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- Herausgeber: John Wiley & Sons
- Kategorie: Ratgeber
- Sprache: Englisch
- Veröffentlichungsjahr: 2011
Features tons of advice for recovery and rehabilitation Get the latest on the symptoms, diagnosis, and treatment of stroke Have questions and concerns about strokes? This reassuring guide provides invaluable information for stroke victims and their loved ones, from what a stroke is and what it feels like to proven treatments and therapies. You'll see how to implement a plan for preventing stroke, treat the lingering effects of stroke, and maximize home caregiver effectiveness while minimizing fatigue. Discover how to: * Understand what causes different types of stroke * Recognize warning signs * Get the most out of doctors and hospitals * Speed recovery with the best treatments * Help prevent future strokes * Decide the best living arrangements after stroke
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Stroke For Dummies
by John R. Marler, MD
Stroke For Dummies®
Published byWiley Publishing, Inc.111 River St.Hoboken, NJ 07030-5774www.wiley.com
Copyright © 2005 by Wiley Publishing, Inc., Indianapolis, Indiana
Published by Wiley Publishing, Inc., Indianapolis, Indiana
Published simultaneously in Canada
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LIMIT OF LIABILITY/DISCLAIMER OF WARRANTY: The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. the views expressed in this work are the author’s and do not necessarily represent the views of the national institutes of health or the united states government. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.
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Library of Congress Control Number: 2005923213
ISBN-13: 978-0-7645-7201-2
ISBN-10: 0-7645-7201-6
Manufactured in the United States of America
10 9 8 7 6 5 4 3
1B/SS/QY/QV/IN
About the Author
John R. Marler, MD (Bethesda, Maryland), a board-certified neurologist and stroke researcher, is Associate Director for Clinical Trials at the National Institute of Neurological Disorders and Stroke. He is a fellow of the American Stroke Association and recipient of the association’s Feinberg Award for Excellence in Clinical Research. He has been administering clinical research in stroke since 1984. He completed his neurology residency training at Mayo Clinic in Rochester, Minnesota and graduated from West Virginia University Medical School in Morgantown, West Virginia.
Dedication
This book is dedicated to participants in clinical research who are leading the way toward new opportunities to treat stroke.
Author’s Acknowledgments
This book could not have been produced without the help of Corbin Collins, editor, and Betsy Sheldon, writer, who took me step by step from rough draft to finished product. I thank them for their insights and suggestions. Likewise, Kathryn Born’s illustrations are remarkable for their clarity and precision. I couldn’t respect any stroke clinician any more than I do the technical editor, J. Donald Easton, MD. His comments have added greatly to this book. I want to thank Sandra Sewell, RN, at Suburban Hospital in Bethesda, Maryland, who helped me understand many of the difficulties faced by stroke patients and their families after hospitalization. Mary Dombovy, MD, MHSA, Unity Health System in Rochester, New York, took the time to talk with me about the basic approach to stroke recovery and rehabilitation. Jeffrey Saver, MD, at the UCLA Stroke Center, along with his colleagues David S. Liebeskind, MD and Reza Jahan, MD, provided the CT and MR images for the figures in the book. And last but far from least, there is Kathy Cox at Wiley whose dare got me to start this project in the first place and whose patience and encouragement motivated me to finish. Thank you all.
Publisher’s Acknowledgments
We’re proud of this book; please send us your comments through our Dummies online registration form located at www.dummies.com/register/.
Some of the people who helped bring this book to market include the following:
Acquisitions, Editorial, and Media Development
Editor: Corbin Collins
Acquisitions Editor: Kathy Cox
Technical Editor: J. Donald Easton, MD
Editorial Manager: Michelle Hacker
Editorial Supervisor and Reprint Editor: Carmen Krikorian
Editorial Assistants: Hanna Scott, Melissa Bennett
Cover Photos: Barros & Barros/Getty Images/ The Image Bank
Cartoons: Rich Tennant (www.the5thwave.com)
Composition Services
Project Coordinator: Maridee Ennis
Layout and Graphics: Carl Byers, Andrea Dahl, Kelly Emkow, Lauren Goddard, Joyce Haughey, Stephanie D. Jumper
Special Art: Kathryn Born
Proofreaders: Leeann Harney, Joe Niesen, Carl William Pierce, Aptara
Indexer: Aptara
Special Help: Betsy Sheldon, Patricia Harrington
Composition Services
Project Coordinator: Maridee Ennis
Layout and Graphics: Carl Byers, Andrea Dahl, Kelly Emkow, Lauren Goddard, Joyce Haughey, Stephanie D. Jumper
Special Art: Kathryn Born
Proofreaders: Leeann Harney, Joe Niesen, Carl William Pierce, Aptara
Indexer: Aptara
Special Help: Betsy Sheldon, Patricia Harrington
Publishing and Editorial for Consumer Dummies
Diane Graves Steele, Vice President and Publisher, Consumer Dummies
Joyce Pepple, Acquisitions Director, Consumer Dummies
Kristin A. Cocks, Product Development Director, Consumer Dummies
Michael Spring, Vice President and Publisher, Travel
Kelly Regan, Editorial Director, Travel
Publishing for Technology Dummies
Andy Cummings, Vice President and Publisher, Dummies Technology/General User
Composition Services
Gerry Fahey, Vice President of Production Services
Debbie Stailey, Director of Composition Services
Contents
Title
Introduction
About This Book
Conventions Used in This Book
What You’re Not to Read
Foolish Assumptions
How This Book Is Organized
Icons Used in This Book
Where to Go from Here
Part I : The Brain and Stroke
Chapter 1: A Brain Attack
Attacking Out of the Blue
Recognizing Types of Stroke: Same Symptoms, Different Causes
Assessing Stroke Risk
Treating Stroke: Fast Response Is Everything
Recovering from Stroke
Living with Stroke: Reasons for Optimism
Chapter 2: Understanding How the Brain Works
An Illustrated Tour of Your Brain
The Brain’s Roadmaps
Fueling the Brain’s Energy Highways
Consequences of Gridlock on the Vascular Interstate
Medical Technologies for Peering into the Brain
Part II : Types of Stroke
Chapter 3: White Stroke (Ischemic): Blood Clots Block the Brain
Getting a Handle on the Jargon
How Blood Clots Cause Stroke
White Stroke Risk Factors
Other Causes of White Stroke
How White Stroke Injures the Brain
Different Sizes of White Strokes
Diagnosing White Stroke
Treating White Strokes
Chapter 4: Transient Stroke (TIA): Warning Sign
Defining Transient Stroke
How a Transient Stroke Occurs
How to Recognize a Transient Stroke
Responding to a Transient Stroke
Preventing the “Big One”
Answering the Wake-Up Call
Chapter 5: Red Stroke (ICH): Bleeding Inside the Brain
Why the Brain Bleeds
How the Brain Reacts to Blood
Treating Brain Hemorrhage in the Hospital
Preventing More Red Strokes
Chapter 6: Red Stroke (SAH): Bleeding Outside the Brain
How SAH Strokes Happen
After an SAH Stroke
Treating SAH Strokes
Predicting SAH Stroke: It’s a Family Affair
Chapter 7: Dementia (Vascular Cognitive Impairment)
Is There a Bright Side to Stroke Dementia?
