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• About : Professor, College of Nursing and Health Sciences
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Jul 30, 2014

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Stroke. Maxwell Lenko SBI3U ISU. Terms. Blood Vessel – a tube through which blood moves through the body Artery – a blood vessel that carries blood directly from the heart through the body Hemorrhage – the escape of blood into an extra vascular area

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Stroke Maxwell Lenko SBI3U ISU

Terms • Blood Vessel – a tube through which blood moves through the body • Artery – a blood vessel that carries blood directly from the heart through the body • Hemorrhage – the escape of blood into an extra vascular area • Atherosclerosis – the deposition of cholesterol in an artery • Thrombosis – a clot that forms in an artery and blocks it • Embolism – a dislodged clot that blocks another artery

Definition • A stroke is: the damaging of brain cells due to blood flow interruption • There are 3 types of strokes: • Ischemic Stroke • Intracerebral Hemorrhage • Subarachnoid Hemorrhage

Ischemic Stroke • Responsible for 80% of all strokes • Results from a clot in an artery in the brain, either through thrombosis or embolism www.memorylossonline.com/glossary/images/stroke.jpg

Intracerebral Hemorrhage • 12% of all strokes • Artery in the brain suddenly ruptures; releases blood into the brain and compresses it • If blood builds up rapidly victim can become unconscious • Usually occurs in the cerebellum, basal ganglia, cortex or brain stem http://www.dhushara.com/book/brainp/brainil/brain.jpg

Subarachnoid Hemorrhage • 8% of all strokes • Caused by blood vessel rupture • Different from intracerebral in that blood surrounds the brain instead of filling it • Sudden build up of blood can cause unconsciousness or even death • Said to cause the “worst headache of one’s life” http://www.strokecenter.org/pat/viewer/sah/sah_coronal_berry_2_500.jpg

Controllable High Blood Pressure Cholesterol Smoking Atrial Fibrillation Diet Lack of Exercise Uncontrollable Over age 55 Being Male African American Hispanic Asian/Pacific Islander Family history Diabetes Causes of Artery Rupture/ Clotting

Immediate Symptoms • Paralysis • Sudden Weakness • Unconsciousness • Death (not as immediate) • Loss of Speech

Post-Stroke Symptoms • Involuntary Muscle Contraction • Balance Problems • Curling of Toes • Central Pain Syndrome • Aphasia (limited communication) • Apraxia (difficulty initiating speech causing movements ) • Auditory Overload ( inability to convert sound to language ) • Dysarthia ( slurring of speech ) • Dysphagia ( food goes down air tube instead of esophagus ) • Depression • One-Side Neglect • Behavioral Changes • Other Subtle Brain Difficulties

Diagnosis • Doctor can perform a number of tests • Risk Factors • Carotid Ultrasonography • Arteriography • Computerized Tomography (CAT scan) • Magnetic Resonance Imaging (MRI)

Immediate Treatment • For an ischemic stroke doctor will remove clot using tissue plasminogen activator (tPA) drugs • For a hemorrhage a tiny clip is placed to close the aneurysm or a coil is placed in it to prevent further rupturing

Rehabilitation • Occurs in either a hospital, subacute care unit, rehab hospital, home therapy, home with outpatient therapy, long term care facility • Therapists such as physicians and speech therapists are required to re-establish basic skills for independence • Nursing is very important • Rehab time is dependent on damage to brain cells

Current/Future Research • Research into implantable pacemakers, artificial hearts, using acetylsalicylic acid in prevention of strokes, clot dissolving drugs (eg. tPA), increasing public awareness about strokes, updating and developing new methods of CPR, bionics, and the promotion of recommendations to the public to deal with high blood pressure

Miscellaneous Facts • 75% of all strokes are preventable • One of the most common causes of death amongst elders in the Western world • Third leading cause of death in America • First leading cause of adult disability • Women more likely to die

