Latest Stroke News
JUNE 2019 NEWS IN STROKE
American Stroke Association
In a new study published in Hypertension, report that 93% of U.S. adults who have measurable high blood pressure when taken in their doctor’s offices don’t take medications because their blood pressure falls in an acceptable range when measured outside the office setting. On the other had fully 1/3 of U.S. adult’s experience “masked hypertension” because their blood pressure levels are more problematic when measured outside the doctor’s office.
In either case, the study determined as many as 104 million Americans should use a blood pressure machine at home to provide backup for – or a contrast with- the results from their doctor’s offices. Barriers to home monitoring are patient compliance, accuracy of the results, out-of-pocket costs of the devices and the time needed to instruct patients how to take their blood pressure.
MUSC Health Florence Medical Center
May is stroke awareness month. There is a lot of information on prevention, receiving quick treatment and discussion of symptoms. This article expands the better known FAST mnemonic to BE FAST. The B stands for balance loss and the E stands for eyesight loss. The goal is to help people seek medical attention faster if they are experiencing stroke like symptoms.
May 2019:- Journal of American College of Cardiology
An increasing number of stroke survivors are between the ages of 18 and 65 – a 44% increase in the number of young adults hospitalized with strokes has occurred in the past decade. This may be thanks to stress, smoking, physical inactivity, poor nutrition, obesity, high cholesterol, diabetes and high blood pressure.
Guidelines for blood pressure monitoring go from normal 120/80 to stage 1 130-139/80-89 to crisis +180/+120. It is very important to monitor our bold pressure and visit your doctor routinely. It is a simple way to avoid a stroke.
April 2019:- American College of Cardiology
New guidelines are being issued for the use of aspirin. While evidence exists that aspirin can prevent heart attacks and stroke, it is known to cause heavy bleeding. Because of this, its use is recommended only sparingly. Aspirin should be limited to people at highest risk of CV disease and a very low risk of bleeding. Those without known CV disease should concentrate on optimizing lifestyle habits and control blood pressure and cholesterol as opposed to taking aspirin.
March 2019:- US NEWS AND WORLD REPORT/GANT NEWS
While stroke symptoms are the same in men and women, women may experience more subtle signs:
Sleepiness or confusion; fatigue; malaise and nausea; vague sense of “feeling funny”; tingling sensation or numbness in any part of the body; weakness in any part of the body; dizziness; balance, walking or coordination problems; behavior changes; memory loss.
Stokes happen to 1 in 5 women. Nearly 60% of stroke deaths occur in women. Women don’t realize that you are twice as likely to have problems with a stroke as you are to have breast cancer.
Women have some unique risk factors of which they should be aware:
-Pregnancy complications such as preeclampsia or high blood pressure can increase risk for many years even beyond childbearing age.
-Smoking in combination while taking combination birth control pills
-HRT – hormone replacement therapy
-Having migraines with aura
-Having Atrial Fibrillation – more common in women
INTERNATIONAL STROKE CONFERENCE
Stroke incidence has not significantly changed between 2010 and 2015, nor did the discrepancy in stroke incidence between black and white adults. In 2010 310 strokes per 100,000 occurred in the black population and 184 strokes per 100,000 occurred in the white population. In 2015 the numbers were 306 and 172 per 100,000 indicating little change.
February 2019: - JOURNAL OF CACHEXIA, SARCOPENIA AND MUSCLE:
Reports a study that finds the amount of skeletal muscle throughout the body declines after a stroke occurring equally in patients with and without limb paresis. 21% of patients had developed cachexia one year later meaning they had lost at least 5% of their body weight. Older patients with moderately severe stroke were particularly prone to developing cachexia.
Exercise training is the most promising way to delay or prevent the progression of muscle wasting and may be a therapy option. Treatment options may also include dietary supplementation.
Neuro-Optometric Rehabilitation Association International:
To out of three stroke survivors will experience visual impairments related to their stroke. These may include diminished central or peripheral vision, eye movement abnormalities or visual perceptual defects. Patients may not be aware that balance issues are connected to vision.
The most common visual complication is homonymous hemianopsia or a visual field defect on the same side of each eye accompanied by a visual midline shift. This shift can directly affect posture, balance and spatial orientation and it will significantly increase the risk of falls. Visual rehab can go a long way in maximizing the vision the patient has.