Small Strokes and Dementia
Recognizing Stroke Dementia
Diagnosing Stroke-Related Dementia
Preventing Stroke Dementia
Planning for When You Can’t Remember
Part III : Preventing Stroke
Chapter 8: High Blood Pressure
Stalking the Silent Killer
Who’s at Risk for High Blood Pressure
Lowering Blood Pressure to Reduce Stroke
Drugs for Lowering Blood Pressure
Chapter 9: Fat and Stroke Risk
Fat and the Body
Getting to Know the Two Types of Fat: Cholesterol and Triglycerides
Fat Transporters: HDL, LDL, and Others
Testing for Fat Trouble in Your Body
Diet and Cholesterol Control
Keeping Fats in Check with Statin Drugs
Chapter 10: Other Risk Factors and Prevention
Reviewing the Major Risks
Tobacco and Stroke
Heart and Vascular Disease
Controlling Diabetes
Fighting Obesity with Diet and Exercise
Making a Plan for Reducing Stroke Risk
Part IV : Treating Stroke
Chapter 11: Get Thee to an Emergency Room
Recognizing Stroke: Sudden Loss of Brain Power
Getting to the Hospital: The EMT Scoop and Run
Deciding on a Hospital
Advocating for the Stroke Patient in the ER
Understanding ER Stroke Strategy
Treating White Strokes
Treating Red Strokes
Chapter 12: Treating Stroke in the Hospital
Preventing Further Strokes
Monitoring for Brain Swelling
Responding to Seizures
Other Problems in the Hospital
Preparing for Life After Stroke
Chapter 13: Rehabilitation
Who Should Go to Rehab
The Rehab Strategy
Meet the Rehab Faculty
Paying for Rehabilitation
Graduating: Life After Stroke
Part V : Living with Stroke
Chapter 14: Returning Home: Adapting to a New Life
Avoid the Three-Stroke Rule
Recovering Slowly but Surely
Rewiring the Brain
New Disabilities Will Affect How You Live
Ongoing Medical Therapy
Seeing Your Physician
Continuing Rehabilitation Therapy at Home
Returning to Work
Get Organized and Motivated
Chapter 15: When You Can’t Go Home Again
Coming to Grips with Your Situation
Getting Your Game Plan Together
Defining Your Care Needs
Determining Your Resources
Considering Nursing-Home Care
Evaluating Assisted-Living Facilities
Life in a New “Home”
Chapter 16: Challenges During Recovery
Muscle Spasticity
Depression and Other Psychological Changes
Adapting to Driving Limitations
Dealing with Incontinence
Swallowing Difficulties
Chapter 17: Taking Care of Family
Stroke Affects Every Type of Family
Admitting When the Family Needs Help
Taking Care of the Caretaker
Pull Together, Not Apart
Financial Realities
You Can’t Take It with You: Wills and Wishes
Part VI : The Part of Tens
Chapter 18: Ten Ways to Help Your Community Manage Stroke
Join a Group for a More Powerful Voice
Share Knowledge with Friends and Family
Work with Local Hospitals
Check into Emergency Medical Services
Educate Schoolchildren About Stroke
Start Your Own Stroke Recovery Group
Suggest News Stories About Stroke Champions
Get Your Community to Participate in Stroke Research
Volunteer for Stroke Research
Make Sense of Health Policy
Chapter 19: Five Remarkable Stroke Recoveries
President Woodrow Wilson Overcomes Stroke and Leads a Country
Miss America Jacqueline Mayer Discovers a Different Kind of Beauty
Composer George Frideric Handel Writes “Messiah” After Stroke
Writer Ken Kesey Found TPA the Drug of Choice After Stroke
Actress Patricia Neal Recovers to Earn an Oscar Nomination
Your Remarkable Stroke Recovery
Chapter 20: Ten Opportunities to Prevent Stroke
Gathering Information
Treating High Blood Pressure
Preventing Blood Clot Formation
Reducing Cholesterol in Your Blood
Treating Atrial Fibrillation
Checking Out Your Carotid Arteries
Eating Right and Staying Hydrated
Stopping Smoking
Exercising Your Muscles and Your Brain
Writing Up a Maintenance Plan
Glossary
Introduction
W elcome to Stroke For Dummies.
In a nutshell: Stroke is the often severely damaging result of a sudden interruption of blood to part of the brain, whether due to a blockage or bleeding. Stroke’s impact on the brain can be catastrophic, causing paralysis, loss of speech, loss of memory, and, of course, death in as many as 30 percent of those who experience stroke.
Stroke is serious stuff. If you have one, you want to get to the emergency room as fast as possible and begin treatment. If you survive one, you want to recover as fully as possible and do everything in your power to never have one again. Helping you achieve these things is what this book is about.
