Silent Strokes: What You Should Know

If you have never had the outward symptoms of a massive stroke and think you are in the clear, think again.  Researchers are finding that more than 11 million Americans suffer from a silent stroke every year.  This is far more than the 750,000 people who have traditional, symptomatic acute strokes.  If you have high blood pressure, high cholesterol, or out of control diabetes, you are at risk for these quiet, symptom-free brain strokes.  Chances are you won’t even know you had one, and they can cause medical issues that may be attributed to other conditions.  Learning about silent strokes – and how to avoid them – is important for all stroke patients over 50, especially if you have risk factors.

Defining a Silent Stroke

A silent stroke means that you do not experience the traditional symptoms of a massive stroke, such as one-sided paralysis, difficulty speaking, or headache after a stroke.  Silent strokes can happen in the same way that regular acute strokes occur.  For instance, either a clot stroke or a bleed stroke can lead to this smaller form of stroke.  The only way you will ever know if you had a silent stroke is if you have a CT scan or an MRI of the brain.  These tests will show a small area of dead brain tissue, usually in an area that does not typically cause traditional acute stroke symptoms.  If you have a silent stroke, it makes you even more susceptible to a transient ischemic attack (TIA) or a massive stroke.

Many different risk factors can lead to a silent stroke.  The most common ones are high blood pressure that is uncontrolled by medication and high cholesterol.  Both of these can lead to clots strokes and bleed strokes in the brain that are too small to cause normal symptoms of a massive stroke.  Atrial fibrillation is another leading cause of stroke.  This is the abnormal beating of one part of your heart that can cause clots.  Diabetes mellitus is another common risk factor for silent strokes.  Metabolic syndrome, a precursor for diabetes, chronic inflammation as indicated by c-reactive protein levels, and cigarette smoking round out the risk factors from which you need to protect yourself.

Silent Stroke and Memory

You might think that having a silent stroke does not affect your life and is not something you should concern yourself with.  In fact, silent strokes can cause memory loss, and this sign is often wrongly interpreted as Alzheimer’s disease.  You can have more than one silent stroke, and the sum consequence of the many minor damages can lead to an overall decline in cognitive ability.  It happens slower than a regular acute stroke, so your doctor may not even be aware that a silent stroke is causing your memory and cognitive problems.

A study published in 2011 in the Journal of Neurology studied 658 people with an average age of 79 and no history or dementia.  They found that 174 people had silent strokes, and these stroke patients did not perform as well as non-stroke patients in cognitive and memory function tests.  If you are having mental decline, it might be worth it to ask for an MRI and also to control your risk factors.

Silent Stroke and Sleep Apnea

New research is showing that one of the more deadly side effects of sleep apnea is the tendency to cause silent strokes.  Sleep apnea is a common condition in which you stop breathing during your sleep.  It is often caused by excess tissue hanging down the back of the throat and closing off the breathing passageway.  Most people who have sleep apnea snore quite loudly or actually gasp in their sleep.  This causes less oxygen to the brain, and sleep apnea has already been implicated in causing high blood pressure and heart failure.  The treatment for sleep apnea is a mask that blows a constant stream of air into your nose and mouth to keep the passage open.  It is often an uncomfortable treatment, and many patients are unable to tolerate the mask.  However, untreated sleep apnea can cause serious medical problems.

A study presented at the American Stroke Association’s International Stroke Conference studied stroke patients who have had strokes or TIAs to see if there was any connection between sleep apnea and acute strokes.  The study found that 91 percent of those who had previous strokes stopped breathing in their sleep.  Since silent strokes and acute strokes occur from the same mechanism of action in the brain, this means that those with sleep apnea are at high risk of silent strokes, as well.  Research is still underway to determine if the lack of oxygen somehow upsets the vasculature in the brain to cause an acute stroke or silent stroke.  The message is clear, though: if you snore or have diagnosed sleep apnea, you need to seek treatment for it to avoid this costly side effect.

