Strokes (Cerebral Vascular Accidents) Are Diagnosed By A Physician or Primary Care Provider

BE FAST With Signs and Symptoms of a Stroke!

B= Balance Loss

E= Blurred Vision

F= Facial Droop

Arm Drift: Numbness or Weakness

S= Slurred Speech

T= Time! Call 911

What is a Stroke? (Cerebral Vascular Accident)

Cerebral Vascular Accident (Commonly know as a Stroke) is a disease that affects the arteries leading to and within the brain. Strokes are the 4th leading cause of death and a leading cause of disability in the United States. A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain either bursts, ruptures, or is blocked by a clot. As a result, the brain cannot get the blood and oxygen it needs, and pieces of the brain die. Strokes claim the lives of 160,264 people per year in the United States.

Stroke Risk Factors

Approximately 80 percent of strokes can be prevented. 87% of strokes are due to a blood clot. Though some strokes risk factors are uncontrollable, such as age and race, other risk factors are in your control and making small lifestyle changes can reduce your stroke risk. For example, hypertension, which is the leading risk factor can be controlled by eating a healthy diet, regular physical activity, not smoking, and by taking prescribed medications. The American Heart Association identifies seven risk factors to control for ideal health. Life’s Simple 7: Be active, control cholesterol, eat a healthy diet, manage blood pressure, maintain a healthy weight, control blood sugar and don’t smoke.

Understanding Stroke Risk

High Blood Pressure (Hypertension)

HBP is the number one cause of stroke and most important controllable risk factor for stroke. People who are overweight or obese, over age 35, have a family history of HBP, African Americans, pregnant women, and those who are physically inactive, eat too much salt and/or drink too much alcohol are at higher risk for HBP.

Of all people with high blood pressure, more than 20 percent are unaware of their condition. Are you one of them? If you don’t know, see your doctor or primary care provider to be tested.

How can you control your blood pressure?

  • Eat a better diet, which may include reducing salt intake.

  • Engage in regular physical activity.

  • Maintain a healthy weight.

  • Avoid tobacco smoke.

  • Take your medications as prescribed.

  • If you drink alcohol, limit your intake (no more than one drink per day for women and two drinks per day for men).


The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system in many ways. The use of oral contraceptives combined with cigarette smoking greatly increases stroke risk.


Many people with diabetes also have high blood pressure, high blood cholesterol and are overweight. This increases their risk ever more. Though diabetes is

treatable, the presence of the disease still increases your risk of stroke.


Diets high in saturated fat, and cholesterol can raise blood cholesterol levels. Diets high in sodium (salt) can contribute to increased blood pressure. Diets with excess calories can contribute to obesity. But a diet that include five of more servings of fruits and vegetables per day may reduce stroke risk.


Being inactive, obese or both can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke. So go on a brisk walk, take the stairs, and do whatever you can make your life more active. Try to get a total of at least 30 minutes of activity on most days.


It also appears that low HDL (“good”) cholesterol is a risk factor for stroke in men, but more data are needed to verify its effect in women.


The heart’s upper chambers quiver instead of beating effectively, which can let the blood pool and clot. If a clot breaks off, enters the bloodstream and lodges in an artery leading to the brain, a stroke result.


People with coronary heart disease or heart failure have a higher risk of stroke than those with hearts that work normally. Dilated cardiomyopathy (an enlarged heart), heart valve disease and some types of congenital heart defects also raise the risk of stroke.


The genetic disorder mainly affects African American and Hispanic children. “Sickled” red blood cells are less able to carry oxygen to tissues and organs. These cells also tend to stick to blood vessel walls, which can block arteries to the brain and cause a stroke.


PAD is the narrowing of blood vessels carrying blood to leg and arm muscles. It caused by fatty buildups of plaque in the artery walls. People with peripheral artery disease have a higher risk of carotid artery disease, which raises their risk of stroke.


The carotid arteries in your neck supply blood to your brain. A carotid artery narrowed by fatty deposits from atherosclerosis may become blocked by a blood clot. Carotid artery disease is also called carotid artery stenosis.

