Review definition, epidemiology, etiology, risk factor for stroke ENID

Definition

Stroke is primarily a clinical syndrome of focal neurologic deficit related to a permanent brain damage
from a rupture or occlusion of a blood vessel. Even silent asymptomatic infarcts are now classified as
strokes reflecting the permanent brain damage. The time criteria of 24 hours for stroke has evolved, and
by itself no longer sufficient to distinguish between stroke and transient ischemic attack (TIA), with
supportive evidence needed from brain imaging studies. 1

Definition of poststroke: occurring in or being in the period following a stroke

Epidemiology

Stroke is a leading worldwide cause of death and disability. In the United States, it is the fourth leading
cause of death, with more than 130,000 people dying of stroke annually. Almost 800,000 Americans
experience a stroke each year, resulting in substantial disability among many stroke survivors. Because
of its prevalence and disability, stroke represents a high financial societal disease burden, with direct
and indirect costs approaching $40 billion in 2010.

Risk factor

1. High blood pressure (hypertension): High blood pressure, defined as a reading of 140/90 or greater, is
the leading risk factor for stroke. When blood pushes too forcefully against the walls of the arteries, it
can weaken them and eventually lead to stroke. Adults should strive to keep their blood pressure below
140/90, or 130/80 or below if they’re at higher risk for stroke. An ideal reading is 120/80 or lower.

2. Atherosclerosis: With this major risk factor for stroke, fatty plaques that build up inside the artery
walls will block or narrow the vessels, which can lead to stroke.

3. Heart disease: Coronary heart disease, heart failure, dilated cardiomyopathy (an enlarged heart), and
other heart diseases place people at higher stroke risk, compared to those with normal hearts.

4. High cholesterol: Excess cholesterol raises one’s chances of heart disease and atherosclerosis. High
cholesterol contributes to plaque buildup in arteries, which can block blood flow to the brain and cause
stroke.

5. Smoking or tobacco use:Smoking lowers oxygen levels in the blood, forcing the heart to work harder
and enabling blood clots to form more readily. Cigarette smoke can also worsen atherosclerosis.
According to the National Stroke Association, smokers have twice the risk of stroke as nonsmokers.

6. Diabetes: People with diabetes face higher risk of stroke because they often have other health
problems and stroke risk factors, including high blood pressure, high cholesterol, and heart disease.

7. Overweight or obesity: Extra weight, along with being sedentary, raises the chances of high blood
pressure or diabetes.

Etiology

1. Ischemic stroke : Reduced blood flow in brain

2. Hemorrhagic stroke : Blood vessel in brain leak or rupture

Risk Factor Modification

• All patients with ischemic strokes require aggressive long-term management of modifiable risk
factors.

• Controlling blood pressure clearly is effective in reducing risk of subsequent strokes. Antihypertensive
therapy should be initiated during the acute hospitalization and proceed slowly with a goal
bloodpressure of <135/80. The optimal drug regimen remains uncertain, but available data support the
use of diuretics and combination therapy with diuretics and most major antihypertensive classes.

• Lipid management is important and the majority of patients likely would benefit from statin therapy,
particularly those with large-vessel atherosclerosis. Atorvastatin 80 mg daily, is the only agent studied
prospectively in a randomized controlled trial (RCT) in patients with TIA or stroke and average low-
density lipoprotein levels that showed a 16% relative risk reduction of stroke over and above other
preventive measures. According to the new guidelines, because of the high associated cardiovascular
risks, stroke would generally stratify in the high-risk group. 11

• Optimizing glycemic control results in more favorable outcomes for cardiovascular diseases, with a
target HbA1c <7%.

• Counseling about lifestyle risk factor reduction should begin prior to discharge. Provide counseling
and offer tobacco cessation assistance for all smokers.

• Recommend increasing regular physical exercise to reduce cardiovascular risk by lowering blood
pressure, reducing obesity, and improving glycemic control.

• It is reasonable to recommend avoidance of heavy alcohol consumption or binge drinking, and a diet
rich in fruits and vegetables and low in cholesterol and cholesterol-raising fatty acids.

Referrals

• Because 40% of patients with stroke have moderate functional impairments and 15% to 30% have
severe disability, early evaluation for and referral to a multidisciplinary acute rehabilitation team is
extremely important. Screening for admission to a rehabilitation program should occur as soon as the
neurologic and medical conditions permit safe participation.

• Depression is very common after stroke, occurring in 30% to 60% of patients. Screen all patients for
depressive symptoms and counsel about the warning signs of depression that may emerge later.

• Patients who have profound disability after stroke or who had poor functional status prior to stroke
may not be appropriate candidates for aggressive inpatient rehabilitation programs. These patients
must continue to receive range of motion exercises, monitoring and treatment of contractures, and
aggressive prevention of decubitus ulcers.

Patient Education

Counsel all patients with stroke about the warning signs of stroke and the importance of medication
adherence. Family members play an important role in poststroke recovery and require education as to
the nature of their loved one’s neurologic deficit, prognosis for recovery, and plan for rehabilitation. All
patients discharged on anticoagulation should receive intensive teaching about signs of bleeding, dietary
issues, and activity modification.
Follow-Up

All patients who have experienced a stroke require follow-up care with primary care providers for long-
term blood pressure management, lipid lowering, diabetes management, dietary and exercise
counseling, smoking cessation, and management of anticoagulation if indicated. Clinicians also should
monitor progress with rehabilitation therapy, changes in physical functional capacity, social functioning,
and emergence of new cardiovascular symptoms or medication side effects. Given the high prevalence,
patients should be screened for depression at follow-up appointments.