References ___ (1998). Stroke. In Encyclopedia of Family Health (vol. 14, pp. 1876- 1881). Toronto: Marshall Cavendish. American Stroke Association. “Warning Signs”, “Life After Stroke”. Retrieved April 8, 2007 from the World Wide Web: < http://www.strokeassociation.org/presenter.jhtml?identifier=12000372 > Mayo Clinic Staff. (2006). Mayo Clinic Family Health Book Third Edition. New York. Harper Collins Publishers. National Stroke Association. “What’s a Stroke?”, “Risk Factors”, “Prevention”, “Recovery”. Retrieved April 8, 2007 on the World Wide Web: < http://www.stroke.org/site/PageServer?pagename=home >. The Internet Stroke Center. “Types of Stroke”. Retrieved April 8, 2007 from the World Wide Web: < http://www.strokecenter.org/pat/stroke_types.htm > The Heart and Stroke Foundation. “All about Research”. Retrieved June 4, 2007 from the World Wide Web: <http://ww2.heartandstroke.ca/Page.asp?PageID=1366&ArticleID=5533&Src=blank&From=SubCategory >.

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• Signs and Symptoms
• Risk Factors
• Stroke Facts
• Stroke Communications Toolkit
• About Heart Disease
• About High Blood Pressure
• About Cholesterol

About Stroke

• Stroke causes parts of the brain to become damaged or die.
• Quick treatment is critical for stroke.
• There are two types of stroke: ischemic and hemorrhagic.
• A transient ischemic attack is sometimes called a “mini-stroke."

A stroke, sometimes called a brain attack, occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts.

In either case, parts of the brain become damaged or die. A stroke can cause lasting brain damage, long-term disability, or even death.

Learn about the health conditions and lifestyle habits that can increase your risk for stroke .

What happens in the brain during a stroke?

The brain controls our movements, stores our memories, and is the source of our thoughts, emotions, and language. The brain also controls many functions of the body, like breathing and digestion.

To work properly, your brain needs oxygen. Your arteries deliver oxygen-rich blood to all parts of your brain. If something happens to block the flow of blood, brain cells start to die within minutes, because they can't get oxygen. This causes a stroke.

Learn more about the signs and symptoms of stroke.

There are two types of stroke:

• Ischemic stroke.
• Hemorrhagic stroke.

A transient ischemic attack (TIA) is sometimes called a "mini-stroke." It is different from the major types of stroke. Blood flow to the brain is blocked for only a short time—usually no more than 5 minutes. 1

Ischemic stroke

Most strokes are ischemic strokes. An ischemic stroke occurs when blood clots or other particles block the blood vessels to the brain.

Fatty deposits called plaque can also cause blockages by building up in the blood vessels.

Hemorrhagic stroke

A hemorrhagic stroke happens when an artery in the brain leaks blood or ruptures (breaks open). The leaked blood puts too much pressure on brain cells, which damages them.

High blood pressure and aneurysms—balloon-like bulges in an artery that can stretch and burst—are examples of conditions that can cause a hemorrhagic stroke.

Transient ischemic attack (TIA or “mini-stroke”)

TIAs are sometimes known as "warning strokes." It's important to know that:

• A TIA is a warning sign of a future stroke.
• A TIA is a medical emergency, just like a major stroke.
• Strokes and TIAs require emergency care. Call 9-1-1 right away if you feel symptoms of a stroke or see signs in another person.
• There is no way to know in the beginning whether symptoms are from a TIA or from a major type of stroke.
• Like ischemic strokes, blood clots often cause TIAs.
• More than a third of people who have a TIA and don't get treatment have a major stroke within 1 year. As many as 10% to 15% of people will have a major stroke within 3 months of a TIA. 1

Recognizing and treating TIAs can lower the risk of a major stroke. If you have a TIA, your health care team can find the cause and take steps to prevent a major stroke.

What CDC is doing

• High Blood Pressure
• Heart Disease
• Cholesterol
• Paul Coverdell National Acute Stroke Program

Million Hearts® and CDC Foundation

" Heart-Healthy Steps." This campaign encourages adults 55 and older to get back on track with the small steps: scheduling their medical appointments, getting active, and eating healthy, so they can get back to living big.

"Live to the Beat." This campaign focuses on empowering Black adults to pursue heart-healthy lifestyles on their own terms—finding what works best individually and consistently, as they live to their own beat.

