Care at the End of Life

Overview
What decisions do you need to make about care at the end of life?

You will face many hard decisions as you near the end of life. Those decisions will include what kind of care you'd like to receive, where you'd like to receive care, and who will make decisions about your care should you not be able to make decisions yourself.

No one knows when his or her time may come. So it’s a good idea to spend some time planning what you want at the end of life. To be prepared:
Decide what kind of health care you want or don't want. For example, you can decide whether you want CPR if your heart or breathing stops.
Let others know what you've decided. Consider writing an advance directive that includes a living will and a medical power of attorney (also called a durable power of attorney). A living will is a legal document that expresses your wishes for medical care if you are not able to speak or make decisions for yourself. A medical power of attorney lets you to choose a health care agent. Your health care agent will have the legal right to make treatment decisions for you, not only at the end of your life but anytime you are not able to speak for yourself.
Decide whether you'd like to donate your organs.
Will you have to choose between palliative care and treatments that might cure you?

One thing to think about is what type of medical care you want. Some people ask their doctors to do everything possible to keep them alive. This is called curative treatment. Others choose palliative care, which does not try to cure your illness or keep you alive longer. It looks at ways to make you more comfortable. For example, palliative care may include giving you medicines to help with pain or with the side effects from treatment.

You can have both types of treatment. You can get palliative care to help keep you comfortable, and you can take medicines or other treatments that might cure you.

But a time may come when you decide one is more important. You may choose to stop curative treatment if it is very clear that your illness can't be cured. If you choose palliative care only, you will still see your doctor and get excellent care. And if your condition changes, you can start curative treatment again.
Where would you like to be treated?

Another thing to think about is where you'd like to receive care. Some people check into a hospital. Others choose to be cared for at home or in a nursing home.

If you have only a few months left, you may choose to receive care through hospice. Hospice services are provided by a team of people that includes doctors, nurses, and volunteers. The team gives palliative care and emotional and spiritual support to people near the end of life and to their families. It also offers practical support like running errands or fixing meals. You can get hospice care in your home or in a hospice center, hospital, or nursing home.
What do you and your doctor need to know?

If you find out that you have a life-threatening disease or condition, talk with your doctor about the kind of medical care you'd like to receive. Ask a lot of questions about your illness and the treatments that are available. It can be helpful to have a friend or family member go to your appointments with you.

When you have decided whether you want palliative care or curative treatment or both, tell your doctor. Also, share your advance directive with your doctor.
How do you talk with your loved ones about your end-of-life choices?

It can be hard to talk with your loved ones about death, but it is important to discuss your choices while you can speak for yourself. Planning ahead will help you and your loved ones make hard decisions when the time comes.

Even though it might be awkward or uncomfortable, look for chances to talk about your end-of-life choices. For example, you could bring up the subject while you are making out your will. Or you could talk with loved ones after a visit to the doctor. Family gatherings are another place to make time to discuss your plans with loved ones.

Whatever you decide and whenever you decide to talk with loved ones, be sure to put your wishes in writing. You can always change your mind if your condition or your wishes change.

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How can I eat a heart-healthy diet?

Introduction

Heart disease is the number one killer of both men and women in the United States. If you are worried about heart disease, one of the most important things you can do is to start eating a heart-healthy diet. Changing your diet can help stop or even reverse heart disease.

At first, it may seem like there is a lot to learn. But you don't have to make these changes all at once. Start with small steps. Over time, making a number of small changes can add up to a big difference in your heart health.

To have a heart-healthy diet:
Eat more fruits, vegetables, whole grains, and other high-fiber foods.
Choose foods that are low in saturated fat, trans fat, and cholesterol.
Limit salt (sodium).
Stay at a healthy weight by balancing the calories you eat with your physical activity.
Eat more foods high in omega-3 fatty acids, such as fish.

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What lifestyle changes will I need to make after a stroke?

After a stroke, you may have a variety of disabilities. Although some disabilities may be permanent, participation in a stroke rehabilitation (rehab) program can help you recover as much of your abilities as possible. The types of disabilities you have and your potential for recovery depend on:
Which side of the brain was affected (whether it's your dominant side).
Which region of the brain was damaged by the stroke.
How much of the brain was damaged.
Your general health before the stroke.

Starting rehabilitation as soon as possible after a stroke—even while you are in the hospital—is vital for your long-term recovery.

Your rehab may take place in different settings. A successful recovery depends on your ability and willingness to participate as well as good support from your family and health professionals.
Hospital and rehabilitation center programs. Stroke rehabilitation may be provided by a special rehab center or by a rehab unit in a hospital. Therapy will be provided by a team of therapists, including rehabilitation doctors and nurses and an occupational therapist, speech therapist, physical therapist, psychologist, and recreational therapist. You may remain hospitalized or participate as an outpatient.
Nursing home programs. Some nursing homes provide stroke rehabilitation programs.
Outpatient programs. Outpatient rehabilitation programs allow you to live at home and receive a full range of services at a hospital outpatient department, rehab center, or day hospital program.
Home health programs. Home health programs allow you to live at home and receive rehabilitation services from visiting health professionals, such as a physical therapist, occupational therapist, or a speech therapist. An important advantage of a home program is that you can learn skills for daily living where you will use them.