About This Book
This book is full of useful information to help you understand the who-what-where-when-why-and-how of stroke. Information is critical in helping you get the most out of stroke treatment, recovery, and adjustment to life after stroke. And, most importantly, information is essential in helping you prevent future stroke. But it’s worthless if it’s so technical you can’t understand it. That’s why I wrote this book.
Stroke For Dummies explains stroke in a simple, straightforward manner, guiding you through a complex field of knowledge with a minimum of technical vocabulary and a maximum of fundamental facts needed to understand this medical condition and take action. The difficult issues are presented unflinchingly — I don’t soft-pedal the cold, hard facts. Stroke is scary. The better you understand that, the more fervently you’ll pursue a focused and effective course of prevention.
Stroke For Dummies offers well-tested, clinically proven courses of action for treatment and prevention of stroke. I spend my life trying to find out which treatments for stroke and other brain diseases really work. You can count on the fact that every treatment mentioned in this book is proven, unless I state otherwise.
Still, every treatment plan poses risks, and doctors don’t agree on everything. Your doctor may not agree that certain treatments described in this book will work for you. This is to be expected and doesn’t mean that either one of us is wrong. The point here is to gather as much good information as possible to help you make the best choices for you.
Stroke For Dummies is not a do-it-yourself book — I do not recommend any specific treatment plan but, instead, offer general information for you to discuss with your physician. Each individual is unique and must develop a customized approach to stroke in partnership with an experienced doctor. This book gives you the basic knowledge you need to be an effective partner in that relationship.
Conventions Used in This Book
The following conventions are used throughout the text to make things consistent and easy to understand:
New terms appear in italics and are closely followed by an easy-to- understand definition.
Bold is used to highlight the action parts of numbered steps or keywords in bulleted lists.
Sidebars, which are enclosed in a shaded gray box, include information that may intrigue you but isn’t critical to your understanding of stroke.
Case studies, set off like sidebars but with a “Case Study” icon, present summarized accounts of fairly typical stroke victims.
What You’re Not to Read
You can safely skip the case studies in this book and still understand the topic at hand. The case studies are merely meant to illustrate and dramatize some aspect of stroke or stroke prevention or care. Some may find them helpful, but they are not essential to understanding the basics of stroke as discussed here.
Likewise, if you came to this book to understand a particular type of stroke that you or a loved one has had, don’t waste time boning up on the other kinds of stroke described in Part II. Many aspects of stroke and its accompanying events and treatments are time sensitive. This book is designed to make it as easy as possible to get in and get out with as much specific and easy-to-digest information as you need depending on your particular circumstances.
Finally, the “Jargon Alert” icon may warn you of impending Latin tongue-twisters, but in many cases you will have to grit your teeth and read the material in the indicated paragraphs in order to get a full understanding of the discussion. Due to the nature of the topic of stroke, some technical terms are unavoidable, and if stroke has touched your life or that of a loved one, you will be glad to have absorbed a few of these when it comes time to discuss the stroke and possible treatments.
Foolish Assumptions
It’s unlikely that someone would pick up a book like this at random. Here is what I assume about you — that you fall into one of three categories:
You’ve recently suffered a stroke and are now on the road to recovery. Perhaps you’re re-learning to walk. Or talk. Or button your shirt. You seek an easy-to-understand resource that can shed light on your new circumstances.
You are a spouse or family member of a stroke survivor who wants to learn as much as possible so you can be a better caregiver.
You returned recently from a visit to your doctor and learned that your high blood pressure, high LDL blood cholesterol, and extra weight put you on a path toward something called stroke and you want to learn more about it.
Or maybe you picked up this book by mistake because you thought it had something to do with golf. In that case, I can’t help you.
In any event, now that I have your attention, I hope to persuade you to continue reading. Stroke is the number three cause of death in the United States. This book could very well save your life — or the life of a loved one. At the very least, Stroke For Dummies can enlighten you about the recovery and treatment process and help you avoid future strokes.
How This Book Is Organized
Stroke For Dummies is organized into six parts. The chapters within each part cover specific topic areas in detail. Because I’ve structured the book this way, you can easily find the topic you’re looking for. Check out the Table of Contents or the Index for your general area of interest and then find the chapter that concerns your particular needs.
Part I: The Brain and Stroke
I begin with some rudimentary background on stroke and how and why it happens. The basic principles of stroke are quite simple, but often get obscured by the terminology used by doctors to describe it. I’ve tried to simplify the explanations so that you can understand what you are told by or what you may overhear from your medical team. I begin in Chapter 1 by describing exactly what happens when you have a stroke. In Chapter 2, I offer a basic biology lesson in the workings of your brain and what happens when things go wrong.
Part II: Types of Stroke
For simplicity, I break stroke down into five types, stemming from two major causes. The most common cause of stroke is a blood clot blocking an artery to or inside the brain — I call these white strokes because they involve a lack of blood. The other cause is bleeding inside the skull, either inside or outside of the brain — I call these red strokes.
Chapters 3, 4, and 7 cover different types of white strokes, and Chapters 5 and 6 deal with the two kinds of red strokes. It’s important to know which type of stroke one is dealing with, because treatment is different for each. For each type, I present the causes, what actually occurs during it, symptoms, risks, how to treat — and how to prevent.
Bear in mind that my “red” and “white” distinction is my own invention. I believe it helps to visualize what is happening in the brain. Of course, I also give you all types of technical terms for each type of stroke and explain them as clearly as I can.
Part III: Preventing Stroke
Three chapters are devoted to ways of reducing risk of stroke in the future — whether you’ve already suffered a stroke or want to maintain your stroke-free record.
Chapter 8 in this part deals with blood pressure, the major risk factor for stroke. I explain how high blood pressure beats down the blood vessels, leading the way for damage and blood clots. Even more importantly, I give you steps you can take to lower your blood pressure.
Chapter 9 addresses another key risk factor for both stroke and heart disease: cholesterol. I discuss the differences between bad cholesterol and good cholesterol — and how you can change your diet and take action to control your blood cholesterol levels and reduce stroke risk.
