CAUSES

You can treat some conditions that make you more likely to have a stroke. Other things that put you at
risk can't be changed:

High blood pressure. Your doctor may call it hypertension. It's the biggest cause of strokes. If your blood
pressure is typically 140/90 or higher, your doctor will discuss treatments with you.

Tobacco. Smoking or chewing it raises your odds of a stroke. Nicotine makes your blood pressure go up.
Cigarette smoke causes a fatty buildup in your main neck artery. It also thickens your blood and makes it
more likely to clot. Even secondhand smoke can affect you.

Heart disease. This condition includes defective heart valves as well as atrial fibrillation, or irregular
heartbeat, which causes a quarter of all strokes among the very elderly. You can also have clogged
arteries from fatty deposits.

Diabetes. People who have it often have high blood pressure and are more likely to be overweight. Both
raise the chance of a stroke. Diabetes damages your blood vessels, which makes a stroke more likely. If
you have a stroke when your blood sugar levels are high, the injury to your brain is greater.

Weight and exercise. Your chances of a stroke may go up if you're overweight. You can lower your odds
by working out every day. Take a brisk 30-minute walk, or do muscle-strengthening exercises like
pushups and working with weights.

Medications. Some medicines can raise your chances of stroke. For instance, blood-thinning drugs,
which doctors suggest to prevent blood clots, can sometimes make a stroke more likely through
bleeding. Studies have linked hormone therapy, used for menopause symptoms like hot flashes, with a
higher risk of strokes. And low-dose estrogen in birth control pills may also make your odds go up.

Age. Anyone could have a stroke, even babies in the womb. Generally, your chances go up as you get
older. They double every decade after age 55.

Family. Strokes can run in families. You and your relatives may share a tendency to get high blood
pressure or diabetes. Some strokes can be brought on by a genetic disorder that blocks blood flow to
the brain.

Gender. Women are slightly less likely to have a stroke than men of the same age. But women have
strokes at a later age, which make them less likely to recover and more likely to die as a result.

Race. Strokes affect African-Americans and nonwhite Hispanic Americans much more often than any
other group in the U.S. Sickle cell disease, a genetic condition that can narrow arteries and interrupt
blood flow, is also more common in these groups and in people whose families came from the
Mediterranean, the Middle East, or Asia.

DESCRIPTION

Stroke is a disease that affects the arteries leading to and within the brain. It is the No. 5 cause of death
and a leading cause of disability in the United States.A stroke occurs when a blood vessel that carries
oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures). When that happens,
part of the brain cannot get the blood (and oxygen) it needs, so it and brain cells die.

Types of Stroke
Just as strokes have many effects, they also have many causes. Learn the various types of stroke.

Ischemic Stroke (Clots)

Occurs when a blood vessel supplying blood to the brain is obstructed. It accounts for 87 percent of all
strokes.

Hemorrhagic Stroke (Bleeds)

Occurs when a weakened blood vessel ruptures. The two types of weakened blood vessels that usually
cause hemorrhagic stroke are aneurysms and arteriovenous malformations (AVMs). The most common
cause of hemorrhagic stroke is uncontrolled high blood pressure.

TIA (Transient Ischemic Attack)

Called a “mini stroke,” it’s caused by a serious temporary clot. This is a warning stroke and should be
taken seriously.

Cryptogenic Stroke

In most cases, a stroke is caused by a blood clot that blocks the flow of blood to the brain. In some
instances, despite testing, the cause of a stroke cannot be determined. A stroke of unknown cause is
called a “cryptogenic stroke.”

Brain Stem Stroke

When stroke occurs in the brain stem, it can affect both sides of the body and may leave someone in a
‘locked-in’ state. When a locked-in state occurs, the patient is generally unable to speak or move below
the neck.

Stroke Prevention

There are many positive steps that you can take now to reduce your risk of stroke. The most common
risk factors for stroke are listed below. These include some conditions that can be changed by lifestyle
modification or medical treatment, and some, such as hereditary factors, that cannot be changed.