For more information, see the topic Stroke Rehabilitation.

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What kind of help will I need after a stroke?

Topic Overview
What is a stroke?

A stroke occurs when a blood vessel in the brain is blocked or bursts . Without blood and the oxygen it carries, part of the brain starts to die. The part of the body controlled by the damaged area of the brain can't work properly.

Brain damage can begin within minutes, so it is important to know the symptoms of stroke and act fast. Quick treatment can help limit damage to the brain and increase the chance of a full recovery.
What are the symptoms?

Symptoms of a stroke happen quickly. A stroke may cause:
Sudden numbness, paralysis, or weakness in your face, arm, or leg, especially on only one side of your body.
New problems with walking or balance.
Sudden vision changes.
Drooling or slurred speech.
New problems speaking or understanding simple statements, or feeling confused.
A sudden, severe headache that is different from past headaches.

If you have any of these symptoms, call 911 or other emergency services right away.

See your doctor if you have symptoms that seem like a stroke, even if they go away quickly. You may have had a transient ischemic attack (TIA), sometimes called a mini-stroke. A TIA is a warning that a stroke may happen soon. Getting early treatment for a TIA can help prevent a stroke.
What causes a stroke?

There are two types of stroke:
An ischemic stroke develops when a blood clot blocks a blood vessel in the brain. The clot may form in the blood vessel or travel from somewhere else in the blood system. About 8 out of 10 strokes are ischemic (say “iss-KEE-mick”) strokes. They are the most common type of stroke in older adults.
A hemorrhagic stroke develops when an artery in the brain leaks or bursts. This causes bleeding inside the brain or near the surface of the brain. Hemorrhagic (say “heh-muh-RAH-jick”) strokes are less common but more deadly than ischemic strokes.
How is a stroke diagnosed?

Seeing a doctor right away is very important. If a stroke is diagnosed quickly—within the first 3 hours of when symptoms start—doctors may be able to use medicines that can lead to a better recovery.

The first thing the doctor needs to find out is what kind of stroke it is: ischemic or hemorrhagic. This is important because the medicine given to treat a stroke caused by a blood clot could be deadly if used for a stroke caused by bleeding in the brain.

To find out what kind of stroke it is, the doctor will do a type of X-ray called a CT scan of the brain, which can show if there is bleeding. The doctor may order other tests to find the location of the clot or bleeding, check for the amount of brain damage, and check for other conditions that can cause symptoms similar to a stroke.
How is it treated?

For an ischemic stroke, treatment focuses on restoring blood flow to the brain. If less than 3 hours have passed since your symptoms began, doctors may use a medicine that dissolves blood clots. Research shows that this medicine can improve recovery from a stroke, especially if given within 90 minutes of the first symptoms.1 Other medicines may be given to prevent blood clots and control symptoms.

A hemorrhagic stroke can be hard to treat. Doctors may do surgery or other treatments to stop bleeding or reduce pressure on the brain. Medicines may be used to control blood pressure, brain swelling, and other problems.

After your condition is stable, treatment shifts to preventing other problems and future strokes. You may need to take a number of medicines to control conditions that put you at risk for stroke, such as high blood pressure, high cholesterol, and diabetes. Some people need to have a surgery to remove plaque buildup from the blood vessels that supply the brain (carotid arteries).

The best way to get better after a stroke is to start stroke rehab. The goal of stroke rehab is to help you regain skills you lost or to make the most of your remaining abilities. Stroke rehab can also help you take steps to prevent future strokes. You have the greatest chance of regaining abilities during the first few months after a stroke. So it is important to start rehab soon after a stroke and do a little every day.
Can you prevent a stroke?

After you have had a stroke, you are at risk for having another one. You can make some important lifestyle changes that can reduce your risk of stroke and improve your overall health.
Don't smoke. Smoking can more than double your risk of stroke. Avoid secondhand smoke too.
Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil. Eat less salt too.
Try to do moderate activity at least 2½ hours a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week. Your doctor can suggest a safe level of exercise for you.
Stay at a healthy weight.
Control your cholesterol and blood pressure.
If you have diabetes, keep your blood sugar as close to normal as possible.
Limit alcohol. Having more than 1 drink a day (if you are female) or more than 2 drinks a day (if you are male) increases the risk of stroke.
Take a daily aspirin or other medicines if your doctor advises it.
Avoid getting sick from the flu. Get a flu shot every year.

Work closely with your doctor. Go to all your appointments, and take your medicines just the way your doctor says to.

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Surgery

Surgery

When surgery is being considered after a stroke, your age, prior overall health, and current condition are major factors in the decision. Surgery is not recommended as part of the initial or emergency treatment for ischemic stroke .