References

Wikipedia; Silent Stroke

http://en.wikipedia.org/wiki/Silent_stroke

ABC News; Study: Million Suffer Silent Strokes; Daniel Q. Hanley

http://abcnews.go.com/Health/story?id=117615&page=1

ABC News; Silent Strokes Linked to Memory Loss in Older Adults; Lara Salahi; December 2011

http://abcnews.go.com/Health/w_AgingNews/silent-strokes-linked-memory-loss-older-adults/story?id=15253301

Huffington Post; Sleep Apnea, Silent Strokes Linked: Study; February 2012

http://www.huffingtonpost.com/2012/02/02/sleep-apnea-silent-stroke_n_1248119.html

Antidepressants and stroke risk

Recently, a new study was published online in the American Journal of Psychiatry which revealed that there is a link between antidepressant therapy and the increased risk for stroke (http://ajp.psychiatryonline.org/cgi/content/abstract/168/5/511).

Dr. Susan Shur-Fen Gau, MD, PhD, professor and chairperson of the Department of Psychiatry at National Taiwan University and senior author of the study said that the results of their study had shown proof which reinforces their hypothesis on acute exposure to antidepressants, most especially those medications which prevents serotonin transport, and increased stroke risk.

Serotonin

Serotonin is a hormone which operates as a neurotransmitter.  It helps relay messages from one area of the brain to another. It is manufactured in the brain where it carries out its primary function. However, majority of our serotonin supply can be located in our digestive tract and in our blood platelets.

Aside from being a neurotransmitter, it also influences a number of our psychological and physiological body functions. It affects our mood, sexual desire and function, appetite, sleep, memory and learning, regulates body temperature and other social behavior.

Depression

It is a common misconception that depression is associated with feelings of sadness or gloom. The National Library of Medicine clears this out by defining it as more than just a feeling but involves the following symptoms:

• loss of interest of activities previous enjoyed
• a change in weight and/or sleeping habits
• energy loss
• feeling “less valued” in life

According to the NLM, the usual causative factors of depression are genetic, environmental, psychological and biochemical factors. Based on statistics, illness is more common in women. The disparity of depression between males and females can be attributed to coping with menstrual cycles, pregnancy and menopause according to the website of the Mayo Clinic. The NLM also said that it can develop as early as 15 years of age. This can be credited to girls typically reaching puberty before boys. It is believed that the frequent hormonal changes during the stage of puberty greatly increase the risk of developing depression in some women.

Treatment of the disorder includes taking antidepressant medications and undergoing talk therapy. Patients may also do best by using both treatments.

Serotonin and depression

Scientists believe that an imbalance in serotonin levels in our body leads to depression. They identified these problems as decreased production of serotonin by the brain, decreased number of receptor sites which can absorb serotonin, the inability of serotonin to reach these receptor sites and the shortage of tryptophan (the chemical from which it is made from). Aside from depression, if these problems occur a person may experience other mental health illnesses such as obsessive-compulsive disorder, anxiety, panic and even anger.

Antidepressant medications

The most common types of antidepressants are called selective serotonin reuptake inhibitors (SSRIs). These medications block the absorption of serotonin on other areas of the body which results to a higher level of serotonin which can be absorbed by receptor sites in the brain. The most common medications are Fluoxetine (Prozac), Citalopram (Celexa), Sertraline (Zoloft), Paroxetine (Paxil) and Escitalopram (Lexapro).

Antidepressant use and stroke risk

Chi-Shin Wu, MD, from Far Eastern Memorial Hospital and a co-author of the study said that depression is known to be an independent risk factor for stroke but whether treating depression with antidepressants reverses this risk is not known.

The authors said that there are increasing concerns on antidepressant therapy and its effects on the cerebrovascular system. This is a result of the growing body of evidence which had shown that antidepressants, most notably SSRIs, can cause bleeding problems and vasoconstriction of the large arteries of the brain.

Dr. Wu and his co-authors made their study to shed more light on whether antidepressant medications do cause cerebrovascular events. Their study involved 24,214 stroke patients who were enrolled in the National Health Insurance Research Database of Taiwan from the years 1998-2007.

