Women and Stroke: What We Need to Know
By Roberta Nubile

Strokes are often thought of in relation to the elder population, and about 75 percent do occur after age 65. But strokes can happen at any age. And women have a higher rate of stroke occurrence. For these reasons, it is vital to know and recognize the signs of stroke in order to speed treatment. We should also know what our rehabilitation options are, and how to reduce our risk of stroke.

A stroke occurs when the flow of oxygen to the brain is cut off. Think of it as a “brain attack.” There are two types. The more common one, ischemic stroke, happens when a blood clot obstructs a blood vessel – the same mechanism as in a heart attack. Clots form either because of fatty deposits in the vessel (atherosclerosis) or atrial fibrillation – an irregular heartbeat that causes the blood to be pumped improperly, allowing it to pool in the atria where clots can develop and travel to the brain.

In the second and less common form of stroke, hemorrhagic, a blood vessel bursts and the resulting blood collection effectively cuts off oxygen to an area in the brain. Blood vessels can burst for a variety of reasons: high blood pressure, which causes vessels to balloon; an aneurysm in a cerebral artery; a congenital defect that weakens the vessel wall; trauma, such as blunt injury; or even violent coughing or vomiting. Whichever side of the brain has been occluded, the effects will show up on the opposite side of the body.

Treatment depends on the type of stroke. For ischemic strokes, the goal is to dissolve or remove the clot. In acute situations, intravenous blood thinners or mechanical methods are used. For long-term prevention of further clots, patients take oral anticoagulants, or blood thinners, such as Coumadin, aspirin, or a nutritional supplement such as nattokinase. With hemorrhagic strokes, which can be diagnosed by CT scan in the ER, the treatment is usually surgical. The goal is to stop bleeding and restore normal blood flow. Patients then take medications to control associated high blood pressure. For both types, early recognition is critical.

Janet Kirwan, M.D., a cardiologist with Champlain Valley Cardiovascular in South Burlington, says, “Behind heart disease and cancer, stroke is the third leading cause of death in the U.S. But deaths are only the tip – more come in with medical complications.”

After a stroke has occurred, Kirwan says, “it’s all about prevention.” A cardiologist, she says, “counsels patients that the same preventable risk factors – high blood pressure, high cholesterol, heart arrhythmias, diabetes, inactivity, obesity, smoking, and alcohol consumption – exist in stroke as in cardiovascular disease.” Stroke and heart disease also share some uncontrollable risk factors, such as age, heredity, and gender. “And while men get strokes at a younger age than women,” says Kirwan, “more women than men get strokes each year.”

Why the higher stroke rate in women? A recent review of past studies and medical literature suggests at least a few reasons. The review, completed by cardiac experts at Rush University Medical Center and published in the September 2009 issue of Gender Medicine (the official peer-reviewed journal of the Partnership for Gender-Specific Medicine at Columbia University), shows that women are more likely to experience physical effects of atrial fibrillation, have a higher frequency of recurrences, and have significantly higher heart rates during atrial fibrillation, which increases the risk of stroke. Additionally, women were shown to be less tolerant of cardiovascular drugs meant to control heart arrhythmias than men. The review also showed that women are not prescribed blood thinners as often as are men – perhaps because of their greater risk of bleeding from anticoagulation therapy – resulting in a higher incidence of blood-clot formation.

It’s also true that the relation of stroke to hormonal fluctuations is not clearly understood. There appears to be a cardiovascular protective element to estrogen: when natural levels dip after menopause, there is an increased risk of arrhythmias and clot formation, both of which increase the risk of stroke. It would seem that hormone replacement therapy is the logical solution – but studies have found a possible correlation between HRT and an increased risk of stroke. This has led scientists to examine the critical timing of HRT in relation to the onset of menopause.