Surgery for ischemic stroke

Carotid endarterectomy. Carotid endarterectomy is surgery to remove plaque buildup in the carotid arteries in people with moderate to severe narrowing of the carotid arteries. This surgery can help prevent additional strokes. For more information, see:
Should I have carotid endarterectomy?

If a stroke has occurred because of a narrowed carotid artery, a carotid endarterectomy may help lower the risk of a future stroke.

You are most likely to benefit from surgery if you have had a TIA or mild stroke in the past 6 months and have 70% or greater narrowing in one of your carotid arteries. Carotid endarterectomy may be appropriate if your carotid arteries are moderately or severely blocked (50% to 69% narrowing) and you have had one or more TIAs or mild strokes.13 Talk to your doctor about whether a carotid endarterectomy is right for you.

Carotid endarterectomies are most successful when they are performed by a surgeon who is experienced in the procedure. Ask your doctor about his or her rate of complications.

Surgery for hemorrhagic stroke

Surgeries for hemorrhagic stroke include:
Surgery to drain or remove blood in or around the brain that was caused by a bleeding blood vessel (hemorrhagic stroke).
A procedure (endovascular coil embolization) to repair a brain aneurysm that is the cause of a hemorrhagic stroke. A small coil is inserted into the aneurysm to block it off. Whether this surgery can be done depends on the location of the aneurysm, its size, and whether you are healthy enough to withstand the procedure.
Surgery to remove or block off abnormally formed blood vessels (arteriovenous malformations) that have caused bleeding in the brain. An arteriovenous malformation is a congenital disorder, which means it was present at birth. An arteriovenous malformation causes an abnormal web of blood vessels and veins in the brain, brain stem, or spinal cord. The vessel walls of an arteriovenous malformation may become weak and leak or rupture.

People with a brain aneurysm need evaluation of all their symptoms to determine whether and when surgery is needed. Endovascular coil embolization is the preferred treatment for people with a brain aneurysm. It is also used for those who are at high risk for complications from a surgical repair of the aneurysm.14 In cases where endovascular coil embolization is not possible, aneurysm clipping with craniotomy is done.

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Treatment

Treatment Overview

Prompt treatment of stroke and medical problems related to stroke, such as high blood sugar and pressure on the brain, may minimize brain damage and improve the chances of survival. Starting a rehabilitation program as soon as possible after a stroke increases your chances of recovering some of the abilities you lost.
Initial treatment for stroke

Initial treatment for a stroke varies depending on whether it's caused by a blood clot (ischemic) or by bleeding in the brain (hemorrhagic). Before starting treatment, your doctor will use a computed tomography (CT) scan of your head and possibly magnetic resonance imaging (MRI) to diagnose the type of stroke you've had. Further tests may be done to find the location of the clot or bleeding and to assess the amount of brain damage. While treatment options are being determined, your blood pressure and breathing ability will be closely monitored, and you may receive oxygen.

Initial treatment focuses on restoring blood flow for an ischemic stroke or controlling bleeding for a hemorrhagic stroke. As with a heart attack, permanent damage from a stroke often occurs within the first few hours. The quicker you receive treatment, the less damage will occur.

Ischemic stroke

Emergency treatment for an ischemic stroke depends on the location and cause of the clot. Measures will be taken to stabilize your vital signs, including giving you medicines.
If your stroke is diagnosed within 3 hours of the start of symptoms, you may be given a clot-dissolving medicine called tissue plasminogen activator (t-PA), which can increase your chances of survival and recovery. But t-PA is not safe for everyone. If you have had a hemorrhagic stroke, use of t-PA would be life-threatening. Your eligibility for t-PA will be quickly assessed in the emergency room.
You may also receive aspirin or aspirin combined with another antiplatelet medicine. But aspirin is not recommended within 24 hours of treatment with t-PA. Other medicines may be given to control blood sugar levels, fever, and seizures. In general, high blood pressure won't be treated immediately unless systolic pressure is over 220 millimeters of mercury (mm Hg) and diastolic is more than 120 mm Hg (220/120, which is also called 220 over 120).

Hemorrhagic stroke

Initial treatment for hemorrhagic stroke is difficult. Efforts are made to control bleeding, reduce pressure in the brain, and stabilize vital signs, especially blood pressure.
There are few medicines available to treat hemorrhagic stroke. In some cases, medicines may be given to control blood pressure, brain swelling, blood sugar levels, fever, and seizures. You will be closely monitored for signs of increased pressure on the brain, such as restlessness, confusion, difficulty following commands, and headache. Other measures will be taken to keep you from straining from excessive coughing, vomiting, or lifting, or straining to pass stool or change position.
Surgery generally is not used to control mild to moderate bleeding resulting from a hemorrhagic stroke. But if a large amount of bleeding has occurred and the person is rapidly getting worse, surgery may be needed to remove the blood that has built up inside the brain and to lower pressure inside the head.
If the bleeding is due to a ruptured brain aneurysm, surgery to repair the aneurysm may be done. Repair may include:
Using a metal clip to clamp off the aneurysm to prevent renewed bleeding.
Endovascular coil embolization, a procedure which involves inserting a small coil into the aneurysm to block it off.
Whether these surgeries can be done depends on the location of the aneurysm and your condition following the stroke.
Ongoing treatment

After emergency treatment for stroke, and when your condition has stabilized, treatment focuses on rehabilitation and preventing another stroke. It will be important to control your risk factors for stroke, such as high blood pressure, atrial fibrillation, high cholesterol, or diabetes.

