In this article:
- Recognizing the different types of stroke
- Factoring in high blood pressure
- Knowing the risk factors and symptoms
- Testing, treating, and getting help for the stroke survivor
Annually, at least 5 million people throughout the world die from strokes (some prefer the term brain attacks over strokes because the condition is similar to a heart attack), and 15 million more survive them.
But stroke survivors may live out the rest of their lives as dependents — unable to speak coherently and/or confined to a wheelchair because of the paralysis that results.
A stroke isn’t necessarily a disease of the elderly; 28 percent of the new cases are people under age 65.
In the United States, 700,000 people have strokes each year and 162,000 die. Seventy percent of those who survive live without the assistance of others, but 30 percent are permanently disabled. Four million stroke survivors in the United States have some degree of disability. In Japan, the incidence of strokes was in decline for many years, but now it’s rising. In Eastern Europe and countries of the Russian Federation, the incidence is also rising, and many more strokes are fatal there as compared to more advanced areas like the United States, Canada, and Western Europe.
A stroke, also known as a cerebrovascular accident (CVA), occurs when blood flow to a part of the brain is cut off or when a blood vessel bleeds in or around the brain.
Depending on the severity of the attack, victims often suffer from impaired vision and speech, convulsions, paralysis, and coma.
The higher the blood pressure, the greater the likelihood of a stroke. Strokes don’t favor any particular group such as the poor or the rich, the famous, or the unknown. Perhaps one of the most famous people to suffer a stroke was United States President Franklin Delano Roosevelt. In 1945, as World War II was coming to a close, President Roosevelt died within a few hours of a brain attack at the age of 63 after years of poorly treated high blood pressure. The famous nineteenth-century French bacteriologist, Louis Pasteur, on the other hand, suffered a stroke at age 46 that left him paralyzed on the left side. Yet Pasteur — making medical history and discovering, among other findings, several bacteria that are responsible for the spread of infectious disease — did his best work during the next 25 years of his life.
In this article, we explain the causes of strokes, the warning signs that predict a stroke, and signs that a stroke is taking place. We also cover the value of early diagnosis and treatment and how to work with a stroke survivor who needs rehabilitation.
Make sure you have a handle on all the information in this chapter so this devastating complication never makes your life miserable.
For a detailed and technical article with even more information, check out: stroke
We separate our discussion of the brain from the heart (see article 5) and the kidneys (see article 6), but that doesn’t mean a person develops brain damage from high blood pressure separate from heart disease or kidney failure. High blood pressure — the silent killer — tends to work its way on various parts of the body simultaneously. As a result, you may discover you have problems in all three areas at the same time.
Understanding the Causes of Strokes
The belief that strokes were random events like bolts of lightning persisted into the twentieth century along with the term apoplexy, coming from a Greek word meaning to be thunderstruck. So folks back then used apoplexy to refer to a stroke. Considered an unpreventable accident, a stroke was also termed cerebrovascular accident (CVA). This explanation is clearly not the case, however.
Strokes, perhaps more than heart attacks and kidney failure, are preventable.
Progress in the treatment of high blood pressure between 1960 and 1990 made this complication of high blood pressure less common. More recently, however, the prevention of strokes has slowed down as a result of both diminished awareness and inadequate treatment. Even with the reduction in the incidence of strokes, it remains the third leading cause of death after heart attacks and cancer.
Although the correlation between high blood pressure and strokes is unmistakable (see the later section “Avoiding Brain Attacks by Reducing High Blood Pressure” for details), strokes come about in a variety of ways: from atherosclerosis, a cerebral embolus, or a brain hemorrhage.
Just as atherosclerosis (damage to the inside of arteries caused by cholesterol deposits) can affect the arteries of the heart (see article 5), it can also affect the arteries leading into and within the brain. About 60 percent of all strokes result from atherosclerosis, which is characterized by fatty deposits on the inner walls of the arteries. As a result, blood flow to critical parts of the brain is diminished. If the blood flow ceases entirely, a stroke may occur.
The blood supply to the brain has multiple sources. (Figures below shows the unique circulation of blood in the brain.)
Left and right cerebral arteries entering the skull in the front of the brain combine with left and right vertebral arteries entering the skull in the back of the brain to produce a circle of blood supply called the circle of Willis at the base of the brain. Other arteries that make up the circle are also shown in the figures above. If one of the arteries is blocked, blood from the other arteries can fill the circle and provide blood to all areas of the brain. But the brain tissue dies when several sources of blood are blocked and the circulation isn’t reopened within three hours.
