Hippocrates created the term apoplexy to describe a disorder where “a person
suddenly falls, without consciousness or motion, retaining pulse and
respiration.” The advent of autopsies during the Modern Era and rapid scientific and technological advancements from the 17th century onward led to the modern definition of stroke, which ultimately replaced apoplexy in the literature.
Optimal stroke care requires urgent recognition of symptoms,
timely initiation of appropriate treatment to all eligible patients, and appropriate secondary prevention measures.
A universally accepted definition of stroke is a sudden loss of brain function caused by interrupted blood flow (ischemic) or rupture of a brain blood vessel (hemorrhagic). The World Health Organization (WHO) definition of stoke is “rapidly developing clinical signs of focal [or global]disturbance of cerebral function, lasting more than 24 hours or leading to death, with vascular origin.”
WHO defines a transient ischemic attack (TIA or a mini-stroke) as “sudden onset of focal neurological symptoms and signs lasting less than 24 hours and caused by reversible cerebral ischemia.” the American Heart Association and the American Stroke Association (AHA/ASA) jointly released an expert consensus document,
“An Updated Definition of Stroke for the 21st Century” incorporates both clinical and
tissue criteria to define stroke and TIA. Healthcare professionals including paramedics, nurses, radiologists, neurologists, and pharmacists must join forces to provide coordinated stroke prevention and care.
Early recognition, access to care, and timely initiation of treatment to all eligible patients are essential to reduce stroke’s global burden. Knowledgeable pharmacists lead by example, promote patient and medical team education and behavior change, and achieve all-around better outcomes.
Approximately 500 000 people in the United States have strokes each year, and 150 000 die as a result. A total of 80% of these strokes are caused by a blood clot that blocks or reduces blood flow to the brain. Others are caused by bleeding into the brain.
Signs of a stroke include:
- weakness on one side of the body
- numbness of the face
- unusual and severe headache
- vision loss
- numbness and tingling
- unsteady walk.
- Ischemic (Clots) and Hemorrhagic (Bleeds) – One-sided facial droop, one arm drifts down when raising both, sudden slurred speech, confusion, difficulty walking, loss of coordination, severe headache and/or difficulty seeing in one or both eyes
- TIA (Transient Ischemic Attack) – Temporary symptoms (as above), only present for a short period of time and completely resolves
The acronym FAST (face
drooping, arm weakness, speech difficulty, and time to call 911) is an easy way to remember the most common signs of Acute ischemic stroke (AIS) and how to respond. A thrombus (blood clot) is the most common cause of stroke, often occluding the middle cerebral artery, the largest branch of the internal carotid artery.
- F – Face drooping: One side of the face may droop or feel numb. When the person smiles, their smile may be uneven.
- A – Arm weakness: One arm may be weak or numb. When the person raises both arms, one arm may drift downward.
- S – Speech difficulty: The person may have trouble speaking or understanding speech. They may slur their words or be unable to speak at all.
- T – Time to call 911: If someone is experiencing any of these symptoms, it is important to call 911 immediately and get to the hospital as quickly as possible.
A thrombus stuck in a blood vessel blocks oxygen transportation to vital brain areas including the frontal, temporal, and parietal lobes. About 1.9 million neurons die every minute without oxygen. Other AIS sources include clots that travel to the brain from the left atria (atrial fibrillation) or ventricle (severe heart failure), or plaque (fatty deposits and cholesterol) accumulation that clogs blood vessels.
Medication plays a critical role in both the prevention and treatment of stroke. The medications used for stroke prevention and treatment can vary depending on the type of stroke and the underlying risk factors.
For the prevention of ischemic stroke, which is caused by a blood clot blocking blood flow to the brain, anticoagulants such as warfarin, dabigatran, rivaroxaban, or apixaban are commonly used to prevent blood clots from forming. Antiplatelet agents such as aspirin, clopidogrel, or ticagrelor may also be used to prevent blood clots from forming. Additionally, medications to control high blood pressure, high cholesterol, and diabetes can help reduce the risk of stroke.
For the treatment of ischemic stroke, thrombolytic therapy with tissue plasminogen activator (tPA) is the most common medication used. tPA is a medication that can dissolve blood clots and restore blood flow to the brain. However, tPA must be given within a few hours of the onset of symptoms, and not all patients are eligible for this treatment.
For the treatment of hemorrhagic stroke, which is caused by bleeding in the brain, medication to control high blood pressure is often used to prevent further bleeding. Surgery may also be necessary to stop the bleeding and remove any blood clots.
Secondary Preventions
Antihypertensives, antiplatelets, and cholesterol-lowering agents are the classes of medication usually used for secondary stroke prevention. Secondary stroke prevention aims to prevent recurrent strokes in individuals who have already experienced a stroke or transient ischemic attack (TIA). Antihypertensives are commonly prescribed to lower blood pressure and reduce the risk of another stroke.
