Stroke

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

What is a stroke?

A stroke occurs when a blood vessel in the brain is blocked or bursts . Without blood and the oxygen it carries, part of the brain starts to die. The part of the body controlled by the damaged area of the brain can't work properly.

Brain damage can begin within minutes, so it is important to know the symptoms of stroke and act fast. Quick treatment can help limit damage to the brain and increase the chance of a full recovery.

What are the symptoms?

Symptoms of a stroke happen quickly. A stroke may cause sudden:

• Numbness, weakness, or paralysis of the face, arm, or leg, especially on one side of the body.
• Trouble seeing in one or both eyes. You may have double vision, or things may look dim or blurry.
• Confusion, and trouble speaking or understanding.
• Trouble walking. You may feel unsteady, dizzy, or clumsy.
• Severe headache.

If you have any of these symptoms, call 911 or other emergency services right away.

See your doctor if you have symptoms that seem like a stroke, even if they go away quickly. You may have had a transient ischemic attack (TIA), sometimes called a mini-stroke. A TIA is a warning that a stroke may happen soon. Getting early treatment for a TIA can help prevent a stroke.

What causes a stroke?

There are two types of stroke:

• An ischemic stroke develops when a blood clot blocks a blood vessel in the brain. The clot may form in the blood vessel or travel from somewhere else in the blood system. About 8 out of 10 strokes are ischemic (say “is-KEE-mik”) strokes. They are the most common type of stroke in older adults.
• A hemorrhagic stroke develops when an artery in the brain leaks or bursts. This causes bleeding inside the brain or near the surface of the brain. Hemorrhagic (say “heh-muh-RA-jik”) strokes are less common but more deadly than ischemic strokes.

How is a stroke diagnosed?

Seeing a doctor right away is very important. If a stroke is diagnosed within the first 3 hours, doctors may be able to use medicines that can lead to a better recovery.

The first thing the doctor needs to find out is what kind of stroke it is—ischemic or hemorrhagic. This is important because the medicine given to treat a stroke caused by a blood clot could be deadly if used for a stroke caused by bleeding in the brain.

To find out what kind of stroke it is, the doctor will do a type of X-ray called a CT scan of the brain, which can show if there is bleeding. The doctor may order other tests to find the location of the clot or bleeding, assess the amount of brain damage, and check for other conditions that can cause symptoms similar to a stroke.

How is it treated?

For an ischemic stroke, treatment focuses on restoring blood flow to the brain. If less than 3 hours have passed since your symptoms began, doctors may use a medicine that dissolves blood clots. Research shows that this medicine can improve recovery from a stroke, especially if given within 90 minutes of the first symptoms.¹ Other medicines may be given to prevent blood clots and control symptoms.

A hemorrhagic stroke can be hard to treat. Doctors may do surgery or other treatments to stop bleeding or reduce pressure on the brain. Medicines may be used to control blood pressure, brain swelling, and other problems.

After your condition is stable, treatment shifts to preventing other problems and future strokes. You may need to take a number of medicines to control conditions that put you at risk for stroke, such as high blood pressure, high cholesterol, and diabetes. Some people need to have a surgery to remove plaque buildup from the blood vessels that supply the brain (carotid arteries).

The best way to get better after a stroke is to start stroke rehab. The goal of stroke rehab is to help you regain skills you lost or to make the most of your remaining abilities. Stroke rehab can also help you take steps to prevent future strokes. You have the greatest chance of regaining abilities during the first few months after a stroke. So it is important to start rehab soon after a stroke and do a little every day.

Can you prevent a stroke?

Once you have had a stroke, you are at risk for having another one. You can make some important lifestyle changes that can reduce your risk of stroke and improve your overall health.

• Don't smoke. Smoking can more than double your risk of stroke.² Avoid secondhand smoke too.
• Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil.
• Get regular exercise on most, preferably all, days of the week. Your doctor can suggest a safe level of exercise for you.
• Control your cholesterol and blood pressure. If you have diabetes, keep your blood sugar in your target range.
• Limit alcohol. Having more than 2 drinks a day increases the risk of stroke.
• Take a daily aspirin if your doctor advises it.
• Avoid getting sick from the flu. Get a flu shot every year.

Work closely with your doctor. Go to all your appointments, and take your medicines just the way your doctor says to.

Frequently Asked Questions

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I have carotid endarterectomy for stroke or transient ischemic attack (TIA)?
	Should I put my loved one who has had a stroke in a nursing home?
	Actionsets are designed to help people take an active role in managing a health condition.
	Managing eating problems after a stroke

Causes of ischemic stroke

An ischemic stroke is caused by a blood clot that blocks blood flow to the brain. A blood clot can develop in a narrowed artery that supplies the brain or can travel from the heart (or elsewhere in the body) to an artery that supplies the brain.

Blood clots are usually the result of other problems in the body that affect the normal flow of blood, such as:

• Hardening of the arteries (atherosclerosis). This is caused by high blood pressure, diabetes, and high cholesterol.
• Atrial fibrillation or other irregular heart rhythms.
• Certain heart valve problems, including having an artificial heart valve, a repaired heart valve, heart valve disease such as mitral valve prolapse, or narrowing (stenosis) of a heart valve.
• Infection of the heart valves (endocarditis).
• A patent foramen ovale, which is a congenital heart defect.
• Blood-clotting disorders.
• Inflammation of blood vessels (vasculitis).
• Heart attack.

