Cerebrovascular Accident (Stroke)

A cerebrovascular accident, commonly called a stroke, is a medical emergency that occurs when blood flow to part of the brain is blocked or when a blood vessel in the brain ruptures. Without immediate treatment, brain cells begin dying within minutes, potentially causing permanent damage, disability, or death.

Stroke, Brain attack, CVA

Table of contents

• What is a cerebrovascular accident?
• Types of stroke
• Warning signs and symptoms
• Who is at risk?
• How strokes are diagnosed
• Treatment options
• Recovery and rehabilitation
• Prevention strategies

What is a cerebrovascular accident?

A cerebrovascular accident is the medical term for a stroke. It happens when something prevents your brain from getting enough blood flow^[1]. Your brain needs oxygen-rich blood to work properly. When blood flow to part of the brain is blocked or a blood vessel breaks, the affected brain cells cannot get the oxygen and nutrients they need, and they start to die within a few minutes^[1].

This can cause lasting brain damage, long-term disability, or even death^[1]. Strokes are the second leading cause of death worldwide and the fifth most common cause of death in the United States^[4]. They are also one of the leading causes of disability^[7].

Healthcare providers sometimes refer to strokes as brain attacks because, like heart attacks, they require immediate medical attention. Every second counts when someone is having a stroke^[4].

Types of stroke

There are two main types of stroke, each caused by different problems with blood flow to the brain^[1].

Ischemic stroke is the most common type, accounting for about 80% to 85% of all strokes^[1][7]. This type happens when a blood clot blocks or plugs a blood vessel in the brain. The blockage can be caused by blood clots or by fatty deposits called plaque that build up in blood vessels^[8].

Hemorrhagic stroke is less common but very serious. It occurs when a blood vessel in the brain breaks open and bleeds into or around the brain^[1]. The leaked blood puts too much pressure on brain cells and damages them^[8]. High blood pressure and aneurysms—balloon-like bulges in arteries that can stretch and burst—are examples of conditions that can cause a hemorrhagic stroke^[8].

A transient ischemic attack (TIA), sometimes called a “mini-stroke,” is another important condition to know about^[1]. During a TIA, blood flow to the brain is blocked for only a short time—usually no more than 5 minutes^[8]. The damage to brain cells isn’t permanent, but having a TIA is a serious warning sign. It puts you at much higher risk of having a major stroke^[1]. More than a third of people who have a TIA and don’t get treatment have a major stroke within one year. As many as 10% to 15% of people will have a major stroke within 3 months of a TIA^[8].

Warning signs and symptoms

The symptoms of a stroke often happen quickly and require immediate action^[1]. The most common symptoms include sudden numbness or weakness of the face, arm, or leg, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden difficulty walking, dizziness, or loss of balance or coordination; and a sudden severe headache with no known cause^[1].

A stroke can cause different symptoms depending on which area of the brain it affects. Other possible symptoms include aphasia (trouble speaking or complete loss of speech), blurry vision or double vision, confusion or agitation, coma, memory loss, mood swings or sudden personality changes, nausea and vomiting, passing out or fainting, seizures, and weakness or paralysis on one side of the face and body^[4].

The F.A.S.T. test can help you remember what to look for if you think someone is having a stroke. Think “FAST” and look for: Face drooping on one side when smiling; Arm weakness when the arms are raised, with one arm drifting downward; Speech that is slurred or strange; and Time to call 911^[1].

Another helpful acronym is BE FAST, which adds two more warning signs: Balance—watch for a sudden loss of balance; and Eyes—look out for sudden vision loss or changes in one or both eyes^[4].

If you think that you or someone else is having a stroke, call 911 right away. Every minute counts during a stroke. Immediate treatment may save someone’s life and increase the chances for successful recovery^[1].

Who is at risk?

Certain factors can raise your risk of having a stroke. Some risk factors cannot be changed, but many others can be controlled through lifestyle choices and medical treatment^[1].

The major risk factors for stroke include high blood pressure, which is the primary risk factor; diabetes; heart diseases, including atrial fibrillation and other heart conditions that can cause blood clots; smoking, which damages blood vessels and raises blood pressure; a personal or family history of stroke or TIA; and increasing age^[1].

People who are African Americans or Hispanic have a higher risk of stroke compared to other groups^[1]. Your risk of stroke increases as you get older^[1].

