A stroke occurs when the blood supply to part of the brain is suddenly interrupted due to the presence of a blood clot (ischemic stroke), or when a blood vessel in the brain bursts, spilling blood into the spaces surrounding brain cells (hemorrhagic stroke). When blood flow to the brain stops, brain cells no longer receive oxygen and nutrients from the blood and die. Sudden bleeding in or around the brain can also cause brain cells to die. This results in temporary or permanent neurologic impairment. Ischemic stroke, also known as cerebral infarction, accounts for 80 to 85% of all strokes, while hemorrhagic stroke accounts for the other 15 to 20%.
Prior to a stroke, some people suffer transient ischemic attacks (TIAs), mini strokes that generally last only 5 to 20 minutes, but can linger for up to 24 hours before the symptoms go away completely. Many times, a TIA is a warning of an impending stroke. Stroke remains one of the most serious of all health problems. Half of stroke sufferers are left disabled, with many undergoing years of rehabilitation.
Signs and Symptoms
Symptoms of a stroke depend on which area of the brain is affected and, in turn, what functions in the body that area controls. Many of the warning signs of a possible stroke (like a TIA) and symptoms of an actual stroke are the same. If any of these symptoms occur, you should seek medical attention right away and start appropriate treatment as quickly as possible. The sooner treatment begins, the more likely it is that brain function will be preserved.
Symptoms and warning signs include:
Women are more likely to report nontraditional symptoms of stroke and, in particular, altered mental states.
Ischemic stroke results from the following causes:
Hemorrhagic stroke results from the following causes:
Free radical damage may make someone susceptible to stroke and other brain disorders. Free radicals are waste products created when the body turns food into energy (metabolism). Even though they are created naturally by normal metabolic processes (called oxidation), free radicals cause harmful chemical reactions that can damage cells in the body. There are also many environmental sources of free radicals, such as ultraviolet rays, radiation, and toxic chemicals in cigarette smoke, car exhaust, and pesticides. Anyone can have a stroke, but certain factors place you at higher risk. You cannot change some factors that increase the risk of stroke, but you can reduce your risk of stroke by implementing certain lifestyle changes.
Ways to help protect yourself include:
Anybody can have a stroke, but certain factors place you at higher risk. Some factors that increase the risk of stroke cannot be changed, while others are linked to lifestyle factors, and thus are under your control.
Risk factors that cannot be changed:
Risk factors that can be changed with medical treatment:
Risk factors that can change through lifestyle modifications:
Other factors that may put you at increased risk for stroke include pregnancy, infection or inflammation, gum disease, and high homocysteine levels. Homocysteine is an amino acid that rises in the body if you have low levels of vitamins B6, B12, B9 (folic acid), and betaine.
If you or someone you know experiences symptoms associated with stroke, call 911 or your local emergency number immediately. There are effective therapies for stroke that must be administered at a hospital within the first 3 hours after stroke symptoms appear. At the hospital, a health care provider will make a diagnosis and guide you in determining which treatment or combination of therapies will work best for you.
The provider will do a complete neurological exam and run a battery of tests, such as blood tests, an electrocardiogram, and a test to measure the severity of the stroke. Imaging techniques, such as CT scans, magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA), may be used to reveal the cause of the stroke and pinpoint blockages or reveal malformations.
The best way to prevent stroke is to reduce your risk factors and take control of your own health:
Medications for prevention
Certain medications have been shown to reduce the risk of stroke. These drugs, which aim to prevent the formation of dangerous blood clots, fall under two major categories:
A stroke is a medical emergency, regardless of whether it is a major stroke or a short-lasting TIA.
A person suffering symptoms consistent with a stroke should be taken immediately to a hospital emergency department.
The ability to quickly pinpoint the type of stroke is critically important in treatment decisions. A stroke caused by a blocked artery is treated in an entirely different way than a stroke caused by bleeding within the brain.
The key to survival and recovery is prompt medical treatment.
