My Doctor Online The Permanente Medical Group

Types

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There are 2 major types of stroke. The first is known as ischemic stroke and is caused by insufficient blood flow due to a clot. The second is caused by bleeding in the brain and is known as a hemorrhagic stroke. Ischemic strokes are more common, accounting for approximately 80 percent of all cases. Hemorrhagic strokes can be more dangerous, however. There are some additional basic facts about the 2 types of strokes:

Ischemic stroke

• Atherosclerosis, or hardening of the arteries, is the most common cause of strokes. 
• The hardening is caused by cholesterol plaques that develop within the blood vessel wall and eventually block the artery or cause the spontaneous formation of a blood clot.
• If your artery remains blocked for more than a few minutes, brain cells may die. This is why immediate medical treatment is absolutely critical.
• Several risk factors for atherosclerosis have been identified, including high blood pressure, elevated cholesterol, diabetes, smoking, and advanced age.

Hemorrhagic stroke

• Hemorrhagic stroke occurs when a blood vessel bursts inside the brain.
• The blood irritates the brain tissue, causing swelling, and collects into a mass called a hematoma.
• In some instances, urgent surgery is required to evacuate or drain the blood to preserve the surrounding brain tissue.
• Poorly controlled high blood pressure is the most common cause of hemorrhagic stroke.

Symptoms

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Stroke symptoms begin suddenly and can include:

• Weakness or numbness on one side of the body
• Confusion, slurring of speech, difficulty finding the correct words to say, or a complete inability to talk
• Changes in vision, such as partial or complete blindness or seeing double
• Trouble walking, vertigo or dizziness, loss of balance or coordination
• Severe sudden headache (with hemorrhagic strokes)

Transient ischemic attack (TIA)

A transient ischemic attack (TIA) is a serious emergency condition, because it can be a warning sign of a future stroke. TIAs occur when hardening of the arteries (atherosclerosis) temporarily interferes with blood flow to a part of the brain. TIAs are often called ministrokes, which is inaccurate. Unlike ministrokes, the symptoms of TIAs do not usually leave permanent damage.

Here are some things to remember about a TIA:

• If the symptoms are short-term, lasting a few minutes or hours, they may be referred to as a TIA.
• If you experience a TIA, seek help immediately because you are at greater risk for a full-blown ischemic stroke.
• Unlike ischemic stroke symptoms, TIA symptoms usually disappear within 10 to 20 minutes, although they may last longer.
• If you have a TIA, you need emergency medical care. Remember: A TIA is a warning signal that a stroke may soon occur, and you have a limited period of time in which to prevent it.

Diagnosis

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Stroke is an emergency condition. If you have symptoms, call 911 or go to the nearest Emergency Room.

In the Emergency Room

• We will examine you to assess the scope and effects of the stroke.
• We will review your history and medical records and ask you about the onset of your symptoms. If you are unable to communicate, we will try to gather this information by talking to a family member or friend.
• We will perform diagnostic tests as appropriate, including blood tests, an electrocardiogram (EKG or ECG), and a CT (computed tomography) scan. We may also perform other tests, including MRI (magnetic resonance imaging), cerebral angiography, carotid ultrasound (carotid doppler or duplex ultrasound), and/or echocardiogram (heart ultrasound).
• We may provide aspirin to reduce the risk of another stroke.
• We may provide a medication called tissue plasminogen activator (tPA) if you are having an acute ischemic stroke. tPA is a clot-busting drug approved for use in some people having a heart attack or ischemic stroke.
• We generally must give tPA within 3 hours of the onset of the stroke for it to be effective. The drug can dissolve blood clots, which cause most heart attacks and strokes.

Once you have been admitted to the hospital

• We will assess whether it is safe for you to swallow. This is important to help prevent infection.
• We will begin to develop a rehabilitation plan for you. This will include evaluating you for any necessary mobility devices and deciding on the most appropriate place for you to continue your rehabilitation.
• We will monitor you for any changes in condition, nutrition, hydration, and other complications.
• We will also work with you to prevent future strokes. This may involve further testing to establish the cause of your stroke.

Treatment

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Treatment depends on the severity and cause of the stroke, although most people who have a stroke will be admitted to the hospital. Many of our hospitals in Northern California are certified by the Joint Commission as "Primary Stroke Centers," meaning that they have undergone and passed rigorous evaluations by a national agency to ensure the highest quality of care.

