What is a Stroke?

A stroke occurs when part of the brain is injured because blood flow is blocked or because bleeding occurs in or around the brain. Stroke is a medical emergency because brain cells can be damaged quickly when they do not receive enough oxygen and blood flow.

There are two main types of stroke. An ischemic stroke happens when a blood clot or blockage reduces blood flow to part of the brain. A hemorrhagic stroke happens when a blood vessel ruptures and causes bleeding into the brain or around the brain. A transient ischemic attack, often called a TIA or “mini-stroke,” causes temporary stroke-like symptoms and should still be treated as urgent.

Anyone with new stroke symptoms should call 911 and seek emergency medical care. De Novo Brain & Spine evaluates adult patients with stroke-related neurosurgical concerns, such as brain hemorrhage, hydrocephalus, aneurysm, vascular malformation, mass effect, or the need for surgical treatment planning after emergency evaluation.

Common Signs and Symptoms

Stroke symptoms usually begin suddenly. Symptoms depend on the area of the brain affected, the type of stroke, and the severity of injury.

Common signs and symptoms may include:

• Sudden weakness or numbness in the face, arm, or leg, especially on one side of the body
• Facial drooping
• Trouble speaking, slurred speech, or difficulty understanding speech
• Sudden confusion
• Sudden vision loss, blurred vision, or double vision
• Sudden dizziness, loss of balance, or trouble walking
• Sudden severe headache, especially with vomiting or neurological changes
• New seizure
• Loss of coordination
• Trouble swallowing
• Sudden change in alertness, fainting, or loss of consciousness
• Nausea or vomiting with neurological symptoms
• Worsening drowsiness or decreased responsiveness

Use the phrase BE FAST to remember common stroke warning signs: Balance, Eyes, Face, Arms, Speech, and Time to call 911.

Seek emergency medical care or call 911 immediately for any sudden stroke-like symptom, even if it improves. Do not wait for symptoms to go away.

What Causes This Condition?

Stroke can be caused by a blocked blood vessel, bleeding from a ruptured blood vessel, or conditions that increase the risk of either problem. The cause depends on whether the stroke is ischemic or hemorrhagic.

Common causes and risk factors may include:

• Blood clots that block blood flow to the brain
• Atherosclerosis, which is plaque buildup in the arteries
• Atrial fibrillation or other heart rhythm problems that can send clots to the brain
• Carotid artery disease or narrowing of blood vessels supplying the brain
• High blood pressure, also called hypertension
• Diabetes
• High cholesterol
• Smoking
• Obesity or physical inactivity
• Prior stroke or TIA
• Brain aneurysm rupture, which may cause subarachnoid hemorrhage
• Brain hemorrhage, also called intracerebral hemorrhage
• Cavernous malformation, dural AV fistula, or other vascular malformation in selected cases
• Blood-thinning medication or bleeding disorders in some patients
• Age, family history, and other medical conditions that affect blood vessels

These are causes or risk factors, not guarantees that a stroke will occur. Stroke prevention and treatment planning depend on the type of stroke, medical history, imaging findings, vascular risk factors, and the patient’s overall health.

How It Is Diagnosed?

Stroke is diagnosed through emergency medical evaluation, neurological examination, and brain imaging. Because treatment may depend on timing, stroke symptoms should be evaluated immediately.

Common diagnostic steps may include:

• Emergency medical assessment to determine when symptoms started and whether stroke treatment may be time-sensitive
• Neurological examination to evaluate speech, vision, eye movement, facial movement, strength, sensation, coordination, balance, alertness, and cognition
• CT scan of the head to look for bleeding, large stroke, swelling, or other urgent findings
• MRI of the brain to identify areas of ischemic injury or other brain abnormalities
• CT angiography, also called CTA, to evaluate blood vessels in the head and neck
• MR angiography, also called MRA, to evaluate arteries and vascular anatomy
• CT perfusion or MR perfusion imaging in selected cases to assess blood flow patterns
• Digital subtraction angiography, also called catheter angiography, in selected cases when detailed vascular imaging is needed
• Blood tests to evaluate clotting, blood count, blood sugar, kidney function, and other medical factors
• Electrocardiogram, also called EKG, and heart rhythm monitoring to look for atrial fibrillation or other heart-related causes
• Echocardiogram in selected cases to evaluate possible heart sources of clot
• Carotid ultrasound in selected cases to evaluate narrowing in the carotid arteries

The goal of diagnosis is to determine whether symptoms are caused by stroke, identify whether the stroke is ischemic or hemorrhagic, find the likely cause, and guide urgent treatment.

Treatment Options

Stroke treatment depends on the type of stroke, when symptoms began, imaging findings, stroke severity, bleeding risk, medical history, and overall health. A stroke is an emergency and should be treated in an emergency department or stroke center.

Treatment options may include:

• Emergency stroke care with rapid imaging, neurological evaluation, and monitoring
• Thrombolytic medication, sometimes called clot-busting medication, for selected ischemic strokes when timing and safety criteria are met
• Mechanical thrombectomy, a catheter-based procedure to remove a clot from a large brain artery in selected ischemic strokes
• Antiplatelet medication or anticoagulation when appropriate for stroke prevention, depending on the cause and bleeding risk
• Blood pressure management, blood sugar management, cholesterol treatment, and risk factor control
• Treatment of carotid artery disease in selected patients, which may involve medical therapy, carotid endarterectomy, or carotid stenting depending on the case
• Emergency treatment for hemorrhagic stroke, including blood pressure control, reversal of certain blood-thinning medications when appropriate, and monitoring for swelling or increased pressure
• Hematoma evacuation in selected brain hemorrhage cases when removing a blood clot may help relieve pressure or support neurological care
• Decompressive craniectomy in selected cases of severe brain swelling from ischemic or hemorrhagic stroke
• Treatment of hydrocephalus, such as external ventricular drainage or shunt placement, when blood or swelling blocks cerebrospinal fluid flow
• Treatment of aneurysm, dural AV fistula, cavernous malformation, or other vascular lesion when one of these conditions is responsible for bleeding or stroke risk
• Rehabilitation, including physical therapy, occupational therapy, speech therapy, swallowing therapy, and cognitive support
• Secondary stroke prevention, which focuses on reducing the risk of another stroke through medication, lifestyle changes, and treatment of underlying causes

Neurosurgical care may be considered for selected stroke patients with brain hemorrhage, swelling, hydrocephalus, vascular malformation, aneurysm, or mass effect. The safest treatment plan depends on the stroke type, imaging findings, neurological condition, and urgency of the situation.