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Cerebral Vascular Disease
Diagnosis, Treatment, and Prevention Overview
Many people are familiar with the dramatic portrayal of strokes in movies. While strokes are clearly a medical emergency, most strokes are far less dramatic. In fact, the symptoms of most strokes are so mild that they are often dismissed as unimportant. The critical time for strokes is immediately after they occur.
- The symptoms of thrombotic strokes include nausea and dizziness; sudden, severe headaches; weakness, numbness; paralysis, particularly to one side of the body; partial or total loss of sight in one eye.
- Diagnostic procedures for thrombotic strokes include ultrasound, CT scan, and MRI.
- Treatment of thrombotic strokes consists of medication, natural supplements, and surgical interventions, based on the underlying cause. Controlling hypertension is essential prevention in the occurrence of ischemic strokes.
- Silent strokes commonly occur after thrombotic strokes and may cause damage weeks or months after the initial stroke.
Ischemic stroke is a medical emergency. Time to treatment of this brain attack is important, concerning what is done once in the emergency room.
- Tissue plasminogen activator is of great importance immediately after a stroke has occurred to help dissolve blood clots before they thrombose.
- Heparin is sometimes used in critical care settings and should be requested by stroke victims.
- Warfarin is the drug of choice to prevent strokes. Unfortunately, warfarin has a large number of contraindications and drug interactions with many commonly used medications.
- Low-dose aspirin is widely recommended to help thin the blood and prevent strokes. One 81-mg tablet of aspirin a day with a heavy meal is recommended for its anticlotting and anti-inflammatory effects.
- Ticlopidine may be recommended as a substitute for aspirin.
- Mevacor, a statin drug (HMG-reductase inhibitor), is being investigated for use in reducing the risk of stroke, primarily because of its effect on cholesterol.
The following drug strategies should be considered in stroke prevention, treatment, and rehabilitation.
- Hydergine, an antioxidant medication that protects brain cells, may be given in an acute situation. The recommended dosage is 10 mg given sublingually and 10 mg administered orally. Because the FDA has not approved Hydergine for this purpose, the patient or patient's advocate should request that the medication be given.
- Piracetam, a nootropic medication, may be useful in the prevention of thrombotic strokes because it appears to protect brain cells from injury during the stroke event. The recommended dosage for piracetam is 4800 mg a day, administered orally.
- Nimodipine is a prescription medication that dramatically increases cerebral blood flow by acting as a calcium channel blocker. Nimodipine may be of clinical benefit in acute stroke. The recommended dose is 30 mg 3 times a day, although up to 60 mg 4 times a day have been used in studies.
- Aminoguanidine, a medication that prevents glycosylation of proteins and helps prevent mental decline in the elderly, may be useful in preventing thrombotic strokes. The recommended dose is 300 mg once a day with food. This dose should not be exceeded.
An aggressive program for stroke prevention begins by addressing the known risk factors for stroke. The risk factors for ischemic strokes are hypertension, arteriosclerosis, and blood that has a propensity to clot abnormally inside vessels. Blood components that increase the risk of abnormal arterial clotting include elevated levels of LDL cholesterol, homocysteine, C-reactive protein, and/or fibrinogen. Drug and alcohol abuse, age, gender, and race are also factors.
Conventional medicine often recommends several drugs to cover some of these risk factors, including antihypertensives, cholesterol-lowering drugs (statins), and anticoagulants, such as Coumadin and aspirin. Each of these drugs has side effects and may interact with each other, particularly with Coumadin. Bleeding is of primary concern with anticoagulant therapy as it dramatically increases the risk of hemorrhagic stroke.
Natural supplements can be used as an adjunct to conventional drugs. Proper testing is required to monitor the effectiveness of both drug and nutritional supplement programs. Recommended blood tests include total cholesterol, HDL, LDL, triglycerides, glucose, prothrombin time, homocysteine, C-reactive protein, fibrinogen, and template bleeding time. Further, the Life Extension Foundation highly recommends using optimal levels, instead of the standard reference ranges, for these laboratory tests. The primary objective of using the following nutrients is to help restore function to injured brain cells.
- CDP-Choline has been shown to be effective and is currently in clinical trials in the United States for treating strokes. CDP - Choline Caps contain 250 mg of pharma c t eutical grade cytidine-5'-diphosphocholine. One capsule a day is recommended for healthy people over the age of 40. Those with neurological impairment should take two capsules daily under the care of a physician.
- Ginkgo biloba has been shown to be very effective as an antioxidant and in treating cerebral vascular deficiency, including stroke. Super Ginkgo Extract contains 120 mg of standardized ginkgo leaf powder. One capsule daily is recommended. Use ginkgo with caution when taking anticoagulants.
