Ischemic Stroke

Ischemic stroke occurs most often when a blood vessel supplying blood to the brain is blocked or obstructed by a blood clot or fatty deposit or any mix thereof.

The brain relies on a constant supply of blood to provide it with oxygen and nutrients and to carry away carbon dioxide. When the blood flow, and therefore this supply, becomes interrupted or blocked, brain cells can quickly begin to stop working. If the blockage lasts for more than a couple of minutes, these cells can die, leading to serious damage to the brain. 1 Depending on the location and supply area of the affected vessel, the damage can range from mildly debilitating to severe or life-threatening.

There are two main types of stroke: the ischemic one introduced above, and the hemorrhagic one. Ischemic stroke is the most common, accounting for roughly 85 percent of all cases in the United States. 2 If prompt treatment is received, the effects of a stroke can be managed in many cases. However, in some cases, ischemic stroke can lead to long-term disability and mortality, i.e. a person dying because of the condition.

In most cases, the symptoms of an ischemic stroke will appear suddenly, within seconds or minutes. Because people experiencing a stroke require immediate treatment, it is important to be aware of the immediate signs and symptoms and take action without delay.

A useful acronym for remembering the signs and symptoms of an ischemic stroke is FAST: 3 4

• Face. Weakness or drooping of the face, usually limited to or more pronounced on one side.
• Arm. Numbness, weakness or strange sensations, e.g. pins and needles, in one or both arms.
• Speech. Difficulty speaking or slurred speech, mumbling or not being able to speak at all.
• Time to call the emergency services. The sooner an ambulance is called, the better the chances of a successful recovery.

Other symptoms of ischemic stroke may include: 5

• Weakness or numbness on one side of the body
• Difficulty walking or getting up, e.g. from a chair or out of bed
• Dropping to the floor
• Headache
• Dizziness
• Sudden, new tinnitus – a ringing, swishing or whooshing sound in the ears
• Nausea and vomiting
• Soreness in the neck or face
• Vision problems, i.e. double vision or an inability to see parts of one’s surrounding or anything at all
• Confusion, sudden sleepiness, difficulty waking up
• Sudden urinary incontinence, newly occurring with other symptoms

The symptoms that are experienced will depend on what part of the brain is affected and may vary in severity from person to person.

Ischemic stroke occurs when a blood vessel of the brain becomes blocked. This can happen as a result of several different conditions, including: 2 5

Most commonly:

• Atherosclerosis
• Small vessel disease
• Atrial fibrillation

In rarer cases:

• Arterial dissection, e.g. due to trauma or fibromuscular dysplasia
• Certain blood clotting problems called coagulopathies, e.g. polycythemia or as a result of hormonal medications
• Inflammation of the blood vessels, known as vasculitis, e.g. giant cell arteritis
• Sickle cell disease

A condition occurring when fatty deposits – called plaques or atheromas – build up on the walls of the arteries, causing them to become narrower, harder and more easily blocked.

Read more about Atherosclerosis »

Small vessel disease involves the collection of deposits within the small blood vessels of the brain. As these deposits develop, the blood vessels become harder and can eventually become completely blocked. It occurs primarily as a result of high blood pressure and diabetes. 5

Atrial fibrillation is a type of irregular heartbeat that can cause blood clots in the heart. These then enter the bloodstream and reach other parts of the body, e.g. the brain. If this happens, ischemic stroke can result.

Arterial dissection is a rarer cause of stroke. The condition occurs when tears in the lining of the arteries develop and blood is able to get in between the different layers of the artery wall. As blood builds up, a blood clot can form and lead to a stroke.

Though uncommon, certain blood clotting problems, where the blood clots too quickly, may cause a stroke. One example is polycythemia vera, a rare condition where the body produces too many red blood cells. This causes blood clots to form more easily – potentially leading to an ischemic stroke. 6 7

This is the term for an inflammation in the blood vessels, which may develop as the result of an infection, another health condition or an adverse reaction to medication. Vasculitis may cause the blood vessels to narrow or even become blocked, potentially leading to an ischemic stroke. 8 One type of vasculitis is giant cell arteritis, a condition that affects the arteries in the head and upper part of the body. 9

This genetic condition causes the shape of red blood cells to be abnormal. These red blood cells do not last very long, leading to anemia, and they can also block blood vessels – potentially leading to a stroke. 10 11

Read more about Sickle Cell Disease »

There are a number of factors which can increase a person’s likelihood of experiencing an ischemic stroke. These include factors which a person themselves or treatment can change over time, and factors that cannot be changed. 4 5

