The Essay On Stroke's Effect In Adult/Elderly People.

Discuss about the effect of Stroke in adult or elderly people.

Aging-Related Changes in the Central Nervous System

Statistics shows that about 16 million people are attacked by stroke every year, and about 5.7 million deaths are reported every year. Stroke is ranked as the third largest killer disease among the neoplastic diseases and the second cause of death after heart disease in the developed countries. Various researchers have shown that stroke is the largest cause of adult disability. The patients who normally recover from stroke mostly do not recover completely, and they require long-term health care.

Stroke can affect both young and old people, although, the prevalence rate is high among the old people. Age has been found to be the non-modifiable risk factor for all types of strokes. Reports show that about 75 % of strokes attack people aged above 65 years (Lapchak & Zhang 2017). Also, it is estimated that the rate of disease attack will rise to 1.2 billion in the next few years. The growth rate of the population of the old people is also estimated to increase in the future. The increase in the rate of stroke attack indicates that the economic cost of the disease will rise. This paper will discuss ischemic stroke since it is the most common type of stroke. Other types of stroke are transient ischaemic attack and hemorrhagic stroke which are not very common.

There are some changes that occur in the brains with age. Studies have shown that the brain weight decreases by about 0.1% every year in people aged between 20 and 60 years. After this age bracket the brain weight decreases rapidly. A lot of this weight loss usually occurs in the cerebral cortex. Various brain weight studies have shown that people aged between 30 to 50 years usually have a weight loss of about 0.1 % per year and increases to 0.5% per year in people aged above 70 years (Gillum Gorelick & Cooper 2010) There is usually a uniform weight loss of the white matter, but the weight loss of the grey matter does not occur uniformly. The grey matter usually decreases after adolescence steadily while the white matter starts to decrease after 40 years. Blood vessels usually fill the void left by the loss of the cortex. Some studies have shown that there was great loss of neurons in elderly brains (Hennerici 2012). Other studies showed that normal brains did not have large neuronal losses. The cognitive declines might be as a result of subtle changes. Some of these changes include neuronal atrophy and perikaryal atrophy (Hreib 2009). Neuronal atrophy is characterised by dendrites .there is some evidence that aging- related changes in the brain micro-vasculature results to leukoaraiosis.

The change that occurs in the brain because of old age usually reduces the cerebrovascular reserves and also exposes the brain to vascular insufficiency and ischemic injury. These changes could result in increased mortality and morbidity rates that are caused by the stroke in the old people (Kamal 2010).

High Blood Pressure

This is the major risk factor that is common in heart disease and stroke. It is present in 50 to 70% of stroke cases (Edwards Maurer & Wellner 2009). The increased blood pressure usually has some long-term effects such that the walls of the arteries are damaged exposing them to thickening or rapture. Medics agree that a reading greater than 140/90 mm Hg is abnormal and a person having such a reading should seek medical attention. There is also an increased risk for stroke even when having a mild rise in blood pressure (Robinson 2010). The mildly elevated pressure can be controlled by having a good lifestyle. Medication is also needed for this mild elevation. Controlled blood pressure results to the low occurrence of stroke.

Stroke Risk Factors

Heart disease is a major risk factor for stroke (Culebras 2013). It is only associated with one subtype of stroke called Ischemic strokes. The disease is a risk factor for stroke in two ways. One way is the damage of the heart may facilitate the formation of clots within the heart. There is a chance that the clots can break and move to the brain causing a type of stroke called cardioembolic stroke. The second way heart disease and stroke are related are that both can be affected by the atherosclerotic disease. If the coronary arteries are infected with this disease, the brains also may be affected (Fuster Topol & Nabel, 2010). Patients suffering from congestive heart failure, coronary artery disease, irregular heart rhythms and diseases of heart valves are prone to stroke attack (Hreib 2009)

Smoking is a lifestyle that facilitates atherosclerosis, and it is an independent risk factor that is caused by a clot (Escandari Pearce & Yao 2010). Cerebral hemorrhage is also caused by smoking. Research has shown those men who smoked over 40 cigarettes every day had double risk of being attacked by stroke then men who smoked less than ten cigarettes every day. A study carried out at Harvard Medical School showed that the number of cigarettes that smoked and risk of stoke had a correlation (Black & Elliott 2013). Studies carried out in Honolulu and Framingham showed that stopping smoking could reduce the rate of stroke attack.

Studies have shown that people suffering from diabetes are at risk for stroke the same way the patients with heart diseases are exposed. Women suffering from diabetes are more prone to stroke compared to men (Norrving 2014) High blood pressure is the contributing risk factor for stroke. Although there is no empirical evidence that treatment of diabetes can lower the risk, it is clear that managing the high blood pressure can reduce the extent of cerebral damage in stroke patients (Mackay & Mensah 2009). Therefore, it is advisable that people having diabetes should try to maintain the blood pressure to minimize the risk of stroke attack.

