Causes and symptoms

Causes

There are four main types of stroke. Cerebral thrombosis and cerebral embolism are caused by blood clots that block an artery supplying the brain, either in the brain itself or in the neck. These account for 70–80% of all strokes. Subarachnoid hemorrhage and intracerebral hemorrhage occur when a blood vessel bursts around or in the brain.

Cerebral thrombosis occurs when a blood clot, or thrombus, forms within the brain itself, blocking the fblood through the affected vessel. Clots most often form due to "hardening" (atherosclerosis) of brain arteries. Cerebral thrombosis occurs most often at night or early in the morning. Cerebral thrombosis is often preceded by a transient ischemic attack (TIA), sometimes called a "mini-stroke." In a TIA, blood flow is temporarily interrupted, causing short-lived stroke-like symptoms. Recognizing the occurrence of a TIA and seeking immediate treatment are important steps in stroke prevention.

Cerebral embolism occurs when a blood clot from elsewhere in the circulatory system breaks free. If it becomes lodged in an artery supplying the brain, either in the brain or in the neck, it can cause a stroke. The most common cause of cerebral embolism is atrial fibrillation, a disorder of the heartbeat. In atrial fibrillation, the upper chambers (atria) of the heart beat weakly and rapidly, instead of slowly and steadily. Blood within the atria is not completely emptied. This stagnant blood may form clots within the atria, which can then break off and enter the circulation. Atrial fibrillation is a factor in about 15% of all strokes. The risk of a stroke from atrial fibrillation can be dramatically reduced with daily use of anticoagulant medication.

Hemorrhage, or bleeding, occurs when a blood vessel breaks, either from trauma or excess internal pressure. The vessels most likely to break are those with preexisting defects such as an aneurysm. An aneurysm is a "pouching out" of a blood vessel caused by a weak arterial wall. Brain aneurysms are surprisingly common. According to autopsy studies, about 6% of all Americans have them. Aneurysms rarely cause symptoms until they burst. Aneurysms are most likely to burst when blood pressure is highest, and controlling blood pressure is an important preventive strategy.

Intracerebral hemorrhage affects vessels within the brain itself, while subarachnoid hemorrhage affects arteries at the brain's surface, just below the protective arachnoid membrane. Intracerebral hemorrhages represent about 10% of all strokes, while subarachnoid hemorrhages account for about 7%.

In addition to depriving affected tissues of blood supply, the accumulation of fluid within the inflexible skull creates excess pressure on brain tissue, which can quickly lead to death. Nonetheless, recovery may be more complete for a person who survives hemorrhage than for one who survives a clot, because the blood deprivation effects are usually not as severe.

Death of brain cells triggers a chain reaction in which toxic chemicals created by cell death affect other nearby cells. This is one reason why prompt treatment can have such a dramatic effect on final recovery.

Risk factors

Risk factors for stroke involve age, sex, heredity, predisposing diseases or other medical conditions, and lifestyle choices, including:

• Age and sex. The risk of stroke increases with increasing age, doubling for each decade after age 55. Men are more likely to have a stroke than women.
• Heredity. Blacks, Asians, and Hispanics all have higher rates of stroke than do whites, related partly to higher blood pressure. People with a family history of stroke are at greater risk.
• Diseases. Stroke risk is increased for people with diabetes, heart disease (especially atrial fibrillation), high blood pressure, prior stroke, or TIA. Risk of stroke increases tenfold for someone with one or more TIAs.
• Other medical conditions. Stroke risk increases with obesity, high blood cholesterol level, or high red blood cell count.
• Lifestyle choices. Stroke risk increases with cigarette smoking (especially if combined with the use of oral contraceptives), low level of physical activity, alcohol consumption above two drinks per day, or use of cocaine or intravenous drugs.

Symptoms

Symptoms of an embolic stroke usually come on quite suddenly and are at their most intense right from the start, while symptoms of a thrombotic stroke come on more gradually. Symptoms may include:

• blurring or decreased vision in one or both eyes
• severe headache
• weakness, numbness, or paralysis of the face, arm, or leg, usually confined to one side of the body
• dizziness, loss of balance or coordination, especially when combined with other symptoms