Factors that can be changed over time (modifiable factors) include: 5

• High blood pressure - this is the strongest single risk factor for the development of both ischemic and hemorrhagic stroke
• Atherosclerosis (fatty deposits in the arteries)
• Hypercholesterolemia (high cholesterol levels in the blood)
• Diabetes
• Obesity and physical inactivity
• Stress
• High alcohol consumption
• Tobacco use
• Illicit (illegal) drug use
• Cardiovascular (heart and heart vessel) diseases
• Blood clotting disorders
• Oral contraceptives (birth control pills)
• Postmenopausal hormone intake

Factors that cannot be changed over time (non-modifiable factors) include: 5

• Being over the age of 40
• Being male
• Ethnicity - African Americans, Native Americans, Alaska Natives, and Hispanic people are at higher risk
• Family history of stroke, heart or heart vessel conditions
• Genetic disorders, e.g. sickle cell disease

Recent childbirth also leads to a somewhat increased risk of stroke, due to an increased risk of blood clotting problems.

Although the above factors may make a stroke more likely, people who do not possess any risk factors may also experience a stroke.

Anyone displaying any signs of stroke should immediately be taken to a hospital emergency room for diagnosis. Typically, this will first involve a physical examination, that may include an ECGto rule out atrial fibrillation and a review of the person’s medical history, before a number of other scans and tests. 4

Brain scans can help establish whether a stroke is ischemic or hemorrhagic, as well as its severity and the part of the brain affected. CT and MRI scans are the most commonly used types of scans for people suspected of having a stroke. 12 5

• CT scans allow doctors to create a 3D image of the brain, enabling them to see what section of the brain is being affected and whether a stroke is ischemic or hemorrhagic. A CT scan is, in general, the best option (gold standard) and is quicker than an MRI scan. However, it may not be able to detect blood vessel blockages in the very early stages. Within the first 30 minutes of the blockage, an MRI will most likely produce more reliable results.
• MRI scans use radio waves and a strong magnetic field to build a detailed image of the interior of the body. In the first 30 minutes from the onset of stroke symptoms, an MRI may be able to detect blood vessel blockages and stroke damage more accurately than a CT scan.

Brain scans should be carried out as quickly as humanly possible when the person reaches the hospital, allowing for prompt and appropriate treatment to be received.

Various heart and blood vessel tests can be used to establish the cause of a stroke. Two of the most common are carotid ultrasound and echocardiography.

• Carotid ultrasound is able to identify any blockages or clots in the arteries running along the neck and leading to the brain.
• Echocardiography is a kind of ultrasound that can produce a detailed picture and provide certain measurements of the heart, enabling doctors to locate any issues that may have contributed to the stroke.

The aim of treatment for ischemic stroke is to restore blood flow as quickly as possible to the affected area of the brain. This will usually involve a combination of different medications while the person is being treated in the hospital and possibly others, once they are at home or at a rehabilitation facility. Some of these will only need to be taken for a short period of time, while others may be used to prevent future recurrences of stroke and will require long-term use. 13 14

Some of the most commonly prescribed medications for treating an ischemic stroke include:

• Alteplase: A type of medication used to dissolve clots and restore blood flow to the brain. Alteplase is most effective when administered as soon as possible after the stroke has taken place. It will most often be given through a drip into a person’s veins, from where it will spread through the entire blood vessel system. Sometimes, the medication has to be given directly into an artery, close to the obstruction - this procedure is then called intra-arterial thrombolysis. Alteplase can only be used for ischemic strokes, not if there is bleeding into the brain - as in the case of a hemorrhagic stroke. To confirm that the stroke is indeed ischemic in nature, alteplase can only be prescribed following a brain scan.
• Antiplatelets: This type of medication helps to prevent further clots from forming. Aspirin is the most common antiplatelet, as well as a painkiller, though others, such as clopidogrel and dipyridamole, are also sometimes used.
• Anticoagulants: This type of medication, sometimes called blood thinners, includes drugs like warfarin or heparin and can be used to help reduce the chances of a stroke recurring by preventing blood clots from forming. Anticoagulants are sometimes also used in the acute treatment of a stroke.

In some cases, usually those involving a blood clot in one of the brain’s larger arteries, a procedure known as a mechanical thrombectomy may be used. During a thrombectomy, a catheter is inserted into the affected artery, through which a device, known as a stent retriever, is able to remove the clot in the artery in the brain. The procedure can be done under general or local anesthetic and is most effective when carried out shortly after the stroke has taken place. The procedure will usually be carried out in addition to IV thrombolytic therapy, e.g. with alteplase.

A number of complications can arise in the days and weeks after a person has experienced a stroke, either while they are still in hospital or once they are at home or in a rehabilitation facility. These complications are important to recognize and treat in a timely manner, as they can, in some cases, lead to serious health problems and mortality (people dying from the condition).

