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Stroke is a disorder that results from impaired blood supply to the brain. Usually a stroke results from an obstructed blood vessel or a burst blood vessel in the brain.

Stroke is a very difficult disorder to treat. In fact, the majority of stroke therapies are effective only as preventions. Most post-stroke treatment methods involve non-drug therapies like rehabilitation and physical therapy. In addition, stroke is generally a disease that affects people with greater frequency as age increases. It is estimated that about 72% of all stroke victims are over the age of 65.

Types of Stroke

There are four types of stroke; two of which result from a blood vessel obstruction, and two of which result from hemorrhage of a blood vessel. The two types of stroke resulting from a blood vessel obstruction are cerebral thrombosis, and cerebral embolism. A cerebral thrombosis refers to a clot that forms and plugs the blood vessel, thereby decreasing blood flow to the brain. A cerebral embolism refers to a blockage in a blood vessel leading to the brain that has been caused by a blood clot that has formed elsewhere in the body (usually the heart), and then moves to the brain. Cerebral embolisms occur commonly in people with atrial fibrillation. Many of the blood clots that form during strokes are formed at night or during morning hours. Often, a stroke is preceded by a transient ischemic attack (TIA), or "mini stroke".

A TIA, or "mini stroke", usually results from atherosclerosis and is usually short lasting. The symptoms of TIA are much like a stroke, and include: weakness, tingling, numbness, language problems, confusion, vertigo, poor balance. Even though the symptoms of TIA usually pass quickly, it is still a very dangerous problem. It has been shown that 1/3 of all people who experience a TIA go on to have a full blown stroke within five years. TIA's are most effectively prevented by controlling blood pressure. Risk factors that contribute to the incidence of a TIA include:

1. Male Over the Age of 60
2. African-American Race
3. Diabetes
4. High Blood Pressure
5. Family History of TIA or Stroke
6. Age (especially over the age of 75)

The two types of stroke resulting from blood vessel hemorrhage are; cerebral hemorrhage, and subarachnoid hemorrhage. These have a much higher fatality rate, although they are sometimes reversible, unlike a stroke resulting from an embolism. A subarachnoid hemorrhage refers to the bursting of a blood vessel on the outside of the brain, which causes the leaking of blood into the space between the brain and the skull but not into the brain. A cerebral hemorrhage refers to the rupture of a defective or weakened artery in the brain which causes the leaking of blood into the surrounding brain. Hemorrhages may kill certain parts of the brain or interfere with brain function by increasing pressure on certain areas of the brain. Increased pressure on certain areas of the brain results from increased blood flow to the tissue surrounding the hemorrhage.

When determining proper treatment/prevention options, it is imperative to consider the type of stroke that has occurred or may occur. Stroke prevention and treatment is always specific to the individual.

The Frequency of Stroke

Stroke is the third leading cause of death and adult disability in the United States. Only cancer and heart disease kill more people yearly. It is estimated that there are about 4.4 million stroke survivors alive today, and that about 600,000 people suffer from a stroke per year. Out of the estimated 600,000 yearly stroke sufferers, about 500,000 are thought to be first attacks, while about 100,000 are thought to be recurrent strokes.

Of the four types of stroke, the most common is cerebral thrombosis. In fact, cerebral thrombosis and cerebral embolism account for 70-80% of all strokes. Also, 15% of all strokes occur in people with atrial fibrillation (cerebral embolism), of which atrial fibrillation is a risk factor that accounts for 14% of all strokes.

Two less frequent types of stroke are cerebral hemorrhage and subarachnoid hemorrhage. About 7% of strokes are caused by subarachnoid hemorrhages, and about 10% of strokes are caused by cerebral hemorrhages. It is interesting to note that of the approximately 10% of stroke sufferers that experience a cerebral hemorrhage, about 50% die from increased pressure in the brain. Nevertheless, people who survive a cerebral hemorrhage tend to recover much better than those who had a stroke that was caused by a blood clot.

The Effects of a Stroke

Stroke can affect someone by two different mechanisms; either by diminishing blood supply to the brain, or by increasing pressure in the brain resulting from blood released during a hemorrhage. Thus, brain cells may die or function inappropriately. As a result, the following symptoms are often observed:

1. Weakness
2. Tingling
3. Numbness (on one or both sides of the body)
4. Language Problems
5. Confusion
6. Vertigo
7. Poor Balance

Not only can stroke diminish a persons quality of life, but it can also lead to hospitalization or even death. It is estimated that about half of all people hospitalized for quick onset neurologic diseases are stroke victims.

Depending on the type of stroke, and the severity of the stroke, people are affected differently. Brain injury resulting from a stroke can affect a person in a number of ways including: uncontrollable emotions, loss of awareness, diminished perception (i.e. damaged seeing, moving, touching, or thinking), problems speaking, problems understanding speech, dysphagia (trouble swallowing or eating), and impaired ability to think clearly. Thus, the severity of stroke necessitates proper treatment and/or prevention, whether before or after a stroke.

Non-Drug Prevention/Treatment

Non-drug therapy is very limited but can be very useful for some individuals. Since atherosclerosis can contribute to the likelihood of a stroke, diet control may be very useful for people with high cholesterol or people who may be at risk for developing atherosclerosis. To learn more about the diagnosis and treatment of high cholesterol Click Here.

Recently, surgical therapy has been developed that decreases the likelihood of a recurring cerebral infarction for people who suffer TIA's.