Atherosclerosis is associated with high levels of lipids in the blood. However, there is no clear evidence that high levels of lipids can increase the risk of stroke (Fisher &Bogousslavsky 2010).  This can result to heart diseases which are identified to be risk factors for stroke. Therefore, it is advisable to reduce cholesterol levels in the blood.

Obesity is a predisposing factor for heart diseases, high blood pressure, and diabetes. They are also independent risk factors for stroke. Weight loss and exercises can help to keep the body fit and reduce these risks (Mohr 2011). Although obesity can be genetic, it can also be caused by poor diets. Therefore, it is important to eat proper diets to reduce obesity.

There is no clear evidence of the role of oral contraceptives in stroke risk since most researchers have been based on effects of estrogens pills that are high-dose and in reality most women use low-dose estrogens pill. It is believed that Estrogens promotes blood clotting. Therefore, high-dose estrogens are believed to increase the risk of stroke and heart diseases in women.  Lower-dose estrogens pills are suitable for use because they do not cause these risks. Estrogens replacement therapy for postmenopausal women may reduce atherosclerotic disease and therefore the use of estrogens at this point may lower risk of stroke.

High Blood Pressure

Several studies have shown that risk of stroke rises with age. After the age of 60 years, the threat of stroke doubles with each passing decade. In every year about 0.1% of people between 65-74 years suffers from a stroke.  About 5% of people in this age bracket who had TIA are usually attacked by a stroke (Lapchak& Zhang 2017). The risk of stroke that is associated with advancing age cannot be eliminated, but there are some preventive therapies that can be used to reduce this risk.

There is a high risk of stroke for people who have a family history of stroke (Norrving 2014).  The risk can be as a result of inherited genetic characteristics and family lifestyles that expose the family members to stroke. The inherited risk factor can be lowered. A certain study showed that vascular disease which was hereditary inherited could be reduced by the stoppage of cigarette smoking.

A person experiencing some symptoms which are related to stroke should seek medical attention. Although the symptoms are not for stroke, they could be symptoms of another disease that require prompt medical attention (Roach Lo& Heyer 2011). Stroke requires immediate treatment because most of the therapies that are used of the treatment are found to be effective if they are applied soon after the appearance of the first symptoms (Ottoboni & Ottoboni 2009). There are several diagnostic tools that physicians can use.  They include history taking and radiological imaging studies. Different tests are performed for the different types of strokes and the severity of the stroke (Robinson 2010). The goals are usually the same despite the test that is used. The goals are usually the exclusion of non-vascular reasons and to determine the cause of stroke, the affected part and the severity of the stroke.

Initial history and physical examination of the patient are the most important diagnostic tools. Important details about the medical examination can be obtained from the family members if the patient is unable to speak.

The physician will have to examine several things such as the orientation of the patient, emotional control, tactile sensation, vision, memory, and the ability of the patient to read, speak and write. A neurologist can use the knowledge of the structure of the brain to identify the part of the brain that is affected by considering the specific symptoms. For instance, if the cerebellum of the patient is damaged, the patient will have walking and posture problems.

The examination should include trying to find out some evidence of the occurrence of high blood pressure, heart diseases and vascular diseases on other parts of the body. The physician can use the findings from the history, general and neurological examination to try to explain where the stroke is located and identify the type of stroke (Slevin 2011). The physician's initial diagnosis can be verified later by the use of laboratory and radiological tests which will confirm or exclude those explanations.

The tests are usually carried out on blood samples, urine, and cerebrospinal fluids (Schweizer & Macdonald 2013). The aim of the tests is to exclude conditions that can worsen stroke or mimic the disease. Some of these conditions are low levels of blood sugar and some infections. The tests can be carried out for diabetes, bleeding disorders, high cholesterol levels in the blood, blood proteins abnormalities (Ferro 2013). This is usually the predisposing factors for heart diseases which may result in stroke.

Heart Disease

There are some techniques that are used to produce anatomic pictures of the brain. These techniques are magnetic imaging (MRI) and computed tomography (Seshadri &Debette 2016). Multiple X-rays are used in the case of computed tomography, and there is computer reconstruction to establish cross-sectional images of the internal structure. Magnetic fields are applied in magnetic resonance imaging to create images. Each method has its advantage under different circumstances, and they can detect some conditions such as bleeding from trauma, and abscesses ( Slevin 2011).  They have the ability to distinguish ischemic stroke from other types of bleeding. The chemical composition of the brain can be measured spectroscopically using magnetic resonance device. The measurement is necessary since it helps to determine the best therapy that the patient can undergo

The examinations are mostly repeated severally after stroke has been detected to determine its size since the severity of the damage may not be quite clear. The tests can be repeated upon the deterioration of patient's health to help to identify the cause of the deterioration (Spencer 2009).

