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Learn About Stroke:

Stroke

Stroke


Definition


A stroke is an interruption of the blood supply to any part of the brain. A stroke is sometimes called a "brain attack."

Alternative Names


Cerebrovascular disease; CVA; Cerebral infarction; Cerebral hemorrhage; Ischemic stroke; Stroke - ischemic

Causes


Every 45 seconds, someone in the United States has a stroke. A stroke can happen when:

  • A blood vessel carrying blood to the brain is blocked by a blood clot. This is called an ischemic stroke.
  • A blood vessel breaks open, causing blood to leak into the brain. This is a hemorrhagic stroke.

If blood flow is stopped for longer than a few seconds, the brain cannot get blood and oxygen. Brain cells can die, causing permanent damage.

ISCHEMIC STROKE

This is the most common type of stroke. Usually this type of stroke results from clogged arteries, a condition called atherosclerosis. (See stroke secondary to atherosclerosis.) Fatty deposits collect on the wall of the arteries, forming a sticky substance called plaque. Over time, the plaque builds up. Often, the plaque causes the blood to flow abnormally, which can cause the blood to clot. There are two types of clots:

  • A clot that stays in place in the brain is called a cerebral thrombus.
  • A clot that breaks loose and moves through the bloodstream to the brain is called a cerebral embolism.

Another important cause of cerebral embolisms is a type of arrhythmia called atrial fibrillation. Other causes of ischemic stroke include endocarditis, an abnormal heart valve, and having a mechanical heart valve. A clot can form on a heart valve, break off, and travel to the brain. For this reason, those with mechanical or abnormal heart valves often must take blood thinners.

HEMORRHAGIC STROKE

A second major cause of stroke is bleeding in the brain hemorrhagic stroke. This can occur when small blood vessels in the brain become weak and burst. Some people have defects in the blood vessels of the brain that make this more likely. The flow of blood after the blood vessel ruptures damages brain cells.

STROKE RISKS

High blood pressure is the number one reason that you might have a stroke. The risk of stroke is also increased by age, family history of stroke, smoking, diabetes, high cholesterol, and heart disease.

Certain medications increase the chances of clot formation, and therefore your chances for a stroke. Birth control pills can cause blood clots, especially in woman who smoke and who are older than 35.

Men have more strokes than women. But, women have a risk of stroke during pregnancy and the weeks immediately after pregnancy.

Cocaine use, alcohol abuse, head injury, and bleeding disorders increase the risk of bleeding into the brain.

See also:

  • Stroke secondary to carotid dissection (bleeding from the carotid arteries)
  • Stroke secondary to carotid stenosis (narrowing of the carotid arteries)
  • Stroke secondary to cocaine use
  • Stroke secondary to FMD (fibromuscular dysplasia)
  • Stroke secondary to syphilis
  • Hemorrhagic stroke
  • Arteriovenous malformation (AVM)

Symptoms


The symptoms of stroke depend on what part of the brain is damaged. In some cases, a person may not even be aware that he or she has had a stroke.

Usually, a SUDDEN development of one or more of the following indicates a stroke:

  • Weakness or paralysis of an arm, leg, side of the face, or any part of the body
  • Numbness, tingling, decreased sensation
  • Vision changes
  • Slurred speech, inability to speak or understand speech, difficulty reading or writing
  • Swallowing difficulties or drooling
  • Loss of memory
  • Vertigo (spinning sensation)
  • Loss of balance or coordination
  • Personality changes
  • Mood changes (depression, apathy)
  • Drowsiness, lethargy, or loss of consciousness
  • Uncontrollable eye movements or eyelid drooping

If one or more of these symptoms is present for less than 24 hours, it may be a transient ischemic attack (TIA). A TIA is a temporary loss of brain function and a warning sign for a possible future stroke.

Exams and Tests

In diagnosing a stroke, knowing how the symptoms developed is important. The symptoms may be severe at the beginning of the stroke, or they may progress or fluctuate for the first day or two (stroke in evolution). Once there is no further deterioration, the stroke is considered completed.

During the exam, your doctor will look for specific neurologic, motor, and sensory deficits. These often correspond closely to the location of the injury in the brain. An examination may show changes in vision or visual fields, abnormal reflexes, abnormal eye movements, muscle weakness, decreased sensation, and other changes. A "bruit" (an abnormal sound heard with the stethoscope) may be heard over the carotid arteries of the neck. There may be signs of atrial fibrillation.

