Dr. James Manos (MD)
January 22, 2016
January 22, 2016
Overview of Stroke and Prevention TIPS
‘Prevention is better than cure’ (Hippocrates, ancient Greek doctor – the father of Western medicine, 460 – 370 B.C.)
Note: in this text, the writer expresses his point of view. Some advice is empirical, so you should consult your family doctor beforehand.
Stroke
• Stroke (also known as cerebrovascular accident (CVA)) is a widespread, devastating condition and a major cause of disability. Causes of stroke include cerebral infarction (87% of cases) with atherothrombotic occlusion or from embolism from the heart (from the heart’s left atrium on patients with atrial fibrillation AF or from the heart’s left ventricle after MI or on a patient with heart failure). Thirteen percent of strokes are intracerebral or subarachnoid hemorrhage, which causes direct neuronal injury and pressure phenomena.
• Bleeding can develop inside areas of ischemia, a condition known as ‘hemorrhagic transformation.’ It is unknown how many hemorrhagic strokes actually start as ischemic strokes.
• In an ischemic stroke, the blood supply to part of the brain decreases, leading to brain tissue dysfunction. There are four reasons why this might happen:
• a) Thrombosis (obstruction of a blood vessel by a blood clot forming locally)
• b) Embolism (obstruction due to an embolus from elsewhere in the body, see below)
• c) Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)
• d) Venous thrombosis
• The Oxford Community Stroke Project classification (OCSP) is based on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) or posterior circulation infarct (POCI). These four entities predict the extent of the stroke, the affected area of the brain, the underlying cause, and the prognosis.
• The TOAST classification is based on clinical symptoms as well as results of further investigations; on this basis, a stroke is classified as being due to: (a) thrombosis or embolism due to atherosclerosis of a large artery, (b) an embolism originating in the heart (c) complete blockage of a small blood vessel, (d) other determined cause, (e) undetermined cause (two possible causes, no cause identified, or incomplete investigation).
• Users of stimulant drugs such as cocaine or amphetamines are at elevated risk for ischemic strokes.
• In thrombotic stroke, a thrombus (blood clot) usually forms around atherosclerotic plaques. Since blockage of the artery is gradual, the onset of symptomatic thrombotic strokes is slower than that of a hemorrhagic stroke. A thrombus (even if it does not completely block the blood vessel) can lead to an embolic stroke if it breaks off and travels in the bloodstream, called an embolus. Two types of thrombosis can cause stroke:
• a) Large vessel disease that involves the common & internal carotid arteries, the vertebral artery, and the Circle of Willis.
• b) Small vessel disease that involves the smaller arteries inside the brain: branches of the circle of Willis, middle cerebral artery, stem, and arteries arising from the distal vertebral and basilar artery.
• An embolic stroke refers to an arterial embolism (a blockage of an artery) by an embolus (a traveling particle or debris in the arterial bloodstream originating from elsewhere). An embolus is most frequently a thrombus (blood clot). Still, it can also be some other substances, including fat (e.g., from bone marrow in a broken bone), air, cancer cells, or clumps of bacteria – septic embolus, usually from infectious endocarditis). Emboli most commonly arise from the heart (especially in a heart arrhythmia called atrial fibrillation) but may originate elsewhere in the arterial tree.
• Cerebral hypoperfusion is the blood flow reduction to all body parts. Hemodynamic stroke is a type of ischemic stroke caused by hypoperfusion rather than embolism or local vasculopathy. It can be caused by systemic diseases such as heart failure or hypotension and severe obstruction of the carotid or vertebral arteries. Other causes include cardiac arrest and severe (unstable) heart arrhythmias (with hemodynamic compromise). Patients with hemodynamic stroke or transient ischemic attack might show specific clinical features distinguishing them from those with embolism or local small-vessel disease. Ancillary investigations of cerebral perfusion can show whether blood flow to the brain is compromised and provide important prognostic information. Treatment aims at increasing cerebral blood flow might be considered in selected patients by information from the case series.
• Cerebral venous sinus thrombosis leads to stroke due to locally increased venous pressure, which exceeds the pressure generated by the arteries. Infarcts are more likely to undergo a hemorrhagic transformation.
• Thirteen percent of strokes are intracerebral or subarachnoid hemorrhage, which causes direct neuronal injury and pressure phenomena.