Approximately 25 percent of strokes are due to cerebral emboli. A cerebral embolus is a blood clot (a solid mass of blood cells, protein, and other blood substances) or solid tissue that breaks off from an atherosclerotic plaque (an irregularity inside the artery; the end result of a cholesterol deposit) and travels into the brain. The bloodstream carries the atherosclerotic plaque particle from its site of origin, often a large artery in the neck, into the arteries of the brain, where it becomes wedged and then cuts off circulation.
Blood clots usually come from the left atrium of the heart in the following steps:
- The heart loses its regular beating pattern and gives way to atrial fibrillation (uncoordinated twitching movements of the atrium).
- The heart’s left atrium fails to completely empty its blood.
- The pool of blood that remains forms clots that can break off and travel via the bloodstream into the arteries of the brain.
Brain hemorrhage — bleeding within the brain or between the skull and the brain — accounts for the remaining 15 percent of strokes. Of these attacks, two-thirds occur within the brain. As a result of high blood pressure or other diseases, the muscular wall of the artery may weaken and form one or more aneurysms (little pouches). Looking like a balloon attached to the artery, an aneurysm can burst and bleed into the brain. However, because the brain doesn’t have extra space to make room for the extra blood, brain tissue is squeezed and may die. Note: Bleeding within the brain can also occur as a result of trauma to the head.
The other one-third of brain hemorrhages occur outside the brain in the subarachnoid space — the thin separation between the inside of your bony skull and the outside of your brain’s fleshy gray matter. Bleeding within this space usually results from an aneurysm that forms inside the skull but outside the brain. If the aneurysm ruptures, the blood flows around the brain, causing increased pressure and a severe headache that’s often accompanied by vomiting.
Avoiding Strokes by Reducing High Blood Pressure
High blood pressure is the most important factor in the development of a stroke, and its control can prevent such an attack. High blood pressure may hasten a stroke by:
- Speeding up the development of atherosclerosis
- Promoting the thickening of the middle layer of the arteries (This causes narrowing of the arteries and reduced blood flow into the brain.)
- Damaging small arteries to the point that they collapse
- Increasing the size of an aneurysm in the brain
- Causing thinning of the aneurysm to the point of rupture and hemorrhage
- Causing formation of aneurysms that rupture in the subarachnoid space to produce a subarachnoid hemorrhage (SAH).
Many clinical trials have shown that reduction of blood pressure reduces the incidence of brain attacks, no matter how high the initial blood pressure or how old the patient. All types of strokes are reduced, from those caused by clots to those caused by hemorrhage. Part III is full of useful information on reducing high blood pressure.
Surveying Additional Predisposing Conditions
In addition to high blood pressure (the number-one contributor), other predisposing conditions play an important role in strokes. These risk factors are divided into what you can’t control and what you can control. Obviously, you want to direct all your emphasis and energy towards factors that you can change. And if you have one or more unchangeable conditions, you must work even harder to minimize those controllable factors.
The hand you’re dealt: Uncontrolled factors
You’re born with most of these uncontrollable risk factors for a stroke:
- Age: The older you get, the more you’re at risk.
- Sex: At any age, strokes tend to occur more often among men than women, but women are more likely to die from their brain attack than men are.
- Family history: If one or more of your parents and grandparents had a brain attack, then you’re at risk.
- History of stroke: If you’re a stroke survivor, then you’re at risk for another one.
The hand you play: Risk factors you control
With some risk factors you can really make a difference. (Part III shows you how.)
The risk factors that are well within your power to change are:
- Alcoholic drinks: Drinking more than two glasses of wine, hard liquor, or beer for men or one glass for women each night may contribute to a brain attack.
- Arteriosclerosis: This disease can be treated, and the arteries to the brain reopened. See article 5 for more details.
- Atrial fibrillation: The irregular rhythm of the heartbeat associated with clots that block brain arteries can be brought under control with the help of the right treatment. Ask your doctor.
- Diabetes: The high blood glucose of uncontrolled diabetes associated with high blood pressure and high cholesterol can be brought under control.
- Excess weight and obesity: Even if you’re only ten pounds overweight, that excess ten pounds contributes to high blood pressure and diabetes. However, dieting and exercising can reduce your weight.