Low blood pressure (hypotension) may also cause an ischemic stroke, although less commonly. Low blood pressure results in reduced blood flow to the brain and may develop as a result of narrowed or diseased arteries, a heart attack, a large loss of blood, or a severe infection.

Some surgeries (such as endarterectomy) or other procedures (such as angioplasty) that are used to treat narrowed carotid arteries may ultimately cause a blood clot to break loose, resulting in a stroke.

Causes of hemorrhagic stroke

A hemorrhagic stroke is caused by bleeding inside the brain (called intracerebral hemorrhage) or bleeding in the space around the brain (called subarachnoid hemorrhage). Bleeding inside the brain may be a result of long-standing high blood pressure. Bleeding in the space around the brain may be caused by a ruptured aneurysm or uncontrolled high blood pressure.

Other causes of hemorrhagic stroke are less common but include:

• Inflammation in the blood vessels, which may develop from conditions such as syphilis, Lyme disease, or tuberculosis.
• Blood-clotting disorders, such as hemophilia.
• Head or neck injuries that result in damage to blood vessels in the head or neck.
• Radiation treatment for cancer in the neck or brain.
• Cerebral amyloid angiopathy (a degenerative blood vessel disorder).

If you have symptoms of a stroke, seek emergency medical care. General symptoms of a stroke include sudden onset of:

• Numbness, weakness, or paralysis of the face, arm, or leg, typically on one side of the body.
• Vision problems in one or both eyes, such as dimness, blurring, double vision, or loss of vision.
• Confusion, trouble speaking or understanding.
• Trouble walking, dizziness, loss of balance or coordination.
• Severe headache.

Symptoms vary depending on whether the stroke is caused by a clot or bleeding. The location of the blood clot or bleeding and the extent of brain damage can also affect symptoms.

• Symptoms of an ischemic stroke (caused by a clot blocking a blood vessel) usually occur in the side of the body opposite from the side of the brain where the clot occurred. For example, a stroke in the right side of the brain affects the left side of the body.
• Symptoms of a hemorrhagic stroke (caused by bleeding in the brain) can be similar to those of an ischemic stroke but may be distinguished by symptoms relating to higher pressure in the brain, including severe headache, nausea and vomiting, neck stiffness, dizziness, seizures, irritability, confusion, and possibly unconsciousness.

Symptoms of a stroke may progress over minutes, hours, or days, often in a stepwise fashion. For example, mild weakness may progress to an inability to move the arm and leg on one side of the body.

• If a stroke is caused by a large blood clot (ischemic stroke) or bleeding (hemorrhagic stroke), symptoms occur suddenly, within seconds.
• When an artery that is narrowed by atherosclerosis becomes blocked, stroke symptoms usually develop gradually over minutes to hours, or rarely, days.
• If several smaller strokes occur over time, the person may have a more gradual change in thinking, behavior, balance, or walking (multi-infarct dementia).

It is not always easy for people to recognize symptoms of a small stroke. They may mistakenly think the symptoms can be attributed to aging, or the symptoms may be confused with those of other conditions that cause similar symptoms.

When you have an ischemic stroke , the oxygen-rich blood supply to part of your brain is reduced. With a hemorrhagic stroke, there is bleeding in the brain.

• After about 4 minutes without blood and oxygen, brain cells become damaged and may die.
• The body tries to restore blood and oxygen to the cells by enlarging other blood vessels (arteries) near the area. If the blockage is in a large blood vessel, such as the carotid artery, the body may not be able to supply blood to the affected area through other blood vessels.
• If blood supply is not restored, permanent brain damage usually occurs.

When brain cells are damaged or die, the body parts controlled by those cells cannot function. The loss of function may be mild or severe, temporary or permanent. This depends on where and how much of the brain is damaged and how fast the blood supply can be returned to the affected cells.

If you have symptoms of a stroke, seek emergency medical care. Life-threatening complications may occur after a stroke. Early treatment may decrease the amount of permanent damage to brain cells, decreasing the amount of disability.

Stroke is the most common nervous system–related cause of physical disability. Of people who survive a stroke, half will still have some disability 6 months after the stroke.³

Recovery depends on the location and amount of brain damage caused by the stroke and the ability of other healthy areas of the brain to take over functioning for the damaged areas. In general, the less damage there is to the brain tissue, the less disability results and the greater the chances of a successful recovery.

You have the greatest chance of regaining your abilities during the first few months after a stroke. Regaining some abilities, such as speech, comes slowly, if at all. About half of all people who have a stroke will have some long-term problems with talking, understanding, and decision-making. They also may have changes in behavior that affect their relationships with family and friends.

Long-term complications of a stroke, such as depression and pneumonia, may develop right away or within months to years after a stroke. Some long-term complications may be prevented with proper home treatment and medical follow-up. For more information, see the Home Treatment section of this topic.

Of people who have a first stroke or transient ischemic attack (TIA), 14% will have another stroke or TIA within 1 year.⁴

What to expect after a stroke

In addition to the more obvious physical problems you experience after a stroke, you (or a caregiver) may also notice:

• Changes in speed of action.
• Changes in judgment.
• Changes in emotions.
• Changes in perceptions (the ability to judge distance, size, position, rate of movement, form, and how parts relate to the whole).
• Memory problems.
• Problems from neglecting the affected side of the body.