• Other rare causes of stroke are vasculitis, venous–sinus thrombosis (e.g., after an infection such as eye – periorbital cellulitis), sudden decrease in BP (e.g., cardiac arrest), and carotid artery dissection.
• An intracranial hemorrhage is the accumulation of blood anywhere within the cranial vault. The main types of intracranial hemorrhage are epidural hematoma (bleeding between the dura mater and the skull), subdural hematoma (bleeding in the subdural space), and subarachnoid hemorrhage (bleeding between the arachnoid mater and pia mater).
• A cerebral hemorrhage is bleeding within the brain tissue. A cerebral hemorrhage can be due to either intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system). Most hemorrhagic stroke syndromes have specific symptoms, particularly headaches, or have evidence of previous head trauma (injury).
• Intracerebral hemorrhage generally occurs in small arteries or arterioles. It is commonly due to hypertension (high blood pressure), intracranial vascular malformations (including cavernous angiomas or arteriovenous malformation), cerebral amyloid angiopathy, or infarcts into which secondary hemorrhage has occurred. Other causes include trauma, bleeding disorders/tendency (bleeding diathesis), amyloid angiopathy, and illicit drug abuse such as cocaine & amphetamines.
• The 24-hour limit divides stroke from transient ischemic attack (TIA), a related syndrome of stroke symptoms that resolve completely within 24 hours. Treatment can reduce stroke severity when given early.
• TIA (Transient Ischemic Attack) or ‘mini stroke’ is a prodrome of stroke with neurological symptoms or temporary blinding (amaurosis fugax) that resolves in less than 24 hours.
• Various systems have been proposed to increase the recognition of stroke. Sudden-onset face weakness, arm drift (i.e., if a person, when asked to raise both arms, involuntarily lets one arm drift downward), and abnormal speech are the findings most likely to lead to the correct identification of a case of stroke, increasing the likelihood by 5.5 when at least one of these is present. Similarly, when all three of these are absent, the likelihood of stroke significantly decreases (likelihood ratio of 0.39). While these findings are not perfect for diagnosing stroke, the fact that they can be evaluated rapidly and easily makes them valuable in the acute setting.
• Ischemic stroke has the symptoms and signs of abrupt onset of hemiparesis (limb weakness, but not paralysis – palsy, in the half side of the body, right or left), hemiplegia (palsy on 1 side of the body, same leg, and hand, and same or opposite side of the face), monoparesis/ monoplegia (‘paresis’ is weakness, and ‘plegia’ is palsy, both refer to one limb, hand or leg), paraparesis/ paraplegia (weakness or palsy on both limbs – legs) or quadriparesis/ quadriplegia (both hands and legs weakness or palsy), dysarthria (difficulty on speaking), vertigo (dizziness with the rotational character), monocular (1 eye) or binocular (2 eyes) visual loss, visual field deficits and diplopia (double vision).
• However, many times, symptoms can distinguish ischemic from hemorrhagic stroke. Hemorrhagic stroke is usually (but not always) more abrupt and is characterized by the sudden onset of a headache, nausea, vomiting, photophobia (fear of light), visual changes, and loss of consciousness. These symptoms occur because of the increased intracranial pressure (ICP) from the leaking blood compressing the brain.
• If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke.
• Risk factors for stroke (described in the following chapter) are increasing age, hypertension, diabetes mellitus (MD), atrial fibrillation (AF, a heart arrhythmia often caused in pts with mitral valve stenosis or regurgitation), previous stroke or TIA (transient ischemic attack), myocardial infarction (MI; heart attack), smoking, alcohol, obesity, sedentary lifestyle with low physical activity, artificial heart valves, vasculitis (e.g., SLE lupus, other collagen diseases), hyperviscosity syndromes (hematological diseases), medications, cocaine, and coagulation defects.
• A physical examination, including a medical history of the symptoms and a neurological status, helps evaluate the location and severity of a stroke. Score systems like the NIH (National Institute of Health) stroke scale may help diagnostically.
• For the NIH stroke scale, you may visit https://en.wikipedia.org/wiki/National_Institutes_of_Health_Stroke_Scale
• The Cincinnati Prehospital Stroke Scale is used to diagnose a potential stroke in a pre-hospital setting. It tests three signs for abnormal findings, which may indicate that the patient is having a stroke. If any of the three tests show abnormal findings, the patient may have a stroke and should be transported to a hospital as soon as possible.