Finally, Chapter 10 rounds up other prevention steps that you can take to reduce your chances of having a stroke — or another stroke.
Part IV: Treating Stroke
This part focuses on the critical steps required for treating stroke. Chapter 11 is perhaps the most essential — responding fast when stroke occurs. Call 911: Stroke is an emergency! The faster you get to the hospital, the more brain you can save. I walk you through the emergency response process, including which actions and procedures are likely to be done. I also offer important advice to the stroke victim and family members — that will help ensure the best care. Chapter 12 deals with the hospital stay and what to expect in terms of care and follow-up testing. And Chapter 13 addresses the rehabilitation process, giving you a sense of what to expect as you make your way along the path toward recovery.
Part V: Living with Stroke
Life after stroke can be daunting for the stroke survivor and family members. It’s a culture shock of sorts that involves learning a “language” of adjustment to new limitations and challenges. You will likely have to make changes to familiar routines and, perhaps, compromises to future plans.
Chapters 14 through 17 help you face the changes brought on by stroke, including returning home from the hospital, considering residential placement, confronting the cost implications, wrestling with family dynamics, returning to normal life, and confronting end-of-life issues.
You’ll pick up on a recurring theme in this section: the importance of asking for help — whether you are the stroke survivor who must give up driving or a caregiver spouse who needs a support group. Asking for help is often difficult, but failing to do so causes a lot of unnecessary pain and impedes recovery.
Part VI: The Part of Tens
In these short and sweet chapters, I offer helpful information that I hope will enhance your understanding of the consequences of stroke and motivate you to do your part to take care of yourself — and others.
Chapter 18 offers ideas for helping your community manage stroke. I especially like Chapter 19, about the notable personalities who’ve contributed to the world — despite their history of stroke. From presidents to beauty queens, from authors to actors, stroke survivors have proven that productive life isn’t over with the onset of stroke. Chapter 20 lists concrete steps you can take to improve your personal stroke care and prevent stroke. The last chapter is a glossary of terms — anytime you feel confused or unsure about a technical term, check the glossary for a quick definition.
Icons Used in This Book
Icons are handy little graphic images meant to point out particularly important information about stroke. You’ll find the following icons in this book, conveniently located along the left margins.
This icon points out stroke stories that illustrate a point and help you recognize stroke issues in yourself and others. They are technically fictional and don’t identify any single patient, but they are based on typical stroke events. They are similar to stories doctors hear over and over as they see the hundreds of stroke patients that come to their hospitals every year.
This icon alerts you to a paragraph that contains new medical terms in case you’re severely allergic to them. The terms will be defined, so don’t get too stressed out about it.
Remember these important points of information, if nothing else. In fact, if you’ve had a stroke, or even if you haven’t, it’s probably a good idea to write them down to put them on the refrigerator or bathroom mirror.
This icon directs you to helpful hints or practical advice for taking care of or preventing stroke.
Everything you do to treat, prevent, or recover from stroke may have side effects or complications. Stroke is a very serious disease and surgery and powerful drugs are warranted in many situations. You need to be aware that there can be problems.
Where to Go from Here
Where you go from here depends on why you are reading the book. You can read it cover to cover or look up specific topics of interest in the Table of Contents or Index.
Part I is written for everyone — stroke victims, family members, and any individual committed to protecting good health. It offers a basic understanding of stroke.
In Part II, you may only want to read about the particular type of stroke that is of most immediate concern or interest to you.
Part III is for the whole world. Preventing stroke isn’t that hard, especially considering the payoff. And preventing another stroke may be absolutely paramount.
If you or a loved one is in the hospital or rehabilitation unit, Part IV is for you.
Part V is for patients, caretakers, and family members struggling with the realities of life after stroke.
Part VI also has something for everyone — particularly the Glossary, which you may find yourself flipping to repeatedly.
If you are a stroke survivor, it is my hope that you will be inspired to maximize your rehabilitation efforts and make the most of your life after stroke. If you are a caregiver, I hope you will increase your understanding of stroke and do what you can to partner in your loved one’s adjustment. If you are an individual concerned with preventing stroke, I hope you will make lifestyle changes to reduce your chances of stroke.
And for all readers, I hope that, armed with knowledge bound in this book, you will move forward with a greater appreciation for your brain — its power and its delicacy — and do everything within your capacity to protect it.
Part I
The Brain and Stroke
In this part . . .
W hat is stroke, what does it do to the brain — and how and why does it do this? These are a few of the questions I tackle in this part. I begin in Chapter 1 by describing the process and mechanisms of the different kinds of stroke. Chapter 2 covers the basics of how the brain does what it does and how stroke disrupts its natural workings.
Chapter 1
A Brain Attack
In This Chapter
Taking a sudden hit from stroke
Targeting the different types of stroke and their causes
Profiling the likeliest stroke victims
Responding to stroke for the best outcome
Coping and adjusting to life after stroke
L et me hit you with the bad news first: Stroke kills, stroke destroys, stroke debilitates. Stroke is the third most common cause of death in the United States, and the number-one cause of serious disability. One year after the most common kind of stroke, approximately 30 percent of those afflicted will have died, and another 30 percent will have a moderate to severe disability.
Now for some good news: Of those who experience the most common type of stroke, approximately 40 percent are left with only a mild or no disability one year later. And each year more people survive and recover from stroke as medical research continues to advance effective treatment. Today, recovery with improvement is the rule rather than the exception.
Stroke is sometimes called a brain attack. I wish this label would catch on, because I think that people might then understand that stroke is an emergency — like a heart attack — and call 911 right away! A heart attack threatens your heart; a stroke threatens your brain. In truth, most stroke is like a heart attack: It’s a problem with blood vessels, and time is really important. However, heart attack is a little easier to recognize. First of all, the pain tells you something is wrong — and it is usually near your heart. Most strokes are painless, and the symptoms, a paralyzed arm or leg for instance, are not obviously related to the brain.
