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	=='''Prevention'''==		=='''Prevention'''==
-	There are many factors which increase the risk of a stroke. It is important to know these factors so that preventative measures can be taken to reduce the occurrence of stroke. Some of these factors can not be controlled by the individual, such as ethnicity, gender, age, and family history <ref name="Prevent">Romero, J. (2007). Prevention of Ischemic Stroke: Overview of Traditional Risk Factors. Current Drug Targets, 8(7), 794-801. doi:10.2174/138945007781077373</ref>.	+	[[Image:stroke-tbl1.jpg]]<videoflash>k9UEtmqBY0s&feature=relmfu|300|200|right</videoflash>
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-	However there are many factors which increase the risk of a stroke, including hypertension, atrial fibrillation, use of preventative drugs, presence of diabetes, smoking, and obesity that can be controlled <ref name="Prevent"/>. The following section will discuss these controllable risk factors in isolation, but it should be noted that most people who suffer from a stroke have a combination of risk factors <ref name="Prevent"/>. <videoflash>k9UEtmqBY0s&feature=relmfu|300|200|right</videoflash>	+
		+	There are many factors which increase the risk of a stroke.<ref name="Prevent">Romero, J. (2007). Prevention of Ischemic Stroke: Overview of Traditional Risk Factors. Current Drug Targets, 8(7), 794-801.
		+	doi:10.2174/138945007781077373</ref>. It is important to know these factors so that preventative measures can be taken to reduce the occurrence of stroke. The following section will discuss these controllable risk factors in isolation, but it should be noted that most people who suffer from a stroke have a combination of risk factors <ref name="Prevent"/>.
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	**For most men this could mean two glasses of wine a day, and one glass of wine per day for women.<ref name="wolff"/>		**For most men this could mean two glasses of wine a day, and one glass of wine per day for women.<ref name="wolff"/>
	*monitor the amount of [http://ldlhdlcholesterollevels.org/ HDL and LDL cholesterol levels] to ensure that their cholesterol levels are being balanced. <ref name="Prevent"/>		*monitor the amount of [http://ldlhdlcholesterollevels.org/ HDL and LDL cholesterol levels] to ensure that their cholesterol levels are being balanced. <ref name="Prevent"/>
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	=='''Treatment'''==		=='''Treatment'''==

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Revision as of 01:06, 1 November 2011

Contents 1 Group 14- Stroke 2 Defintion 3 Background Information 4 Types of Strokes 5 Stroke risk factors 6 Effects of a Stroke on Survivors 6.1 Communication 6.2 Motor Movement 6.3 Quality of Life 7 Effects of Stroke on Caregivers 7.1 Relationship with Survivor 7.2 Changes 8 Prevention 8.1 Hypertension 8.2 Atrial Fibrillation 8.3 Aspirin 8.4 Diabetes 8.5 Smoking 8.6 Lifestyle Changes 9 Treatment 9.1 Medications 9.2 Surgery 9.3 Non-Surgical Procedures 10 Rehabilitation 10.1 Physical Therapy 10.2 Constraint-Induced Movement Therapy 10.3 Occupational Therapy 10.4 Speech and Language Therapy 11 Notes and References

Group 14- Stroke

• 1. Jessica Kremble
• 2. Jennifer Martin
• 3. Holly Vlasov
• 4. Krystin Piedl

Defintion

What is a stroke?

A stroke, clinically defined as a cerebrovascular accident, which occurs when there is loss of blood blow to a specific brain area ^[1]. Strokes vary in magnitude and can have rarely noticeable effects or major cognitive impairments in extreme cases. In most circumstances motor abilities are most affected, due to where the damage occurs in the brain. This includes language skills, facial paralysis and the paralysis of limbs ^[1] .

Background Information

Strokesare a very serious health issue, it is the third largest cause of death and within the first 10 days of a stroke occurring a third of patients will die ^[2]. In addition, survivors of strokes may experience cognitive impairments, depression, language impairments and physical disabilities. In addition to the patients, families and caregivers also suffer after a stroke when trying to help a loved one recover ^[2].

