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STROKE OVERVIEW — Stroke is the term doctors use when a part of the brain dies because it goes without blood for too long. (See "Patient education: Stroke symptoms and diagnosis (Beyond the Basics)".)
During a stroke, one or more areas of the brain can be damaged. Depending upon the area affected, a person may lose the ability to move one side of the body, the ability to speak, the ability to see normally, or a number of other functions. The damage may be temporary or permanent, and the function may be partially or completely lost. A person's long-term outcome depends upon how much brain is damaged, how quickly treatment begins, and a number of other factors.
There are two main types of stroke: ischemic stroke, which is caused by a blockage in a blood vessel in the brain, and hemorrhagic stroke, which is caused by bleeding in the brain or surrounding area. This topic discusses the treatment of ischemic strokes. Information about hemorrhagic strokes is available separately. (See "Patient education: Hemorrhagic stroke treatment (Beyond the Basics)".)
VERY EARLY TREATMENTS — After an ischemic stroke, the goal of treatment is to restore blood flow to the affected area of the brain as quickly as possible, that is, within the first hours after the onset of stroke symptoms. The main very early treatments for ischemic stroke are:
●Thrombolytic therapy – This involves giving a medication called alteplase (also known as tPA, for "tissue plasminogen activator"), or a similar medication called tenecteplase, by IV (through a vein). It works by breaking up the clot that is blocking blood flow to the brain.
●Mechanical thrombectomy – This is a procedure that involves a specialist placing a catheter in the blocked artery and removing the clot. This is done using a "stent retriever device" or suction to reopen the blocked artery.
Both thrombolytic therapy and mechanical thrombectomy require care in a hospital that has expertise in these areas and can coordinate emergency services, rapid consultation with a neurologist (a physician who specializes in the brain), intensive care services, and brain and vascular imaging with CT or MRI scans.
Thrombolytic therapy — Thrombolytic therapy uses a medication called alteplase (also called tissue plasminogen activator or tPA), or a similar medication called tenecteplase, that is injected into a vein. These medications work to dissolve clots that are blocking blood flow in arteries in the brain. The benefit of thrombolytic treatment slowly decreases over several hours. For this reason, the earlier the treatment is given after the stroke begins, the more likely it is to be successful.
A risk of thrombolytic therapy is intracerebral hemorrhage (excess bleeding in the brain), which can be fatal in some cases. However, this risk is generally outweighed by the benefits of the treatment, provided it is given early enough.
Mechanical thrombectomy — This is a procedure that can help if the person has a blood clot blocking one of the large arteries in the brain. It involves inserting a catheter with a device that can remove the clot into the artery. This treatment can reduce long-term disability caused by the stroke.
Mechanical thrombectomy is beneficial if it is performed within six hours from the start of a person's stroke symptoms. It can even be beneficial for up to 24 hours from the start of symptoms in certain situations (depending on the results of brain imaging tests). It may be done in addition to thrombolytic therapy (see 'Thrombolytic therapy' above). The sooner the treatment is performed, the more likely it is to help.
Mechanical thrombectomy for stroke is a highly specialized treatment and should only be performed at hospitals with experience in the use of stent retrievers.
OTHER EARLY TREATMENTS — Other medications sometimes used for the early treatment of ischemic stroke are antiplatelets and anticoagulants.
Antiplatelets — Antiplatelet therapy is often used immediately for ischemic stroke if thrombolytic therapy cannot be given, or it may be given following thrombolytic therapy. (See 'Thrombolytic therapy' above.)
Aspirin is the best-known antiplatelet medication. Clopidogrel, cilostazol, and dipyridamole are other antiplatelets sometimes prescribed. Platelets are tiny cell fragments circulating in the blood that normally clump together to stop bleeding. This clumping leads to the formation of a blood clot. When a person has a stroke, platelets clump together and form clots inside of narrowed arteries, blocking blood flow in the brain.
