1. Stroke

2. Stroke
Stroke is the 3rd leading cause of death.
Every 5 minutes someone has a stroke
A woman is 3 times more likely to have a stroke than breast cancer.
Women account for approximately 43% of strokes that occur and 61% of stroke deaths
Stroke risk increases with age. Almost doubles each decade over 55yrs
28% of people who suffer a stroke are under 65 yrs old.
People with uncontrolled high blood pressure are 7 times more likely to have a stroke than those with controlled high blood pressure.
The risk of stroke is 2.5 times higher in people with diabetes

3. What is a stroke?
A sudden interruption in the blood flow to the brain which is caused by a
blockage or bleeding.
The brain needs a constant flow of blood as it carries necessary oxygen and nutrients to function.
Arteries carry blood from the heart to different parts of the brain. If an artery blocks, blood flow ceases and the brain cells start to die.

4. Types of stroke
2 main types -
Ischaemic stroke
1. A blood clot forms in the artery itself. Commonly occurs over fatty tissue/
furred arteries.
2. A blood clot forms in another part of the body e.g. heart or in the arteries of
the neck , dislodges and travels to the brain.
The clot is made of plaque/debris .
3. Ischaemic strokes are the most common-representing 85% of all strokes.
Haemorrhagic stroke
1. Bleeding within the substance of the brain.
2. Haemorrhagic strokes represent approximately 10%.

5. The Brain
The brain consists of several lobes, and each lobe has a defined function.
When the affected brain cells die, a particular function will be lost.
2 million brain cells will die every minute until treatment is received.

6. Each lobe in the brain does a different job.
The symptoms exhibited will depend on the area of the brain that has had the blood supply cut and which particular brain cells have been affected.
Frontal lobe Inability to recognise and regulate emotion.
Personality and behavioural changes.
Problems with speech(expressive) planning and problem solving
Incontinence.
Weakness and mobility issues. Impaired concentration.
Parietal lobe Difficulty in recognising objects, with dressing and positioning.
Difficulty in ascertaining length, depth and size of objects.
calculating, sensation, speech, hand and eye coordination,
visual. Confusion of left and right side of the body. Neglects the
opposite side of their body.
Inattentive, apathetic and bored.
Occipital lobe Loss of facial recognition. Visual Illusion – Objects appear larger
or smaller; or shape, colour, number disturbance.
Cerebellum Balance, posture, coordination, tremor
Temporal lobe Hearing, speech (receptive), smell, Interpretation of memory,
perception and emotions

7. Transient Ischaemic Attack ( TIA or mini stroke)?
This is a sudden, temporary interruption of blood flow which can last from a few minutes to no more than 24 hours.
This is a warning that something is wrong and if not changed, you could go on to have a full blown stroke in the future.

8. F A S T FACE Ask them to smile. Does one side of the face droop? ARMS
Ask them to raise both their arms.
Does one arm drift downwards? S
SPEECH
Ask them to speak a sentence.
Is their speech slurred or strange? T
TIME
What time is it?
Time to call 999

9. Symptoms
Facial droop
Arm or leg weakness on one side of the body
Clumsiness
Numbness or pins and needles on one side of your body or face.
Speech disturbance; slurred or difficulty getting words out.
Visual problems such as double vision, loss of vision or black spots
Sudden, severe headache
If you think someone is having a TIA use the FAST test, if positive dial 999

10. If you have had a TIA you will be seen in the TIA clinic on Solomon Ward RSCH. Each referral is triaged and scored by ABCD2.
A Age over 60 years of age point
B Blood pressure over 140/ point
C Clinical features:
Weakness on one side points
Speech disturbance without weakness point
0 points
D Duration:
Over 60 minutes points
10-59 minutes point
0-10 minutes points
Diabetes point
TOTAL 7
Score 4 or more and you will be seen in the TIA clinic within 24hrs unless it’s a weekend. Score 3 or less and you will be seen within 7 days. If a TIA you will be started on aspirin 300mg for 2 weeks followed by clopidogrel 75mg thereafter, plus simvastatin 40mg

12. Stroke/TIA risk factors
Modifiable
High blood pressure
High cholesterol
Diabetes
Previous TIA/Stroke
Diet
Smoking
Alcohol
Physical inactivity
Drug abuse
Non modifiable
Age
Sex
Race/ethnicity
Family history

13. Why do these factors increase the risk of stroke?
Hypertension
The most important risk factor and the most treatable risk factor. Studies
show that by lowering blood pressure , the stroke risk is lowered by 30-40%
Bp reading comprises of systolic and diastolic.
Systolic is the pressure of blood through the heart when it is beating.
Diastolic is the pressure created when the heart is at rest.
BP rises with age. Diastolic peaks at 50 yrs. old, plateaus and then falls.
Systolic rises until 70 yrs. or older.
When 60 yrs. or older the systolic becomes the most significant component.