Types of Stroke

Ischemic Strokes (Clots)

Ischemic stroke accounts for about 87 percent of all cases. Ischemic strokes occur as a result of an obstruction within a blood vessel supplying blood to the brain. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls. This condition is called atherosclerosis. These fatty deposits can cause two types of obstruction:

  • Cerebral thrombosis refers to a thrombus (blood clot) that develops at the clogged part of the vessel.

  • Cerebral embolism refers generally to a blood clot that forms at another location in the circulatory system, usually the heart and large arteries of the upper chest and neck. A portion of the blood clot breaks loose, enters the bloodstream and travels through the brain’s blood vessels until it reaches vessels too small to let it pass. A second important cause of embolism is an irregular heartbeat, known as atrial fibrillation. It creates conditions where clots can form in the heart, dislodge, and travel to the brain.

Silent cerebral infarction (SCI), or “silent stroke,” is a brain injury likely caused by a blood clot interrupting blood flow in the brain. It’s a risk for future strokes which could lead to progressive brain damage due to these strokes.

Transient Ischemic Attack (TIA)

A TIA is a temporary blockage of blood flow to the brain. Since it doesn’t cause permanent damage, it might seem like no big deal. But ignoring it is a big mistake. That’s because a TIA may signal a full-blown stroke ahead.

TIAs are often “mini-strokes,” because they can be relatively benign in terms of immediate consequences. But the term “warning stroke” is more appropriate for these temporary episodes because they can indicate the likelihood of a coming stroke. Like most strokes, TIAs are caused by a clot or blockage in the brain. TIAs should be taken very seriously. If you suspect a TIA or stroke of any kind, be sure to call 9-1-1. Know the warning signs of stoke or TIA.

Blockage is short-term or temporary during a TIA or warning stroke. The clot may dissolve on its or get dislodged so that it stops causing symptoms. Temporary symptoms may occur. A third of U.S. adults have had symptoms consistent with a TIA. The symptoms are similar to an ischemic stroke, but TIA symptoms usually last less than five minutes with an average of about a minute. When a TIA is over, that particular blockage usually causes no permanent injury to the brain.

A TIA is an important warning sign. Warning strokes can signal a problem that may lead to disability, further strokes or even death.

Do TIAs Cause Lasting Damage? Why Not?

  • The body resolves the blockage. The blockage causing the TIA may get pushed “downstream” or may be broken up by natural clot-dissolvers (called anticoagulants) in the blood, so the blockage is not in place long enough to cause any lasting damage to the brain.

  • Blood flow is restored quickly. Without blood flow, brain tissue can be injured. The severity of any blockage-related stroke is determined by how long the tissue was without blood flow and the location of the injury in the brain. When an episode is diagnosed as a TIA, it’s because there is evidence of a blockage but no lasting damage has happened yet.

TIA Statistics

  • Warning strokes are often followed by more severe strokes. About a third of the people who have a TIA and don’t get treatment go on to have a more severe stroke within a year.

  • People who have severe strokes often report having earlier warning strokes. Among patients who are treated for a blockage-related stroke (called an ischemic stroke), between 7 and 40% report experiencing a TIA first.

  • Warning strokes are often followed by more severe strokes. About a third of the people who have a TIA go on to have a more severe stroke within a year.

Who Is at Risk for TIA?

  • All stroke survivors should pay particular attention to the signs of TIA. Survivors who experience a TIA after they have had a stroke should go to the emergency room immediately, because something in their treatment plan has not worked. Having a first stroke increases the likelihood of having another one, so take the warning seriously.

  • Anyone can experience a TIA, but the risk increases with age.

  • People at greater risks for stroke have higher risks for TIA’s. Learn more about this risk factors including smoking, cardiovascular diseases, diabetes, and blood clots called embolisms.

  • Why is TIA an Emergency? What can be done about a TIA?

  • Even though a TIA may seem to be resolved within minutes, with no noticeable or lasting effects, anyone who has symptoms should be rushed to the emergency room.

  • When stroke symptoms are first noticed, it isn’t safe to assume they will disappear without urgent medical care.

  • We can all learn to spot a stroke and act by calling 9-1-1. Educated bystanders can help patients get the care they need so these “warnings” are not overlooked.

What are the Treatments for a TIA?