Another source of estrogen, birth-control pills and patches, come with warnings stating the risk of blood-clot formation. The American Heart Association (AHA) has long warned against smoking while on birth control pills, estimating that the combination can raise the risk of stroke by 30 percent. More recently, the patch – which exposes women to 60 percent more estrogen than a typical birth control pill – has come under investigation for further raising rates of stroke in women, as reported by the Food and Drug Administration. The causes are not well understood, and the Women’s Heart Association states that more research is also needed in the following areas with regard to their impact on risk of stroke: lipid-lowering drugs, blood-pressure reduction in various age and race subgroups of women, weight reduction, and treatment of diabetes mellitus.

The AHA’s Go Red for Women campaign aims to reduce cardiovascular disease and stroke in women by 25 percent in 2010. The organization’s recently published special journal on stroke featured studies on unique stroke risk factors among women and gender disparities in stroke care. “Science and research have been critical components of our Go Red For Women initiative since its inception,” says Lori Mosca, M.D., a Go Red spokesperson and director of preventive cardiology at New York-Presbyterian Hospital, on the AHA’s Web site. “These new research findings, showing women have unique risk factors for stroke and are more greatly impacted by the consequences of stroke, should be a wake-up call for women to raise their awareness of stroke risk and for health-care providers to close treatment gaps that can save lives.”

Kirwan judges that “the acute treatment for stroke has made great strides in the past ten years.” The intravenous drug Tissue Plasminogen Activator (t-PA), in use since the 1990s, breaks up clots and increases blood flow by thinning the blood. But time is a critical factor in its use: t-PA must be given within three hours, with the greatest benefit occurring in the first 90 minutes. Says Kirwan, “The general public needs to know the F.A.S.T. method for recognizing stroke” – see sidebar – “and change the thinking to ‘brain attack’ so it gets the same priority as heart attack.”

Jean Prunty, M.D., a neurologist with Copley Health Systems in Morrisville who sees stroke patients in the ER, says the acute treatment field is changing every day. “Through the use of telemedicine, an outlying hospital can send files and exam results for immediate consultation with a Level I trauma center, and avoid wasting precious time,” Prunty says. For patients ineligible for t-PA use, she adds, “there is a new device called a MERCI retriever to remove blood clots in the brain.” Prunty would like to see more people familiar with the FAST method of stroke detection, but also advises people to “be on the watch for unusual symptoms, such as dizziness, chest pain, and even hiccups. But the most important approach is education and prevention.”

The goals of stroke prevention are to keep fatty deposits down in the blood, and to keep the blood flowing. Donna Powell, D.N. (Doctor of Naturopathy) at Health Resolutions in Burlington, says her approach is to look at the individual’s lifestyle and risk factors – such as a lot of traveling, which can increase clot formation – and determine why is the blood thick and what’s needed to thin it out. Powell recommends that post-menopausal women have their blood sugar and cholesterol levels checked – keeping in mind that, of the two components of cholesterol, “the HDLs [high-density lipoproteins] have a protective quality, so you want that number to be high.”

Other natural approaches to supporting good circulation and blood vessel strength, says Powell, could include regular exercise, the use of fish oils, B-vitamins, garlic, herbs such as gingko or hypericum, and stress-reduction techniques to lower the blood pressure. She also looks at how a person digests fats, and whether her diet includes highly processed or sugary foods. The combination of fat and sugar has been linked to plaque formation in blood vessels, Powell explains.

Stroke rehabilitation will vary with each individual. Carol Talley, M.D., is a physiatrist (a doctor who specializes in physical medicine and rehabilitation), an attending physician at Fletcher Allen Health Care, and an assistant professor at the University of Vermont in the department of orthopedics and rehabilitation. Talley sees stroke patients who have been discharged from neurology but not sent directly home for outpatient rehabilitation. Inpatient rehabilitation patients, Talley says, “have problems with movement, sensation, thinking, and speaking. The age group I see the most is 55 to 85.”

These more seriously affected patients are evaluated by a multidisciplinary team that includes a physiatrist, a physical and occupational therapist, a speech language pathologist, a psychologist, a recreational therapist, a rehab nurse, and, frequently, a nutrition specialist. The overriding goal, says Talley, is for patients to “be the best you can be.” Some patients will go home with visits from the Visiting Nurses Association; others will continue in outpatient rehabilitation.