14. Ideal blood pressure should be 120/80 mmHg .
Consistent BP of 140/90 mmHg or more is mild hypertension.
Mild hypertension systolic is mmHg
Moderate hypertension is mmHg
Severe hypertension is equal to or greater than 180 mmHg
Hypertensive individuals are at 7 times the risk of stroke than those with normal BP.

15. Why are we concerned if you have high blood pressure?
Leading cause of stroke.
Heart has to work harder under greater pressure to circulate blood to the brain.
Causes damage and weakening of the blood vessels. Risk of haemorrhage increased.
Cardiac factors increase the risk of stroke.
eg. Atrial fibrillation (AF) ; increases the risk up to 17 times therefore a predictor
of stroke .
Blood clots can form.
AF causes blood clots to be thrown off from the heart due to irregular
electrical impulses.
Warfarin reduces stroke risk by 60-70%. INR of 2.0 is optimal.

16. Diet /Obesity. - Obesity increases the risk of high blood pressure, high blood
cholesterol, diabetes and stroke.
- Remove salt from your diet as much as possible. Salt raises
your blood pressure. Max 1.5g/100g (o.6g sodium).
- Avoid processed food. Eating 5 servings of fruit/veg reduces
risk.
- Fats such as high saturated fat, trans fat and cholesterol raises
the blood cholesterol level. Eat low fat, low sugar food, and take
exercise.
High cholesterol Cholesterol is a fat that is produced by liver and found in food.
- Cholesterol travels round your body and sticks to the blood
vessel walls narrowing them ( atherosclerosis).
- Raised cholesterol levels above 5 mmol/l increase a person’s
stroke risk
2 main lipoproteins:
(LDL) Low density lipoprotein( bad) – causes damage to the heart
and circulation by leaving the fatty deposits in the blood
vessels.
(HDL) High density lipoprotein (good) – Leads the cholesterol to
the liver to be excreted in the CBD.
Simvastatin 40mg and dietary advice is needed for those with levels greater than
5.0mmol/L until reduced by 30% or LDL (bad) less than 2.0 mmol/L.

17. Nutrients that increase cholesterol
Monosaturated fats are the healthiest fats.
They decrease your total blood cholesterol but maintain your HDL (good) cholesterol.
Ideally, most of the fat in your diet should come from this group, which includes: almonds, avocadoes, cashews, canola oil, hazelnuts, macadamia nuts, natural peanut butter, olive oil, olives, pecans, peanuts, peanut oil, pistachios, sesame oil, sesame seeds, and tahini paste.
Polyunsaturated fats are somewhat healthy fats.
They decrease your total blood cholesterol by lowering both the LDL (bad) cholesterol and the HDL (good) cholesterol. Lowering your total cholesterol is great, but because these fats also lower your HDL (good) cholesterol, you should only enjoy them in moderation. You'll find polyunsaturated fats in corn oil, mayonnaise, pumpkin seeds, and sunflower seeds. Omega 3 fats are heart-healthy and can be found in:
high-fat fish (albacore tuna, mackerel and salmon), other seafood (herring, lake trout,
oysters, sardines, shellfish and shrimp), and plant sources (butternuts (white
walnuts), flaxseed, flaxseed oil, hempseed, hempseed oil, soybean oil, and walnuts).
Remember that these fats are still high in calories. So limit your total fat intake to less than
30% of your total calories each day. This is about grams each day (more or less
depending on your calorie needs)

18. To lower your cholesterol, avoid these unhealthy fats:
Saturated fat is unhealthy fat.
It increases both your total cholesterol and your LDL (bad) cholesterol.
No more than 10% of your calories should come from saturated fats—that's about 15-25 grams daily, depending on your calorie needs. Keep this number as low as possible.
Try to limit or avoid these sources of saturated fat:
Bacon, bacon grease, beef, butter, cheese, cocoa butter, coconut, coconut milk, coconut
oil, cream, cream cheese, ice cream, lard, palm kernel oil, palm oil, pork, poultry, sour
cream, and whole milk.  
Trans fat is the unhealthiest fat you can eat!
It increases your total cholesterol and your LDL (bad) cholesterol while lowering your HDL (good) cholesterol.
Even eating a small amount of trans fats significantly increases your risk of heart disease—especially if you already have risk factors like high cholesterol.
Limit your intake of trans fats as much as possible. Experts haven't established any level of trans fats as safe, so keep you intake near 0 grams.
Food products that contain trans fat include:
vegetable shortenings, hard stick margarines, crackers, candies, cookies, snack foods,
fried foods, doughnuts, pastries, baking mixes and icings, store-bought baked goods,
and more.
REMEMBER: You do not have to be fat to have high cholesterol.