If you have concerns, discuss them with your doctor. Your doctor will provide support and may offer other suggestions for dealing with these issues.

Risk factors for stroke include those you can change and those you can't change.

Certain diseases or conditions increase your risk of stroke. These include:

• High blood pressure (hypertension). High blood pressure is the second most important stroke risk factor after age.⁵
• Diabetes. About one-quarter of people with diabetes die of stroke. Having diabetes doubles your risk of stroke because of the circulation problems associated with the disease.⁵
• High cholesterol. High cholesterol can lead to hardening of your arteries (atherosclerosis). Hardening of the arteries can cause coronary artery disease and heart attack, which can damage the heart muscle and increase your risk for stroke.
• Coronary artery disease, which can lead to heart attack and stroke.
• Other heart conditions, such as atrial fibrillation, endocarditis, heart valve conditions, patent foramen ovale, or cardiomyopathy.
• Smoking, including secondhand smoke.
• Physical inactivity.
• Being overweight.
• Diet. A recent study suggests that women who eat more fruits, vegetables, fish, and whole grains (for example, brown rice) may have a lower risk of stroke than women who eat lots of red meat, processed foods such as lunch meat, and refined grains (for example, white flour).⁶
• Use of some medications, such as birth control pills—especially by women who smoke or have a history of blood-clotting problems—and anticoagulants or steroids. In postmenopausal women, hormone replacement therapy has been shown to slightly increase the risk of stroke.⁷
• Heavy use of alcohol. People who drink alcohol excessively, especially people who binge drink, are more likely to have a stroke. Binge drinking is defined as drinking more than 5 drinks in a short period of time.
• Use of cocaine and other illegal drugs.

Risk factors you cannot change include:

• Age. The risk of stroke increases with age.
• Race. African Americans, Native Americans, and Alaskan Natives have a higher risk than those of other races.⁴ Compared with whites, young African Americans have 2 to 3 times the risk of ischemic stroke , and African-American men and women are more likely to die from stroke.⁴
• Gender. Stroke is more common in men than women until age 75, when more women than men have strokes.² At all ages, more women than men die of stroke.⁴
• Family history. The risk for stroke is greater if a parent, brother, or sister has had a stroke or transient ischemic attack (TIA). For more information, see the topic Transient Ischemic Attack (TIA).
• History of stroke or TIA.

Call 911 or other emergency services immediately if:

• Signs of a stroke develop suddenly. These may include:
  • Numbness, weakness, or inability to move the face, arm, or leg, especially on one side of the body.
  • Vision problems in one or both eyes, such as dimness, blurring, double vision, or loss of vision.
  • Confusion, trouble speaking or understanding.
  • Trouble walking, dizziness, loss of balance or coordination.
  • Severe headache with no known cause.
• You have signs of a transient ischemic attack (TIA). Symptoms are similar to those of a stroke, except:
  • The loss of vision is usually described as a sensation that a shade is being pulled down over one eye.
  • TIA symptoms typically disappear after 10 to 20 minutes but may last up to 24 hours. Since there is no way to tell whether the symptoms are caused by a stroke or TIA, emergency medical care is needed for both conditions.

Call your doctor immediately if you have:

• Had recent symptoms of a TIA or stroke, even if the symptoms have disappeared.
• Had a TIA or stroke and are taking aspirin or other medications that prevent blood clotting and you notice any signs of bleeding.
• Had a stroke and have a choking episode from food going down your windpipe.
• Signs of a blood clot in a deep blood vessel, which include redness, warmth, and pain in a specific area of your arm or leg.

Call your doctor for an appointment if you:

• Think you have had a TIA in the past and have not talked with your doctor about it.
• Have had a stroke and have a pressure sore. Pressure sores, which usually develop along the elbows, heels, knees, buttocks, and tailbone and on the back along the spine, are caused by staying in one position too long. The first sign of a pressure sore is a reddened area that does not go away with rubbing or massaging.
• Have had a stroke and notice that your affected arm or leg is becoming increasingly stiff or you are not able to straighten it (spasticity).
• Have had a stroke and notice signs of a urinary tract infection. Signs may include fever, pain with urination, blood in urine, and low back (flank) pain. For more information, see the topic Urinary Tract Infections in Teens and Adults.
• Have had a stroke and you are having trouble keeping your balance.

Watchful Waiting

Watchful waiting is not appropriate if you have signs of a stroke. Emergency medical care is needed to prevent or treat any complications that may be life-threatening. Prompt treatment may prevent extensive damage to the brain, decreasing permanent disabilities from the stroke.

If the stroke is caused by a blood clot, early care by a doctor in the emergency room or hospital is critical. If you seek help within 3 hours, you can sometimes receive a medication (tissue plasminogen activator, or t-PA) that dissolves clots, but this medication should be given within the first 3 hours after symptoms begin. Not everyone can safely receive this medication.

Who To See

Doctors who can diagnose and treat stroke include:

• Emergency medicine specialists.
• Family medicine physicians.
• Internists.
• Neurologists.

If you need surgery or have other health problems, other specialists may be consulted, such as a:

• Neurosurgeon.
• Cardiologist.
• Vascular surgeon (specialist in surgery of the blood vessels).

