The Center for Brain and Neuro Care is dedicated to providing the best prevention, diagnosis, treatment, care and outcomes for patients with a wide range of cerebrovascular disorders.

Dr. Gunawardane is Board certified in Stroke (cerebrovascular disease) and Neurosonology. At our Center’s Stroke Clinic, we are uniquely positioned to help patients who have suffered a stroke and need the care of a neurologist.

The Center serves:

Emergent patients – Those who have just suffered a stroke or cerebral hemorrhage. A stroke specialist will be available to provide acute stroke treatment at Howard County General Hospital

Patients who need follow-up care in the stroke clinic.

When developing treatment plans for our patients, we focus on a multidisciplinary approach.  Patients will be educated about stroke risks factor modification and have yearly screening for blood vessel narrowing and blood clots.

If you think you may be having a stroke, call 911 or your local emergency number immediately. There are effective therapies for stroke that must be administered at a hospital within the first 3 hours after stroke symptoms appear. If you get to the hospital within those 3 hours, you will be able to receive the clot-busting agent tPA. CT scans, magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) may be used to reveal the cause of the stroke and pinpoint blockages or reveal malformations.

At the Center for Brain and Neuro Care, we treat all types of stroke:

+ Ischemic stroke

+ TIAs (transient ischemic attacks)

+ Hemorrhagic stroke

Stroke (Ischemic stroke)

A stroke that occurs when the blood supply to part of the brain is suddenly interrupted due to the presence of a blood clot is called an ischemic stroke. When blood-flow to the brain stops, brain cells no longer receive oxygen and nutrients from the blood and they die. Ischemic stroke is also known as cerebral infarction and accounts for 80 – 85% of all strokes. 

TIA

Prior to a stroke, some people suffer transient ischemic attacks (TIAs, also called mini-strokes). Many times, a TIA is a warning of an impending stroke. TIA’s generally last only 5-20 minutes but can linger for up to 24 hours before the symptoms go away.

Hemorrhagic stroke

A stroke that occurs when a blood vessel in the brain bursts, leaking blood into the spaces surrounding brain cells, is called a hemorrhagic stroke.

Question – is this about hemorrhagic stroke or something else?

Sudden bleeding in or around the brain can also cause brain cells to die. This results in temporary or permanent neurologic impairment, while hemorrhagic stroke accounts for the other 15 – 20%.

TREATMENT

A stroke is a medical emergency, regardless of whether it is a major stroke or a short-lasting TIA.  A person suffering symptoms consistent with a stroke should be taken immediately to a hospital emergency department.

The ability to quickly pinpoint the type of stroke – ischemic or bleeding type – is critically important in treatment decisions. A stroke caused by a blocked artery is treated in an entirely different way than a stroke caused by bleeding within the brain. The key to survival and recovery is prompt medical treatment.

If the stroke is caused by a blockage in an artery, medications called thrombolytics can be used. The only drug in this class approved by the Food and Drug Administration (FDA) for treatment of stroke is tissue plasminogen activator (tPA). Popularly referred to as clot busting, this medication has been used for years to treat ischemic strokes within the 3-hour window.

Surgery and Other Procedures

If the stroke or TIA is caused by a blockage, a procedure called carotid endarterectomy can be used to remove the buildup of plaque from inside the effected carotid artery, one of the major vessels supplying blood to the head and neck.

This surgical procedure is best for those who have had symptoms and have a blockage of 70% or more of one of their carotid arteries. If the narrowing of the vessel is less than 50%, medication (not surgery) is the most appropriate treatment to prevent future strokes.

If an aneurysm is present but has not bled, your doctor will discuss the possibility of removing it surgically. The decision is based primarily on the size of the aneurysm.

Complications of stroke

There are many possible complications associated with stroke.

+ Paralysis

+ Speech problems

+ Seizures

+ Cognitive (thinking) deficits

+ Emotional difficulties

+ Pain

+ Daily living problems that prevent you from living independently

+ Next steps

After your immediate treatments for stroke, there are several follow-up steps that can help you recover, including:

Rehabilitation — Helps you relearn certain skills that you might have lost. This is critical following a stroke. There are several kinds of rehabilitation including:

Physical therapy — Helps you regain those activities that may have been affected by the stroke, such as walking, sitting, lying down, and switching from one type of movement to another.