Additional factors linked to higher stroke risk include alcohol and illegal drug use; not getting enough physical activity; high cholesterol; unhealthy diet; and having obesity^[1]. According to medical guidelines, the recommended blood pressure for people with stroke should be less than 140/90 mm Hg^[5].

Understanding your risk factors is important because approximately 80% of strokes are preventable^[7]. If you know that a particular risk factor affects you, you can take steps with your healthcare provider to reduce its impact.

How strokes are diagnosed

When you arrive at the hospital with possible stroke symptoms, the healthcare team works quickly to diagnose your condition. The goal is to complete the initial evaluation and assessment, including imaging and laboratory studies, within 60 minutes of your arrival^[15].

To make a diagnosis, your healthcare provider will ask about your symptoms and medical history^[1]. They will perform a physical exam that includes checking your mental alertness, coordination and balance, any numbness or weakness in your face, arms, and legs, and any trouble speaking and seeing clearly^[1].

The medical team will run tests that may include diagnostic imaging of the brain, such as a CT scan or MRI. These scans help show what type of stroke you had and which areas of the brain were affected^[1]. Brain scans should be completed within 20 minutes of arrival, with interpretation within 35 minutes^[15].

Heart tests may also be performed to help detect heart problems or blood clots that may have led to the stroke. Possible tests include an electrocardiogram (EKG) and an echocardiography^[1].

Blood tests are important to check glucose levels, as both hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) can produce symptoms that mimic stroke and can worsen ongoing brain damage^[15].

Noting the time when symptoms first appeared is critical. Emergency responders and hospital staff need to know this information to determine which treatments are possible. Certain treatments can only be given within specific time windows after symptoms begin^[21].

Treatment options

Treatment for a stroke depends on what type of stroke you had and how quickly you receive care. Time is critical—the sooner treatment begins, the better your chances of recovery^[1].

For ischemic stroke, the main treatment is a medicine called tissue plasminogen activator (tPA), also known as Alteplase IV r-tPA^[10][16]. This clot-busting drug breaks up the blood clots that block blood flow to your brain^[10]. A healthcare provider injects tPA into a vein in your arm. This medicine must be given within 3 hours after stroke symptoms start, though in certain eligible patients it may be given up to 4.5 hours after symptoms begin^[10]. If administered within this time window, tPA may improve the chances of recovering from a stroke^[16].

If you cannot receive tPA, your provider may give you an anticoagulant or blood-thinning medicine, such as aspirin or clopidogrel, to help stop blood clots from forming or getting larger^[10].

Medical procedures may also be used to treat ischemic stroke. A thrombectomy removes the clot from the blood vessel. During this procedure, a surgeon puts a long, flexible tube called a catheter into your upper thigh and threads it to the blocked blood vessel in the brain^[10]. Mechanical thrombectomy can be performed up to 6 hours after symptoms begin, and recent research has shown that in selected cases of large vessel blockage, this window can be extended up to 24 hours^[5].

For hemorrhagic stroke, treatment focuses on stopping the bleeding and reducing pressure on the brain. This may include medicines, surgery to remove blood or repair damaged blood vessels, or procedures to stop pressure building up inside the skull or brain^[1][11].

During initial treatment in the hospital, healthcare providers also manage other factors that affect recovery. They control blood glucose levels, targeting 140-180 mg/dL^[15]. They monitor and manage blood pressure carefully, as both very high and very low blood pressure can affect outcomes^[15]. They provide supplemental oxygen when needed and treat fever with medication like acetaminophen if your temperature rises above 100.4°F (38°C)^[15].

Recovery and rehabilitation

Stroke recovery is a process that varies greatly from person to person. Some people may take days or weeks to recover with little impact on their life, while for others, recovery can take months or years and may mean making significant life changes^[20]. Your recovery depends on how much the stroke affected you physically and mentally, and on your rehabilitation plan^[20].

In most cases, people do most of their recovery in the first one to three months after stroke^[22]. However, even after you receive treatment, it’s common for effects to linger. Symptoms and after-effects can continue for a year or longer^[4].

A stroke can affect virtually every part of a person’s life and many different abilities. It may impact movement, energy levels, sleep, speaking, swallowing, long-term memory, thinking and short-term memory, activities of daily living like eating and dressing, continence, emotional regulation, and vital body functions^[22].