Rehabilitation. learning certain skills that you might have lost is crucial following a stroke and can consist of one or more of the following:
In addition, learning yoga may help you recover after a stroke, even months later. If you have had a stroke and are considering yoga, talk to your doctor first. Then, find a qualified teacher in your area who has worked with stroke victims. Consulting a qualified teacher is very important because you should avoid certain yoga postures if you have high blood pressure, narrowed carotid arteries (the main arteries in your neck supplying blood to the brain), or history of stroke. Check with your physical therapist for a referral.
If the stroke is caused by a blockage in an artery, your doctor may prescribe medications called thrombolytics. The only drug in this class approved by the Food and Drug Administration (FDA) for treatment of stroke is tissue plasminogen activator (tPA). Popularly referred to as clot busting, this medication has been used for years to treat heart attacks. More recently doctors have begun using clot-busting medications to help treat stroke.
Not all hospitals are equipped to give tPA to people having a stroke. Before this drug can be given, doctors must be certain that the stroke is the result of a blockage in the artery, not due to bleeding from an artery. This is determined through imaging procedures such as a computed tomography (CT) scan or magnetic resonance imaging (MRI). Unfortunately, not all hospitals have around-the-clock imaging services. If the stroke is due to bleeding, this powerful blood thinner can worsen the hemorrhage.
If tPA cannot be used (for example, too much time has passed since the stroke symptoms began), your doctor may consider a less potent blood thinner called heparin.
Once the acute phase of the stroke has resolved, other less potent blood thinners called antiplatelet agents (such as aspirin and ticlopidine), or anticoagulants (such as warfarin), may be used to prevent future strokes due to blood clots (See "Preventing Care").
If a stroke is caused by bleeding, medication (such as mannitol) can reduce swelling of brain tissue.
Following the acute treatment of a stroke, while in recovery, your doctor will prescribe medications to control risk factors for stroke like high blood pressure and high cholesterol, and / or adjust your medication if you are already taking these drugs. Daily aspirin is also recommended for those who have had a stroke or a TIA.
Surgery and Other Procedures
If the stroke or TIA is caused by a blockage, a procedure called carotid endarterectomy can be used to remove the buildup of plaque from inside the effected carotid artery, one of the major vessels supplying blood to the head and neck.
This surgical procedure is best for those who have had symptoms and have a blockage of 70% or more of one of their carotid arteries. If the narrowing of the vessel is less than 50%, medication (not surgery) is the most appropriate treatment to prevent future strokes.
Unfortunately, carotid endarterectomy may actually cause a stroke. Therefore, the risks and benefits of this procedure must be carefully weighed with your doctor.
If the stroke is caused by bleeding, an artery within the brain can sometimes be "clipped" to prevent further bleeding. Emergency surgery for a bleeding stroke may involve locating and surgically removing blood that has pooled in the brain tissue (called a hematoma). A brain specialist, called a neurosurgeon, will determine if this procedure is appropriate for you.
Interventional radiologists, if this specialized service is available at your hospital, may be trained to perform carotid angioplasty. This procedure begins with carotid angiography, as described earlier, to locate the blockage in this main artery supplying blood to the brain. Once located, a tiny balloon is threaded up to the blocked area and then inflated to break up the clot or plaque responsible for the narrowing in the vessel. The specialist may leave a wire mesh (stent) inside the vessel to keep it open. This procedure is quite risky, however, and may even cause a stroke.
If an aneurysm is present but has not bled, your doctor will discuss the possibility of removing it surgically. The decision is based primarily on the size of the aneurysm.
Nutrition and Dietary Supplements
You should seek conventional medical treatment for stroke. You should use complementary and alternative therapies only under the supervision of a health care provider. Supplements can have negative effects on certain segments of the population, and can interact negatively with prescription medications. Make sure all of your medical providers are aware of any supplements you are considering taking.