Some hospitals have a stroke team made up of many different health professionals, such as a physical therapist, an occupational therapist, a speech therapist, a doctor, a nurse, and a social worker.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Time is critical when diagnosing a stroke. A quick diagnosis within the first 3 hours may enable your doctor to use medications that can lead to a better recovery.

The first priority will be to determine whether you are having an ischemic or hemorrhagic stroke . This distinction is critical because the medication given for an ischemic stroke (caused by a blood clot) could be life-threatening if the stroke is hemorrhagic (caused by bleeding). Your doctor will also want to rule out other conditions that have symptoms similar to a stroke and to check for complications.

The first and most important test after a stroke is a cerebral computed tomography (CT) scan, which is a series of X-rays of your brain that can identify whether there is bleeding.¹ This test will help your doctor diagnose whether the stroke is ischemic or hemorrhagic. A magnetic resonance imaging (MRI) may also be done to determine the amount of damage to the brain and help predict recovery.

Other initial tests recommended for ischemic stroke include:¹

• Electrocardiogram (ECG, EKG) to check for heart problems, including arrhythmias and atrial fibrillation.
• Blood tests, such as a complete blood count (CBC), blood sugar, electrolytes, liver and kidney function, and prothrombin time (a test that measures how long it takes your blood to clot). These tests are done to help your doctor make choices about your treatment and to check for conditions that may cause symptoms similar to a stroke.

If your doctor suspects or other tests indicate narrowing of a carotid artery, he or she may want you to have a carotid ultrasound/Doppler scan to evaluate blood flow through the artery. Your doctor may also request magnetic resonance angiogram (MRA), CT angiogram, or carotid angiogram.

If your doctor believes the stroke may have been caused by a problem with your heart, an echocardiogram or Holter monitoring or telemetry test may be done.

New guidelines recommend that risk factors for heart disease also be assessed after a stroke to prevent disability or death from a future heart problem.⁸ This is because many people who have had a stroke also have coronary artery disease.

Prompt treatment of stroke and medical problems related to stroke, such as high blood sugar and pressure on the brain, may minimize brain damage and improve the chances of survival. Starting a rehabilitation program as soon as possible after a stroke increases your chances of recovering some of the abilities you lost.

Initial treatment for stroke

Initial treatment for a stroke varies depending on whether it's caused by a blood clot (ischemic) or 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 determine 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 (ischemic stroke) or controlling bleeding (hemorrhagic stroke). As with a heart attack, permanent damage from a stroke often develops 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 medications.

• If your stroke is diagnosed within 3 hours of the start of symptoms, you may be given a clot-dissolving medication called tissue plasminogen activator (t-PA), which can increase your chances of survival and recovery. However, 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 medication. However, aspirin is not recommended within 24 hours of treatment with t-PA.¹ Other medications 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 over 120).¹

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 medications available to treat hemorrhagic stroke. In some cases, medications 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. However, 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:
  • Using a metal clip to clamp off the aneurysm to prevent renewed bleeding.
  • 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.

Ongoing treatment

After emergency treatment for stroke, and once your condition has stabilized, treatment focuses on rehabilitation and preventing another stroke. It will be important to control your risk factors for stroke, such as high blood pressure, atrial fibrillation, high cholesterol, or diabetes.

Your doctor will probably want you to take aspirin or other antiplatelet medications. If you had an ischemic stroke (caused by a blood clot), you may need to take anticoagulants to prevent another stroke. You may also need to take medications, such as statins, to lower high cholesterol or medications to control your blood pressure. Medications to lower high blood pressure include:

• Angiotensin-converting enzyme (ACE) inhibitors.
• Angiotensin II receptor blockers (ARBs).
• Beta-blockers.
• Diuretics.
• Calcium channel blockers.

Your doctor may also recommend carotid endarterectomy surgery to remove plaque buildup in the carotid arteries. For more information on this decision, see:

Should I have carotid endarterectomy?

A relatively new procedure called carotid artery stenting is another option for some people who are at high risk of stroke. This procedure is much like coronary angioplasty, which is commonly used to open blocked arteries in the heart. During this procedure, a vascular surgeon inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque. The surgeon may use a stent that is coated with medication to help prevent future blockage.

Early aggressive rehabilitation may allow you to regain some normal functioning. Your rehabilitation will be based on the physical abilities that were lost, your general health before the stroke, and your ability to participate. Rehabilitation begins with helping you resume activities of daily living, such as eating, bathing, and dressing. For more information, see the topic Stroke Rehabilitation.

Changes in lifestyle may also be an important part of your ongoing treatment to reduce your risk of having another stroke. It will be important for you to exercise to the extent possible, eat a balanced diet, and quit smoking, if you smoke. Your doctor may suggest that you follow the Dietary Approaches to Stop Hypertension (DASH) diet if you have high blood pressure. If you have high cholesterol, you may need to follow the Therapeutic Lifestyle Changes (TLC) diet. These eating plans stress a diet that is low in fat (especially saturated fat) and contains more whole grains, fruits, vegetables, and low-fat dairy products.

Treatment if the condition gets worse

Depression is common in people who have had a stroke. You may need medications for depression and pain to help you cope.

If you get worse, it may be necessary for your loved one to move you to a care facility that can meet your needs, especially if your caregiver has his or her own health problems that make it difficult to properly care for you. It is common for caregivers to neglect their own health when they are caring for a loved one who has had a stroke. If your caregiver's health declines, the risk of injury to you and your caregiver may increase. For more information, see:

Should I put my loved one who has had a stroke in a nursing home?