How to reduce your risk

Most of the controllable risk factors for stroke relate to cardiovascular fitness. Because stroke is a form
of cardiovascular disease, it makes sense that keeping your heart and blood vessels as healthy as
possible will reduce your risk of stroke. The following are the most important measures you can take to
control your stroke risk. These include changing risk factors by medical treatment as well as by positive
lifestyle modifications.

Regular medical check-ups

Risk factors such as heart disease, high blood pressure, and elevated blood cholesterol must be
monitored by your physician on a regular basis. These risk factors can be changed or, at minimum,
controlled by proper medical treatment and appropriate diet and lifestyle modifications.

Control blood pressure

High blood pressure (hypertension) is the single most important risk factor for stroke. Even mild
hypertension, if not adequately treated, increases stroke risk. In general, blood pressure should be
below 120/80.

Elevated blood pressure promotes atherosclerosis and puts abnormal pressure on blood vessel walls,
which can cause a rupture at a weak spot. Hypertension is often called the "silent killer" because there
may be no obvious symptoms. It is important to check your blood pressure regularly. Controlling blood
pressure, whether by a low-sodium diet, weight control, stress management and/or medication will
reduce your risk of stroke.

Remember: medication to control hypertension is effective only if taken on a regular basis, so it is

important to follow your physician's instructions.

Treatment of hypertension in older adults is also important. However, in elderly individuals, an abrupt
fall in blood pressure may actually cause a stroke. Therefore, treatment of high blood pressure in the
elderly may need to start with small doses of medication, so that blood pressure is reduced gradually.

Stop smoking

Studies confirm that smokers have a higher risk of stroke, regardless of other factors such as age, high
blood pressure, or heart disease. The risk declines dramatically within a few years of stopping smoking.

Treat heart disease

A variety of heart conditions, including irregular heart rhythms (atrial fibrillation), heart attacks and
heart valve disorders, can cause stroke. Treatment of these disorders can reduce stroke risk.

Improve diet

Consumption of foods high in fat, cholesterol and salt increases the risk for stroke. The following
recommendations are among the most important for stroke prevention. Ask your doctor for more help
in identifying dietary culprits and making appropriate substitutions.

Avoid excess fat

High intakes of fat, particularly saturated fat, and cholesterol may contribute to atherosclerosis, which is
associated with stroke. Dietary fat and cholesterol may be reduced by limiting fat or oil added in
cooking, trimming fat and skin from meats and poultry, using low-fat or non-fat dairy products, broiling
and baking foods rather than frying, and limiting eggs to no more than three a week.

Avoid excess sodium

Excess sodium in the diet is linked to hypertension. Table salt is the primary source of dietary sodium.
There is also "hidden" salt in most processed and canned foods. Disodium phosphate, monosodium
glutamate, sodium nitrate, or any similar compounds in the list of ingredients indicate a high sodium
content. Try to eat fresh food whenever possible.

Limit alcohol intake

Individuals who drink alcoholic beverages (more than two drinks per day) have an increased risk of
stroke. For heavy drinkers, the risk of stroke increases further. Healthy young adults are just as
susceptible to the risk of stroke incurred by heavy alcohol consumption as are older persons.
Maintain a healthy weight

Being overweight strains the heart and blood vessels and is associated with high blood pressure. Obesity
also predisposes a person to heart disease and diabetes, both of which increase the risk for stroke.
Keeping your weight to recommended levels for your height and build is a prudent preventive measure.

Exercise regularly

The percentage of fat in our bodies tends to increase with age. Regular exercise helps keep this increase
to a minimum. There appears to be an inverse relationship between exercise and atherosclerosis, i.e.,
more exercise is linked to lower levels of atherosclerosis.

If you have not exercised regularly and would like to start an exercise program, or if you have medical
problems or family history of serious disease, consult your physician before beginning an exercise
program. Select an exercise program that is most suitable for you. Experts recommend at least 20 to 30
minutes of aerobic exercise three to four times a week in order to achieve and maintain an improved
level of fitness.