According to Welch (2011), cardiac evaluation begins with an electrocardiogram (ECG).  It is usually an ultrasound examination that usually helps to identify the source of an embolus. This method is important because it helps to identify various heart diseases. The heart diseases are usually risk factors for stroke.

This method involves the injection of a contrast medium into blood vessels to make them visible in X-ray pictures. Many abnormalities that lead to stroke can be detected through this method. Some of those abnormalities are atherosclerosis, narrowing of the blood vessels, arteriovenous malformations, and embolus. Some serious complication may occur because this method involves the introduction of some substances into the body. Allergic reactions, worsening of stroke and sometimes death is some of the complications that may arise. Noninvasively methods such as magnetic resonance imaging can be used instead of this method to produce an angiogram.

Some sound waves are used detect the blood vessels and the flow of blood in the body. In the diagnosis of stroke, there are two types of ultra sounds that are used which include carotid ultra-sound and transcranial Dopler. Despite that ultrasound does not produce clear images as compared to angiography, it has the advantages that it is risk-free and it is painless. This method is used before invasive methods are used for screening patients (Wiebers Feigin &Brown 2008).

 Some methods are used to detect the flow of blood in the body. They include positron emission tomography, xenon inhalation, and single-photon-emission computed tomography. These methods are very sensitive to any changes after the first symptoms of stroke. They are reliable since other methods such as magnetic resonance and computed tomography may remain negative for several days after the first symptoms of stroke appear (Hennerici 2012). The methods may be used to determine prognosis early and the mechanism of stroke. However, these methods can only be found in large medical centers only.

The new drug therapy has helped to change the treatment of stroke. Physicians currently are trying to stop the progression of the stroke disease and prevent its reoccurrence. In the past years, stroke was believed to have no treatment because it was believed that usually, all the brain cells die when they lack blood for a very short period. The modern therapies were spurred by animals coming back to life after going through Ischemia (Black & Elliott 2013). Researchers have proven that brain cells can survive for several hours or even some days with a very minimal flow of blood. The brain cells that surround the infarct are used during the use of experimental drug therapies which are designed to for restoration of blood flow.

Smoking

Researchers are continuing to find out that lack of blood flow is not the only cause of death of cells. They have found out that other processes called Ischemic cascade may contribute to the damage of neurons (Ferro 2013). The doctors can prevent the cascade which damages the brain and therefore prevent damaging of the brain which stroke usually attacks.

The treatment of stroke at this point consists of maintaining electrolytes and fluids in the blood. The treatment also consists of avoiding low blood pressure and trying to avoid some secondary complications of a stroke. Some of those complications are muscle contractures, pneumonia, bedsores, and some urinary tract infections.

Acute stroke can be treated by the use of anticoagulant medications such as heparin. Despite the fact that heparin cannot dissolve the existing clots it can hinder the formation of new clots. Therefore its administration can help to prevent subsequent strokes which consist of about 20% of ischemic stroke cases. The use of heparin is restricted to those patients with the highest risk of recurrent stroke because it can cause bleeding in some patients. There are some alternative drugs that can be used which are called heparinoids which are effective and have lower risks of bleeding. Although surgery is not used to treat acute stroke, it can be used to treat hemorrhagic stroke and during the removal of blockage of a carotid artery.

A lot of emphases is placed on recovery and rehabilitation after the acute phase has passed. Also, the prevention of further vascular events such as myocardial infarction and ischemic stroke is emphasized. The therapy may involve administration of drugs, modification of the risk factor, surgery or it may include a combination of these. Treatment of the risk factors such as high blood pressure, diabetes and not smoking could help in the treatment of stroke. The other risks, such as cholesterol and obesity are can also be modified.

 Platelets are some of the components of the blood which are used in blood clotting process. Aspirin is known to inhibit the functioning of platelet, and therefore stroke patients can use it to prevent blood clotting. Studies have shown that aspirin therapy has resulted in the decrease in the number of stroke-related deaths and also reduces the risk of stroke.

Anticoagulants inhibit the blood clotting mechanism by affecting the enzymes that are required during the clotting process. Warfarin is the most commonly used anticoagulant since it is more powerful than aspirin. It is normally administered to patients after aspirin therapy has failed and when it is clear that the clots are formed in the heart (Toyoda 2013). Patients who are using the warfrin should be administered closely because low dose may increase the risk of stroke while on the other hand high dose can cause bleeding.