Your doctor will probably want you to take aspirin or other antiplatelet medicines. If you had an ischemic stroke (caused by a blood clot), you may need to take anticoagulants to prevent another stroke. You may also need to take medicines, such as statins, to lower high cholesterol or medicines to control your blood pressure. Medicines to lower high blood pressure include:
Angiotensin-converting enzyme (ACE) inhibitors.
Angiotensin II receptor blockers (ARBs).
Beta-blockers.
Diuretics.
Calcium channel blockers.

Your doctor may also recommend carotid endarterectomy surgery to remove plaque buildup in the carotid arteries. For more information on this decision, see:
Should I have carotid endarterectomy?

A procedure called carotid artery stenting is another option for some people who are at high risk of stroke. This procedure is much like coronary angioplasty, which is commonly used to open blocked arteries in the heart. During this procedure, a doctor inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque. The doctor may use a stent that is coated with medicine to help prevent future blockage.

Early aggressive rehabilitation may allow you to regain some normal functioning. Your rehabilitation will be based on the physical abilities that were lost, your general health before the stroke, and your ability to participate. Rehabilitation begins with helping you resume activities of daily living, such as eating, bathing, and dressing. For more information, see the topic Stroke Rehabilitation.

Changes in lifestyle may also be an important part of your ongoing treatment to reduce your risk of having another stroke. It will be important for you to exercise to the extent possible, eat a balanced diet, and quit smoking, if you smoke. Your doctor may suggest that you follow the Dietary Approaches to Stop Hypertension (DASH) diet if you have high blood pressure. If you have high cholesterol, you may need to follow the Therapeutic Lifestyle Changes (TLC) diet. These eating plans stress a diet that is low in fat (especially saturated fat) and contains more whole grains, fruits, vegetables, and low-fat dairy products.

If you take warfarin (such as Coumadin), see:
Anticoagulants: Vitamin K and your diet.
Safety tips when taking anticoagulants.
Treatment if the condition gets worse

If you get worse, it may be necessary for your loved one to move you to a care facility that can meet your needs, especially if your caregiver has his or her own health problems that make it difficult to properly care for you. It is common for caregivers to neglect their own health when they are caring for a loved one who has had a stroke. If your caregiver's health declines, the risk of injury to you and your caregiver may increase. For more information, see:
Should I put my loved one who has had a stroke in a nursing home?
Palliative care

If your condition gets worse, you may want to think about palliative care. Palliative care is a type of care for people who have illnesses that do not go away and often get worse over time. It is different from care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.
End-of-life issues

Although stroke rehabilitation is increasingly successful at prolonging life, a stroke can be a disabling or fatal condition. People who have had a stroke may consider discussing health care and other legal issues that may arise near the end of life. Many people find it helpful and comforting to state their health care choices in writing with an advance directive while they are still able to make and communicate these decisions.

Advance directives can include the ability to refuse treatment in specific situations. The three main types of advance directives are:
Do not resuscitate orders (DNRs).
Living wills.
Durable power of attorney for health care (DPA).

Do not resuscitate orders (DNRs)typically request that no extraordinary measures be used to save your life. Extraordinary measures include cardiopulmonary resuscitation (CPR), use of an electrical shock to stop a fatal abnormal heart rhythm (defibrillation), intubation (placement of a breathing tube down your throat), or the use of lifesaving drugs. People with DNR orders will only be given drugs that make them more comfortable in their last moments. You may request that you be identified as a DNR if you wish to avoid expensive, uncomfortable, or invasive medical care that probably will not improve your long-term prognosis and may increase your discomfort.

Living wills are written documents that contain specific instructions about the type of treatment you wish to receive at the end of your life. Unlike a DNR order, which applies to a specific moment when you require resuscitation, living wills apply to more general situations.

One of two broad conditions must be triggered:
You have slipped into a permanent coma.
You are unable to make decisions about the type of care you wish to receive.

Whenever two doctors agree that one of these conditions has been met, your doctor will deliver care based on the directions in your living will. Usually, living wills instruct doctors not to prescribe any treatment that would unnecessarily lengthen the process of dying.