Clearly, the more you know about stroke — its symptoms, causes, risks, treatment, and prevention — the better your chances of living a full and productive life with or, better yet, without stroke. And the first lesson is to learn what stroke is and how and why stroke occurs.
If you’ve already had a stroke, there are many opportunities to reduce the disability that stroke causes and prevent another stroke attack. A serious stroke will affect your entire family. You can fight back together.
Real-life examples
A 57-year-old man arrives early at work to prepare for an important presentation he has to make at 10 a.m. At about 9:15 he notices a headache. He thinks this is unusual, because he doesn’t have many headaches. He remembers that he did forget his blood pressure medication. He continues to work for a few minutes and then notices his right hand is not working and he can’t concentrate. He calls for his assistant who finds him looking very unusual. His mouth is twisted. He starts to talk but his speech is difficult to understand. She asks if he is okay. He says no. He starts to get up but his right arm gives way and he almost falls. His assistant calls 911.
A 68-year-old woman is preparing breakfast for herself and her husband. He has made the coffee and is reading the newspaper. He hears her drop a plate and looks up to see her standing and looking at her left hand. He asks her what’s wrong. She says she doesn’t know. Her face — particularly the way she is holding her mouth — looks unusual. She keeps looking at her hand. “My hand is numb,” she says. He asks her to sit down. She seems confused as he leads her to a chair. He asks if it hurts. She says no. “I think you’re having a stroke,” he says. He dials 911.
A 38-year-old lawyer is out jogging on a canal towpath. She starts to feel pain in her head that gets worse and worse. She stops, puts her hand to her head, and falls to the ground. A man walking ahead of her sees her fall. He runs to her but she is unconscious. He pulls out his cellphone and dials 911.
Attacking Out of the Blue
Stroke is nothing if not fast. Each year, as many as 750,000 people in the United States suffer a sudden and unexpected attack of the brain. When part of the brain is deprived of oxygen — which is what is happening when stroke hits — it doesn’t take long for the catastrophe to make itself evident. A minute or less.
Whether it’s a sudden inability to speak, the crash of a dish from a hand that can no longer grasp, or loss of consciousness, a brain attack strikes its victims quickly and powerfully and without warning.
Or does it? Although your stroke may occur in a lightning flash, it has most likely been years in the making, with conditions such as high blood pressure, high cholesterol, obesity, and diabetes possibly serving as warning signs that the brain is in danger. Basically, as these conditions cause wear and tear on your blood vessels, your risks increase of suffering either a blockage or rupture of a brain artery. And — suddenly — you’re in stroke mode.
So how does it happen? It starts with the brain.
Going to the source: Stroke is in the brain
Because of a number of possible causes — which I explain in detail in this book — part of your brain may be deprived of blood. When that happens, it doesn’t take long for your brain to suffer. In a nutshell, the glucose and oxygen transported by one of the brain’s arteries are not reaching some part of the brain, which in less than a minute will begin to shut down. And you will show signs of stroke.
The 50 professional groups forming the Brain Attack Coalition describe the signs of stroke as follows:
Sudden numbness or weakness of face, arm, or leg, especially on one side of the body
Sudden confusion, trouble speaking or understanding speech
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden severe headache with no known cause
Most of the time, a stroke victim feels no pain as the stroke is occurring — so there is not much evidence to clue you in that the reason your hand looks funny and doesn’t move when you want is because there’s something wrong in your head.
Most people who have a stroke don’t know what is happening to them. Most people who see someone who’s had a stroke don’t know what is happening.
A stroke doesn’t hurt (except if a headache accompanies it), and its most obvious effects are far from the brain where the problem is located. This means a lot of people don’t recognize they are having a stroke and can’t use the opportunities they have to get into the hospital quickly and be treated.
Damage in your brain, symptoms someplace else
So, why is it that a blocked artery in your brain causes you to lose control of your legs and fall to the floor? Suppose a small blood clot forms in your heart and flows with the blood up into your brain and plugs an artery that feeds a part of your brain near the top of your head. Normally, that part of the brain sends nerve impulses down threadlike fibers through the base of your brain and along your spinal cord down to a point a couple of inches below your lowest rib. There those nerve fibers connect to other nerve fibers that extend down to muscles in your legs.
But without blood flow, the affected part of the brain stops sending messages. Your leg muscles only work when they receive messages, so they stop working. But the other parts of your brain that are getting oxygen and glucose don’t understand that the whole team’s not on board and look at the leg in confusion, trying to comprehend why it’s not cooperating, not realizing that the problem is right upstairs.
The brain is sensitive to the slightest touch of your skin, but completely insensitive to serious injury to itself. As remarkable as it may seem, the brain is very poor at recognizing when it has been injured. This makes it hard for you to figure out what is going on when you have a stroke.
Responding quickly: Time is brain
Your brain is completely unprepared when blood flow is cut off. The organ is so packed full of knowledge and memories that there is no room in the design for storing sugars and fats that could keep brain cells alive in hard times when blood stops flowing.
Most other cells in the body can survive for up to an hour without blood flow. The brain cells stop working in a matter of seconds and start dying after five minutes.
The brain counts on the heart to do its job. That’s why when you have a heart attack it is so important to get the heart restarted quickly. Within seconds after your heart stops, your brain stops working. Within minutes of the heart stopping, the brain is permanently injured and can’t recover even if the heart gets going again.
In stroke, you have a little more time than in a heart attack. Because the heart keeps pumping, some blood can often get around the obstruction or broken portion of the blood vessels, or seep in from areas of the brain that are still getting blood. But get yourself to a hospital right away. Call 911. If you are going to get the best treatment, you need to get to a hospital within 60 minutes.
Recognizing Types of Stroke: Same Symptoms, Different Causes
Doctors can typically identify stroke when a patient comes in with symptoms — they’re even pretty good at knowing what part of your brain may be damaged by the stroke just by looking at you. With some scenarios, such as a bursting aneurysm, a doctor can guess what caused the stroke. With other cases, it is almost impossible to tell what caused the stroke, although there is little doubt that a stroke is in progress.