The brain requires a high amount of energy and blood supply. As little as 60-90 seconds of the brain being deprived by oxygen, damage can occur ^[2]. When a stroke occurs there is a small window of time to be able to have medical attention, after three hours, if there is still no oxygen to the stroke location the results are irreversible ^[2]. If a stroke occurs, you must act promptly and seek medical attention.

Atherothromboembolism and cardiogenic embolism are the main cause of stroke around the world. These are the scientific terms to describe ischemic and hemorrhage types of strokes. Ischemic strokes which are the cause arterial occlusion comprise of 80% of cases and in addition hemorrhage strokes are 15 % of all cases ^[3].

Types of Strokes

Ischemic: Local insufficiency of blood, because of a blood clot or other obstruction that has blocked the artery. Oxygen supplies get cut off and damages part of the brain ^[1].

Ischemic subtypes:

• Lucunar infarct – A very small lesion that is deep into the artery tissue which can prevent or block blood flow. This type of stroke is the most typical and seen in more men than women. The prevalence is also higher in Chinese, Mexican and African Americans ^[4].

• Artery anteroclerosis – Most prevalent in individuals with high cholesterol, causing the artery walls to become thicker ^[5].

• Cardioembolism – The result of atrial fibrillation. This type of stroke has a higher prevalence in white population compared to other racial groups ^[5].

• Transient ischemic attack – A blood clot in brain, which results in stroke like symptoms. After a transient ischemic attack, a patient is most likely to experience a real stroke, and should take measures into preventing strokes with medication and lifestyle changes. Symptoms of a TIA go away within 24 hours ^[2].

Although there are many subtypes of ischemic stroke, 15-40% of all cases are undetermined ^[6].

Hemorrhage: The result of a ruptured artery or blood vessel within the brain. After this occurs there is a large amount of oxygen that floods at area and also causes damages due to the rupture ^[1]. Hemorrhage stroke is least common and have a higher chance of being fatal than ischemic ^[2].

Stroke risk factors

Atrial fibrillation is the largest risk factor for strokes. Atrial fibrillation is the result of an abnormal heart beat. As you age the risk for atrial fibrillation and stroke increases, as it is associated with greater risks for ischemic strokes. In addition heart failure, hypertension, diabetes and being over the age of 75 also have large impacts of the risk for having a stroke ^[5]. Many environmental factors have a large impact on the risk for having a stroke, which includes smoking, alcohol consumption and poor diet. These environmental factors increase the risk for heart disease and cholesterol which can lead to strokes ^[7].

Strokes can happen to an individual at any age, even though it is more popular in the aging society. In a recent study risk factors were taken into account to compare the younger generation and older generation in stroke related causes ^[8]. The study concluded that in the younger group 50-75 yrs, the main factors for stroke were; obesity and high cholesterol levels. It was also concluded that smoking and regular alcohol consumption was highly correlated with men and that heart disease was more frequently related to women. For the older group 75 years and over the main risk factors included atrial fibrillation, hypertension and diabetes ^[8] .

Effects of a Stroke on Survivors

Strokes affect each individual differently in terms of the outcomes and difficulties they have post stroke. The outcomes are affected by how severe the stroke is as well as what type of stroke the individual has.

Communication

Communication is an area of struggle for individuals who have suffered strokes. Aphasia is a disorder in which the individual has difficulty comprehending speech or understands it but cannot produce what they want to say.Dysarthria is characterized by an individual knowing what they want to say but being unable to produce them, and therefore find other ways of communication such as drawing or writing the words. Communication with other people is often very stressful and time consuming, so much so that it affects social relationships ^[9]. People who suffer from aphasia have half the social network size post stroke in relation to pre stroke ^[9]. This difference in social network size may be due to social isolation because of the difficulty communicating ^[9]

Aphasia

Dysarthria

Motor Movement

Paralysis is the loss of motor movement of an area of the body. It can occur post-stroke, and is on the side of the body opposite of where the stroke occurred. Balance and gait is also affected by stroke. Post-stroke, individuals walk slower and have poor balance compared to other elderly individuals ^[10]. Hypokinetic movement disorders are characterized by slower or reduced motor movements ^[11]. Hyperkineticmovement disorder is characterized by an increased amount of motor movement ^[11].