Palliative care

As your condition gets worse, you may want to think about palliative care. Palliative care is a type of care for people who have illnesses that do not go away and often get worse over time. It is different than care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End-of-life issues

Although stroke rehabilitation is increasingly successful at prolonging life, a stroke can be a disabling or fatal condition. People who have had a stroke may consider discussing health care and other legal issues that may arise near the end of life. Many people find it helpful and comforting to state their health care choices in writing with an advance directive while they are still able to make and communicate these decisions.

Advance directives can include the ability to refuse treatment in specific situations. The three main types of advance directives are:

• Do not resuscitate orders (DNRs).
• Living wills.
• Durable power of attorney for health care (DPA).

Do not resuscitate orders (DNRs) typically request that no extraordinary measures be used to save your life. Extraordinary measures include cardiopulmonary resuscitation (CPR), use of an electrical shock to stop a fatal abnormal heart rhythm (defibrillation), intubation (placement of a breathing tube down your throat), or the use of lifesaving drugs. People with DNR orders will only be given drugs that make them more comfortable in their last moments. You may request that you be identified as a DNR if you wish to avoid expensive, uncomfortable, or invasive medical care that probably will not improve your long-term prognosis and may increase your discomfort.

Living wills are written documents that contain specific instructions about the type of treatment you wish to receive at the end of your life. Unlike a DNR order, which applies to a specific moment when you require resuscitation, living wills apply to more general situations.

One of two broad conditions must be triggered:

• You have slipped into a permanent coma.
• You are unable to make decisions about the type of care you wish to receive.

Once two doctors agree that one of these conditions has been met, your doctor will deliver care based on the directions in your living will. Usually, living wills instruct doctors not to prescribe any treatment that would unnecessarily lengthen the process of dying.

A durable power of attorney for health care document (DPA) appoints a specific person (surrogate) to make decisions about your care if you are incapacitated. (A DPA can also be called the appointment of a health care agent or health care surrogate.) Unlike DNRs or living wills, DPAs allow an independent observer of your choice to assess your current health condition and to speak to your doctor before any decision about your care is made. DNRs and living wills do not allow for this type of dialogue, because your treatment is based on choices you made without knowing the exact nature of your condition.

For more information about these options, see the topic Care at the End of Life.

What To Think About

People who are unconscious immediately after a stroke have the least chance of a full recovery. Some people may have a poor recovery because of the location and extent of brain damage. However, many people do successfully recover.

It is not possible to predict precisely how much physical ability you will regain. The more ability you retain immediately after a stroke, the more independent you are likely to be when you are discharged from the hospital. After a stroke:

• People usually show the greatest progress in being able to walk during the first 6 weeks. Most recovery occurs within the first 3 months, but you may continue to improve slowly over the next few years.
• Speech, balance, and skills needed for day-to-day living return more slowly and may continue to improve for up to a year.
• About half of the people who suffer a stroke have problems with coordination, communication, judgment, or behavior that affect their work and personal relationships.³

After a person has had a stroke, family members can learn ways to provide rehabilitation support and encouragement to their loved one.

For some people, stroke prevention may begin after a transient ischemic attack (TIA)—a warning sign that a stroke may soon occur. Prompt medical attention may help prevent a stroke.

Seek emergency medical help immediately if you have symptoms of a TIA, which are similar to those of a stroke and include problems with vision, speech, behavior, and thought processes. A TIA may cause loss of consciousness, seizure, dizziness (vertigo), and weakness or numbness on one side of the body. Symptoms of a TIA, however, are temporary and usually disappear after 10 to 20 minutes, although they may last up to 24 hours.

Many strokes can be prevented by controlling risk factors and treating other medical conditions that can lead to a stroke.

• If you have been told that you have hardening of the arteries (atherosclerosis), check with your doctor about whether you should take an aspirin each day and/or a medication to lower your cholesterol. Taking an aspirin daily can also reduce the risk of stroke in a person who has already had an ischemic stroke , a TIA, or carotid endarterectomy surgery.
• If your doctor hears a swishing sound—a bruit—when listening to blood flow through the large blood vessels in your neck (carotid arteries), ask whether you need further testing (usually carotid ultrasound). Aspirin or surgery to reopen a blocked carotid artery may be appropriate. For more information on this surgery, see:

  Should I have carotid endarterectomy?

A relatively new procedure called carotid artery stenting is another option for some people at high risk of stroke. This procedure is much like coronary angioplasty, which is commonly used to open blocked arteries in the heart. During this procedure, a vascular surgeon inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque. The surgeon may use a stent that is coated with medication to help prevent future blockage.

