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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Man to Man Man to Man
 

Guys -- Start Protecting Your Brain Now!


January 24, 2013

By Harvey B. Simon M.D.

Harvard Medical School

Nearly 800,000 Americans will have a stroke in 2008 and about 150,000 will die as a result. To put it another way, every 40 seconds, someone in the United States has a stroke, and every three to four minutes someone dies from a stroke.

Most men who suffer strokes have a long history of risk factors that can be detected and treated to head off a "brain attack" and brain damage. Start protecting your brain now by:

  • Getting tested for risk factors
  • Treating any risk factors you have
  • Learning to recognize warning symptoms and know what to do about them
  • Calling 911 if you or your loved ones show signs of a stroke.

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Who's Vulnerable?

Although young people can have strokes, the problem is much more common in older individuals. Between the ages of 55 and 75, strokes are more common in men than women.

Some strokes occur without rhyme or reason, but most people who have a stroke have one or more of these risk factors:

  • High blood pressure
  • Heart disease
  • Smoking
  • Diabetes
  • Lack of exercise
  • Obesity
  • Abnormal cholesterol levels
  • Drug abuse

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Mini Strokes: A Warning From the Brain

Strokes develop when something interferes with the brain's blood supply. Sometimes a brief interruption in blood flow occurs that can be a warning sign of a future stroke. The patient develops symptoms that are similar to those of a stroke, but they go away completely when blood flow is restored and the brain cells recover. These warning attacks or "mini-strokes" are called transient ischemic attacks or TIAs. No brain cells die. A person usually recovers in less than an hour and the symptoms are always gone within 24 hours.

Typical Symptoms of TIAs and Strokes

  • Tingling, numbness, or loss of feeling in the face, arm, or leg, especially on one side of the body
  • Weakness or inability to move the muscles of the face, arm, or leg, especially on one side of the body
  • Difficulty finding words or speaking clearly
  • Difficulty understanding spoken words
  • Loss of vision, especially in one eye
  • Severe dizziness, incoordination, or loss of balance
  • A sudden, very severe headache

Because TIAs are brief, at least half the men who have them never even tell their doctors. That's a big mistake, since about 10% of TIA patients have a true stroke within the next three months.

Contact your doctor promptly if you have symptoms of a possible TIA. In most cases you'll be evaluated for stroke risk factors and you'll have a carotid ultrasound to check for blockages in the arteries in your neck that carry blood to your brain. You'll also have an EKG and possibly an echocardiogram (ultrasound exam of the heart) to check for problems that can cause blood clots.

But if blood flow to a small area of the brain is permanently interrupted, a true mini stroke can occur. Because the damage is so small, patients don't notice them at all. But people who suffer a series of silent, little strokes often develop memory loss, or dementia. You can protect your brain from this terrible problem by controlling your blood pressure and other risk factors.

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Types of Strokes

There are two types of major strokes:

  • Ischemic strokes – About 90% of strokes develop when a blood clot blocks an artery in the brain, depriving brain cells of the oxygen-rich blood they need. In some cases, the clot starts in the brain artery itself. More often, though, the clot develops in the heart or in one of the large arteries that carry blood to the brain. These clots break off and travel to the brain, where they do their damage.

 

  • Hemorrhagic strokes – About 10% of stokes develop when a blood vessel in the brain leaks or bursts. In some cases, blood spills into the brain tissue itself. In others, the blood seeps into the fluid that surrounds the brain. Hemorrhagic strokes usually cause a horrible headache and collapse. Often, the culprit is a tiny area of damage in the wall of one of the brain's arteries.

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What To Do When You Suspect a Stroke

Symptoms of a stroke should trigger a call to 911 and a prompt trip to the emergency room. Treatment needs to start as soon as possible for it to work best.

It's difficult to remember all the possible symptoms of stroke during an emergency. Here is a simple way to determine if someone is having and stroke so you can act FAST:

  • Face: Ask the person to smile. If one side droops, it may indicate a TIA or stroke.

 

  • Arms: Ask the person to hold out both arms in front of the body. If one arm droops, it may indicate a TIA or stroke.

 

  • Speech: Ask the person to repeat a simple sentence. Slurred speech, garbled words, or other errors may indicate a stroke or TIA.