Occupational therapy — Helps you relearn eating, drinking, swallowing, dressing, bathing, cooking, reading, writing, and toileting.

Speech therapy — Helps you relearn language and communication skills. Often, non-verbal alternatives are encouraged until speech returns.

Psychological/psychiatric therapy — Helps relieve some mental and emotional stresses (such as depression) that often accompany a stroke. These feelings may be due to the location of the brain damage itself or may be a reaction to the stroke.

Acupuncture – Helps you recover, regain motor and cognitive skills, and improve your ability to manage daily functioning.  National Institutes of Health recommends acupuncture as an alternative therapy for stroke rehabilitation.

Yoga – May also help you recover after a stroke, even months later.

Nutrition and Dietary Supplements

Potentially beneficial nutritional supplements include:

+ Alpha-lipoic acid

+ Calcium

+ Folic Acid

+ Vitamin B6

+ Vitamin B12

+ Vitamin C

+ Vitamin E

+ Betaine

+ Magnesium

+ Omega-3 Fatty Acids

+ Coenzyme Q10

+ Selenium

+ Herbs

The use of herbs is another approach to strengthening the body and treating disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medicines. For these reasons, you should take herbs only under the supervision of a healthcare provider knowledgeable in the field.

Potentially beneficial herbs are:

+ Garlic

+ Ginkgo (Ginkgo biloba)

+ Turmeric

The specific symptoms of a stroke depend on which area of the brain is affected. The sooner treatment begins, the more likely it is that brain function will be preserved.

If any of these symptoms or warning signs occur, call 911 as quickly as possible.

+ Sudden weakness or numbness of the face, arm, and leg on one side of the body

+ Sudden loss of vision or dimmed vision, particularly in one eye

+ Loss of speech, or trouble talking or understanding speech

+ Sudden, severe headaches with no apparent cause

+ Unexplained dizziness, unsteadiness, or sudden falls, especially if accompanied by any of the previous symptoms

Women are more likely to report nontraditional symptoms of stroke and, in particular, altered mental states.

Ischemic stroke is caused by:

+ A clot (embolus) that travels from the heart or neck (carotid) arteries through blood vessels and then becomes wedged in a brain artery.

+ A blood clot (thrombus) that forms in a brain artery due to long standing hypertension, high cholesterol, or diabetes. This type of blood clot can attach to the artery wall until it grows large enough to block blood flow.

Hemorrhagic stroke is caused by:

+ A bleeding aneurysm, which is a weak or thin spot on an artery wall that, over time, has stretched or ballooned out under pressure from blood flow. The wall ruptures and blood leaks into the space surrounding brain cells.

+ Long standing hypertension, high cholesterol, and diabetes, which can make artery walls lose their elasticity and become brittle and thin, prone to cracking.

+ Arteriovenous malformation (AVM), which is a tangle of defective blood vessels and capillaries within the brain that have thin walls that can rupture.

Some risk factors cannot be changed.  Other risk factors can be controlled with medical treatment or lifestyle changes.

Risk factors that cannot be changed:

Age — After age 55, the incidence of stroke doubles. The older a person gets, the greater the risk of stroke.

Sex — Men are 30% more likely to have a stroke than women. But after menopause, a woman’s risk of stroke rises significantly.

Family history — Having a parent, grandparent, or sibling who has had a stroke puts you at greater risk yourself.

Race — African-Americans have a greater risk of stroke than Caucasians. This is related to an increased risk of high blood pressure, obesity, and diabetes in African-Americans.

Heart attack – If you have had a heart attack in the past, you are more likely to have a stroke than someone who has not had a heart attack.

History of migraine headaches — Recent studies indicate that people with migraines may be at higher risk for ischemic stroke.

Prior stroke — If you have had a stroke, you are at increased risk for another.

Sickle cell anemia — People with this condition are at risk for stroke at a younger age.

Berry aneurysms — These aneurysms may rupture without warning, causing bleeding within the brain.

Risk factors that can be controlled with medical treatment:

High blood pressure (hypertension) — Regular blood pressure checks are important. High blood pressure can be easily and successfully controlled with medication.