The effects of stroke vary widely, depending on the area of brain affected, and the extent of the damage. The following women shared their stories for this article. All expressed hope that in telling them, they could help others.

Andrea Goedken, 40, of Colchester, stroke at age 38

“I was called to my daughter’s school to pick her up, as she was sick. I brought her home, and soon I got sick as well and started throwing up. I also had a headache, which would get worse at night. It was the weekend, so I called my doctor’s office. They said to try coffee or Advil for relief and to come in Monday if I wasn’t better. I went to the doctor on Monday still having headache and they prescribed migraine medicine, but said not to take it until I got home as it would make me drowsy. I picked up the kids, went to soccer registration, got home and put a lasagna in the oven, took the medication and went to the couch with a pillow on my head, trying not to yell at the kids because my headache was now so bad! I told my son Ethan, then 8, to ‘call Daddy and tell him he has to come home,’ which Ethan did. A few minutes later, when I was checking the oven again, I said, ‘Call Daddy. I don’t feel good.’ It was the last thing I said before I flopped on the couch. I didn’t pass out, but I couldn’t speak. I was totally conscious and knew what was going on.

“Ethan was my total hero. He handed me the phone and said, ‘I am going to get our neighbor.’ I hung up the phone as I couldn’t speak. When my neighbor came I motioned to my pills, and she knew to take my blood pressure. I had a sense it might have something to do with my blood pressure. I had a history of high blood pressure. It was then I thought, ‘This is odd, I can’t feel the blood pressure cuff.’ And I noticed my left leg drooping, and left arm hanging off the couch. I knew what a stroke was – my dad had one and I’d been in the ER with him. I thought, ‘That’s odd, this looks a lot like a stroke.’ The EMTs got there before my husband – he’d called them when I hung up on him. Ethan was so great. He remembered to take the lasagna out of the oven and took my daughter Carley, then 5, into another room to play.

I got my speech back in the ambulance. I said to the EMT, ‘Doesn’t this look like a stroke?’ He didn’t answer me directly. I was remembering when my Dad had a stroke, and a nurse friend kept saying, ‘T-PA within three hours!’ When I got to the hospital, I would go in and out of talking and never could say what I wanted to say, which was ‘Give me t-PA!’ It was a huge gift my Dad gave me – it took away my fear.

“I was two days in the ICU with a huge headache. They tried to get me into inpatient rehab, because it was going to be hard for me to go home and care for two kids, but insurance wouldn’t cover it because I wasn’t bad enough for that. I didn’t have balance issues. I had weakness and numbness in my left upper extremities. My biggest deficits were with speech and sensory overload, and I worked with outpatient occupational therapy for that. Now, after one and a half years, I am much better, but typically I feel total fatigue and am overwhelmed with too much sensory stimuli, such as sports events. When I do too much, I crash, like a computer rebooting, with five days of power up and one day of power down. I usually crash hard Sunday night – I need to be in a dark place, no movement, and sleep for twelve hours.

“It turns out I had a right-sided carotid artery dissection, which is like a deflated artery but then a clot forms as well. They think what may have caused it was maybe the force of the throwing up and then the migraine may have helped throw the clot. There is a family history of migraines, but I have never had them, and I was not a smoker and in excellent shape. At the end of the day I didn’t have the risk factors. I’d had high blood pressure, but it was well monitored and controlled with meds, especially after my father had his stroke.

“The best part of this for me was that Ethan was given a certificate by Colchester Rescue for his actions, and the fact that I met Theresa” – (see story below) – “through friends who heard of her and thought we should connect. When I met her, it was as if somebody had paddled up to my desert island all of a sudden – that one person who gets it. I call her ‘my cool breeze in hell’. It will be two years in April. There have been huge changes in my life, but I have heard enough stories about people who don’t make it at all. The brain is not to be messed with! I feel grateful for my outcome.”