- High blood cholesterol: Even without diabetes, cholesterol increases the risk of a brain attack. Diet, exercise, and medications, if necessary, can control this factor.
- Illegal drugs: Using illegal drugs such as amphetamine, ecstasy, and cocaine increases blood pressure and your chances of a brain attack.
- Lack of exercise: A sedentary lifestyle predisposes you to a brain attack, but exercise can drastically decrease your chances of having a brain attack.
- Tobacco: Smoking cigarettes or cigars or chewing tobacco reduces oxygen in the blood and damages the walls of the blood vessels. Conversely, kicking your tobacco habit oxygenates the blood and decreases the likelihood of damaged blood vessels.
- Transient ischemic attack (TIA): This is a milder form of stroke (brain attack), and TIA symptoms are always temporary. (See the “Moving Fast When You See Symptoms of a Brain Attack” section later in this article.) Drugs can reduce the incidence of these attacks.
If you keep these risk factors under control, you’re sure to decrease the likelihood of a disabling stroke (brain attack).
Funduscopic examination minus the fun
When a doctor looks into your eyes with an ophthalmoscope (called a funduscopic exam), he’s observing the one area of the brain that can be seen directly. High blood pressure causes changes in the blood vessels of your eyes that are similar to the changes it causes in small blood vessels in the brain. The earliest change that the doctor sees with the ophthalmoscope is a narrowing of the arteries: The artery walls thicken, and although blood may still flow, the column of blood is not visible and the artery looks like a silver wire. As the arteries thicken, nearby veins are also compressed, and arteriovenous (AV) nicking (in US) or nipping (in UK), (a compression of a vein where the artery crosses it) appears. Your physician may see other changes in your eyes due to high blood pressure with his ophthalmoscope:
- The eye’s major central retinal vein, which carries blood away from the retina (the tissue that acts as a screen for sight), can close. Then vision is lost in that eye, and the back of the eye appears to be bleeding.
- As blood flow fails, areas of the retina die, leaving a white, patchy appearance (called cotton wool spots).
- Appearing as sacs attached to arteries, aneurysms can form in the arteries of the eyes just as elsewhere in the brain due to the high blood pressure. They rarely cause hemorrhage within the eye, but if they do, it may be necessary to clot them with laser treatment.
- Hemorrhaging from the retina’s arteries produces a flame-shaped area in the retina — a sign of malignant or accelerated (out-of- control) high blood pressure (article 6 discusses this condition).
Working some miracles with preventive drugs
If you’re at high risk to have a stroke because you previously had one or had a TIA or because you have atrial fibrillation or narrowing of the carotid arteries (the main arteries arising from the aorta that provide blood to the brain), a number of drugs can lower the risk. The most valuable are as follows:
- Aspirin, a drug that prevents platelets in the blood from forming a clot: If you have a TIA, aspirin may reduce your risk of a stroke by 30 percent. You should use no more than a "baby-aspirin" (81 milligrams in US) daily, but check with your doctor. (Note about aspirin dose: Adult aspirin tablets are produced in standardised sizes, which vary slightly from country to country, for example 300 mg in Britain and 325 mg in the USA. Smaller doses are based on these standards; e.g. 75 and 81 mg tablets are used (81 mg tablets can be referred to as "baby-strength" aspirin); there is no medical significance in the slight difference)
- Clopidogrel (Plavix), an antiplatelet drug: It doesn’t cause the gastrointestinal bleeding of aspirin, but its reduction of stroke risk is similar to aspirin’s.
- Dipyridamole plus Aspirin (Aggrenox): This drug helps prevent a second stroke for people who have already had one but causes gastrointestinal bleeding more often than aspirin.
- Anticoagulants such as warfarin (Coumadin): These drugs prevent for- mation of clots but run the risk of excessive bleeding. They must be monitored with blood tests, which are inconvenient.
Interestingly, a study in the January 2007 Archives of Internal Medicine indicates that combining aspirin and oral anticoagulants like warfarin provides no better protection than aspirin alone and runs the risk of much increased major bleeding.
Moving Fast When You See Symptoms of a Stroke
The symptoms of an impending brain attack come on suddenly. Don’t waste a minute getting to a hospital. You may prevent much of the damage if you receive treatment within the first three hours. If you experience any of the following symptoms or see another individual displaying one or all of them, call an ambulance!