Antiplatelet therapy helps prevent new clots from developing and is beneficial for the treatment of acute ischemic stroke. Unlike thrombolytic medications (ie, alteplase or tenecteplase), antiplatelet medications do not dissolve clots that are already present. Most people with transient ischemic attack (TIA) or ischemic stroke are treated with aspirin. In certain cases, a person might be treated with short-term (eg, 21 to 90 days) "dual antiplatelet therapy" (DAPT) using aspirin plus clopidogrel, particularly people with minor ischemic stroke symptoms or those with TIA who are deemed to be at high risk for stroke. After the 21 to 90 period of DAPT, however, the treatment is changed so that only one of these antiplatelet medications is continued.
Anticoagulants — Anticoagulants, or anti-clotting medications, are often referred to as "blood thinners." However, they don't actually cause the blood to become thinner, only less likely to clot. Heparin and low molecular weight heparin are anticoagulants given by injection or infusion (through a vein). Warfarin is an older anticoagulant that is taken by mouth. Newer anticoagulants taken by mouth include dabigatran (brand name: Pradaxa), apixaban (brand name: Eliquis), edoxaban (brand names: Savaysa, Lixiana), and rivaroxaban (brand name: Xarelto).
Because of the risk of excessive bleeding, anticoagulation is seldom given for the treatment of acute ischemic stroke. However, full-dose anticoagulant therapy with heparin or low molecular weight heparin is used by some clinicians for certain types of stroke. For example, some doctors use anticoagulants for the early treatment of stroke caused by blood clots that travel from the heart (called "cardioembolism") in people who have heart valve disease or severe heart failure, and for people who have stroke caused by dissection (a tear of the inner blood vessel wall) of a large artery that supplies blood to the brain.
Low-dose anticoagulant therapy with heparin or low molecular weight heparin is sometimes used for people with ischemic stroke who cannot move due to paralysis from the stroke. This treatment can help to prevent blood clots from forming in the leg veins or other veins in the body, which can cause pain and swelling. These clots are especially dangerous because they could break free and travel to the lungs, a life-threatening condition called pulmonary embolism (PE). (See 'Blood clots' below and "Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)" and "Patient education: Pulmonary embolism (Beyond the Basics)".)
LONG TERM PREVENTION OF ISCHEMIC STROKE — In the longer term, treatment is aimed at reducing the chances that a person will have another stroke. This is called "secondary prevention." Options for secondary prevention of ischemic stroke include antiplatelet medications, anticoagulants, and surgical procedures to reopen blockages in blood vessels (revascularization).
Medications — Many different medications help reduce the risk of having another stroke. They include medications to control high blood pressure, lower cholesterol, and prevent blood clots from forming. Different people need different combinations of medications, depending on their health and medical history.
Blood pressure medications — Having high blood pressure (hypertension) increases a person's risk of stroke, especially if they have already had one. This involves lifestyle changes (see 'Lifestyle changes' below) as well as medication therapy. Several different medications are used to treat high blood pressure. (See "Patient education: High blood pressure treatment in adults (Beyond the Basics)".)
Cholesterol-lowering medication — Having high cholesterol can also increase a person's risk of stroke. Treatment of high cholesterol in people who have had a stroke usually involves a medication called a statin in addition to lifestyle changes. In addition to lowering cholesterol, statin medications have other favorable effects on the linings of blood vessels. They may help promote healing and stabilization of plaques that tend to develop on the surface of blood vessels that supply the brain and heart. They do this even in people who have normal cholesterol levels. (See "Patient education: High cholesterol and lipid treatment options (Beyond the Basics)", section on 'Statins' and 'Lifestyle changes' below.)
Antiplatelet therapy — The antiplatelet medicines aspirin, clopidogrel, and the combination of aspirin plus extended-release dipyridamole and cilostazol are all acceptable options for preventing recurrent ischemic stroke for people whose stroke was not caused by embolism from the heart.
Aspirin — Aspirin (even at relatively low doses) is effective for preventing ischemic stroke. It is used as first-line treatment after a noncardioembolic stroke, meaning a stroke in which the blood clot did not originate from the heart (see 'Antiplatelets' above). Aspirin and may then be continued longer term or switched to a different antiplatelet medication. Aspirin has the advantage of being less expensive than the other antiplatelet medications.
Possible side effects of aspirin include stomach upset and gastrointestinal bleeding.