Tests are performed to determine the type, location, and cause of the stroke and to rule out other disorders that may be responsible for the symptoms. These tests include:

  • Head CT or head MRI -- used to determine if the stroke was caused by bleeding (hemorrhage) or other lesions and to define the location and extent of the stroke.
  • ECG (electrocardiogram) -- used to diagnose underlying heart disorders.
  • Echocardiogram -- used if the cause may be an embolus (blood clot) from the heart.
  • Carotid duplex (a type of ultrasound) -- used if the cause may be carotid artery stenosis (narrowing of the major blood vessels supplying blood to the brain).
  • Heart monitor -- worn while in the hospital or as an outpatient to determine if a heart arrhythmia (like atrial fibrillation) may be responsible for your stroke.
  • Cerebral (head) angiography -- may be done so that the doctor can identify the blood vessel responsible for the stroke. Mainly used if surgery is being considered.
  • Blood work may be done to exclude immune conditions or abnormal clotting of the blood that can lead to clot formation.

Treatment


A stroke is a medical emergency. Physicians have begun to call it a "brain attack" to stress that getting treatment immediately can save lives and reduce disability. Treatment varies, depending on the severity and cause of the stroke. For virtually all strokes, hospitalization is required, possibly including intensive care and life support.

The goal is to get the person to the emergency room immediately, determine if he or she is having a bleeding stroke or a stroke from a blood clot, and start therapy -- all within 3 hours of when the stroke began.

IMMEDIATE TREATMENT

Thrombolytic medicine, such as tPA, breaks up blood clots and can restore blood flow to the damaged area. People who receive this medicine are more likely to have less long-term impairment. However, there are strict criteria for who can receive thrombolytics. The most important is that the person be examined and treated by a specialized stroke team within 3 hours of when the symptoms start. If the stroke is caused by bleeding rather than clotting, this treatment can make the damage worse -- so care is needed to diagnose the cause before giving treatment.

In other circumstances, blood thinners such as heparin and Coumadin are used to treat strokes. Aspirin may also be used.

Other medications may be needed to control associated symptoms. Pain killers may be needed to control severe headache. Medicine may be needed to control high blood pressure.

Nutrients and fluids may be necessary, especially if the person has swallowing difficulties. The nutrients and fluids may be given through an intravenous tube (IV) or a feeding tube in the stomach (gastrostomy tube). Swallowing difficulties may be temporary or permanent.

For hemorrhagic stroke, surgery is often required to remove pooled blood from the brain and to repair damaged blood vessels.

LONG-TERM TREATMENT

The goal of long-term treatment is to recover as much function as possible and prevent future strokes. Depending on the symptoms, rehabilitation includes speech therapy, occupational therapy, and physical therapy. The recovery time differs from person to person.

Certain therapies, such as repositioning and range-of-motion exercises, are intended to prevent complications related to stroke, like infections and bed sores. People should stay active within their physical limitations. Sometimes, urinary catheterization or bladder/bowel control programs may be needed to control incontinence.

The person's safety must be considered. Some people with stroke appear to have no awareness of their surroundings on the affected side. Others show indifference or lack of judgment, which increases the need for safety precautions. For these people, friends and family members should repeatedly reinforce important information, like name, age, date, time, and where they live, to help the person stay oriented.

Caregivers may need to show the person pictures, repeatedly demonstrate how to perform tasks, or use other communication strategies, depending on the type and extent of the language problems.

In-home care, boarding homes, adult day care, or convalescent homes may be required to provide a safe environment, control aggressive or agitated behavior, and meet medical needs.

Behavior modification may be helpful for some people in controlling unacceptable or dangerous behaviors.

Family counseling may help in coping with the changes required for home care. Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful.

Legal advice may be appropriate. Advance directives, power of attorney, and other legal actions may make it easier to make ethical decisions regarding the care of a person who has had a stroke.

Support Groups


Additional support and resources are available from the American Stroke Association -- www.strokeassociation.org.

Outlook (Prognosis)


The long-term outcome from a stroke depends on the extent of damage to the brain, the presence of any associated medical problems, and the likelihood of recurring strokes.