When you’re discharged from hospital, your healthcare team will create a home recovery plan to support your continued progress^[20]. Your plan may include physiotherapy and exercises to help with movement, including problems such as numbness down one side of the body; cognitive behavioral therapy (CBT) to help with anxiety, depression, and tiredness; activities to improve your memory, concentration, thinking, and mood (cognitive rehabilitation); exercises to help improve problems with speech, swallowing, and vision; and advice, exercises, and medicines to help with bowel or bladder problems^[20].

You can choose how you want to do your rehabilitation—in person or, if it’s easier, online (telerehabilitation). Your healthcare team will make sure you have the right equipment to do this at home and should offer you the training or technical support you need to use it^[20].

After about 6 months, you should get a review of your progress. If you don’t receive this review, speak to your team about it^[20].

Starting the right rehabilitation program as soon as possible may help survivors recover better. A rehabilitation program designed specifically for you, whether at a hospital or at home, is critical^[25]. The exercises, activities, and therapy sessions you do as part of your rehabilitation are often difficult, but they will help you make progress^[20].

Everyday tasks may become more challenging after a stroke. Simple activities like getting dressed, making a meal, doing laundry, or staying organized for the week may become obstacles^[18]. Simple everyday tasks may need to be relearned, and you may need more frequent rest breaks^[18]. Every stroke is unique, and your recovery will be too.

Prevention strategies

Many strokes can be prevented through healthy lifestyle choices and working with your healthcare team to control health conditions that raise your risk^[26]. According to the American Heart Association, approximately 80% of strokes are preventable^[7].

Important lifestyle changes you can make include getting regular exercise. Physical activity can improve your health and fitness in general, lowering your risk of contributing factors like high blood pressure and obesity. A minimum of 150 minutes of moderate physical activity is the recommended weekly amount^[19].

If you smoke, don’t ignore this critical risk factor. Smoking damages and tightens blood vessels, increasing your risk of stroke. Exposure to second-hand smoke can put you at risk as well. Ask your physician about programs and products that can help you quit^[19].

Minimize alcohol consumption. Avoid drinking too much alcohol, which can raise your blood pressure. Men should have no more than two drinks per day, and women should have no more than one per day^[23].

Keep your weight under control. Being overweight or obese can increase your risk for stroke. Work with your physician to create a reasonable weight loss plan through diet and exercise^[19]. Try to eat no more than 1,500 to 2,000 calories a day, depending on your activity level and current body mass index^[23].

Improve your nutrition. Choose healthy foods and drinks. Eat plenty of fresh fruits and vegetables—4 to 5 cups every day. Eat one serving of fish two to three times a week and several daily servings of whole grains and low-fat dairy^[23]. Eat more whole foods; avoid processed foods, sugar, and salt; reduce your fat intake; and eat poultry or fish instead of red meat^[19]. Lower your salt intake to no more than 1,500 milligrams a day (about a half teaspoon)^[23]. Avoid high-cholesterol foods such as burgers, cheese, and ice cream^[23].

Control your blood pressure. High blood pressure usually has no symptoms, so be sure to have it checked on a regular basis^[26]. Hypertension is the leading cause of ischemic stroke and the most common modifiable risk factor^[5]. If you have high blood pressure, your doctor might prescribe medicine, suggest some changes in your lifestyle, or recommend choosing foods with lower sodium^[26].

Lower your cholesterol. Your doctor should test your cholesterol levels at least once every 5 years. If you have high cholesterol, medicine and lifestyle changes can help lower your risk for stroke^[26].

Control your blood sugar levels if you have diabetes. Work with your healthcare team to manage this condition effectively^[26].

Manage stress. Learning how to cope with stress is important. Ask your physician about finding techniques to lower your stress levels^[19].

Care for your mental health. Your care team can connect you with professional help when necessary, so be sure to share these concerns openly^[19].

Talk to your physician about other ways to prevent stroke. You may benefit from taking aspirin to help prevent your first stroke. It is also important to discover if you have atrial fibrillation, an irregular heartbeat that can increase your risk of stroke^[19].

Taking action today to control your risk factors can reduce your risk or possibly prevent a stroke from happening. Small lifestyle changes can help prevent your first stroke or lower your risk of having another one^[19].