Quality of Life

Depression affects the quality of life of stroke survivors, especially within the first six-month period post stroke ^[12]. Every stroke survivor experiences depression two weeks after their stroke ^[12]. This onset of depression can sometimes lead to death in stroke patients because of the impact it has on the psyche of the individual ^[12]. Quantitatively, stroke survivors are satisfied with their quality of life ^[13] . Qualitatively, with the effects of dependency on others, loss of movements, inability to perform usual activities, stroke survivors are dissatisfied with their quality of life ^[13]. Returning to work post stroke often affects the life of the survivor. Even though many stroke patients are older, some are young and also many are working before their stroke. Work situations may have been stressful and one of the causes of their stroke, so return to work may not be a good idea for stroke survivors because could increase chance of another stroke ^[14] . Working individuals find it important to work because it allows for stability with money and the home ^[14]. Stroke survivor's return to work is dependent on recovery, and the barriers caused by the stroke that they deal with ^[14].

Effects of Stroke on Caregivers

Relationship with Survivor

Strong relationships are important in the recovery of the stroke survivor; excess stress placed by the caregiver could be detrimental ^[15]. Loss of a partner as who they used to be is a common result of a stroke ^[15]. Caregivers are often overprotective and fearful of the survivor having another stroke, which could cause the survivor to feel like they are being treated as a child ^[15].Intimacy is a very important factor in a relationship, this is often lost post stroke, due to loss of mobility in the survivor ^[15]. Familial roles change after stroke, the caregiver must now be the provider, caretaker, and strong individual ^[15]. This is increasingly difficult if the stroke survivor is the dominant male of the household. Family roles can often change with other members of the family; children and grandchildren for instance may become less important to the carer in relation to the stroke survivor ^[15]. This can be detrimental to all of the emotional lives of everyone in the family, and everyone affected by the stroke. Burden is a common feeling of caregivers due to the need to spend many hours of their days and weeks caring and aiding the survivors in their recovery and daily activities ^[16].

Changes

Work is an important way of supporting a family, caregivers often experience changes in their employment with either now having to work, working more hours or having to cut back due to care taking responsibilities ^[15]. All of the work changes can affect the caregiver; some often report it helped keep them sane throughout the recovery process ^[15]. Friends are often put on hold during recovery leading to isolation being felt by the caregiver ^[15]. Stress can affect the social relationships as well because they feel they are abandoning the survivor and cannot enjoy themselves when they go out ^[15]. It is not all bad changes; caregivers can often feel more self-worth and see their life in a more positive direction because of the new roles taken on.

Prevention

There are many factors which increase the risk of a stroke.^[17]. It is important to know these factors so that preventative measures can be taken to reduce the occurrence of stroke. The following section will discuss these controllable risk factors in isolation, but it should be noted that most people who suffer from a stroke have a combination of risk factors ^[17].

Hypertension

Hypertension, which is commonly known as high blood pressure, significantly increases the risk of both hemorrhagic and ischaemic strokes.^[17] Unfortunately, less than 25% of the world’s hypertensive population strictly monitors their blood pressure levels.^[18]. However, by lowering blood pressure levels to a normal range, patients can reduce their risk of stroke by 30-40 %! ^{[17] [19]} Blood pressure levels can be lowered by healthy lifestyle modifications, such as not smoking, increasing the amount of exercise, and implementing a healthy diet. ^[17][18]