Treat diabetes

The association between diabetes and increased stroke risk seems to be related to the circulatory
problems caused by diabetes. Good control of diabetes appears to reduce the cardiovascular
complications of the disease.

Reduce stress

Because stress may increase blood pressure, it is linked indirectly to stroke risk. A one-time stressful
event rarely causes a stroke, but long-term unresolved stress can contribute to high blood pressure.
Stress management, including relaxation techniques, biofeedback, exercise and counseling, appear to be
useful in the treatment of high blood pressure, thus lowering the risk of stroke.

Use of oral contraceptives

Oral contraceptives, especially those with high estrogen content, appear to increase the risk of blood
clots, including clots that cause stroke, especially in women over age 30. The risk is even higher in
women who smoke. Consult your physician for advice regarding alternative methods of birth control if
you have stroke risk factors and are currently using oral contraceptives

Post-menopausal estrogen use

Recent studies have shown that post-menopausal estrogen resplacement is associated with a small
increase in the risk of stroke.

Risk factors for stroke

The most important risk factor for stroke is hypertension (high blood pressure), which weakens artery
walls and promotes atherosclerosis (thickening of the arterial lining). Atherosclerosis, in turn, narrows
the arteries and reduces blood flow.

The Stanford Stroke Center is participating in clinical trials that are evaluating some recently described
stroke risk factors. These risk factors may predispose to atherosclerosis or blood clot formation and
appear to be treatable.
Risk factors that cannot be changed

Age

The chance of having a stroke increases with age. Two-thirds of strokes occur in persons over the age of
65.

Gender

For reasons that are not yet clear, stroke is 25 percent more common in men than in women.

Race

The incidence of stroke varies among races for reasons that are probably related to genetic factors.
Social factors, such as lifestyle and environment, can also play a part. African-Americans have a higher
incidence of hypertension than Caucasians, and also a higher rate of stroke. Furthermore, they are more
likely to suffer strokes at an earlier age.

Family or individual history

A history of cerebrovascular disease in a family appears to be a contributing factor to stroke. While you
have no control over your family history, you can take steps to decrease your risk through diet, exercise
and other means discussed in this guide.

If you have experienced a stroke or TIA in the past, you are at increased risk for having a stroke in the
future. Therefore, all the preventive measures discussed in this section are of particular importance.

What is a stroke?

A stroke, also known as a cerebrovascular accident or CVA is when part of the brain loses its blood
supply and the part of the body that the blood-deprived brain cells control stops working. This loss of
blood supply can be ischemic because of lack of blood flow, or hemorrhagic because of bleeding into
brain tissue. A stroke is a medical emergency because strokes can lead to death or permanent disability.
There are opportunities to treat ischemic strokes but that treatment needs to be started in the first few
hours after the signs of a stroke begin. The patient, family, or bystanders, should call 9-1-1 and activate
emergency medical services immediately should a stroke be suspected.

A transient ischemic attack (TIA or mini-stroke) describes an ischemic stroke that is short-lived where
the symptoms resolve spontaneously. This situation also requires emergency assessment to try to
minimize the risk of a future stroke. By definition, a stroke would be classified as a TIA if all symptoms
resolved within 24 hours.

What causes a stroke?

Thrombotic stroke

The blockage of an artery in the brain by a clot (thrombosis) is the most common cause of a stroke. The
part of the brain that is supplied by the clotted blood vessel is then deprived of blood and oxygen. As a
result of the deprived blood and oxygen, the cells of that part of the brain die and the part of the body
that it controls stops working. Typically, a cholesterol plaque in one of the brain's small blood vessels
ruptures and starts the clotting process.
Risk factors for narrowed blood vessels in the brain are the same as those that cause narrowing blood
vessels in the heart and heart attack (myocardial infarction). These risk factors include:

* high blood pressure (hypertension),

* high cholesterol,

* diabetes, and

* smoking.

