are healthy enough to withstand the procedure. Surgery to remove or block off abnormally formed blood vessels (arteriovenous malformations) that have caused bleeding in the brain. An arteriovenous malformation is a congenital disorder, which means it was present at birth. An arteriovenous malformation causes an abnormal web of blood vessels and veins in the brain, brain stem, or spinal cord. The vessel walls of an arteriovenous malformation may become weak and leak or rupture.

People with a brain aneurysm need evaluation of all their symptoms to determine whether and when surgery is needed. Endovascular coil embolization is the preferred treatment for people with a brain aneurysm. It is also used for those who are at high risk for complications from a surgical repair of the aneurysm.11 In cases where endovascular coil embolization is not possible, aneurysm clipping with craniotomy is done.

Medications It is very important to seek emergency medical attention for stroke symptoms. If you are having an ischemic stroke, which is caused by a blood clot, you may be given medicines that get rid of the clot. If you are having a hemorrhagic stroke, which is caused by bleeding in the brain, you will not be given medicines. If you are having an ischemic stroke, you may be able to receive tissue plasminogen activator (t-PA), a clotdissolving medicine. This medicine is strongly recommended, but it works best when it is given right away after stroke symptoms start.1 If you receive t-PA, it may improve your recovery. But t-PA can be life-threatening because it can cause bleeding in the brain. It is not used to treat hemorrhagic stroke.

Blood clots cause most strokes, so medicines that prevent the formation of blood clots are used to prevent additional ischemic strokes. These medicines are usually given after the initial treatment for stroke. They are not recommended in the first 24 hours after t-PA has been given. The two types of medicines used to prevent clotting are:

Antiplatelet medicines, which prevent the smallest cells in blood (platelets) from sticking together. Aspirin is the antiplatelet medicine most commonly used to prevent strokes. People who cannot take aspirin or who have transient ischemic attacks (TIAs) or a stroke while taking aspirin are sometimes given other antiplatelet medicines, such as clopidogrel (Plavix). Another medicine that can prevent ischemic stroke is Aggrenox, which is aspirin combined with extended-release dipyridamole. Aspirin is not recommended within the first 24 hours of giving t-PA. For more information, see: Anticoagulants, which prevent the production of proteins needed for blood to clot normally. Anticoagulants (particularly warfarin) are the best method of preventing blood clots that form in the heart because of atrial fibrillation, heart attack, heart valve problems, or heart failure. Anticoagulants are not given as emergency treatment for stroke. If you take warfarin (such as Coumadin), see:

For people with coronary artery disease, treatment with cholesterol-lowering drugs called statins can slow the development of atherosclerosis in the carotid arteries and may also reduce the chance of having a TIA or stroke. Studies have shown a reduced risk of stroke in people taking statins.5, 9, 6 (For more information on statins, see the topic High Cholesterol.) Medication Choices Medicine used in the emergency treatment of stroke caused by a clot (ischemic stroke) includes tissue plasminogen activator (t-PA), a medicine that breaks up clots. After emergency treatment for a stroke, the focus will turn to preventing future transient ischemic attacks (TIAs) or another stroke. Your doctor will decide which medicines to use based on the risks and possible side effects of the medicines. These medicines are not usually given until at least 24 hours after treatment with t-PA. Antiplatelets decrease blood clot formation by preventing the smallest blood cells (platelets) from sticking together and forming blood clots. Antiplatelet medicines include the following:

Aspirin with extended-release dipyridamole (Aggrenox) is used for the prevention of ischemic stroke. Aspirin is an antiplatelet medicine often used for a first TIA or ischemic stroke or if you have atherosclerosis. Talk with your doctor before you start taking aspirin to prevent a stroke. Clopidogrel (Plavix) may be used if you have had a TIA or ischemic stroke and cannot take aspirin.

Anticoagulant medicines Anticoagulants (warfarin and heparin) are often used instead of or in combination with antiplatelets, such as aspirin or clopidogrel. Anticoagulants are used for people who are at risk for stroke because of:

Abnormal heart rhythms (atrial fibrillation). Heart attack, if a clot is present in the heart. Heart failure. Abnormal or artificial heart valves.

If you have high blood pressure, your doctor may want you to take medicines to lower it. Blood pressure medicines include:

Angiotensin-converting enzyme (ACE) inhibitors. Angiotensin II receptor blockers (ARBs).

Beta-blockers. Diuretics. Calcium channel blockers.

Medicines used to treat depression and pain may be prescribed after a stroke. Medicines to lower cholesterol (statins) may be prescribed after a stroke.