Trained medical staff need to evaluate the patient’s condition. Some signs ae only visible with hospital equipment, so appropriate medical care is important, which may include:

Assessing vital signs and testing brain function for signs of immediate stroke. Initial assessment includes some quick tests to help determine if the cranial nerves are intact, vision is normal, muscles have strength and specking and thinking seem normal. Heart rate, temperature and blood may also help to provide an overall picture of what is happening. Checking the blood flow and tissue within the brain tissue may be important to determine the cause of the TIA or any brief symptoms of a stroke. These images can be seen using a magnetic resonance imaging (MRI) scan or a computerized tomography (CT) scan.

An electrocardiogram (ECG) is often helpful. The main artery leading from the heart to the brain, called the carotid artery, may also be checked for signs of stiffening or blockage.

Assessing medical history and risks of cardiovascular disease, along with an evaluation of blood chemistry, can help determine the appropriateness of medication to prevent blood clots or a procedure to remove fatty deposits (plaques) from the arteries that supply blood to the brain (carotid endarterectomy).

Referring a patient to a specialist is sometimes appropriate. When a TIA occurs in a young person and there are no clear risk factors for a stroke, the patient may be sent to a neurologist for special testing to rule out vasculitis, carotid artery dissection and other types of injury or infection.

Extreme Obesity, And What You Can Do

Too much weight can take a toll on your body, especially your heart. The good news is that there are steps you can take to get healthier-and even losing a little body weight can start you on the right path.

Why Lose weight

Losing weight can reduce your risk of heart disease and strokes, risk factors like high blood pressure, plasma glucose and sleep apnea. It can also help lower your total cholesterol, triglycerides and raise “good” cholesterol – HDL.

Understanding Extreme Obesity

A healthy BMI range from 17.5 -25kg/m2. If your body mass index is 40 or higher, you are considered extremely obese (or morbidly obese). Check out the American Heart Association’s BMI calculator for adults to determine if your weight is in a healthy range. (Note: BMI in children is determined using a different BMI calculator from the CDC).

A woman is extremely obese if she’s 5 feet 4 inches tall and weighs 235 pounds, making her BMI 40.3 kg/m2. To reach a healthy BMI of 24.8, she would have to lose 90 pounds to reach a weight of 145 pounds.

A man is extremely obese if he’s 6 feet 2 inches tall and weighs 315 pounds, making his BMI 40.4 kg/m2. To reach a healthy BMI of 25.0, he would need to lose 120 pounds to reach a weight of 195 pounds.

Doctors use BMI to define severe obesity rather than a certain number of pounds or set weight limit, because BMI factors weight in relationship to height.

How to Get Healthier

If you’re extremely obese, taking action to lose weight and improve your health may seem overwhelming. You may have had trouble losing weight or maintaining your weight loss, been diagnosed with medical problems and endured the social stigma of obesity. Speak with a compassionate doctor or primary care provider, nutritionist, and a mental health professional.

Treatment Options

Talk with your doctor about the health benefits and the risks of treatment options for extreme obesity:

  • Change your diet. You may be referred to a dietician who can help you with a plan to lose one to two pounds per week. To lose weight, you have to reduce the number of calories you consume. Start by tracking everything you eat.

  • Consider adding physical activity under the direction of your physician.

  • Surgery. If changing your diet, getting more physical activity and taking medications haven’t helped you lose weight, bariatric or “metabolic” surgery may be an option. The American Heart Association recommends surgery for those who are healthy enough for the procedure and have been unsuccessful with lifestyle changes and medication. Risks can include infections and potentially dangerous blood clots soon after the operation, and concerns about getting the right amount of vitamins and minerals long-term.

Strokes Are Diagnosed By A Physician or Primary Care Provider

Get the Social or Medical Support you Need.

Although some people can modify their lifestyle and lose weight on their own, many need extra help. A social support system can help encourage your progress and keep you on track. Decide what support best fits your needs-either a weight-loss support group or one-on-one therapy.

Some people with extreme obesity suffer from depression. Talk to your doctor about the best treatment, as some anti-depressant medications can cause weight gain.

How to Eat Healthy without “Dieting.”

Eating healthy can be easy, tasty, and inexpensive if you stick to some simple guidelines. Who isn’t trying to eat healthy these days?

