Striking Back at Stroke
by Evelyn Zamula

     At the time, the president's personal physicians believed it
was necessary to keep from the public the truth about the
president's health. With the second World War not yet won, they
would neither confirm nor deny that he was ill and told no one,
not even his family, that he had serious heart problems and blood
pressure as high as 260/150. But Americans could see for
themselves that the president was failing rapidly. The signs of
it were in his face, and in the reduced vigor of his voice.
Still, it came as a shock when Franklin D. Roosevelt died of a
massive cerebral hemorrhage nearly 50 years ago.
     President Roosevelt was one of 129,144 Americans who died of
stroke in 1945. Today, with a population almost twice as large,
about 150,000 people die of the half million who are stricken
each year. Another 200,000 are left with some disability.
Although the statistics are looking better, stroke remains the
third leading cause of death, preceded only by heart disease and
cancer.
     A stroke is damage to brain cells resulting from an
interruption of the blood flow to the brain. The brain must have
a continual supply of blood rich in oxygen and nutrients for
energy. Although the brain constitutes only 2 percent of the
body's weight, it uses about 25 percent of the oxygen and almost
75 percent of the glucose (sugar) circulating in the blood.
Unlike other organs, the brain cannot store energy. If deprived
of blood for more than a few minutes, brain cells die from energy
loss and from certain chemical interactions that are set in
motion. The functions these cells control--speech, muscle
movement, comprehension--die with them.
     Dead brain cells can't be revived, but in recent years the
Food and Drug Administration has approved new drugs that may
prevent stroke in susceptible people and in those who have
already had a stroke.
     The majority of strokes are caused by blockages in the
arteries that supply blood to the brain. (These are called
ischemic strokes or infarctions, just as a heart attack--in which
the heart muscle is deprived of blood--is called myocardial
infarction.) The blockages may be caused by a clot, or thrombus,
that forms on the inner lining of a brain or neck artery already
partly clogged by atherosclerotic plaque--deposits of fat-
containing materials and calcium.
     Although atherosclerosis, or hardening of the arteries, is
primarily a disease of the elderly, the process may begin as
early as childhood. Autopsies of soldiers who died in the Korean
and Vietnam wars showed that atherosclerosis was already evident
in the arteries of many of the young men.
     A blood clot formed in another part of the body may also
cause stroke. Usually, a wandering clot like this--called an
embolus--breaks off from plaque in an artery wall, or originates
in the heart.
     Emboli may form in rheumatic heart disease, after a heart
attack, or during atrial fibrillation, an abnormal heart rhythm.
Instead of beating forcefully to fill the ventricles (the larger
heart chambers that pump blood to the lungs and throughout the
body), the atria (smaller heart chambers) beat irregularly and 
don't empty fully, causing blood to stagnate in the heart and
form clots. If one lodges in a brain artery, a stroke results.
     The most serious kinds of stroke occur not from blockage,
but from hemorrhage, when a spot in a brain artery weakened by
disease--usually atherosclerosis or high blood pressure--ruptures
or begins to leak blood. If an artery inside the brain ruptures,
it is called a cerebral hemorrhage. When a blood vessel on the
brain's surface ruptures, filling the space between the brain and
the skull with blood, it is known as a subarachnoid hemorrhage.
This type of stroke may also be caused by an aneurysm, a section
of the artery wall so thin that it may balloon out and burst,
especially when high blood pressure is present. (In many cases,
people are born with these fragile spots in a brain artery wall,
or may develop weak spots in arteries due to malformed blood
vessels or hemorrhagic disease.)
     Not only does the part of the brain served by the blood
vessel die in hemorrhagic strokes, but blood may spurt out so
forcefully that surrounding brain cells are damaged. A large clot
may form and press on adjacent brain tissue, increasing pressure
inside the skull and causing swelling. Hemorrhagic strokes
account for less than 20 percent of all types of strokes, but are
far more lethal, with a death rate of over 50 percent.
     Strokes caused by emboli or hemorrhage usually strike
suddenly, with little or no warning, and do all their damage in a
matter of seconds or minutes. In thrombotic strokes, symptoms
often progress by steps. A slight clumsiness on arising in the
morning may be followed by loss of half the field of vision in
both eyes by breakfast time (which the victim may not be aware
of) and an inability to speak. Paralysis in one arm may be
followed in the course of several hours or a day or so by
complete paralysis on that side of the body.