- Sudden blurred or decreased vision in one or both eyes
- Numbness, weakness, or paralysis of the face, arm, or leg on one or both sides of the body
- Difficulty speaking or understanding
- Sudden dizziness, loss of balance, or an unexplained fall
- Nausea, vomiting, or difficulty swallowing
- Sudden headache or change in the pattern of headaches
If these symptoms last 5 to 20 minutes (and never more than 24 hours), the condition is a TIA. It’s usually the result of:
- Completely blocked arteries that are rapidly reopened by certain chemi- cals in the blood or the force of the blood pressure.
- Small emboli (see the earlier section “Cerebral embolus”) that briefly interrupt blood flow. The emboli can be dissolved by drugs or bypassed by using a blood vessel or artificial tube to go around the blockage.
One-third of TIA victims eventually suffer a severe brain attack with permanent symptoms, but the other two-thirds don’t. TIAs must be taken seriously, and the patient needs a doctor’s evaluation to see whether the cause is an atherosclerotic plaque in an artery or atrial fibrillation. The doctor can bypass the plaque surgically or provide anticoagulants to prevent clotting from atrial fibrillation.
Capturing Brain Function on Film
The brain is specialized; each area performs certain functions. When a brain attack occurs, the doctor pinpoints the damaged part of the brain to first localize the probable blocked or bleeding artery and then determine whether treatment is feasible. Th figures below show the location of the various functions.
As you can see, loss of blood supply to specific areas of the brain can result in the loss of a specific function and consequent signs and symptoms (see the previous section for a list of these signs). Because the right side of the brain controls the left side of the body, and because the nerves cross over, careful mapping of the loss of function (noting the nerves that correspond) can determine the area of the brain that’s damaged. For example, paralysis of the left leg means that the right brain leg control area is knocked out.
Some functions like memory, however, are controlled by only one side of the brain. If the brain attack affects the right side of the brain, for example, the victim may experience some of the following symptoms in addition to weak- ness or paralysis on the left side of his body:
- Tendency to be impulsive or disorganized
- Lack of coordination and tendency to fall
- Inability to remember
- Lack of insight and judgment
If the stroke or brain attack occurs on the left side of your brain, you may experience some difficulty communicating in addition to right-sided weakness or paralysis.
Although specific sites in the brain affect corresponding bodily functions, scientists don’t fully understand and can’t exactly locate which arteries affect that specific brain site because of the overabundance of cross circulation in the brain. As a result, mapping of function loss can determine the affected area, but determining the source of the impairment (like an aneurysm within an artery that feeds the brain) may be extremely difficult.
Other symptoms that aren’t particular to one side of the body may follow a brain attack. For example, the survivor may not see or think as she did before; her perceptions are altered. As a result, she may be depressed or suffer mood swings — suddenly bursting into laughter for no apparent reason. In another instance, one side of the body is weaker and vision on that side is poorer. The individual may lose awareness of that side of her body and tend to bump into objects with that side.
The doctor may need to perform various sophisticated tests to clarify where the damage has occurred and why. The following list describes a few of the tests your doctor may perform:
- Computerized axial tomography (CAT scan) or magnetic resonance imaging (MRI) can
- Pinpoint the location of dead brain cells
- Examine minute areas of the brain
- Differentiate between a TIA and a hemorrhage
In addition, the MRI can look for aneurysms and malformations that can eventually cause hemorrhage in the arteries and veins.
The patient’s head is placed within a circular machine that takes X-rays from different angles. It’s painless!
- Digital subtraction angiographies (DSA) take X-rays after dye has been injected directly into the brain’s circulation. DSA can pinpoint the brain’s blood vessels that are prohibiting normal circulation of the blood.
- Doppler ultrasound tests evaluate blood flow in an artery. Sound waves are directed to the artery (usually in the neck in this case) to indicate whether blood is flowing slowly or normally.
- Electroencephalograms (EEG) test electrical activity in the brain to
- Indicate whether the brain is functioning and, if so, where.
- Determine whether an unconscious person is brain dead after a brain attack so a ventilator (to help the victim breathe) can be continued or disconnected.
In this painless procedure, electrodes are directly applied to the scalp surface.
Multiplying the Treatments for Strokes
When a stroke attack occurs, usually the ischemic core (area of restricted blood supply) suffers a permanent loss of brain cells. The ischemic penumbra (the larger area around that core) is still alive and can be saved with quick action using a tissue plasminogen activator (tPA, brand name Activase) or another clot-dissolving drug to break up any clot or obstruction to the flow of blood. This drug must be used within the first three hours after the brain attack to really benefit the brain and prevent more tissue loss.