January 2019: - New England Journal of Medicine
On December 19th, JAMA published the study;” Global, Regional, and Country-Specific Lifetime Risks of Stroke, 1990-2016”. Findings state that globally, one in four people over the age of 25 is a risk for a stroke during their lifetime.
Depending upon where they live, lifetime risk for 25 year olds in 2016 ranged from 8% to 39% with the highest being for people in China and the lowest in sub-Saharan Africa. The senior author of the study termed the results “startling”. HE states that it is imperative that physicians warn their patients about prevention of stroke and other vascular diseases at earlier points in patient’ lives. Younger adults can make a real difference by eating healthier diets, exercising regularly and avoiding tobacco and alcohol.
Heart and Vascular Institute
It is well documented that high blood pressure can cause strokes and heart disease over time by damaging blood vessels throughout the body. When that happens arteries can burst or clog more easily. Evidence supports high blood pressure may also cause TIAs . Exercise, good sleep habits and no smoking will lead to a healthier lifestyle and regular physicals plus periodic checking of your blood pressure are the best ways to combat high blood pressure.
December 2018: - National Institute of Neurological Disorders and Stroke
This institute functions within the National Institutes of Health (NIH) and seeks to gain fundamental knowledge about the brain and nervous system to reduce the burden of neurological disease. They attempt to foster a balance of basic, transactional and clinical research supporting most of the basic medical research in the field. The private sector supports little of this research because the return on investment is highly unpredictable.
NINDS basic research is divided between research on the normal development and working of the nervous system plus research related to disease mechanisms. The focus is on the following areas: neurodegeneration; the control of the environment of nerve cells by supporting cells; systems and cognitive neuroscience; nervous system repair and plasticity; and, the role of genes in the normal and diseased nervous system .
An example of the research funded through this institute is the a recent study published in JAMA finding that diet is a major contributor to the increased risk of hypertension in black as compared to white Americans. The study addressed a leading cause of racial disparity in mortality and identified potential lifestyle changes that could reduce racial disparities in both stroke and heart disease. Diets of high amounts of fried and processed foods as well as sweetened beverages was identified as the greatest risk factor. Other factors included salt intake and education levels while women has the additional risk factor contributing to racial differences of waist size and obesity. This is further speculated to affect the racial life expectancy disparity.
JAMA Network Open
Reports a study looking at the link between obesity and stroke. It was reported that there is no direct causal link. However, there is what is termed a “supportive causal association”. What this means is that a causal link can be found between obesity and a higher risk for type 2 diabetes and coronary artery disease. Both type 2 diabetes and CAD are high risk factors for stroke.
November 2018: -The British Medical Journal and panel discussion School of Public Health – Harvard
The study featured in this month’s Frontal Lobe blog looked at the effect of lifestyle changes on those genetically predisposed to stroke. Analyzing over 300,000 patients over a 7 year period it was determined that men had a higher likelihood of stroke than women but, at the same time, those with unhealthy lifestyles had a 66% greater chance of stroke than those who had made healthful lifestyle choices. The most critical lifestyle factors were smoking and whether or not they were overweight. People with both high genetic risk and an unhealthful lifestyle were more than twice as much at risk.
In a panel discussion at Harvard, the experts noted that although stroke deaths have fallen sharply in recent decades, we are seeing a leveling off and we are seeing strokes occurring in younger people, those 35-64. The reasons speculated are the high rate of diabetes, obesity and physical inactivity.
Tracking 2.3 million American recreational marijuana users who were hospitalized indicated that there is an increased risk for stroke. This does not establish causation but does suggest further research is called for. In addition, the researcher do not know if the risk may be tied to smoking or ingesting or the amount of the drug used. Also, there was no tracking for possible other drug usage or other risk factors.
Study from the Netherlands projects that 48% of women and 36% of men aged 45 are likely to be diagnosed with dementia, Parkinson’s or have a stroke. These are the three most common neurological diseases in the elderly population. While there is a great deal of focus on heart disease and cancer in middle age, there is less attention and research on diseases of the brain. Focus on preventive interventions at the population level could substantially reduce the burden of these common neurological diseases in the aging population. They estimate that if the onset of dementia were delayed by one to three years, the remaining risk of developing the conditions could be cut by 20% among 45 year olds and more that 50% in those over 85.