Distinguishing a Stroke from a TIA
     Any evidence of disruption of blood supply to the brain
(such as inability to grasp with one hand or difficulty speaking)
that lasts longer than 24 hours may be used to diagnose stroke.
Effects of a stroke can range in severity from a slight one-sided
facial sagging that disappears within two weeks to inability to
walk or loss of control of bodily functions that lead to long-
term problems such as incontinence. The kind of disability a
stroke victim is left with depends on the location and extent of
brain damage.
     An incident involving physical symptoms that last less than
24 hours (usually not longer than a few minutes or hours at most)
and leave no permanent disability is called a transient ischemic
attack (TIA) or "ministroke." A TIA is a signal that the brain's
blood supply has been temporarily interrupted, either from small
clots that lodge in a tiny brain artery and then dissolve
spontaneously, or from briefly reduced blood flow in narrowed
arteries.
     The most commonly reported symptoms of a TIA include
temporary difficulty in speaking or understanding the speech of
others; minor numbness or weakness of the face, arm or leg on one
side of the body; unsteadiness, dizziness or falls; and blurred
vision or sudden blindness in one eye that may last a few
minutes. A TIA may occur shortly before a stroke occurs, or may
be a predictor of future stroke. Some individuals have repeated 
attacks of TIAs without any serious consequences, but these
symptoms should not be ignored and need immediate medical
attention.

Resourceful Brain
     The brain is resourceful. After brain swelling goes down
following a stroke, small blood vessels around the blocked area
enlarge to allow more blood flow to the damaged section. Some
incapacitated cells may recover partially or completely. In many
cases, other brain cells can assume the functions of the damaged
ones. This is especially true of infants and young children,
whose nervous systems are still developing.
     "Less than 1 in every 50,000 newborns suffers a stroke
caused by clots that travel from the fetal or placental
circulation around the time of birth," says Rebecca Ichord, M.D,
a pediatric neurologist at Johns Hopkins University Hospital,
Baltimore, Md. "Newborn infants do remarkably well and have less
long-term disability than an adult with a comparable injury. Even
though part of the brain is damaged, infants have other healthy
brain cells that aren't dedicated to any particular function as
yet, and these take over for the damaged cells."
     Each of the two hemispheres of the brain controls the
opposite side of the body. Paralysis on the right side of the
body means that the left side of the brain (the dominant
hemisphere in a right-handed person) is injured. As speech and
language are associated with areas in the left brain, individuals
with left-brain damage may have trouble with speaking and
understanding, a condition called aphasia.
     A right-brain stroke may leave persons with a paralyzed left
side and spatial-perceptual deficits--difficulty in judging
distance, size, position, and speed. They may not know whether
they're standing or sitting upright or leaning. Because they may
not sense where they are in the road or how near they are to the
next car, driving should be left to others.
     Both types of brain injury may result in memory loss and
personality changes. Stroke victims may also suffer from visual
field defects and hearing loss on one side of the body, called
"one-sided neglect." The condition may cause problems in
something as basic as getting dressed--they may neglect their
left side, for example, and put only the right arm in a sleeve,
or the right foot in a shoe. When these people see their own arm
and leg lying beside them, they often think someone is in bed
with them and become incensed. In her memoir, Reprieve, Agnes de
Mille, who had left-brain injury, tells of losing track of her
"lost" right hand and hunting for it among the bedclothes.

