Ischemic Stroke - AJPHI

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Vol. 1 No. 2 (2024)

Date Log

Submitted
August 8, 2024
Accepted
October 18, 2024
Published
October 18, 2024

Understanding Ischemic Stroke: Symptoms, Risks, and the Importance of Timely Intervention

https://doi.org/10.69512/ajphi.v1i2.61
Aakriti Karki
Jalalabad Ragib Rabeya Medical College and Hospital, Bangladesh
Lumanti Manandhar
Rajiv Gandhi University of Health Sciences, Bangalore, India

Corresponding Author(s) : Aakriti Karki

iamaakritikarki@gmail.com

The American Journal of Patient Health Info, Vol. 1 No. 2 (2024)

Abstract

An ischemic stroke transpires when a blood vessel supplying blood to the brain becomes obstructed or constricted, leading to decreased blood flow to a particular area of the brain. The absence of blood circulation restricts the supply of oxygen and nutrients to the brain cells, resulting in their demise or impairment. The obstruction typically arises from a thrombus or other debris that impedes the flow of blood in the artery. Globally, stroke is the second leading cause of death responsible for approximately 11% total deaths. In the United States, an estimated 795,000 people experience a new or recurrent stroke annually, and approximately 87% of these are ischemic strokes. A stroke can come on suddenly, and its effects can be devastating. If someone is suspected to be suffering from a stroke, it is important to call 911 or seek medical attention immediately. Time is of essence in the treatment of stroke.

Keywords

Cerebrovascular disease Stroke TIA Ischemic Stroke Thrombolysis Thrombolytics
Karki, A., & Manandhar, L. (2024). Understanding Ischemic Stroke: Symptoms, Risks, and the Importance of Timely Intervention. The American Journal of Patient Health Info, 1(2). https://doi.org/10.69512/ajphi.v1i2.61
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References
  1. Walter K. What is acute ischemic stroke? JAMA [Internet]. 2022 Mar 1;327(9):885. Available from: https://jamanetwork.com/journals/jama/fullarticle/2789540
  2. Shahjouei S, Sadighi A, Chaudhary D, Li J, Abedi V, Holland N, et al. A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack. JAMA Neurology. 2020 Oct 12; Available from: https://jamanetwork.com/journals/jamaneurology/fullarticle/2771410
  3. World Health Organization. The top 10 causes of death [Internet]. World Health Organization.WHO;2020.Available from https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death
  4. Martin SS, Aday AW, Almarzooq ZI, Cheryl A.M. Anderson, Arora P, Avery CL, et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation. 2024 Jan 24;149(8). Available from: https://pubmed.ncbi.nlm.nih.gov/38264914/
  5. Boehme AK, Esenwa C, Elkind MSV. Stroke Risk Factors, Genetics, and Prevention. Circulation research. 2017 Feb 3;120(3):472–95. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5321635/
  6. Jin J. Warning Signs of a Stroke. JAMA [Internet]. 2014 Apr 23;311(16):1704. Available from: https://jamanetwork.com/journals/jama/fullarticle/1861804
  7. Vilela P, Rowley HA. Brain ischemia: CT and MRI techniques in acute ischemic stroke. European Journal of Radiology. 2017 Nov; 96:162–72. Available from: https://www.ejradiology.com/article/S0720-048X(17)30333-9/abstract
  8. de Lucas EM, Sánchez E, Gutiérrez A, Mandly AG, Ruiz E, Flórez AF, et al. CT Protocol for Acute Stroke: Tips and Tricks for General Radiologists. RadioGraphics. 2008 Oct;28(6):1673–87. Available from: https://pubmed.ncbi.nlm.nih.gov/18936029/
  9. American Heart Association. Echocardiogram (Echo) [Internet]. www.heart.org. 2010Availablefrom:https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-attack/echocardiogram-echo
  10. Zhang L, Harrison JK, Goldstein LB. Echocardiography for the detection of cardiac sources of embolism in patients with stroke or transient ischemic attack. Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association [Internet]. 2012 Oct 1 [cited 2024 Mar 25];21(7):577–82. Available from: https://pubmed.ncbi.nlm.nih.gov/21367623/
  11. Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke [Internet]. 2013;44(3):870–947. Available from: https://www.heart.org/idc/groups/heart-public/@wcm/@mwa/documents/downloadable/ucm_450485.pdf
  12. Herpich F, Rincon F. Management of Acute Ischemic Stroke. Critical Care Medicine [Internet]. 2020 Oct 9;48(11):1654–63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540624/
  13. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. New England Journal of Medicine [Internet]. 2008 Sep 25;359(13):1317–29. Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa0804656
  14. Ma H, Campbell BCV, Parsons MW, Churilov L, Levi CR, Hsu C, et al. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. New England Journal of Medicine. 2019 May 9;380(19):1795–803. Available from: https://pubmed.ncbi.nlm.nih.gov/31067369/
  15. Raha O, Hall CB, Malik A, D’Anna L, Kyriakos Lobotesis, Kwan J, et al. Advances in mechanical thrombectomy for acute ischaemic stroke. BMJ Medicine [Internet]. 2023 Aug 1;2(1):e000407–7.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10414072/
  16. Pan Y, Elm JJ, Li H, Easton JD, Wang Y, Farrant M, et al. Outcomes Associated with Clopidogrel-Aspirin Use in Minor Stroke or Transient Ischemic Attack. JAMA Neurology. 2019 Dec 1;76(12):1466. Available from: https://pubmed.ncbi.nlm.nih.gov/31424481/
  17. Baiu I, Stern JR. Carotid Artery Stenting. JAMA. 2020 Oct 27;324(16):1690. Available from: https://pubmed.ncbi.nlm.nih.gov/33107946/
  18. Muth CC. Recovery After Stroke. JAMA. 2016 Dec 13;316(22):2440. Available from: https://jamanetwork.com/journals/jama/fullarticle/2592503
  19. Diener HC, Hankey GJ. Primary and Secondary Prevention of Ischemic Stroke and Cerebral Hemorrhage. Journal of the American College of Cardiology [Internet]. 2020 Apr;75(15):1804–18.Available from: https://www.sciencedirect.com/science/article/pii/S0735109720344260?via%3Dihub
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Aakriti Karkia Lumanti Manandharb