Some of the most common complications include: 5

While recovering from ischemic stroke, there is an increased risk of developing blood clots due to lack of moving around. This can be especially serious if a clot develops in the deep veins of the leg (deep vein thrombosis), breaks off and travels to the lungs. This can result in a condition known as pulmonary embolus or embolism, which can be potentially fatal. Older age and a lack of mobility during the recovery period increases the risk of deep vein thrombosis.

Doctors and physical therapists will advise on how to help prevent the development of blood clots. This may include the use of intermittent pneumatic compression devices, i.e. an inflatable sleeve that is wrapped around the legs, helping to increase circulation, compression stockings and anticoagulant medication. People recovering from a stroke are also encouraged to move around frequently.

Dysphagia refers to difficulty swallowing. This can occur after a stroke due to problems coordinating between the muscles of the tongue, mouth and throat. Dysphagia results in an increased risk of inhaling saliva or food into the lungs, which can lead to aspiration pneumonia, a condition that can worsen the prognosis of people who have had a stroke.

To determine whether a person is experiencing difficulty swallowing, doctors will typically perform a water test. This involves swallowing a small amount of water while being monitored. If dysphagia is suspected, people may be temporarily fed through a drip into the veins, a nasogastric feeding tube or, in rarer cases, a percutaneous endoscopic gastrostomy tube. Further details are provided below.

People recovering from a stroke often experience difficulty consuming enough calories. This can prolong the recovery period and in some cases lead to long-term disability. If it is suspected that a person will not be able consume enough calories themselves, a type of feeding tube known as a nasogastric tube (NGT)may be fitted through the nose. Through this tube, food and necessary nutrients can be supplied directly to the stomach as a short-term solution. In some cases, a percutaneous endoscopic gastrostomy (PEG) tube may need to be fitted through the abdomen (belly) as a longer-term feeding solution. 15 16

Urinary tract infections are a common complication of a stroke. This is generally because people in recovery often experience difficulty with getting out of bed to urinate, bladder leakage and problems fully emptying their bladders. Depending on the type of stroke, temporary use of a catheter may be recommended to decrease the risk of urinary tract infection. However, the use of a catheter comes with its own risk of urinary tract infection, meaning most people are advised to only use a catheter when necessary and to change the catheter regularly.

Heart abnormalities seem to be quite common in people who have had a stroke. Though often difficult to do so, in the interests of effective care, it is important to identify whether the heart problems led to the stroke, resulted from the stroke, or are entirely unrelated, and treat them accordingly to minimize the risk of further complications. Through an electrocardiogram, blood tests and monitoring, doctors are able to determine the potential risk of heart problems and recommend appropriate treatment options. 17

Bed sores are common in people recovering from a stroke due to the large amount of time spent in bed. Bed sores can vary in severity from mild redness to deep sores extending down to the bone. Bed sores can cause severe irritation and increase the risk of infection.

Frequent movement, which may need to be assisted, is recommended to prevent the development of bed sores. Care should also be taken to avoid pressure on sensitive areas such as the knees, ankles and heels.

People recovering from a stroke may experience difficulty walking. Lack of movement can increase the risk of bone thinning and muscle weakness, which can in turn increase the chances of falling and breaking a bone. To help prevent this, people will often be encouraged to partake in muscle strengthening exercises and rehabilitation appropriate to their condition.

Although some of the risk factors of a stroke – such as family history and being over the age of 40 – are uncontrollable, other risk factors can be managed to help decrease the chances of a stroke. These risk factors include: 18

• High blood pressure: If a person’s blood pressure is outside the normal range, steps can be taken to help bring it down. These steps may include maintaining a healthy weight, exercising and eating healthily. If these measures are not sufficient and it is deemed necessary by a medical professional, taking appropriate medication against hypertension may also be recommended.
• Smoking: Quitting smoking reduces the risk of stroke. Doctors and specialists are able to recommend supportive measures, e.g. structured programs and/or medications to help people quit.
• Heart problems: Heart disorders, such as coronary artery disease and irregular heartbeat (atrial fibrillation), increase the risk of stroke. People with such a heart problem should seek medical attention. Treatment for these heart problems will help reduce the chances of stroke.
• Diabetes: Receiving proper treatment for diabetes type 2, as well as type 1, is helpful in preventing a stroke.
• Obesity/inactivity: A sedentary, inactive and nutritionally unhealthy lifestyle leading to obesity is strongly linked to heart problems, diabetes and high blood pressure. Maintaining a healthy weight and leading an active lifestyle is an effective way of helping to prevent a stroke.

Q: What is the difference between an ischemic stroke and a hemorrhagic stroke?
A: An ischemic stroke occurs when a blood vessel leading to the brain becomes blocked or obstructed. This is the most common type of stroke, accounting for roughly 85 percent of all cases. A hemorrhagic stroke occurs when a weakened blood vessel ruptures, usually as a result of high blood pressure. 19

Read more about Hemorrhagic Stroke »