The best current evidence suggests eating a balanced diet, controlling our weight, staying active, not smoking, moderate drinking and control of blood pressure and cholesterol will lead to better brain health in the elderly.
September, 2018: Lancet
The controversy in the benefits of a daily aspirin regime continues with the latest report in Lancet. While the benefit of taking aspirin by patients who have suffered a CVA either heart of stroke has been well documented, this study from Brigham and Women’s Hospital in Boston report there is no impact on those who have not suffered a CVA and there may be increased risk of major bleeding
It is evident that use of aspirin as a prophylactic or as a therapy should only be undertaken after consultation with your physician.
A study in Australia finds that fewer than 15% of patients receive information on intimate relations post-stroke despite clinical guidelines. This is problematic as sexuality, which includes so much more than just sex, is an essential part of human experience and strongly linked with emotional and mental health. Using a broad definition of sexuality, the study explored dimensions such as gender roles and identity, presentation of self to others, sexual expression, intimacy, relationships and reproduction. Not only is it possible that gender-based roles may change, one’s relationship with his/her body may have to redefined and/or sexual intimacy may exacerbate feelings leading to heightened levels of anxiety.
Health professionals reluctance to address sexuality may be due to lack of knowledge and confidence in the subject matter. Education and training is needed.
A new study suggest that adults with mood disorders like anxiety and depression may be more likely to have a heart attack or stroke than people without a mental illness. In age groupings of 45-79 years of age, it was reported that men with moderate psychological distress were 20% more likely to have a stroke, women were 28% more likely. Men with high levels of distress were 44% more likely to have a stroke while women were 68% more likely.
The stronger association of distress to stroke in women may be attributable to the greater likelihood of women seeking care for mental and physical health problems than or, alternatively there may some hormonal basis offering a greater degree of protection. More study must be done to understand linkages between mental and physical health.
August, 2018: University of York
Observational study of the link between loneness and social isolation and stroke and heart issues suggests an increased risk as much as 32%. This is one of a number of studies that point in this direction and further the need for research in how our mental health impacts our risk of developing CVA problems.
While men and women share the major risk factors for stroke of smoking, high blood pressure and elevated cholesterol, women’s stroke risk is influenced by female-only factors such as hormones, childbirth, pregnancy, birth control pills and migraine headaches with aura among others. Stroke is the third leading cause of death for women as opposed to the fifth for men. Preeclampsia and atrial fibrillation among women also add to higher risk values.
Loyola University Health System
Dr. Camilo Gomez who first coined the phrase “time is brain” reports in a new study that this rule is not as simple as it first seemed in 1993. In his latest model, Dr. Gomez identified four distinct types of ischemic stroke based on the collateral circulation. After an ischemic stroke strikes, a core of brain tissue begins to die. Around this core is a penumbra of cells that continue to receive blood from surrounding arteries in a process called collateral circulation. Collateral circulation can keep the cells in the penumbra alive for a time before they start to die. Good circulation slows down the rate at which the cells die. What dr. Gomez has found is the volume of injured tissue within a given interval after the time of onset shows considerable variability in part due to the beneficial effect of a robust collateral circulation. This means that the rigid paradigm is subject to considerable uncertainty.
Brigham and Women’s Hospital
This study did not demonstrate conclusively that aspirin could reduce the occurrence of major cardiovascular events. While the benefits of aspirin for preventing second events in patients with previous heart attack or stroke is well established, the study participants who took aspirin tended to have fewer heart attacks, particularly those aged 50-59, but there was no effect on stroke. Rates of gastrointestinal bleeding and some other minor bleedings were higher in the aspirin group, but there was no difference in fatal bleeding between groups.
July, 2018: New Zealand Medical Journal
In concert with the alarm being raised for Parkinson’s, this study projects that the number of strokes will increase by 40% by 2028. The reason is the growing aging population. Since it is believed that up to 90% of stroke may be prevented by modifying metabolic and behavioral risk factors, it is suggested increasing stroke prevention initiatives is critical.