Atrial Fibrillation

Atrial fibrillation) occurs from an irregular beating of the heart that causes blood to collect in one of the heart's chambers. The resulting blood clot can dislodge and lead to a stroke. It is a disorder characterized by a common and persistent irregular heart rhythm, which accounts for 15% of all strokes. ^{[17] [20]} Persons with AF are at least five times more likely than persons with normal heart rhythms to have strokes ^[20]. It is estimated that every one out of four persons over the age of 40 will have AF,^[17][20] and the international population of persons with AF is expected to double, at minimum, due to the ageing populace by year 2050. ^[20] Strokes caused by atrial fibrillation are more likely to be fatal than non atrial fibrillation induced strokes.^[20] Clinicians are responsible for determining whether it is most advantageous for the individual to leave the AF untreated, or to go on medications. The most effective treatments for persons with AF are anticoagulant (i.e. warfarin, dibigatran, antrithrombotic (i.e. aspirin) therapies. ^[17][20] The clinician will decide which treatment plan to use depending on the individuals medical history and age. ^[20] Typically, individuals with AF who are at a higher risk of having a stroke are put on a warfarin treatment plan. This reduces the likelihood of a stroke by 66%, which is far more effective than aspirin (risk reduction of only 20%).^[20] However, the complications associated with warfarin are greater than aspirin, in that warfarin holds a high propensity for reactions to both food and other medications. ^[20]

Aspirin

Physicians have commonly prescribed aspirinas a preventative measure for strokes in the elderly population. It has been effective for both men and women in reducing the number of people affected by cardiovascular disease, including myocardial infarction and ischemic stroke. ^[21] However, individuals who have taken aspirin as a preventative measure for strokes have shown an increased likelihood of major bleeding events (most commonly bleeding in the gastrointestinal tract).^[21] Research has found that men who take aspirin prior to a stroke are more likely to have a hemorrhagic stroke, whereas aspirin was not seen to significantly affect stroke type in women.^[21]

Diabetes

Data compiled from Stats Canada recorded that in 2010, 1,841,527 Canadians or 6.4 percent of Canada's population have diabetes.^[22] The percentage increases with age, with an estimated 17.7% of the population over 65 years old expected to have diabetes (21.2% risk in males and 14.9% risk in females).^[22] The prevalence of diabetes continues to increase annually; in the past five years the population of people with diabetes has increased by 1.5%.^[22] Diabetes increases the likelihood of cardiac diseases and significantly increases the risk of stroke ^[17]. In most cases, diabetes occurs in conjunction with other cardiovascular risk factors. For example, an estimated 60% of diabetics have hypertension as well^[17]. The most effective prevention method for strokes in diabetics is lifestyle changes ^[17].

Smoking

An estimated 20% of Canadians report to be smokers.^[23] Smoking increases the risk of having a stroke by a factor of two.^[17] This risk increases proportionally to the number of cigarettes smoked daily - so increasing the amount of cigarettes smoked daily increases the risk of stroke to the individual. The day a smoking person decides to stop smoking their, risk of stroke immediately starts to decrease. After five smoke-free years, the former individuals risk of stroke is comparable to someone who has never smoked.^[17]

Lifestyle Changes

The most beneficial measure any individual can take to reduce the risk of stroke is by making healthy lifestyle changes. The following measures are effective in reducing the risk of stroke:

• Increasing the amount of exercise will help the individual lose excess weight and decrease cholesterol.
  • Even as little as half an hour a day can be helpful to prevent stroke and other cardiovascular diseases.^{[17] [21]}
• implement a healthy diet, rich in a variety of nutrient packed foods and eaten in moderation.^[17][19]
• drinking alcohol in moderation can decrease the risk of stroke.
  • For most men this could mean two glasses of wine a day, and one glass of wine per day for women.^[21]
• monitor the amount of HDL and LDL cholesterol levels to ensure that their cholesterol levels are being balanced. ^[17]

Treatment

The main goals of treatment for stroke are to prevent brain damage from progressing and to prevent another stroke from occurring.^[24]

