What to know about cerebrovascular disease

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In the United States, cerebrovascular disease is the fifth most common cause of death. In 2020, it caused 48.6 fatalities per 100,000 people, or 160,264 deaths in total.

Around 87% of strokes are ischemic strokes. Ischemic strokes result from a lack of blood flow to part of the brain, as opposed to hemorrhagic strokes, which result from bleeding.

Strokes can occur at any age, but they are more likely to affect people over 65 years old. In 2009, 66% of hospitalized people due to strokes were over 65 years old.

Black people are more at risk of death due to stroke, and their risk of having a first stroke is almost twice as high as white people. According to the American Stroke Association (ASA), more than 2 in 3 Black Americans have at least one of the following risk factors for stroke:

• high cholesterol
• high blood pressure
• diabetes
• more weight or obesity
• sickle cell anemia
• consuming too much salt
• smoking
• stress

However, the ASA also states that not all of the reasons for this increased risk of stroke are clear.

Death rates from strokes have increased among Hispanic people since 2013, whereas for other racial or ethnic groups, death rates have fallen. According to the ASA, additional social determinant risk factors include:

• language barriers
• access to healthcare
• education levels
• income levels
• access to transportation

A person can make lifestyle changes to help prevent the risk of stroke and maintain regular discussions with their doctor for further advice.

Learn more about the relationship between race and cardiovascular disease here.

The symptoms of cerebrovascular disease depend on the location of the blockage and its impact on brain tissue.

Different events may have different effects, but common symptoms include:

• a severe and sudden headache
• paralysis of one side of the body, or hemiplegia
• weakness on one side, also known as hemiparesis
• confusion
• difficulty communicating, including slurred speech
• losing vision on one side
• loss of balance
• becoming unconscious

Stroke, TIA, and subarachnoid hemorrhage are types of cerebrovascular disease.

Aneurysms and hemorrhages may cause severe health problems. Blood clots can form in the brain or travel there from other parts of the body, causing a blockage.

Different types of cerebrovascular disease include:

Ischemic stroke

These occur when a blood clot or atherosclerotic plaque blocks a blood vessel that supplies blood to the brain. A clot, or thrombus, may form in an artery that is already narrow.

A stroke occurs when the lack of blood supply results in the death of brain cells.

Dissection

A tear in the lining of the carotid artery, which is in the neck, can lead to ischemic stroke. The tear lets blood flow between the layers of the carotid artery, narrowing it and reducing blood supply to the brain.

Carotid or vertebral artery dissections are often related to trauma. However, they can sometimes occur spontaneously.

Embolism

An embolic stroke is the most common type of ischemic stroke. An embolism occurs when a clot breaks off from elsewhere in the body and travels to the brain to block a smaller artery.

People who have arrhythmias, which are conditions that cause an irregular heart rhythm, are more prone to developing an embolism.

Learn more about thrombus, which can lead to embolism, here.

Cerebral aneurysm

This can result from structural problems in the blood vessels of the brain. An aneurysm is a bulge in the arterial wall that can rupture and bleed.

The leaking of blood can damage brain cells.

Hemorrhagic stroke

This occurs when a blood vessel in part of the brain weakens and bursts open, causing blood to leak into the brain.

The leaking blood puts pressure on the brain tissue, leading to edema, which damages brain tissue. The hemorrhage can also cause nearby parts of the brain to lose their supply of oxygen-rich blood.

There are two types of hemorrhagic stroke:

• Intracerebral hemorrhage: When an artery in the brain ruptures and bleeds into the surrounding tissue.
• Subarachnoid hemorrhage: When a blood vessel ruptures and bleeds between two membranes surrounding the brain.

Cerebrovascular disease develops for a variety of reasons.

If damage occurs to a blood vessel in the brain, it will not be able to deliver enough or any blood to the area of the brain that it serves. The lack of blood interferes with the delivery of adequate oxygen, and without oxygen, brain cells will start to die.

Brain damage is irreversible. Emergency help is vital to reduce a person’s risk of long-term brain damage and increase their chances of survival.

Atherosclerosis is a primary cause of cerebrovascular disease. This occurs when high cholesterol levels, together with inflammation in the arteries of the brain, cause cholesterol to build up as a thick, waxy plaque that can narrow or block blood flow in the arteries.

This plaque can limit or completely obstruct blood flow to the brain, causing a cerebrovascular attack, such as a stroke or TIA.

Risk factors

Stroke is the most common type of cerebrovascular event.

The risk of stroke increases with age, especially if a person or a close relative has previously had a cerebrovascular attack. This risk doubles every 10 years, between 55 and 85 years of age.

However, a stroke can occur at any age, even during infancy.

Factors that increase the risk of stroke and other types of cerebrovascular disease include:

• hypertension (blood pressure of 130/80 millimeters of mercury (mm Hg) or higher)
• smoking
• obesity
• poor diet and lack of exercise
• diabetes
• blood cholesterol levels of 240 milligrams per deciliter (mg/dl) or higher

The same factors increase a person’s chances of a cerebral aneurysm. However, people with a congenital anomaly or who have experienced head trauma may also be at higher risk of a cerebral aneurysm.

Pregnancy can also increase the chance of cerebral venous thrombosis, which is a blood clot affecting a vein in the brain.

Other risk factors of cerebrovascular disease include:

• moyamoya disease — a progressive condition that can lead to a blockage of the cerebral arteries and their major branches
• venous angiomas, which affect around 2% of the U.S. population and rarely bleed or cause symptoms
• a vein of Galen malformation — an arterial disorder that develops in a fetus during pregnancy

Certain drugs and medical conditions can make the blood more likely to clot and increase the risk of ischemic stroke.