A durable power of attorney (DPA) for health care document appoints a specific person (surrogate) to make decisions about your care if you are incapacitated. (A DPA can also be called the appointment of a health care agent or health care surrogate.) Unlike DNRs or living wills, DPAs allow an independent observer of your choice to assess your current health condition and to speak to your doctor before any decision about your care is made. DNRs and living wills do not allow for this type of dialogue, because your treatment is based on choices you made without knowing the exact nature of your condition.

For more information about these options, see the topic Care at the End of Life.
What To Think About

People who are unconscious immediately after a stroke have the least chance of a full recovery. Some people may have a poor recovery because of the location and extent of brain damage. But many people do successfully recover.

It is not possible to predict precisely how much physical ability you will regain. The more ability you retain immediately after a stroke, the more independent you are likely to be when you are discharged from the hospital. After a stroke:
People usually show the greatest progress in being able to walk during the first 6 weeks. Most recovery occurs within the first 3 months, but you may continue to improve slowly over the next few years.
Speech, balance, and skills needed for day-to-day living return more slowly and may continue to improve for up to a year.
About half of the people who suffer a stroke have problems with coordination, communication, judgment, or behavior that affect their work and personal relationships.

After a person has had a stroke, family members can learn ways to provide rehabilitation support and encouragement to their loved one.

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Who is affected by stroke

About 780,000 people in the United States have a stroke each year. About 600,000 are first strokes and about 180,000 are recurrent attacks:1
Stroke is the third leading cause of death, behind heart disease and cancer.
Stroke is a leading cause of serious, long-term disability in the United States.
Women are less likely than men to have a stroke in all age ranges except 75 and older.
Blacks are about twice as likely as whites to have a stroke.
References
Citations

American Heart Association (2008). Heart disease and stroke statistics—2008 update (At-A-Glance version). Available online: http://www.americanheart.org/presenter.jhtml?identifier=3037327.

Ischemic versus hemorrhagic stroke

An ischemic stroke happens when a blood vessel (artery) supplying blood to an area of the brain becomes blocked by a blood clot. About 80% of all strokes are ischemic strokes.

A hemorrhagic stroke happens when an artery in the brain leaks or bursts (ruptures).

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What Increases Your Risk

Risk factors for stroke include those you can change and those you can't change.

Certain diseases or conditions increase your risk of stroke. These include:
High blood pressure (hypertension). High blood pressure is the second most important stroke risk factor after age. It is a risk factor you can change.
Diabetes. Having diabetes doubles your risk of stroke because of the circulation problems associated with the disease.

High cholesterol. High cholesterol can lead to hardening of your arteries (atherosclerosis). Hardening of the arteries can cause coronary artery disease and heart attack, which can damage the heart muscle and increase your risk for stroke.
Coronary artery disease, which can lead to heart attack and stroke.
Other heart conditions, such as atrial fibrillation, endocarditis, heart valve conditions, patent foramen ovale, or heart failure.
Peripheral arterial disease, for example narrowing of the carotid artery (carotid artery stenosis).

Certain behaviors can increase your risk of stroke. These include:
Smoking, including secondhand smoke.
Physical inactivity.
Being overweight.
Diet with few fruits and vegetables. Research suggests that people who eat more fruits, vegetables, fish, and whole grains (for example, brown rice) may have a lower risk of stroke than people who eat lots of red meat, processed foods such as lunch meat, and refined grains (for example, white flour).2
Diet with too much salt. A healthy diet includes less than 2,300 mg of sodium a day (about one teaspoon).
Use of some medicines, such as birth control pills—especially by women who smoke or have a history of blood-clotting problems. In postmenopausal women, hormone replacement therapy has been shown to slightly increase the risk of stroke.3
Heavy use of alcohol. People who drink alcohol excessively, especially people who binge drink, are more likely to have a stroke. Binge drinking is defined as drinking more than 5 drinks in a short period of time.
Illegal drug use (such as a stimulant, like cocaine).

Risk factors you cannot change include:
Age. The risk of stroke increases with age.
Race. African Americans, Native Americans, and Alaskan Natives have a higher risk than those of other races. Compared with whites, African Americans have about 2 times the risk of a first ischemic stroke . And African-American men and women are more likely to die from stroke.4
Gender. Stroke is more common in men than women until age 75, when more women than men have strokes. Because women live longer than men, more women than men die of stroke.4
Family history. The risk for stroke is greater if a parent, brother, or sister has had a stroke or transient ischemic attack (TIA). For more information, see the topic Transient Ischemic Attack (TIA).
History of stroke or TIA.

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What Happens

When you have an ischemic stroke , the oxygen-rich blood supply to part of your brain is reduced. With a hemorrhagic stroke, there is bleeding in the brain.
After about 4 minutes without blood and oxygen, brain cells become damaged and may die.
The body tries to restore blood and oxygen to the cells by enlarging other blood vessels (arteries) near the area.
If blood supply is not restored, permanent brain damage usually occurs.