Prevention Control high blood pressure (hypertension). If you've had a stroke, lowering your blood pressure can help prevent a subsequent transient ischemic attack or stroke. Exercising, managing stress, maintaining a healthy weight, and limiting sodium and alcohol intake are all ways to keep hypertension in check. In addition to recommendations for lifestyle changes, your doctor may prescribe medications to treat hypertension, such as diuretics, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers. Lower your cholesterol and saturated fat intake. Eating less cholesterol and fat, especially saturated fat, may reduce the plaques in your arteries. If you can't control your cholesterol through dietary changes alone, your doctor may prescribe a cholesterol-lowering medication. Don't smoke. Quitting smoking reduces your risk of stroke. Several years after quitting, a former smoker's risk of stroke is the same as that of a nonsmoker. Control diabetes. You can manage diabetes with diet, exercise, weight control and medication. Strict control of your blood sugar may reduce damage to your brain if you do have a stroke. Maintain a healthy weight. Being overweight contributes to other risk factors for stroke, such as high blood pressure, cardiovascular disease and diabetes. Weight loss of as little as 10 pounds may lower your blood pressure and improve your cholesterol levels. Exercise regularly. Aerobic exercise reduces your risk of stroke in many ways. Exercise can lower your blood pressure, increase your level of HDL cholesterol, and improve the overall health of your blood vessels and heart. It also helps you lose weight, control diabetes and reduce stress. Gradually work up to 30 minutes of activity such as walking, jogging, swimming or bicycling on most, if not all, days of the week. Manage stress. Stress can cause a temporary spike in your blood pressure a risk factor for brain hemorrhage or long-lasting hypertension. It can also increase your blood's tendency to clot, which may elevate your risk of ischemic stroke. Simplifying your life, exercising and using relaxation techniques are all approaches that you can learn to reduce stress. Drink alcohol in moderation, if at all. Alcohol can be both a risk factor and a preventive measure for stroke. Binge drinking and heavy alcohol consumption increase your risk of high blood pressure and of ischemic and hemorrhagic strokes. However, drinking small to moderate amounts of alcohol can increase your HDL cholesterol and decrease your blood's clotting tendency. Both factors can contribute to a reduced risk of ischemic stroke. Don't use illicit drugs. Many street drugs, such as cocaine and crack cocaine, are established risk factors for a TIA or a stroke. Follow a healthy diet In addition, eat healthy foods. A brain-healthy diet should include: Five or more daily servings of fruits and vegetables, which contain nutrients such as potassium, folate and antioxidants that may protect you against stroke. Foods rich in soluble fiber, such as oatmeal and beans. Foods rich in calcium, a mineral found to reduce stroke risk. Soy products, such as tempeh, miso, tofu and soy milk, which can reduce your LDL cholesterol and raise your HDL cholesterol level. Foods rich in omega-3 fatty acids, including cold-water fish, such as salmon, mackerel and tuna. However, pregnant women and women who plan to become pregnant in the next several years should limit their weekly intake of cold-water fish because of the potential for mercury contamination.

Early risk factor screening. The AHA recommends that all people, beginning at age 20, undergo risk factor screening that includes recording blood pressure, body mass index, waist circumference and pulse at least every two years, and cholesterol and glucose testing at least every five years. Risk estimation. The AHA recommends that doctors estimate each person's percentage risk of developing cardiovascular disease within the next 10 years. The estimate would be based on the risk factor screening. The AHA recommends estimation of risk every five years for people age 40 or older, or for anyone with two or more risk factors. Complications By Mayo Clinic staff A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain suffers a lack of blood flow and which part was affected. Complications may include:

Paralysis or loss of muscle movement. Sometimes a lack of blood flow to the brain can cause a person to become paralyzed on one side of the body, or lose control of certain muscles, such as those on one side of the face. With physical therapy, you may see improvement in muscle movement or paralysis. Difficulty talking or swallowing. A stroke may cause a person to have less control over the way the muscles in the mouth and throat move, making it difficult to talk, swallow or eat. A person may also have a hard time speaking because a stroke has caused aphasia, a condition in which a person has difficulty expressing thoughts through language. Therapy with a speech and language pathologist may improve this disability. Memory loss or trouble with understanding. It's common that people who've had a stroke experience some memory loss. Others may develop difficulty making judgments, reasoning and understanding concepts. These complications may improve with rehabilitation therapies. Pain. Some people who have a stroke may have pain, numbness or other strange sensations in parts of their bodies affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm. You may also be sensitive to temperature changes, especially extreme cold. This is called central stroke pain or central pain syndrome (CPS). This complication generally develops several weeks after a stroke, and it may improve as more time passes. But because the pain is caused by a problem in the brain instead of a physical injury, there are few medications to treat CPS. Changes in behavior and self-care. People who have a stroke may become more withdrawn and less social or more impulsive. They may lose the ability to care for themselves and may need a caretaker to help them with their grooming needs and daily chores.