Jean Cote, 44, of Westminster, stroke at age 38

“I was going to work at the Sojourns Community Health Clinic, a holistic health care center, in January of 2004, when all of a sudden I felt like something had given out in back. Luckily, I arrived within minutes. My tongue was thick, I couldn’t form a word, and my right arm was heavy. At the clinic they assessed me and gave me acupuncture. Then I was taken to the hospital for CT scan, an MRI, and a transesophageal echocardiogram. I believe in a holistic, non-traditional approach. I feel that way of healing is much easier on your body. I also wanted to get all the tests I could so I could know there was not something physically wrong, and I didn’t have to live in fear it might happen again.

“I was never admitted. What had happened was that some sort of inflammation in my front cerebral hemisphere had caused me to have an intermittent block in the left side of my brain. There was no clot, and no bleed. It left residual symptoms, like a loss of equilibrium. I couldn’t multitask anymore, and couldn’t understand if more than one person was talking. I set up a hospital bed at my house, and people came every day. I received acupuncture, massage therapy, and physical therapy. I also used zero balancing techniques, and Jin Shin Jyutsu, forms of acupressure. I worked on a lot of little things – like brushing my teeth. My husband would put the toothpaste on and I had to work on the second part of bringing it to my mouth. Or I could open the refrigerator door but didn’t know how to reach in and get something. I had about six months of therapy which brought me back around. I am thankful there is not much residual. If I get tired, that side of my body is weak, and the right side of my face has a numb, Novocain-like feeling.

“I was on Coumadin for a short while, about six to nine months. All the tests were good, so I went off Coumadin and went on nattokinase and baby aspirin. I have my blood checked for clotting time every six months, as well as a c-reactive protein blood test just to make sure everything is all in line. I know I can’t get overtired or stressed out. My balance and equilibrium are still off a little, and I still can’t multitask well. But I am very thankful, because I don’t have a lot of problems from the stroke. I work and drive now. I went back to work in May, just a few days a week, a few hours a day.

“My advice to anyone is, if you have to go through it, just try to stay as positive as you can. From the moment they said I had a stroke, I looked at them and said, ‘I do not want to be an invalid so let’s do what we have to do.’ I started with baby steps, and there were days when I would just cry. It can be so discouraging but you can’t give up. You have to keep therapy going and keep a positive outlook. If you give your body a chance it will heal. It just takes time. There may be things you can’t do again, but they may be minor compared to having your life back. It changed my life. The things that used to be major problems are minor bumps – it’s a whole new way of looking at life. It was a huge eye-opener to all the things we take for granted, the routine things we do every day. One of my favorite moments was when I went to the kitchen and scrambled an egg. I was so ecstatic – it was such a huge feat!”

Linda Stokes, 55, of Springfield, stroke at age 45

“It happened in June 1999 on a Sunday morning. I got up and went into the kitchen and had breakfast. I stooped to get the dish detergent under the sink, and when I stood up, I was seeing double. Nothing else happened, except seeing double. I shook my head, was still seeing double. My husband at the time was washing the car, so I made my way downstairs and out front. I said, ‘Something’s wrong.’ I then passed out and he drove me to Springfield Hospital. Apparently I’d had a stroke. A lot I don’t remember. I was transferred to Dartmouth-Hitchcock for five days. I had a blood clot in the left side of my brain so there was a right side effect – a droopy face, and memory loss. As I was feeling fine, I asked if I could go home for a day for my daughter’s graduation. Then I just stayed home. I was never in the ICU, just the neurology floor.

“I had several tests and CT scans to find out why [the stroke had occurred]. I didn’t have any risk factors. They were never able to come up with a reason for the blood clot. Until last fall, I was still taking Coumadin and still getting blood draws. Now I take one aspirin a day. While on the Coumadin I bruised easily and my period was very thin, but it also reduced my cramping.

“When I first got home I slept a lot. I had rehab for six months for my arm and leg, and a couple of appointments for help with my memory. I wasn’t aware of how much memory loss I had until someone would say something I couldn’t remember, but once it was said it would come back to me. With computer programs, I had to learn them all over again. I was very emotional, I cried a lot, two to three days a week sometimes. I would forget names, and my short term memory still isn’t great. I say, ‘My elevator doesn’t reach the top floor.’ When I walk, I may need to swing my right arm with my other to help stay in balance, and when I get tired I will stumble. I feel very fortunate to have come back as far as I have. I now work full-time after I finished raising kids, and I have been divorced and remarried. I could never have done it without friends and family. What I learned is, treasure what you have because you don’t know how long you will have it. And for anyone else who may have to go through this, count on your friends and family and don’t be afraid to let people help you.”