Embolic stroke

Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque (cholesterol
and calcium deposits on the wall of the inside of the heart or artery) breaks loose, travels through the
bloodstream, and lodges in an artery in the brain. When blood flow stops, brain cells do not receive the
oxygen and glucose they require to function and a stroke occurs. This type of stroke is referred to as an
embolic stroke. For example, a blood clot might originally form in the heart chamber as a result of an
irregular heart rhythm, like atrial fibrillation. Usually, these clots remain attached to the inner lining of
the heart, but occasionally they can break off, travel through the bloodstream (embolize), block a brain
artery, and cause a stroke. An embolism, either plaque or clot, may also originate in a large artery (for
example, the carotid artery, a major artery in the neck that supplies blood to the brain) and then travel
downstream to clog a small artery within the brain.

Cerebral hemorrhage

A cerebral hemorrhage occurs when a blood vessel in the brain ruptures and bleeds into the
surrounding brain tissue. A cerebral hemorrhage (bleeding in the brain) causes stroke symptoms by
depriving blood and oxygen to parts of the brain in a variety of ways. Blood flow is lost to some cells.
Additionally, blood is very irritating and can cause swelling of brain tissue (cerebral edema). Edema and
the accumulation of blood from a cerebral hemorrhage increases pressure within the skull and causes
further damage by squeezing the brain against the bony skull. This further decreases blood flow to brain
tissue and its cells.

Subarachnoid hemorrhage

In a subarachnoid hemorrhage, blood accumulates in the space beneath the arachnoid membrane that
lines the brain. The blood originates from an abnormal blood vessel that leaks or ruptures. Often this is
from an aneurysm (an abnormal ballooning out of the blood vessel). Subarachnoid hemorrhages usually
cause a sudden severe headache, nausea, vomiting, light intolerance, and stiff neck. If not recognized
and treated, major neurological consequences, such as coma, and brain death may occur.

Vasculitis

Another rare cause of stroke is vasculitis, a condition in which the blood vessels become inflamed
causing decreased blood flow to parts of the brain.

Migraine headache

There appears to be a very slight increased occurrence of stroke in people with migraine headache. The
mechanism for migraine or vascular headaches includes narrowing of the brain blood vessels. Some
migraine headache episodes can even mimic stroke with loss of function of one side of the body or
vision or speech problems. Usually, the symptoms resolve as the headache resolves.

What are the types of Stroke?

Strokes are usually classified by what mechanism caused the loss of the blood supply, either ischemic or
hemorrhagic. A stroke may also be described by what part of the brain was affected (for example, a right
temporal stroke) and what part of the body stopped working (stroke affecting the left arm).

Ischemic stroke

An ischemic stroke is caused by an artery in the brain being obstructed or blocked, preventing oxygen-
rich blood from being delivered to brain cells. The artery can be blocked in a couple of ways. In a
thrombotic stroke, an artery can narrow over time because of cholesterol buildup, called plaque. If that
plaque ruptures, a clot is formed at the site and prevents blood from passing to brain cells downstream,
which are then deprived of oxygen.

In an embolic stroke, the artery is blocked because of debris or a clot that travels from the heart or
another blood vessel. An embolus or embolism is a clot, a piece of fatty material or other object that
travels within the bloodstream that lodges in a blood vessel to cause an obstruction.

Blood clots that embolize usually arise from the heart. The most common cause of these blood clots is a
heart arrhythmia called atrial fibrillation, where the upper chambers of the heart, the atria, do not beat
in an organized rhythm. Instead, the chaotic electrical rhythm causes the atria to jiggle like a bowl of Jell-
O. While blood still flows to the ventricles (the heart's lower chambers) to be pumped to the body, some
blood along the inner walls of the atrium can form small blood clots. If a clot breaks off, it can travel or
embolize to the brain, where it can block blood flow to a part of the brain and cause a stroke.

The carotid arteries are two large blood vessels that provide the brain with blood supply. These arteries
can narrow, or develop stenosis, with cholesterol plaque that may build up over time. The surface of the
plaque is irregular and bits of debris can break off and embolize to the brain to block blood vessels
downstream and deprive brain cells of oxygen-rich blood.