Other ways you can control your risk factors include:

• Having regular medical checkups. Work with your doctor to control your high blood pressure. This is especially important if you also have diabetes.
• Becoming more active. Try to do activities that raise your heart rate. Exercise for at least 30 minutes on most, preferably all, days of the week. A large study shows that physical activity significantly lowers your risk of stroke, partly by reducing the two greatest risk factors for stroke: high blood pressure and heart disease. The more physically active you are, the greater the reduction in risk. Moderately active people had a 20% lower risk of stroke than inactive people. Highly active people had a 34% reduction of risk.⁹ Exercise can also help raise HDL ("good") cholesterol levels in your body, which also reduces the risk of stroke.
• Controlling high cholesterol, heart disease (especially atrial fibrillation), diabetes, or disorders that affect your blood vessels, such as coronary artery disease.
• Not smoking and avoiding secondhand smoke. If you do smoke, quit. (For tips, see the topic Quitting Tobacco Use.) Daily cigarette smoking increases the risk of stroke by 2½ times.²
• Taking cholesterol-lowering medications called statins if you have high cholesterol or have had a heart attack, TIA, or stroke.^{10, 11}

Other ways you may be able to decrease your risk for stroke include:

• Taking aspirin if you have had a heart attack.²
• Taking anticoagulants, as prescribed by your doctor, if you have atrial fibrillation or have had a heart attack with other complications.²
• Maintaining a healthy weight. Being overweight increases your risk of developing high blood pressure, heart problems, and diabetes, which are risk factors for TIA and stroke.
• Eating a nutritious, balanced diet that is low in cholesterol, saturated fats, and salt. Foods high in saturated fat and cholesterol can worsen hardening of the arteries. Eat more fruits and vegetables to increase your intake of potassium and vitamins B, C, E, and riboflavin. Add whole grains to your diet; one study showed whole grains reduced the risk of ischemic stroke in women.¹² Eating fish once a month or more may also reduce your risk of stroke.¹³
• Limiting alcohol. Low to moderate alcohol consumption (from 1 drink per week to less than 2 drinks per day) may decrease the risk of ischemic stroke. Excessive use of alcohol (more than 2 drinks per day) increases a person's risk of stroke.
• Avoiding cocaine and other illegal drugs. Cocaine can increase blood pressure and cause the heart to beat more rapidly, thereby increasing your risk of stroke.
• Avoiding birth control pills if you have other risk factors. If you smoke or have high cholesterol or a history of blood clots, taking birth control pills increases your risk of having a stroke.
• Avoiding hormone replacement therapy. In women who have gone through menopause, hormone replacement therapy has been shown to slightly increase the risk of stroke.⁷
• Avoid getting sick from the flu. Get a flu shot every year.

After a stroke, home treatment will be an important part of your rehabilitation.

You may need to use assistive devices to help you:

• Eat. Large-handled silverware can be easier to grab and use if you have a weak hand.
• Get dressed. Devices called reachers can help you put on socks or stockings if you have weakness in one arm or hand.
• Walk. Canes and walkers can be used to help prevent falls.

Tips for a successful recovery

• Be as involved as possible in your care. Although you may feel like letting a caregiver take charge, the more you can participate the better. Ask for help in dealing with any disabilities you may have, and try to make people understand your limitations.
• Recognize and deal with depression. Depression is common after a stroke and can be treated.
• Participate in a stroke rehabilitation program as soon as possible. After a stroke, a combination of physical, speech, and occupational therapies can help you manage the basics of daily living, such as bathing, dressing, and eating. A team that includes your doctor, a variety of therapists, and nurses will work with you to overcome disabilities, learn new ways to accomplish tasks, and strengthen parts of your body impaired by the stroke. For more information, see the topic Stroke Rehabilitation.

Tips for dealing with the effects of a stroke

• Managing getting dressed. Getting dressed may be easier if you use stocking/sock spreaders, rings or strings attached to zipper pulls, and buttonhooks. Talk with a nurse or physical therapist about assistive devices that may be available to help you get dressed.
• Managing vision problems. After a stroke, some people have problems seeing to one side. For example, people with right-sided paralysis may have difficulty seeing to the right.
• Managing eating problems. You may not be able to feel food on one or both sides of your mouth. This increases your risk for choking. You may need further tests or an evaluation by a speech therapist.
• Managing bowel and bladder problems. Some people who have a stroke suffer loss of bladder control (urinary incontinence) after the stroke. However, this is usually temporary, and it can have many causes, including infection, constipation, and the effects of medications.

Tips for family members and caregivers

• Family adjustment will be important to your loved one's recovery. Strong support from the family can greatly enhance recovery.
• Help manage speech and language problems with some simple tips. These problems may involve any or all aspects of language use, such as speaking, reading, writing, and understanding the spoken word. Speaking slowly and directly and listening carefully can help.
• Rehabilitation support involves participating in your loved one's rehabilitation as often as you can. Give as much support and encouragement as possible.

For more information on rehabilitation at home, see the topic Stroke Rehabilitation.

Although stroke rehabilitation is increasingly successful at prolonging life, a stroke can be a disabling or fatal condition. People who have had a stroke may consider discussing health care and other legal issues that may arise near the end of life. Many people find it helpful and comforting to state their health care choices in writing with a living will or other advance directive while they are still able to make and communicate these decisions. For more information, see the topic Care at the End of Life.

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 able to receive tissue plasminogen activator (t-PA), a clot-dissolving medication. This medication is strongly recommended, but it is most effective if given within 3 hours of the onset of stroke symptoms.¹ If you receive t-PA within this 3-hour window, it may improve your recovery. New evidence shows that there may be some benefit in giving t-PA even beyond 3 hours.¹⁴ However, t-PA can be life-threatening because it can cause bleeding in the brain. It is not used to treat hemorrhagic stroke.

