Stroke

Background: What Is Stroke?

When blood supply to the brain is reduced, oxygen cannot reach the brain cells, and they begin to die within minutes. There are three major types of strokes. Ischemic strokes are caused by blood clots that block blood flow to the brain. These account for about 87% of strokes.  Hemorrhagic strokes are caused by a blood vessel rupturing and reducing blood flow to the brain. Transient ischemic attacks (TIA or "mini-stroke") are caused by small clots that temporarily block blood flow to the brain. 

All of these are serious. Ischemic and hemorrhagic strokes can lead quickly to major disability or death. TIAs are sometimes thought of as warnings that a larger and more dangerous ischemic stroke may be likely.

Why Are Strokes A Special Concern To HCM Patients?

Blood clots that develop as a result of atrial fibrillation (afib) account for about ⅙ of all ischemic strokes. 

HCM patients are especially likely to develop afib. One reason HCM patients need to treat afib seriously is the danger of stroke. Afib can also be very debilitating apart from the chances of stroke.

Hemorrhagic strokes are often caused, at least in part, by high blood pressure. While this is not necessarily a result of HCM, it is fairly common for HCM patients to have hypertension.

Symptoms of stroke

It is crucial to pay attention to the time when symptoms of a stroke began. Some treatments are most effective soon after the onset of a stroke. Signs and symptoms of stroke include:

• Facial paralysis. Those who are having a stroke may experience sudden numbness, weakness, drooping, or paralysis of the face. Ask the person to smile. Is one side of their face drooping? If so, it is in an indicator of possible stroke.
• Arm weakness. An arm may suddenly be weak. Usually, this only affects one side of the body. If the person can't raise one arm very far, or if it drifts down after they raise it, this is an indicator of possible stroke.
• Speech difficulties. Speech may become slurred and difficult to understand. Those who are having a stroke may be confused, slur their words, or have a difficult time understanding others communicating with them. All of these are indicators of possible stroke.
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These three symptoms are the most prominent indicators of possible stroke. They are often referred to as F.A.S.T. (Facial paralysis, Arm weakness, Speech difficulties = Time to get emergency medical attention). Other symptoms can include:

• Sudden changes in vision. Those experiencing a stroke may suddenly have blurred or blackened vision in one or both of the eyes. They may also see double.
• Difficulties in coordination. Those experiencing a stroke may stumble, lose their balance, have sudden dizziness, or loose coordination.
• Sudden, severe headache. It may also be accompanied by vomiting, dizziness, or altered consciousness.

The more rapid the medical attention, the better the person's chances of surviving with reduced damage. Receiving medical attention within the first hour is particularly important! Fewer people die of strokes today than in the past. There are also fewer people who are severely disabled. This is because of two factors: greater awareness of strokes and the importance of emergency treatment, and improvement in treatments. In other words, strokes are not less dangerous, but we are somewhat better at treating them.

Prompt treatment of strokes is critical to reduce the amount of damage and further complications. 

Consequences of stroke

Strokes can be devastating. They can cause temporary or even permanent disabilities, depending on how brain flow to the brain was affected. Loss of muscle movement, paralysis of part of your body, difficulty talking or swallowing, inability to speak, memory loss, and cognition difficulties. Some of these can cause significant pain. Strokes can kill you. 

We may not need to say this, but we will: there is nothing good about strokes, and you should do whatever you can to reduce your risk of stroke!

What puts me at risk for a stroke? What can I do?

Atrial fibrillation is a leading cause of stroke and therefore is important to identify and treat. If you have had episodes of atrial fibrillation that were not reactions to heart surgery, you need treatment. This is true even if you are not currently having afib! Take your anticoagulant drugs as prescribed. 

Additional factors that put people at an increased risk of stroke include overweight, being inactive, heavy or binge drinking, and the use of recreational drugs. High blood pressure, smoking or secondhand smoke exposure, high cholesterol, diabetes, obstructive sleep apnea, COVID-19, personal or family history of strokes, and cardiovascular diseases like atherosclerosis increase your risk substantially. Your risk is not constant throughout life. Those 55 years an older have a higher risk than younger people. African Americans have a higher risk than those of other ancestries. Men have greater risk than women. Unfortunately, women having strokes are more likely to die from them than men. Estrogen therapies (whether birth control or not) also increase risk of stroke. Obviously you can't do anything about some of these! But if you are at greater risk (for example, because you are an older male) then you should certainly be more careful about the things you can do something about (like smoking, drinking, exercise, and your blood pressure).

Knowing your risk factors, following your doctor's recommendations, and living a healthy lifestyle are the best measures to prevent a stroke. Even if you have already had a stroke, these steps can help to prevent future strokes from happening. Healthy lifestyle recommendations include controlling blood pressure, lowering cholesterol and saturated fat in your diet, quitting the use of tobacco, properly managing diabetes, maintaining a healthy weight, eating properly, exercising regularly, avoiding illegal drugs, and drinking alcohol in moderation, if at all. If you have had afib, take your anticoagulants.

What if I have a stroke anyway?

There are no guarantees in life: you might have a stroke even if you are careful. If you think you might be having a stroke, you will need to be taken to the hospital immediately. Your team of doctors will try to determine whether you are having a stroke, and what type it is. They will probably give you a CT scan or other imaging tests. Other possible causes of your symptoms like drug reactions and brain tumors will need to be ruled out. Other tests you may need to have include a physical exam, blood tests, MRI, ultrasound, and an echocardiogram.

Treatments depend on the type of stroke:

• To treat ischemic strokes, blood flow to the brain must be quickly reestablished. This may be done by administering thrombolytic ("clot-busting") emergency IV medication like tissue plasminogen activator (tPA). This is the gold standard treatment for early treatment of this type of stroke. Usually, it can only be administered in the first three hours or so. There are potential risks with this drug, such as potential bleeding in the brain, so your doctor will determine if it is appropriate for you. In some cases, emergency surgical procedures are used to remove a clot. For example, this procedure is often used when the clot is too large for tPA to completely dissolve. Sometimes both are used.

• To treat hemorrhagic stroke, doctors work to control bleeding and reduce intracranial pressure caused by the excess fluid. You might be given drugs to lower the pressure, or drugs to counteract the effects of anticoagulants you may be taking. Surgery is sometimes used if the bleed is large. 

After undergoing the appropriate procedure, you will be closely monitored. After that, the focus will shift to helping you recover as much function as possible and return to independent living. If the stroke affected the right side of your brain, the left side of the body may be affected. If the stroke affected the left side of your brain, the right side of the body may be affected. Brain damage to the left brain can cause speech and language disorders. 

Many who have survived stroked go to rehab programs. Your doctor will recommend the appropriate program based on your age, health, and the degree of disability from your stroke. Rehab may begin before you even leave the hospital. After being discharged, you may continue the same program, switch to another facility as an outpatient, or do it at home. It is important to remember that recovery from stroke is different for every person.

If you have had an ischemic stroke or TIA, your doctor may recommend that you take antiplatelet drugs or anticoagulants to reduce your risk of having another one. Antiplatelet drugs make the platelets in your blood less sticky, so clots are less likely to form. Aspirin is the most commonly used antiplatelet drug. Anticoagulant drugs also reduce blood clotting. Heparin and warfarin are examples of anticoagulant drugs. 

Strokes can be devastating, but many people--especially those receiving quick medical attention--recover from them and go on to live long, active lives. Do what you can to minimize your risk of stroke. If you have had a stroke, though, do not give up! There is a lot to live for, and a good possibility that you can still enjoy life!

Post -procedure freedom from stroke with the MAZE procedure has been over 99%.