• a) Facial droop: Have the person smile or show their teeth. If one side doesn't move as well as the other, so it seems to droop, that could be a sign of a stroke.
• Normal: Both sides of the face move equally
• Abnormal: One side of the face does not move as well as the other (or at all)
• b) Arm drift: Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds. If one arm does not move, or one arm winds up drifting down more than the other, that could be a sign of a stroke.
• Normal: Both arms move equally or not at all
• Abnormal: One arm does not move, or one arm drifts down compared with the other side.
• c) Speech: Have the person say, ‘You can't teach an old dog new tricks,’ or some other simple, familiar saying. If the person slurs the words, gets some words wrong, or is unable to speak, that could be a sign of a stroke.
• Normal: Patient uses correct words with no slurring
• Abnormal: Slurred or inappropriate words or mute
• Patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke. If all 3 findings are present, the probability of an acute stroke is more than 85%.
• For diagnosing ischemic stroke in the emergency setting:
• a) Non–contrast CT scan (without contrast enhancements): sensitivity 16% and specificity 96%.
• b) MRI scan: sensitivity 83% and specificity 98%.
• For diagnosing hemorrhagic stroke in the emergency setting:
• a) Non–contrast CT scan (without contrast enhancements): sensitivity 89% and specificity 100%.
• b) MRI scan: sensitivity= 81% and specificity= 100%
• For detecting chronic hemorrhages, an MRI scan is more sensitive
• If a patient is suspected of suffering from a stroke, the clinician must perform an emergency non-contrast CT.
• A non-contrast CT is a CVA's main initial image test; however, a contrast CT, MRI, and SPECT/ PET may be used later. Recently, MRI has improved diagnostic sensitivity for acute stroke.
• CT angiogram (CTA) is a minimally invasive study requiring a time-optimized rapid intravenous contrast injection, and thin-section helical CT images are obtained in the arterial phase.
• CT perfusion is more widely available than magnetic resonance imaging (MRI) and can be performed quickly on any standard helical CT scanner right after unenhanced CT. A rapid intravenous contrast infusion is administered during CT perfusion, and brain sections are repeatedly imaged.
• MRI (magnetic resonance imaging) images (T1 and T2) are good at detecting vasogenic edema present in the subacute phase of stroke and seen at more than 24 hours to several days. Fast spin-echo T2-weighted sequences can clearly demonstrate areas of edema not visible on the CT and help identify a subacute stroke.
• MR diffusion is a technique that dramatically affects the approach and management of acute ischemic stroke patients. MR diffusion is diffusion-weighted images (DWI) and can be obtained within 10 minutes at some centers and dramatically alters care, so the clinical determination of ischemic stroke can be confirmed quickly.
• Perfusion imaging of the entire brain is one of the main advantages of perfusion-MR (perfusion-weighted imaging=PWI), in which MMT or TTP perfusion maps are generated for the entire brain
• Magnetic resonance angiography (MRA) can be performed with brain MRI in the stroke setting to help guide therapeutic decision-making. It can detect high-grade atherosclerotic lesions in the neck and head. It is also helpful for detecting less common causes of ischemic stroke, such as carotid and vertebral artery dissection, fibromuscular dysplasia, and venous thrombosis.
• Other diagnostic tools include:
• An ultrasound/ Doppler study of the carotid arteries to detect carotid stenosis or dissection of the precerebral arteries.
• An electrocardiogram (ECG) to identify arrhythmias and an echocardiogram (cardiac Echo) to detect resultant clots in the heart, which may spread to the brain vessels through the bloodstream.
• A Holter monitor study to identify intermittent abnormal heart rhythms.
• An angiogram of the cerebral vasculature (if a bleed is thought to have originated from an aneurysm or arteriovenous malformation)
• Blood tests to determine high blood cholesterol, if there is an abnormal tendency to bleed, and if some rarer processes such as homocystinuria might be involved.