• National, Heart, Lung, and Blood Institute: What Is a Stroke?
• National Institute of Neurological Disorders and Stroke (NINDS): Stroke Information Page
• NINDS Know Stroke Campaign
• NINDS Know Stroke Campaign Spanish Toolkit
• American Stroke Association. Transient ischemic attack (TIA). American Heart Association. Accessed January 29, 2024. https://www.stroke.org/en/about-stroke/types-of-stroke/tia-transient-ischemic-attack

Stroke is a leading cause of death in the United States and is a major cause of serious disability for adults. It is also preventable and treatable.

For Everyone

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• http://orcid.org/0000-0002-6020-510X Jacob Day 1 ,
• Housam Monla-Haidar 2 ,
• Vasant Raman 3 ,
• Stuart Weatherby 4
• 1 Neurology , Royal Devon University Healthcare NHS Foundation Trust , Exeter , UK
• 2 Ophthalmology , Musgrove Park Hospital , Taunton , UK
• 3 Ophthalmology , University Hospitals Plymouth NHS Foundation Trust , Plymouth , UK
• 4 Neurology , University Hospitals Plymouth NHS Foundation Trust , Plymouth , UK
• Correspondence to Dr Jacob Day, Neurology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, EX2 5DW, UK; jacobday{at}doctors.org.uk

A man in his 90s presented with acute monocular loss of vision; the emergency department triage alerted the stroke team. He underwent urgent parallel assessments by the stroke and ophthalmology teams and was diagnosed with central retinal artery occlusion. The ultimate decision was made to manage him conservatively, rather than with intravenous thrombolysis, and his visual function has remained poor. We discuss the current evidence for using intravenous thrombolysis in people with central retinal artery occlusion and use this case to exemplify the practical issues that must be overcome if ongoing randomised clinical trials of central retinal artery occlusion confirm a definite benefit from using intravenous thrombolysis.

• CLINICAL NEUROLOGY
• FIBRINOLYSIS

Data availability statement

No data are available.

https://doi.org/10.1136/pn-2023-003998

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Case presentation

A man in his early 90s was brought to the emergency department by his daughter after suddenly losing vision in his right eye 3 hours before. There was no associated pain or eye redness. He had been well with no preceding fever or headache.

His relevant ocular history indicated wet age-related macular degeneration. He had a medical history of myocardial infarction and coronary artery bypass grafting, chronic obstructive pulmonary disease and peptic ulcer disease. 4 months before this event, he had been admitted under gastroenterology with retrosternal pain and weight loss. He was found to have atrial flutter but did not start anticoagulation as outpatient investigations were planned. Outpatient upper gastrointestinal endoscopy and CT scans of the thorax, abdomen and pelvis found no explanation for his symptoms. His weight stabilised, but anticoagulation was not started.

His current medications were bisoprolol, clopidogrel, simvastatin, lansoprazole, finasteride, tamsulosin and a Trimbow inhaler. He lived alone without carers, walked unaided and had maintained a driving licence.

The emergency department team triaged him routinely then put out an acute stroke alert because of the recent symptoms of acute neurological deficit. The assessing stroke team found no focal neurological deficits beyond the monocular loss of vision. His visual acuity in the affected right eye was perception of light and in the left eye it was 20/50. The right eye had a relative afferent pupillary defect. The clinical impression was of a right central retinal artery occlusion. Handheld funduscopy could not confirm the diagnosis nor confidently exclude an alternative cause for the visual loss. The immediate management dilemma was to discern rapidly and safely whether any acute treatment, in particular intravenous thrombolysis, might improve his vision.

A CT scan of the head (to identify contraindications to thrombolysis) showed no acute infarction or haemorrhage. CT angiography showed 40% stenosis of the right internal carotid artery and 50% stenosis of the left, with no arterial occlusion. Serum C reactive protein was 3 mg/L (<10). There were therefore no identified absolute contraindications to thrombolysis, although handheld ophthalmoscopy through a non-dilated pupil could not confidently exclude vitreous or retinal haemorrhage.