When brain cells are damaged or die, the body parts controlled by those cells cannot function. The loss of function may be mild or severe and temporary or permanent. This depends on where and how much of the brain is damaged and how fast the blood supply can be returned to the affected cells.

If you have symptoms of a stroke, seek emergency medical care. Life-threatening complications may occur after a stroke. Early treatment may decrease the amount of permanent damage to brain cells, decreasing the amount of disability.

Stroke is the most common nervous system–related cause of physical disability. Of people who survive a stroke, half will still have some disability 6 months after the stroke.

Recovery depends on the location and amount of brain damage caused by the stroke, the ability of other healthy areas of the brain to take over functioning for the damaged areas, and rehabilitation. In general, the less damage there is to the brain tissue, the less disability results and the greater the chances of a successful recovery.

You have the greatest chance of regaining your abilities during the first few months after a stroke. Regaining some abilities, such as speech, comes slowly, if at all. About half of all people who have a stroke will have some long-term problems with talking, understanding, and decision-making. They also may have changes in behavior that affect their relationships with family and friends.

Long-term complications of a stroke, such as depression and pneumonia, may develop right away or months to years after a stroke. Some long-term complications may be prevented with proper home treatment and medical follow-up. For more information, see the Home Treatment section of this topic.
What to expect after a stroke

In addition to the more obvious physical problems you have after a stroke, you (or a caregiver) may also notice:
Changes in speed of action.
Changes in judgment.
Changes in emotions.
Changes in perception (the ability to judge distance, size, position, rate of movement, form, and how parts relate to the whole).
Memory problems.
Problems from neglecting the affected side of the body.

If you have concerns, discuss them with your doctor. Your doctor will provide support and may offer other suggestions for dealing with these issues.

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Symptoms

If you have symptoms of a stroke, seek emergency medical care. General symptoms of a stroke include:
Sudden numbness, paralysis, or weakness in your face, arm, or leg, especially on only one side of your body.
New problems with walking or balance.
Sudden vision changes.
Drooling or slurred speech.
New problems speaking or understanding simple statements, or feeling confused.
A sudden, severe headache that is different from past headaches.

Symptoms vary depending on whether the stroke is caused by a clot or bleeding. The location of the blood clot or bleeding and the extent of brain damage can also affect symptoms.
Symptoms of an ischemic stroke (caused by a clot blocking a blood vessel) usually occur in the side of the body opposite from the side of the brain where the clot occurred. For example, a stroke in the right side of the brain affects the left side of the body.
Symptoms of a hemorrhagic stroke (caused by bleeding in the brain) can be similar to those of an ischemic stroke but may be distinguished by symptoms relating to higher pressure in the brain, including severe headache, nausea and vomiting, neck stiffness, dizziness, seizures, irritability, confusion, and possibly unconsciousness.

Symptoms of a stroke may progress over minutes, hours, or days, often in a stepwise fashion. For example, mild weakness may progress to an inability to move the arm and leg on one side of the body.
If a stroke is caused by a large blood clot (ischemic stroke) or bleeding (hemorrhagic stroke), symptoms occur suddenly, within seconds.
When an artery that is narrowed by atherosclerosis becomes blocked, stroke symptoms usually develop gradually over minutes to hours, or (in rare cases) days.
If several smaller strokes occur over time, the person may have a more gradual change in walking, balance, thinking, or behavior (multi-infarct dementia).

It is not always easy for people to recognize symptoms of a small stroke. They may mistakenly think the symptoms can be attributed to aging, or the symptoms may be confused with those of other conditions that cause similar symptoms.

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Prevention Stroke

You can help prevent a stroke if you control risk factors and treat other medical conditions that can lead to a stroke.

And if you have already had a stroke or a transient ischemic attack (TIA), you can prevent another stroke in the same way, by controlling risk factors and treating medical conditions that can lead to stroke.

A transient ischemic attack (TIA) is a warning sign that a stroke may soon occur. Prompt medical attention for a TIA may help prevent a stroke.

Seek emergency medical help immediately if you have symptoms of a TIA, which are similar to those of a stroke. Symptoms include problems with vision, speech, behavior, and thought processes. A TIA may cause loss of consciousness, seizure, dizziness (vertigo), and weakness or numbness on one side of the body. But symptoms of a TIA are temporary and usually disappear after 10 to 20 minutes, although they may last longer.

Treating other medical conditions can help prevent a stroke.
Hardened arteries. If you have been told that you have hardening of the arteries (atherosclerosis), check with your doctor about whether you should take an aspirin each day and/or a medicine to lower your cholesterol. Taking an aspirin daily can also reduce the risk of stroke in a person who has already had an ischemic stroke , a TIA, or carotid endarterectomy surgery.
Blocked carotid artery. If your doctor hears a swishing sound—a bruit (say "broo-E")—when listening to blood flow through the large blood vessels in your neck (carotid arteries), ask whether you need further testing (usually carotid ultrasound). Surgery to reopen a blocked carotid artery may be appropriate. For more information on this surgery, see:
Should I have carotid endarterectomy?