• In case of ischemic (but not in hemorrhagic) stroke patient can be treated with the thrombolytic r-TPA (also used in STEMI), but only if there aren’t any contraindications for it (e.g., bleeding disease, recent major surgery, anticoagulation the past 48 hours, history of intracranial hemorrhage and so on), if patients are older than 18 years with BP (blood pressure) less than 185/110 old and if the patient has arrived less than 3 hours after the onset of the symptoms. The last condition minimizes the occasions of thrombolysis because most patients visit the hospital later than 3 hours from the onset of the symptoms. There should be a neurosurgical consultation for surgical treatment in hemorrhagic stroke (e.g., cerebellum hemorrhage).
• Prevention of stroke is essential and includes stopping smoking, avoiding excess alcohol, avoiding excess salt, doing regular exercise, having a healthy diet, and controlling our weight.
• Patients with non-hemorrhagic strokes are treated with antiplatelets such as aspirin (unless they take warfarin), which prevents stroke in patients with TIAs (transient ischemic attacks).
• In those who have previously had a stroke, treatment with medications such as aspirin, dipyridamole, and clopidogrel may be beneficial (clopidogrel is an alternative to aspirin intolerance). Of course, patients must consult their physician for drug therapy.
• Patients with AF (atrial fibrillation, an arrhythmia) are anticoagulated with warfarin, which is used for patients with rheumatic heart disease, prosthetic heart valve, and dilated cardiomyopathy. Also, patients should control their BP (blood pressure). Also, patients with stroke should take a statin (cholesterol-lowering agent), such as simvastatin. In case of patients with stroke or TIA history and/or more than 70% carotid artery stenosis (from atherosclerosis), then surgical therapy (carotid endarterectomy) or carotid artery angioplasty and stenting (if these patients don’t have any severe disability).
Cardiovascular disease (CVD, including coronary artery disease (CAD), stroke, and peripheral vascular disease (PVD)) risk factors
The cardiovascular disease (CVD) risk factors related to coronary artery disease (CAD) & stroke are classified into:
Modifiable: these include tobacco use/ smoking, hypertension (high blood pressure), dyslipidemia [increased blood lipids (fats), such as cholesterol and triglycerides], diabetes mellitus (elevated blood sugar), diet (rich with saturated fats and carbohydrates), overweight/ obesity, heart failure and left ventricular dysfunction, specific behavior (being competitive, combative, or feeling overly stressful) and sedentary lifestyle (lack of physical activity). Other modifiable risk factors include depression, increased blood fibrinogen (which is a factor of blood clotting), and increased blood homocysteine (congenital with premature atheromatosis or from decreased intake of vitamin B12, B6, and folic acid).
Hypertension is the single biggest risk factor for stroke. It also plays a significant role in heart attacks. It can be prevented and successfully treated if diagnosed, and the patient complies with their doctor’s recommended management plan.
Abnormal blood lipid levels comprise elevated levels of total cholesterol, triglycerides, low-density lipoprotein (LDL; also known as ‘bad’ cholesterol), or low levels of high-density lipoprotein (HDL; also known as ‘good’ cholesterol) cholesterol. High blood lipids increase the risk of heart disease and stroke. Changing to a healthy diet, exercise, and medication (such as the ‘statins’ cholesterol-lowering drugs) can modify the blood lipid profile.
Tobacco use, whether it is smoking or chewing tobacco, increases the risks of cardiovascular disease. The risk is especially high if someone has started smoking when young, smokes heavily or is a woman. Passive smoking is also a risk factor for cardiovascular disease. Stopping tobacco use can significantly reduce the risk of cardiovascular disease, no matter how long someone has smoked.
Physical inactivity increases the risk of heart disease and stroke by 50%. Obesity is a major risk for cardiovascular disease and predisposes to diabetes.
Diabetes is a risk factor for cardiovascular disease. Type 2 diabetes mellitus is a major risk factor for coronary heart disease and stroke. Having diabetes makes a person twice as likely as someone who does not develop cardiovascular disease. If diabetes is uncontrolled, the person is more likely to develop cardiovascular disease earlier than others, and it will be more devastating. In pre-menopausal (before menopause) women, diabetes cancels out the protective effect of estrogen, and the risk of heart disease rises significantly.
A diet high in saturated fat increases the risk of heart disease and stroke. It is estimated to cause about 31% of coronary artery disease (CAD) and 11% of strokes worldwide.