Medications

After a patient has been admitted to the hospital due to stroke, a tissue plasminogen activator (tPA) may be administered. tPA may only be used if there is a blockage in the brain.^[25] The tPA works to break up the blood clot which is stopping blood and oxygen from reaching areas of the brain.^[25] Patients must have a CT scan to ensure that the stroke is in fact due to a blood clot as opposed to bleeding in the brain.^[25] Administering tPA to an individual who has had a hemorrhagic stroke (bleeding) can be extremely dangerous and worsen the effect of the stroke.^[25] It is widely believed that the tPA must be administered within 3 hours of onset of stroke symptoms for the drug to be affective. Recent studies, however, have shown that patients can significantly benefit from treatment with a tPA which has been administered up to 4.5 hours after onset of stroke.^[26]

Surgery

Patients who have suffered from a hemorrhagic stroke may require surgery to reduce further damage to the brain. Blood that has collected after hemorrhagic stroke can begin clotting and may require surgical removal to relieve pressure on the brain.^[24] Surgery may also be required to repair ruptured blood vessels that caused the bleeding.^[27]

Non-Surgical Procedures

Carotid angioplasty and stenting is a treatment method after ischemic stroke which involves insertion of a balloon-like device into the artery. ^[27] The device opens the clogged artery and allows doctors to insert a metal stent which helps to keep the artery open and allow blood to reach the brain.^[27] An aneurysm is a blood-filled bulge that results from weak artery walls. Blood vessels may be filled with flexible coils to prevent an aneurysm from rupturing and causing stroke.^[27]

Rehabilitation

The goal of rehabilitation after stroke is to reach the optimal level of function and movement, allowing patients to regain as much independence as possible.^[28] Rehabilitation usually begins while the patient is in the hospital and may continue on an outpatient basis.^[24] Most drastic improvements are usually noticed within the first 3-6 months but rehabilitation may continue for much longer.^[24][28] To ensure maximum recovery, rehabilitation should begin as soon as possible after stroke. Studies have shown that those who began rehabilitation earlier had better functional outcomes than patients who started rehabilitation later.^[29] In addition, patients who undergo more intensive rehabilitation have shown to have better and faster improvement with activities of daily living.^[29]

Most stroke patients receive integrated treatment from a rehabilitation team and may require multiple types of therapy.^[28]

Physical Therapy

A physical therapist almost always part of the rehabilitation team and work with the patient to increase range of motion and to maintain muscle tone of the affected limb.^[24] Physical Therapists may also teach exercises that the family can work on with the patient or that the patient could do themselves when they are released from the hospital. For patients with partial paralysis, physiotherapy may also include learning to walk again.^[24]

Constraint-Induced Movement Therapy

Constraint-Induced Movement Therapy is a type of rehabilitation therapy in which patients are forced to use their affected limb by restraining the good arm.^[30] It is suggested that the repetitive and forced movement of the disabled limb causes neurons to take on their old function. CIMT has shown to improve patient’s ability to complete activities of daily living.^[30]

Occupational Therapy

Occupational therapists work with stroke patients to accomplish aspects of everyday living such as dressing, bathing and eating.^[24] To help patients accomplish these tasks to the best of their ability, the Occupational Therapist may suggest helpful modifications to compensate for their loss.^[24] Examples of these modifications may include suggesting Velcro shoes and installing handrails throughout the home. If the patient has recovered enough, the Occupational Therapist may also help them to start working again.^[24]

Speech and Language Therapy

Speech therapy usually starts in the hospital where therapists obtain simple yes/no questions from the patient, either verbally or through non-verbal methods.^[24] Speech and Language Therapists strive to teach the patient to communicate to the best of their ability. Patient’s may be taught to use specific communication aids such as gestures, repetition or pointing to pictures.^[24] Speech and Language Therapists also assess swallowing ability of the patient and help with management if problems are found.^[28]

The patient may also benefit from help with a psychologist, a dietician and a pharmacist.^[25] Patients should be included in the decisions regarding rehabilitation as much as possible.^[24] Recovery of the patient depends on various factors such as the site of injury, general health of the patient, personality and will, family support, and the care received.^[24]

.