Clopidogrel — Clopidogrel (brand name: Plavix) is another antiplatelet medication that can be used after a stroke to reduce a person's risk of having another stroke.
Compared with aspirin, clopidogrel causes a slightly higher frequency of rash and diarrhea, and a slightly lower frequency of stomach upset and gastrointestinal bleeding.
In some cases, aspirin and clopidogrel are used together for the first 21 to 90 days after an ischemic stroke. This strategy is called "dual antiplatelet therapy" or DAPT. After 21 to 90 days, however, the treatment is changed so that only one of these antiplatelet medications is continued. Long-term treatment using clopidogrel in combination with aspirin is not usually recommended after a stroke because the combination is no more effective for preventing another stroke than either clopidogrel or aspirin alone, while using the two in combination increases the risk of bleeding in the brain. However, certain people who have had a recent heart attack or other acute coronary syndrome, or recent heart stent placement, are often treated with the combination of clopidogrel plus aspirin.
Dipyridamole — Dipyridamole is a medication that may be given after a stroke to reduce the risk of another stroke. It is often given in an extended-release form, which combines dipyridamole with aspirin (brand name: Aggrenox). It is taken two times per day.
Side effects of dipyridamole include headache, stomach upset, and/or diarrhea. Headaches usually improve over the first week.
Cilostazol is an antiplatelet medication in the same class as dipyridamole.
Anticoagulants — Anticoagulant therapy is used to prevent stroke in people with certain medical conditions and risk factors. For example, for long-term stroke prevention, most people with a heart rhythm problem called "atrial fibrillation" who have a history of stroke should be treated with an anticoagulant.
Warfarin (brand name: Jantoven) is an anticoagulant medication that is taken by mouth. It is often recommended as a long-term treatment for people who have conditions that promote the formation of blood clots, such as atrial fibrillation. People who take warfarin must be closely monitored with regular blood tests to ensure that the correct dose is used and that the risk of excessive bleeding or developing blood clots is minimized. (See "Patient education: Warfarin (Beyond the Basics)".)
Dabigatran (brand name: Pradaxa), apixaban (brand name: Eliquis), edoxaban (brand names: Savaysa, Lixiana), and rivaroxaban (brand name: Xarelto), are newer anticoagulants that work as well as warfarin, have a lower risk of bleeding than warfarin, and do not require regular monitoring with blood tests. If a person is a candidate for anticoagulant therapy, their doctor can provide guidance on whether one of these newer medications may be an alternative to warfarin.
Lifestyle changes — In addition to medication therapy, lifestyle changes are also a key part of preventing another stroke. The most important include:
●Quitting smoking – For people who smoke, quitting is one of the best ways to reduce the risk of another stroke, as well as improve overall health. (See "Patient education: Quitting smoking (Beyond the Basics)".)
●Avoiding or cutting back on alcohol
●Eating a healthy diet and exercising regularly – Many experts recommend following a "Mediterranean" diet rich in fruits, vegetables, fish, and low-fat dairy products, and low in red meat, sweets, and refined grains (such as white bread and white rice). It is also a good idea to limit the amount of sodium (salt) in the diet, since this can help keep blood pressure under control. Regular exercise is also very important; even moderate activity like brisk walking can be beneficial.
In addition to improving overall health, eating a balanced diet and getting regular physical activity can also help with weight loss in people who are overweight. Maintaining a healthy body weight can help with both high blood pressure and high cholesterol, both of which increase a person's chance of having another stroke. (See "Patient education: High blood pressure, diet, and weight (Beyond the Basics)" and "Patient education: High cholesterol and lipid treatment options (Beyond the Basics)".)
Carotid artery revascularization — Revascularization is the medical term for reestablishing blood flow to an area. In people who have had a stroke, revascularization usually refers to a procedure aimed at opening up a narrowing in the carotid artery. One way to do this is with a surgical procedure called "carotid endarterectomy" (CEA). This involves making an incision to open a blocked artery in the neck (the carotid artery), removing plaque that has built up, then repairing the artery to restore blood flow to the brain and reduce the risk of another stroke. Another way to open up the artery is called "carotid stenting." This involves placing a device called a stent in the carotid artery to hold it open and improve blood flow.
