All about

Stroke

What is stroke or “brain attack”?A stroke or “brain attack” is the result of a sudden interruption of blood supply due to blockage of a blood vessel that goes to the brain or a rupture of a blood vessel inside the brain. The patient’s signs and symptoms depend on the location and extent of the injured area of the brain.

What are the types of stroke? Ischaemic Stroke / Infarct• Isduetoblockageofabloodvesselsupplying

an area of the brain.• Theblockagemaybeofasmallbloodvessel

or a large blood vessel. • Theblockagemayoccurbecauseofthrombus

formation in the blood vessel or embolism (blockage by a blood clot that escapes from another place and travels to the brain artery. Such sources include a blood vessel in the neck or the heart).

Hemorrhagic Stroke / Hemorrhage• Isduetoburstingorruptureofabloodvesselinthe

brain. This is less common than ischaemic stroke.• Thebleedingmaybeintraparenchymal(bleed

within the brain) or subarachnoid (bleeding into the space around the brain).

• The most common cause of bleeding ishypertension (high blood pressure).

• Rarely, it may be due to an arteriovenousmalformation(AVM,abnormalconnectionofblood vessel) or aneurysm (a balloon-like bulge in an artery).

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What is TIA (Transient Ischemic Attack)?• Alsocalled“mini-stroke”orpre-warningstroke.• Patientsshowsignsandsymptomsofstrokethatlastsonlyforafewminutes

to hours.

Mechanism of TIA

NormalBloodflowseasilythrough clear artery

BlockagePlaquefragment and / or blood clot blocksartery,reducingbloodflowtobrain

Blockage ClearedTheplaqueorbloodclot dissolves or breaks upquickly,restoringbloodflowtobrain.Thebraincellsrecover,and no permanent brain damage occurs

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What are the risk factors that can be modified?

3. Diabetes mellitus Uncontrolled diabetes over a long period of time can cause damage to your blood

vessels and nerves. The risk of stroke is 1.5 times more in diabetic patients.

5. Irregular heart beat Patientswithirregularheartbeathave60%to80%riskofhavingastroke.

2. Hypertension Uncontrolled hypertension increases the risk of

stroke by four times. High blood pressure should be treatedifitisrepeatedlyabove140/90mmHg.Ifyouhavediabetes,yourbloodpressureshouldbebelow130/80mmHg.

4. Increased cholesterol Increasedcholesterollevelscancausethenarrowingof

blood vessels in your body. This can lead to blockage ofthebloodflowtoyourvitalorgansincludingthebrain,thusincreasingtheriskofstroke.

1. Smoking Smoking increases the risk of stroke by 1.5 to 2.5

timesforyouandyourfamily.Thisriskissignificantlyreduced when you stop smoking. Your risk of stroke willbeequivalenttothatofanon-smokerafterfiveyears of stopping.

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6. Previous stroke or TIA Havingstrokeincreasestheriskofanotherstrokewithintheyearby10%to12%.

Thereafter,theriskgraduallydecreases.

10. Substance abuse Intravenousdrugabuseenhancesbloodvessel

disorders and oral drug abuse like amphetamines increases sympathetic response causing increased blood pressure.

8. Obesity Obesity is the accumulation of excess body fat.

It isassociatedwithvariousstroke risk factorssuchasdiabetes,highbloodpressureandhighcholesterol levels.

7. Excessive alcohol consumption An average of more than one alcohol drink a day for

women(30mlofhardliquor,330mlofbeeror120mlof red wine) or two drinks a day for men raise blood pressure and can lead to stroke.

9. Sedentary lifestyle Stroke risk is higher with sedentary lifestyle. Exercise

atleastthreetofivetimesaweek,30-60minuteseachtime.Regularexercisehelpstoreduceobesityand also aids in the prevention and management of highbloodpressure,diabetesandhighcholesterol.

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Seek urgent medical attention if these symptoms develop. These symptoms may also be caused by other illnesses that would also need treatment.

F A S TFace Arm Speech Time

Does one side of the face droop?

Does one arm drift downwards?

Does the speech sound slurred

or strange?

Call995and go to a hospital

immediately.

What are the risk factors that cannot be modified?Age Gender HereditaryThe chance of stroke increases with age.

Male gender has higher risk of stroke compared to femalebutbecomesequalafter menopause.

Those who have family history of stroke at a young age has a higher risk.

What are the signs and symptoms of stroke?You may be having a stroke when you have sudden onset of:

• Weaknessoffacial,arm,legmusclesononeside• Numbnessofface,armlegononeside• Slurredspeechordifficultyexpressingoneself• Inabilitytocomprehend• Unsteadygaitorlossofcoordination• Blurredordoublevision• Difficultyswallowing• Severeheadachewithnauseaandvomiting

My nname iss... Briia...