Obviously, the doctor can’t use a tPA in a hemorrhagic brain attack (see the earlier section “Brain hemorrhage”) because it doesn’t involve blood clots. Unfortunately, hemorrhage is an occasional side effect of tPAs and can then bring on another stroke.
Patients who have had a stroke use the same drugs to prevent future attacks (I discuss these drugs earlier in this chapter):
- Aspirin to prevent further attacks if you’ve had a TIA
- Warfarin for
- Frequent and unstable TIAs
- Atrial fibrillation (see the “Cerebral embolus” section earlier in this article for more about this condition)
In addition to drugs, the following procedures are possible:
- Clipping or tying off a bleeding aneurysm that’s the source of the brain attack may stop the bleeding and prevent it from rupturing. The decision to perform this procedure depends on the location of the aneurysm. It may not be approachable without damaging important brain tissue.
- Endarterectomies can remove an obstruction, especially in the carotid arteries (the arteries outside and leading to the brain). During this surgery, the doctor opens the neck where the artery is blocked and removes the blockage. Note: Even if surgery successfully repairs one blood vessel, it may not cure the problem because the brain’s blood supply comes from so many blood vessels; others may also be obstructed.
- Merci Retrieval System is a new technique to treat ischemic strokes due to blockage. The doctor threads a catheter into the obstructed blood vessel, grabs the clot with the Merci device at the end of the catheter, and then removes the clot through the catheter. The procedure works about half the time, especially for larger clots.
- Stents can be used in carotid artery blockage just as they are in coronary artery blockage (see article 5 for information). So far, though, studies haven’t determined whether carotid endarterectomy or stenting is the better procedure.
Making Your Way Back through Rehabilitation
Preventing a stroke is so much better than having to deal with the consequences of a stroke. Nevertheless, millions of people throughout the world have suffered strokes, and an enormous amount of resources is available for stroke survivors. The following sections provide some insights into what the brain attack victim can expect after the attack and how to get help.
Current methods of treatment are excellent, and resources are so great that the vast majority of people who have suffered a stroke can return to some level of satisfactory function in the long term.
Regaining movement following a stroke
Many people who have had a stroke have trouble swallowing initially because the swallowing muscles and the mouth have been affected. They must sometimes be supported with intravenous, naso-gastric feeding or feeding via a PEG tube into the stomach until they can swallow without the food going into the trachea, the tube leading into the lungs.
It may take a month after the stroke to determine how much function is going to return and what retraining has to take place. However, rehabilitation begins within 24 hours of a stroke if the patient is stable enough. The patient is encouraged to move and change position often, from lying in bed to sitting to standing and walking if possible. If limbs are paralyzed, the nurse or physical therapist moves the limbs passively.
As time passes, therapists help the patient to perform the activities of daily living: bathing, shaving, brushing teeth, combing hair, and using the toilet. When the patient starts regaining these skills, he begins to have confidence that his life isn’t over and that he may be able to function independently after all.
Checking out rehabilitation locations
The location and goals of rehabilitation depend on the limitations of the brain attack survivor. Several rehabilitation choices are available:
- In-home therapy: Sometimes, the physical therapist comes to a person’s home because the stroke survivor can live at home but can’t be transported to the hospital. This is also an opportunity for the therapist to inspect the home and offer suggestions that protect the patient from accidents and make activities of daily living more efficient.
- Inpatient rehabilitation unit: Rehabilitation can take place at the hospital if the survivor is immobile and unable to take care of himself. The unit’s staff carefully analyzes the survivor’s level of function and sets clear goals for restoration. For several hours daily, six days a week, the patient works with physical therapists, doctors, specialized nurses, and the best equipment to regain his self-sufficiency.
- Nursing facility: Stroke survivors who can’t go home alone but also don’t need the inpatient rehabilitation unit can go to a nursing facility. Skilled nursing facilities perform rehabilitation, and a nursing home provides mostly food and shelter along with medications as needed.
- Outpatient rehabilitation unit: After the survivor can move around fairly well (or if the physical disabilities don’t prevent a satisfactory life outside the hospital), he goes to an outpatient unit and returns home after each treatment. The unit may be at the hospital with the same doctors, nurses, and other specialists, but treatment doesn’t take place on a daily basis. The program depends on the survivor’s needs.