Antiplatelets, such as aspirin or clopidogrel, are often used to prevent blood clots from forming and blocking blood vessels in the brain. Cholesterol-lowering agents, such as statins, are prescribed to reduce the risk of atherosclerosis and subsequent stroke.
- Total cholesterol: under 200 mg/dL of blood
- LDL (bad) cholesterol: under 100 mg/dL
- HDL (good) cholesterol: above 60 mg/dL
Other medications, such as anticoagulants, may also be used in some cases depending on the individual’s specific health status and risk factors. It’s important to note that medication therapy for secondary stroke prevention should always be individualized based on the patient’s specific medical history and risk factors, and should be closely monitored by a healthcare professional.
A low-dose aspirin every day may prevent strokes and heart attacks in people at higher risk, but the actual benefit is considered to be small. It acts as a blood thinner, preventing blood clots from forming in arteries partly blocked by cholesterol and plaque, but it also carries a risk of internal bleeding, which can be life-threatening. It’s not for everyone, though, so don’t start taking aspirin without talking to your doctor first.
Prevent a Stroke
- Reduce the salt in your diet to no more than 1,500 milligrams a day (about a half teaspoon).
- Avoid high-cholesterol foods, such as burgers, cheese, and ice cream.
- Eat 4 to 5 cups of fruits and vegetables every day, one serving of fish two to three times a week, and several daily servings of whole grains and low-fat dairy.
- Get more exercise — at least 30 minutes of activity a day, and more, if possible.
- Quit smoking, if you smoke.
- Try to eat no more than 1,500 to 2,000 calories a day (depending on your activity level and your current BMI).
- Increase the amount of exercise you do with activities like walking, golfing, or playing tennis, and by making activity part of every single day.
- Take a walk around your neighborhood every morning after breakfast.
- Start a fitness club with friends.
- When you exercise, reach the level at which you’re breathing hard, but you can still talk.
- Take the stairs instead of an elevator when you can.
- If you don’t have 30 consecutive minutes to exercise, break it up into 10- to 15-minute sessions a few times each day.
- Have no more than one glass of alcohol a day.
- Consider red wine as your first choice, which some studies suggest might help prevent heart disease and stroke.
- Watch your portion sizes. A standard-sized drink is a 5-ounce glass of wine, 12-ounce beer, or 1.5-ounce glass of hard liquor.
- If you have symptoms such as heart palpitations or shortness of breath, see your doctor for an exam.
- You may need to take an anticoagulant drug (blood thinner), such as one of the direct-acting anticoagulant drugs to reduce your stroke risk from atrial fibrillation. Your doctors can guide you through this treatment.
- Monitor your blood sugar as directed by your doctor.
- Use diet, exercise, and medicines to keep your blood sugar within the recommended range.
- Ask your doctor for advice on the most appropriate way for you to quit smoking.
- Use quit-smoking aids, such as nicotine pills or patches, counseling, or medicine.
- Don’t give up. Most smokers need several tries to quit. See each attempt as bringing you one step closer to successfully beating the habit.
Stroke Belt
Studies have shown that the Southeastern region of the United States, often referred to as the “stroke belt,” has the highest stroke mortality rates compared to other regions of the country.
This is believed to be due to a combination of factors, including high rates of hypertension, smoking, and obesity, as well as limited access to healthcare and preventive services in some areas. It is crucial to address these disparities and promote stroke prevention and education throughout the country, particularly in high-risk areas, to reduce the burden of stroke and improve health outcomes.
Controlled blood pressure, regular exercise, and healthy body weight are a list of components of “Life’s Simple 7” as defined by AHA/ASA. “Life’s Simple 7” is a set of health factors and behaviors identified by the American Heart Association (AHA) and the American Stroke Association (ASA) as critical for improving cardiovascular health and reducing the risk of heart disease and stroke. The seven components of “Life’s Simple 7” are:
- Manage blood pressure
- Control cholesterol
- Reduce blood sugar
- Get active
- Eat better
- Lose weight
- Stop smoking
These components are evidence-based and focus on both lifestyle changes and medical management of cardiovascular risk factors. By following these simple guidelines, individuals can significantly reduce their risk of heart disease and stroke and improve overall cardiovascular health. It’s important to note that mental health and alcohol avoidance are also important factors in overall health and well-being, but they are not included as components of “Life’s Simple 7” as defined by AHA/ASA.
It is important to note that medication is just one component of stroke prevention and treatment. Lifestyle modifications, such as regular exercise, a healthy diet, and not smoking, are also important for reducing the risk of stroke.
Further Reading
Sources
- “What Can Help Prevent a Stroke?” WebMD
- Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236.
- “7 things you can do to prevent a stroke” Harvard Health Publishing
- Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344-e418.
- Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032-2060.
- “3 Ways to Avoid a Second Stroke” John Hopkins Medicine