A procedure called carotid artery stenting is another option for some people at high risk for stroke. This procedure is much like coronary angioplasty, which is commonly used to open blocked arteries in the heart. During this procedure, a doctor inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque. The doctor may use a stent that is coated with medicine to help prevent future blockage.

Control your risk factors for stroke by:
Having regular medical checkups.
Controlling your high blood pressure by working with your doctor.
If you have diabetes, keeping your blood sugar levels as close to normal as possible.
Controlling high cholesterol, heart disease (especially atrial fibrillation), diabetes, or disorders that affect your blood vessels, such as coronary artery disease.
Taking cholesterol-lowering medicines called statins if you have high cholesterol or have had a heart attack, TIA, or stroke.5, 6
Not smoking and staying away from secondhand smoke. If you do smoke, quit. (For tips, see the topic Quitting Smoking.) Daily cigarette smoking increases the risk of stroke by more than 2 times.
Limiting alcohol. Low to moderate alcohol consumption may decrease the risk of ischemic stroke. Moderate drinking is 2 drinks a day for men, and 1 drink a day for women. Excessive use of alcohol (more than 2 drinks a day) can raise your risk of stroke.
Staying at a healthy weight. Being overweight increases your risk of developing high blood pressure, heart problems, and diabetes, which are risk factors for TIA and stroke.
Becoming more active. Do activities that raise your heart rate. Try to do moderate activity at least 2½ hours a week. One way to do this is to be active 30 minutes a day, at least 5 days a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week.7 A large study showed that physical activity lowers your risk of stroke, partly by reducing the two greatest risk factors for stroke: high blood pressure and heart disease. The more physically active you are, the lower your risk. Moderately active people had a 20% lower risk of stroke than inactive people. Highly active people had about a 30% reduction of risk.8 Exercise can also help raise HDL ("good") cholesterol levels in your body, which also lowers the risk of stroke.

Lower your risk for stroke by:
Taking aspirin if you have had a heart attack. For more information, see:
Should I take daily aspirin to prevent a heart attack or a stroke?
Taking anticoagulants, as prescribed by your doctor, if you have atrial fibrillation or have had a heart attack with other complications.
Eating a nutritious, balanced diet that is low in cholesterol, saturated fats, and salt. Foods high in saturated fat and cholesterol can make hardening of the arteries worse. Eat more fruits and vegetables to increase your intake of potassium and vitamins B, C, E, and riboflavin. Add whole grains to your diet. Eating fish one or more times a month may also reduce your risk of stroke. Limit the amount of salt you eat too. For more information, see:
Heart disease: Eating a heart-healthy diet.
High blood pressure: Using the DASH diet.
Avoiding illegal drugs (such as a stimulant, like cocaine). Cocaine can increase blood pressure and cause the heart to beat more rapidly, thereby increasing your risk of stroke.
Avoiding birth control pills if you have other risk factors. If you smoke or have high cholesterol or a history of blood clots, taking birth control pills increases your risk of having a stroke.
Avoiding hormone replacement therapy. In women who have gone through menopause, hormone replacement therapy has been shown to slightly increase the risk of stroke.3
Avoid getting sick from the flu. Get a flu shot every year.

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Causes of ischemic stroke

An ischemic stroke is caused by a blood clot that blocks blood flow to the brain. A blood clot can develop in a narrowed artery that supplies the brain or can travel from the heart (or elsewhere in the body) to an artery that supplies the brain.

Blood clots are usually the result of other problems in the body that affect the normal flow of blood, such as:
Hardening of the arteries (atherosclerosis). This is caused by high blood pressure , diabetes, high cholesterol, and smoking.
Atrial fibrillation or other irregular heart rhythms.
Certain heart valve problems, including having an artificial heart valve, a repaired heart valve, heart valve disease such as mitral valve prolapse, or narrowing (stenosis) of a heart valve.

Infection of the heart valves (endocarditis).
A patent foramen ovale, which is a congenital heart defect.
Blood-clotting disorders.
Inflammation of blood vessels (vasculitis).
Heart attack.
Heart failure.

Low blood pressure (hypotension) may also cause an ischemic stroke, although less commonly. Low blood pressure results in reduced blood flow to the brain and may develop as a result of narrowed or diseased arteries, a heart attack, a large loss of blood, or a severe infection.

Some surgeries (such as endarterectomy) or other procedures (such as angioplasty) that are used to treat narrowed carotid arteries may cause a blood clot to break loose, resulting in a stroke.
Causes of hemorrhagic stroke

A hemorrhagic stroke is caused by bleeding inside the brain (called intracerebral hemorrhage) or bleeding in the space around the brain (called subarachnoid hemorrhage). Bleeding inside the brain may be a result of long-standing high blood pressure. Bleeding in the space around the brain may be caused by a ruptured aneurysm or uncontrolled high blood pressure.