June, 2018: Journal of the American Heart Association
Treating of high blood pressure in stroke survivors could cut deaths by one-third. More than one-half of all strokes are attributable to uncontrolled high blood pressure. Guidelines have been changed to 130/80 and medications are recommended for all stroke survivors with blood pressure higher. Adherence to the new guidelines would result in a 66.7% increase in the number of stroke survivors diagnosed with hypertension and recommended for medication; a 53.9% increase in the proportion of stroke survivors already taking medication who will be proscribed additional medication; and a 32.7 reduction in deaths.
May, 2018: Cleveland Clinic
In an article by neuropsychologist Dalene Floden, PhD, the emotional effects of stroke are discussed to remind us strokes may present challenges beyond the physical. The most common issue is stroke effecting 1 in 3 people. About 20% will develop major depressive disorder which means symptoms are bad enough to impact a person’s day-to-day functioning.
It is important to recognize the symptoms and seek help. Mood changes may lead to disengagement with recovery and discouragement which, in turn, may lead to poorer outcomes. It is easy for a stroke survivor to become isolated - engaging with others is important along with learning from others.
University of Sheffield
Study of aerobic exercise after stroke showed blood pressure reduction for those who started exercise within six months of their stroke mirroring blood pressure drops you would expect if someone started taking medication. The drop was even more significant in those who received lessons on diet and health. Exercise as a treatment should be thought of as important as mediation.
While this study was not designed to prove that exercise actually resulted in few repeat strokes for this group of patients one study that tracked patients for 3 years did find exercise participants were approximately 80% less likely to be hospitalized or die from stroke or CV disease during that period.
April, 2018: The Lancet
According to their comprehensive study the focus of aid to low and middle income countries now focused on controlling communicable diseases should really be on controlling non-communicable diseases like cancer, stroke, and heart disease which are keeping the poorest communities poor and negatively impacting economic development in these countries.
Early death and disability from these non-communicable diseases is alarming in that these diseases were previously only seen in high-income countries. Focus has been on infant and child mortality which has brought great improvement but the need to address adults with non-communicable diseases is of increasing importance.
University of Helsinki
Analysis of isolation and loneliness as a predictor of stroke, AMI and associated mortality. Hazard for stroke was increased by 83% while social isolation appeared to be more important in resultant mortality.
In a study of 1,195 people who had suffered ischemic strokes, it was found damage goes well beyond the physical disability. There were three main areas where stroke survivors experienced the most change in their daily lives. Physical function problems were reported by 63%, 46% reported increased difficulty in thinking and 58% reported greater dissatisfaction with their ability to participate in social and work-related activities. This indicates that more needs to be done to focus on the thinking and social problems that people face after a stroke because they greatly impact the person’s quality of life.
March, 2018: MEGASTROKE – International Stroke Collaborative
The study of more than half a million people around the world has identified 22 new genetic risk factors for stroke. There were 32 genetic variants – or 149 genes – identified as risk factors in the research, 11 are in biological areas not previously thought to contribute to stroke. Drugs on the market are already targeting 16 genes in the management of other diseases such as epilepsy which provided possibilities for further research into the use of these medications for stroke. Also discovered was a genetic link between haemorragic and ischemic strokes.
University of Helsinki
Social isolation was associated with a higher risk of AMI and stroke in models adjusted for demographics. Similar results were demonstrated with loneliness. In the fully adjusted model, social isolation but not loneliness was associated with increased mortality among those with a history of AMI and stroke. In other words. Isolated and lonely persons are at increased risk of AMI and stroke, and, among those with a history of AMI or stroke, increased risk of death.
February, 2018: Brigham and Women’s Hospital - Boston
A study reports that 55,000 more women have strokes than men each year in the US. It is the leading cause of disability and the third leading cause of death in women. Risk factors unique to women are:
Menstruation before age 10
Menopause before age 45
Low levels of the hormone dehydroepiandrosterone (DHEAS)
Use of birth control pills.
History of pregnancy complications
While the risk factors are common, women should be made aware that they are at higher risk and be motivated to adhere to healthy life style behaviors to decrease risk of high blood pressure.
American Stroke Association
ASA is lobbying for the preservation of a number of rehabilitation extenders at risk in the current budget for Medicare. This includes therapy caps placing limits on treatment options for treatments medically necessary over the cap amounts. Also, telestroke services are only reimbursable in rural settings while 94% of stroke occur in urban settings. Supervision of cardio and pulmonary rehab currently needs to be overseen by a physician. ASA would like to see this go to PAs, NPs and clinical nurse specialists which would increase participation by increasing access to services.