Drug Therapies for Stroke Prevention/Treatment

When the decision has been made to use preventive drug therapy, people must consider the risks and benefits of Coumadin (Warfarin), Aspirin, Plavix, and Ticlid (Ticlodipine) therapy. Three of these drugs (Aspirin, Plavix and Ticlid) are effective antiplatelet therapies, and Coumadin reduces the level of clotting factors. All of these drugs decrease the likelihood of developing a blood clot that can lead to a stroke. Plavix is preferred over Ticlid. Often the toughest decision is between Aspirin or Coumadin use.

Whereas Coumadin is expensive it is still considered to be a cost-effective drug. However, it has been shown that people under the age of 65, who do not have significant risk factors, do not benefit from Coumadin use when compared with cost. This conclusion was made by a study printed in the Journal of the American Medical Association in 1995. The study compared the cost of Coumadin therapy with the avoided costs of rehabilitation and hospitalization.

It has also been shown that Coumadin therapy is proven extremely beneficial for those with risk factors for cerebral embolism resulting from atrial fibrillation. In addition, Coumadin has been shown to be superior to Aspirin when used in people who have suffered from a recent thromboembolic event. However, it is important to note that Coumadin increases the risk of severe hemorrhage, which is a very significant risk in some older adults.

In general, the following criteria can be used to get a good idea of what type of anticoagulant therapy to use:

1. People under the age of 75, who don't have significant risk factors, can use Aspirin.
2. People under the age of 75, who do have significant risk factors and have no contraindications to Coumadin, can use Coumadin.
3. People older than 75 years, with or without significant risk factors, can benefit from either anticoagulation therapy, but should keep in mind the risk of gastrointestinal (GI) bleeding and drug-induced intracranial bleeding.

People should always discuss therapy options with their doctor. Stroke prevention is always adjusted to the individual and thus requires the help of a doctor.

If Aspirin is chosen for anticoagulant therapy, then the lowest dose possible should be used. It has been shown that GI bleeding is directly proportional to the daily dose of Aspirin taken. Regardless of Aspirin's relative risk of GI ulceration, it has been shown that it does not increase the risk of intracranial hemorrhage proportionally with dose. Therefore, Aspirin may be useful for people at significant risk of intracranial hemorrhage, in particular, people over the age of 75. It is important to note that Aspirin has been shown to be effective in reducing the number of TIA's, and thus may be a good option for people with recurring TIA's.

Two other anticoagulant therapies exist, both of which are minimally effective. They include Anturane (Sulfinpyrazone) and Persantine (Dipyridamole). Persantine weakly inhibits platelet aggregation, but has not been shown to be useful as a single agent in stroke prevention. Thus, Persantine is an AgeNet excluded form of stroke prevention. Anturane has also been shown to inhibit platelet aggregation, although it has been shown only to have a limited use in stroke prevention. Nevertheless, Anturane is a better antiplatelet option than Persantine and is thus an AgeNet non-preferred form of stroke prevention.

Calcium channel blockers, like Nimotop (Nimodipine) and Cardene (Nicardipine), have also been shown to reduce the incidence of stroke in people with high blood pressure. Calcium channel blockers are usually used to manage hypertension, and some have even been shown to be more effective than Coumadin therapy. The use of certain calcium channel blockers like Nimotop and Cardene is supported by the finding that a direct relationship exists between reduction of blood pressure and a decrease in the incidence of stroke. Nevertheless, not all antihypertensives have been proven effective, in particular alpha 1 blockers, and centrally acting antihypertensive agents. It is important to keep in mind that Nimotop and Cardene are more effective only for people that require antihypertensive therapy.

Until recently, treatments for stroke did not exist. A new drug, called Activase (Tissue Plasminogen Activator), has been developed that is extremely effective in treating people with strokes that result from a thromboembolic event. Nevertheless, Activase has limitations; it must be administered within three hours of the stroke and it must not be given to people who suffer a stroke that results from a hemorrhage, otherwise severe intracranial bleeding could result. Two other drugs that are similar to Activase, in that they can break up blood clots, are Eminase (APSAC) and Streptase (Streptokinase). Both are manufactured using bacteria which makes these drugs more prone to causing allergic reactions. Because of this, Activase may be the best clot lysing option.

Another drug, Heparin (in particular low-molecular weight heparins like Lovenox), has been shown to be effective at reducing the likelihood of developing an early recurrent ischemic stroke. Heparin is generally administered after the stroke has occurred for a short amount of time or until antiplatelet therapy begins.

In addition to understanding drug therapy options, it is important to note that people who seek treatment at a combined acute and rehabilition clinic have better outcomes than those who are treated in general wards. It is widely accepted that the combination of acute treatment with rehabilitation at the same clinic helps practitioners understand each individual better.

We hope this review has provided you with information to help you become informed about the prevention and treatment options available for stroke.

Drugs Used To Treat Stroke

Drug	Cost	Manufacturer	Generic	Cost
Heparin	$ (various)	brand	Heparin	$ (various)
Activase (Tissue Plasminogen Activator)	$$$$	brand	no	na

Drugs Used To Inhibit Clot Formation

Preferred Drugs	Cost	Manufacturer	Generic	Cost
Aspirin	$	brand	Aspirin	$
Coumadin	$$$	brand	Warfarin	$$
Plavix (Clopidogrel)	$$$$	brand	no	na

Non-Preferred Drugs	Cost	Manufacturer	Generic	Cost
Anturane	$$	brand	Sulfinpyrazone	$

Excluded Drugs	Cost	Manufacturer	Generic	Cost
Ticlid (Ticlodipine)	$$$	brand	no	na
Persantine	$$	brand	Dipyridamole	$

Calcium Channel Blockers

Drug	Cost	Manufacturer	Generic	Cost
Nimotop (Nimodipine)	$$$$$	brand	no	na
Cardene (Nicardipine)	$$$	brand	no	na

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