After all, it can help reduce your risk of heart disease, stroke, and lots of other tings you’d rather avoid. The good news is, eating right doesn’t have to be hard or require you to give up things you love. It’s all about making smart choices to build an overall healthy dietary pattern.

Here are some simple ways you and your family can eat healthier:


  • Fruits and vegetables

  • Whole grains

  • Beans and legumes

  • Nuts and seeds

  • Fish (preferably oily fish with lots of omega-3 fatty acids), skinless poultry, and plant based alternatives

  • Low-fat and fat-free dairy products

  • Healthier fats and non-tropical oils


  • Sweets and added sugars, especially sugary drinks.

  • Sodium and salt

  • Saturated fat

  • Fatty or processed meats-if you choose to eat meat, select leaner cuts.


  • Trans fat and partially hydrogenated oils.


  • Choose mindfully, even with healthier foods. Ingredients and nutrient content can vary a lot.

  • Read labels. Compare nutrition information on package labels and select products with the lowest amounts of sodium, added sugars, saturated fat and trans-fat, and no partially hydrogenated oils.

  • Watch your calories. To maintain a healthy weight, eat only as many calories as you use up through physical activity. If you want to lose weight, take in fewer calories, or burn more calories.

  • Eat reasonable portions. Often this is less than you are served, especially when eating out.

  • Don’t dismiss entire food groups. Eat a wide variety of foods to get all the nutrients your body needs.

  • Cook and eat at home. You’ll have more control over ingredients and preparation methods.

  • Look for the Heart-Check mark to easily identify foods that can be part of an overall healthy eating pattern.

What to Expect in Stroke Rehabilitation.

Following a stroke, about two-thirds of survivors receive some type of rehabilitation. This is a time of both hope and anxiety for stroke families: hope that the survivor will make a good recovery; anxiety or fear about what happens next and what to expect.

Once medically stable, survivors and discharged to either an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF), or home.

Determine What is Needed

Once admitted to the impatient rehabilitation facility (IRF) a physiatrist (or neurologist with rehabilitation experience) performs a general assessment of the stoke survivor’s abilities. The physiatrist determines when the person is ready for rehabilitation.

Sometimes there are precautions that must be kept in mind and made clear in the medical orders for staff and therapist to follow. According to Richard Harvey, M.D. section chief for Stoke Rehabilitation at the Shirley Ryan AbilityLab (formerly Rehabilitation Institute of Chicago) stated in an interview “For example, some patients need to have a fairly high blood pressure after their stroke to maintain good blood flow to the brain. There may be limitations to what the survivor can do because of that, and the physiatrist will want the therapist to monitor blood pressure closely while they’re doing therapy. Medical precautions is important information that would be placed into the medical orders.”

Once the orders are written, the actual therapy begins the next day. Each type of therapist seeing the survivor performs his or her own thorough assessment of specific functions such as motor skills and communication. These measure how independently the survivor is able to function using a standard measuring tool, such as the Functional Independence Measure (FIM). It measures a wide variety of activities such as dressing your upper and lower body, going to the toilet, walking, climbing stairs, communication, problem solving and memory. Each category receives a score between 1 (completely unable)

To 7 (complete independence); total score possible is 118 points. “Patient goals are critical to care planning and their thoughts are gathered on admission by the physician and nurse and also on the next day by the individual therapist”, Harvey said.

Results of these assessments and discussions provide a baseline from which to set goals and guide the kind of therapy the survivor receives. “We set goals for what we hope survivors can achieve at discharge and that drives the rehabilitation therapy that we do,” Harvey said. “The therapy will focus on achieving those goals. So, a physical therapist sets goals for walking and mobility. An occupational therapist sets goals for dressing and other activities of daily living (ADL’s) and a speech therapist works with communication, swallowing, and memory and cognition. They all have specific goals. Nursing is involved as well and helps with things like bladder and bowel control, skin and nutrition.