“Susan” (name withheld), 50, of Burlington, stroke at age 42

“I was not a smoker and was in excellent physical condition, but I’d been suffering from migraines for fifteen days. I persistently went to my doctor, and was given narcotics and a minimal office scan. I woke up one morning with my left eye drooping. I again called my doctor who had me come into the office, and then was sent to Fletcher Allen for a CT scan and an MRI. I ended up having emergency surgery for a bleeding aneurysm.

“I also underwent a second stroke while in a drug-induced coma to help reduce the swelling, despite constant CT scans. I think I was too inhibited to advocate for myself in the beginning. I came out partially paralyzed on my left side. I now go to the Rehab Gym in Colchester two to three times a week and do water therapy and one-on-one exercise with a therapist to strengthen my body equally. Having a stroke is an expensive adventure – insurance covers part of it but not all. I was unable to return to my job, and because I am partially paralyzed I can’t drive yet.

“It’s been a slow process of recovery, but it is conceivable I will fully recover. For years they thought the brain once damaged was always damaged. Now they know the brain can heal itself and do remarkable things. My goal is for 85 percent return of my function. I do positive visualization and every day I meditate on my body – I visualize my brain and how it is healing. And while I have tried many approaches, basic exercise has worked the best for me. I take medication for depression and to help me sleep, common effects of the stroke. What I want to tell others is that things can happen overnight, and we have to change with it fast and adjust. It also helps to have wonderful friends and family like I do, who have been very available and supportive.”

Virginia Leboeuf, 50, of Ogdensburg, NY, stroke at age 42

“My father had died three days earlier. The funeral was on a Wednesday, and on Thursday I went to work. The next day, Friday afternoon at 2 o’clock, I was not feeling well. My legs felt weak and I felt dizzy and lightheaded. When I tried to pick up something with my left hand, it kept slipping out from my thumb and finger. I said to my coworker, ‘I don’t feel well, I think I’m going to sit down.’ Another co-worker said, ‘She’s having a stroke.’ I had already thought when it started to happen, ‘Gee, I’m having a stroke.’

“My boss came out said, ‘Ginny, do you want me to call rescue?’ I said, ‘Yeah, I think you better.’ Coincidentally, my husband and son were coming to pick up the car to change the oil. They opened the door for the rescue squad not knowing it was for me! They followed the ambulance to the hospital. Everything else is vague after that. I remember my friends and family coming to see me in the hospital, and different people asking me to squeeze their fingers. They wanted to keep me overnight for observation. I wanted to go home because I felt fine. But when I sat up in bed the next morning, I said to my husband, ‘Get the nurse, I don’t feel well.’ It turns out I got a second stroke.

“I was transferred to Fletcher Allen, and was in the ICU there for a week, of which I don’t remember much. Then I spent seven weeks at Fanny Allen rehab, where I worked on walking, which came along very well. I was walking by the time I left, with an ankle brace. My left arm was useless, though. In the beginning my speech was bad, and I spent time with a speech therapist. For a while my understanding was difficult. Now, I get distracted easily, long conversations are tiring, and I sometimes get confused in crowds with different conversations going on. I couldn’t work and had to go on disability. I can drive for short trips. I still get occupational therapy in my home. They used Botox on my hand and elbow which had been very tight and contracted. I was so amazed, it opened right up. I didn’t know it had uses other than cosmetic!

“My stroke was caused by a right carotid artery clot. I had no risk factors, and no previous indication. They thought it might be congenital. I thought, ‘I’m so glad this happened now and not when my boys were young.’ My message to others? Don’t give up hope. My strong religious background has helped me. My goal is to get completely better.”