Sometimes, with severe headache, for example, it’s hard to tell whether a stroke is happening at all because the symptoms are similar to those of a migraine headache. A stroke might cause dizziness that is difficult to distinguish from an inner-ear infection.
Fortunately, testing instruments such as CT or MRI scans can indicate if there is a stroke and what its cause might be.
Red or white: Color-coding stroke types
A friend of mine, a cardiologist, once told me that neurologists make stroke too complicated with their jargon and classification. He said he just thinks of stroke like wine: There’s red wine and white wine — and red stroke and white stroke.
What did he mean by this? Basically, some strokes are caused by broken blood vessels — which results in blood in the brain or brain area (thus, the red); other strokes are caused by the blockage of vessels to the brain, so no blood gets there (hence, white).
I liked his use of the color-coding and have found that when I talk to patients and their families, this explanation helps them better understand the cause of the stroke and what is happening in the brain. So throughout this book, you’ll see that I classify the five major types of stroke into two general categories based on whether they are caused by bleeding (red) or blockage (white).
Oh, don’t worry — I promise to give you the complex, hard-to-pronounce terminology, as well! Throughout the book, you will find the most commonly accepted medical terms for the types of stroke.
If you’re ready now to track it down in a medical textbook, you’ll find out more about red stroke under the term hemorrhagic stroke or intracerebral hemorrhage. White stroke is covered under the term ischemic stroke, embolic stroke, or thrombotic stroke.
A stroke by any other name
Stroke means that part of your brain has suddenly stopped working because of a problem with its blood supply. It may help to think of strokes caused by blockage as white strokes; they’re most typically referred to as ischemic strokes by doctors. But here are some other names for this type of stroke:
occlusive stroke
cerebrovascular accident (CVA)
acute ischemic stroke
atherothrombotic stroke
embolic stroke
small vessel stroke
lacunar stroke
large vessel stroke
cardioembolic stroke
Ischemic stroke and CVA are probably the most common terms used. Doctors usually know what all these terms mean and use them each in different situations to mean virtually the same thing. “Little white stroke” and “big white stroke” could probably replace all these fine technical terms just as well, and everyone would know exactly what they meant.
I refer to strokes caused by bleeding in or around the brain as red strokes. Names for these types of stroke are equally varied:
subarachnoid hemorrhage (SAH)
intracranial hemorrhage
intracerebral hemorrhage (ICH)
brain bleeding
brain hemorrhage
Understanding white stroke
As you age, your blood pressure, diet, and the ravages of time roughen the fragile lining of your blood vessels and heart.
Your blood-vessel lining is like the coating on your best cookware — it keeps your blood from sticking and clotting. However, as you approach senior status, that Teflon-like protection starts breaking down, and your vessels develop spots where blood and other buildup stick to them.
Blood clots block blood to the brain
The most common sign of blood-vessel damage is atherosclerosis, also known as hardening of the arteries, the condition in which a rough, scarred area called a plaque forms because of high blood pressure and high fat content in your blood. (There is more about atherosclerosis in the Glossary and in Chapter 9.) The roughness makes it more likely that blood inside your arteries will form clots that can block arteries in the brain or break up into smaller pieces that are carried downstream to lodge in small brain arteries. Sometimes blood clots can break off and flow downstream to form a blockage somewhere else, called an embolism (see Figure 1-1 for illustrations of atherosclerosis, blood clots, and embolism).
Figure 1-1: Plaque building up in the blood vessel causes a blood clot to form, which can block an artery and cause a stroke. Clots can also travel and block vessels down- stream.
If the clot blocks blood to a part of your brain, you have a stroke. If the clot stays in place for even a short time, part of your brain dies, leaving a hole called a brain infarction. The affected area of brain turns from pink to white because there is no red blood flowing (another good reason to refer to this type of stroke as white).
Dissection: Blood vessel lining splits
White ischemic strokes are also caused by dissection. No, this doesn’t mean somebody is practicing brain surgery on you. Dissection refers to the splitting of the blood vessel lining, typically occurring at a place where the blood vessel bends back and forth, such as in your neck. It can also happen where atherosclerotic plaque has built up in a brain artery. At the bend point or at the rough surface of atherosclerosis, a little flap of the vessel lining peels off and catches the blood as it flows quickly past. The blood dives under the flap and keeps tearing it. Eventually the blood can pack the lining against the other side of the vessel and stop blood flow completely. When the blood stops flowing, a white stroke occurs. Figure 1-2 shows how dissection causes stroke.
Figure 1-2: Blood flow can worsen a tear in the lining of a blood vessel and end up blocking it.
Transient strokes: Just as serious
White ischemic strokes may last just a couple of minutes and then clear completely. If the blood clot breaks up right away, the stroke is transient — so fleeting that no permanent tissue death occurred. These transient strokes are officially called transient ischemic attacks. Try to say that ten times fast. Doctors abbreviate it as TIA.
I don’t like the term TIA or what it stands for because it doesn’t tell you plainly that you had a stroke. A stroke is very serious even if it is transient, and you still need to consider it a medical emergency requiring a rapid response. After a TIA stroke, your next stroke may not be transient and you need to get busy to prevent it from happening. It could happen tomorrow.
You can have more than one transient ischemic stroke. As the number of these small strokes add up, your brain can just slow down generally, and you can suffer from dementia, as each small stroke erodes away more of your brain. Small white ischemic stroke dementia is often called vascular dementia or vascular cognitive impairment. This is the death of the brain by a thousand cuts.
Getting a handle on red stroke
Blood vessels can break and bleed into or around the brain, causing some of the most serious and deadly strokes. These type of strokes may result in similar symptoms to white stokes — although some are unique to red stroke — but in many cases, they should be treated differently.
Bleeding within the brain
A stroke caused by a blood vessel that breaks inside the substance of the brain is called intracerebral hemorrhage,brain hemorrhage, or brain bleeding. The brain goes from pink to red. Hence, the term red stroke. The vessels that bleed are often damaged extensively by high blood pressure or diabetes (Figure 1-3). The blood vessels have thick, fibrous, but weak walls. They form little blebs — bubble-like growths — from time to time. These brain vessels are very prone to break, especially when blood pressure is high.
