Cerebrovascular disease: an introduction
People with diabetes are at increased risk for cerebrovascular disease, a group of disorders affecting the brain that result from problems with the blood vessels that supply the brain with blood. We know that the key causes of cerebrovascular disease are abnormal lipids and high blood pressure (also called hypertension), both of which contribute to atherosclerosis.
Even though this is scary information if you’ve been diagnosed with type 2 diabetes, you can also look at it as an opportunity to make changes that will help you lead a healthier life. To lower your risk for cerebrovascular disease, you can start today by:
- Keeping blood pressure under controlled
- Getting and keeping abnormal lipids under control
- Kicking the habit if you smoking
- Moderating your consumption of alcohol (no more than 2 drinks per day (2 12 oz beers, 10 oz wine, or 3 oz 80-proof whiskey) for men and no more than 1 drink per day for women and lighter-weight men)
- Controlling your elevated blood glucose
- Losing weight and keeping it off (if you are overweight or obese)
- Getting regular exercise of moderate intensity
In atherosclerosis, a build-up of fatty deposits (called plaques) on the inner wall of the artery causes an artery to become narrow, constricting the flow of blood. When atherosclerosis is present in the arteries that feed the brain, there is a risk that plaques will rupture, causing a blood clot to form and travel down the artery toward the brain, where it can block the flow of blood to a section of the brain. It is this blockage that causes an ischemic stroke (the most common type of stroke, in which the blood flow to the brain is interrupted). People with diabetes have a 2 to 4 times greater risk of having a stroke compared to people without diabetes. Almost a quarter of all strokes that occur in the US result from the complications of diabetes alone or in combination with hypertension.1,2
In addition to ischemic stroke, which accounts for more than 8 out of 10 strokes, there is another type of stroke called the hemorrhagic stroke, which results from the rupture of a blood vessel within the brain.1
If you have type 2 diabetes, by making the healthy life choices listed above not only can you lower your risk for stroke, but since people with diabetes tend to also have worse outcomes if they have a stroke, you can protect yourself from severe disability and possible death.
Stroke warning signs and symptoms
|Weakness or numbness||Affecting the face, arm, or leg, typically on one side of the body|
|Speech problems||Speech loss or difficulty understanding speech|
|Vision problems||Dimness or loss of vision that occurs suddenly and typically affects only one eye|
|Headache||Severe, sudden headache with no apparent cause|
|Dizziness||Unsteadiness, loss of balance, or sudden falls (usually accompanied by some of the symptoms listed above)|
What are the signs and symptoms of a stroke?
When a stroke happens, there is an interruption in the flow of blood to the brain or part of the brain. Several characteristic signs and symptoms appear when the brain stops getting the blood (and oxygen) it needs. These include:
- Sudden weakness or numbness in the area of the face, arm, or leg (typically this occurs only on one side of the body)
- Vision problems, including a loss of vision or sudden dimness in one eye (loss of vision may progress from top to bottom in the eye)
- Difficulty speaking or understanding speech
- Dizziness (vertigo)
- Severe headache
A stroke can range greatly in severity. In fact, you can have what is known as a “mini” stroke or a transient ischemic attack (TIA), where blood flow to the brain is temporarily interrupted, resulting in some or all of the symptoms listed above. Typically, symptoms resolve after about 5 to 15 minutes. A TIA is different from a stroke in that the symptoms last for a short time and they are reversible. With a stroke, blood flow to the brain is typically interrupted for a much longer period and permanent damage occurs. If you or someone you care for experiences the symptoms of a stroke, it is critically important to get help quickly. If they are having a TIA and receive treatment in a timely manner, the risk of a subsequent stroke can be decreased. If they are having a stroke, getting rapid medical treatment can be the difference between minimal and severe brain damage.
You can reduce your risk of stroke
If you have diabetes, your risk of cerebrovascular disease and stroke is greater than a person without diabetes. However, you can take steps to reduce your risk, by identifying the modifiable factors that increase your risk stroke and, through a combination of lifestyle changes, medications, and, in some cases, surgery (eg, carotid endarterectomy, balloon angioplasty with stenting), you can lower your risk and lead a healthier life.
What are the risk factors for stroke?
There are a number of factors that increase your risk for cerebrovascular disease including stroke. Some of these are factors that you can not change, such as your family history (if your parent or sibling has cardiovascular disease or has had a stroke), your race (African Americans are significantly more likely to have a stroke than Caucasians), your gender (men are at greater risk for stroke than women), and age (as you grow older your risk increases). While some stroke risk factors are outside of our ability to control, there are many more that we can do something about. These make up a long list of factors that will be familiar to you from other types of cardiovascular disease, including:
- High blood pressure
- Abnormal lipid levels
- Heart disease
- Consumption of high amounts of alcohol (more than 2 drinks per day (2 12 oz beers, 10 oz wine, or 3 oz 80-proof whiskey) for men and more than 1 drink per day for women and lighter-weight men)
- Use of drugs that increase stroke risk
- Uncontrolled of blood glucose
- Being overweight or obese
How can I reduce my risk for stroke?
