Are You a Stroke Risk? Top Neurologist Talks Types of Strokes and Prevention

Sometimes strokes are deadly, and other times they leave a victim with physical and communication limitations. They're always frightening, whether they strike old or young. But many can be prevented. Neurologist Brian Silver, M.D., explains the different kinds of strokes and how they occur. Learn if you’re at risk… That’s right: More people in their 30s and 40s are having strokes. But many of them are preventable, says Brian Silver, M.D., a neurologist at the Rhode Island Hospital and a spokesperson for the American Stroke Association (ASA). “The single biggest thing people can do to reduce their stroke risk factor is have their blood pressure checked,” he says. “One study estimated that if all cases of high blood pressure were treated, strokes would decrease by 40%,” Silver says. “So we currently have 800,000 strokes per year in the U.S. That means there would be 320,000 fewer strokes a year.” In this edited Lifescript interview, Silver explains how to detect strokes, prevent them and recover from one. What’s the most important step people should take to prevent stroke? Have their blood pressure checked. You should also quit smoking and make sure diabetes is treated. Why is untreated hypertension so rampant? A lot of people don’t know they have high blood pressure and [many] who know don’t have it controlled for multiple reasons. Sometimes it’s difficult to control. The average person with high blood pressure needs three pills to control it. Sometimes it’s a financial issue. Some people have to choose between buying food and medicine. Others don’t take it seriously enough. High blood pressure doesn’t hurt, so if some people don’t feel it, they don’t want to treat it. Are the side effects of high blood pressure medicine a factor? The side effects can be bothersome. Some men become impotent. Some people have swelling or weight gain. Unfortunately, doctors often don’t hear these complaints. Patients just stop taking the medication. But everyone should know that there are at least four or five classes of high blood pressure medication. So if someone doesn’t tolerate one medication, we can try something else. Atrial fibrillation is also a factor in some strokes. What is this? Treating atrial fibrillation — often called “a-fib” — is probably the second-most important thing that people can do to reduce their stroke risk. Atrial fibrillation is a condition when your heart chambers, or atria, aren’t working in sync. Your atrium fibrillates or quivers, so blood can pool and clot, then pieces of this clot could break off. If [they] go to the brain, you have a stroke. Who’s most at risk for atrial fibrillation and related strokes? It’s particularly prevalent in older patients. About 5% of people over 65 have atrial fibrillation, and among people in their 80s, it’s 10%. Fortunately, blood-thinning medication reduces the chance of stroke. We’ve used the drug Coumadin to treat atrial fibrillation for many years. Now, we also have Pradaxa [an anticoagulant medication]. You could also take aspirin daily and reduce your stroke risk, but not as much as if you were taking a prescription blood-thinning medication. Can people feel atrial fibrillation? Some people feel a sort of fluttering or they feel as if their heart is beating irregularly. But not everybody feels it. Often there are no symptoms. How is it diagnosed? Atrial fibrillation is usually diagnosed with an EKG [electrocardiogram], but sometimes it takes longer monitoring. We have devices that patients wear for 48 hours or more because longer duration monitoring provides a more sensitive gauge. Sometimes, the condition is episodic. It might only occur every third day, for example. What surprises people about stroke? People are often surprised to learn stroke can happen to someone in their 30s or 40s. In fact, the incidence of stroke has risen in younger Americans. That’s probably due to the rising rates of obesity, which mean more people have high blood pressure and diabetes. What are the warning signs of a stroke? Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. Also sudden confusion, trouble speaking or understanding. Trouble walking, dizziness or loss of coordination. Or a sudden severe headache. [To confirm whether someone is having a stroke, ask them to repeat a sentence to check for slurring of words and recall. Second, have them close their eyes and raise their arms as you look for a difference in ability to control one arm compared with the other. Third, ask them to smile so you can check for facial asymmetry. ] Are there different types of strokes? Yes. Ischemic stroke — which occur when a blood vessel gets blocked by a piece of a clot — is the most common. About 87 % of strokes are ischemic. The other type – hemorrhagic stroke – is when blood vessels burst. About 13% of strokes are hemorrhagic. Is one worse than the other? Hemorrhagic stroke patients have a higher risk of death than ischemic. About 40% of hemorrhagic stroke victims die, compared to 30% of ischemic stroke victims. Looking at it in a more positive light, though, about a third of the people with ischemic strokes will recover pretty well. A quarter of the hemorrhagic stroke patients will have a good outcome. What’s