Of those who survive a stroke, many have long-term disabilities, but about 10% of those who have had a stroke recover most or all function. Fifty percent are able to be at home with medical assistance while 40% become residents of a long-term care facility like a nursing home.

Possible Complications


  • Problems due to loss of mobility (joint contractures, pressure sores)
  • Permanent loss of movement or sensation of a part of the body
  • Bone fractures
  • Muscle spasticity
  • Permanent loss of brain functions
  • Reduced communication or social interaction
  • Reduced ability to function or care for self
  • Decreased life span
  • Side effects of medications
  • Aspiration
  • Malnutrition

When to Contact a Medical Professional


Call your local emergency number (such as 911) if someone has symptoms of a stroke. Stroke requires immediate treatment!

Prevention


To help prevent a stroke:

  • Get screened for high blood pressure every 1 - 2 years, especially if you have a family history of high blood pressure.
  • Have your cholesterol checked. If you are high risk, your LDL "bad" cholesterol should be lower than 100 mg/dL. Your doctor may recommend you try to reduce your LDL cholesterol to as low as 70 mg/dL.
  • If you have high blood pressure, diabetes, high cholesterol, and heart disease, make sure you follow your doctor's treatment recommendations.
  • Follow a low-fat diet.
  • Quit smoking.
  • Exercise regularly -- 30 minutes a day if you are not overweight; 60 - 90 minutes a day if you are overweight.
  • Do not drink more than 1 to 2 alcoholic drinks a day.

Aspirin therapy (81mg a day or 100mg every other day) is now recommended for stroke prevention in women under 65 as long as the benefits outweigh the risks. It should be considered for women over age 65 only if their blood pressure is controlled and the benefit is greater than the risk of gastrointestinal bleeding and brain hemorrhage. Ask your doctor if aspirin is right for you.

Your doctor may also recommend that you take aspirin or another blood thinner if you have had a TIA or stroke in the past, or if you currently have a heart arrhythmia (like atrial fibrillation), mechanical heart valve, congestive heart failure, or risk factors for stroke.

Carotid endarterectomy (removal of plaque from the carotid arteries) may help prevent new strokes from occurring in people with large blockage in their blood vessels.

References


American Heart Association. Heart Disease and Stroke Statistics -- 2005 Update. Dallas, Texas: American Heart Association; 2005.

Goldman L, Ausiello D, eds. Cecil Textbook of Medicine, 22nd ed. Philadelphia, Pa: Saunders; 2004.

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002.

Mosca L, Banka CL, Benjamin EJ, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007; Published online before print February 19, 2007.

Wolff T, Miller T. Evidence for the reaffirmation of the U.S. Preventive Services Task Force recommendation on screening for high blood pressure. Ann Intern Med. 2007;147(11): 787-91.

 

Review Date: 3/21/2008
Reviewed By: A.D.A.M. Editorial Team: David Zieve, MD, MHA, Greg Juhn, MTPW, David R. Eltz, Kelli A. Stacy, ELS. Previously reviewed by Larry A. Weinrauch, MD, Assistant Professor of Medicine, Harvard Medical School, and Private practice specializing in Cardiovascular Disease, Watertown, MA. Review provided by VeriMed Healthcare Network (3/15/2007).
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
adam.com

Hemorrhagic Stroke

Hemorrhagic stroke


Definition


Hemorrhagic stroke involves bleeding within the brain, which damages nearby brain tissue. See also:

  • Hypertensive intracerebral hemorrhage
  • Intracerebral hemorrhage

Alternative Names


Brain bleeding; Brain hemorrhage; Stroke - hemorrhagic

Causes


Hemorrhagic stroke occurs when a blood vessel bursts inside the brain. The brain is very sensitive to bleeding and damage can occur very rapidly, either because of the presence of the blood itself, or because the fluid increases pressure on the brain and harms it by pressing it against the skull.

Bleeding irritates the brain tissue, causing swelling. The surrounding tissues of the brain resist the expansion of the bleeding, which is finally contained by forming a mass (hematoma). Both swelling and hematoma will compress and displace normal brain tissue.

Most often, hemorrhagic stroke is associated with high blood pressure, which stresses the artery walls until they break.