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What to do if you have a stroke?Call 995 for ambulance immediately.

Complications of strokePatientswithamajorstrokemaysufferfrommanycomplications:

Infections Becauseofswallowingimpairmentordrowsiness,foodorsalivamayaccidentallyenter the lungs and cause an infection (pneumonia). Urinary tract infection may occur if good hygiene is not maintained in the genital area.

Bed sores Constant pressure over certain body parts may cause the skin at that area to break down,resultinginbedsores.

Dehydration, malnutrition Thisoccurswhenthereis inadequateintakeoffoodorwaterduetoswallowingimpairment or drowsiness.

Constipation Thisoccurswhenthereisinadequateintakeoffluidsorfibre,orwhenthepatientdoes not open the bowels regularly.

Incontinence Stroke patients may be unable to control their bladder or bowel movements. More likelytooccurinpatientswhoaredrowsyorhavesufferedamajorstroke.

Contractures This occurs when limbs become fixed in a certain position due to irreversible contractionandfibrosisofmuscles.

Heart attack Stroke and heart attack have similar risk factors. The factors that cause blockage ofarteriesinthebrainmayalsocauseblockageofarteriesintheheart,causingheart attack.

Another stroke Despitetakingmedicationsandmodifyingriskfactors,theriskofhavinganotherstroke cannot be totally removed.

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What are the diagnostic procedures available for stroke?Dependingonthekindofstrokeanditslocation,thedoctormayorderanyofthefollowing diagnostic procedures:

Brain Scan • CT Scan (computerized tomography) Todetecthemorrhagicstroke,largeischemicstroke.

• MRI / MRA (Magnetic Resonance Imaging / magnetic resonance)

To detect very small stroke especially in the brainstem thatmaynotbeseenwellintheCTscanwhiletheMRAcan show non-invasively the blood vessels in the brain.

Blood tests To check for risk factors like diabetes, increasedcholesterol,clottingproblemetc.

Electrocardigram (ECG) / 2D echocardiogram (ultrasound of the heart)To check for underlying heart conditions.

Carotid and Vertebral Ultrasound To assess the major blood vessels of the neck that supply the brain.

Computed Tomography Angiography (CTA) Carotid Isanoninvasiveproceduretoconfirmnarrowingorseverity of occlusion of the blood vessel that may be the cause of the stroke.

Four Vessel Angiogram A small tube is inserted in the groin and moved to the level of the brain after which dyeisinjected.Itprovidesmoreinformationifnecessary,onthelocationandseverityof blood vessel abnormality that maybe responsible for the stroke.

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How is stroke treated?You may receive the following treatments:

Clot dissolving medication - Recombinant Tissue Plasminogen Activator (rTPA) Thisisgiventopatientswhohavefulfilledtheinclusioncriteriafor intravenousthrombolysis. It isafibrinolyticmedication used to dissolve blood clot.

Blood thinner (anti-platelet like aspirin or anti-coagulant like warfarin) Thisisusedforpatientswithischemicstrokeasitsignificantlydecreasestheriskof a second stroke.

Cholesterol lowering medication (“statins”) Thissignificantlydecreasestheriskofastroke.

Blood pressure lowering medication Thismedicationisavoidedduringthefirst24hoursfromthestrokeonset.After24hours,itmaybegivendependingonthepatients’clinicalconditionandbloodpressure readings during hospital stay.

Surgery Surgery will only be done according to the neurosurgeon’s assessment of the patient’s condition. There are several options of surgical interventions. These are:

• Carotid Endarterectomy (CEA) For severe narrowing of the blood vessels in the neck

• Hemicraniectomy For patients with large infarct only. Depending on patient’s condition and the neurosurgeon’sassessment,theneurosurgeonmaytakeofftheskullattheaffectedarea

• External Ventricular Drainage (EVD) / Ventricular Peritoneal (VP) shunting Todecreaseexcessiveamountoffluidinthebrain

• Clipping of Aneurysm / Coiling To clip or insert coils into the outpouching of the blood vessel in the brain to

prevent further rupture

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What happens when you are hospitalised for stroke?You may be in the hospital for two weeks or more depending on your recovery.