Drugs to Inhibit Clots
     As blood clots play a major role in causing thrombotic and
embolic stroke, agents that inhibit blood from coagulating may
prevent clot formation. Physicians have several such drugs at
their disposal, including the workhorse of the medicine chest--
aspirin--to treat those who've had TIAs or previous stroke.
     Aspirin works by preventing blood platelets from sticking
together. The amount of aspirin for optimum stroke prevention is
controversial.
     "We don't know exactly how much aspirin is best for stroke
prevention," says Chung Hsu, M.D., Ph.D., professor of neurology
at Washington University School of Medicine, St. Louis, Mo. "The
literature appears to suggest if a patient can tolerate four
aspirin (325 mg each) a day, that's probably the preferred
treatment. However, on four aspirin a day, some patients have
side effects. If the patient can't take four, I'll try three,
then two. On some patients I would try one a day." Many
physicians use as little as one baby aspirin (80 mg) daily.
     Allergy, stomach irritation, or more serious
gastrointestinal complaints are the chief side effects of
aspirin. And in some people, especially the very old, aspirin is
just not effective.
     Aspirin's easy availability has led many to take it without
their doctors' recommendation, but this practice may be unwise.
The physician labeling for aspirin states that aspirin is safe
and effective for reducing the risk of recurrent TIAs and stroke
in men who have had transient ischemia of the brain due to emboli
and recommends a dosage of 1,300 mg a day, in divided doses.
However, it also states there is inadequate evidence of
effectiveness in women and no evidence of benefit in treating
completed strokes in men or women. The labeling advises persons
who have had TIA symptoms to have a complete medical and
neurologic evaluation to rule out other disorders that resemble
TIAs. A study in the Jan. 7, 1994, British Medical Journal
stressed that people at low risk of stroke should not take
aspirin because it may cause bleeding into the brain. There is no
evidence that daily use of aspirin will prevent strokes in people
who have never had a TIA or other symptoms.
     Late in 1992, FDA approved Ticlid (ticlodipine), another
anti-platelet drug for stroke prevention that's labeled for use
in patients who cannot tolerate aspirin. In the Ticlodipine
Aspirin Stroke Study, a large, multicenter randomized study,
researchers found that Ticlid was superior to aspirin for
preventing thrombotic stroke in both men and women who had
recently had a TIA, or who had had a minor nondisabling stroke.
Compared to aspirin, Ticlid reduced the overall risk of stroke an
additional 24 percent.
     "If somebody fails on aspirin, that's an indication to try
Ticlid," says Hsu. "We use it in a selected group of patients
because it's more expensive than aspirin and in approximately one
out of every 100 patients, its use is associated with
neutropenia, a blood side effect [reduction in the white blood
cells that fight infection]. Also, patients must be monitored
carefully, because some get diarrhea and rash."
     People taking Ticlid must have complete blood counts taken
every two weeks during the first three months of treatment to
check for neutropenia, which is usually reversible when Ticlid is
stopped.
     Another clot-preventing drug is Coumadin (warfarin), which
interferes with the production in the liver of certain proteins
that are necessary for blood coagulation. Use of warfarin carries
a risk of hemorrhage, but treatment with low doses has been very
successful in preventing embolic stroke in people who have atrial
fibrillation or heart valve abnormalities.