a Jalalabad Ragib Rabeya Medical College and Hospital, Bangladesh

b Rajiv Gandhi University of Health Sciences, Bangalore, India

Key Highlights

  1. An ischemic stroke is a medical emergency caused by decreased blood flow to the brain, often due to blocked blood vessels, which deprive brain cells of oxygen and nutrients, leading to damage or death.
  2. A mini-stroke or transient ischemic attack is a temporary episode of brain dysfunction due to decreased blood flow. Sometimes, it precedes a stroke.
  3. Symptoms of an ischemic stroke include sudden numbness or weakness on one side of the body, confusion, speech impediment, vision problems, and severe headaches.
  4. Time is a major determining factor for stroke management. It is crucial to keep a record of the onset of symptoms and call 911 or seek medical attention immediately.
  5. Ischemic strokes are preventable, requiring a well-coordinated and integrated approach to risk education, screening, and management of modifiable or causal risk factors, as well as adopting a healthy lifestyle and diet.

Background

An ischemic stroke occurs when a blood vessel supplying blood to the brain becomes obstructed or constricted, leading to decreased blood flow to a particular area of the brain. The absence of blood circulation restricts the supply of oxygen and nutrients to the brain cells, resulting in their damage or death. [1] The obstruction typically arises from a thrombus or other debris that impedes blood flow in the artery. This is different compared to hemorrhagic stroke, which is equally fatal and ensues when a cerebral blood vessel ruptures, resulting in intracranial or extracranial bleeding that affects regular brain activity. Sometimes, you can have a temporary episode of brain dysfunction. This is called a ministroke or transient ischemic attack (TIA), which occurs when blood flow to the brain is temporarily blocked, usually lasting a few minutes to hours. TIAs often precede full strokes, serving as critical warning signs for potential underlying cardiovascular issues. [2]

Globally, stroke is the second leading cause of death, responsible for approximately 11% of total deaths.[3] In the United States, an estimated 795,000 people experience a new or recurrent stroke annually, and approximately 87% of these are ischemic strokes. [4] A stroke can come on suddenly, and its effects can be devastating. If you suspect someone is suffering from a stroke, call 911 immediately. Time is of the essence in the treatment of stroke.

Risk Factors of Ischemic Stroke

It is essential to understand the risk factors to lower the chances of ischemic stroke. Some common risk factors for an ischemic stroke include:[5]

Figure 1.