Day Treatment and Monitoring Activity Nutrition

1-3 • YouwillbeadmittedtoeitherAcuteStrokeUnit(ASU)orGeneralWardfor close monitoring and treatment

• Yourconsciousnesslevel, heart beat and blood pressure will be monitored

• Youwillbefastedfrommidnightto take your blood sugar and cholesterol levels in the morning

• Youwillbestartedonmedicalmanagement according to your stroke type

• Investigationwillbedoneaccordingto your stroke type

•Youmaybereferred to allied health professionals (Speech Therapist /Physiotherapist/ Occupational Therapist / Dietitian / DiabeticNurse/ Smoking Cessation Counsellor / Medical Social Worker)whennecessary

• Dependingonthe swallowing test or the speech therapist assessment,you will start feeding either orally or by nasogastric tube(NGT)

4-6 • Doctorswilladviseyouiffurther test and other medical managementarerequired

• YouwillbereferredtoRehabilitationMedicine if necessary

•Continuerehabilitation byPT/OT/ST

•Caregivertraining if required

• Continueoralfeeding.

• IfyouareonNGT,youwillbe reassessed by ST for your safety of oral feeding

Discharge from Hospital

Ifyouarestablefordischarge,intheAcuteHospitalsetting,youwillbe:• dischargedhomewith/without acaregiver,or

• transferredtocommunityhospitalfor further rehabilitation or

• referredtoDayRehabCenteror• followupatCGHout-patientRehabor

• admittedtoaNursingHome

You will continue to take your medications, doyourexercises,modify your lifestyle and follow-up with doctors for the control of your risk factors

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What to expect after discharge from hospital?1. Take your medications Medicationsimprovequalityoflife,preventasecondstrokeandimprovesurvival.

Take your medications as prescribed.

Thepharmacistwillexplainyourmedicationtoyou.Itisimportanttoknowthenamesofyourmedications,whattheyareusedfor,howoftenandatwhattimesto take them.

Keepalistofyourmedicationsandbringthemwhenyouvisitanydoctor.Informyourdoctorifyouaretakinganysupplements,vitaminsandoverthecountermedications.

Talk to your doctor or pharmacist if you have any doubt or problem regarding yourmedications.Neverstoptakingyourmedicationswithoutfirstdiscussingwith your doctor.

Medications prescribed by your doctor may be used to: a)Preventstroke c)Controldiabetes b) Control blood pressure d) Lower cholesterol

2. Dietary modifications Avoidfoodhighincholesterol,saturatedfats,transfats,salt,sugarandalcohol.

Bake,boilorsteamyourfood.Avoidfrying.Consumemorefibres,freshfruitsand vegetables.

3. Exercise regularly

4. Quit smoking Ifyousmokeafterstroke,yourchanceofhavingasecondstrokeishigher.You

canquitsmokingbygatheringsupportfromfamilyandfriendsor joiningasmoking cessation clinic. You may contact the following:

CGH Smoking Cessation Counselling Foranappointment,pleasecall

CGH Appointment Centre Tel:68503333

5. Limit alcohol intake

Health Information Centre (Level 3) Health Promotion Board (HPB) 3 Second Hospital Avenues Singapore168937 Tel:64353954 Fax:65361277 Website: http://www.hpb.gov.sg

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This is a list of medications that you may be on:

Class of Medication

Name of Medication

What the Medication Does

Reason for Medication

Common Side Effects

Precautions and Advice

Antiplatelet Agents

Aspirin,Clopidogrel,Dipyridamole

Preventplatelets in the blood from sticking together.

Reducelikelihoodof clot formation.

- Best to take with food. Look for increase in bleeding or bruising.

Anticoagulants Warfarin/Coumadin,

Decreases the clotting ability of the blood.

Preventharmfulclots from forming in the blood vessels. May prevent the clots from becoming larger and causing more serious problems.

- Patientson this medication needs to be monitored closely with regular blood testing.

Dabigatran,Rivaroxaban

These medications do not need blood testing.

Statins Cholesterol lowering drugs

Atorvastatin,Lovastatin,Pravastatin,Rosuvastatin,Simvastatin

Lower cholesterol in your body. Keep the plaquesinyour arteries stable.

Used to lower LDL (“bad” cholesterol) and lower triglyceride levels.

- Patientson these medications must be monitored to check effectivenessand how well the liver is tolerating the medication.

Angiotensin- Converting Enzyme (ACE) Inhibitors

Captopril,Enalapril,Lisinopril,Perindopril,Ramipril

Expand blood vessels and decrease resistance to blood flow.Helpthe heart to work more efficiently.

Treat high blood pressure and heart failure and prevent stroke.

Drycough,dizziness and changes in taste.

Do not take additional potassium supplements. Avoid use of salt substitute.

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Class of Medication

Name of Medication

What the Medication Does

Reason for Medication

Common Side Effects

Precautions and Advice

Angiotensin IIreceptorBlockers (or Inhibitors)(Also known asARBs)

Candesartan,Losartan,Telmisartan,valsartan

Expand blood vessels and decrease resistance to blood flow.Helpthe heart to work more efficiently.