Being poor, no matter where in the globe, increases the risk of heart disease and stroke. A chronically stressful life, social isolation, anxiety, and depression increase the risk of heart disease and stroke.
Having one to two alcoholic drinks a day may lead to a 30% reduction in heart disease, but above this level, alcohol consumption will damage the heart muscle.
Certain medicines such as contraceptive pills and hormone replacement therapy (HRT) may increase the risk of heart disease.
Left ventricular hypertrophy (LVH) is a risk factor for cardiovascular mortality.
Non – modifiable heart disease risk: age, men (if less than 65 years old, because of the protective role of estrogens on women; after menopause, women have a similar risk to men. Risk of stroke, however, is similar for men and women), race (e.g., from India), low socioeconomic status, personal or family medical history of CHD, and low birth weight [IUGR (intrauterine growth restriction), SGA (small for gestational age)].
Simply getting old is a risk factor for cardiovascular disease; the risk of stroke doubles every decade after age 55.
A family’s history of cardiovascular disease indicates the risk. If a first-degree blood relative has had coronary heart disease or stroke before the age of 55 years (for a male relative) or 65 (for a female relative), the risk increases.
Gender is significant: a man is at greater risk of heart disease than a pre-menopausal (before menopause) woman. But after menopause, women have a similar risk to men.
Ethnic origin also plays a role. People with African or Asian ancestry risk developing cardiovascular disease more than other racial groups.
· For an online risk calculator, you may visit:
Stroke risk & prevention
· For a stroke risk calculator, you may check:
· For a stroke risk calculator for patients with atrial fibrillation:
http://www.preventaf-strokecrisis.org/calculator/
• Some factors for stroke that can’t be modified by medical treatment or lifestyle changes include:
• Age.
• Stroke occurs in all age groups. Studies show the risk of stroke doubles for each decade between the ages of 55 and 85. But strokes can also occur in childhood or adolescence. Although stroke is often considered a disease of aging, the risk of stroke in childhood is highest during the perinatal period, encompassing the last few months of fetal life and the first few weeks after birth.
• Gender.
• Men have a higher risk for stroke, but more women die from stroke. Men live fewer years than women, so men are usually younger when they have a stroke and, therefore, have a higher survival rate.
• Race.
• People from certain ethnic groups have a higher risk of stroke. For African Americans, stroke is more common and more deadly (even in young and middle-aged adults) than for any ethnic or another racial group in the USA. Studies show that the age-adjusted incidence of stroke is about twice as high in African Americans and Hispanic Americans as in Caucasians. An important risk factor for African Americans is sickle cell disease, which can cause a narrowing of arteries and disrupt blood flow. The incidence of the various stroke subtypes varies considerably in different ethnic groups.
• Family history of stroke.
• Stroke seems to run in some families. Several factors may contribute to familial stroke. Family members might have a genetic tendency for stroke risk factors, such as an inherited predisposition for high blood pressure (hypertension) or diabetes. A common lifestyle's influence among family members could also contribute to familial stroke.
• Some of the most important treatable risk factors for stroke are:
• Hypertension (high blood pressure)
• Hypertension is by far the most potent risk factor for stroke. Hypertension causes a two to four-fold increase in the risk of stroke before age 80. If blood pressure is high, the patient’s doctor must devise a strategy to bring it down to the normal range. Some ways that work: Maintaining proper weight. Avoiding drugs is known to raise blood pressure. Eating right: cutting down on salt and eating fruits and vegetables to increase potassium in the diet. Exercising more. A doctor may prescribe medicines that help lower blood pressure. Controlling blood pressure will also help avoid heart disease, diabetes, and kidney failure.
• The goal is to maintain blood pressure (BP) of less than 120 the systolic BP (top number) over less than 80 the diastolic BP (bottom number). Someone can achieve it by:
• Reducing the salt in the diet to a maximum of 1,500 milligrams a day (about a half teaspoon).
• Avoiding high-cholesterol foods, such as burgers, cheese, and ice cream.
• Eating 4 to 5 cups of fruits and vegetables daily, fish two to three times a week, and several servings of whole grains and low-fat dairy.
• Getting more exercise: at least 30 minutes of daily activity, and more, if possible.
• Quit smoking.