Surgical Treatments

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There are a range of surgical options available for treating a stroke:

Carotid artery surgery (endarterectomy)

• During a carotid endarterectomy, a vascular surgeon removes plaque (fatty deposits) from the carotid arteries in your neck that supply blood to your brain.
• The timing of the surgery will depend on a number of factors, including the extent of brain damage and your overall health. 
• If you had a TIA (transient ischemic attack) or ischemic stroke, we recommend surgery when your carotid artery is narrowed by 70 percent, or more, on the side that supplies the area of the brain affected by the TIA.  
• If your artery is narrowed by less than 50 to 69 percent after a TIA, treatment to control stroke risk factors with medication appears to be about as effective as surgery.
• If your artery is narrowed by less than 50 percent, we usually recommend medication rather than surgery.
• If you have not had a TIA or ischemic stroke, but you have narrowed carotid arteries, we may recommend surgery in order to prevent strokes. However the benefit is not as dramatic as it is for patients with TIA or ischemic stroke even if the narrowing is severe.
• Since carotid artery surgery is not without risks, we will carefully consider the risks and benefits before considering surgery if you have no symptoms.

Angioplasty and stent replacement

• Angioplasty and stent replacement is a less common procedure for opening arteries that have been narrowed by plaque buildup.
• During the procedure, we place a catheter into an artery in the groin and guide it, via X-ray, to the site of blood vessel narrowing.
• The blood vessel is then dilated with a balloon, and a tiny cylindrical wire mesh (known as a stent) inserted into the artery to keep it open.
• We may recommend this procedure if you have suffered a TIA or have severe carotid artery stenosis and your general health makes you a poor candidate for carotid artery surgery. 
• We may also use angioplasty if you have already had carotid artery surgery on a blood vessel and it has narrowed again.

Medication Treatments

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Anticlotting medications are used to reduce the chances of blood clots forming and thus reduce the risk of stroke. These include:

Some stroke medications should not be taken by women who are trying to get pregnant or are at risk for pregnancy because they can cause birth defects. If you are a woman of childbearing age (15 to 49) and are not planning to get pregnant, use an effective form of birth control. You must be using a highly reliable birth control method if you are taking certain medications to prevent stroke.

Risk Factors

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Everyone can be at risk of stroke. Some risk factors are outside of your control. Others are associated with medical conditions or lifestyle habits. Some of these risk factors can be controlled. If you have one or more modifiable risk factors, we will work closely with you to minimize your risk and prevent a stroke.

Uncontrollable risk factors

• Age. The risk for stroke increases with age and doubles every decade after 55.
• Race. African Americans and Hispanics are at greater risk of stroke compared to other races. Young African Americans are 2 to 3 times more likely to experience ischemic stroke and are more likely to die from stroke compared to Caucasians. 
• Gender. Stroke is more common in men than women. However, stroke is more severe in women at all ages, and more women than men die of stroke.
• Family history. You are at greater risk for stroke if you have a parent or sibling who has had a heart attack or stroke.
• Prior history of stroke or TIA. About 14 percent of people who have a stroke have another stroke within 1 year; 25 percent have another stroke within 5 years.

Medical and lifestyle risk factors

If you have suffered a stroke, we will work with you to control or minimize your modifiable risk factors. These controllable risk factors include the following:

• High blood pressure (hypertension).
• Diabetes.
• High cholesterol.
• Obesity.
• Smoking.
• Carotid artery disease.
• Atrial fibrillation. This is an abnormal heart rhythm that causes blood clots to form within the heart. These clots can break off and lodge in the blood vessels supplying the brain.
• Other heart conditions, including endocarditis, heart valve conditions, and cardiomyopathy (heart pumping problem).
• Sleep apnea (sleep-related breathing disorder) has recently been linked to increasing risk of stroke.
• Other rarer diseases and conditions, such as lupus, syphilis, hemophilia, pneumonia, high levels of homocysteine, and periodontal disease.
• Use of birth control pills. Young healthy women (less than 35 years old, nonsmoking, who do not have high blood pressure) can use hormonal birth control because, for them, the risk for stroke is very low. If you are older, smoke, or have hypertension, we advise using the lowest dose of hormonal birth control. You may also choose a nonhormonal method of birth control like condoms or an intrauterine device (IUD).

Women with a history of stroke may be at higher risk for another stroke if they become pregnant. If you are a woman of childbearing age (15 to 49) and have had a stroke, use a highly reliable form of birth control and discuss any plans for pregnancy with us before trying to conceive.