Working Toward Goals

After the assessments are complete and goals are set, the rehabilitation team meets do discuss the results and the patient’s goals. Next is to determine how long it will take to accomplish the goals, finally a discharge date is set. The discharge date is a target dat. The rehabilitation team meets weekly to evaluate progress. If the target date no longer seems feasible, a new plan is proposed. If a survivor’s progress seems slow, the team works to determine why and adjusts the plan accordingly. The rehabilitation team works closely with the patient and family to develop a mutually agreeable plan. There is communication all along the way and plenty of opportunities to assess readiness for discharge and develop the next steps.

Patients’ perspectives are sought and considered throughout their stay in an IRF. “Any concern raised by the patient is addressed by the team,” he said. “If one team member cannot address it, that team member will seek out the team member who can. Communication between rehabilitation members is critical and constant."

The rehabilitation team meets and reassesses performance every week. At those meetings, any barriers to progress are addressed. “For example, if the patient has muscle spasticity that’s interfering with their ability to walk, we might start a medication to treat that. Or if they need any special split or braces, we make that determination at that meeting,” he said.

These team meetings are rarely, if ever attended by survivors or family members. However, family members are welcome at therapy sessions, which should occupy at least three hours a day in IRF.

“Lots of times we schedule time for the family to come in and learn to assist the patient,” Harvey said. “If the patient needs help when they go home, we want the family to assist them at the right level, to do it safely so that neither the patient nor family member gets injured. We want them to provide the right amount of help. We often work with the family one-on-one to train them on how to do this. But it’s also helpful for caregivers to be around and see what’s going on in therapy. It helps them feel engaged in the whole process. Of course, many families can’t do that because of work, but usually at some point, we need the family to come in and spend some time with us to get an idea what’s going on. In addition, caregivers can be educated in the fine art of saying no and setting limits.

What to Expect of Therapy?

Most IRF stroke programs have many elements to support the many aspects of stroke recovery. These may include:

  • Individual therapies

  • Group therapies

  • Teaching strategies to compensate for functions that aren’t fully recovered.

  • Psychological, emotional support

  • Establishing daily and weekly routines

  • Goal setting

  • Education on: Cause of stroke, preventing another stroke, medications, diet, protection of skin, management of spasticity, stretching, caregiver training, and community resources after discharge.

Different members of the team handle different aspects. For example, secondary prevention is generally something a physician and members of the nursing staff do more than therapists. On the other hand, setting functional goals tends to fall more to the therapist than the nurse and physician.

“Our goal is to get survivors ready to be discharged safely to their homes,” Harvey said. “Most of the time that involves individual therapy. Occasionally we give group therapy. We often have an upper-body exercise group for people who need to strengthen their weak arm. Or a speech group where patients communicate with each other under the supervision of a speech therapist, but mostly it’s individual therapy.

In stroke rehabilitation, there is a constant balancing of recovery and compensation. In IRFs, the goal is to work on recovery first-strengthening arms and legs using whatever strength is regained to help perform functional tasks. “In some cases, that’s impossible, so if a person’s balance is very severely impaired and walking is unsafe, we may shift focus to practice on wheelchair propulsion, which is a compensatory way to move around. But the goal is to help this person be able to do what they need to do as independently as possible. And that either is going to be recovery back toward normal performance of improvement of function based on compensator strategies with or without devices.

“Our goal is to get survivors ready to be discharged safely to their homes. Most of the time that involves individual therapy.”

Rehabilitation Technologies

Although interesting technology is being used, it is not widely adopted because scientific evidence to date does not show that it offers improvement over standard of care.

Robots for walking or improving hand use are mostly available in research or academic medical centers. “Robots are very expensive,” Harvey said. On the other hand, electrical stimulation for retraining arms and legs is more widely accepted and cheaper.

Video game systems with motion-sensitive controls (like the Nintendo Wii) and computer programs or games are sometimes used as training tools to incorporate a survivor’s weak side, improve balance or challenge them cognitively.

Harvey is working with a research fellow who’s developing a smartphone app for stroke patients to practice using their weak upper limb. Speech therapist also use tablets and smartphones for both language recovery as well as a device to help survivors communicate with others.


For the first three months after a stroke, the brain is much like a child’s brain, ready to learn, ready to make new connections. This ability for our brains to adjust is known as neuroplasticity and it plays a crucial role in recovery.

