I have just spent the day at the hospital with another family member who had a stroke today and I am again reminded that, as diabetics, we are at increased risk for strokes. If you read nothing more, please make sure your doctor is checking your blood pressure and your carotid arteries -- and memorize the warning signs of stroke below. Paula ========= HIGH BLOOD PRESSURE: What is high blood pressure? If your blood pressure is over 140/90 (either number higher than those), then you should talk to your doctor about how to bring your blood pressure down. You may be advised to improve your diet, avoid salt, lose weight, or take medications. Whatever treatment is recommended, don't put it off. If it doesn't make sense to you or you don't feel like doing it, get a second opinion, but don't just decide it isn't too important. It is very important that we all make sure that we are regularly checked for high blood pressure and that, if we do have high blood pressure, it is being well-treated. CLOGGED CAROTIDS: Your carotid arteries are the two arteries on the front and side of your neck that help carry blood to your brain. Does your doctor check to see how your carotid arteries are? There are non-invasive Doppler tests that can give you some idea of whether your carotid arteries are clogged up and to what extent. Some amount of blockage can be disregarded but if the blockage appears significant, you may need to have further testing and consult with a very good vascular surgeon about whether you need to have surgery to clear some of the blockage. This surgery is generally better done before the blockage becomes severe and before one's health deteriorates a great deal. Surgery on diabetics is never done lightly but, for some of us, the benefits may well outweigh the risks. If you do have surgery, be sure that your surgical team is very skilled and perform this surgery often. If you need to travel to get to the best doctors available, make the trip. TWO KINDS OF STROKES: Strokes are also called Cerebrovascular Accidents (or CVA). They occur when blood flow to the brain is disrupted, which causes brain cells to die. There are two kinds of strokes: hemorrhagic and ischemic. Hemorrhagic strokes are when a blood vessel bursts and ischemic strokes are when a blood clot forms and blocks blood flow to the brain. Ischemic Strokes These can result from blood clots formed within an artery in the brain or arteries leading to the brain. This kind is called a cerebral thrombosis. They can also be caused by pieces of blood clots that travel from some other part of the body and finally reach a place where they block blood flow to the brain. This kind is called a cerebral embolism. Ischemic stroke is the most common type of stroke, causing about 80% of strokes. Blood clots often form in arteries damaged by atherosclerosis, with rough fatty deposits building up on the walls of arteries, narrowing the passage way, causing blood flow to slow down and, sometimes, completely blocking the artery. Hemorrhagic Strokes These can result from bleeding in the area between the brain and skull and called a subarachnoid hemorrhage. They can also result from the bursting of a blood vessel in the brain. This kind is called an intercerebral hemorrhage. Intercerebral hemorrhages are often due to an aneurysm that has been bulging and weakened over the years by high blood pressure, which finally causes it to burst; they are often symptomless until they burst. They may also be caused by a cluster of abnormal blood vessels called an arteriovascular malformation (or AVM); often AVMs are accompanied by symptoms including seizures, progressive neuro- logical problems, and severe headaches. Cerebral hemorrhage tends to occur in people who suffer from a combination of atherosclerosis and high blood pressure. WARNING SIGNS OF STROKES: - Sudden weakness, numbness or paralysis of the face, arm, or leg (especially on one side of the body). - Loss of speech or trouble talking or understanding language. - Sudden loss of vision, especially in only one eye. - Sudden, severe headache with no apparent cause. - Unexplained dizziness, loss of balance or co-ordination (especially if associated with an above symptom). Sometimes strokes are preceded by warning signs, called Transient Ischemic Attacks (TIAs). About 1/3 of all strokes are preceded by these "mini-strokes," which can occur days, weeks or even months before a stroke. TIAs are caused by temporary interruption to the blood flow in the brain. The symptoms usually occur rapidly, last for a short time (a few minutes to a few hours) and are followed by complete recovery within 24 hrs. IF YOU HAVE SYMPTOMS: If you experience