News from Medicine

The American Hearth Association has identified several factors that increase the risk of stroke. The more risk factors a person has, the greater the chance that he or she will have a stroke.

Increasing age-The chance of having a stroke more than doubles for each decade of life after age 55 with two-thirds of all strokes occur in people over 65.
Sex--Men have a higher risk for stroke, but more women die from stroke.
Heredity- (family history) and race- The chance of stroke is greater in people who have a family history of stroke. The incidence of stroke among African-Americans is almost double that of white Americans.
Prior stroke- The risk of stroke for someone who has already had one is many times that of a person who has not. The risk of a recurrent stroke is greatest right after a stroke, with the risk decreasing with time.
High blood pressure- High blood pressure is the most powerful risk factor that contributes to stroke. People with hypertension have a risk for stroke that is four to six times higher than the risk for those without hypertension.
Cigarette smoking- Smoking is the most powerful modifiable stroke risk factor. Smoking almost doubles a person’s risk for ischemic stroke.
Diabetes mellitus- Diabetes is an independent risk factor for stroke that is commonly associated with high blood pressure.
Carotid artery disease- A carotid artery damaged by atherosclerosis (a fatty buildup of plaque in the artery wall) is prime for a blood clot leading to a stroke.
High alcohol consumption- Chronic excessive drinking as well as binge drinking can lead to stroke.
Certain kinds of drug abuse- Cocaine and crack cocaine can cause stroke. Cocaine use has been closely related to strokes, heart attacks and a variety of other cardiovascular complications.

Evaluating symptoms, reviewing the medical history, and performing a physical examination are the first steps in making the diagnosis of stroke. In addition, certain tests assist in determining the type of stroke and the extent of damage to the brain. The physician uses this information to develop the best treatment for each patient.

Computed tomography (CT) scan
A test which assesses a stroke’s size, location and cause, as well as any brain damage that has occurred. The brain is scanned and then the information is fed into a computer that makes pictures of the brain. The patient may be injected with a contrast medium (usually iodine) to help highlight the areas in the brain being examined. This is usually the first test done to determine if an ischemic or hemorrhagic stroke has occurred.

Magnetic resonance imaging (MRI)
This advanced diagnostic tool provides a high level of anatomic detail for precisely locating the stroke and determining the extent of the damage. Due to its high level of sensitivity, MRI is considered especially useful when the stroke involves small blood vessels.

Magnetic resonance angiography (MRA)
A test that detects blood vessel changes such as blockage, narrowing or the presence of an aneurysm. This test combines an MRI and an angiogram but is not invasive. The procedure is similar to that described for an MRI.

Carotid ultrasound
A noninvasive test which evaluates the blood flow of the carotid arteries. During this painless test, a gel is applied to the skin of the neck over the carotid artery. A transducer is used to send an ultrasound signal. The reflected signal received is transmitted to a microprocessor that calculates the degree of narrowing in the artery.

Cerebral angiography (or arteriography)
A test that uses x-rays to check for impaired blood flow or blockage of the arteries that supply blood to the brain. It also can detect an aneurysm or an arteriovenous (AV) malformation. Cerebral angiography provides detailed pictures of blood vessels that cannot be obtained by other means. This test is invasive and some people have minor discomfort during the test.

Transcranial doppler (TCD)
A test that is a new, noninvasive ultrasound procedure that allows the assessment of blood flow through the cerebral vessels via a small probe placed against the skull. This may be used several times to follow the progress of medical treatment for a stroke.

PET scanning
A test that measures brain cell metabolism, can determine if brain tissue is functioning even if blood flow to that area appears to be diminished.

Generally, there are three treatment stages for stroke: prevention, therapy immediately after stroke, and post-stroke rehabilitation. The type of stroke therapy a patient receives depends upon the stage of their disease. Therapies for stroke include medications, surgery or rehabilitation.

Medications

Medication or drug therapy is the most common treatment for stroke. The most popular classes of drugs used to prevent or treat stroke are antithrombotics, thrombolytics and neuroprotective agents.