To decide whether a person is a candidate for one of these procedures, a doctor can look at the carotid artery using an imaging test such as an ultrasound, CT angiogram, MR angiogram, or conventional arteriogram. (See "Patient education: Stroke symptoms and diagnosis (Beyond the Basics)".)
Carotid endarterectomy is most successful when it is performed by a vascular surgeon who has specialized training and experience with the procedure. However, even in experienced hands, the procedure has risks, including bleeding, brain injury, stroke, and even death. Some people are likely to benefit from carotid endarterectomy while for others, the risks of the procedure are greater than the potential benefits. Carotid stenting is associated with a greater risk of stroke and other problems, especially in people over the age of 70 years. However, stenting may be a better choice than CEA when the carotid artery narrowing is not suitable for surgery, or in people with co-existing problems like significant heart or lung disease that increase the risk of surgery and anesthesia.
COMPLICATIONS AFTER STROKE — A number of problems can develop in people who have had a stroke. In fact, approximately half of deaths after stroke are due to medical complications. In the days and weeks after a stroke, there are some things you can do to decrease the risk of some of these complications. Common complications include the following:
●Blood clots
●Difficulty eating and drinking, which increases the risk of pneumonia and malnutrition
●Urinary tract infection
●Bleeding in the digestive system
●Heart attack or heart failure
●Pressure sores
●Falls
●Depression
Blood clots — People who have had a stroke are at an increased risk of developing blood clots as they recover. A deep vein thrombosis (DVT) is a blood clot that develops in the deep veins of the leg. If the clot breaks off, it can travel to the lung, where it is called a pulmonary embolus (PE). A PE can cause serious problems, including difficulty breathing and even death. (See "Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)" and "Patient education: Pulmonary embolism (blood clot in the lungs) (The Basics)".)
Blood clots occur most often between the second and seventh day after the stroke. The risk is especially high in people who have difficulty with moving or walking around while they are recovering from stroke. Difficulty walking may be related to paralysis caused by the stroke or due to other medical conditions. Lack of movement increases the risk of a DVT, which can lead to a PE. Older people are also at greater risk of developing clots.
Treatments to prevent blood clots in people at high risk include "intermittent pneumatic compression devices" and anticoagulant medication. Intermittent pneumatic compression devices use an inflatable sleeve that wraps around the legs; the sleeves are attached to an air pump that inflates and deflates the sleeves at regular intervals to help increase blood flow in the leg veins. Anticoagulation generally involves the temporary use of low-dose heparin or low molecular weight heparin. Anticoagulant therapy to prevent blood clots is different than anticoagulation used for treatment of an ischemic stroke; the dose used for prevention is typically smaller than that used for treatment.
To decrease the risk of blood clots, the person will likely be encouraged to get up and move around frequently as soon as they are able after a stroke. A physical therapist is often available to help, especially if the person has weakness in their legs as a result of the stroke.
Difficulty swallowing — The act of swallowing requires coordination of the nerves and muscles of the tongue, mouth, and throat. The brain damage that occurs as a result of a stroke can cause muscle weakness and difficulty swallowing. "Dysphagia" is the medical term for difficulty swallowing.
Dysphagia can be a problem because it can cause a person to inhale saliva or food into the lungs. This can cause a type of pneumonia known as aspiration pneumonia, which increases the risk of long-term problems and even death. However, in people who have weakness of one side of the body, dysphagia is often temporary because both sides of the brain and body control swallowing.
To determine if a person is at risk for inhaling food or drinks into the lungs, doctors can do a simple test to see how well they can swallow water. If the person has difficulty, the doctor may recommend temporarily avoiding eating or drinking, and instead getting nutrition (as well as medication) through a vein (see 'Malnutrition' below). Specific exercises and training programs can help to retrain a person how to swallow despite muscle or nerve damage. An additive to thicken liquids may also be recommended.
Malnutrition — As a result of muscle weakness that can cause difficulty swallowing, some people have trouble consuming an adequate number of calories after a stroke. This can make it more difficult to recover, potentially increasing the risk of long-term disability.