January, 2018: Please read this month’s blog for important news regarding new Stroke Treatment Guidelines – game changing treatment methodology.
Rush University Medical Center – Chicago
A study of 106 stroke survivors over 4.7 years examined for cognitive decline including one’s ability to think, reason and remember while adhering to the MIND diet – Mediterranean-DASH Intervention for Neuordegenerative Delay. Participants were grouped according to adherence to the diet and examined for other factors known to affect cognitive performance including age, gender, education, participation in cognitive stimulating activities, physical activities, smoking and genetics. The findings were:
- Those who adhered most closely to the diet, had a substantially slower rate of cognitive decline compared to those who adhered less rigorously.
- The estimated effect of the diet remained strong even after taking into account other factors.
- Adherence to the MIND diet appear to be better suited to overall brain health and preserving cognition that either the Mediterranean or DASH diet.
The MIND diet combines the Mediterranean and DASH diets but features nuts, beans, poultry, whole grains and moderate wine consumption. It limits red meats and red meat products, butter, trans fat margarines, cheese, sweets and pastries as well as fried and fast foods. Studies have found that folate, vitamin E, omega-3 fatty acids, carotenoids and flavonoids are associated slower rates of cognitive decline.
Caution is urged since this is a preliminary study and involves a relatively small number. Additionally, the study is observational and findings cannot be interpreted in a cause-and-effect relationship.
American Heart Association
Reporting at the International Stroke Conference, the AHA reported that only 1 out of 100 or 1% of stroke survivors actually take the recommended medical steps to restore their cardiovascular health and prevent recurrence. The seven steps to prevent recurrence are: increase activity, eat healthier, lose weight, avoid smoking, manage blood pressure, control cholesterol, and lower blood sugar levels.
The report, based on data from nearly 68,000 stroke survivors, showed that rates had increased for diabetes – 56%- and obesity – 39% since the late 1980”s. Poor diets rose from 14% in the late 80’s to over 50% today.
On the good side, rates of high blood pressure and high cholesterol are down since the 1980’s.
December 2017: News from Stanford University
Although they do not want to overpromise, an early phase study of 18 patients has shown some remarkable results. Transplanting stem cells into the cells that have survived just outside the stroke has resulted in resurrecting the circuits. They are able to pump out very powerful growth factors, molecules and proteins that enhance native mechanisms of recovery such as new synapses of neurons that are there, new blood vessels and a modulation of the immune system. Three quarters of the patients showed what is called “a meaningful recovery” over a period of six months and sustained it at 12 months.
These results have spurred a larger, multi-center, double-blind controlled study of 156 patient throughout the country. Results from this study should be available in about a year.
November 2017: News from American Stroke Association
New high blood pressure guidelines have been announced dropping 140/80 being considered hypertensive to 130/80. Association physicians state that by the time someone’s blood pressure is at 130/80, they have already doubled their risk for stroke, heart attack and other cardiac events.
Lifestyle modifications are key – shedding pounds, giving up fast food, exercise, watching salt intake and reducing stress.
News from the Journal of Endocrine Society
A study found that consuming two sugar- sweetened drinks a week could increase the risk of developing type 2 diabetes by 42% and just one a week could elevate blood pressure. They call for more research on this alarming study result.
October 2017: News from Mount Sinai, New York
A longitudinal study following patients 13 years, presents evidence that a single ischemic stroke continues to be associated with a gradual increase in disability over the long term. Stroke is traditionally seen as a discrete, monophasic event assumed to stabilize following the 3-6 month recovery period after the incident. The research did not indicate that participants who had strokes had any higher slope of increasing disability before the stroke than those who eventually do not have strokes. They further noted that stroke’s long term adverse effects leading to accelerated functional decline may be treatable.
News from the German Stroke Foundation
Post Stroke Depression (PSD) is experienced by about one third of all strokers usually three to six months afterwards. Symptoms include listlessness, feelings of guilt, sleep disorders and a generally gloomy mood that persists for at least two weeks. It can be caused to some extent by the effect of the stroke on the brain, but is made worse by the restrictions on the person’s lifestyle that often follow. Hormones may also play a part. It is important to know that this is treatable, usually temporary and there is a good chance of recovery.