 Controlling High Blood Pressure
     Because high blood pressure is responsible for about 70
percent of hemorrhagic strokes, controlling blood pressure is the
most effective way to prevent this type of stroke, as well as
strokes due to blockages. If President Roosevelt's physicians had
had the kind of blood pressure-lowering drugs available today,
FDR probably would have lived at least long enough to share
victory in the second World War.
     Included among today's more commonly prescribed medications
to treat hypertension are diuretics that stimulate urination,
thus reducing blood volume and blood pressure by eliminating
excess fluid and sodium; beta blockers that lessen the heart's
work by slowing heart rate and output of blood; calcium channel
blockers that relax and dilate blood vessels by preventing
calcium from entering into body cells; and ACE (angiotensin-
converting enzyme) inhibitors that block the release of a kidney
hormone that causes blood vessels to narrow.
     Individuals who have had a stroke from subarachnoid
hemorrhage due to a ruptured aneurysm may have another
complication a week or so later when an artery near the injured
area constricts, or goes into spasm, cutting off the blood supply
and causing a second stroke. Nimotop (nimodipine), a calcium
channel blocker approved in 1988, decreases the chance of another
stroke by preventing spasm and may reduce the severity of stroke-
related disabilities.
     In cases where it seems that narrowed carotid arteries in
the neck are causing or will cause strokes, a procedure called
carotid endarterectomy may be recommended. Surgeons remove the
atherosclerotic plaque that is clogging the carotid artery by
opening up the artery, scraping out the plaque, and sewing the
artery together again.
     The North American Symptomatic Carotid Endarterectomy Study,
published in Stroke (June 1991), showed that the operation
reduced the risk of a major or fatal stroke in patients with
carotid artery blockages of 70 percent or greater who had had
recent TIAs or a mild stroke. Studies are ongoing to find out
whether the operation will benefit symptomatic patients with less
than 70 percent narrowing and those who have significant clogging
and no symptoms.
     Most people who have had mild strokes, and about half of
those who have had moderate or severe paralysis on one side,
recover enough to walk out of the hospital under their own steam
or with some mechanical aid and resume their lives, though with
certain limitations. But others are not so lucky. Many of the
survivors face a bleak future, with disabilities that require
special services or lifelong institutional care. People with one
or more risk factors for stroke (see accompanying article) should
do everything they can to avoid the consequences of this
devastating disease. 

Evelyn Zamula is a freelance writer in Potomac, Md.

Reducing Risk Factors

     Though more common in the elderly, stroke may occur at any
age. The American Heart Association reports that more than 1 in 7
who die from stroke are under 65. Reducing risk factors can help
prevent stroke. These risk factors include:
    High blood pressure. The force of blood beating with great
pressure against artery walls weakens the walls and promotes the
buildup of atherosclerotic plaque.
    Elevated blood cholesterol. Clots that can travel to the
brain don't usually form in normal hearts, but they may form in
heart disease and after a heart attack and heart surgery.
Reducing high blood levels of LDL-cholesterol--the so-called
"bad" type--and increasing levels of HDL-cholesterol may retard
the formation of atherosclerotic plaque. (See "Lowering
Cholesterol" in the March 1994 FDA Consumer.) A low-fat, low-
cholesterol diet benefits not only the coronary arteries, but
arteries throughout the body, including those supplying blood to
the brain.
    Cigarette smoking. Many studies have shown a relationship
between smoking and strokes. If you smoke, try to stop.
    Heavy alcohol consumption. Chronic alcoholism and very heavy
drinking are risk factors for both thromboembolic and hemorrhagic
stroke, as well as increased mortality from stroke. Some studies
show that moderate alcohol consumption may protect against
cerebrovascular disease by raising HDL levels and helping prevent
excessive blood clotting. But alcohol consumption should be
limited to no more that one or two drinks a day, a drink being
defined as 12 ounces of beer, 4 ounces of wine, or 1.5 ounces of
80-proof spirits.
    Diabetes. People with diabetes--especially women--have
almost double the risk of stroke. Diabetes causes atherosclerosis
earlier in life and of greater severity. Besides damaging blood
vessels, diabetes appears to interfere with the normal breakdown
of fibrin, a plasma protein that holds blood clots together.
    TIAs. If you have any evidence of a TIA--a sudden buckling
of one leg leading to a fall, temporary blindness in one eye,
slurred speech--tell your doctor immediately.
    Family history. If a parent or sibling has had a stroke or
TIA, you may also be at increased risk. It's not known whether
this increased risk is inherited or from unhealthy family
lifestyles.
    Men have a higher stroke risk than women, and blacks have a
higher stroke risk than people of other races.
     Since age, gender, heredity, and race can't be changed, it's
wise to work on the stroke risk factors that can be altered, such
as high blood pressure, high cholesterol levels, cigarette
smoking, and heavy alcohol consumption. 
--E.Z.