Antithrombotics prevent the formation of blood clots that can become lodged in a cerebral artery and cause strokes. This includes two groups of drugs: antiplatelet drugs and anticoagulants. Antiplatelet drugs prevent clotting by decreasing the activity of platelets, blood cells that contribute to the clotting property of blood. The most widely known and used antiplatelet drug is aspirin. Other antiplatelet drugs include Plavix (clopidogrel) and Ticlid (ticlopidine).

Anticoagulants reduce stroke risk by reducing the clotting property of the blood. The most commonly used anticoagulants include Coumadin (warfarin) and heparin.

Thrombolytic agents are used to treat an ongoing, acute ischemic stroke caused by an artery blockage. These drugs halt the stroke by dissolving the blood clot that is blocking blood flow to the brain. Recombinant tissue plasminogen activator (rt-PA) can be effective if given within 3 hours of stroke symptom onset for ischemic stroke.

Neuroprotectants are medications that protect the brain from secondary injury caused by stroke. Although only a few neuroprotectants are FDA approved, one drug, a calcium channel blocker called Nimotop (imodipine), has been shown to decrease the risk of neurological damage that results from subarachnoid hemorrhage.

Surgery

Surgery can be used to prevent stroke, to treat acute stroke or to repair vascular damage or malformations in and around the brain. The most common surgical procedure done for strokes is called a carotid endarterectomy. A carotid endarterectomy removes fatty deposits from the inside of one or both of the carotid arteries. The carotid arteries, which are located in the neck, are the main suppliers of blood to the brain. Studies have shown this to be a safe and effective stroke prevention therapy.

Rehabilitation Therapy

Stroke is the number one cause of serious adult disability in the United States. Physical therapy (PT) is used to restore movement, balance and coordination that may have been lost from a stroke. The aim of PT is to have the stroke patient relearn motor activities such as walking, sitting, standing, lying down, and the process of switching from one type of movement to another. Another type of therapy is occupational therapy (OT). OT involves exercise and training to help the stroke patient relearn everyday activities such as eating, drinking and swallowing, dressing, bathing, cooking, reading and writing and toileting. Finally, speech therapy is employed to help stroke patients with speech and language problems because of damage to the language centers in the brain.

Although stroke is a disease of the brain, it can affect the entire body. Some of the disabilities that can result from a stroke include paralysis, cognitive defects, speech problems, emotional difficulties, daily living problems and pain.

1) When did the client have the last stroke?

There is a postponement period between six to twelve months following the diagnosis of a stroke. The exact date of the last stroke is the starting point of the risk assessment process.

2) Has the client had more than one stroke?

A single episode of a stroke is priced much differently than multiple episodes of strokes. Multiple strokes indicate a poor medical and underwriting outcome.

3) What kind of permanent damage has the client sustained from the stroke?

The severity of a stroke can range from mild to fatal. Most strokes leave some form of permanent damage (neurological sequelae). It is important to document the exact nature of the damage the stroke has caused for the client (i.e. paralysis of an arm or leg, changes in ability to walk or talk, etc.).

4) Does the client smoke or have histories of either diabetes or hypertension?

The major risk factors for strokes are a history of smoking, diabetes (insulin dependent or non-insulin dependent) or hypertension. It is important to know if these risk factors exist in the client's medical history. Poorly controlled diabetes or hypertension combined with smoking in clients who have had a stroke generally renders the client uninsurable for individual coverage.

5) Does the client have a history of either cardiac arrhythmia's or heart valve disease?

Irregular heart rhythms or disease of the heart valves can create clotting events that lead to strokes. It is important to know if these risk factors exist in a client's medical history. Cardiac arrhythmia's or heart valve disease combined with a history of a stroke generally renders the client uninsurable for individual coverage.

6) What are the current medications that the client is taking?

Clients who experience a stroke are placed on some form of clot prevention therapy (i.e. anti-coagulants). These medications include aspirin, Plavix, Ticlid or Coumadin.

7) Has there been any reoccurrence of any of the symptoms that occurred with the last stroke?

Strokes are by definition neurological changes that last beyond twenty-four hours. It is important to clarify if any of these symptoms have reoccurred since the last stroke. Reoccurring symptoms indicate clinical instability and generally render the client uninsurable for individual coverage.