Potentially beneficial nutritional supplements include the following:
Alpha-lipoic acid. Alpha-lipoic acid works together with other antioxidants, such as vitamins C and E. It is important for growth, helps prevent cell damage, and helps the body rid itself of harmful substances. Because alpha-lipoic acid can pass easily into the brain, it has protective effects on brain and nerve tissue, and shows promise as a treatment for stroke and other brain disorders involving free radical damage. Animals treated with alpha-lipoic acid, for example, suffered less brain damage and had a four times greater survival rate after a stroke than the animals who did not receive this supplement, especially when alpha-lipoic acid is combined with vitamin E. While animal studies are encouraging, more research is needed to understand whether this benefit applies to people as well.
Calcium.. In a population-based study (one in which large groups of people are followed over time), women who took in more calcium, both through the diet and supplements, were less likely to have a stroke over a 14-year period. More research is needed to fully assess the strength of the connection between calcium and risk of stroke.
Folic Acid, Vitamin B6, Vitamin B12, and Betaine. Many clinical studies indicate that patients with elevated levels of the amino acid homocysteine are up to 2.5 times more likely to suffer from a stroke than those with normal levels. Homocysteine levels are strongly influenced by dietary factors, particularly vitamin B9 (folic acid), vitamin B6, vitamin B12, and betaine. These substances help break down homocysteine in the body. Some studies have even shown that healthy individuals who consume higher amounts of folic acid and vitamin B6 are less likely to develop atherosclerosis than those who consume lower amounts of these substances. One study found that lowering homocysteine with folic acid and vitamins B6 and B12 reduced the overall risk of stroke, but not stroke severity or disability. Despite these findings, the American Heart Association (AHA) reports that there is insufficient evidence to suggest that supplementation with betaine and B vitamins reduce the risk of atherosclerosis, or that taking these supplements prevents the development or recurrence of heart disease. The AHA does not currently recommend population-wide homocysteine screening, and suggests that folic acid, as well as vitamin B6, B12, and betaine requirements be met through diet alone. Individuals at high risk for developing atherosclerosis, however, should be screened for blood levels of homocysteine. If elevated levels are detected, a provider may recommend supplementation.
Magnesium. Population-based information suggests that people with low magnesium in their diet may be at greater risk for stroke. Some preliminary scientific evidence suggests that magnesium sulfate may be helpful in the treatment of a stroke or TIA. More research is needed to know for certain if use of this mineral following a stroke or TIA is helpful. Magnesium may lower blood pressure and potentially interact with some heart medicines.
Omega-3 Fatty Acids. Strong evidence from population-based studies suggests that omega-3 fatty acid intake (primarily from fish) helps protect against stroke caused by plaque buildup and blood clots in the arteries that lead to the brain. In fact, eating at least 2 servings of fish per week can reduce the risk of stroke by as much as 50%. However, people who eat more than 3 grams of omega-3 fatty acids per day (equivalent to 3 servings of fish per day) may be at an increased risk for hemorrhagic stroke, a potentially fatal type of stroke in which an artery in the brain leaks or ruptures. Omega-3 fatty acids may increase the chances of bleeding, especially in those taking anticoagulant medications, such as warfarin (Coumadin) or even aspirin.
The FDA recommends that pregnant women and women of childbearing age, who may become pregnant, avoid large predatory fish such as shark, tuna, and swordfish. These fish have much higher levels of methyl mercury than other commonly consumed fish. Since the fetus may be more susceptible than the mother to the adverse effects of methyl mercury, FDA experts say that it is prudent to minimize the consumption of fish that have higher levels of methyl mercury.
Potassium. Although low levels of potassium in the blood may be associated with stroke, taking potassium supplements does not seem to reduce the risk of having a stroke.
Vitamin C. Having low levels of vitamin C contributes to the development of atherosclerosis and other damage to blood vessels and the consequences, such as stroke. Vitamin C supplements may also improve cognitive function if you have suffered from multiple strokes.