Hormone replacement therapy (HRT) may increase the risk of an attack in a person who already has atherosclerosis or carotid artery disease.

Find out more about strokes and how to recognize them here.

A cerebrovascular event requires emergency treatment. Rapid assessment and treatment are crucial because a person must receive stroke medications within a specific time from the onset of symptoms.

In the case of an acute stroke, the emergency team may administer a medication called tissue plasminogen activator (tPA) that breaks up the blood clot.

Catheter-directed mechanical thrombectomy is an emergency stroke treatment that is becoming more widely available in dedicated stroke centers. This procedure involves a doctor inserting a catheter into an artery. Then, the surgeon inserts a small clot-removing device through the catheter to suck out the clot.

A neurosurgeon must evaluate an individual who has a brain hemorrhage. They may carry out surgery to reduce the increased pressure that a bleed causes. Doctors usually perform surgical procedures, including carotid endarterectomy, carotid angioplasty, and stenting, to prevent a person from having another stroke.

A carotid endarterectomy involves making an incision in the carotid artery and removing the plaque. This allows the blood to flow again. The surgeon then repairs the artery with sutures or a graft.

Some people may require carotid angioplasty and stenting, which involves a surgeon inserting a balloon-tipped catheter into the artery. They will then inflate the balloon so that it reopens the artery.

Afterward, the surgeon fits a slender, metal mesh tube, or stent, inside the carotid artery to improve blood flow in the previously blocked artery. The stent helps to prevent the artery from collapsing or closing up after the procedure.

Rehabilitation

As a cerebrovascular event can cause permanent brain damage, people may experience temporary or permanent disability following one.

For this reason, they may require a range of supportive and rehabilitative therapies so that they can retain as much function as possible.

These may include:

• Physical therapy: This aims to restore mobility, flexibility, and limb function.
• Speech therapy: This may help people communicate more clearly and regain speech after a stroke or cerebrovascular attack.
• Occupational therapy: This can help a person access facilities that support a return to work and daily life.
• Psychological therapy: Physical disability can create unexpected emotional demands and require intensive readjustment. A person may benefit from visiting a psychiatrist, psychologist, or counselor after a cerebrovascular event if they feel overwhelmed.

Find out all about physical therapy here.

Reducing the risk of stroke

Taking blood platelet inhibitors, including Clopidogrel and Plavix, can reduce the risk of stroke before it occurs. These can help prevent stroke in people with a history or high chance of having a cerebrovascular attack.

Historically, doctors recommended that people took a daily dose of aspirin to reduce the risk of a heart attack or stroke. However, current guidelines urge people to speak with their doctor before taking daily low-dose aspirin. This is because aspirin increases the risk of bleeding.

Doctors prescribe statins to lower and manage high cholesterol levels and decrease the risk of ischemic stroke and heart attack.

Any cerebrovascular event is a medical emergency, and a person who recognizes the symptoms must contact 911 for evaluation and support. Early diagnosis is key to reducing brain damage.

At the hospital, a doctor will ask about the individual’s medical history and look for specific neurological, motor, and sensory difficulties, including:

• changes in vision or visual fields
• reduced or altered reflexes
• abnormal eye movements
• muscle weakness
• decreased sensation

A doctor may use:

• a cerebral angiography: A doctor uses this to identify a vascular abnormality, such as a blood clot or a blood vessel defect. It involves injecting dye into the arteries to reveal any clots and display their size and shape on a computed axial tomography (CAT), CT, or magnetic resonance imager (MRI) scan.
• an MRI scan: This can detect even early stage strokes.
• a magnetic resonance angiogram (MRA): This procedure takes place in an MRI. The MRA shows the blood vessels in the neck and brain. It may help to detect aneurysms and blockages.
• a CAT scan: This can help a doctor diagnose and detect hemorrhagic strokes as it can distinguish between blood, bone, and brain tissue. However, it does not always reveal damage from an ischemic stroke, especially in the early stages.
• a CT angiography (CTA): This scan allows healthcare professionals to see blood vessels in a person’s head and neck.
• an electrocardiogram (EKG or ECG): This can detect cardiac arrhythmia, which is a risk factor for embolic strokes.
• a lumbar puncture (spinal tap): This may help detect bleeding caused by a cerebral hemorrhage. This procedure involves removing cerebrospinal fluid with a needle.

People can take steps to reduce their chances of developing cerebrovascular disease.

Methods that reduce the risk of cerebrovascular disease include:

• not smoking, and avoiding nicotine and tobacco
• getting at least 150 minutes of moderate to intense physical exercise every week
• eating a balanced diet that supports vascular health, such as the DASH diet, which the National Heart, Lung, and Blood Institute recommends
• maintaining a healthy body weight
• managing blood cholesterol and blood pressure with diet and medications if necessary

Individuals with heart arrhythmia should talk with their doctor about whether they should be taking a blood thinner to prevent strokes.

Stroke and other cerebrovascular events can cause death, but with rapid medical attention, a full or partial recovery is possible. People with cerebrovascular disease should follow healthy lifestyle tips and their doctor’s instructions to reduce the chance of an attack.

The outlook depends on the type of event, its severity, and how quickly a person receives treatment.

Cerebrovascular disease can cause death or may lead to long-term disability. However, some people will make a full recovery.

Prompt treatment and a lifestyle that reduces the risk of stroke are the best ways to improve the outlook for a person with cerebrovascular disease.

A suspected stroke is a medical emergency. If a person believes that they are experiencing symptoms of a stroke, they should call 911 or go to an emergency room immediately.