“It’s a time of really rapid change in the central nervous system,” Harvey said. “About three months after the stroke, neuroplasticity is becoming more normalized, sort of the same neuroplasticity that everybody else has.” At that point, there’s still plenty of recovery available, but Harvey equates it to learning to play the guitar from scratch: “If I wanted to learn how to play the guitar, I would have to get a guitar and take lessons and practice and practice and maybe in a year or two, I’d be able to play some basic songs on the guitar,” he said. That’s a skill that I would have to learn. Survivors can still improve their function, but it requires lots of practice to improve skill.”

Am I Receiving Appropriate Care?

Though survivors can continue to improve their function for a long time, there is only one opportunity to get the most out of the heightened neuroplasticity during the early weeks and months of rehabilitation following a stroke. Knowing that you’re getting appropriate care that is helping you make progress towards your goals is important.

There are some signs to watch for to be sure you’re getting appropriate care. According to Harvey, too much group therapy is some to be wary of, “Acute inpatient rehabilitation should mostly focus on one-to-one therapy.”

Does the facility have equipment like treadmills with bodyweight support, parallel bars and walkers to get them on their feet? “Acute stoke rehabilitation should get people on their feet and work on walking,” Harvey said, “If they’re spending more time working on a mat just doing leg strengthening, rather than performing function, then you should be concerned because what survivors really need is practice walking and they will gain strength.”

If they’re focusing only on compensatory strategies and survivors are spending more time in a wheelchair than on their feet, that’s an issue.

If caregivers or survivors don’t like what they see happening, Harvey says they should speak to the physician in charge because they are ultimately responsible for the care of the patient. There maybe a legitimate reason for the altered therapy, but the families should receive an explanation.

“Working with a therapist is not a business transaction, it’s a relationship.”

By its very nature, therapy is personal, and sometimes conflict arises between patient and therapist. Harvey says that when this happens, they rarely assign a new therapist, preferring instead that the people work out the problem. “We encourage them to communicate about it and to be honest about what the issues are and see if they can come to an understanding,” he said. “That’s what you’re supposed to do in life, isn’t it? So, it’s part of therapy to do that. Now if that conflict cannot be resolved, then a manager can arrange for a different therapist. But we try not to do that because that’s just not the way to deal with things in life. Working with a therapist is not a business transaction, it’s a relationship.”

When It Is Time To Leave

Discharge protocols differ from facility to facility but often involve a home assessment, caregiver education, family involvement, home therapy referrals as well as information on driving and community resources.

“What we usually do is family education and training and then we order equipment, if that is needed,” Harvey said. “We arrange for follow-up including with a neurologist and also for outpatient therapy. That may be home therapy, but it could be outpatient therapy. Some patients may go from inpatient

Rehabilitation facility to a nursing facility before they can transition home. But when you do transition home, it’s important to have follow-up outpatient therapy and continue rehabilitation after discharge.”

Actual inpatient therapy, Harvey points out, is an important, but small, part of the whole rehabilitation process. “Inpatient care is intended to help a patient be safe to return home, but it does not address all the functional and rehabilitation needs a patient has. Stroke recovery takes three to 12 months and beyond, and inpatient is usually less than three weeks. “To maintain gains and work on evolving needs, patients must continue to work at recovery.


Caregivers play a crucial role in a survivor’s recovery. “It’s important for caregivers to understand how much the survivor can do and what they can’t do so they assist them to the level they need but don’t over-assist them,” Harvey said. “Survivors need to continue working on independence. It’s always good to have some things that you’re working on improving at home. For example, if you can’t put on your shirt on your own maybe that’s something that the patient can work on doing and improving at home and the family can support this.” Encourage them to continue working on getting more independent.

“The other thing is to remember that rehabilitation is lifelong. I tell all my patients, all of us should have time when we take care of our bodies, when we exercise, when we work on strength or conditioning, and people with stroke are the same. They should always be working on their body, always taking care of it.”

“The last thing you want is for a stroke survivor to go home and say, “I had a stroke so I can’t do anything anymore.” Maybe you can’t do everything you used to, but there are certain things that you can do and there are certainly ways that you can improve your performance if you just focus and work on it a little bit every day. We can all practice being better people in this world, and stroke survivors are no different.