Brain Attack

SEE ALSO

Carotid endarterectomy

Prevention of Stroke -Carotid Artery disease and treatment. 

• Stroke is the 3 rd commonest cause of death after coronary artery disease and cancer
• Annually 2 out of every 1000 people will suffer a stroke.
• Three quarters of all strokes affect people over 60 years of age.

Stroke is an acute loss of focal cerebral (brain) function for a period exceeding 24 hrs.

When the symptoms of Stroke resolve in less than 24 hrs it is called a TIA (transient ischemic attack).

20% of strokes are due to a bleed into the brain and 80% are due to shut off of blood supply to part of the brain.

Blood supply to part of the brain is cut off when the artery (blood vessel) carrying blood to that part is suddenly blocked. This happens when clot or clot-like material blocks the artery. This mechanism is very similar to what happens in the heart when a coronary artery is shut off, thus causing a heart attack. A Stroke is thus nothing but a BRAIN ATTACK!!

As in a heart attack where a clot busting medicine is given, to prevent progression of a heart attack and coronary bypass surgery is done to prevent further heart attacks; clot busting drugs can be given to prevent worsening of stroke and surgery (carotid endarterectomy), can be done to prevent further strokes.

Blockage of the blood supply to part of the brain causes damage to that part of the brain leading to a Stroke.

What are the risk factors for stroke?

The r isk factors for stroke are the same as for other cardio-vascular diseases like heart attacks.

• Smoking
• High blood pressure
• High cholesterol
• Obesity and sedentary lifestyle
• Diabetes Mellitus
• Advancing age
• Male sex
• Strong family history of cardio-vascular disease

Are all factors that increase the risk of stroke.

What are the symptoms of Stroke?

The first signs that someone has had a stroke are very sudden . Symptoms include:

• numbness, weakness or paralysis on one side of the body (signs of this may be a drooping arm, leg or lower eyelid, or a dribbling mouth)
• slurred speech or difficulty finding words or understanding speech
• sudden blurred vision or loss of sight
• confusion or unsteadiness
• a severe headache .

How do I confirm that it is a stroke or TIA?

Use the FAST test

F acial weakness: Can the person smile? Has their mouth or an eye drooped?
A rm weakness: Can the person raise both arms?
S peech problems: Can the person speak clearly and understand what you say?
T ime to call the ambulance and get to the hospital immediately.

What tests should be done at the hospital?

• Clinical examination to confirm stroke or TIA
• Blood tests
• ECG
• CT scan of the brain (to diffrenciate between a bleed and infarct)
• Duplex ultrasound scan of the carotid arteries
• Sometimes an echocardiogram may be necessary
• On ocassions an MR angiogram of the carotid arteries may be needed
• ABCD2 scoring

What is ABCD2 scoring?

The ABCD2 scoring is used to determine who is at higher risk of having a further stroke in the future.

Up to 20% of patients who have suffered a minor stroke or a TIA are at risk of having a further stroke within the first week of the primary event. Thus urgent action is necessary to prevevt this catostrophe.

Of this patient group some are at high risk of having a further stroke within 48 hrs. The ABCD2 scoring sysem help to pick out the group that need emergency stroke prevention treatment.

The ABCD2 Scoring system

Maximum score on ABCD2 is : 7

Score 0 to 3: Risk of stroke within 48 hrs is low - 1%

Score 4 to 5: Risk of stroke in 48 hrs is moderate - 4.1%

Score 6 to 7: Risk of stroke in 48 hrs is high - 8.1%

It is recommended that anybody who scores 4 and above should have immediate imaging tests and stroke prevention therapy ( carotid endarterectomy, correction of heart rytym ect.) within 48 hrs.

Remmember TIME IS BRAIN!

What is the role of clot busting medication (Thrombolysis)?

There is a role for this in selected patients. The medicine is given either into a vein in the form of a drip or given directly into the clot via a special catheter placed there under x-ray guidance. The patient must have this treatment within 4 to 6 hours of the stroke A CT scan in needed prior to your doctor recommending thrombolysis Patients who are suitable are chosen on the basis of the findings on the CT /MRI scan of the brain When successful this can help reduce and sometimes completely resolves the signs and symptoms of stroke. As this is a clot dissolving medicine, thre is a risk of bleeding from other sites. Once this has been successfully perfomed stroke prevention therapy must be instituted.

What medications are usually prescribed to prevent stroke?

Your doctor will usually prescribe the following medications.

• Anti platelet drug; either Aspirin or Clopidogrel
• Cholesterol lowering drug; usually a Statin
• Blood pressure medication if necessary
• Blood thining medication like warfarin may be needed for certain patients
• Medication to help quit smoking.

Are there any therapeutic measures to remove the carotid artery blockage and thus prevent stroke?

The therapeutic measures to prevent stroke in patients with significant carotid artery stenosis are

• Best medical therapy
• Catotid endarterectomy
• Carotid angioplasty and stenting

Best medical therapy is essential in reducing the risk of future cardiovascular events. Best medical therapy includes control of diabetes and hypertension, cessation of smoking, weight loss and anti-platelet and statin therapy.

In spite of best medical therapy there is still a risk of future stroke in patients whose carotid artery symptoms have produced symptoms. The risk depends on the degree of stenosis.

Thus a patient with a 90% carotid artery stenosis has a 35% risk of having a stroke in 3 years with the biggest risk being in the first week after the first event