The ophthalmology team assessed him urgently; however, being out of hours, they were not immediately available on site. They confirmed the appearances of a central retinal artery occlusion ( figure 1 ) and were able to exclude other causes of acute monocular visual loss that might have required alternative urgent treatments, such as retinal detachment and intraocular haemorrhage. 1 However, by the time these investigations and reviews had occurred, it was beyond 4.5 hours from symptom onset. Following discussion with the patient, his daughter, the ophthalmology and neurology teams, it was decided not to offer thrombolysis.

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Widefield fundus photograph showing early central retinal artery occlusion in the right eye. Arrow shows pallor of the central retina.

Acutely, the patient underwent ocular massage and intravenous acetazolamide as first-line treatment according to local protocol. These aim to lower intraocular pressure, which can induce vasodilatation and dislodge the embolus. He received a loading dose of aspirin and started apixaban the following day. Carotid Doppler studies found no significant stenosis of the symptomatic side. When last reviewed, 27 months after presentation, his right eye visual acuity remained perception to light only.

This case was particularly challenging because we needed to make a rapid decision about a treatment with potentially serious side effects in a clinical presentation that is not typically managed via an acute stroke pathway.

Central retinal artery occlusion is most commonly due to embolic arterial occlusion, analogous to the pathophysiology of embolic cerebral stroke, and its long-term visual outcomes are typically poor. 2 The risk factors are the same as for cerebral stroke and there is a high rate of cerebral stroke in the first few weeks after central retinal artery occlusion. 3–5 This suggests that acute stroke pathways and treatments could also be effective for central retinal artery occlusion. However, current acute stroke pathways are not designed to identify patients with monocular visual loss and the management of such patients might fall in between the stroke team (who might be able to offer acute stroke intervention) and ophthalmology team (who typically assess and follow-up this presentation). Moreover, there is limited evidence for using thrombolysis in central retinal artery occlusion and a minority of cases are due to vasculitis (approximately 2.0% 6 ), especially giant cell arteritis, which has a very different pathophysiology and management.

Potential delays at multiple steps along a patient journey might currently limit the options for acute treatment of central retinal artery occlusion. In this case, delays occurred for several reasons: the patient did not call 999 and was not brought to hospital by ambulance; he did not undergo emergency triage on arrival; the stroke CT scan of the head could not be rapidly approved by the radiographers because the patient did not have ‘typical’ stroke symptoms; the ophthalmology team had to travel to the emergency department to assess the patient. If we are to assess and potentially treat patients rapidly with hyperacute central retinal artery occlusion, several interventions would need to be put in place. ‘Eye symptoms’ would need to be incorporated into public awareness campaigns in a similar way to the face/arm/speech test (FAST) campaign for cerebral stroke in the UK. 7 Urgent ophthalmology assessment would need to be available in the emergency department alongside initial assessment and CT scans of the head. Finally, consideration of and blood testing (especially of serum C reactive protein) for possible giant cell arteritis would need to be implemented rapidly. 8

However, even if all this were in place, is thrombolysis an effective and safe treatment for central retinal artery occlusion? The evidence to date is inconclusive. Animal studies suggest that there is a time-limited ischaemic period of up to 240 min beyond which the retina is irreversibly damaged. 9 The presence of a cherry-red spot may be a surrogate for irreversible retinal damage. Several prospective interventional case series have reported a functional visual improvement in 30%–55% patients receiving intravenous thrombolysis. 6 10 11 However, there are no reliable randomised controlled trials of intravenous or intra-arterial thrombolysis in patients with early central retinal artery occlusion. A randomised placebo-controlled study of alteplase for central retinal artery occlusion in 2011 recruited 16 patients, 8 of whom received alteplase: the 2 who received it within 6 hours had significant visual recovery at 1 week but this was not maintained at 6 months. 12 One patient who received alteplase>6 hours developed an intracranial haemorrhage and the trial was halted. There have been two meta-analyses of observational cohorts receiving intravenous thrombolysis, both of which showed significantly enhanced recovery rates in those patients given thrombolysis within 4.5 hours (visual recovery: 50% vs 17.7% and 37.3% vs 17.7%). 13 14 There were no cases of symptomatic intracranial haemorrhage in participants treated with alteplase within 4.5 hours. Similarly, a separate literature review of alteplase used for central retinal artery occlusion found no cases of intracranial or ocular haemorrhage in patients treated within 4.5 hours. 15 However, the numbers are reasonably small and observational studies cannot eliminate the risk of bias. There are three European randomised controlled trials underway (of either alteplase or tenecteplase for central retinal artery occlusion: NCT04965038 , NCT04526951 , NCT03197194 ) and should give clinicians valuable information to answer this question in the coming years.