Figure 1-3: When a weakened blood vessel bursts inside the brain, an intracerebral hemorrhage is the result.
Bleeding around the brain
Sometimes red — or hemorrhagic — strokes are caused by bleeding just outside the brain, but still inside the skull (Figure 1-4). This type of red stroke is known as subarachnoid hemorrhage. The most common cause in this case is a little peanut or marble-sized bubble or pouch that forms at a Y-junction in a brain-bound artery. This bubble is called an aneurysm. It has tough, thin, rubbery walls and may actually be present for years before it starts causing trouble. Some never do cause trouble. But aneurysms may get larger as time passes and, as they do, doctors believe they are more likely to burst.
The result can be devastating as high-pressure blood from larger brain arteries floods into the space around the brain. If you aren’t killed immediately, you have to survive weeks of recovery as your body tries to clean up the resulting mess. Further injury to your brain and rebleeding are likely, unless you get immediate medical attention.
Figure 1-4: When a vessel bleeds into the space surrounding the brain, the result is a stroke called a sub- arachnoid hemorrhage.
This type of red subarachnoid hemorrhage stroke is usually accompanied by severe headache. Many people also fall down unconscious when the stroke first hits. The pain and loss of consciousness are both strong warnings that something serious is happening.
When red and white stroke occur together
White ischemic strokes can turn red if a blood vessel is injured and breaks in the area where lack of blood flow caused a brain infarction. The bleeding can become a major intracranial hemorrhage or it may just be a small leak that doesn’t do much more damage than has already been done by the ischemia.
In a stroke that starts out as subarachnoid hemorrhage caused by an aneurysm, white ischemic strokes can occur 4 to 14 days after the aneurysm bursts. This is a time when the blood around the brain irritates the brain’s blood vessels and they clamp shut. Blood flow stops and ischemic stroke can result. This is of course bad news for someone who has just started to recover from the bleeding.
Five stroke scenarios
Blood clots and bleeding aren’t the only causes of stroke — but about 99 percent of strokes can be attributed to one of these reasons. In this book, I’ve identified the five most common stroke scenarios and dedicate a full chapter to each type:
White strokes
Ischemic stroke, caused by a blood clot (Chapter 3)
Transient ischemic stroke (TIA), also caused by a blood clot (Chapter 4)
Multiple small ischemic strokes causing dementia or vascular cognitive impairment (Chapter 7)
Red strokes
Intracerebral hemorrhage caused by bleeding in the brain (Chapter 5)
Subarachnoid hemorrhage caused by rupture of an aneurysm and bleeding around the outside of the brain (Chapter 6)
Assessing Stroke Risk
If you’ve suffered a stroke, let me assure you of one thing: You are not alone. In the United States, 750,000 people experience a stroke each year. Of these three-quarters of a million strokes, here’s how they break down in our red and white categories:
Eighty percent are white ischemic strokes, including TIA and dementia.
Fifteen percent are red intracerebral hemorrhages.
Five percent are red subarachnoid hemorrhages.
Survival rates by type of stroke vary greatly. Clearly, your chances of survival are much better with a white stroke than a red subarachnoid hemorrhage:
80–90 percent survival rate of ischemic stroke
60–70 percent survival rate of intracerebral hemorrhage
40–50 percent survival rate of subarachnoid hemorrhage
Taking steps to prevent stroke
Fact is, neither you nor I nor your doctor knows for certain whether a stroke is in your future. It’s not really possible to predict with any certainty exactly who will suffer a stroke. To some extent, having a stroke is a matter of bad luck.
But we do know that certain characteristics place you at a greater risk for stroke. We know that you are more prone to this particular form of bad luck if you have high blood pressure, smoke cigarettes, and/or have heart disease, diabetes, or high blood cholesterol levels. Researchers have identified a number of indicators that can help predict the likelihood of stroke. Some you can influence; others you can’t.
Risk factors beyond your control
Unfortunately, you may be carrying some genetic, hereditary, gender, or age baggage that you simply can’t change, such as:
You’ve already had a stroke.
You are 65 or older.
You are African American.
You are Hispanic.
Stroke runs in your family.
You are a man.
You have diabetes.
Risk factors you can control
So you can’t change your age (don’t we all wish we could?), your sex, your past, or your forebears’ genetic makeup. But I can offer you plenty of ways to make changes in your life that will significantly reduce your risk of stroke. In fact, I devote four chapters of this book (Chapters 8, 9, 10, and 20) to stroke-prevention topics.
Some of the steps you can take to improve your outlook for a stroke-free future include the following:
Treat high blood pressure with medication, if necessary.
Reduce sodium in your diet to help control high blood pressure.
Stop smoking.
Lower “bad” cholesterol and raise “good” cholesterol through medication and diet.
Maintain a healthy weight, which may reduce blood pressure and improve cholesterol levels.
For women, consider the use of oral contraceptives or estrogen replacement therapy with the advice of a physician.
Treating Stroke: Fast Response Is Everything
Damage occurs quickly with the onset of stroke. Whether a brain artery starts bleeding or is plugged by a blood clot, in just minutes the symptoms become apparent. And in the next hours most of the damage will be done and the course set for the future.
In those first minutes and hours, a quick response and prompt course of treatment are critical in terms of reducing the amount of permanent damage and increasing odds for an optimal recovery.
Bottom line? Get to the hospital! If you’re having the stroke, call 911. If you’re watching the symptoms of stroke overtake an individual, call 911.
Once at the emergency room, the first course of action will likely be a battery of tests to verify which sort of stroke you are having. ER docs will likely take your blood pressure, start an IV, draw blood, check your heart, and perform a CT scan or an MRI to see your brain and determine what’s going on. They’ll gather this evidence as quickly as possible so they can start the appropriate course of treatment.