Treat high blood pressure. Preventstrokeand heart failure.

Dizziness and changes in taste.

Do not take additional potassium supplements. Avoid use of salt substitute.

Beta Blockers Atenolol,Bisoprolol,Carvedilol,Metoprolol,Propranolol,Sotalol

Decrease workload and oxygen demand of the heart. Lower blood pressure and make the heart beat more slowly.

Treat high bloodpressure,abnormal heart rhythms and chest pain.

Tiredness,dizziness,cold hands andfeet,slow heart beat,andbreathless -ness.

This side effectoftiredness wear offovertime.Informyourdoctor if you haveasthma,fainting or near fainting spells.

Calcium channel blockers

Amlodipine,Diltiazem,Nifedipine

Relaxtheblood vessels.

Used to treat high blood pressure,chestpain and some abnormal heart rhythms.

Headache,flushing,dizziness,palpitation,swelling of feet.

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Frequently asked questions What are the chances of recovery? Therateofrecoveryafterastrokediffersforeachpersonbutmostoftherecovery

isusuallyobservedinthefirstthreetosixmonths.

Ingeneral:-30% of stroke patients will have very good or full recovery-30% of the patients will have partial recovery.-30% of the patients will have poor recovery.-10–20%ofstrokepatientsdonotsurvive,especiallythosewithlargestroke.

What are the chances of a recurrence of stroke? Forpatientswhohadastroke,theriskofanotherstrokewithintheyearis10to

12%.Thereafter,theriskgraduallydecreases.

Is there a stroke support group for stroke patients and carers? TheSingaporeNationalStrokeAssociation is thenational strokesupport

group.Itorganisestalksandactivitiesforthepublicaswellasstrokepatientsand their families.

Tel:63584138oEmail: sporensa@singnet.com.sg Website: www.snsa.org.sg

Is there any service which we could consult if we have other questions?

ChangiGeneralHospitalhasanAsk-a-CGHNurseserviceasanadditionalavenueforyoutoaskhealth-relatedquestions.Theserviceisprovidedbyourteamofexperiencednurses,inconsultationwithourmedicalspecialistsandparamedicalstaff.Thisserviceisnotintendedtosubstitutemedicaladviceorconsultation.

Tousethisservice,gotoourwebsiteathttp://www.cgh.com.sg and click on “Ask-a-CGHNurse”tosubmityourquestion.Youwillhearfromuswithinthreeworking days.

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When can I start driving again?

Group 1(Class 1, 2 & 3 licences)

Group 2(Class 4, 5 & Vocational Licences)

Stroke Patientswithoutanyresidualdisabilitymay resume driving after 1 month.

Patientswithdisabilitiessuchasresidualweakness,significantvisualfielddefects,perceptualormentalimpairment,incoordination,etc,severeenoughtointerfere with control of the vehicle should not drive.

Patientswithmildresidualdisabilitiesthat may not interfere with control of the vehicle may undergo Driving Assessment andRehabilitationProgramme(DARP) >1 month after stroke. They may be allowedtodriveiftheypassDARP,afterfinalreviewbyadoctor.

Able to return to driving if all following conditions are met:• >1yearpoststroke• Strokeisnotduetohigh-risk

underlying condition which is left untreated (e.g. high gradecarotidstenosis,untreated aneurysym)

• Fullyrecovered• PassedDARP• Compliantwithtreatment• Finalclearancegivenby

a doctor

Transient ischemic Attack (TIA)

Single TIA: Allowed to return to driving oncefreeofTIAfor1month

Multiple TIA: Allowed to return to driving oncefreeofTIAfor6months

Able to return to driving if all following conditions are met:• >6monthspost-TIA (forsingleTIA)or>1yearpost-TIA(multipleTIAsorbrainstemTIA)

• TIAisnotduetohigh-riskunderlying condition which is left untreated (e.g. high grade carotid stenosis)

• Compliantwithtreatment• Finalclearancegivenby

a doctor

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2SimeiStreet3Singapore529889 Tel:67888833Fax:67880933

RegNo198904226R

Forappointmentsandenquiries, please call the CGH Appointment Centre at

Tel:(65)68503333

CGH Appointment Centre operating hours: 8.30amto8.00pm(MondaytoFriday) 8.30amto12.30pm(Saturday&Sunday)

ClosedonPublicHolidays

Formoreinformation,pleasevisit http://www.cgh.com.sg

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Allinformationisvalidatthetimeofprinting(February2014) and subject to revision without prior notice.