There are no UK guidelines for managing acute retinal artery occlusion. The American Academy of Ophthalmology Preferred Practice Panel for Retinal and Ophthalmic Artery Occlusions recommend urgent referral of acute occlusions to a stroke centre for consideration of acute interventions. 16 It lists intravenous/intra-arterial thrombolysis as an option for management, although without definite evidence of benefit. The American Heart Association Statement on Management of Central Retinal Artery Occlusion concludes that there is ‘equipoise in the utility of intravenous tPA [tissue plasminogen activator] for central retinal artery occlusion, and the decision to use this therapy rests on a thorough discussion between the treating specialist and the affected patient’. 8 They note that half of academic neurologists in the USA consider intravenous thrombolysis for acute central retinal artery occlusion and that 5.8% of patients admitted to hospitals in the USA with this condition received thrombolysis. 17

So, what will we do next time a patient with acute monocular visual loss attends the emergency department? Assuming we cannot enrol them into a randomised controlled trial, we will treat as a time-sensitive emergency via the usual acute stroke pathway, while simultaneously involving the ophthalmology team and considering giant cell arteritis as an underlying pathology. It is essential to involve ophthalmology urgently and in parallel to ensure the correct diagnosis is reached. If a central retinal artery occlusion due to embolus is confirmed within 4.5 hours and there are no contraindications to intravenous thrombolysis, we will have a frank discussion with the patient about their priorities and acceptance of risk and so come to a collaborative patient-centred decision. Some patients will be willing to accept greater risks to try and preserve their vision. They can be reassured that the rate of complications from thrombolysis within 4.5 hours appears to be low but should be informed that randomised trials have not shown benefit to visual function. It is essential that they are counselled with a summary of current evidence of risks and benefits for the off-label use of thrombolysis and that if delivered it is done so within the structure of the stroke service.

Central retinal artery occlusion typically has a poor outcome in terms of recovery of vision.

It is most often caused by embolic occlusion, which has the potential to respond to acute reperfusion therapy.

When assessing patients with monocular vision loss, clinicians should involve the ophthalmology team urgently and should consider giant cell arteritis as a possible cause of retinal artery occlusion.

Observational data suggest intravenous thrombolysis given within 4.5 hours of central retinal artery occlusion is helpful, although randomised controlled studies are ongoing.

Further reading

Mac Grory B, Schrag M, Biousse V, Furie KL, Gerhard-Herman M, Lavin PJ, et al . Management of central retinal artery occlusion: a scientific statement from the American Heart Association. Stroke . 2021;52(6):e282–e94.

Dumitrascu OM, Newman NJ, Biousse V. Thrombolysis for central retinal artery occlusion in 2020: time is vision! J Neuroophthalmol . 2020;40(3):333–45.

Ethics statements

Patient consent for publication.

Consent obtained directly from patient(s).

Ethics approval

Not applicable.

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X @DrJacobDay

Contributors JD, HM-H and SW reviewed the patient during admission. SW conceived and critically reviewed the article. JD wrote the first draft of the article. HM-H provided annotated retinal photographs and critically reviewed the article. VR critically reviewed the article.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned. Externally peer reviewed by Luke Bennetto, Bristol, UK and Susan Mollan, Birmingham, UK.

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• Click on "Blank presentation" to create your presentation from scratch, or pick your preferred free PowerPoint template from the options at the top (there's also a host of editable templates you can find on the Microsoft 365 Create site ).
• Create your presentation as normal. Your edits will be saved automatically to your Microsoft OneDrive as long as you're connected to the internet.