an aneurysm? It’s a type of hemorrhagic stroke. It’s actually a rupture of blood into the wrapping around the brain. About 25% of people who suffer from an aneurysm die before they even get to the hospital. Even with aneurysms, though, [some people] have good outcomes. We can screen for aneurysms using an MRI [magnetic resonance imaging]. Should everyone get an MRI to try to detect aneurysms? No, it’s not practical or necessary for everyone to get screened. But if two first-degree relatives have an aneurysm, the rest of the immediate relatives should have an MRI. Statistics suggest that if just a single person in your family had an aneurysm, you’re not at any greater risk than anyone else, so we don’t recommend you get an MRI. Can an aneurysm be inherited? Probably about 10% of aneurysms are genetic. The majority are not inherited. Risk factors for these types of strokes include being female and a smoker. How is smoking linked to aneurysm stroke risk? Smoking weakens blood vessel walls. Sometimes people have small, inoperable aneurysms. We tell them to stop smoking, which sometimes stops the aneurysm growth. If they continue to smoke, though, it can cause the aneurysm to grow, increasing the risk of rupture. How are aneurysms operated on? We’re now commonly doing a minimally invasive procedure called endovascular coiling on aneurysms. This is where a small tube, similar to a cardiac catheter, is inserted into the femoral artery in the leg and navigated up through the vascular system to the aneurysm. The aneurysm is then sealed off. The outcomes for coiling are better compared to traditional brain surgery. But not every artery is suitable for this technology, and not all aneurysms need a procedure. If an aneurysm is smaller than 7 millimeters, the risk of rupture is lower, and the risk of complications of doing a procedure outweighs the stroke risk. That’s a general rule. Besides therapy for speech and physical movement, what does treatment look like for patients after a stroke? Virtually everyone takes cholesterol-lowering medication afterward. People with high blood pressure take hypertension medication. Someone who has had an ischemic stroke will take aspirin daily or anticoagulation medication such as that used for atrial fibrillation. [Diabetics without] good control of blood sugar we send to an endocrinologist to focus on better blood sugar control. We definitely want smokers to consider using a nicotine patch. We do pretty well getting people to quit smoking. Once you have a stroke, you tend to be a captive audience. When you have paralysis on your left or right side, that’s a convincing signal that you better stop or it could happen again. Are there ways to improve a stroke victim’s chance of a good recovery? Yes, getting stroke victims to the hospital quickly can do wonders. If we give patients who’ve had an ischemic stroke a clot-buster medication called a tPA [tissue plasminogen activator] within the first 4.5 hours after a stroke, it can limit the damage or even sometimes lead to a cure. About one-third to one-half of people with ischemic stroke can benefit from tPA. For hemorrhagic stroke, unfortunately, we don’t currently have anything like this treatment. Can a doctor tell by looking at someone what kind of stroke they’re having? No, not by looking at them, but a CT scan will tell. What are small strokes or mini-strokes? They’re TIAs, or transient ischemic attacks. TIAs aren’t true strokes, but cause stroke-like symptoms for only an hour or two. Sometimes they're actually warnings. TIAs precede a real stroke in about 16% of all strokes. So about one in six patients who have a stroke had a TIA warning [beforehand]. But with medical intervention we can lower the stroke risk after a TIA. For example, we can operate on a narrowed carotid artery before a real stroke occurs. Or if a-fib caused the TIA, we’d start medication right away. Does a person’s diet or exercise habits matter when it comes to stroke risk? Yes, I think they do. And, as physicians, we are guilty of not counseling patients enough about lifestyle. People need to get the message of not eating a diet with excessive fat, and eating more fruits and vegetables. There’s some data that the Mediterranean diet can reduce the risk of future heart attack, and many [stroke experts] say it may also be protective against stroke. I believe what you eat does matter. The problem with diet, though, is that it’s hard to prove. Randomized controlled trials are the gold standard of research, and we don’t have that type of study to link diet and stroke. But research from food surveys suggests that people who report eating more fruit and vegetables are less likely to have a stroke. We also know that a lot of people simply don’t get enough physical activity. Research shows that physical inactivity poses a big stroke risk. We’re not sure why, but people who are not physically active have a higher stroke incidence. For more information, visit Stroke Health Center. Are You on the Road to a Heart Attack? Every 20 seconds, a heart attack occurs somewhere in the United States. Coronary heart disease, the leading cause of death in this country, contributes to the 1.5 million heart attacks that occur each year. Will you become a part of this statistic?