News from University of Liverpool:
Examining a group of 915 post stroke patients, 95% of survivors had visual impairments relating to central or peripheral vision, eye movement abnormalities or visual perceptual defects.
- 24% had reduced clarity of vision (central visual acuity)
- 16% of those with a visual impairment developed a squint (ocular motility disorders)
- 68% had impairments in eye movement (ocular motility disorders)
- 52% suffered from Peripheral visual field loss
- 15% developed visual inattention which causes those afflicted to ignore everything on one side of their visual world
October 6, 2017: Study attributes stroke decline to prevention education
Interesting article citing a decline in strokes in Iowa of 33%. The Iowa Department of Public Health attributes this decline to more education on prevention; strengthening of stroke triage and care at the stroke centers in the state; changing EMS protocols to immediate transfer to centers with the highest level of care; and, developing and implementing a Stroke registry.
This is interesting in that it shows what comprehensive care and education can do to reduce what is primarily a preventable incident.
September 28, 2017: This is why more and more young people are having Strokes
Although contraceptive use and smoking have both been cited, this article cites the JAMA Neurology study findings that the prevalence of having three to five stroke risk factors has more than doubled for women under 45. These include hypertension, lipid disorders – high cholesterol – diabetes, tobacco use and obesity. Older adults tend to manage these risk factors and the result I a decline in strokes in older adults.
August 2017: Does Diet Soda raise the Risk of Stroke?
In the Harvard Heart Letter, they take a look at the reports that have been put out linking Strokes to drinking Diet Soda. Review of the studies indicate no provable cause and effect link to stroke and diet soda. In a 2012 study following 127,000 people for more than 2 decades, there was a slightly higher risk of stroke in those who drank more than one soda a day – diet or regular. However, there was no higher stroke risk from sugary beverages even though many studies have demonstrated regular dinking of sugary beverages can lead to weight gain, diabetes, heart disease and stroke.
The Framingham Heart Study releases 2017 reported that people drinking at least one artificially sweetened soda a day compared with less than one a week were twice as likely to have a stroke. Explanations for this finding include survival bias which opines that people who drink sugary beverages may have died earlier from other diseases such as heart disease. Conversely, diet drinks may be linked because of a different issue called reverse causation. Overweight and diabetic patients may be more likely to choose diet drinks. The heightened stroke risk may come from those health problems.
July 7, 2017: Family Rehab proves ineffective
Interesting study in India states that even trained family members prove to be ineffective caretakers of stroke patients at home. The study looked at physiotherapy and occupational therapy at home finding that the degree of recovery or improvement in quality of life issues was not as expected.
This study supports the need for on-going professional help to recover from strokes – difficult to obtain throughout the world.
July 2, 2017: More Millennials are having Strokes
Research from the CDC indicates strokes among those 18-34 years of age have increased 34% in women and 15% in men. There is also a reported statistically significant increase for young adults in Mid-West and Western cities of over 1mm in population. (the so called “Stroke Belt” is the Southeast). In Western Cities between 2003 and 2012 strokes rose by 85% while rising 34% Mid-Western cities in the same time frame.
There appears to be not one explanation for the numbers but it is posited that obesity and inactivity along with diabetes may have greater impact in younger stroke victims. Drug usage likely plays a role as wee. Better imaging and detection does not account for all the difference – if this were the case we would see increases across all age groups when in fact the total numbers nationwide are declining. The urban bias may be influenced by the closure of many rural facilities reducing access to care. The data was also not adjusted for racial disparities – more African Americans have strokes than the general population.
June 29, 2017: The Obesity Paradox
Examining participant’s BMI in the Framington Heart Study, a comparison to those not experiencing a stroke indicated that those above a healthy bodyweight had higher survival rates from those in the normal range for bodyweight. Analysis controlled factors such as smoking, hypertension and diabetes.
This “Obesity Paradox” is reported in both CV disease and Diabetes as well as Stroke and may be the result of reverse causality – an individual’s weight may be reflective of illness or the health deteriorating effect of under nutrition in non-overweight subjects may contribute. Yet another explanation posits that imminent death may have a causal relationship to weight loss. While obesity remains a critical risk factor for CV and metabolic disease.
COMPASSIONATE, EFFECTIVE, AFFORDABLE CARE