Stroke is the brain equivalent of a heart attack (brain attack) and can result from either the development of a thrombus (clot) in a cerebral blood vessel (ischemic stroke) or from a ruptured cerebral blood vessel that leads to a hemorrhage (hemorrhagic stroke). Ischemic strokes frequently occur at night or early in the morning and are often preceded by a transient ischemic attack - referred to as a 'mini-stroke.' In contrast, hemorrhagic strokes usually result from head trauma or the presence of other risk factors (e.g., hypertension). While ischemic strokes are most common (70-80% of all strokes), hemorrhagic strokes are the most devastating as the highest rates of fatality occur following this type of stroke.10 Strokes represent the third most common cause of mortality in industrial countries accounting for about 5.5 million deaths worldwide. Nearly 15 million people annually suffer a stroke and about 5 million of these individuals are left permanently disabled.9 Ischemic strokes result in mortality within 30 days of the event in about 10% of Americans while hemorrhagic strokes lead to mortality in over 35% over the same period of time. However, the mortality rate for white females is nearly twice that for white males. In contrast to CHD which seems to effect American populations equivalently, African Americans, American Indians, Alaskan Americans, and Hispanic Americans appear to possess a much higher incidence of stroke than whites regardless of gender.1 African American males and females exhibit an incidence rate for stroke that is twice as high as that observed for white Americans. In addition, the risk of stroke increases dramatically with age as the chance of having a stroke more than doubles with each decade of life after age 55. Thus, while the incidence of stroke is higher in certain minority populations, the incidence of mortality following a stroke is significantly higher in white females than any other population group.

The therapeutic management of stroke (see 6.10 Stroke/Traumatic Brain and Spinal Cord Injuries; 6.34 Thrombolytics) primarily relies on the use of drugs that dissolve clots such as tissue plasminogen activator (TPA) which has significantly reduced the morbidity and recovery rate for patients who experience a stroke. However, as with

MI, this agent must be delivered very quickly after the onset of symptoms in order to be effective. In addition to 'clot busters' like TPA, other forms of therapeutic management rely on treating some of the other underlying risk factors such as hypertension or cardiac disorders (e.g., atrial fibrillation or damaged heart valves) that promote blood clotting. Newer forms of management include cerebral angioplasty or carotid endarterectomy that may be used to improve cerebral blood flow. In spite of these new techniques and agents for treatment, the primary methodology employed to manage stroke patients is appropriate physical and mental therapy to overcome the disabilities that normally accompany the event.

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