Prevention

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There are a number of steps you can take to prevent a stroke, or a further stroke, from occurring:

Know your blood pressure

If your blood pressure is high (more than 140/90), we will work with you to help you eat better and maintain a healthy weight, take medication, stop smoking, and get more exercise.

Take statins to control your cholesterol

We treat elevated cholesterol, especially elevated LDL (known as bad cholesterol) with statin type drugs that have been shown to reduce the risk of subsequent stroke. The target LDL cholesterol for patients who have had a previous ischemic stroke or TIA is less than 100. If you have diabetes and have had a TIA or ischemic stroke, then your LDL should be less than 70.

Quit smoking

Stopping smoking reduces the relative risk of stroke by about 30 percent immediately. Within just a few years after quitting, your stroke risk will be the same as for nonsmokers. 

Use anticlotting agents

A variety of medications are commonly used to reduce the chances of blood clots forming and thus reduce the risk of ischemic stroke. These include:

• Aspirin. Among patients at high risk of ischemic stroke, those taking aspirin have a 20 to 30 percent lower risk of ischemic stroke compared to those not taking aspirin.
• Aspirin-Persantine combination treatment. This medication is also very effective in reducing ischemic strokes and may be used in some cases instead of aspirin.
• Clopidogrel. This is another alternative for patients who cannot tolerate aspirin products.
• Warfarin. This requires more monitoring and has a higher chance of complications than aspirin. However, it is better at preventing ischemic strokes in certain patients with mechanical heart valve replacements or atrial fibrillation.

Your Care with Me

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If you or someone you are with has symptoms of stroke, call 911 and seek care immediately at the closest emergency room. Don't wait. Stroke is an emergency, just like a heart attack. The sooner you are treated, the better your outcome is likely to be.

When you are admitted to the Emergency Department

When you come in to our Emergency Department, you will be evaluated by a member of our stroke team, which will oversee your care. Our stroke team consists of emergency room physicians, neurologists, and internists who specialize in hospital-based medicine (called “hospitalists”).

After you leave the Emergency Department

If you are able to recover fully in the Emergency Department, you may be able to go home. Before we discharge you, we will schedule an appointment with your personal physician. He or she will assess your risk factors for stroke, perform a physical examination, review the tests done in the Emergency Department, and decide whether to order additional brain imaging studies and lab work to assess your risk for transient ischemic attacks (TIAs) or strokes in the future.

When you are admitted to the hospital due to stroke or TIA

If you had a stroke, depending on your symptoms, we will consult with a number of clinicians who specialize in helping patients recover. Speech therapists will assess your ability to swallow foods and liquids safely, physical therapists will evaluate you to plan or begin your rehabilitation, and nurses will monitor you for any changes or complications. We will prescribe the most appropriate anticlotting medication for you to take and educate you about how to take it. To prevent further strokes, we may order diagnostic imaging tests. Depending on the results, we may recommend surgery to prevent further strokes. We may perform the surgery while you are still in the hospital, or we may schedule it for a later date.

After you leave the hospital

When you are ready to be discharged from the hospital, we will schedule a follow-up appointment with your personal physician. We may also schedule appointments with other specialists and clinical providers, depending on your specific needs. These may include continued physical therapy and speech therapy appointments. Your personal physician will manage your care once you are discharged.

If there are questions about your symptoms or the results of the tests that were done in the hospital or the Emergency Room, you may be referred for outpatient consultations with me or someone in the Neurology department. Personal physicians work closely with neurologists to ensure that patients who are recovering from stroke, or at risk of stroke, are monitored closely. Your personal physician will schedule a referral appointment for you while you are still in the office, or if that is not possible, we will call you to make arrangements.

In some cases, your personal physician may call me or one of my colleagues while you’re in the office so we can all discuss your care together. If we decide you need an appointment with me after our discussion by phone, we can usually schedule it the same day.

When You See Me

During your office visit, we will discuss your medical and family history and I will perform a physical exam. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

If we decide that surgery is an appropriate option, I will refer you to a vascular surgeon, who will evaluate you to see whether you are a candidate for surgery. If you and your surgeon decide to proceed, he or she will discuss the procedure with you, including how to prepare, what to expect on the day of the surgery, and how long it is likely to take you to recover.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If surgery or a procedure is a treatment option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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