a moment or two of weakness or numbness in an arm or leg, or momentary loss of vision, or a momentary difficulty speaking, do not ignore it. Contact your doctor and seek immediate medical attention, even if the symptoms have disappeared. If you do not have a doctor, call the nearest emergency room. If the symptoms last for more than 10 - 15 minutes, call an ambulance. The majority of stroke patients do not seek help until a day or more after the first symptoms have appeared. By then, it is usually too late for the best and newest treatments to help. If you can get medical attention within the first 3 hours of your symptoms and your stroke is due to a blood clot, you may benefit from the clot-dissolving drug called t-PA. This treatment is recommended for carefully selected stroke patients by the U.S. gov't National Institute of Health, National Institute of Neurological Disease and Stroke (in its alert 12/14/95.) RISK FACTORS FOR STROKES: All diabetics are at increased risk for strokes. Other risk factors include: 1. Age. The risk increases with age. Two-thirds of strokes occur in people aged 65 and older. 2. Sex. Strokes are somewhat (25%) more common in men than in women. 3. Race. African-Americans have a higher rate of high blood pressure and of strokes than Caucasians and tend to suffer strokes at earlier ages. 4. History. Family history of strokes seems to increase risk of having a stroke. You are also more likely to have a stroke if you have already had one. 5. High Blood Pressure. This is the single most important risk factor for stroke. Even mild hypertension increases the risk of stroke. If your blood pressure is over 140/90, you may need some form of treatment. (This number is not an absolute and may vary. For example, some doctors might consider blood pressure up to 160/90 to be acceptable among patients more than 60 yrs old.) 6. Heart disease. Irregular heart rhythms (atrial fibrillation), heart attacks and valve disorders can increase the risk of stroke. 7. Smoking. Smokers have a higher risk of stroke, but this declines dramatically after a smoker quits. 8. Poor diets. Diets high in fat (especially saturated fat from animal sources) may contribute to atherosclerosis. Diets higher in fiber and lower in fat and cholesterol may help. Salt-sensitive people should also be careful to limit salt. 9. Alcohol. Drinking more than 2 drinks a day has been shown to increase the risk of stroke. Heavy drinking increases the risk of stroke even more. 10. Lack of exercise. Exercise appears to help considerably in reducing the degree of atherosclerosis. Being sedentary is associated with increased risk for strokes. 11. Oral Contraceptives. The risk is especially increased among women using high estrogen content Pills, who are over the age of 30 and smoke. Some studies suggest that post-menopausal use of estrogen for hormone-replacement therapy does not appear to increase the risk for stroke. Be sure to consult your doctor. PREVENTIVE MEDICATIONS: Anticoagulants (like heparin and warfarin) and anti-platelet agents (like aspirin and ticlopidine or "ticlid") are often given to people at high risk of having a stroke or having another stroke. Anticoagulants thin the blood and prevent clotting. Anti-platelet agents help reduce or prevent platelets in the bloodstream from clumping together and ultimately forming clots. People using any of these drugs, particularly blood thinners, need to get regular blood tests to make sure the dosage is just right. Some experts believe that many diabetics would benefit from daily low-doses of aspirin to reduce risk of heart attack and ischemic strokes. There is much to be said for the idea, but even aspirin is not without its side-effects and may not be the wisest choice for those with certain other conditions. Be sure to check with your doctor before deciding to embark on daily aspirin treatment and get your doctor's guidance about the appropriate dosage, if any, for you. AFTER SURVIVING A STROKE: Strokes can be extremely disabling. The main goal following a stroke is to return the person to as independent a lifestyle as possible. This often requires a considerable amount of rehab therapy. Damage to the left side of the brain is usually associated with damage to the right side of the body. Damage to the right side of the brain is usually associated with damage to the left side of the body. Paralysis and loss of feeling on one side of the body, loss of ability to speak or understand language, learning and memory problems, inability to read or write, perception problems, emotional and behavioral changes, and problems walking and swallowing are common results of strokes and vary in severity.