Vitamin E. Eating plenty of foods rich in vitamin E, along with other antioxidants like vitamin C, selenium, and carotenoids, reduces your risk for stroke. In addition, low levels of vitamin E in the blood may be associated with risk of dementia (memory impairment) following stroke. Animal studies also suggest that vitamin E supplements, possibly in combination with alpha-lipoic acid, may reduce the amount of brain damaged if taken prior to the actual stroke. Researchers suggest testing this theory in people who are at high risk for stroke. Thus far, however, some large, well-designed studies of people suggest that it is safest and best to obtain this antioxidant via food sources, and that supplements do not provide any added benefit.
Others. Additional supplements that require further research but may be useful as part of the treatment or prevention of stroke include:
The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, you should take herbs only under the supervision of a health care provider knowledgeable in the field.
Bilberry (Vaccinium myrtillus). A close relative of the cranberry, bilberry fruits contain flavonoid compounds called anthocyanidins. Flavonoids are plant pigments that have excellent antioxidant properties. This means that they scavenge damaging particles in the body known as free radicals and may help prevent a number of long-term illnesses, such as heart disease. Bilberry may slow blood clotting and therefore may increase the risk of bleeding in people who take blood-thinning medications, such as warfarin (Coumadin), aspirin, and others.
Garlic (Allium sativum). Clinical studies suggest that fresh garlic and garlic supplements may prevent blood clots and destroy plaque. Blood clots and plaque block blood flow and contribute to the development of heart attack and stroke. Garlic may also be beneficial for reducing risk factors for heart disease and stroke like high blood pressure, high cholesterol, and diabetes. Homocysteine, similar to cholesterol, may contribute to increasing amounts of blood clots and plaque in blood vessels. If you take aspirin or other blood thinners like warfarin (Coumadin), ACE inhibitors (a class of blood pressure medications), sulfonylureas for diabetes, birth control medications, medications for HIV, or statins for high cholesterol, talk to your doctor before using garlic supplements.
Ginkgo (Ginkgo biloba). Gingko may reduce the likelihood of dementia following multiple strokes (often called multi-infarct dementia) by preventing blood clot formation. Most providers choose to use medications for this effect rather than herbs. Ginkgo may also decrease the amount of brain damage following a stroke. While animal studies support these possible benefits of ginkgo, more research is needed. Also, ginkgo should not be used with blood-thinning medications, such as warfarin (Coumadin), aspirin, and others, unless specifically instructed by your provider.
Ginseng (Panax ginseng). Asian ginseng may decrease endothelial cell dysfunction. Endothelial cells line the inside of blood vessels. When these cells are disturbed, it may lead to a heart attack or stroke. The potential for ginseng to quiet down the blood vessels may prove to be protective against these conditions. More research is needed. Ginseng can have stimulating effects that may be harmful to certain people. Ginseng may also thin your blood and, therefore, should be used only under the supervision of a doctor, particularly if you are taking blood-thinning medication, such as warfarin (Coumadin), aspirin, and others.
Turmeric (Curcuma longa). Early studies suggest that turmeric may prevent heart attack or stroke. Animal studies have shown that an extract of turmeric lowered cholesterol levels and inhibited the oxidation of LDL (bad) cholesterol. This is helpful because oxidized LDL deposits in the walls of blood vessels and contributes to the formation of atherosclerotic plaque and other damage to the vessels. Turmeric may also prevent platelet build up along the walls of an injured blood vessel. Platelets collecting at the site of a damaged blood vessel cause blood clots to form and contribute to blocking the artery as well. Turmeric may also thin your blood and, therefore, should only be used under the supervision of a provider, particularly if you are taking blood-thinning medications, such as warfarin (Coumadin), aspirin, and others. More research is needed to determine whether these effects apply to people.
Although an experienced homeopath might prescribe a regimen for treating stroke that includes one of the remedies listed below, the scientific evidence to date does not confirm the value of homeopathy for this purpose.
