2. Stroke 101

3. Goals of Presentation What is a stroke? Types of stroke Warning signs of stroke Why did I have a stroke? Are there treatments for stroke? How can I prevent a stroke?

4. What Is a Stroke? Interruption of normal blood flow to the brain Ischemic Blockage or clot 80% of strokes Hemorrhagic Rupture of blood vessel 20% of strokes

5. Stroke Types Ischemic (blood clot) stroke Embolic Neck blockage (carotid artery) Heart (atrial fibrillation) Thrombotic Cholesterol plaque ruptures Artery becomes blocked at the plaque

6. Ischemic Stroke Hemorrhagic Stroke

7. Carotid Ultrasound

8. How Common Is Stroke? 4th leading cause of death in U.S. 795,000 strokes/year 1 every 40 seconds 130,000 deaths from stroke/year 1 out of every 17 deaths in the USA Stroke is a leading cause of serious, long- term disability in the U.S. Data from NINDS, CDC, American Heart Association

9. Stroke Warning Signs Sudden onset of: Weakness or numbness of the face, arm or leg, especially on one side of the body Confusion, trouble speaking or understanding Trouble seeing in one or both eyes Trouble walking, dizziness, loss of balance or coordination Severe headache with no known cause

10. Stroke Warning Signs FAST Face Arm Speech Time

11. Why Did I Have a Stroke?

12. Stroke Risk Factors Modifiable High blood pressure Heart disease Atrial fibrillation Smoking High cholesterol Diabetes Carotid atherosclerosis Heavy alcohol Drug abuse Non-modifiable Age Sex Race History of prior stroke Family history

13. Why Did I Have a Stroke? Ischemic stroke 80% Hemorrhagic stroke 12% Other 5% Cryptogenic 30% Heart 20% Small vessel disease “lacunae” 25% Atherosclerosis 20%

14. Are There Any Stroke Treatments?

15. Early Treatment Better IV-tPA Clot-buster that re-opens arteries < 3 hours* from symptom onset * May be extending to 4.5 hours soon Earlier the better! Dead brain Dying brain

16. Other Treatments None approved for stroke treatment yet… Clot retrieval devices

17. None approved for stroke treatment yet… Clot retrieval devices Clot suctioning devices Newer clot-busting drugs Combination treatments clot-buster + blood thinners clot-buster + ultrasound / microbubbles clot-buster + cooling body temperature Other Treatments

18. Stroke Prevention Primary Prevent a first-ever stroke Secondary (Recurrent) Prevent a second stroke [after the 1 st ]

19. Primary Prevention Stop smoking Keep blood pressure, cholesterol and diabetes under control Irregular heartbeat, atrial fibrillation – work with your doctor to control Eat a healthy diet Increase physical activity

20. Primary Prevention Smoking New treatments are available Talk to your doctor Multiple attempts might be necessary Don’t get discouraged if you failed once (or twice)

21. Primary Prevention Hypertension Goal BP <140/90 Diabetes Normal finger stick blood sugars 80-120 Hemoglobin A1c blood test < 7.0 Cholesterol LDL (bad cholesterol) < 100 Always try diet and exercise first

22. Primary Prevention Hypertension Goal BP <140/90 Small changes in your BP can result in large decrease in your stroke risk (as little as 2-3 points) Example: BP 142/90  139/84

23. Atrial Fibrillation (Afib) Irregular heart rhythm Predisposes to stroke During heart pauses  blood pools  forms a blood clot  travels to the brain  STROKE Stroke prevention Anticoagulation Usually with warfarin (Coumadin) Get your blood levels: INR: goal 2-3 New treatments are on the way….

24. Primary Prevention Carotid stenosis >60% blockage meets criteria for surgery Even if no history of stroke

25. Primary Prevention Sickle Cell Disease (SCD) Predisposes patients (mostly children of African- American decent) to stroke Ultrasounds (Transcranial Doppler- TCD) help select patients who need blood transfusions Transfusions significantly reduce the chance of having a first-ever stroke By 91%!

26. Secondary Prevention Blood thinners Aspirin Clopidogrel Extended-release dipyridamole/aspirin Warfarin More aggressive lowering of cholesterol Surgery for carotid plaque

27. Secondary Prevention High Blood Pressure (Hypertension) Small reductions = BIG impact on stroke 60 80 100 120 140 160 136912182430364248 Months of follow-up Blood pressure (mm Hg) Average BP difference: 9 /4 mm Hg BP Meds Sugar pill Systolic Diastolic

28. Proportion with 2 nd Stroke Sugar pill BP Meds 0.2 0.15 0.10 0.05 0.0 0 1234 (Years) 28% reduction Stroke Risk Reduction

29. High Blood Pressure You may need 3 or more medications Goal 120/80 Get your own blood pressure cuff Take it twice a day Write the #s down and show your doctor

30. Diabetes Goal is to get sugars back to a normal range Hemoglobin A1c Average of blood sugars over 3 months Goal for stroke patients <7.0 May need multiple medications including insulin

31. High Cholesterol 2 important forms of cholesterol LDL (“bad”) & HDL (“good”) Statin medications: goal is primarily to get the LDL lower Statins: depends on whether there is a history of heart disease If history of heart disease (& stroke) Start if the LDL is >100 Target of <70 if multiple risk factors Data from: Stroke 2008;39:1647-1652.

32. High Cholesterol QUESTION: But I’ve only had a stroke and I don’t have a history or heart disease. Should I be on a statin medication? ANSWER: Yes, if your LDL is >100. Data from: Stroke 2008;39:1647-1652.

33. Modify and improve what you eat Monitor portion control Increase fruits, vegetables and whole grains Bake, roast or grill foods Drink water Healthier Eating

34. It all adds up – do what you can do! Improvement comes from you! Patient has to be motivated to move or do exercises. Do it safely Work up to 30 minutes/day for exercise Can include walking, chair exercise Exercise

35. A Dreaded 2 nd Stroke Within 5 years of your first stroke Your risk for another stroke can increase more than 40% 24% of women and 42% of men will experience a second (recurrent) stroke Recurrent strokes Higher rate of death and disability because parts of the brain already injured by the original stroke may not be as resilient

36. “But Doc….I Feel Fine” Goal is prevention You won’t feel the medicines working Follow your doctor’s directions and take your medicine