Another cause of hemorrhagic stroke is an aneurysm. This is a weak spot in an artery wall, which balloons out because of the pressure of the blood circulating inside the affected artery. Eventually, it can burst and cause serious harm. The larger the aneurysm is, the more likely it is to burst. It is unclear why people develop aneurysms, but genes may play a role, since aneurysms run in families.

Stroke can also be caused by the accumulation of a protein called amyloid within the artery walls, particularly in the elderly. This makes the arteries more prone to bleeding.

Amyloid protein is also implicated in the brain damage related to Alzheimer's disease, but the difference is that people with Alzheimer´s disease have amyloid accumulation in the brain tissue instead of in the arteries. Therefore people with Alzheimer´s usually do not develop brain bleeding.

Some people with brain hemorrhage have abnormal connections between arteries and veins. Under normal circumstances, circulating blood travels through the arteries into the capillaries, where it provides nutrients and oxygen to the tissues. Once the blood has deposited the nutrients and oxygen, it is carried back to the heart from the capillaries via the veins.

In some people, however, a brain artery may connect directly to a vein, instead of going through the capillaries first. This is called an arterial-venous malformation (AVM). Since blood pressure in the arteries is much greater than in the veins, the veins may rupture, causing bleeding into the brain.

Another important brain disease that can cause bleeding is cancer. This is especially true for cancers that spread to the brain from distant organs, such as the breast, skin, and thyroid.

About 20% of strokes are hemorrhagic -- but the other 80% are caused by the opposite problem: too little blood reaching an area of the brain, which is usually due to a clot that has blocked a blood vessel. This is called "ischemic stroke." This type of stroke can sometimes lead to a brain hemorrhage because the affected brain tissue softens and this can lead to breaking down of small blood vessels.

In addition, brain hemorrhage can occur when people have problems forming blood clots. Clots, which are the body's way of stopping any bleeding, are formed by proteins called coagulation factors and by sticky blood cells called platelets. Whenever the coagulation factors or platelets do not work well or are insufficient in quantity, people may develop a tendency to bleed excessively.

Some medications (often used, ironically, to prevent ischemic stroke) prevent clot formation. These work by blocking the production of clotting factors (such as the blood thinner warfarin) or interfering with the function of platelets (such as aspirin). The most common side effects of such medications is bleeding, which may occasionally affect the brain. Controlling bleeding to avoid stroke is a very fine balancing act.

Illicit drugs, such as cocaine, can also cause hemorrhagic stroke.

Symptoms


Stroke symptoms are typically of sudden onset and may quickly become worse. The following is a list of possible problems:

  • Weakness or inability to move a body part
  • Numbness or loss of sensation
  • Decreased or lost vision (may be partial)
  • Speech difficulties
  • Inability to recognize or identify familiar things
  • Sudden headache
  • Vertigo (sensation of the world spinning around)
  • Dizziness
  • Loss of coordination
  • Swallowing difficulties
  • Sleepy, stuporous, lethargic, comatose, or unconscious

Exams and Tests


A neurologic exam is almost always abnormal. The patient may look drowsy and confused. An eye examination may show abnormal eye movements, and changes may be seen upon retinal examination (examination of the back of the eye with an instrument called ophthalmoscope). The patient may have abnormal reflexes. However, these findings are not specific to brain hemorrhage.

The most important test to confirm the presence of a brain hemorrhage is a CT scan, which provides pictures of the brain. A CT scan should be obtained without delay. A brain magnetic resonance imaging (MRI) scan can also be obtained later to better understand what caused the bleeding. A conventional angiography (x-ray of the arteries using dye) may be required to identify aneurysms or AVM.

Other tests may include:

  • CBC
  • Bleeding time
  • Prothrombin/partial thromboplastin time (PT/PTT)
  • CSF (cerebrospinal fluid) examination (rarely needed)

Treatment


Treatment includes life-saving measures, relieving symptoms, repairing the cause of the bleeding, preventing complications, and starting rehabilitation as soon as possible. Recovery may occur over time as other areas of the brain take over functioning for the damaged areas.

IMMEDIATE TREATMENT

Treatment is ideally administered in an intensive care unit, where complications can immediately be detected. Medical personnel pay careful attention to breathing because sometimes persons with brain hemorrhage develop very irregular breathing patterns or even stop breathing entirely.