As with any brain injury, the success of treating these complications will vary from person to person.

BEHAVIORAL STRAND
Risk factors

Family history. Your risk of stroke is slightly greater if one of your parents or a brother or sister has had a stroke or TIA. Age. Your risk of stroke increases as you get older. Sex. Stroke affects men and women about equally, but women are more likely to die of stroke than are men. Race. Blacks are at greater risk of stroke than are people of other races. This is partly due to a higher prevalence of high blood pressure and diabetes. High blood pressure (hypertension). High blood pressure is a risk factor for both ischemic and hemorrhagic strokes. It can weaken and damage blood vessels in and around your brain, leaving them vulnerable to atherosclerosis and hemorrhage. Undesirable levels of blood cholesterol. High levels of low-density lipoprotein (LDL) cholesterol, the "bad" cholesterol, may increase your risk of atherosclerosis. In excess, LDLs and other materials build up on the lining of artery walls, where they may harden into plaques. High levels of triglycerides, a blood fat, also may increase your risk of atherosclerosis. In contrast, high levels of high-density lipoprotein (HDL) cholesterol, the "good" cholesterol, reduce your risk of atherosclerosis by escorting cholesterol out of your body through your liver. Cigarette smoking. Smokers have a much higher risk of stroke than do nonsmokers. Smoking contributes to plaques in your arteries. Nicotine makes your heart work harder by increasing your heart rate and blood pressure. The carbon monoxide in cigarette smoke replaces oxygen in your blood, decreasing the amount of oxygen delivered to the walls of your arteries and your tissues, including the tissues in your brain. Diabetes. Diabetes is a major risk factor for stroke. When you have diabetes, your body not only can't handle glucose appropriately, but it also can't process fats efficiently, and you're at greater risk of high blood pressure. These diabetes-related effects increase your risk of developing atherosclerosis. Diabetes also interferes with your body's ability to break down blood clots, increasing your risk of ischemic stroke. Obesity. Being overweight increases your chance of developing high blood pressure, heart disease, atherosclerosis and diabetes all of which increase your risk of a stroke. Cardiovascular disease. Several cardiovascular diseases can increase your risk of a stroke, including congestive heart failure, a previous heart attack, an infection of a heart valve (endocarditis), a particular type of abnormal heart rhythm (atrial fibrillation), aortic or mitral valve disease, valve replacement, or a hole in the upper chambers of the heart known as patent foramen ovale. Atrial fibrillation is the most common condition associated with strokes caused by embolic clots. In addition, atherosclerosis in blood vessels near your heart may indicate that you have atherosclerosis in other blood vessels including those in and around your brain. Previous stroke or TIA. If you've already had a stroke, your risk of having another one increases. In addition, people who have had a TIA are much more likely to have a stroke as are those who haven't had a TIA. Elevated homocysteine level. This amino acid, a building block of proteins, occurs naturally in your blood. But people with elevated levels of homocysteine have a higher risk of heart and blood vessel damage. Use of birth control pills and hormone therapy. The risk of stroke is higher among women who take birth control pills, especially among smokers and those older than 35. However, today's low-dose pills carry a much lower risk than their earlier counterparts. Hormone therapy for menopause also carries a slightly increased risk of stroke. Other factors that can increase your risk of stroke include heavy or binge drinking, the use of illicit drugs such as cocaine, and uncontrolled stress.

POPULATIO STRAND
Epidemiology Stroke could soon be the most common cause of death worldwide. Stroke is the third leading cause of death in the Western world, after heart disease and cancer,and causes 10% of deaths worldwide. The incidence of stroke increases exponentially from 30 years of age, and etiology varies by age. Advanced age is one of the most significant stroke risk factors. 95% of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65. A person's risk of dying if he or she does have a stroke also increases with age. However, stroke can occur at any age, including in fetuses. Family members may have a genetic tendency for stroke or share a lifestyle that contributes to stroke. Higher levels of Von Willebrand factor are more common amongst people who have had ischemic stroke for the first time. The results of this study found that the only significant genetic factor was the person's blood type. Having had a stroke in the past greatly increases one's risk of future strokes. Men are 1.25 times more likely to suffer strokes than women, yet 60% of deaths from stroke occur in women. Since women live longer, they are older on average when they have their strokes and thus more often killed (NIMH 2002). Some risk factors for stroke apply only to women. Primary among these are pregnancy, childbirth, menopause and the treatment thereof (HRT).

Stroke is the third largest cause of death in Malaysia. Only heart diseases and cancer kill more. It is considered to be the single most common cause of severe disability, and every year, an estimated 40,000 people in Malaysia suffer from stroke. Anyone can have a stroke, including children, but the vast majority of the cases affect adults.

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