You can take a several very powerful steps to decrease your risk for stroke (as well as heart disease), including3:
Stop smoking (if you smoke).. Cigarette smoking promotes a number of health problems, including cerebrovascular disease. If you have type 2 diabetes and smoke, you should consider stopping. Talk with your doctor about your options for quitting smoking. There are many smoking cessation programs and some medications that you can use to help you kick the habit. Keep in mind that quitting smoking is hard to do and often takes several attempts. You may need some help, so talk to your doctor about what you can do to kick the habit and don’t give up until you’ve succeeded!
Get and keep your blood pressure under control at or below your target level, using lifestyle modifications and/or medication. The American Diabetes Association (ADA) recommends that you keep your blood pressure below 140/80 mmHg or perhaps lower (130/80 mmHg) if you are in a certain patient group.4)
Keep your low-density lipoprotein (LDL) cholesterol and triglyceride levels under control at or below target levels, using lifestyle modifications and/or medications (specifically statins). LDL cholesterol level should generally be below 100 mg/dL and in some cases below 70 to 80 mg/dL. Talk to your doctor about what your lipid targets should be as they can depend on underlying illnesses or health conditions.5
Consider taking aspirin. Daily low-dose aspirin (75-162 mg per day) is recommended for some people with type 2 diabetes who are at risk of cardiovascular disease. Daily low-dose aspirin is recommended by the ADA for people with type 2 diabetes who are at increased risk for cardiovascular disease, including most men over the age of 50 years and women over the age of 60 years who have at least one additional major risk factor for cardiovascular disease (family history of cardiovascular disease, high blood pressure, smoking, abnormal lipids, or albuminuira).4
Consider taking aspirin.Daily low-dose aspirin (75-162 mg per day) is recommended for some people with type 2 diabetes who are at risk of cardiovascular disease. Daily low-dose aspirin is recommended by the ADA for people with type 2 diabetes who are at increased risk for cardiovascular disease, including most men over the age of 50 years and women over the age of 60 years who have at least one additional major risk factor for cardiovascular disease (family history of cardiovascular disease, high blood pressure, smoking, abnormal lipids, or albuminuira).4
Get and keep your blood sugar under control. It is necessary to keep your blood sugar under control to prevent many of the complications of diabetes, heart disease included. For many people, this will involve monitoring your blood sugar and checking it with a blood glucose meter. For most people the target before a meal is 70 to 130 mg/dL. Make sure you check with your doctor to determine your target blood sugar level, as it can vary from person to person depending on individual factors4
Get regular moderate exercise. Regular exercise can help you lower your risk for heart disease and can benefit you in many other ways if you have diabetes. Talk to your doctor before you start an exercise program.
If you are overweight, lose weight and keep it off. Try to lose 5% to 10% from your starting weight and keep as much of this weight off as possible.
Moderate your consumption of alcohol. If you have diabetes, you should limit your consumption of alcohol to no more than 2 drinks per day (2 12 oz beers, 10 oz wine, or 3 oz 80-proof whiskey) for men and no more than 1 drink per day for women and lighter-weight men6
Avoid using drugs that increase stroke risk. Many drugs, including prescription and recreational drugs, may increase your risk for stroke. These include cocaine, amphetamines, LSD, diet medications, ergot derivatives, and certain birth control medications. These drugs can cause increases in your blood pressure and increase your risk for stroke. Talk to your doctor about any and all drugs and medications (both prescription and nonprescription, recreational and otherwise) you are taking and whether they increase your risk for stroke.
Are there medical or other treatments that lower risk for stroke?
In addition to making healthy lifestyle changes, there are several medications that are useful in reducing risk for stroke or recurrence of stroke. These include platelet antiaggregants and anticoagulants.
Platelet antiaggregants are effective at reducing risk for vascular events after an initial stroke and are recommended over oral anticoagulants (such as warfarin [Coumadin]) for people who have had an ischemic stroke not caused by a clot that formed in the heart. Specific types of platelet antiaggregants include aspirin, clopidogrel (Plavix), dipyridamole combined with aspirin (Aggrenox).
(also called blood thinners), including warfarin (Coumadin), are used to prevent the recurrence of a stroke in people who have had a stroke caused by a clot that formed in the heart.
In addition to medications, a surgical procedure called an endarterectomy may be a useful treatment approach in a person who has had a TIA or a mild-to-moderate stroke and has significant blockage (more than 50%) in the carotid artery. In an endarterectomy, the carotid artery in the neck is opened up and plaque build-up in the artery is removed surgically.
How is a stroke diagnosed?
Your doctor will diagnose a stroke based on characteristic symptoms. Use of imaging techniques, including a brain computed tomography (CT) scan or magnetic resonance imaging (MRI) can help your doctor further determine whether the stroke is ischemic or hemorrhagic. A scan of the carotid artery using ultrasound is sometimes used to determine whether the artery is narrowed or completely blocked. However, angiography used in combination with CT scan (called computed tomography angiography [CTA]) is a more reliable way to visualize the blood vessels to determine the extent of blockage in the artery feeding the brain.
How is stroke treated?
Treatment of stroke depends on the specific type of stroke you have and its severity. In general, following a stroke, a person is typically admitted into the hospital and is cared for by a neurologist. If an ischemic stroke can be treated within 3 hours the time it begins, a drug called a tissue plasminogen activator may be used to help dissolve the clot. After a person has been stabilized following a stroke, a multi-disciplinary team of experts in rehabilitation medicine (including a dietitian, speech therapist, physical therapist, occupational therapist, and physical medicine therapist) will assist in recovery from the stroke.