  • Age older than 50 years
  • Medical conditions like high blood pressure and diabetes
  • High cholesterol levels- specifically LDL cholesterol
  • Smoking
  • A sedentary lifestyle and lack of exercise
  • Abnormal heart rhythm called atrial fibrillation
  • Personal history of heart and coronary artery diseases
  • Family history of heart or coronary artery diseases
  • Previous history of stroke or a transient ischemic attack (TIA)
  • Medical conditions that increase blood clotting or blood vessel inflammation

Understanding stroke risk factors makes it easier to identify what can be changed to prevent future strokes. While family history, age, race, and ethnicity are non-modifiable, conditions like high blood pressure, diabetes, and smoking can be managed. By focusing on these modifiable factors, individuals can take steps to reduce their risk.

Symptoms of Ischemic Stroke

The specific area of the brain affected by the stroke determines the symptoms. Some common signs of stroke include:[6]

Figure 2.

  • Numbness or weakness of the face, arm, or leg, especially on only one side of the body
  • Confusion or trouble speaking
  • Trouble seeing with one or both eyes
  • Trouble walking, dizziness, or loss of balance or coordination
  • Severe headache with no known cause

Diagnosis of Ischemic Stroke

Physical examination is an important aspect of diagnosing stroke as it can give a clue to the type of stroke area of the brain involved and, most importantly, helps to act immediately. The most commonly used method early on is the use of mnemonic FAST.

  • F - Face: Look in the mirror and smile or ask the person to smile. Check if one side of the face is drooping.
  • A - Arms: Raise both arms. Check if you can raise both arms fully or if lifting both arms causes one arm to slide lower.
  • S - Speech: Repeat a simple phrase, like "Hello, I live in the US." Note if the speech is slurred or if they have difficulty speaking.
  • T - Time: Act fast. Time is critical during a stroke.

Imaging studies: Commonly used imaging studies for stroke diagnosis are Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) of the brain. [7] CT scan is the most common imaging study to detect a stroke. [8] It is widely available and quick to perform in hospitals. A CT scan of the brain helps ensure no bleeding in the brain. The changes caused in your brain by an ischemic stroke might not be evident on a CT scan within a few hours. In this case, an MRI of the brain can provide an improved visualization of the brain tissue, stroke–affected regions, and arteries.

Additional imaging studies may be required, such as an ultrasound of the carotid arteries, which are large blood vessels around the neck, and an ultrasound of the heart, commonly called an echocardiogram.[9,10]

Treatment of Ischemic Stroke

Management of Ischemic Stroke involves immediate intervention to restore blood flow to the brain, minimize damage, and prevent further strokes. Early suspicions or recognition and transfer to a stroke center are crucial for management. [11,12]

Figure 3.

1. Immediate treatment (Acute Phase)

  • Intravenous Thrombolysis: The mainstay of acute treatment is tissue plasminogen activator (tPA), a clot-busting medication. It should be administered within 3-4.5 hours of symptom onset to break down the clot and restore blood flow. [13]Depending on the specific blocked artery in the brain, TPA restores blood flow to the brain in an estimated 10% to 50% of cases.[13] TPA decreases the risk of permanent impairment following an acute ischemic stroke, but it raises the risk of brain hemorrhage [14]; therefore, it is avoided in case of stroke due to brain hemorrhage. TPA can do more harm if it is administered more than 4.5 hours after the onset of stroke symptoms. It is crucial, therefore, to record the exact time that you or someone around you first noticed stroke symptoms as well as the time that you or they were last seen well.
  • Mechanical Thrombectomy: It is recommended for patients with large artery blockages. [15] This is usually beneficial if done within 24 hours after the first onset of stroke symptoms. In this procedure, a catheter is guided to the affected blood vessel in the brain through an artery in the arm or leg. The process is monitored using continuous X-ray imaging to ensure no errors. [15].These procedures require highly trained physicians and advanced equipment. Mechanical thrombectomy is also not available at every hospital. Smaller hospitals may transfer you to a larger facility where mechanical thrombectomy can be performed if you are a candidate for the procedure.