High blood cholesterol levels — Studies have shown that lowering cholesterol levels by changing your lifestyle and taking medication can reduce the risk of stroke by as much as 30%. Keeping cholesterol low can reduce the risk of blood clots and plaque buildup within the walls of arteries in the brain.

TIAs (“mini-strokes”) — TIAs can be warning signs that you might soon have a stroke. So do not ignore TIAs. 50% of people who have had a TIA suffer a stroke within one year. It is very important to seek medical attention as soon as a TIA happens. There are definite steps you can take to help prevent a major stroke from happening.  Your doctor may prescribe blood thinners such as aspirin, warfarin (Coumadin), or other drugs to prevent blood clot.

Cardiovascular disease — Certain disorders of the heart or blood vessels, such as atherosclerosis (plaque buildup in artery walls) and atrial fibrillation (an abnormal heart rhythm), can cause blood clots that may break loose and travel to the brain. These conditions can be  treated with blood thinners like Coumadin, Pradaxa, or Xeralto to reduce risk of stroke.

Diabetes — People with diabetes are more at risk. Type 2 diabetes (often called adult onset) can be affected by certain lifestyle factors, particularly diet and excess weight.

Blood clotting disorders — Some people form blood clots more easily than others. These are called hypercoagulable conditions. Protein C , S deficiency, Factor 5 lyden mutation, increased homocystein, and lupus anticoagulant disease are some of the rare  causes of stroke. Hypercoagulable states are also treated with blood thinners such as warfarin (Coumadin) to try to prevent stroke and other complications.

Sleep apnea — People with sleep apnea have 3 – 6 times the risk of stroke compared to people who do not have this disorder.  It is generally treatable by losing weight and using a special device called a CPAP machine.

Risk factors that you can change:

Cigarette smoking — Cigarette smoking has been linked to strokes, as well as heart attacks, artery disease in the legs, and lung cancer. Nicotine raises blood pressure, carbon monoxide reduces the amount of oxygen the blood can carry to the brain, and cigarette smoke makes the blood thicker and more likely to clot. It is never too late to give up smoking.

Smoking and birth control pills — Research shows that smoking and taking birth control pills significantly increases a woman’s risk for stroke. Together, they can cause blood clots to form. Women who take birth control pills should not smoke.

Drinking large amounts of alcohol – Frequent intoxication can make a person more likely to experience bleeding in the brain (heamorhage). Alcohol in large amounts can raise blood pressure.

Obesity — Being overweight increases your risk of having a stroke, along with other health problems.

Lack of exercise — Moderate exercise can help keep blood pressure and cholesterol levels within normal ranges.

Poor diet — A diet high in fat and sugar can cause conditions  — such as  type 2 diabetes, and high cholesterol — that contribute to a greater risk of stroke.

Stress — Ongoing stress can raise blood pressure. Plus, not dealing well with stress can contribute to unhealthy habits such as smoking and overeating. Finding healthy ways to handle stress is important.

Other factors that may put you at increased risk for stroke include pregnancy, infection or inflammation, gum disease, and high homocysteine levels. Homocysteine is an amino acid that rises in the body if you have low levels of vitamins B6, B12, B9 (folic acid).

The best way to prevent stroke is to reduce your risk factors:

+ Treat and control high blood pressure and high cholesterol

+ If you smoke, stop smoking — many excellent smoking cessation programs are available; your health care provider can advise you about tools to use, such as the nicotine patch, as well as exercise and other changes in your activities.

+ Keep your weight within normal limits.

+ Exercise regularly; try for 5 days a week.

+ Eat a diet that is rich in fruits, green leafy vegetables, fish, whole grains, and nuts (especially walnuts).

+ If you have diabetes, keep it under good control.

If you have heart disease or an abnormal heart rhythm, work with your doctor. Certain problems with the heart and blood vessels, such as atherosclerosis and atrial fibrillation, can cause blood clots to form. These clots can travel through the bloodstream and block an artery in the brain, causing a stroke (or can block a blood vessel in the heart and cause a heart attack).

Medications for prevention

+ Antiplatelet agents — These include aspirin and stronger prescription drugs like clopidogrel (Plavix). In one study, aspirin therapy reduced the risk of cardiovascular events, including stroke, by 21%. These drugs help keep tiny blood cells called “platelets” from clumping together in the bloodstream.