- Essential fatty acids, including alpha-linolenic acid ( ALA ) and docosahexaenoic acid (DHA) from fish oils are recommended. Essential fatty acids are necessary to control inflammation leading to elevated levels of C-reactive protein and to lower fibrinogen levels. Super GLA/DHA provides high potency anti-inflammatory fatty acids. Six 1000-mg capsules a day are recommended. Perilla oil provides high potencies of precursors to EPA and DHA. Six 1000-mg capsules a day are recommended.
- Vitamin C is recommended as a daily supplement for healthy people and may also be of benefit in stroke; 1000-4000 mg of high-quality vitamin C may be taken daily. Vitamin C should be taken with cofactor lysine for maximum benefit.
- Vitamin E is an antioxidant and blood-thinner. The recommended dose for most people is 400-500 IU of alpha tocopherol, 200 mg of gamma tocop o herol, and at least 50 mg of the tocotrienols. Vitamin E should be used with caution with warfarin because it thins the blood.
- Alpha-lipoic acid may also be considered. Super Alpha Lipoic Acid with Biotin contains 250 mg of pharmaceutical-grade alpha-lipoic acid and 3000 mcg of biotin. One to two capsules daily are suggested for healthy people. Up to 4 capsules can be taken for therapeutic effect. Alpha-lipoic acid should be taken with vitamin B12 because it may cause a worsening of symptoms in those with a vitamin B12 deficiency.
- Minerals, including calcium, magnesium, potassium, and selenium should be considered based on the results of serum electrolytes (although serum levels may not represent mineral stores in the body). Thiazide and loop diuretics deplete potassium and coffee increases excretion. Magnesium is needed for the absorption of potassium.
- The Mineral Formula for Men contains four different forms of magnesium, two forms of calcium, potassium, and manganese. One to four capsules daily are recommended as a booster to the minerals contained in the Life Extension Mix.
- The Mineral Formula for Women contains more calcium, which reflects the greater need by women. One to four capsules daily are recommended as a booster to the minerals contained in the Life Extension Mix.
- Calcium and magnesium are available separately in several forms, including calcium citrate with vitamin D3, calcium carbonate powder, calcium/magnesium powder, magnesium, magnesium citrate, and magnesium oxide powder.
- Super Selenium Complex contains three different forms of selenium in capsule form. One capsule per day is recommended. Selenium drops are also available. One to five drops are suggested daily. Lower doses of selenium are recommended when taking Life Extension Mix.
- Vitamin B6, vitamin B12, folic acid, and trimethylglycine should be considered if homocysteine levels are elevated (see the Cardiovascular Disease protocol for more information).
- TMG t T ablets contain 500 mg of trimethylglycine. One to five tablets are recommended daily for healthy people. Up to 12 tablets can be taken daily if high levels of homocysteine persist.
- Vitamin B6 may be taken at doses up to 800 mg daily to reduce homocysteine levels though high doses of 100-250 mg daily are usually adequate.
- Vitamin B12, 300-1500 mcg daily.
- Folic acid, 800 mcg daily.
- Elevated fibrinogen leads to the formation of blood clots. Many of the recommended supplements to control homocysteine and lower cholesterol levels will work synergistically in keeping fibrinogen levels in the normal range. The following supplements may also be considered:
- Green tea extract, 350 mg daily.
- Vitamin A, 20,000 IU in a liquid base.
- Beta carotene, one 25,000-IU softgel daily.
- Bromelain, one 500-mg tablet at the beginning of each meal.
- Niacin, 1500-3000 mg daily. Niacin should be monitored to avoid liver toxicity at doses above 1000 mg daily. Flush-free niacin may be taken to avoid the red face and flushing sensation of regular niacin.
- SAMe may be considered, particularly if there is related depression. SAMe tablets contain 200 or 400 mg of pharmaceutical-grade S-adenosyl-methionine. The recommended total daily dose is 400-1600 mg. SAMe is best taken without food, unless GI upset occurs.
- Policosanol has been shown to have a dramatic effect on lowering cholesterol, reducing platelet aggreg r ation and decreasing the size of experimentally induced thrombus. Policosanol tabs contain 10 mg of policosanol. The ideal cholesterol range is between 180-200 mg/dL. The average person uses 10 mg a day to achieve optimal cholesterol levels. Some people may only need 5 mg a day, while others may require 20 mg a day. Cholesterol levels should be monitored regularly because levels below 150 may be dangerous.
- Garlic extract, 1000-6000 mg daily, may help lower cholesterol levels. (See the Cardiovascular Disease protocol for more information.) Garlic is available in two effective forms. One is the aged garlic extract under the Kyolic brand name. Use the formula that provides 1000 mg of Kyolic odorless garlic in each caplet. Pure-Gar Caps provide a high-allicin garlic that is not odor-free (900 mg garlic powder), and Pure-Gar with EDTA (a chelating agent).
- Melatonin readily crosses the blood-brain barrier and may help protect against further free radical-induced brain cell injury. Melatonin is to be taken before bed as a sleep-enhancer, 300 mcg-10 mg nightly is recommended.
- Hormones play a clear role in neuronal functioning and repair. Blood testing is recommended for all people over 40 to determine hormonal deficiencies.