Other causes of hemorrhagic stroke are less common but include:
Inflammation in the blood vessels, which may develop from conditions such as syphilis, Lyme disease, vasculitis, or tuberculosis.
Blood-clotting disorders, such as hemophilia.
Head or neck injuries that result in damage to blood vessels in the head or neck.
Radiation treatment for cancer in the neck or brain.
Cerebral amyloid angiopathy (a degenerative blood vessel disorder)

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What is a stroke?

A stroke occurs when a blood vessel in the brain is blocked or bursts . Without blood and the oxygen it carries, part of the brain starts to die. The part of the body controlled by the damaged area of the brain can't work properly.

Brain damage can begin within minutes, so it is important to know the symptoms of stroke and act fast. Quick treatment can help limit damage to the brain and increase the chance of a full recovery.
What are the symptoms?

Symptoms of a stroke happen quickly. A stroke may cause:
Sudden numbness, paralysis, or weakness in your face, arm, or leg, especially on only one side of your body.
New problems with walking or balance.
Sudden vision changes.
Drooling or slurred speech.
New problems speaking or understanding simple statements, or feeling confused.
A sudden, severe headache that is different from past headaches.

If you have any of these symptoms, call 911 or other emergency services right away.

See your doctor if you have symptoms that seem like a stroke, even if they go away quickly. You may have had a transient ischemic attack (TIA), sometimes called a mini-stroke. A TIA is a warning that a stroke may happen soon. Getting early treatment for a TIA can help prevent a stroke.
What causes a stroke?

There are two types of stroke:
An ischemic stroke develops when a blood clot blocks a blood vessel in the brain. The clot may form in the blood vessel or travel from somewhere else in the blood system. About 8 out of 10 strokes are ischemic (say “iss-KEE-mick”) strokes. They are the most common type of stroke in older adults.
A hemorrhagic stroke develops when an artery in the brain leaks or bursts. This causes bleeding inside the brain or near the surface of the brain. Hemorrhagic (say “heh-muh-RAH-jick”) strokes are less common but more deadly than ischemic strokes.
How is a stroke diagnosed?

Seeing a doctor right away is very important. If a stroke is diagnosed quickly—within the first 3 hours of when symptoms start—doctors may be able to use medicines that can lead to a better recovery.

The first thing the doctor needs to find out is what kind of stroke it is: ischemic or hemorrhagic. This is important because the medicine given to treat a stroke caused by a blood clot could be deadly if used for a stroke caused by bleeding in the brain.

To find out what kind of stroke it is, the doctor will do a type of X-ray called a CT scan of the brain, which can show if there is bleeding. The doctor may order other tests to find the location of the clot or bleeding, check for the amount of brain damage, and check for other conditions that can cause symptoms similar to a stroke.
How is it treated?

For an ischemic stroke, treatment focuses on restoring blood flow to the brain. If less than 3 hours have passed since your symptoms began, doctors may use a medicine that dissolves blood clots. Research shows that this medicine can improve recovery from a stroke, especially if given within 90 minutes of the first symptoms.1 Other medicines may be given to prevent blood clots and control symptoms.

A hemorrhagic stroke can be hard to treat. Doctors may do surgery or other treatments to stop bleeding or reduce pressure on the brain. Medicines may be used to control blood pressure, brain swelling, and other problems.

After your condition is stable, treatment shifts to preventing other problems and future strokes. You may need to take a number of medicines to control conditions that put you at risk for stroke, such as high blood pressure, high cholesterol, and diabetes. Some people need to have a surgery to remove plaque buildup from the blood vessels that supply the brain (carotid arteries).

The best way to get better after a stroke is to start stroke rehab. The goal of stroke rehab is to help you regain skills you lost or to make the most of your remaining abilities. Stroke rehab can also help you take steps to prevent future strokes. You have the greatest chance of regaining abilities during the first few months after a stroke. So it is important to start rehab soon after a stroke and do a little every day.
Can you prevent a stroke?

After you have had a stroke, you are at risk for having another one. You can make some important lifestyle changes that can reduce your risk of stroke and improve your overall health.
Don't smoke. Smoking can more than double your risk of stroke. Avoid secondhand smoke too.
Eat a heart-healthy diet that includes plenty of fish, fruits, vegetables, beans, high-fiber grains and breads, and olive oil. Eat less salt too.
Try to do moderate activity at least 2½ hours a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week. Your doctor can suggest a safe level of exercise for you.
Stay at a healthy weight.
Control your cholesterol and blood pressure.
If you have diabetes, keep your blood sugar as close to normal as possible.
Limit alcohol. Having more than 1 drink a day (if you are female) or more than 2 drinks a day (if you are male) increases the risk of stroke.
Take a daily aspirin or other medicines if your doctor advises it.
Avoid getting sick from the flu. Get a flu shot every year.

Work closely with your doctor. Go to all your appointments, and take your medicines just the way your doctor says to.

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