For these reasons, a person's nutritional status should be evaluated before discharge from the hospital. This includes a review of past and current body weight, a basic history of eating habits, blood tests, and a physical examination that focuses on the condition of the eyes, hair, skin, mouth, and muscles.
If a person is not able to consume enough calories, a feeding tube may be placed through the nose and into the stomach (called a nasogastric or NG tube). If the feeding tube will be needed for more than two to three weeks, a tube can be inserted through the abdomen into the stomach instead. This type of tube is called a percutaneous endoscopic gastrostomy (PEG) tube. The PEG tube may be removed if the person regains the ability to eat and swallow normally.
Urinary tract infection — Urinary tract infections are a common complication after stroke, occurring in about 11 percent of people during the first three months after stroke.
After a stroke, some people have difficulty getting out of bed to empty their bladder. Others have problems with leaking urine, or are unable to empty their bladder completely because of muscle weakness. For these reasons, doctors often place a catheter to empty the bladder, especially during the first few days to weeks after a stroke. However, use of a catheter increases a person's risk of developing urinary tract infections (UTIs).
There are things doctors can do to decrease the risk of urinary tract infections in people who require a catheter. They include using a catheter only when necessary and removing it as soon as possible. If a urinary tract infection does develop, this is treated with antibiotics.
Gastrointesintal bleeding — People who have had a severe stroke, especially those who are in the intensive care unit and require a ventilator to breathe, have an increased risk of developing a bleeding ulcer in the stomach. Medication to lower the stomach's production of acid can reduce this risk.
Heart problems — Heart problems, such as an irregular heart rhythm (arrhythmia) or heart attack (myocardial infarction) are commonly seen following stroke, with some occurring in up to 70 percent of people. It is important to determine whether the heart problems are a result of the stroke, the cause of the stroke, or unrelated to the stroke.
Tests often performed to screen for these problems include an electrocardiogram (ECG), blood testing, and continuous monitoring of the heart rhythm (called telemetry). Because many people with ischemic strokes also have coronary artery disease, there is a risk of reduced blood flow in the heart during the stroke. In some cases, the person may not be able to tell the clinician that they feel chest pain (a symptom of reduced blood flow). The ECG will help the clinician to diagnose and treat heart problems as quickly as possible.
Other heart testing may also be recommended, such as an echocardiogram. This test uses sound waves to examine the heart and the aorta (the main artery that carries blood from the heart); blood vessels that supply the brain with blood originate from the aorta (figure 1). In some people, the heart or aorta is the source of the blood clot that led to the stroke.
Pressure sores — Pressure sores, also called "pressure ulcers" or "bed sores," are areas of skin and underlying tissue that are injured when compressed for a prolonged period of time. They can happen when a person has a limited ability to move without assistance. The most common places for pressure sores to form are places where bone is close to the skin, eg, where the tailbone presses against the bed mattress.
Pressure sores can range from mild skin redness to deep ulcers extending all the way down to the bone. They can be uncomfortable or painful, and increase the risk of infection. A person can reduce their risk of pressure sores by moving or turning (or being moved by a family member or nurse) at least every two hours. To help reduce the risk of pressure sores:
●A person should be at a 30 degree incline when lying on their side to avoid direct pressure over the hip bone. However, avoid elevating the head of the bed higher than this, as this can cause the person to slide down (which can also cause skin injury).
●Pillows or foam wedges can be placed between the ankles and knees, and under the lower legs, to avoid pressure at these sites. Special heel protectors may also be recommended.
People who use a wheelchair are also at risk of developing pressure sores; they may need to be repositioned more frequently, eg, every hour. A special seat cushion may also help.
Falls — After a stroke, some people have difficulty walking due to muscle weakness, paralysis, or lack of coordination. When a person becomes less active or unable to walk, they are at increased risk of bone thinning (osteoporosis) and worsened muscle weakness. These risks greatly increase the chance of breaking a bone after a fall. Falls are one of the most common complications of stroke, occurring in up to 25 percent of people.
Several things can help reduce a person's risk of falling:
●Muscle strengthening and balance retraining exercises – This may include exercise or rehabilitation programs tailored to the person's individual needs and abilities. Group classes, such as Tai Chi, may be helpful for people who are able to walk without assistance.