- Pregnenolone is synthesized from cholesterol. It acts as a memory enhancer and converts to progesterone and DHEA. One 50-mg capsule, 1-4 times daily.
- DHEA improves brain cell activity and suppresses overproduction of the adrenal hormone, cortisol. The usual dose for men is 50 mg daily. For women the usual dose is 15-25 mg early in the day. See the DHEA Replacement protocol for additional information and warnings.
- Testosterone and estrogen replacement are determined by blood testing. These hormones must be prescribed by a physician.
- Arginine, vitamin B2, vitamin B3, and folic acid may be considered as a way to naturally increase nitric oxide synthesis. L-Arginine c C aps contain 900 mg of pure L-Arginine HCl. Arginine should be used with caution in diabetics and those with psychosis.
- Carnosine may be useful in protecting the brain from neurological damage. Super Carnosine contains 500 mg of pure carnosine. One capsule 2-3 times a day is recommended.
- Vinpocetine has been shown to have a positive effect on brain metabolism and to protect against excitotoxicity and may be of benefit in stroke recovery. Take 10 mg 3 times daily. For additional protection against excitotoxicity, consider a sublingual vitamin B12 lozenge called methylcobalamin in the dose of 5-40 mg a day.
- Theanine, an amino acid found in green tea, produces a tranquilizing effect on the brain by increasing production of GABA, an inhibitory neurotransmitter. Theanine may also prevent ischemic damage to neurons. Up to four 100-mg capsules can be taken daily.
- Dietary measures to lower stroke risk include high amounts of fresh fruits and vegetables every day and several servings of fish a week.
To learn about therapies that may protect arteries prior to a thrombotic stroke, or to reduce the risk of further disease or stroke attacks, refer to the protocols on Cardiovascular Disease and Thrombosis Prevention. To learn more about therapies that may restore neurological function following thrombotic stroke, refer to the protocol for Age-Associated Mental Impairment.
Hemorrhagic Stroke
For those who have experienced a hemorrhagic stroke or who have a cerebral vascular disease, such as cerebral aneurysm, it is suggested that nutrients that help build collagen and elastin be taken to help rebuild the endothelial lining of the cardiovascular arterial system. Nutrient supplements have also been reported to help reduce the risk of or damage caused by aneurysm or hemorrhage.
Of all patients diagnosed with an aneurysm or cerebral hemorrhage, 50% have hypertension. Cerebral atherosclerosis is also an underlying risk factor for cerebral vascular disease.
Although hemorrhagic strokes account for only 15% of all strokes, hemorrhagic strokes have a much higher mortality rate. There are two subcategories of hemorrhagic stroke: intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Although ICH and SAH are very similar, they generally result from different causes.
Intracerebral Hemorrhage (ICH)
ICH is defined as the rupturing of cranial blood vessels, resulting in the leakage of blood into brain tissues. Symptoms of ICH include:
- Partial or total loss of consciousness
- Vomiting or severe nausea
- Weakness, numbness, or paralysis, especially on one side of the body
- Sudden, severe headache
- Severe vertigo (unable to walk or stand)
If these symptoms occur, it is essential to receive immediate medical attention.
ICH rarely occurs in people under the age of 45; however, the risk for developing ICH doubles every 10 years thereafter. ICH accounts for 11% of stroke deaths. ICH occurs more frequently in men, and African-Americans are more likely to be affected than are Caucasians.
Risk Factors
Risk factors for intracranial hemorrhage include:
- Untreated hypertension, 50%
- Amyloid angiopathy, 17%
- Anticoagulation treatment (Warfarin), 10%
- Brain tumors, 5-10%
- Smoking, 5%
- Drug abuse, especially crack cocaine and amphetamines, 5%. (This is the most common cause of ICH for people in their 20s and 30s.)
The most common risk factor for ICH is chronic hypertension. Hypertension causes arteries and arterioles to become weakened, resulting in leakage. A Chinese study noted that there was considerable increased risk for ICH in hypertensive patients who did not regularly take their medications (Hsiang et al. 1996).
Anticoagulants, such as Coumadin or Heparin, are prescribed for a variety of conditions, including ischemic stroke, myocardial infarction, and deep vein thrombosis. Proper monitoring of these medications is essential because they increase the risk of ICH.
Aspirin has also been shown to increase the risk of ICH in elderly patients (Wong et al. 2000). An article in the journal Stroke identified epistaxis (nosebleed) as a risk factor for ICH in middle-aged and elderly people, both independently and combined with the use of aspirin. The authors proposed that nosebleeds may be a warning sign for increased risk of ICH in people using aspirin (Saloheimo et al. 2001).
Hepatitis C virus infection has been identified as a risk factor for ICH. ICH patients with hepatitis C infections were also found to have lower cholesterol levels, lower platelet counts, and longer prothrombin times than ICH patients without hepatitis C, although most of the values were within normal range (Karibe et al. 2001). |