+ Anticoagulants — These drugs also prevent clots, but are much stronger than antiplatelet agents. Common anticoagulants are warfarin (Coumadin), Xeralto, Pradaxa and heparin (which is generally given at the hospital through injection into a vein).

Sub-links to the complete dietary supplement information

Nutrition and Dietary Supplements

Alpha-lipoic acid. Alpha-lipoic acid works together with other antioxidants, such as vitamins C and E. It is important for growth and helps to prevent cell damage.

Calcium – (what do you want to include here about benefits post-stroke?)

Folic Acid, Vitamin B6, Vitamin B12, and Betaine. Many clinical studies indicate that patients with elevated levels of the amino acid homocysteine are as much as 2.5 times more likely to suffer from a stroke than those with normal levels. Homocysteine levels are strongly influenced by dietary factors, particularly vitamin B9 (folic acid), vitamin B6, vitamin B12, and betaine. These substances help break down homocysteine in the body.

Some studies have even shown that healthy individuals who consume higher amounts of folic acid and vitamin B6 are less likely to develop atherosclerosis than those who consume lower amounts of these substances. One recent study found that lowering of homocysteine with folic acid and vitamins B6 and B12 reduced the overall risk of stroke, but not stroke severity or disability.

Magnesium. Population-based information suggests that people with low magnesium in their diet may be at greater risk for stroke. Some preliminary scientific evidence suggests that magnesium sulfate may be helpful in treating a stroke or transient ischemic attack. More research is needed to know for certain if use of this mineral following a stroke or TIA is helpful.

Omega-3 Fatty Acids. Strong evidence from population-based studies suggests that omega-3 fatty acid intake (primarily from fish) helps protect against stroke caused by plaque buildup and blood clots in the arteries that lead to the brain. In fact, eating at least 2 servings of fish per week can reduce the risk of stroke by as much as 50%. However, people who eat more than 3 grams of omega-3 fatty acids per day (equivalent to 3 servings of fish per day) may be at an increased risk for hemorrhagic stroke.

If you are pregnant, the U.S. Food and Drug Administration (FDA) recommends that you limit eating fish that have high levels of methyl mercury, such as tuna, shark, and swordfish.  Methyl mercury has a potential risk to your fetus.

Vitamin C. Having low levels of vitamin C can cause damage to blood vessels and may lead to a stroke. Vitamin C supplements may also improve cognitive function if you have suffered from multiple strokes.

Vitamin E. Eating plenty of foods rich in vitamin E, along with other antioxidants like vitamin C, selenium, and carotenoids, reduces your risk for stroke. In addition, low levels of vitamin E in the blood may be associated with risk of dementia (memory impairment) following stroke. Animal studies also suggest that vitamin E supplements, possibly in combination with alpha-lipoic acid, may reduce the amount of brain damaged if taken prior to the actual stroke.

Coenzyme Q10 — Co Q10 works as an antioxidant and may reduce damage following a stroke. However, it may interfere with some blood-thinning medicines, such as warfarin (Coumadin) and others.

Selenium — Low levels of selenium can worsen plaque build up (atherosclerosis). However, it is not known if taking selenium supplements will help.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, you should take herbs only under the supervision of a health care provider knowledgeable in the field.

Garlic. Clinical studies suggest that fresh garlic and garlic supplements may prevent blood clots and destroy plaque. Blood clots and plaque block blood flow and contribute to the development of heart attack and stroke. Garlic may also be beneficial for reducing risk factors for heart disease and stroke like high blood pressure, high cholesterol, and diabetes. If you have diabetes, or take statins for high cholesterol, talk to your doctor before using garlic supplements. 

Ginkgo (Ginkgo biloba). Gingko may reduce the likelihood of dementia following multiple strokes (often called multi-infarct dementia). It may help to prevent blood clot formation and may decrease the amount of brain damage following a stroke. More research in humans is needed.  Ginkgo should not be used with the blood thinner warfarin (Coumadin) unless specifically instructed by your health care provider.

Turmeric (Curcuma longa). Turmeric may help reduce stroke and heart attack by lowering the bad cholesterol (LDL) that causes plaque build up.  It can also prevent platelet build up along damaged blood vessels that can lead to blood clots. However, turmeric can cause your blood to thin, so if you are taking blood thinners like Coumadin, you need to consult your doctor.