Meeting rehabilitation specialists
In the US a physiatrist (specializing in physical medicine and rehabilitation) completely evaluates the patient and determines the patient’s physical limitations. With the help of the other rehabilitation specialists, she draws up a plan of action including goals and time frames. The following list includes the titles and responsibilities of other rehabilitation specialists:
- Occupational therapist: Teaches the skills needed to perform physical work, whether it’s cleaning the house, gardening, painting, or other crafts. They teach patients how to perform tasks with one hand that nor- mally require two hands, for example, and how to make the home safe and more efficient.
- Physical therapist (physiotherapist): Helps the patient regain muscular movement and strength in the affected limbs and use the unaffected limbs to compen- sate for loss of function. To overcome the patient’s lack of awareness of affected limbs, therapists use selective sensory stimulation, a technique that stimulates the limbs.
- Rehabilitation nurse: Trains the brain attack patient to perform the activities of daily living including transferring from bed to chair, bathing, and controlling urination if incontinence is a problem.
- Speech-language therapist/pathologist: Helps patients who’ve developed aphasia (inability to speak properly after a stroke) to regain speech. The therapist/pathologist also evaluates swallowing, determines the cause of the disability, and then provides techniques to correct the problem.
- Vocational therapist: Helps the patient to regain useful work using the patient’s greatest strengths. Therapists work as job counselors for patients, informing them of their rights as disabled workers and helping them find suitable work that accommodates their residual limitations.
Finding help after a stroke
Resources for the person who has suffered a stroke are plentiful. Most resources are on the Internet, but we also provide addresses so you can get information through the mail as well. With these resources and the amazing number of links that their Web sites point to, you should get an answer to any question. Someone else who has had the same experience or has asked the same question is always out there.
American Stroke Association is a subdivision of the American Heart Association. It offers many publications on the causes, natural history, and treatments of brain attacks as well as publications about high blood pressure. The association also offers Stroke Connection Magazine with timely articles on all aspects of brain attacks.
Web site: www.strokeassociation.org
Mailing address: American Stroke Association, 7272 Greenville Avenue, Dallas, TX 75231
Phone: 888-478-7653 (888-4-STROKE); 800-553-6321
Registry of over 2,000 stroke support groups
Family Caregiver Alliance was the first organization to offer help to people caring for a loved one. It offers everything you need to know about caregiving for patients with brain attacks and many other medical conditions.
Web site: www.caregiver.org
Mailing address: Family Caregiver Alliance, 180 Montgomery Street, Suite 1100, San Francisco, CA 94104
The National Aphasia Association promotes public education, research, rehabilitation, and support services to assist people with aphasia and their families. It sells educational gifts and helps to form support groups for aphasia patients. The Web site is packed with useful information and many personal accounts of a stroke and the aphasia that followed; its links on aphasia make the site invaluable.
Web site: www.aphasia.org
Mailing address: The National Aphasia Association, 350 Seventh Avenue, Suite 902, New York, NY 10001
National Institute of Neurological Disorders and Stroke (NINDS) has a huge database on every aspect of strokes. Of great interest are the studies that patients can enter such as “Observational Learning in Stroke Patients” and “Vitamin Therapy for Prevention of Strokes.”
Web site: www.ninds.nih.gov the site has numerous publications and fact sheets that you can copy or order.
Mailing address: NIH Neurological Institute, P.O. Box 5801, Bethesda, MD 20824
National Rehabilitation Information Center is funded by the federal government to serve anyone on topics concerning rehabilitation. Their database is vast and their links to more rehabilitation information are outstanding.
Web site: www.naric.com
Mailing address: National Rehabilitation Information Center, 8201 Corporate Drive, Suite 600, Landover, MD 20785
National Stroke Association calls itself the voice for stroke, and its mission is “to reduce the incidence and impact of this life-threatening medical condition.” The association offers publications on the cause, prevention, and treatment of a brain attack and on rehabilitation after a brain attack.
Web site: www.stroke.org
Mailing address: National Stroke Association, 9707 East Easter Lane, Centennial, CO 80112
Phone: 800-787-6537 (800-STROKES)
Strokes Clubs International offers help and experience from people with strokes to people with strokes.
Mailing address: Strokes Clubs International, 805 12th Street, Galveston, TX 77550