Hemorrhagic stroke

When a blood vessel leaks and spills blood into brain tissue, those brain cells stop working. The bleeding
or hemorrhage is often due to poorly controlled high blood pressure that weakens the wall of an artery
over time. Blood may also leak from an aneurysm, a congenital weakness or ballooning of an artery wall,
or from an AVM (arteriovenous malformation), a congenital abnormality where an artery and vein
connect incorrectly. The bleeding can form a hematoma that directly damages brain cells and may also
cause swelling that puts further pressure on surrounding brain tissue.

Describing a stroke by anatomy and symptoms

There are four major arteries that supply the brain with blood.

* The right and left carotid artery are located in the front of the neck and their pulse can be felt with the
fingers.

* The right and left vertebral arteries are encased in bone as they run through the vertebrae in the neck.
As the two enter the brain, they join to form the basilar artery.
* The carotid arteries and the vertebrobasilar arteries join to form the Circle of Willis at the base of the
brain and from this circle, arteries branch off to supply the brain with blood.

The left side of the brain controls the right side of the body and vice versa. Speech tends to be located in
the dominant hemisphere, most often the left brain.

The anterior and middle cerebral arteries provide blood supply to the front two-thirds of the brain,
including the frontal, parietal, and temporal lobes. These parts of the brain control voluntary body
movement, sensation, speech and thought, personality, and behavior.

The vertebral and basilar arteries are considered the posterior circulation and supply the occipital lobe
where vision is located, the cerebellum that controls coordination and balance, and the brainstem that
is responsible for the unconscious brain functions that include blood pressure, breathing, and
wakefulness.

Strokes may be described based upon the function of the body that is lost and by the area of the brain
that is affected. Most commonly in strokes that involve the brain, the symptoms involve either the right
or left side of the body. In strokes that affect the brainstem or the spinal cord, symptoms may present
on both sides of the body.

Strokes may affect motor function or the ability for the body to move. Part of the body may be affected,
like the face, a hand, or an arm. An entire side of the body may be affected (for example, the left part of
the face, left arm, and left leg). Weakness on one side of the body is called hemiparesis (hemi = half +
paresis = weak) and paralysis is hemiplegia (hemi = half + plegia = paralysis).

Similarly, sensory function -- the ability to feel -- can affect the face, hand, arm, trunk, or a combination
of these.

Other symptoms like speech, vision, balance, and coordination help locate the part of the brain that has
stopped working and helps the health care professional make the clinical diagnosis of stroke. This is an
important concept since not all loss of neurologic function is due to stroke and if the anatomy and
physiology do not match the loss of body function, other diagnoses may be considered that can affect
both brain and body.

A lacunar stroke describes the blockage of a single tiny penetrating artery branch in the brain. The area
of the involved brain is small but can still cause significant neurologic deficits, just like a stroke involving
a larger blood vessel and more brain tissue. In some cases, however, the stroke is silent, meaning that
no obvious body function is lost and an old lacunar stroke can be seen as an incidental finding on a CT or
MRI scan of the head that might be done for other reasons. The term lacune means empty space and a
tiny empty space of an old lacunar stroke can be seen on imaging where brain tissue has been lost.

What is a transient ischemic attack (TIA)?

A transient ischemic attack (TIA, mini-stroke) is a short-lived stroke that gets better and resolves
spontaneously. It is a short-lived episode (less than 24 hours) of temporary impairment of brain function
that is caused by a loss of blood supply. A TIA causes a loss of function in the area of the body that is
controlled by the portion of the brain affected. The loss of blood supply to the brain is most often
caused by a clot that spontaneously forms in a blood vessel within the brain (thrombosis). However, it
can also result from a clot that forms elsewhere in the body, dislodges from that location, and travels to
lodge in an artery of the brain (emboli). Arterial spasm and, rarely, a bleed into brain tissue are other
causes of a TIA. Many people refer to a TIA as a "mini-stroke."

