QUESTION 1: Your article on demystifying of stroke was very interesting and illuminating. However I want to ask is it proper to take aspirin daily along with high blood pressure drugs as prevention for stroke' I have high BP and high cholesterol. Thank you. Solomon I. S., Abuja, Nigeria.Response: This is an important question. When it comes to preventing stroke using daily aspirin, the context is very important, i.e. whether it is primary stroke prevention or secondary stroke prevention. Primary stroke prevention refers to reducing a person's risk of a first-time stroke, while secondary stroke prevention refers to reducing the risk of a repeat stroke in a person, who has already experienced a stroke.The role of daily aspirin use in secondary stroke prevention is well established ' people, who have already experienced a stroke should be taking a low (81mg also known as 'baby aspirin') to medium (325mg also known as 'adult aspirin') dose of aspirin (or drugs like it) daily to ward off future strokes.Recommendations with regard to the use of daily aspirin in primary stroke prevention (someone who has not yet experienced a stroke), which is the situation you describe in your question, are not as straightforward. The only group that seems to clearly benefit from using a daily aspirin to prevent a first time stroke, are women at or above the age of 65 years. For those people, who are not women at or above the age of 65 years, the use of daily aspirin to prevent a first time stroke is either extremely modest or non-existent, and for such individuals the focus of their stroke should largely be on properly treating their identifiable stroke risk factors.In your case, your physician should be emphasising the optimal control of your blood pressure and cholesterol. All of this notwithstanding, there may be a role for aspirin in your daily drug regimen. This would be for preventing a first time heart attack. Although you did not mention your age, men at or above the age of 40 years, especially with two or more risk factors for a heart attack (in your case high blood pressure and high cholesterol) are candidates for daily 'baby aspirin' therapy of 81mg daily to ward off a first time heart attack.Question 2: I read your article in The Guardian and I'd like to ask: How do you know when someone has a blood clot pre-stroke i.e. when it is still benign' How do you manage someone with a high BPand high cholesterol so as to prevent Stroke' I heard Lipitor is soon going off patent and may become available as a generic drug will you recommend it' Thank you.Rotimi A. (Location not provided).Response: It is indeed difficult to identify a blood clot that may cause a stroke before it occurs. First, the period between the formation of the blood clot is fairly short ' anything from a few minutes to possibly several days. As such a person will probably need to be under frequent imaging surveillance for an indefinite period of time, i.e. using CT scans or MRI scans to constantly check for blood clots, which is likely not cost-effective or practical.Second, the presence of a blood clot in an artery supplying the brain with blood does not necessarily mean it will cause a stroke ' the clot may be too small to cause symptoms or the body's own natural ant-clotting system may dissolve the clot before it wreaks any havoc in the form of a stroke.The more reasonable approach would be to identify individuals at high risk for stroke based on their clinical picture, i.e. closely monitoring and promptly treating all their personal risk factors for stroke. Such an approach has proven to be both effective and practical. Regarding the hypothetical person you mention with high blood pressure and high cholesterol, that person would greatly benefit from medications and lifestyle modification (most people need both) to bring their blood pressure and cholesterol levels to within target range, based on their personal stroke risk factor profile.Lipitor (also known as atorvastatin) is one such medication for treating high cholesterol. It is currently generic. In a study of over 4,000 stroke patients around the world, atorvastatin 80mg was shown to reduce the risk of a repeat stroke by 16 per cent and first time heart attacks by about 30 per cent.Based on subsequent analyses of this study, it appears that only patients with the ischemic or 'blood clot' type of stroke benefit, not those with the hemorrhagic or 'bleeding' type of stroke. It should be noted that there are other medications in the same drug class as atorvastatin, such as simvastatin (zocor) and pravastatin (pravachol), and it is believed that because the other medications in this drug class all generally have the same mechanism of action as atorvastatin, patients should derive benefit regardless of the agent used.Question 3: I just read your piece on stroke in The Guardian. I would say it was an excellent one and very timely as well. Please when are you going to write part 2' My dad suffered a stroke in December last year. It is the Ischemic type. The left side of his face was affected and hewas hospitalised for two weeks. He has since been discharged because the doctors felt his BP has been brought down to a manageable level. He's expected to go in every fortnight for a check. He is 74 years old, and I am very concerned about his recovery. He is expected to start classes on physio. I just would like to know if there are things you want to suggest that we do especially for speedy recovery and also for forestall second attack' Kayode F. (Location not provided).Response: I am sorry to hear about your dad's stroke. It sounds like he is in great clinical hands, so my first recommendation is that you and your family closely adhere to the doctor's instructions. Regarding recovery, the rule of thumb is that ischemic or 'blood clot' stroke patients, who survive the initial two weeks after stroke onset, tend to improve their functional level with time. This improvement in functional level is greatly aided by regular physical and occupational therapy, as well as speech and cognitive therapy (i.e. if the latter two therapies are also indicated).To put it roughly, the goal of therapy is to train the brain cells that were not damaged by the stroke, to take on some (or all) of the 'duties' of those brain cells that were damaged by the stroke. It has been shown that the degree of improvement is often most pronounced within the first three months after stroke onset, and then improvement continues albeit to a less impressive degree over the next nine months, but then approximately a year after stroke onset, most stroke patients tend to plateau, i.e. not make clinically discernible gains in their functional level.It is hard to predict at this time how well your dad is going to recover since this is based on what part of his brain was affected, the size of his stroke, your dad's age, how healthy your dad was before the stroke, etc. Unfortunately only one of 10 stroke survivors returns completely to baseline (according to information from patients and family, as well as evaluations by doctors).However, try not to be discouraged, your dad could certainly recover to his baseline or at least very close to it. This is the best time to optimize physiotherapy administered by the therapists. I am very impressed by your two-part question because understandably many stroke patients and their family members are rather focused on recovering from the stroke that just occurred, but not as focused on preventing a repeat stroke from occurring.The truth is that the single biggest predictor of stroke occurrence is having experienced a prior stroke ' almost one of every three strokes is a repeat stroke. Furthermore, and perhaps not surprisingly, the impact of a repeat stroke is often much more devastating than the prior stroke, including resulting in a much higher risk of dying. So please see my responses to the queries above.All things being equal, your father should be on a blood thinner (e.g. aspirin or clopidogrel), a cholesterol reducer (e.g. atorvastatin or simvastatin) and a blood pressure medication; maintain an ideal weight and not take more than a teaspoon of salt a day. It should be remembered that stroke patients are also at high risk for heart attacks, but fortunately the treatments for preventing stroke and preventing heart attacks are similar in many respects. All the best.
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