After a stroke, what do we need to know?

August 4, 2009 6:28 AM

About 4 weeks ago, my father had a stroke. He's more or less recovered now and is finally going to see a neurologist for his follow-up. What questions should he ask?

Four weeks ago, my father woke up feeling very dizzy and sluggish. He couldn't find his footing to get out of bed and found it very difficult to walk for the rest of the day. He had no numbness, or paralysis, and no loss of cognitive function. About six hours into the day as these symptoms persisted, someone in the family suggested he go to the emergency room (good call). The doctors there said he had had a stroke, but that it was a mild stroke, as there were no signs of damage on the tests they performed (catscan and ekg). Further tests have been done since by his General Practitioner and he's been given the OK to resume his usual routine, drive a car, etc.

A brief medical history of my dad:

My father is 65 years old. He's in relatively good shape, maybe 15 lbs overweight (he's 6 ft, weighs about 205-10). He's moderately active, plays golf weekly at least (he does not use a cart or a caddy). His cholesterol levels are within tolerable levels, and he does not have high blood pressure. He doesn't smoke or drink alcohol. He has been living with Crohn's disease for about 30 years (a moderate case, managed with medication).

His father died of a heart attack in his seventies. His mother died of a stroke at almost 90. His risk factors for stroke are really quite low, so this came as quite a surprise to him and the whole family.

So, he's going to see a neurologist tomorrow to talk about his test results. My mother is convinced they need to do a more detailed MRI, and they're going to ask the obvious questions like, "what caused this?" and "Do we have any way of preventing another one". But I want them to go in with more. What are some questions, obvious and not-so-obvious, that my mother and father should be asking at this appointment?

posted by wabbittwax to health & fitness (7 comments total)

1) Does the meds your father is one for Crohn's Disease have any effect on blood clotting?
2) What are the early warning signs of strokes? This is for the whole family, in case it happens again. In a stroke, time is *everything* -- the faster treatment starts, the faster blood flow can be restored, and the less damage caused.
posted by eriko at 6:50 AM on August 4

Sorry to hear about your dad, but it's awesome that he's made a full recovery.

Mr. Maisie had a small stroke about 6 years ago after being otherwise completely healthy and normal for his whole life up until the stroke. It turned out that he has a PFO, which is a small hole between the chambers of his heart. That condition can result in small blood clots being formed in the heart that then get sent out to the body. They had to do a special test to detect this and as a result of finding this, the doctor changed Mr. M. from Plavix to warfarin. You may want to ask about that test. Unfortunately, the root cause of a surprisingly high percentage of strokes is never found.

Also nthing finding out about the early warning signs of a stroke.

Good luck!
posted by Maisie at 8:33 AM on August 4

My husband had a pretty severe midbrain stroke last fall at age 37. They could find no cause and the neurologist just wrote it off as bad luck. Luckily, our family
dr kept digging and we found out that he has a blood disorder that makes him clot too quickly. I'm telling you this to be sure that you make sure you find out why he had a stroke and then you can address that problem. My husband has healed very well, took time but he's doing fine. Best of luck to you and your family. Stroke is a difficult thing.
posted by pearlybob at 9:01 AM on August 4

I don't have a direct answer to your question, but I would strongly recommend reading Dr. Jill Bolte Taylor's My Stroke of Insight or listening to her TED talk. The book has some great information on how to help people that suffered from a stroke.
posted by TNOTGILL at 9:49 AM on August 4

Disclaimer: I am not a neurologist but this is how I think about working up and treating stroke.

I am going to assume that your father suffered from an ischemic stroke (that is, as opposed to a hemorrhagic stroke). If he was admitted to hospital he likely had a workup similar to the one I will describe. As far as I know, this is pretty much standard of care at a Canadian hospital (my working environment).

Diagnosis: CT is completely adequate. Sometimes, if we see nothing on a CT and are still really suspicious of stroke or other CNS pathology we may order an MRI. If the stroke showed on a CT you have your diagnosis and there is usually little reason to go for MRI.

Looking for risk factors:

1) Echocardiogram (ultrasound of the heart) to look for PFO as mentioned above or septal aneurysm, cardiac thrombus or any other abnormalities that may indicate the clot was thrown from the heart.

2) Carotid dopplers to look for narrowing of the carotid arteries secondary to atherosclerotic plaques. There are evidence based guidelines as to what to do if narrowing is found. He had a stroke so is, by definition symptomatic, so the management plan would depend on how much narrowing was found. A very narrowed (stenotic) carotid artery may require surgery.

3) Holter monitor to look for arrhythmias (eg paroxysmal Atrial Fibrillation) that make the flow through the heart abnormal leading to stasis of blood and the risk of forming blood clots in the heart that can break off and travel to the brain.

4) In young people (in whom it is unusual to have stroke) we may do a complex hematologic workup looking for clotting disorders as in the case of pearlybob's husband. This is usually not done in older people (your dad among them) where stroke is by far more likely to be due to the usual mechanisms not some esoteric clotting disorder.

Medications for prevention:

In addition to any intervention that may be done if something is found in the workup outlined above, there are also a number of meds that pretty much anybody with a history of stroke should be on (barring allergies, inability to tolerate the meds etc) These are as follows:

1) Antiplatelet therapy to prevent thrombosis: aspirin, plavix or aggrenox

2) Cholesterol lowering agents: namely a statin such as atorvastatin (lipitor). You mentioned that your father has tolerable cholesterol levels but, even so, most docs would recommend a statin as there is good evidence that this has some morbidity benefit for people with stroke.

3) Blood pressure control: There are many agents for this but often ACE inhibitors (eg ramipril) are used as there is evidence to show benefit in stroke.

Whew. Sorry about the long post. I may well have missed some things but I think I covered the basics. As I said before, your father has probably already had a similar workup but you may want to ask about specifics. There may be reasons as to why certain things are different from what I described in your father's case - medicine isn't a cookbook and your fathers MD is much better equipped to make these decisions with you that a random person on the internet (ie me!).
posted by madokachan at 1:13 PM on August 4 [2 favorites]

A very narrowed (stenotic) carotid artery may require surgery.

My dad had a TIA (transient ischemic attack), which is a kind of "Stroke Jr", a stroke that doesn't leave aftereffects. They think it was caused by narrowing of the carotid artery, and he had surgery (called an endarterectomy) that basically amounted to opening the artery and scraping out some of the gunk that was narrowing the passage. The surgery and recovery were relatively easy. (Obviously I have no idea what's happening in your dad's case, just giving you a search term to look up before the appointment.)
posted by LobsterMitten at 6:41 PM on August 4

You might also want to ask if there are any signs of lingering damage from the stroke, which might show up gradually over the next few months. (motor problems, verbal problems, etc) I'm imagining these might be different from the things you would look for to recognize a new stroke happening.
posted by LobsterMitten at 6:44 PM on August 4