A person having a hemorrhagic stroke may be unable to protect the airway during coughing or sneezing because of impaired consciousness. Saliva or other secretions may go "down the wrong pipe," which is potentially serious and may cause lung problems such as aspiration pneumonia. To treat or prevent these breathing problems, a tube may need to be placed through the mouth into the trachea to start mechanical ventilation.

The blood pressure may be too high or too low in patients with brain hemorrhage. These problems need to be addressed immediately by doctors. In addition, brain bleeding may cause swelling of surrounding brain tissue, and this may require therapy with some drugs called hyperosmotic agents (mannitol, glycerol, and hypertonic saline solutions).

Bedrest may be advised to avoid increasing the pressure in the head (intracranial pressure). This may include avoiding activities such as bending over, lying flat, sudden position changes or similar activities. Stool softeners or laxatives may prevent straining during bowel movements (straining also causes increased intracranial pressure).

Medications may relieve headache but should be used with caution because they may reduce consciousness. This may produce the wrong impression that the patient is getting worse. Antihypertensive medications may be prescribed to moderately reduce high blood pressure. Medications such as phenytoin may be needed to prevent or treat seizures.

Nutrients and fluids may need to be supplemented if swallowing difficulties are present. This can be intravenous or through a feeding tube into the stomach (gastrostomy tube). Swallowing difficulties may be temporary or permanent.

Positioning, range-of-motion exercises, speech therapy, occupational therapy, physical therapy, and other interventions may be advised to prevent complications and promote maximum recovery of function.

SURGERY

Sometimes, surgery is needed to save the patient's life or to improve the chances of recovery. The type of surgery depends upon the specific cause of brain bleeding. For example, a hemorrhage due to an aneurysm requires special treatment (see aneurysm).

For other types of bleeding, removal of the hematoma may occasionally be needed, especially when bleeding occurs in the back of the brain. Some physicians are currently investigating whether the injection of a "clot buster" inside the hematoma can facilitate the removal of brain hemorrhages through needles or catheters, allowing less invasive surgery.

One common problem related to brain bleeding is hydrocephalus, which is the accumulation of a water-like fluid within the brain cavities called ventricles. To solve this problem, the fluid may need to be drained with a special procedure called ventriculostomy.

For AVM, different treatments are available, including surgical removal of the AVM network, radiosurgery (using ionizing radiation to reduce the size of the AVM), and intra-arterial embolization (a procedure in which glue is injected into the AVM to close the connection between arteries and veins).

LONG-TERM TREATMENT

Recovery time and the need for long-term treatment are highly variable in each case. Physical therapy may benefit some patients. Activity should be encouraged within the person's physical limitations. Alternative forms of communication such as pictures, verbal cues, demonstration or others may be needed depending on the type and extent of language deficit. Speech therapy, occupational therapy, or other interventions may increase the ability to function.

Urinary catheterization or bladder or bowel control programs may be required to control incontinence.

A safe environment must be considered. Some people with stroke appear to have no awareness of their surroundings on the affected side. Others show a marked indifference or lack of judgment, which increases the need for safety precautions.

In-home care, boarding homes, adult day care, or convalescent homes may be required to provide a safe environment, control aggressive or agitated behavior, and meet physiologic needs.

Behavior modification may be helpful for some patients in controlling unacceptable or dangerous behaviors. This consists of rewarding appropriate or positive behaviors and ignoring inappropriate behaviors (within the bounds of safety). Reality orientation, with repeated reinforcement of environmental and other cues, may help reduce disorientation.

Family counseling may help in coping with the changes required for home care. Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful.

Legal advice may also be appropriate early in the course of the disorder. Advance directives, power of attorney, and other legal actions may make it easier to make ethical decisions regarding the care of the person with hemorrhagic stroke.

Outlook (Prognosis)


Stroke is the third leading cause of death in developed countries. About one-forth of people who have a stroke die as a result of the stroke or its complications, about one-half have long-term disabilities, and about one-forth recover most or all function.

Hemorrhagic stroke is less common but more frequently fatal than ischemic stroke.