Notes and References

1. ↑ ^{1.0 1.1 1.2 1.3} Kalat , J. (2009). Biological psychology . (10 ed., pp. 139-141). Belmont, CA USA: Wadsworth Cengage Learning..
2. ↑ ^{2.0 2.1 2.2 2.3 2.4 2.5} Westerby, R. (2011). Stroke and TIA. Practice Nurse, 41(13), 30-37.
3. ↑ Hankey, G. J. (2005). Preventable stroke and stroke prevention. Journal of Thrombosis & Haemostasis, 3(8), 1638-1645..
4. ↑ Mok VC, Wong A, Lam WW, Baum LW, Ng HK, Wong L. A case-controlled study of cognitive progression in Chinese lacunar stroke patients. Clin Neurol Neurosurg. Jul 2008;110(7):649-56.
5. ↑ ^{5.0 5.1 5.2} Shen, A., Chen, W., Yao, J., Brar, S., Wang, X., & Go, A. (2008). Effect of Race/Ethnicity on the Efficacy of Warfarin: Potential Implications for Prevention of Stroke in Patients with Atrial Fibrillation. CNS Drugs, 22(10), 815-826.
6. ↑ Todo, K., Moriwaki, H., Saito, K., & Naritomi, H. (2009). Frequent Premature Atrial Contractions in Stroke of Undetermined Etiology. European Neurology, 61(5), 285-288..
7. ↑ Murat Sumer, M. M., & Erturk, O. O. (2002). Ischemic stroke subtypes: risk factors, functional outcome and recurrence. Neurological Sciences, 22(6), 449..
8. ↑ ^{8.0 8.1} Chih-Ying, W., Hung-Ming, W., Jiann-Der, L., & Hsu-Huei, W. (2010). Stroke risk factors and subtypes in different age groups: A hospital-based study. Neurology India, 58(6), 863-868..
9. ↑ ^{9.0 9.1 9.2} Vickers, C. (2010).Social networks after the onset of aphasia: The impact of aphasia group attendance. Aphasiology, 24:6-8, 902-913.
10. ↑ Hyndman, D., Ashburn, A., Yardley, l., & Stack, E. (2006). Interference between balance, gait and cognitive task performance among people living with stroke in the community. Disability and Rehabilitation, 28:13-14, 849-856
11. ↑ ^{11.0 11.1} Ghika, J. (2005). In Recovery after stroke, edited by Barnes, Michael, Dobkin, Bruce H., Bogousslavsky, Julien, 259-285. New York, NY, US:Cambridge University Press.
12. ↑ ^{12.0 12.1 12.2} Gbiri, C.A., Akinpelu, A.O., & Odole, A.C. (2010) Prevalence, pattern, and impact of depression on quality of life of stroke survivors. International Journal of Psychiatry in Clinical Practice, 14:3, 198-203.
13. ↑ ^{13.0 13.1} Tariah, H.A., Hersch, G., & Ostwald, S.K. (2006) Factors associated with quality of life: Perspectives of stroke survivors. Physical & Occupational Therapy in Geriatrics, 25:2, 33-50.
14. ↑ ^{14.0 14.1 14.2} Alaszewski, A., Alaszewski, H., Potter, J., & Penhale, B. (2007) Working after a stroke: Survivors’ experiences and perceptions of barriers to and facilitators of the return to paid employment.Disability and Rehabilitation, 29:24, 1858-1869.
15. ↑ ^{15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 15.8 15.9} Buschenfeld, K., Morris, R., & Lockwood, S. (2009) The experiences of partners of young stroke survivors. Disability and Rehabilitation, 31:20, 1643-1651
16. ↑ Tooth, L., McKenna, K., Barnett, A., Prescott, C., & Murphy, S.(2005) Caregiver burden, time spent caring and health status in the first 12 months following stroke. Brain Injury, 19:12, 963-974