• If needed, taking blood pressure-lowering medicines (antihypertensive drugs).
• Cigarette smoking
• Cigarette smoking causes about a two-fold increase in the risk of ischemic stroke and up to a four-fold increase in the risk of hemorrhagic stroke. It has been linked to atherosclerosis (hardening of the arteries) in the carotid artery (the main neck artery supplying blood to the brain). Blockage of this artery is the leading cause of stroke in Americans. Also, nicotine raises blood pressure; carbon monoxide from smoking reduces the amount of oxygen blood can carry to the brain. Cigarette smoke makes the blood thicker and more likely to clot. Smoking also promotes aneurysm formation. A doctor can recommend programs and medications that may help quit smoking. Quitting at any age also reduces the risk of lung disease, heart disease, and several cancers, including lung cancer.
• Heart disease
• Common heart disorders such as coronary artery disease (CAD), valve defects, atrial fibrillation (an irregular heartbeat), and ventricular hypertrophy (enlargement of one of the heart's chambers) can result in blood clots that may break loose and block vessels in or leading to the brain. Atrial fibrillation (AF), more prevalent in older people and people with hyperthyroidism and alcoholics, is responsible for one in four strokes after age 80 and is associated with higher mortality and disability. The most common blood vessel disease is atherosclerosis (hardening of the arteries). Hypertension promotes atherosclerosis and causes mechanical damage to the walls of blood vessels. A doctor will treat heart disease and may also prescribe medication, such as aspirin, to help prevent the formation of clots. A doctor may also recommend surgery to clean out a clogged neck artery if the patient matches a particular risk profile. If someone is over fifty, NINDS scientists believe that the patient and their doctor should decide about aspirin therapy. A doctor can evaluate the risk factors and help someone decide if they will benefit from aspirin or other blood-thinning therapy.
• Diabetes mellitus
• In terms of stroke and cardiovascular disease, having diabetes is the equivalent of aging 15 years. Diabetes mellitus causes destructive changes in the blood vessels throughout the body, including the brain. Also, if blood glucose levels are high at the time of a stroke, then brain damage is usually more severe and extensive than when blood glucose is well-controlled. Hypertension is common among diabetics, accounting for much of their increased stroke risk. Treating diabetes can delay the onset of complications that increase the risk of stroke.
• Cholesterol imbalance
• Low-density lipoprotein cholesterol (LDL – cholesterol; ‘bad’ cholesterol) carries cholesterol (a fatty substance) through the blood and delivers it to cells. Excess LDL-cholesterol can cause cholesterol to build up in blood vessels, leading to atherosclerosis (hardening of the arteries). Atherosclerosis is the major cause of blood vessel narrowing, leading to heart attack and stroke.
• Physical inactivity and obesity.
• Obesity and inactivity are associated with hypertension, diabetes, and heart disease. Waist circumference to hip circumference ratio equal to or above the mid-value for the population increases the risk of ischemic stroke three-fold.
• Warning signs or history of TIA (transient ischemic attack) or stroke.
• If someone experiences a TIA, they should get help at once. If someone previously had a TIA or stroke, the risk of a stroke is many times greater than someone who has never had one. Many communities encourage those with stroke warning signs to dial 911 (or 112 in Europe) for emergency medical assistance. If someone has had a stroke in the past, reducing the risk of a second stroke is important. A second stroke can be twice as bad.
• Aspirin
• The landmark Women’s Health Initiative study found that women over 65 taking daily baby aspirin lowers stroke risk. Aspirin helps by preventing blood clots from forming.
• The goal: Taking a baby aspirin every day (if it’s appropriate for the specific person). First, someone must talk to a doctor to ensure aspirin is safe and appropriate. If the patient has a bleeding disorder, they may need to reduce the dose every other day or avoid this regimen altogether.
• Drinking in moderation
• Drinking can make someone less likely to have a stroke, up to a point. Studies show that the risk may be lower if someone has about one drink per day. However, once the person starts drinking more than two drinks daily, their risk increases sharply.
• The goal: Drinking alcohol in moderation. How to achieve it:
• Have one glass of alcohol a day.
• Make red wine the first choice because it contains resveratrol & polyphenols, which are thought to protect the heart and brain.
• Watch the portion sizes. A standard-sized drink is a 5-ounce glass of wine, 12-ounce beer, or 1.5-ounce glass of hard liquor.