Possible Complications


  • Pressure sores
  • Permanent loss of movement or sensation of a part of the body
  • Joint contractures
  • Muscle spasticity
  • Permanent loss of cognitive or other brain functions (dementia)
  • Disruption of communication, decreased social interaction
  • Decreased ability to function or care for self
  • Decreased life span
  • Urinary and respiratory tract infections

When to Contact a Medical Professional


Go to the emergency room or call the local emergency number (such as 911) if symptoms of stroke occur. A stroke is a "brain attack," and minutes can make a huge difference in disability and death rates.

Emergency symptoms include seizures or breathing difficulties, loss of consciousness, sudden difficulties with movement or sensation, eating or swallowing difficulties, sudden vision change or loss of vision in one or both eyes, rapid onset of speech changes, and sudden (severe) headache.

Call your health care provider if the condition of a family member with stroke deteriorates to the point that the person cannot be cared for at home.

Prevention


Most cases of hemorrhagic stroke are associated with specific risk factors, such as high blood pressure, smoking, or cocaine use. Controlling blood pressure and avoiding smoking and cocaine can reduce the chances of brain bleeding. Surgery to correct blood vessel abnormalities like aneurysms or AVMs is sometimes advisable to prevent bleeding.

 

Review Date: 9/10/2006
Reviewed By: Daniel Kantor, MD, Director of the Comprehensive MS Center, Neuroscience Institute, University of Florida Health Science Center, Jacksonville, FL. Review provided by VeriMed Healthcare Network.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
adam.com

Mini Stroke

Transient ischemic attack


Definition


A transient ischemic attack is a "mini-stroke" caused by temporary disturbance of blood supply to an area of the brain, which results in a sudden, brief decrease in brain function.

Alternative Names


Mini stroke; TIA; Little stroke

Causes


In a TIA, the blood supply is only temporarily blocked. For example, a blood clot may dissolve and allow blood to flow normally again.

A TIA is different than a small stroke. The symptoms of TIAs go away in less than 24 hours, usually less than one hour. TIAs do not show lasting changes on CT or MRI scans. (Small strokes do show changes on such tests.) TIAs are like warnings that a true stroke may happen in the future if something is not done to prevent one.

A brief interruption in the blood flow to the brain can cause a decrease in brain function. This is called a neurologic deficit. Too little blood flow to the brain for some time can cause brain cells to die.

The loss of blood flow to the brain can be caused by:

  • Narrowing of a blood vessel
  • Blood clot within an artery of the brain
  • Blood clot that travels to the brain from somewhere else in the body (for example, the heart)
  • Injury to blood vessels

Atherosclerosis ("hardening of the arteries") is a condition where fatty deposits occur on the inner lining of the arteries. This condition dramatically increases the risk for both TIAs and stroke. Approximately 80-90% of people who have a stroke due to atherosclerosis had a TIA episode before.

Less common causes of TIA include:

  • Blood disorders (including polycythemia, sickle cell anemia, and hyperviscosity syndromes where the blood is very thick)
  • Spasm of the small arteries in the brain
  • Problems with blood vessels caused by disorders such as fibromuscular dysplasia, inflammation of the arteries (arteritis, polyarteritis, granulomatous angiitis), systemic lupus erythematosus, and syphilis.

In some cases, hypotension (low blood pressure) may be seen before symptoms of a TIA occur. Other risks for TIA include high blood pressure (hypertension), heart disease, migraine headaches, smoking, diabetes, and increasing age.

About a third of those diagnosed with TIA will later have a stroke. TIAs are more common among men and black people.

Symptoms


Symptoms of TIA are the same as those that occur in stroke and include the sudden development of:

  • Numbness, tingling, changes in sensation
  • Weakness, heavy feeling of extremities
  • Speech difficulty (garbled speech; slurred speech)
  • Vision changes
    • Loss of vision in one eye
    • Decreased vision
    • Double vision
  • Sensation that the person or the room is moving (vertigo)
  • Loss of balance
  • Lack of coordination
  • Gait changes, staggering
  • Falling (caused by weakness in the legs)

Additional symptoms:

  • Facial paralysis
  • Eye pain
  • Confusion

Note: Symptoms begin suddenly, last only a short time (from a few minutes to 24 hours), and disappear completely. Symptoms may occur again at a later time. Symptoms usually occur on the same side of the body if more than one body part is involved.