2. Secondary Prevention

  • Antiplatelet Therapy: Patients after a stroke are generally asked to be on aspirin and/or clopidogrel (commonly known as Plavix) to reduce the risk of future strokes. [16] Your neurologist may recommend being on a combination of aspirin and clopidogrel for a short term before transitioning you to an antiplatelet medication.
  • Anticoagulation: If cardiac arrhythmia as atrial fibrillation is found on home heart monitoring, you might be a candidate for stronger blood thinners (anticoagulants) like warfarin or direct oral anticoagulants (DOACs) to prevent further stroke episodes. [16]

3. Blood Pressure Management

After an ischemic stroke, controlling your blood pressure is critical. Hypertension is managed with medications like angiotensin-converting enzyme inhibitors, beta-blockers, or diuretics to reduce the risk of future strokes. We recommend making a blood pressure log to monitor your blood pressure at home.

4. Cholesterol Management

Statins are prescribed to lower cholesterol and reduce the risk of further ischemic events. They help stabilize the plaque, which is a build-up of cholesterol in arteries, and prevent clots from forming. This would prevent these plaques from getting dislodged and causing stroke.

Carotid Artery Stenting and its Role in Ischemic Stroke

Carotid arteries are the blood vessels on each side of the neck and carry blood and oxygen to the brain. Over time, these arteries can be narrowed, called carotid artery stenosis.

Your doctor usually diagnoses carotid artery stenosis with an ultrasound of the carotid arteries but sometimes uses CT or MRI angiography of the neck to evaluate the anatomy and blood flow in the blood vessels. Most patients with carotid artery stenosis never have symptoms, but when the carotid vessels are narrow, you might be at an increased risk of stroke. If someone has 70% stenosis and has had a recent stroke, your doctor may consider you for carotid artery stenting. [17] carotid endarterectomy, or Trans Carotid Artery Revascularization (TCAR). The risks and benefits of this procedure should be discussed, as not every patient benefits from it.

A stent is a hollow tube designed to fit and cover a blood vessel's walls and allow blood to flow through it. Carotid artery stenting is a procedure where a small metal tube or stent is placed through the site of the stenosis to keep the artery open and restore blood flow through the vessels again.

Role of Rehabilitation after a Stroke

People are often left with significant impairments after a stroke, depending on the brain vessels involved. Some people are often left with weakness or numbness in their hands and legs. Some are left with vision problems, slurred speech, and issues with swallowing. Others face difficulties with language, balance, and coordination.

Rehabilitation is an essential aspect of stroke recovery[18]. It can be done in hospitals, nursing facilities, outpatient offices, clinics, or at home. Formal rehabilitation programs commonly last for up to 3 or 4 months, but if improvements are substantial, patients may continue their recovery in the program.

The main goals for a patient after a stroke are to regain function and independence and optimize recovery, possibly to their baseline health. The stroke rehabilitation process involves a multidisciplinary team that involves:

  • Physical therapists: Help improve balance and walking.
  • Occupational therapists: Help improve function in daily activities such as bathing, dressing, and putting on, among others.
  • Speech and language therapists: Treat speech and language, swallowing, and thinking issues.
  • Physiatrists and rehabilitation neurologists: Medical doctors specializing in rehabilitation and coordinating care.

Prevention of Ischemic Stroke

The risk of stroke can be prevented by adopting a healthy lifestyle and diet [19]. It is advisable to make sustainable goals for lifestyle changes.

Figure 4.

  • Eat a healthy diet. Choose a diet low in sodium with plenty of fruits and vegetables.
  • If you are obese, work on weight loss. Maintain a healthy weight.
  • Be physically active.
  • Do not smoke. Avoid secondhand smoke.
  • Limit alcohol usage.

Questions to ask your Doctor

  1. What are my chances of having a second stroke?
  2. What lifestyle changes would help me prevent a second stroke?
  3. Should I be admitted to a rehabilitation center for a recovery program?
  4. How long should I be on a blood thinner?
  5. Do I need to take a blood thinner if I bleed easily?

Conflict of Interest

Aakriti Karki serves as a non-paid research assistant at eHealthyInfo. Lumanti Manandhar worked as a paid freelance medical journalist with eHealthyInfo from 2022 to 2023. There are no other conflicts of interest to declare.

