Presented By: Enrique Leira, MD, MS Learning Objec-ves § 
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How and why strokes occur Factors that increase your risk of stroke Ways to prevent stroke The signs to idenCfy stroke How to cope with the effects of stroke. Major U.S. Public Heath Burden § 
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800,000 strokes per year 1 stroke < 45 seconds 5° Cause death 1° Cause disability What is a Stroke? §  Sudden Injury to part of the brain §  Death of brain cells due to a vascular problem (blood flow) §  Blockage of an artery (Ischemic) §  Breaking of an artery (hemorrhagic) Types of Stroke ISCHEMIC §  Arterial (80%) §  Venous (2%) HEMORRHAGIC §  Intracerebral (13%) §  Subarachnoid (5%) Why do Strokes Occur? Atherosclerosis § 
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Also known as fat deposits in arteries Affects all arteries (Brain, heart, legs) GeneCc predisposiCon High Blood Pressure Diabetes High Cholesterol Smoking Other Non-­‐atherosclero-c Arterial Causes § 
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Artery Injury (dissecCons) Drugs InflammaCon (VasculiCs) InfecCons RadiaCon Injury Clot Lodged Artery § 
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Also known as embolism Comes from heart Through the heart (hole) Variety of causes (heart disease) Atrial fibrillaCon increases with age Sources Clots “Emboli” §  Atrial fibrillaCon is an abnormal heart rhythm with irregular contracCons §  Causes stagnaCon of blood à clots §  Atrial fibrillaCon increases with age §  Mechanical ProstheCc Valves §  Heart Valve Disease §  Recent Heart A_ack Causes of Bleeding Brain §  Damage on arteries from High blood pressure §  Aneurysms §  Vascular MalformaCons §  Drugs §  Blood Thinners §  Alcohol Binges Factors that Increase Risk of Stroke § 
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Prior Stroke Age Gender Race Hypertension Atrial FibrillaCon Diabetes Smoking Hyperlipidemia §  Obesity §  Physical InacCvity §  Postmenopausal /
Estrogen Replacement §  Migraine §  Drug and Alcohol abuse Ways to Prevent Stroke Medical Choices §  ✓ Blood Pressure, and treat if needed §  ✓ Cholesterol, and treat if needed §  ✓ Blood Sugar, and treat if needed §  If Atrial fibrillaCon: blood thinners Personal Choices §  Exercise regularly §  Loose weight §  Eat healthy (vegetables, fruit, grains) §  Quit smoking & drugs §  Moderate alcohol Signs of Stroke: Sudden.. § 
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Unusual headache Speech disturbance Ignoring one side of the world Weakness one side Numbness one side IncoordinaCon one side Loss or double vision Inability to walk Dizziness Unique Stroke Symptoms in Women Loss of consciousness or fainCng Nausea or vomiCng Seizures Hiccups Sudden shortness of breath and chest pain §  HallucinaCons § 
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FAST An easy way to remember the signs of stroke, and what to do, is by the acronym F.A.S.T. §  FACE. Ask the person to smile. Check to see if one side of the face droops. §  ARMS. Ask the person to raise both arms. See if one arm drigs downward. §  SPEECH. Ask the person to repeat a simple sentence. Check to see if words are slurred and if the sentence is repeated correctly. §  TIME. If a person shows any of these symptoms, Cme is essenCal. It is important to get to the hospital as quickly as possible. Call 9-­‐1-­‐1. Act F.A.S.T. Stroke or TIA (Transient Ischemic ARack)? § 
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Symptoms are the same DuraCon shorter with TIA Same Risk Factors Same Way to prevent Stroke leaves a “scar” on imaging Is important to react the same (rapidly) regardless Ischemic Stroke is a Time-­‐Dependent Emergency In Stroke/TIA Time is B
rain! PENUMBRA=
COLLATERAL FLOW
(20-50 cc/100gr/min)
INITIAL
INFARCT
CORE
<20cc/
100gr/min
PROGRESSIVE DEATH (1.9 MILLION NEURONS/minute)
FINAL
INFARCT
What to do if someone is having a stroke? § 
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Note last Cme normal Don’t give an aspirin (or anything by mouth) Call 911 Request the closest Stroke Center Chain of Survival for Stroke PaCent & Family Response EMS Stroke Center The ER is going to need Witnesses What can be done for Stroke? Thrombolysis IV rtPA <4.5h Stroke Unit Ancillary Care Decompresive Surgery Large MCA, cerebellar InfarcCons Endovascular IA Therapy? rtPA (Clot Bus-ng Drug) § 
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Breaks clots in the body Can be given within 4.5h Infusion over one hour Need a CT scan and meet criteria Has bleeding risks Doubles Odds of favorable outcome The sooner is given, be_er outcomes Benefit of rtPA depends on Time to Treatment Marler et al. Neurology 2000
Clot Removal Therapy § Remove clots that did not open with rtPA §  Need specialized team §  Only available comprehensive centers PRE
POST
Surgical Treatment §  Stroke leads swelling §  Large strokes can lead to lethal increases in pressure within skull §  Surgery might allow survival of such strokes Dedicated Stroke Units Lead to BeRer Outcomes 47.20%
40.10%
25.40%
20.90%
Stroke Unit
Control
NTT=22
Dead
Dependent
Causes of Death
Survival Stroke §  6.4 million stroke survivors in the US •  73% have residual disability § Impaired movement, sensaCon, cogniCon, vision, etc. § Limited acCviCes of daily living § Restricted parCcipaCon in community life •  ~65% are unable to walk 1 week post •  ~80% have arm weakness The Brain Repairs itself aXer Stroke Rehabilita-on Speeds that Process § 
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Physical Therapy OccupaConal Therapy Speech Therapy InpaCent unit OutpaCent Therapy Summary §  Strokes can be prevented §  Stroke is a Cme-­‐dependent emergency §  “Cme is brain” §  Efficient treatment starts with early recogniCon by public §  We have effecCve stroke intervenCons §  Stroke can be largely prevented