Many studies have been conducted on the effects of acupuncture during stroke rehabilitation. These studies show that acupuncture reduces hospital stays and improves recovery speed. Acupuncture has been shown to help stroke patients regain motor and cognitive skills and to improve their ability to manage daily functioning. Based on the available data, the National Institutes of Health recommend acupuncture as an alternative or supplemental therapy for stroke rehabilitation. In general, the evidence indicates that acupuncture is most effective when initiated as soon as possible after a stroke occurs, however positive outcomes have been found for acupuncture started as late as 6 months following a stroke.
People who have suffered a stroke often have a deficiency of qi in the liver meridian and a relative excess in the gallbladder meridian. In addition to a primary needling treatment on the liver meridian and the supporting kidney meridians, moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) may be used to enhance therapy. Treatment may also include performing acupuncture on affected limbs. Certain scalp acupuncture techniques that have been developed by Chinese, Korean, and Japanese practitioners also show promise.
Chiropractors do not treat stroke, and high velocity manipulation of the upper spine is considered inappropriate in individuals who are taking blood-thinning medications, or other medications used to reduce the risk of stroke. It should also be noted that chiropractic spinal manipulation of the neck is associated with an exceedingly small risk of causing stroke (reports range from 1 per 400,000 to 1 per 2,000,000).
Traditional Chinese Medicine
In Traditional Chinese Medicine, there are reports of more than 100 substances that have been used to treat stroke. In fact, pharmacologic research of these substances focuses on understanding the ingredients and their mechanisms of action in order to develop new drugs.
Prognosis and Complications
There are many possible complications associated with stroke, including:
Many people begin to recover from a stroke almost immediately after it has occurred.
The recovery process is most rapid in the first 3 months after a stroke, but improvement will continue for 6 months to a year. Many stroke survivors even report that they slowly continue to regain function for years after their stroke. It is very important not to lose hope.
Amarenco P, Labreuche J, Touboul PJ. High-density lipoprotein-cholesterol and risk of stroke and carotid atherosclerosis: A systematic review. Atherosclerosis. 2007; [Epub ahead of print].
Berger J, Brown D, Becker R. Low-Dose Aspirin in Patients with Stable Cardiovascular Disease: A Meta-analysis. The American Journal of Medicine. 2008;121(1).
Blanco M, Nombela F, Castellanos M, et al. Statin treatment withdrawal in ischemic stroke: a controlled randomized study. Neurology. 2007;69(9):904-10.
Boye Knudsen S, Strandgaard S, Paulson OB. Secondary prevention of stroke with effective antihypertensive treatment. Ugeskr Laeger. 2013;175(15):1024-8.
Broderick J, Connolly S, Feldmann E, et al; American Heart Association/American Stroke Association Stroke Council; American Heart Association/American Stroke Association High Blood Pressure Research Council; Quality of Care and Outcomes in Research Interdisciplinary Working Group. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation. 2007;116(16):e391-413.
Carod-Artal FJ, Egido JA. Quality of life after stroke: the importance of a good recovery. Cerebrovasc Dis. 2009;27 Suppl 1:204-14.
Chen C, Venketasubramanian N, Gan RN, et al. Danqi Piantang Jiaonang (DJ), a traditional Chinese medicine, in poststroke recovery. Stroke. 2009;40(3):859-63.
Desrosiers J, Noreau L, Rochette A, et al. Effect of a home leisure education program after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88(9):1095-100.
Dickerson L, Carek P, Glen Quattlebaum R. Prevention of Recurrent Ischemic Stroke. American Family Physician. 2007;76(3).
Dorhout Mees S, van den Bergh W, Algra A, Rinkel G. Antiplatelet therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2007;(4):CD006184.
Egan M, Kessler D, Laporte L, Metcalfe V, Carter M. A pilot randomized controlled trial of community-based occupational therapy in late stroke rehabilitation. Top Stroke Rehabil. 2007;14(5):37-45.