●Evaluation of fall risk – An evaluation may be recommended to determine if a person is at risk for falling. If there is a risk of falling, treatments (eg, a walker, balance training) may be recommended to decrease the risk.
●Home hazards – Home hazards such as poor lighting or loose rugs can increase the risk of falling. The following tips can reduce this risk:
•Remove loose rugs, electrical cords, or other items that could lead to tripping, slipping, and falling
•Ensure that there is adequate lighting in all areas inside and around the home (including stairwells and entrance ways)
•Avoid walking on ice, wet or polished floors, or other potentially slippery surfaces; avoid walking in unfamiliar areas outside
•Wear sturdy shoes with a non-slip sole
Depression — It is common to feel sad or depressed after a stroke. If you feel this way, or if you are concerned about your family member, talk to a clinician. They can do an evaluation and suggest treatments that can help, if appropriate. (See "Patient education: Depression in adults (Beyond the Basics)".)
OUTCOME AFTER STROKE — A person's long-term prognosis after stroke depends on many different factors, and can be difficult to predict. Factors that affect outcome include the person's age and health, the location and severity of the stroke, and whether there were complications. In general, the majority of a person's recovery happens in the first three to six months after the stroke; after this, improvements in physical and mental function can still happen, but progress tends to slow down. Your health care team can give guidance on your (or your family member's) situation and what you can do to help with recovery and reduce the risk of certain complications.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Stroke (The Basics)
Patient education: Medicines after an ischemic stroke (The Basics)
Patient education: Lowering the risk of having a stroke (The Basics)
Patient education: Transient ischemic attack (The Basics)
Patient education: Aphasia (The Basics)
Patient education: Recovery after stroke (The Basics)
Patient education: Atherosclerosis (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Stroke symptoms and diagnosis (Beyond the Basics)
Patient education: Hemorrhagic stroke treatment (Beyond the Basics)
Patient education: Warfarin (Beyond the Basics)
Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Long-term antithrombotic therapy for the secondary prevention of ischemic stroke
Approach to reperfusion therapy for acute ischemic stroke
Atrial fibrillation in adults: Use of oral anticoagulants
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
Cerebrovascular disorders complicating pregnancy
Clinical diagnosis of stroke subtypes
Cryptogenic stroke and embolic stroke of undetermined source (ESUS)
Malignant cerebral hemispheric infarction with swelling and risk of herniation
Definition, etiology, and clinical manifestations of transient ischemic attack
Differential diagnosis of transient ischemic attack and acute stroke
Stroke: Etiology, classification, and epidemiology
Cerebral venous thrombosis: Etiology, clinical features, and diagnosis
Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis
Headache, migraine, and stroke
Initial assessment and management of acute stroke
Initial evaluation and management of transient ischemic attack and minor ischemic stroke
Intracranial large artery atherosclerosis: Treatment and prognosis
Lacunar infarcts
Complications of stroke: An overview
Neuroimaging of acute stroke
Overview of the evaluation of stroke
Posterior circulation cerebrovascular syndromes
Secondary prevention for specific causes of ischemic stroke and transient ischemic attack
Overview of secondary prevention of ischemic stroke
Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis
Spontaneous intracerebral hemorrhage: Acute treatment and prognosis
Aneurysmal subarachnoid hemorrhage: Treatment and prognosis
The following organizations also provide reliable health information.
●National Library of Medicine
(https://medlineplus.gov/healthtopics.html)
●National Institute of Neurological Disorders and Stroke
(https://www.ninds.nih.gov/Disorders/All-Disorders/Stroke-Information-Page)
●American Stroke Association
●Several books are also recommended:
•Caplan LR. Stroke, American Academy of Neurology and Demos Publishers, New York 2006.
•Caplan LR. Navigating the Complexities of Stroke, American Academy of Neurology and Oxford University Press, New York 2013.
•Hutton C, Caplan LR. Striking Back at Stroke: A Doctor-Patient Journal, Dana Press, New York 2003.
•Hutton C. After a Stroke: 300 Tips for Making Life Easier, Demos, New York 2005.