Some TIAs develop slowly, while others develop rapidly. By definition, all TIAs resolve within 24 hours.
Strokes take longer to resolve than TIAs, and with strokes, complete function may never return and
reflect a more permanent and serious problem. Although most TIAs often last only a few minutes, all
TIAs should be evaluated with the same urgency as a stroke in an effort to prevent recurrences and/or
strokes. TIAs can occur once, multiple times, or precede a permanent stroke. A transient ischemic attack
should be considered an emergency because there is no guarantee that the situation will resolve itself
and function will return spontaneously without the help of medical intervention.

A TIA from a clot in the blood vessel that supplies the retina of the eye can cause temporary visual loss
(amaurosis fugax), which is often described as the sensation of a black, dark curtain coming down. A TIA
that involves the carotid artery (the largest blood vessel supplying the brain) can produce problems with
movement or sensation on one side of the body, which is the side opposite to the actual blockage. An
affected patient may experience temporary double vision; dizziness (vertigo); loss of balance; one-sided
weakness or complete paralysis of the arm, leg, face, or one whole side of the body; or be unable to
speak or understand commands.

Prevention

Prevention is always the best treatment, especially when the illness can be life-threatening or life-
altering. Ischemic strokes are most often caused by atherosclerosis, or hardening of the arteries, and
carry the same risk factors as heart attacks (myocardial infarction, coronary artery disease) and
peripheral vascular disease. These include high blood pressure, high cholesterol, diabetes, and smoking.
Stopping smoking and keeping the other three under lifelong control greatly minimizes the risk of
ischemic stroke.

Patients who have had a transient ischemic attack (TIA) are often prescribed medications to decrease
their risk of a subsequent stroke. These include medications to lower blood cholesterol levels and
control blood pressure. In addition, antiplatelet medications may be prescribed to make platelets less
likely to promote blood clot formation. These include aspirin, clopidogrel (Plavix), and
dipyridamole/aspirin (Aggrenox).

Patients with a TIA are usually evaluated for carotid stenosis or narrowing of the carotid artery. Surgery
to open critically narrowed carotid arteries (termed endarterectomy) may decrease stroke risk.

Lifelong control of high blood pressure decreases the risk of hemorrhagic stroke.

Atrial fibrillation is the most common cause of embolic stroke. Ideally the heart rhythm can be
converted to normal sinus rhythm but in those patients whose hearts are chronically in atrial fibrillation,
anticoagulation or “blood thinning” minimizes the risk of blood clot formation in the heart and
subsequent embolization and stroke. The drug that is prescribed depends upon the specific patient and
individual situation. Patients who are prescribed apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran
(Pradaxa), or warfarin (Coumadin), have a decreased chance of stroke but are at risk for bleeding
complications.

Effective ways

Engage in Physical Activity

Exercise of 30 minutes or more, most days of the week is advised to improve the health of your heart
and circulatory system. Physical activity can help manage your weight and reduce your risk of
developing other conditions that make your circulatory system work harder, like high blood pressure,
diabetes and high cholesterol. Exercise is even effective when broken down into shorter sessions.

Quit Smoking and Tobacco Use

Smoking and using tobacco products significantly increases your risk for heart disease. Damage to your
heart and circulatory system by the chemical compounds in tobacco can cause atherosclerosis, which
may lead to heart attack. Once you quit smoking, your risk of heart disease significantly decreases over
the next year, according to the MayoClinic website. Regardless of how long you have smoked or used
other tobacco products, you will notice the benefits of quitting as soon as you do.

Eat High Quality Foods

Your food intake can significantly improve the health of your circulatory system and heart. Diets
containing five to 10 servings of fruits and vegetables, whole grains and low-fat dairy products are most
beneficial to the circulatory system. Avoiding processed foods, foods that are high in saturated and trans
fats, and excessive alcohol consumption can also improve your circulatory system health.

Maintain a Healthy Weight

Managing a healthy weight plays a major role in the health of your circulatory system. Being overweight
can increase risk of high blood pressure, diabetes and high cholesterol, all of which put you at increased
risk for heart attack and other circulation problems. By just losing 10 percent of your body weight, you
can significantly increase the odds of not developing these chronic diseases.