Ellis C, Egede LE. Stroke recognition among individuals with stroke risk factors. Am J Med Sci. 2009;337(1):5-10.
Ferri: Ferri's Clinical Advisor 2014. 1st ed. Philadelphia, PA: Elsevier Mosby; 2013.
Ford I, Murray H, Packard CJ, Shepherd J, Macfarlane PW, Cobbe SM; West of Scotland Coronary Prevention Study Group. Long-term follow-up of the West of Scotland Coronary Prevention Study. N Engl J Med. 2007;357(15):1477-86.
Fu QH, Pei J, Jia Q, Song Y, Gu YH, You XX. Acupuncture treatment programs for post-stroke motor-rehabilitation in community hospitals: study protocol of a multicenter, randomized, controlled trial. Zhong Xi Yi Jie He Xue Bao. 2012;10(5):516-24.
Fuentes B, Martinez-Sanchez P, Diez-Tejedor E. Lipid-lowering drugs in ischemic stroke prevention and their influence on acute stroke outcome. Cardiovas Dis. 2009;27 Suppl 1:126-33.
Hassan AE, Zacharatos H, Suri MF, Qureshi AI. Drug evaluation of clopidogrel in patients with ischemic stroke. Expert Opin Pharmacother. 2007;8(16):2825-38.
Hinkle JL, Guanci MM. Acute ischemic stroke review. J Neurosci Nurs. 2007;39(5):285-93, 310.
Jamieson DG, Skliut M. Gender considerations in stroke management. Neurologist. 2009;15(3):132-41.
Jang SH. A review of motor recovery mechanisms in patients with stroke. NeuroRehabilitation. 2007;22(4):253-9.
Junhua Z, Menneti-Ippolito F, Xiumei G, et al. Complex traditional Chinese medicine for poststroke motor dysfunction: a systematic review. Stroke. 2009;40(8):2797-804.
Kong JC, Lee MS, Shin BC, et al. Acupuncture for functional recovery after stroke: a systematic review of sham-controlled randomized clinical trials. [Review]. CMAJ. 2010;182(16):1723-9.
Kong KH, Wee SK, Ng CY, et al. A double-blind, placebo-controlled, randomized phase II pilot study to investigate the potential efficacy of the traditional Chinese medicine neuroaid (MLC 601) in enhancing recovery after stroke (TIERS). Cerebrovasc Dis. 2009;28(5):514-21.
Kruger E, Teasell R, Salter K, Foley N, Hellings C. The rehabilitation of patients recovering from brainstem strokes: case studies and clinical considerations. Top Stroke Rehabil. 2007;14(5):56-64.
Labreuche J, Touboul PJ, Amarenco P. Plasma triglyceride levels and risk of stroke and carotid atherosclerosis: a systematic review of the epidemiological studies. Atherosclerosis. 2009;203(2):331-45.
Lackland DT, Elkind MS, D'Agostino R, et al. Inclusion of stroke in cardiovascular risk prediction instruments: a statement for healthcare professionals from the American Heart Association / American Stroke Association. Stroke. 2012; 3(7):1998-2027.
Lee MS, Choi TY, Shin BC, et al. Cupping for stroke rehabilitation: a systematic review. [Review]. J Neurol Sci. 2010;294(1-2):70-3.
Lee MS, Shin BC, Kim JI, et al. Moxibustion for stroke rehabilitation: systematic review. Stroke. 2010;41(4):817-20.
Lisbeth LD, Brown DL, Hughes R, Majersik JJ, Morgenstern LB. Acute stroke symptoms: comparing women and men. Stroke. 2009;40(6):2031-6.
Lynch EA, Hillier SL, Stiller K, Campanella RR, Fisher PH. Sensory retraining of the lower limb after acute stroke: a randomized controlled pilot trial. Arch Phys Med Rehabil. 2007;88(9):1101-7.