Exams and Tests


Because symptoms and signs may have completely disappeared by the time one gets to the hospital, A diagnosis of a TIA may be made on a person's medical history alone.

A physical examination should include a neurological exam, which may be abnormal during an episode but normal after the episode has passed.

Blood pressure may be high. The doctor will use a stethoscope to listen to your heart and arteries. An abnormal sound called a bruit may be heard when listening to the carotid artery in the neck or other artery. A bruit is caused by irregular blood flow.

Tests will be done to rule out a stroke or other disorder that may cause the symptoms. Tests to diagnose a TIA may include:

  • CBC and PT tests to rule out a blood disorder
  • Head CT scan or cranial MRI
  • Carotid duplex (ultrasound)
  • Echocardiogram
  • Cerebral arteriogram

Additional tests and procedures may include:

  • Blood glucose
  • Blood chemistry
  • Serum lipids
  • ESR (Sedimentation rate)
  • Tests for syphilis
  • ECG
  • Chest x-ray

Your doctor may use these tests to check for hypertension, heart disease, diabetes, high blood lipids, vasculitis, and peripheral vascular disease.

Treatment


The goal is to improve the arterial blood supply to the brain and prevent the development of a stroke.

Treatment of recent TIA (within the prior 48 hours) usually requires admission to the hospital for evaluation of the specific cause and determination of long-term treatment. Underlying disorders should be treated appropriately, including such disorders as hypertension, heart disease, diabetes, arteritis, and blood disorders.

Smoking should be stopped.

Treatment of symptoms of blood disorders (such as erythrocytosis, thrombocytosis, or polycythemia vera, which include an increase in the number of some types of blood cells) may include phlebotomy, hydration, and treatment of the underlying (causative) blood disorder. Antihypertensive medications may be used to control high blood pressure. Medications to lower cholesterol may be useful in reducing high blood cholesterol levels.

Platelet inhibitors and anti-coagulant medications (blood thinners) may be used to reduce clotting. Aspirin is the most commonly used medication. Others include dipyridamole, clopidogrel, Aggrenox or heparin, Coumadin, or other similar medications. Treatment may be continued for an indefinite time period.

A reduced amount of sodium in the diet to help control high blood pressure; diet for diabetics; reduced dietary fat, or other dietary changes may be recommended.

Surgery (carotid endarterectomy) may be appropriate for some people.

Outlook (Prognosis)


By definition, an episode of TIA is brief and recovery is complete. It may recur later that same day or at a later time. Some people have only a single episode, some have recurrent episodes, and some will have a stroke. A TIA needs to be treated as aggressively as a stroke would, as any given TIA could develop into a stroke.

Possible Complications


  • Stroke
  • TIA recurrence
  • Injury that occurs from falls
  • Bleeding as a result of anti-coagulant medications

When to Contact a Medical Professional


TIA is a medical emergency. Call 911 or other local emergency number immediately. Do not ignore symptoms just because they resolve! They may be a warning of an impending stroke. Even if symptoms resolve completely, it is important to call your healthcare provider or an emergency number and get immediate medical attention.

Prevention


Prevention of TIA includes controlling the risk factors. Hypertension, diabetes, heart disease, and other associated disorders should be treated as appropriate. Smoking should be stopped.

The use of blood thinners may prevent strokes in some patients who have blood clots or atrial fibrillation.

Aspirin therapy (81mg a day or 100mg every other day) is now recommended for stroke prevention in women under 65 as long as the benefits outweigh the risks. Women over age 65 should take aspirin to prevent heart attack and stroke only if their blood pressure is controlled and the benefit is greater than the risk of gastrointestinal bleeding and brain hemorrhage.

Carotid endarterectomy in select patients may prevent stroke.

References


Mosca L, Banka CL, Benjamin EJ, et al. Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update. Circulation. 2007; Published online before print February 19, 2007.

 

Review Date: 2/20/2007
Reviewed By: Updated by: A.D.A.M. Editorial Team: Greg Juhn, M.T.P.W., David R. Eltz, Kelli A. Stacy. Previously reviewed by Daniel Kantor, M.D., Director of the Comprehensive MS Center, Neuroscience Institute, University of Florida Health Science Center, Jacksonville, FL. Review provided by VeriMed Healthcare Network.(2006)
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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Speech impairment

Speech impairment (adult)


Definition


Speech impairment may be any of several speech problems, particularly the following:

  • Dysarthria is difficult, poorly pronounced speech, such as slurring.
  • Aphasia is a problem with expressing or understanding written or spoken language.