Peer Reviewed by

Sumit Saurav Karna, MD

Charleston Area Medical Center, WV, USA

References

  1. Walter K. What is acute ischemic stroke? JAMA [Internet]. 2022 Mar 1;327(9):885. Available from: https://jamanetwork.com/journals/jama/fullarticle/2789540
  2. Shahjouei S, Sadighi A, Chaudhary D, Li J, Abedi V, Holland N, et al. A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack. JAMA Neurology. 2020 Oct 12; Available from: https://jamanetwork.com/journals/jamaneurology/fullarticle/2771410
  3. World Health Organization. The top 10 causes of death [Internet]. World Health Organization.WHO;2020.Available from https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death
  4. Martin SS, Aday AW, Almarzooq ZI, Cheryl A.M. Anderson, Arora P, Avery CL, et al. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation. 2024 Jan 24;149(8). Available from: https://pubmed.ncbi.nlm.nih.gov/38264914/
  5. Boehme AK, Esenwa C, Elkind MSV. Stroke Risk Factors, Genetics, and Prevention. Circulation research. 2017 Feb 3;120(3):472–95. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5321635/
  6. Jin J. Warning Signs of a Stroke. JAMA [Internet]. 2014 Apr 23;311(16):1704. Available from: https://jamanetwork.com/journals/jama/fullarticle/1861804
  7. Vilela P, Rowley HA. Brain ischemia: CT and MRI techniques in acute ischemic stroke. European Journal of Radiology. 2017 Nov; 96:162–72. Available from: https://www.ejradiology.com/article/S0720-048X(17)30333-9/abstract
  8. de Lucas EM, Sánchez E, Gutiérrez A, Mandly AG, Ruiz E, Flórez AF, et al. CT Protocol for Acute Stroke: Tips and Tricks for General Radiologists. RadioGraphics. 2008 Oct;28(6):1673–87. Available from: https://pubmed.ncbi.nlm.nih.gov/18936029/
  9. American Heart Association. Echocardiogram (Echo) [Internet]. www.heart.org. 2010Availablefrom:https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-attack/echocardiogram-echo
  10. ‌Zhang L, Harrison JK, Goldstein LB. Echocardiography for the detection of cardiac sources of embolism in patients with stroke or transient ischemic attack. Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association [Internet]. 2012 Oct 1 [cited 2024 Mar 25];21(7):577–82. Available from: https://pubmed.ncbi.nlm.nih.gov/21367623/
  11. Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke [Internet]. 2013;44(3):870–947. Available from: https://www.heart.org/idc/groups/heart-public/@wcm/@mwa/documents/downloadable/ucm_450485.pdf
  12. Herpich F, Rincon F. Management of Acute Ischemic Stroke. Critical Care Medicine [Internet]. 2020 Oct 9;48(11):1654–63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540624/
  13. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. New England Journal of Medicine [Internet]. 2008 Sep 25;359(13):1317–29. Available from: https://www.nejm.org/doi/full/10.1056/NEJMoa0804656
  14. Ma H, Campbell BCV, Parsons MW, Churilov L, Levi CR, Hsu C, et al. Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke. New England Journal of Medicine. 2019 May 9;380(19):1795–803. Available from: https://pubmed.ncbi.nlm.nih.gov/31067369/
  15. Raha O, Hall CB, Malik A, D’Anna L, Kyriakos Lobotesis, Kwan J, et al. Advances in mechanical thrombectomy for acute ischaemic stroke. BMJ Medicine [Internet]. 2023 Aug 1;2(1):e000407–7.Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10414072/
  16. Pan Y, Elm JJ, Li H, Easton JD, Wang Y, Farrant M, et al. Outcomes Associated with Clopidogrel-Aspirin Use in Minor Stroke or Transient Ischemic Attack. JAMA Neurology. 2019 Dec 1;76(12):1466. Available from: https://pubmed.ncbi.nlm.nih.gov/31424481/
  17. Baiu I, Stern JR. Carotid Artery Stenting. JAMA. 2020 Oct 27;324(16):1690. Available from: https://pubmed.ncbi.nlm.nih.gov/33107946/
  18. Muth CC. Recovery After Stroke. JAMA. 2016 Dec 13;316(22):2440. Available from: https://jamanetwork.com/journals/jama/fullarticle/2592503
  19. Diener HC, Hankey GJ. Primary and Secondary Prevention of Ischemic Stroke and Cerebral Hemorrhage. Journal of the American College of Cardiology [Internet]. 2020 Apr;75(15):1804–18.Available from: https://www.sciencedirect.com/science/article/pii/S0735109720344260?via%3Dihub

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