Theresa Moss, 34, of Colchester, stroke at age 30

“I was in Florida vacationing at a friend’s house in late February 2006. I flew on a late flight and slept on the plane with my head curled up on my chest. For a couple of weeks prior I’d had dizziness and was disoriented on occasion. I told my friends, ‘I’m not myself,’ and I chalked it up to stress. Once I arrived, the dizziness got worse and I had an extreme headache. On the second day I got out of bed and everything started to spin. I went to my knees and vomited. My friend’s mother took me to the ER. They did blood work and a CT scan, and decided I had stress migraines. They gave me a drug called Antivert and told me to enjoy the rest of my vacation.

“Eighteen hours later in the middle of the night, I woke up out of a dead sleep. The room was spinning. I couldn’t call out ‘I need help’ to my friend in the other room. I was drooling, slurring, and mumbling. I remembered my cell phone was nearby. I had extreme vertigo and headache, which would calm down for a second. I flipped open the phone during one of the calm seconds, but the blue light of the phone started it all up again. I closed my eyes and felt my way to my friend’s number. I heard her phone ring. I let my body drop to the floor, and crawled to the door of the guest room. I couldn’t hold my body up, the pain was excruciating, and there was a swishing noise in my head that was louder than a freight train, just unbelievably loud and painful. My friend heard her phone and I heard her come into the kitchen. I was trying to say, ‘It’s me, it’s me, I need you,’ but I was really just mumbling and drooling, making sounds. She finally saw me and I gestured to the bathroom. She dragged me in there and I was able to wrap my arms around the toilet and vomited, still having excruciating head pain. My friend and her husband couldn’t figure out what was happening. It looked like I was just throwing up, maybe with the flu or something. I remember thinking about my boys, and the hug they gave me before I left, and I thought, ‘This will not be the last hug they give me.’

“They took me to the ER again. They did another CT scan, which is not as diagnostic as an MRI. They couldn’t do an MRI on me as I had metal plates and rods in me from a previous car accident. They still could not diagnose me, because with a CT scan (I have since learned), the brain damage does not show up until 24-28 hours later. They admitted me. I couldn’t walk, couldn’t sit up by myself, could only speak a little, and I couldn’t hold consciousness for very long.

“My savior was a young neurologist who had a hunch. He’d read something that seemed to fit my case – all these random strange things in my life. The previous car accident which was a side collision and caused neck trauma, sleeping in an airplane in a fetal position, there were even theories related to my being a former gymnast. He ordered another CT scan with a different view, and confirmed two hemorrhagic strokes from a vertebral dissection, which is rare. He told me the next day, ‘Theresa, you have had two strokes.’

“The second stroke was much bigger than the first. Both strokes were in the cerebellum, and I’m not able to say why after all this time. There was a tear in the vertebral artery, which is the main artery that supplies blood to the brain. Mine had torn open, and with every heart beat it squirted into the cerebellum and clotted.

The reason could be any one of a dozen of things.

“Now, anything that is in my peripheral vision that is moving, I have to ask a person to stop as it makes me sick. I get exhausted, and there isn’t a day I haven’t been tired on some level. I will have a burst of energy – ‘Great, I can clean my house today!’ – then it wipes me out for five days. I lose words, and I am person of words. I lose my balance, as the cerebellum controls focus, balance, and language. And my typing can be a little dyslexic at times.

“Post-stroke, I absorb information much like someone with a mild learning disability. I have to read and re-read things that I need to remember, and I have to write myself a lot more notes. It's not that my memory is bad, because once I absorb something, I don't forget it. It's the absorption process that has changed significantly. I do not have any memory loss of things that happened in my life pre-stroke, though. This is because my brain damage is in my cerebellum, which has little to do with memory.

“In keeping a sense of humor about as much as possible, I love to blame just about everything on ‘the brain damage,’ while I laugh sarcastically!

“I'm finally starting to come back to life physically. Before the strokes I was a runner and was training to run in my second marathon. After the strokes I have done nothing but maybe take a walk or two. However, I have just joined a women's ‘Learn to Play Hockey’ league! It's pretty low-key for hockey, but I am so happy to be moving again after almost four years!

Roberta Nubile is a freelance writer from Shelburne.

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