21. Physical inactivity. At least 30 minutes per day
Physical inactivity. At least 30 minutes per day. Exercise lowers your BP, helps you
to lose weight and helps balance your sugar levels. OO
---

22. No excuses anyone and everyone can exercise

23. Diabetes An independent risk factor
Diabetes An independent risk factor. Diabetes puts you at increased risk as
it raises BP and cholesterol levels and weight.
BP needs to be <130/80mmHg.
Meticulous control of blood sugars required.
Atrial fibrillation This is a type of irregular heart rhythm and represents an important
risk factor for stroke. Because the heart does not beat properly,
there is a risk of blood clots forming in a chamber of the heart,
which may subsequently break up. Fragments of clot may then
lodge in the brain, causing stroke.
Smoking Makes the blood stickier and more prone to clotting, damages and
constricts the artery walls.
Increases the bad cholesterol in the blood and reduces the good
Doubles the risk of stroke.

24. Exessive Alcohol
Raises BP, thins the blood, raises cholesterol and homocysteine levels (clotting factor) and triggers AF. There is a strong relationship between heavy drinking and stroke. Risk doubles.
DOH recommends : 2-3 units per day for women or less than 14 u/week
3-4 units per day for men or less than 21u/week
1 or 2 alcohol free days per week
To calculate: Multiply the volume by the % and divide by 100
Example: ml bottle of wine at 12%
750x12 = = 9 units
has an online unit calculator for the most common drink brands.

25. Bottle of wine (12% ABV)…………. …9 Units
Large can of strong cider……………..4 Units
Pub measure (50 ml) of :
Port, Sherry, Martini …………………...1 Unit

26. Anterior-posterior projection left internal carotid artery injection showing cross-filling via the anterior communicating artery with occlusion of the M1 segment of the right middle cerebral artery at the level of the anterior temporal artery. The occlusion is shown by the arrow.

27. Insufficient blood flow to the brain leads to poor oxygen supply ( cerebral hypoxia) This results in brain cell death
(cerebral ischaemia).
Approximately 2 million brain cells will die every minute.
CT scan of a normal brain
Right hemispheric cerebral infarct
Left hemisphere cerebral haemorrhage

28. Can YOU help prevent this process?
Smoking constricts blood vessels and causes clogged arteries. This can lead to impotence in men.
Quit smoking
Smoking constricts your arteries.
Cholesterol blocks your arteries.
A blood clot forms in your arteries .
Blood flow is reduced in your arteries
Artery with Thrombus

29. A STROKE STRIKES

30. How can I reduce my risk of having a stroke ?
Controlling high blood pressure is crucial. In general, blood pressure should be below
120/80.
Methods for controlling blood pressure include a low-sodium diet, weight control, and/or
medication.
• Monitoring elevated blood cholesterol and controlling via diet and lifestyle modifications
or medication.
Treat atrial fibrillation if necessary. Take anti-clotting and antiplatelet drugs to thin the
blood and lower the risk of blood clots forming.
• Stop smoking.
• Dietary improvements include avoiding excess fat, particularly saturated fat, avoid
excess sodium and avoid excess alcohol intake . Maintain a healthy weight.
• Exercise regularly - the recommendation is at least 20 to 30 minutes of aerobic exercise at
least five times a week in order to achieve and maintain an improved level of fitness.
• In patients with diabetes, it is important to maintain good control blood sugar levels, as
this group of patients is at particular risk of cardiovascular disease.

31. STROKE High Blood pressure Smoking Diabetes High cholesterol Alcohol
Diet
Physical Inactivity
THINK BRAIN: Can you reduce the risk of stroke yourself?

32. FAST so: Take your prescribed medication Eat healthily Stop smoking
Take exercise
See your doctor
If concerned dial 999
FAST

33. Karen Kay
Stroke Coordinator
Royal Sussex County Hospital