Dysarthria is occasionally confused with aphasia. It is important to distinguish between a difficulty in pronunciation of words, as opposed to a problem with the production of language, as these have different causes.

Alternative Names


Language impairment; Impairment of speech; Inability to speak; Aphasia; Dysarthria; Slurred speech

 

Considerations


DYSARTHRIA

Dysarthria is generally apparent in daily conversation where there is difficulty expressing certain sounds or words. This condition may be caused by taking excess medications such as narcotics, phenytoin, or carbamazepine. Alcohol intoxication causes dysarthria.

Degenerative neurological (nervous system) disorders affecting the cerebellum, basal ganglia, or brainstem (all are important parts of the brain) can also cause dysarthria. Stroke that affects the brainstem or cerebellar regions can also cause dysarthria. Any facial weakness, such as Bell's palsy or tongue weakness, can cause dysarthria.

APHASIA

Aphasia is loss of communication skills that were previously learned. It commonly occurs following strokes, or in people with brain tumors or degenerative diseases that affect the language areas of the brain. This term does not apply to children who have never developed communication skills.

In some cases of aphasia, the problem eventually corrects itself, but in others the condition is irreversible.

Causes


DYSARTHRIA

  • Poorly fitting dentures
  • Alcohol intoxication
  • Side effects of medications that act on the central nervous system
  • Degenerative neurological disorders, such as Parkinson disease or Huntington disease (more common in dysarthria than aphasia)
  • Stroke
  • Transient ischemic attack (TIA)
  • Head trauma
  • Other dementias
APHASIA
  • Head trauma
  • Alzheimer's disease
  • Stroke
  • Transient ischemic attack (TIA)
  • Brain tumor (more common in aphasia than dysarthria)
  • Other dementias

Home Care


For dysarthria, speaking slowly is encouraged, and the use of hand gestures, when necessary, is recommended. Family and friends need to provide plenty of time for those afflicted with the disorder to express themselves. Medications that are causing the problem should be stopped, if possible. Use of alcohol should be minimized.

For aphasia, family members may need to provide frequent orientation reminders, such as what day it is, because disorientation and confusion often follow the onset of aphasia.

A relaxed, calm environment where external stimuli are kept to a minimum is important.

Speak in a normal tone of voice (this condition is not a hearing or emotional problem), use simple phrases to avoid misunderstandings, and don't assume that the affected person understands. Frustration, profanity, and depression are typical responses in people suffering from aphasia.

Provide communication aids, if possible, depending on the particular person and condition.

When to Contact a Medical Professional


  • If impairment or loss of communication comes on suddenly, call your health care provider immediately.
  • If there is any unexplained impairment of speech or written language, call your provider.

What to Expect at Your Office Visit


The health care provider will take a medical history and perform a physical examination. The medical history may require the assistance of family or friends.

Medical history questions documenting speech impairment may include the following:

  • When did it develop?
  • Did it develop suddenly?
  • Is there a problem with clearly pronouncing words (dysarthria)?
  • Is there a problem understanding speech?
  • Is there a problem expressing thoughts through speech?
  • Is there a problem understanding writing?
  • Is there a problem expressing thoughts through writing?
  • Has there been a recent head injury?
  • Are there problems with dentures?
  • What medications are used?
  • Is there recent or former heavy alcohol use?
  • What other symptoms are also present?

The physical examination will include a detailed evaluation of brain function.

Diagnostic tests that may be performed include the following:

  • CT scan of the head
  • MRI of the head
  • EEG
  • X-rays of the skull
  • Blood tests
  • Urine tests
  • Lumbar puncture
  • MR angiography
  • Cerebral angiography

The health care provider may provide a referral to a speech pathologist, and in some cases, to a social worker.

 

Review Date: 9/7/2006
Reviewed By: Kenneth Gross, M.D., Neurology, North Miami, FL. Review provided by VeriMed Healthcare Network.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- 2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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