It's important to keep in mind, though, that while you're free to use this web version of PowerPoint to create your slides and edit templates, there are certain features it doesn't have that you can find on the paid version. For instance, you can access only a handful of font styles and stock elements like images, videos, icons, and stickers. Designer is also available for use on up to three presentations per month only (it's unlimited for premium subscribers). When presenting, you won't find the Present Live and Always Use Subtitles options present in the paid plans. The biggest caveat of the free version is that it won't get any newly released features, unlike its premium counterparts.

Method #2: Install Microsoft 365 (Office) To Your Windows

Don't fancy working on your presentation in a browser? If you have a Windows computer with the Office 365 apps pre-installed or downloaded from a previous Office 365 trial, you can use the Microsoft 365 (Office) app instead. Unlike the individual Microsoft apps that you need to buy from the Microsoft Store, this one is free to download and use. Here's how to get free PowerPoint on the Microsoft 365 (Office) app:

• Search for Microsoft 365 (Office) on the Microsoft Store app.
• Install and open it.
• Sign in with your Microsoft account. Alternatively, press "Create free account" if you don't have one yet.
• Click on Create on the left side panel.
• Select Presentation.
• In the PowerPoint window that opens, log in using your account.
• Press Accept on the "Free 5-day pass" section. This lets you use PowerPoint (and Word and Excel) for five days — free of charge and without having to input any payment information.
• Create your presentation as usual. As you're using the desktop version, you can access the full features of PowerPoint, including the ability to present in Teams, export the presentation as a video file, translate the slides' content to a different language, and even work offline.

The only downside of this method is the time limit. Once the five days are up, you can no longer open the PowerPoint desktop app. However, all your files will still be accessible to you. If you saved them to OneDrive, you can continue editing them on the web app. If you saved them to your computer, you can upload them to OneDrive and edit them from there.

Method #3: Download The Microsoft PowerPoint App On Your Android Or iOS Device

If you're always on the move and need the flexibility of creating and editing presentations on your Android or iOS device, you'll be glad to know that PowerPoint is free and available for offline use on your mobile phones. But — of course, there's a but — you can only access the free version if your device is under 10.1 inches. Anything bigger than that requires a premium subscription. If your phone fits the bill, then follow these steps to get free PowerPoint on your device:

• Install Microsoft PowerPoint from the App Store or Google Play Store .
• Log in using your existing Microsoft email or enter a new email address to create one if you don't already have an account.
• On the "Get Microsoft 365 Personal Plan" screen, press Skip For Now.
• If you're offered a free trial, select Try later (or enjoy the free 30-day trial if you're interested).
• To make a new presentation, tap the plus sign in the upper right corner.
• Change the "Create in" option from OneDrive - Personal to a folder on your device. This allows you to save the presentation to your local storage and make offline edits.
• Press "Set as default" to set your local folder as the default file storage location.
• Choose your template from the selection or use a blank presentation.
• Edit your presentation as needed.

Do note that PowerPoint mobile comes with some restrictions. There's no option to insert stock elements, change the slide size to a custom size, use the Designer feature, or display the presentation in Immersive Reader mode. However, you can use font styles considered premium on the web app.

Method #4: Use Your School Email Address

Office 365 Education is free for students and teachers, provided they have an email address from an eligible school. To check for your eligibility, here's what you need to do:

• Go to the Office 365 Education page .
• Type in your school email address in the empty text field.
• Press "Get Started."
• On the next screen, verify your eligibility. If you're eligible, you'll be asked to select whether you're a student or a teacher. If your school isn't recognized, however, you'll get a message telling you so.
• For those who are eligible, proceed with creating your Office 365 Education account. Make sure your school email can receive external mail, as Microsoft will send you a verification code for your account.
• Once you're done filling out the form, press "Start." This will open your Office 365 account page.

You can then start making your PowerPoint presentation using the web app. If your school's plan supports it, you can also install the Office 365 apps to your computer by clicking the "Install Office" button on your Office 365 account page and running the downloaded installation file. What sets the Office 365 Education account apart from the regular free account is that you have unlimited personal cloud storage and access to other Office apps like Word, Excel, and Outlook.

Read the original article on SlashGear .