Dr. Wu and his study team evaluated the rates of antidepressant medication use by the stroke survivors within a week, two weeks and for one month. They found out that the stroke patients had a mean age of 68.6 years when they had their stroke. They noted that almost half (48.3%) of the subjects were women and that 8789 (36.3%) stroke patients had mood disorders. They also observed that majority of the subjects (75.9%) had experienced an ischemic stroke.

Dr. Wu and his team said that the risk for a stroke grew by 48% if the use of anti-depressant medication was 2 weeks prior to the stroke. But, they did note that there was no association between stroke and the number of antidepressant prescriptions of the previous year.

They added that there was no link between taking antidepressant medication and stroke risk in the two weeks before the stroke for patients who are already taking 3 to 5 antidepressant prescriptions in the previous year. They did point out that the risk of having a stroke is decreased for patients who were already taking more than 6 antidepressant prescriptions. On the other hand, patients taking 1 to 2 antidepressant medications had a greater risk of stroke. They also emphasized that there is an increased risk of stroke for patients who use SSRIs than other types of antidepressant medications.

The authors of the study stated that their findings are similar with previous studies which had shown that a high inhibition of the serotonin transporter can cause a more potent anti-platelet effect and is more associated with a higher risk of abnormal bleeding in other organ systems.  They also pointed out that patients taking high-potency serotonin inhibitors were associated with a greater risk of having an ischemic stroke. They theorized that this is a result of antidepressant-induced constriction of the blood vessels of the brain.

These results made the study team comment that underlying mechanisms for stroke risk in relation to antidepressant use should be investigated more.  They made this assessment after also finding out that patients who were long-term users of antidepressants may actually be protected against a stroke.

These paradoxical findings need to be further studied. They said that the results may indicate that the frequency of exposure to antidepressant medications changes over time. They also hypothesized that their results might have been influenced by other factors such as emotional distress. They also pointed out that using a database as reference is not a sure fire way of measuring adherence to the medications.

In spite of these limitations, they still believe that the results of their study have a major clinical and public health implication. They suggested that patients start with low doses of antidepressants while monitoring side effects most especially to patients who are at a greater risk of having a cerebrovascular event because stroke risk appears to be more of dose related and more noticeably during the first few prescriptions.

Inconsistent Findings

Patients who were taking low-potency serotonin inhibitors should not rejoice prematurely.  The team pointed out that the use of low-potency serotonin inhibitors is associated with a higher risk for any stroke type.

Dr. Gau repeated their team’s prior recommendation of closely monitoring patients who were newly started on antidepressant medications. She said that antidepressant therapy should be started at low doses and closely monitoring the side effects for initial prescriptions most notably for patients with a higher stroke risk. She added that patients who were at a greater risk for stroke should be advised to use other antidepressant with a decreased affinity of serotonin reabsorption as treatment for their depression.

Reference:

Medscape.com

Nlm.nih.gov

Ajp.psychiatryonline.org

Emedicinehealth.com

Webmd.com

Mayoclinic.com

An increased risk of stroke for patients with psoriasis

A stroke is an event in somebody’s life which truly can alter the life process of an individual and his or her family. Because of a stroke, a person might have problems with mobility, language, logic and emotions. It may also affect the normal body system of a stroke patient. It may weaken the body’s normal response to stressors. That is the usual turn of events after an acute stroke – a stroke is the cause of “something”. However, a new study has made an interesting discovery which counters the series of events after a stroke. This new study had made a link between psoriasis, an autoimmune disorder, which may cause a stroke in the future. Scientists are now looking at psoriasis as another risk factor of having a brain attack.

What is Psoriasis?

Psoriasis is a chronic or lifelong disease which affects the immune system. Its manifestation varies from person to person and response to the known treatment of psoriasis also differs from one person to another. It usually manifests as red lesions and irritations on the skin. It can manifest anywhere in the body. Lesions can form on the eyelids, on the ears, mouth and lips, skin folds, hands and feet and even on the nails.