 

  • Time: If any warning signs are present, call 911. Ask for the nearest hospital with an emergency department and, if possible, a stroke center.

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Evaluating Stroke Patients

If you have symptoms that could indicate a stroke, your doctors will consider the following, often with the help of specialists:

  • Monitoring and managing your blood pressure and vital functions

 

  • Testing for diabetes, cholesterol and kidney function

 

  • Testing for heart disease, usually with an immediate EKG and often with an echocardiogram (heart ultrasound)

 

  • Imaging the brain and its circulation. A CT scan is often the first step, sometimes followed by an MRI. Doctors can also evaluate blood vessels in the neck and brain by using a contrast material (CT-angiography, MR-angiography.

 

  • Testing for carotid artery blockages (ultrasound, CTA, MRA)

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Treatment

Stroke treatment is complicated and tricky. Whenever possible, it should take place in a stroke center where neurologists, neurosurgeons and neuroradiologists can work together.

All patients need to have their blood pressure, heart and lung function, and metabolism carefully monitored. Additional treatment depends on the type of stroke and must always be tailored to a particular patient's needs. Here are some general considerations:

Ischemic strokes

  • "Clot busting drugs" – To be effective, this treatment, which opens blocked brain arteries, must be given within a few hours of the stroke. To be safe, it must be prescribed by experts who take the risk of bleeding into account.

 

  • Anti-platelet treatment – This reduces the risk of new clots and additional strokes. Low-dose aspirin (81 mg a day) is the mainstay of anti-platelet therapy. Many experts recommend adding the prescription drug dipyridamole (Persantin). Another prescription drug, clopidogrel (Plavix), may be helpful in special circumstances.

 

  • Carotid endarterectomy or angioplasty with stent – Certain patients who have severe narrowing of the carotid artery benefit from an operation to open the artery and prevent additional strokes. But simple anti-platelet therapy can protect many patients with less severe carotid blockages.

 

  • Anticoagulants ("blood thinners") – These can reduce the risk of stroke for patients whose clots originate in the heart. Warfarin (Coumadin) tablets are usually prescribed for long-term use. Patients need frequent blood tests to regulate the dosage along with precautions to prevent bleeding.

Hemorrhagic strokes

  • Urgent treatment to:
    1. Diagnose the cause of bleeding
    2. Control blood pressure
    3. Monitor fluid pressure in the brain
    4. Stop medication that can contribute to bleeding

     

  • Draining fluid to relieve high brain pressure

 

  • Surgery to repair abnormal blood vessels in the brain or to remove blood that has accumulated in the brain; other options include threading a tiny tube (catheter) into the artery and placing a coil or glue-like material to seal the leak

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Rehabilitation

Many stroke patients are left with mild to severe disabilities. They need to relearn skills that are lost when part of the brain is damaged. A team of specialists, such as doctors, nurses and therapists coordinate treatment to prevent complications and to restore as much function as possible. Key elements include:

  • Physical therapy to retrain the brain and body
  • Speech therapy to improve speech and swallowing
  • Nursing care to prevent infection and bed sores
  • Good nutrition
  • Assistance devices and training to prevent falls
  • Medication to prevent blood clots in the legs of patients who can't walk.

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Prevention

Doctors call strokes cerebrovascular accidents. The term tells us that strokes involve blood vessels in the brain. But it's misleading to think of strokes as random accidents. In fact, most strokes are predictable and preventable. Here's how you can protect your brain and your life:

  • Control your blood pressure. Healthy men should aim for 140/90 or lower, If you have diabetes, heart or blood vessel disease, kidney problems, or previous strokes, aim for 130/80 or lower.

 

  • Quit smoking and avoid secondhand smoke.

 

  • Cut down on sodium, saturated fat and trans fats. Eat plenty of fruits and vegetables. Whole grains will help, too.

 

  • Exercise regularly.

 

  • Control your weight. It's hard, but exercise and diet can really help.

 

  • Control your blood sugar.

 

  • Improve your cholesterol. If diet and exercise don't bring you to your goal, a statin drug can reduce your risk of stroke by 15% to 30%.

 

  • Limit alcohol to two drinks a day.

 

  • Take medication to prevent clots if you have problems like an irregular pumping rhythm called atrial fibrillation.

 

  • Reduce stress.

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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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