Since blood clots cause most strokes, medications that prevent the formation of blood clots are used to prevent additional ischemic strokes. These medications are usually given after the initial treatment for stroke. They are not recommended in the first 24 hours after t-PA has been given.¹ The two types of medications used to prevent clotting are:

• Antiplatelet medicines, which prevent the smallest cells in blood (platelets) from sticking together. Aspirin is the antiplatelet medication most commonly used to prevent strokes. Two large studies showed that taking aspirin within 48 hours of a stroke may reduce the chance of another stroke and prevent death.^{15, 3} People who cannot take aspirin or who have transient ischemic attacks (TIAs) or a stroke while taking aspirin are sometimes given other antiplatelet medications, such as clopidogrel or ticlopidine. Aggrenox is a medication that combines aspirin with extended-release dipyridamole to prevent ischemic stroke. Aggrenox reduces the risk of stroke as much as aspirin and significantly more than clopidogrel.^{15, 16} Aspirin is not recommended within the first 24 hours of giving t-PA.¹
• 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.

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.¹⁷ (For more information on statins, see the topic High Cholesterol.)

Medication Choices

Medication used in the emergency treatment of stroke caused by a clot (ischemic stroke) includes tissue plasminogen activator (t-PA), a medication 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 medications to use based on the risks and possible side effects of the medications. These medications are not usually given until at least 24 hours after treatment with t-PA.

Antiplatelets

Antiplatelets decrease blood clot formation by preventing the smallest blood cells (platelets) from sticking together and forming blood clots. Antiplatelet medications include the following:

• Aspirin with extended-release dipyridamole (Aggrenox) is used for the prevention of ischemic stroke.
• Aspirin is an antiplatelet medication 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.
• Ticlopidine (Ticlid) or clopidogrel (Plavix) may be used if you have had a TIA or ischemic stroke and cannot take aspirin.

Anticoagulants

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 medications to lower it. Blood pressure medications include:

• Angiotensin-converting enzyme (ACE) inhibitors.
• Angiotensin II receptor blockers (ARBs).
• Beta-blockers.
• Diuretics.
• Calcium channel blockers.

Medications used to treat depression and pain may be prescribed after a stroke.

What To Think About

Choosing which medication to use to prevent stroke is based on evaluation of your risks and the benefits of taking that medication. The American College of Physicians recommends:

• Warfarin for people who are at risk for stroke because of abnormal heart rhythms (atrial fibrillation) or blood clots that form in the heart or another place in the body.
• Aspirin for people who have had a transient ischemic attack (TIA). Talk with your doctor before you start taking aspirin to prevent a stroke.
• Other antiplatelet medications, such as aspirin with extended-release dipyridamole (Aggrenox), clopidogrel (Plavix), or ticlopidine (Ticlid).

However, the American College of Cardiology and the American Heart Association recommend that short-acting dipyridamole alone not be used by people who have chronic stable angina (an indicator of coronary artery disease) because dipyridamole may reduce blood flow to portions of the heart (ischemia) during exercise.¹⁸ Extended-release formulations, such as Aggrenox, do not appear to have this risk and may be safe for people with angina. Talk to your doctor if you are considering taking a medication that contains dipyridamole.

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 .¹

Your doctor may perform:

• 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:

  Should I have carotid endarterectomy?

• Surgery to drain or remove blood in or around the brain that was caused by a bleeding blood vessel (hemorrhagic stroke).
• Surgery (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 repair abnormally formed blood vessels (arteriovenous malformations) that have caused bleeding in the brain. An arteriovenous malformation is a congenital disorder that 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.

If a stroke has occurred because of a narrowed carotid artery, a carotid endarterectomy may help lower the risk of a future stroke.

Carotid endarterectomies are most successful when they are performed by a surgeon who is experienced in the procedure and in a hospital that is well-equipped to take care of any complications that may occur during or after the procedure. Ask your doctor about his or her rate of complications and the complication rate at the hospital where the surgery will be done.

Carotid endarterectomy is not recommended:

• As an emergency treatment for people who have had a stroke caused by a clot (ischemic stroke ).
• For people who are not expected to survive after their stroke.
• When the risks of surgery outweigh the benefits. A person may have medical problems that make surgery too risky, or a skilled surgeon may not be available.
• For people who have a transient ischemic attack (TIA) or stroke involving arteries in the back of the brain (vertebrobasilar arteries).
• For people who have minimal hardening and narrowing of the carotid arteries (less than 50% narrowing), even if they have had a transient ischemic attack (TIA). For these people, the surgical risks outweigh the benefits.
• For people with moderate hardening and narrowing of the carotid arteries (50% to 69% narrowing). The benefit of surgery for these people is still under investigation.

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.¹⁹ In cases where endovascular coil embolization is not possible, aneurysm clipping with craniotomy is done.

Stroke rehabilitation is a critical part of a successful recovery. Half of the people who have a stroke lose some of their independence, and 20% are completely dependent on others for their care. Early rehabilitation, begun as soon as possible after the stroke, helps to lessen dependence on others. Most recovery occurs during the first 3 months after a stroke but may continue slowly over the next few years. For more information, see the topic Stroke Rehabilitation.

New treatments

Carotid artery stenting can sometimes be used to open narrowed arteries to the brain in an effort to prevent stroke. Carotid artery stenting (also called cerebral percutaneous transluminal angioplasty) is similar to the procedure used to open narrowed arteries that supply blood to the heart (cardiac angioplasty). During this procedure, a vascular surgeon inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque.