Treatment response for white stroke
In ischemic stroke, the goal is to dissolve or remove the blood clot as quickly as possible before the affected brain has gone from ischemia to infarction, or brain cell death. This is most often done with a drug called tissue plasminogen activator — or TPA.
TPA is a valuable drug and effective treatment, but it poses some risks. For example, it can aggravate bleeding — so it’s critical to ensure that the stroke is a white stroke — and not red. Because of its risks, emergency-room physicians are cautious about using TPA. If they can’t verify that the stroke onset was less than three hours prior, they will not prescribe TPA. After three hours has passed, the damage to the brain is mostly done, and the risks of TPA outweigh any benefit.
Treatment response for red stroke
Red stroke poses greater challenges to the emergency-room team. Treatments to stop bleeding are still being developed, and, currently, little can be done. However, your physicians will be keenly focused on keeping you alive through the first few days after your stroke. They will take efforts to lower your blood pressure, reduce any brain swelling, and keep you breathing.
The bleeding may cause you to stop breathing, or may make your brain swell. If we’re talking subarachnoid hemorrhage — bleeding outside the brain — your doctors may consider surgery to patch an aneurysm or repair a ruptured vessel. I cover treatments for intracerebral and subarachnoid strokes in detail in Chapters 5 and 6.
Most people who find themselves in the middle of a stroke are unprepared — and being unprepared means losing precious time for treatment. The good news for you is this: Because you are reading this book, your eyes are now opened to the importance of fast response. Now’s the time to research whether your community is one of the growing number of stroke-prepared locations where the emergency medical system and hospitals are fully prepared to respond to stroke. Stake out the best emergency center for stroke and have your “evacuation” plan in place. It’s a minimal effort for maximum results.
Recovering from Stroke
If you’ve already had a stroke, improving your chances of recovery is as important as preventing the next one. And you can take many positive steps to increase your odds of a successful recovery.
Connecting with the best experts
You can prepare your own taxes and repair your car, but evidence is strong that placing your stroke care in the hands of a specialist will result in a healthier outcome than if you try to manage your recovery by yourself.
Stroke specialists from neurologists to physical therapists have a great deal to offer you, including the latest treatment opportunities when you first get to the hospital (quickly, we hope) and throughout your recovery. Some therapists are more experienced than others in taking care of stroke patients, however, and you want to seek out the best.
One of the best steps you can take is to find hospitals in your community that have special certifications as stroke centers. Check with your own doctor and with stroke patients in your community to find stroke specialists and experienced therapists.
Exercising your brain cells
You may have heard that your brain can’t regenerate new brain cells to replace those that are injured by a stroke. For any practical application to your stroke, this is probably true. However, scientists are learning that the brain can change significantly in response to injury. Stroke studies of animals have established that new connections do form, and some evidence supports that this happens in humans, as well.
We don’t know yet the extent to which exercise and physical and cognitive therapy can increase the extent of the restoration of function after a stroke. Exercising brain doesn’t seem to build new brain tissue the same way that exercising muscle does. However, exercising muscles and joints does keep them flexible and strong so that they are more responsive to small improvements in brain function. And it is well-established that if you don’t maintain your strength and flexibility after a stroke, you are less likely to regain as much useful function of an arm or leg.
Your full therapy program, developed and supervised by an expert, is likely to play an important role in your recovery. Adhering to the advice of your physical therapists and others on your recovery team will increase your results.
Asking for help
Stroke not only injures your brain and disables you, it also places stress on your family and your financial security. Often these stresses are more than a married couple or a family can cope with. Recovery can be more complete if you decide to take advantage of a wide array of community, employer, and government programs that suit your needs.
You can learn a lot about the different ways to organize and pay for all the care available after a stroke. It often takes two or more people to keep track of all the different medical, social, and financial interactions that are imposed on you by your stroke disability.
Several million people in the United States are living with the consequences of stroke. Getting to know some of them can help you recover from your own stroke — and perhaps provide emotional support as an added bonus. Com- munity organizations, hospital social workers, and perhaps your own doctor may be able to put you in touch with support groups and helpful resources.
Letting “use it or lose it” be your guiding principal
The basic principle of stroke recovery is use it or lose it. Use your muscles or they won’t be there for you — even if your brain is able to rewire or relearn old skills. Keep your joints flexible, or you won’t be able to bend them when you do recover some strength. Use the opportunities to prevent another stroke, or the next one you have may destroy all the gains of your recovery from your first stroke. Use your community resources and the help of friends when you need it. They often don’t offer more than once, if at all.
Living with Stroke: Reasons for Optimism
No doubt about it, stroke is a devastating event, a medical calamity that can leave its victims severely disabled — or worse.
But study after study has shown that patients recovering from stroke do indeed improve with time. They are better at three months than they were when they left the hospital — and further along at a year than they were at three months. Function returns, depression fades, and the skills to live independently are gradually regained by a significant proportion of patients. And as stroke survivors become more knowledgeable about stroke and how to prevent it, they follow treatment plans that can dramatically reduce the chances of a second stroke.
Just as there are a lot of people who have strokes, there are a lot of people who survive their stroke and learn to live with a disability. Life can return to normal after a very mild stroke, but even with residual disability, you can still have a meaningful life.
Stroke comes as an unexpected bolt from the blue and can dramatically change your life. There are many opportunities to take actions that will reduce the bad effects of stroke on your independence and quality of life. Arming yourself with as much information as possible will take you far in your recovery and improve your ability to cope with life after stroke.
Chapter 2
Understanding How the Brain Works
In This Chapter
Touring the brain
Reading the brain’s roadmap
Driving the brain: Blood vessels as energy highways
Picturing the brain: From X-rays to ultrasound
T he brain is arguably the most complex biological machine known. Buried within its folds of gray matter are operational mysteries that continue to confound the world’s most brilliant minds.
Our brains are what make us us. Your dreams, daydreams, personalities, quirks, and unique points of view are all contained in your brain. Likewise, your philosophies, political ideas, prejudices, knowledge, and passions are buried inside your brain — though nobody really knows exactly where.