It occurs when the body’s immune system sends out incorrect signals which speed up the growth cycle of skin cells.  However, it is neither communicable nor contagious. You could not be “infected” by a person with psoriasis and you could not infect other people if you have the disease because it is an autoimmune disorder.  An autoimmune disorder is a condition that occurs when the immune system mistakenly sees the cells of the body as “aliens” and attacks and destroys normal healthy body tissues.

It is considered as the most common autoimmune disease.  There are approximately 7.5 million people affected with psoriasis in the United States alone while all over the globe, about 125 million people are afflicted with this disorder.

A number of people with psoriasis may experience problems with self-confidence because of the lesions on the skin which is the usual symptom of the disorder.

Finding the link between psoriasis and stroke

A new study made by scientists from Denmark had found that patients with psoriasis have an increased risk of experiencing atrial fibrillation (the most common heart problem where both right and left atrium contract very fast and very irregularly) and an ischemic stroke (a stroke caused by a clot in the blood vessels in the brain) in the future. Their study is an addition to the growing body of research which had linked psoriasis with problems with the heart and blood vessels. The results of their study were published online last August in the European Heart Journal.

The link between psoriasis and stroke as well as other cardiovascular diseases can be attributed to two main reasons. First, individuals with the disorder tend to have more cardiovascular risk factors. These include obesity, smoking and having high lipid levels in the blood. Second, people with psoriasis are in a constant state of inflammation. This natural response of the body is believed to be “the link” between the two conditions.

They said that the link between psoriasis and stroke can be attributed to problems with an individual’s lifestyle. The results of the latest study theorized that all persons who have psoriasis are likely candidates for a change of lifestyle which may include smoking cessation having a healthy weight, increasing physical activity, having a healthy diet, and etc.  The latest paper also said that selected patients with psoriasis need to undergo medical treatment such as reducing hypertension, treatment which can lower lipids (fats in the body) and other medical treatments.

The scientists believe that their latest research is a step towards acknowledging the fact that the role of psoriasis as a risk factor for future cardiovascular event which includes a stroke. They also deem that their findings call for an increased awareness of cardiovascular risk factor management in people afflicted with psoriasis. And since a large number of people have the disorder, there is also a bigger problem of how to modify the lifestyles of these patients to lessen their chances of experiencing AF or a stroke in the future.

The numbers game

Using national registries of inpatient hospitalization and dispensing of medications, the researchers tried to determine the risk of having an AF and an ischemic stroke in patients with varying degrees of psoriasis (36,765 patients with mild psoriasis and 2,793 patients with severe psoriasis) and also from a large number of psoriasis-free individuals (4.5 million).

The researchers said that their study showed alarming results. They found out that the risk of having AF was increased by as much as 50% when a patient is below 50 years old and has mild psoriasis. On the other hand, an increase of 16% was observed on patients who have mild psoriasis and were older than 50. People with severe psoriasis were more prone to having AF. The researchers said that the chances of having AF rose by 198% for patients younger than 50 years of age while the chances of older patients was pegged at 29%.

The chances of having an ischemic stroke were no different from the chances of having AF.  They said that the risk of having a future ischemic stroke grew by 97% for patients who have mild psoriasis and were younger than 50 years. They painted a grim picture for people with severe psoriasis. They said that their chances of experiencing an ischemic stroke in the future were increased by as much as 180%.  They also gave a bleak prediction for older patients with mild and severe psoriasis. They said that their chances of having an ischemic stroke grew by 13% and 14% respectively.

What should be done?

The researchers proposed that patients with psoriasis should be closely monitored for any indicators of cardiovascular disease which includes arrhythmias. They also suggested that these individuals should be considered as potential candidates for interventions which can greatly reduce the risk of having cardiovascular disease. These interventions can include lifestyle modifications such as increasing physical activity, smoking cessation and even taking medications.

The researchers did point out that an important goal for future research is to evaluate the impact of changes in primary cardiovascular prophylaxis in patients with psoriasis, such as medical management.   They also revealed that an important thing to consider is whether improving psoriasis treatment such can modify the risk of having cardiovascular events in the future.

Reference:

Medscape.com

Msnbc.msn.com

Nhlbi.nih.gov

Medterms.com

Psoriasis.org

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