Your Stroke Questions, Answered.

We just wrapped up National Stroke Awareness Month. All month, we took your questions for INTEGRIS Health neurologist Dr. Ashish Masih. Here are his answers.

1. What exactly is a stroke?

There are two types of stroke, Ischemic and Hemorrhagic. Ischemic stroke occurs when a blood vessel carrying blood to the brain is blocked by a blood clot. This causes a lack of blood to the brain. High blood pressure is the most important risk factor for this type of stroke. Ischemic strokes account for more than 80 percent of all strokes.

When blood flow to part of the brain stops for a transient period of time, this is called a transient ischemic attack (TIA). It will mimic stroke-like symptoms. These symptoms last for just a short period of time. A TIA does not cause permanent brain damage, but it should not be ignored, as a TIA is often a warning a big stroke might be coming.

Hemorrhagic strokes are less common. Only approximately 15 percent of all strokes are hemorrhagic, but they are responsible for about 40 percent of all stroke deaths. A hemorrhagic stroke is caused by bleeding in the brain, by either a ruptured brain aneurysm or a weakened blood vessel leak. Blood spills into or around the brain and creates swelling and pressure, damaging cells and tissue in the brain.

2. How big of a role does family history play in stroke?

Family history of stroke does increase your chance of stroke.  We call that a “non-modifiable” risk factor. Some other non-modifiable risk factors include the following.

• Age - After the age of 55, stroke risk doubles for every decade a person is alive.
• Gender – In people under 75, men have more strokes than women. However, women in total experience more strokes each year than men, mainly because women live longer than men and stroke occurs more often at older ages. Stroke kills twice as many women as breast cancer does every year.
• Race and ethnicity - African Americans have twice the risk of stroke, partially because they are more susceptible to high blood pressure, diabetes and obesity. Hispanic and Asian/Pacific Islanders also have higher risk of stroke than Caucasians.

But remember, there are a lot of things you can do to prevent strokes! We call these “modifiable” risk factors. They are treatable with medications and/or special diets or lifestyle changes. These include:

• High blood pressure – a.k.a hypertension, this is the No. 1 cause of stroke. People who have high blood pressure have one-and-a-half times the risk of having a stroke compared to those who consistently have optimal blood pressure of 120/80. The most important thing you can do is to control it through healthy eating habits, physical activity or medications.
• High cholesterol – a.k.a. hyperlipidemia. High cholesterol in the arteries can block normal flow to the brain and cause a stroke. LDL cholesterol (the bad one) levels less than 100 are recommended and if yours is higher, it can be controlled through healthy eating habits, physical activity or medications.
• Diabetes - People with diabetes are up to four times more likely to have a stroke than people who don’t. Weight loss, exercise, changes in eating habits, oral medications and insulin shots are all ways to control diabetes.
• Tobacco use and smoking - Smoking doubles the risk of stroke when compared to a nonsmoker. Smoking increases clot formation, thickens blood, and increases the amount of plaque buildup in the arteries.
• Being overweight - Excess weight puts a strain on the entire circulatory system. It can also make people more likely to have high cholesterol, high blood pressure and diabetes, all of which can increase stroke risk.

3. What is the "golden hour?"

The golden hour is a general concept in medicine in which very rapid therapy is more effective than later therapy. The reason it is "golden" is that stroke patients have a much greater chance of surviving and avoiding long-term brain damage if they arrive at the hospital and receive treatment within that first hour.

Treatment within the golden hour is more successful because patients are candidates for the powerful clot-busting drug known as tPA (short for tissue plasminogen activator), which must be given within the first few hours after a stroke. The golden hour reinforces the importance of reacting quickly to stroke symptoms because "time lost is brain lost.”

4. I’ve heard several stories in the past few years of younger stroke victims. Is there any reason in the medical community as to why? What could make people in their 20s or 30s who are otherwise healthy be susceptible to stroke?

There have been changes in how we diagnose strokes, primarily imaging advances with the MRI, so more young people are perhaps receiving a stroke diagnosis. Additionally, it’s possible this has something to do with the early appearance of risk factors, such as obesity, high blood pressure and diabetes on younger people. Finally, there is also the possibility that a person has an undiagnosed cardiac abnormality or family history of early-onset stroke, which are both risk factors. But an otherwise healthy 20-year-old isn’t more susceptible to stroke now than in the past.

5. Why does a stroke typically only affect movement on one side of the body?

It’s a matter of brain anatomy. Stroke usually affects one side of the brain. Movement for one side of the body is controlled by the opposite side of the brain; therefore, if your stroke affected the right side of your brain, you will have problems with the left side of your body.

6. If my grandfather survives his stroke, what side effects can we expect to see?

It’s hard to know without examining the patient and knowing the location of the stroke to identify which part of the brain was injured, but he will likely have some disabilities in the first few weeks after a stroke, which can include things like weakness or paralysis (usually on one side of the body), problems with speech and language and vision, difficulty with balance and controlling his bladder and bowels, and swallowing. Many people make a good recovery after a stroke but some will be left with long-term disability. Stroke is the leading cause of disability in the country.