• Exercising
• Exercise contributes to losing weight and lowering blood pressure and is also an independent stroke reducer. One 2012 study found that women who walked three hours a week were less likely to have a stroke than women who didn’t walk.
• The goal: Exercising at least five days a week moderately. How to achieve it:
• Taking a walk around the neighborhood every morning after breakfast.
• Starting a fitness club with friends.
• When someone is exercising, they should reach the level at which they are breathing hard but can still talk.
• Taking the stairs instead of an elevator.
• If someone doesn’t have thirty consecutive minutes to exercise, they may break it up into 10 to 15-minute sessions a few times daily.
• Losing weight if overweight or obese
• Obesity and its complications, including hypertension (high blood pressure) and diabetes mellitus, raise the odds of stroke. If someone is overweight, losing as little as 10 pounds (4.5 kg) can impact their stroke risk.
• The goal: Keeping body mass index (BMI) at 25 or less. How to achieve it:
• The body mass index (BMI) is a value derived from an individual's mass (weight) and height. BMI is defined as the body mass divided by the square of the body height and is universally expressed in units of kg/m2, resulting from mass in kilograms and height in meters.
• For a BMI calculator, you may visit
http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi-m.htm
http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi-m.htm
• BMI Categories:
• Underweight = <18.5
• Normal weight = 18.5–24.9
• Overweight = 25–29.9
• Obesity = BMI of 30 or greater
TIPS for reducing BMI if >25:
• Limiting or avoiding saturated and trans fats.
• Trying to eat no more than 1,500 to 2,000 calories daily (depending on the person’s activity level and current body mass index).
• Increasing the amount of exercise with activities such as walking, golfing, or playing tennis and making the activity part of every day.
Thanks for reading!
Reference – Links(Retrieved: January 20, 2016):https://en.wikipedia.org/wiki/Stroke#Definition https://en.wikipedia.org/wiki/National_Institutes_of_Health_Stroke_Scale https://en.wikipedia.org/wiki/Cincinnati_Prehospital_Stroke_Scale http://www.ajnr.org/content/early/2013/08/01/ajnr.A3690.full.pdfhttp://emedicine.medscape.com/article/1916852-overviewhttp://emedicine.medscape.com/article/1916662-overviewhttp://www.hindawi.com/journals/srt/2013/767212/http://www.uptodate.com/contents/neuroimaging-of-acute-ischemic-strokehttp://emedicine.medscape.com/article/338385-overview#showallhttp://stroke.ahajournals.org/content/24/11/1691.full.pdfhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088377/http://www.thelancet.com/pdfs/journals/laneur/PIIS1474-4422(10)70185-X.pdfhttp://www.ninds.nih.gov/disorders/stroke/preventing_stroke.htm#Treatable Risk Factorshttp://www.health.harvard.edu/womens-health/8-things-you-can-do-to-prevent-a-strokehttp://www.stroke.org/understand-stroke/preventing-strokehttps://en.wikipedia.org/wiki/Body_mass_indexBibliographyLongo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J.L., Loscalzo J.L., Harrison’s manual of medicine, 18th edition, McGraw – Hill, 2013.Longmore M., Wilkinson I.B., Davidson E.H., Foulkes A., Mafi A.R., Oxford Handbook of Clinical Medicine, 8th edition, Oxford University Press, 2010.Ahmed N., Clinical Biochemistry, Oxford University Press, 2010.Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.Longmore M., Wilkinson I., Turmezei T., Kay Cheung C., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 7th edition, 2008.Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.Stone C.K., Humphries R.L., Current Diagnosis and Treatment in Emergency Medicine, McGraw – Hill LANGE, 6th edition, 2008.Disease prevention & health maintenance, p. 1103 – 1130, Harrison’s Manual of Medicine, Fauci A.S., Braunwald E.B., Kasper D.L., Hauser S.L., Longo D.L., Jameson J.L., Loscalzo J., 17th edition, Mc Graw Hill Medical, 2009. mcgraw-hillmedical.comScreening in the future, p. 160 – 161, Oxford Handbook of General Practice, C. Simon, H. Everitt, T. Kendrick, 2nd edition, Oxford University Press,2005. www.oup.com
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