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Jay S. Luxenberg, MD and Ernest H. Rosenbaum, MD

Strokes are the third leading cause of death in the United States. There are approximately 700,000 strokes in the United States each year, and about 160,000 deaths. An estimated 11 million Americans annually suffer small strokes every year that are silent; they do not produce symptoms that are recognized but indicate an increased risk of larger strokes in the future.

A stroke is a highly treatable disease like a heart attack, but one must immediately get to a stroke center or hospital for early treatments. Unfortunately,due to delays, many are left with major physical debilities that totally change their lives.

Strokes are the second most common cause of disability in high income countries and death worldwide. The incidence varies with age, and in Western societies about 80% of strokes are caused by focal cerebral ischemia due to arterial occlusion, and 20% is due to hemorrhage.1

It is a complex process of extracellular excitatory amino acids, free-radical formation, and inflammation. Initially, a central core of low perfusion is surrounded by dysfunction due to a loss of structural integrity from ischemia. In a few minutes to hours, there are clinical deficits, many of which can be reversible with immediate care (less than three hours), and much depends on the remaining blood flow to the ischemic area. The thirty-day mortality in Western society is between 10-17%, and this percentage increases with age and comorbidities, such as ischemic heart disease, diabetes, and, most importantly, the size of the infarct. After a few months, mortality is reported at 2.5% with lacunars infarcts to 70% with space occupying hemisphere infarction.

- Stroke is characterized by a sudden onset of a focal neurological deficit with a stepwise gradual progression of symptoms, including vision loss, speech loss, weakness, unstable balance, sensory loss, usually unilateral, and, sometimes, loss of consciousness.
- Occasionally, onset is with seizures or unconsciousness, with the differential being migraine, postictal (seizure) paralysis, low blood sugar, and difficulty with conversation versus a subdural hematoma or brain tumor.
- A cardioembolism may cause brain ischemia, often in younger patients less than age 50 with no known cardiovascular risk factors. Rarely, carotid artery dissection, fever, a cardiac murmur, suggesting infective endocarditis, with headache and an increased sedimentation rate, and giant cell arteritis in patients over age 50 are seen.

Signs of a Stroke:
Each year, 700,000 Americans suffer from strokes. About half do not realize that they are having a stroke. About 150,000 Americans die of stroke per year.
Red flags:
- Sudden weakness on one side of the body, slurred speech or inability to speak, numbness and tingling in an arm or leg, facial droop, decreased vision in one eye.
- Keep a record of your medications in your wallet, as well as your medical history.
- The sudden onset of dizziness, unsteadiness or a sudden fall, visual dimness especially in one eye, difficulty speaking or trouble understanding speech, and numbness, weakness in face, arms or legs, especially on one side of the body are significant signs of a stroke.

The Risk Factors for a Stroke
Risk evaluation is dependent on many factors, some of which cannot be changed.
1. Age - as one ages, the risk doubles every ten years after age 55.
2. Sex - men have more strokes than women.
3. Race - African Americans, Hispanics, and Asian Americans have a higher rate of strokes than non-Hispanic whites.
4. Genetics - a family history of a stroke places family members at greater risk.
5. Previous strokes - one in six people with ischemic (atherosclerotic) strokes, who survive, are at greater risk of another stroke within two years.
6. People who have TIAs (transient ischemic attacks - a mini stroke) are at about a ten-times greater risk of having a major stroke.
7. Hypertension - increases the strain on the blood vessels in the brain.
8. Heart disease - cardiovascular coronary artery disease.
9. Poor nutrition - not eating fruits, vegetables, whole grains and fish with excess dietary sodium and a low potassium diet.
10. Lack of a daily exercise program.
11. Overweight and obesity.
12. Diabetes is a stroke risk and requires active treatment.
13. Cigarette smoking almost doubles the risk of stroke.

Strokes can be prevented through controlling blood pressure (hypertension), cholesterol (HD/LD/triglycerides lipids), and other modifiable factors. Changes in lifestyle, such as not smoking, moderate to vigorous exercise thirty minutes a day, maintaining a healthy weight and eating a prudent heart-healthy diet are also very important.

It has been estimated that about 80% of the risk of a stroke is related to high blood pressure. When the blood pressure is controlled, the stroke risk may decrease about 40%, which also reduces the heart attack rate by about 27% and heart failure by 54%.

Once a person is in the recovery phase, an active stroke rehabilitation program may take many months, often six months to a year to get the maximum recovery from a stroke.

Prevention of strokes
1. Diet - fruits and vegetables are often rich in potassium along with a healthy diet, as well as potassium supplementation if needed.
2. Eating fish two or three times a week provides omega-3 fatty acids that may help lower stroke and heart attack rates. Those eating salmon, tuna (baked or broiled) or herring four times a week were seen to have a 27% lower risk of stroke than those who ate it once a month. Those eating fried fish or fish burgers more than once a week had a 40% higher risk of stroke.
3. Exercise thirty minutes a day (moderate to vigorous) - by accumulating several activities including housework, walking stairs, or taking brisk walks. Exercise lowers blood pressure, reduces blood clots, and can cut the stroke rate in half.
4. Those who are overweight or obese have at least a 30% or about 50% higher risk for stroke respectively compared to normal weight men. Exercise helps maintain a healthy weight and also treats diabetes actively.
5. Talk to your doctor to see if daily aspirin would be helpful for you.

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