Lynton H, Kligler B, Shiflett S. Yoga in stroke rehabilitation: a systematic review and results of a pilot study. [Review]. Top Stroke Rehabil. 2007;14(4):1-8.
Magnusson G, Ballegaard S, Karpatschof B, et al. Long-term effects of integrated rehabilitation in patients with stroke: a nonrandomized comparative feasibility study. J Altern Complement Med. 2010;16(4):369-74.
Mazzucco S, Turri G, Mirandola R, Bovi P, Bisoffi G. What is still missing in acute-phase treatment of stroke: a prospective observational study. Neurol Sci. 2013;34(4):449-55.
McColl BW, Allan SM, Rothwell NJ. Systemic inflammation and stroke: aetiology, pathology and targets for therapy. Biochem Soc Trans. 2007;35(Pt 5):1163-5.
O'Keefe JH, Bybee KA, Lavie CJ. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am Coll Cardiol. 2007;50(11):1009-14.
Outpatient Services Trialists. Therapy-based rehabilitation services for stroke patients at home. [Review]. Cochrane Database Syst Rev. 2003;(1):CD00.
Pan W, Kastin AJ. Tumor necrosis factor and stroke: Role of the blood-brain barrier. Prog Neurobiol. 2007; [Epub ahead of print].
Richards LG, Stewart KC, Woodbury ML, Senesac C, Cauraugh JH. Movement-dependent stroke recovery: A systematic review and meta-analysis of TMS and fMRI evidence. Neuropsychologia. 2007; [Epub ahead of print].
Saposnik G, Ray JG, Sheridan P, McQueen M, Lonn E. Homocysteine-lowering therapy and stroke risk, severity, and disability: additional findings from the HOPE 2 trial.
Saposnik G, Mamdani M, Bayley M, et al. EVREST Steering Committee; EVREST Study Group for the Stroke Outcome Research Canada Working Group. Effectiviness of Virtual Reality Exercise in Stroke Rehabilitatio (EVREST): rational, desing, and protocol of a pilot randomized clinical trial assessing the Wii gaming system. Int J Stroke. 2010 Feb;5(1):47-51.
Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9):1424-8.
Spence JD. Review: Perspective on the efficacy analysis of the Vitamin Intervention for Stroke Prevention trial. Clin Chem Lab Med. 2007; [Epub ahead of print].
Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2007;(4):CD000197.
Tettenborn B. Stroke and Pregnancy. Neurologic Clinics. Philadelphia, PA: W.B. Saunders Company. 2012;30(3).
Venketasubramanian N, Chen CL, Gan RN, et al. CHIMES Investigators. A double-blind, placebo-controlled, randomized, multicenter study to investigate Chinese medicine neuroaid efficacy on stroke recovery (CHIMES study). Int. J Stroke. 2009;4(1):54-60.
Wang Q, Capistrant BD, Ehntholt A, Glymour MM. Long-term rate of change in memory functioning before and after stroke onset. Stroke. 2012;43(10):2561-6.
Wu P, Mills E, Moher D, et al. Acupuncture in poststroke rehabilitation: a systematic review and meta-analysis of randomized trials. [Review]. Stroke. 2010;41(4);e171-9.
Yew K, Cheng E. Acute Stroke Diagnosis. American Family Physician. 2009;80(1).
Zhang C, Qin YY, Chen Q, et al. Alcohol intake and risk of stroke: a dose-response meta-analysis of prospective studies. Int J Cardiol. 2014;174(3):669-77.
Zhang JH, Wang D, Liu M. Overview of systematic reviews and meta-analyses of acupuncture for stroke. Neuroepidemiology. 2014;42(1):50-8.
Zhang S, Wu B, Liu M, et al. Acupuncture efficacy on ischemic stroke recovery: multicenter randomized controlled trial in China. Stroke. 2015;46(5):1301-6.
Review Date: 2/4/2016
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.