7. Does a cancer diagnosis or cancer treatment increase the risk for stroke?

Yes, cancer itself is a hypercoagulable state, which means a person with cancer has an increased risk for blood clots developing in the arteries and veins. In addition, some medications used to treat cancer, such as tamoxifen, can have clotting issues as a side effect. So, we believe that both cancer and its treatments affect blood vessels and the body's clotting system, causing the blood to thicken. Blood clots can be prevented and treated with medication. Talk with your doctor about your risk of developing a blood clot and the steps you can take to prevent one.

8. How long does it take to regain speech after a stroke?

Language impairment -- or aphasia -- occurs in more than a third of people who survive a stroke on the left side of their brain. Many recover within a few months after the stroke, but up to 60 percent still have language impairments more than six months after a stroke, a condition known as chronic aphasia. Working with a speech therapist is best way to recover as fully as possible.

9. What is the time frame to receive tPA for an Ischemic stroke? Have the guidelines changed?

After a stroke, you've got very little time to get treatment. A drug called tissue plasminogen activator (tPA) dissolves clots and restores blood flow. The drug must be given as soon as possible after a stroke. With every passing minute, more brain cells die. Current recommendations discourage tPA use more than three hours after onset of a stroke because the risks of tPA treatment, such as uncontrollable bleeding in the brain, outweigh the benefits. However, some recent clinical trials found that selected patients still benefit from tPA up to 4.5 hours after a stroke.

10. I had toxemia and high blood pressure while pregnant. I heard these can double my stroke risk, is this true? I am 60 now.

Toxemia is a condition in pregnancy, also known as pre-eclampsia characterized by abrupt hypertension (a sharp rise in blood pressure), albuminuria (leakage of large amounts of the protein albumin into the urine) and edema (swelling) of the hands, feet and face. Pre-eclampsia is the most common complication of pregnancy. It affects about 5 percent of pregnancies. It occurs in the third trimester (the last third) of pregnancy. The data is limited on long-term effects of toxemia and stroke.  To answer your question: your risk of stroke is not doubled due to your history of toxemia, perhaps there is only a minimally increased risk.

11. My dad recently had a stroke because of high blood pressure. My health is good now, but I want to take action now to prevent a stroke in my future. What can I do to avoid it? I’m in my late 20s.

Regardless of your family history, a stroke doesn’t have to be inevitable. Here are some ways to protect yourself starting today.

• Don’t smoke.
• Get regular exercise, at least 30 minutes a day.
• Eat a healthy diet
• Keep your body mass index at 25 or less.
• Drink alcohol in moderation.
• Monitor your blood pressure and maintain a blood pressure of less than 120/80. I like the DASH Diet (Dietary Approaches to Stop Hypertension) to help lower blood pressure without medication.

14. Does Vitamin K prevent stroke?

Current guidelines don’t recommend taking vitamin K to prevent stroke.

15. My husband gets horrible headaches after his stroke. Is there anything I can do to help him?

Headaches are quite common after a stroke. There are some good medications, such as Neurontin or amitriptyline, which can make a drastic improvement in the severity of his headaches.

16. Why is my mother so mean after her stroke? Is this a lasting change to her personality?

Unfortunately, personality changes are common after stroke. A stroke causes structural changes to the brain, depending on the location of the stroke. If the frontal-lobe is affected, personality changes can result. In addition, many stroke survivors experience feelings of anger, frustration, anxiety, sadness, fear and hopelessness. These emotions are common with post-stroke depression, which affects more than a third of stroke survivors. I recommend a discussion about antidepressant medication with her doctor to improve this outcome.

17. Is there a simple set of stroke symptoms I can remember?

Yes! When it comes to stroke, the key word is FAST.

• Face: does one side of the person’s face look uneven or drooping?
• Arm: have they lost strength in one arm?
• Speech: are they slurring their words or having a hard time communicating verbally?
• Time: call 9-1-1 immediately.

18. What steps need to be taken for appropriate stroke rehabilitation?

The sooner someone begins rehabilitation treatment, the better the outcome. The goal of rehab is to help you relearn the skills you lost. Although it depends on the severity of the stroke and the related complications, it’s common for rehab to begin 24 to 48 hours after stroke. Although some stroke survivors recover quickly, most need some form of long-term rehabilitation. This can include inpatient, outpatient, and home health rehabilitation. Your rehabilitation plan will change during your recovery as you relearn skills and your needs change. With ongoing practice, you can continue to make gains over time.

Dr. Masih is a board certified general neurologist. He attended St. Christopher College of Medicine in Luton, England, and completed residency training at the University of Cincinnati. He cares for adults with all types of neurologic diseases. His interests include epilepsy and stroke, but he also enjoys seeing patients with multiple sclerosis, headaches and movement disorders.

Dr. Masih believes in preventive medicine and partners with his patients to improve their overall health. He works closely with primary care physicians and specialists to provide better patient care and applies evidence based medicine to his practice. He believes that having a good sense of humor will make his patients feel at ease.