STROKE (CVA)
W. G. Franklin, M.D.
S trokes afflict 500,000 people per year resulting in 150,000 deaths per year. In comparison, heart attacks cause 500,000 deaths and breast cancer causes 50,000 deaths per year.
99% of heart attacks and 80% of strokes are caused by arteriosclerosis. Hence, arteriosclerosis causes 13 times more deaths then breast cancer. The remaining 20% of strokes are due to bleeding (hemorrhage) in the brain.
In the vast majority, strokes like heart attacks, occur without warning with no symptoms at all until the day of the stroke. Infrequently, temporary symptoms (such as weakness or loss of sensation in an extremity, loss of vision, inability to speak, etc.) may occur for minutes to hours and then resolve. This is called a TIA (transient ischemic attack) and indicates a high risk of stroke.
Arteriosclerosis is often diagnosed in one part of the body (such as the coronary arteries, aorta, or the arteries to the legs) but remains undiagnosed elsewhere. As a result, the most common complication of CABG (coronary bypass surgery) is stroke (CVA), which occurs approximately 5% of the time. Similarly, operations on the carotid arteries, aorta, and femoral arteries are sometimes complicated by heart attacks. Preoperative evaluation with stress tests and carotid sonograms (Duplex study) is advisable.
Aortic aneurysms and aortic valve sclerosis (thickening) are arteriosclerotic processes that should raise suspicions of the presence of the disease elsewhere.
Certain findings on physical exam or ancillary tests may indicate a higher likelihood of arteriosclerosis:
- Collections of cholesterol around the eyes (Xanthelesma) or in the Achilles tendon (Xanthoma)
- Collection of cholesterol around the iris (arcus senilis) before the age of 65
- Detection of calcium in the aorta on chest x-ray
- Detection of aortic valve sclerosis (thickening) on echocardiography
- Detection of plaques in the aorta on transesophageal echocardiography (TEE
Testing for the risk of stroke may include:
- Duplex carotid sonogram: good for detection of disease but suboptimal for quantifying degree of obstruction
- MRI angiogram is an improvement regarding quantification
- Carotid angiography is optimal for quantification
- An MRI can detect previous strokes
Treatment includes:
- Modification of risk factors including
Smoking, hypertension, elevated cholesterol, diabetes
- Consideration of ABCD's of medication: Aspirin 325 mg per day or Plavix 75 mg per day or both Beta blocker Cholesterol lowering STATIN ACE inhibitor or ARB
- Carotid surgery (endarterectomy)
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Indicated if TIA has occurred with 70% or greater blockage
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To be considered if asymptomatic with 70% or greater blockage and surgeon's mortality and stroke rate is low
- Carotid angioplasty (only available at select centers) for 70% or greater blockage
- Emergency thrombolytic therapy (intravenous clot dissolving medicine) with TPA is available in most emergency departments for acute stroke
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Treatment should be initiated within 1-2 hours of the onset of symptoms
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