Stroke Prevention and Treatment

by Food and Drug Administration (FDA)

Rusty Van Sickle considers herself one of the lucky ones.

A victim of two massive strokes in 1993, one of which left her in a three-week coma, the Florida resident has, in her words, "come back." She's at the point where, with some accommodations, she can hold down a job in her field of social work.

"I can drive now," says Van Sickle, 43. "I cook and do home chores. I do many of the things I used to do." But, she adds, hinting at the long road she's had to recovery, "I've had to relearn all of them."

She has lingering effects such as a lack of visual sharpness and skewed spatial judgment. Paralysis on the left side of her body and damage to her brain's balance center keep her confined to a wheelchair most of the time.

But she keeps a positive outlook and admits that her stroke was "not really that bad when you compare it with what others have been through."

Stroke ranks as the third leading killer in the United States, behind heart disease and cancer. The chart at right shows the incidence of stroke compared with other disabling neurological disorders. More than a half million Americans have a stroke each year, according to the National Institute of Neurological Disorders and Stroke (NINDS). Following a 25-year decline, stroke deaths are now on an upswing. Figures from the American Heart Association show that 158,061 Americans died of stroke in 1995, the latest year for which statistics are available — a 10 percent jump over the 143,769 deaths in 1992.

Some professionals have explanations. "The increase in stroke deaths is linked to the aging of the population and may also be the result of a decrease in the detection and treatment of high blood pressure," says Russell Luepker, M.D., director of epidemiology at the University of Minnesota. He adds that high blood pressure is one of the primary risk factors for stroke, and that about one-third of the Americans who have it are unaware.

Stroke also is the most common cause of adult disability. "Millions of people are challenged by the devastating aftermath of stroke," says Jan Breslow, M.D., president of the American Heart Association, adding that up to one-third of stroke survivors need help caring for themselves, 20 percent need help walking, and 70 percent are not able to perform the same job tasks they did before the stroke.

Amid these grim statistics, however, hope is emerging that the devastating effects of stroke can be lessened, possibly reversed, in many cases. Activase (alteplase), a genetically engineered version of the body's own tissue plasminogen activator (t-PA) that can dissolve clots, was approved by the Food and Drug Administration in 1996 for treating the most common type of stroke. It had been approved earlier for treating heart attacks. In clinical trials, Activase boosted recovery odds significantly in selected stroke patients treated within the first three hours of the onset of symptoms.

FDA also has approved the anticoagulant drug Coumadin (warfarin) for treating patients at high risk of having a stroke, such as those with a heart valve defect or who have suffered a heart attack. Doctors also prescribe low-dose aspirin to their patients who have had previous heart attacks or strokes because studies have shown that aspirin can prevent repeat heart attacks and strokes in these patients. Aspirin is an "antiplatelet" that can prevent the "clumping" of blood platelets that creates clots and triggers heart attacks and strokes. Last November, FDA approved another antiplatelet drug for treating stroke, Plavix (clopidogrel), and for several years, doctors have prescribed the drug Ticlid (ticlopidine hydrochloride), also approved as an antiplatelet.

Several drug treatments, including one designed to stop the rapid death of brain cells following a stroke, are in clinical trials now. Also under study is a spring-like device used to prop open blood vessels after blockages are removed, a therapy that may reduce the chance of stroke.

Medical professionals emphasize that there are at least five risk factors that, when treated, can decrease the possibility of stroke. Knowing stroke's warning signs and seeking emergency help immediately if they appear can reduce the risk of death or disability significantly.

What Is a Stroke?

Sometimes called a "brain attack," a stroke occurs when blood circulation to the brain fails. This cuts off oxygen and can kill brain cells, affecting neurological functions such as speech, vision, coordination, and thought.

Strokes fall into two broad categories: those caused by blood-flow blockage and those caused by bleeding. An ischemic stroke, which occurs when a blood vessel in the brain or neck is blocked, is the most common stroke, responsible for about 80 percent of cases. Such blockages may form within a blood vessel of the brain or neck (thrombosis), may migrate to the brain or neck as a clot from another part of the body (embolism), or may result from severe narrowing of an artery in or leading to the brain (stenosis).

Less common is hemorrhagic stroke, in which a blood vessel bursts, causing bleeding into the brain or in the spaces surrounding the brain.

Stroke is an equal threat to men and women. It occurs in all age groups and races, though African-Americans suffer more severe strokes and have a death rate nearly double that of whites. Scientists have identified a "stroke belt" in the Southeastern states, especially in the coastal plain areas of the Carolinas and Georgia. A study in the May 1997 issue of the journal Stroke showed that stroke deaths in this Southern region are more than double those of the nation overall in ages 35 to 54. For ages 55 to 74, deaths in the belt are 1.7 times greater. Why? "It could be a wide range of things," says George Howard, professor of epidemiology at Bowman Gray School of Medicine in Winston-Salem, N.C., and lead author of the Stroke study. He says possible factors include the region's lifestyle choices such as smoking more or eating more fat and salt.

Though most strokes occur in adults over 40, children also have strokes, though these are typically caused by underlying conditions such as congenital heart disease or sickle cell anemia.

Sometimes young adults between 20 and 40 fall victim. Bill McGarry was a 22-year-old engineer in 1977 when a stroke plunged him into a three-month coma on advanced life-support machines. More than 20 years later, he still has paralysis, blindness, and nagging problems such as greatly reduced mathematical and analytical abilities. Speech therapy allowed him to regain control of his vocal cords. In 1989, he received a master of education degree from the University of New Orleans and began working as a career counselor in 1990. He now lives independently in his own home in Austin, Texas.

The key to this kind of recovery, he says, is to stay focused on getting better and to not lose faith when rehabilitation reaches a plateau. Support from family and friends also is crucial. "Improvement is almost glacial at times," he says. "But it adds up ... a step here and a second there and eventually you can walk across the room or down to the corner."

About the Author

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