17. ↑ ^{17.00 17.01 17.02 17.03 17.04 17.05 17.06 17.07 17.08 17.09 17.10 17.11 17.12 17.13 17.14 17.15} Romero, J. (2007). Prevention of Ischemic Stroke: Overview of Traditional Risk Factors. Current Drug Targets, 8(7), 794-801. doi:10.2174/138945007781077373
18. ↑ ^{18.0 18.1} Chalmers, J., & Chapman, N. (2001) Challenges for the Prevention of Primary and Secondary Stroke. The importance of lowering blood pressure and total cardiovascular risk. Blood Pressure, 10(5/6), 344-351. doi:10.1080/080370501753400647
19. ↑ ^{19.0 19.1} Lüders, S. (2007). Drug Therapy for the Secondary Prevention of Stroke in Hypertensive Patients: Current Issues and Options. Drugs, 67(7), 955. Retrieved from EBSCOhost.
20. ↑ ^{20.0 20.1 20.2 20.3 20.4 20.5 20.6 20.7 20.8} Westerby, R. (2011). Stroke and TIA. Practice Nurse, 41(13), 30-37. Retrieved from EBSCOhost.
21. ↑ ^{21.0 21.1 21.2 21.3 21.4} Wolff, T., Miller, T., & Ko, S. (2009). Aspirin for the Primary Prevention of Cardiovascular Events: An Update of the Evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 150(6), 405-W.72. Retrieved from EBSCOhost.</ref name="raju">Raju, N., Sobieraj-Teague, M., Hirsh, J., O'Donnell, M.., Eikelboom, J. Effect of Aspirin on Mortality in the Primary Prevention of Cardiovascular Disease. The American Journal of Medicine (July 2011), 124 (7), pg. 621-629. doi: 10.1016/j.amjmed.2011.01.018.
22. ↑ ^{22.0 22.1 22.2} Statistics Canada. (2006a). Diabetes by age group and sex. (Table 502-0002). Retrieved from http://www40.statcan.gc.ca/l01/cst01/health53b-eng.htm
23. ↑ Statistics Canada. (2011). Smokers, by age group and sex. (Table 602-0992). Retrieved from http://www40.statcan.ca/l01/cst01/health73a-eng.htm
24. ↑ ^{24.00 24.01 24.02 24.03 24.04 24.05 24.06 24.07 24.08 24.09 24.10 24.11 24.12} Brass, L. (1992). Stroke. In B. L. Zaret, M. Mosner & L. S. Cohen (Eds.), Yale University School of Medicine heart book. New York: Hearst Books.
25. ↑ ^{25.0 25.1 25.2 25.3 25.4} Rudd, A., Irwin, P.,& Penhale, B. (2005).Stroke: The comprehensive and medically accurate manual about stroke and how to deal with it. London: Class Publishing Ltd. .
26. ↑ Hacke, W., Kaste, M., Bluhmki, E.,, Brozman, M., Dávalos, A., Guidetti, D., Larrue, V., Lees, K. R. Md., Medeghri, Z., Machnig, T., Schneider, D., Von Kummer, R., Wahlgren, N., Toni, D., et al. (2008). Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. The New England Journal of Medicine. 359(13), 1317-1329.
27. ↑ ^{27.0 27.1 27.2 27.3} Mohr, J. P. (2011). Stroke: Pathophysiology, diagnosis, and management. Philadelphia: Saunders..
28. ↑ ^{28.0 28.1 28.2 28.3} Fawcus, R. (Ed.). (2000). Stroke rehabilitation: a collaborative approach. Massachusetts: Blackwell Science Ltd..
29. ↑ ^{29.0 29.1} Hu, M., Hsu, S., Yip, P., Jeng, J., & Wang, Y. (2010). Early and intensive rehabilitation predicts good functional outcomes in patients admitted to the stroke intensive care unit. Disability and Rehabilitation, 32(15), 1251-1259..
30. ↑ ^{30.0 30.1} Marklund, I., Klassbo, M., & Hedelin, B. (2010). “I got knowledge of myself and my prospects for leading and easier life”: Stroke patients’ experience of training with lower-limb CIMT. Advances in Physiotherapy, 12, 134-141..