Early studies show carotid artery stenting to be as effective as carotid endarterectomy in preventing stroke, heart attack, and other complications in people who are at high risk of stroke.²⁰ Further studies are ongoing to clarify when carotid artery stenting should be used.

Other studies are under way regarding new methods for treating stroke.

Organizations

• Choosing a Health Care Agent
• Coronary Artery Disease
• High Cholesterol
• Hospice Care
• Stroke Rehabilitation
• Transient Ischemic Attack (TIA)
• Writing an Advance Directive

Citations

1. Adams HP, et al. (2003). Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke, 34(4): 1056–1053.

2. Kasner SE, Morgenstern LB, (2004). Cerebrovascular disorders. In DC Dale, DD Federman, eds., ACP Medicine, section 11, chap. 4. New York: WebMD.

3. Warburton E (2004). Stroke management. Online version of Clinical Evidence (12): 1–18.

4. American Heart Association (2002). 2002 Heart and Stroke Statistical Update, p. 14. Dallas: American Heart Association.

5. Sacco RL (2005). Pathogenesis, classification, and epidemiology of cerebrovascular disease. In L Rowland, ed., Merritt's Neurology, 11th ed., pp. 275–290. New York: Lippincott Williams and Wilkins.

6. Fung TT, et al. (2004). Prospective study of major dietary patterns and stroke risk in women. Stroke, 35: 2014–2019.

7. Wassertheil-Smoller S, et al. (2003). Effect of estrogen plus progestin on stroke in postmenopausal women. The Women's Health Initiative: A randomized trial. JAMA, 289(20): 2673–2684.

8. Adams RJ, et al. (2003). Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: A scientific statement for healthcare professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association. Circulation, 108(10): 1278–1290.

9. Lee CD, et al. (2003). Physical activity and stroke risk: A meta-analysis. Stroke, 34(10): 2475–2481.

10. Corvol JC, et al. (2003). Differential effects of lipid-lowering therapies on stroke prevention. Archives of Internal Medicine, 163(6): 669–676.

11. Heart Protection Study Collaborative Group (2004). Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20,536 people with cerebrovascular disease or other high-risk conditions. Lancet, 363(9411): 757–767.

12. Liu S, et al. (2000). Whole-grain consumption and risk of ischemic stroke in women. JAMA, 284(12): 1534–1540.

13. He K, et al. (2002). Fish consumption and risk of stroke in men. JAMA, 288(24): 3130–3136.

14. The ATLANTIS, ECASS, and NINDS rt-PA Study Group Collaborative (2004). Association of outcome with early stroke treatment: Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet, 363(9411): 768–774.

15. Albers G, et al. (2001). Antithrombotic and thrombolytic therapy for ischemic stroke. Sixth ACCP Consensus Conference on Antithrombotic Therapy. Chest, 119(1, Suppl): 300S–320S.

16. Sacco R, Elkind M (2000). Update on antiplatelet therapy for stroke prevention. Archives of Internal Medicine, 160(11): 1579–1582.

17. Lip GYH, et al. (2004). Stroke prevention, search date 2003. Online version of Clinical Evidence (12): 253–284.

18. Gibbons RJ, et al. (2002). ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina: A Report of the American College of Cardiology Foundation and the American Heart Association Task Force on Practice Guidelines, p. 50. Available online: http://www.acc.org/clinical/guidelines/stable/stable_clean.pdf.

19. Mayer SA, et al. (2000). Subarachnoid hemorrhage. In L Rowland, ed., Merritt's Neurology, 10th ed., pp. 260–267. New York: Lippincott Williams and Wilkins.

20. Yadav JS, et al. (2004). Protected carotid-artery stenting versus endarterectomy in high-risk patients. New England Journal of Medicine, 352(15): 1493–1501.

Other Works Consulted

• Adams HP, et al. (2005). Guidelines for the early management of patients with ischemic stroke. 2005 guideline update: A scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke, 36: 916–921.

• American Heart Association/American College of Cardiology (2006). AHA/ACC Guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation, 113(19): 2363–2372.

• Coull BM, et al. (2002). Anticoagulants and antiplatelet agents in acute ischemic stroke. Report of the Joint Stroke Guideline Development Committee of the American Academy of Neurology and the American Stroke Association (a division of the American Heart Association). Stroke, 33(7): 1934–1942.

• Hacke W, et al. (2004). Association of outcome with early stroke treatment: Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet, 363(9411): 768–774.

• Latchaw RE, et al. (2003). Guidelines and recommendations for perfusion imaging in cerebral ischemia. Stroke, 34(4): 1084–1104.

• Sacco RL, et al. (2006). Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack. Stroke, 37: 577–617.

• Straus SE, et al. (2002). New evidence for stroke prevention: Scientific review. JAMA, 288(11): 1388–1395.

• Thorogood M, et al. (2004). Changing behaviour, search date 2003. Online version of Clinical Evidence (12): 85–114.

Author:	Lila Havens Merrill Hayden	Last Updated March 7, 2006
Medical Review:	Caroline S. Rhoads, MD - Internal Medicine Kathleen Romito, MD - Family Medicine John W Cole, MD, MS - Neurology, Stroke and Epidemiology
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