Surgery is carried out to allow blood flow in the brain. Surgery entails some procedures called carotid endarterectomy which involves removal of atherosclerotic plaque which is found in the carotid artery. There are some findings from various researches which were carried out in 1991 which were based on carotid endarterectomy. The patients were suffering from TIA or acute stroke, and they had a blockage of more than 70 percent in their carotid artery. Patients who had a surgery showed a reduction in stroke compared to those who did not undergo surgery. This shows that carotid surgery can prevent the recurrent stroke in future.

Diabetes

Recovery from stroke is influenced by several things such as the location of the brain injury, family support, and general health of the patient, the care that the patient is given and finally is the personality of the patient (Bogousslavsky 2009). Patients who had a small ischemic stroke usually shows the best recovery while on the other hand large subarachnoid hemorrhages usually have most challenges in the recovery process.

The process of caring for a stroke patient is usually complex. The care must entail helping the victim to recover from the deficits and learn to live the new life after the stroke. The process will involve dealing with the emotions of the patient and the family. Proper caring should be carried out to prevent recurrent strokes.

Immediately after the stroke, there is a great need for medical attention to reduce complications. In case the patient has some challenges in swallowing, they may require being fed intravenously until they recover. Most patients can recover very quickly, and they are discharged from the hospital in about two weeks.

Rehabilitation process should commence immediately after the stroke. If the week limbs are given proper attention, the patient can have a quick recovery. Frequent exercises and changing of positions in bed can help to improve blood circulation, maintain normal muscle tone and maintain the flexibility of joints. After five days after stroke, physical therapy can be administered to patients. As the patient becomes more stable, the rehabilitation process should be more active (Wiebers Feigin & Brown 2008).

 The main aim of this goal is to help the patient to go back to his or her job. The therapy also involves all aspects of day to day activities. The therapy helps the patients to regain muscular coordination that is required when dressing, bathing and going to the toilet. A paralyzed patient is trained how to dress clothes using the able part of the body (Black &Elliott 2013).  The patients are also trained on how to use a wheelchair and also how to move from the wheelchair to the bed and vice versa. The occupational therapist advice the family to make some changes such as, the construction of ramps instead of stairs, installation of handrails in the washrooms and enlargement of the doors to allow easy movement of the wheelchair.

Aphasia and dysarthria are some of the common disorders that are associated with stroke. Aphasia refers to difficulty in a language while Dysarthria refers to difficulty with the articulation of words (Hreib 2009). These disorders are not associated with the disability of thinking or understanding.

The paralysis of muscles around the neck and the face causes dysarthria. It is characterized by slow speech, change of quality of the voice and slurring of words (Biller 2011).  A speech therapist can help a stroke survivor to regain communication skills.  The speech therapy should start from the time the patient is admitted to the hospital.

 The rehabilitation process may proceed on a patient who is not hospitalized, and the recovery process may continue for some time. Dramatic changes are usually experienced during the first 3-6 months, and some mild changes may be experienced onwards. Although there are no guidelines on how much the therapies benefits the patients, they should be applied thoroughly but not to the extent of causing frustrations. The recovery process from stroke is usually painful. Patience is required for both the patient and the family to note changes. The family members should have a positive feedback and encourage the patient. Stroke does not affect the patient only, but it does affect even the family as well. The knowledge of the effects of stroke can help the family to deal with the recovery process (Bhandari 2008).

Cholesterol

The impact of other necrological deficits can be lessened by the family members. The patients who may experience some challenges in memory, they can be reminded by the family members. Patients whose left hemisphere has been damaged may tend to be slow, and disorganized when they are faced with a different situation (Basson 2009).  The family members can commend them for things which the patients do correctly. On the other hand, patients whose right hemisphere has been damaged tend to act hastily and impulsively. They tend to make poor judgments, and therefore, the family members can help this type of patient by advising them to do things slowly and carefully

Other common problems that are associated with stroke include poor concentration, disturbed sleep cycles, poor judgment of time, impaired memory, loss of sexual desires, depression and anxiety, impaired judgment, depression and poor emotional control. These challenges are very common, but they are not universal to all patients (Baltan 2014).

Physical impairment is what is focused greatly on families and stroke patients. The brain controls our thoughts and emotions, and therefore its damage is very difficult to deal with. Stroke patients can have loss of emotional control because a stroke may have damaged the part of the brain that controls the emotions (Bhatt 2016). They may have some weird behavior such as laughing out suddenly or they may also cry. They may not feel happy or sad at some times. Some patients may be irritated quickly and get angry quickly with very little provocation.

Patients suffering from stroke usually have depression because their lives have changed drastically and they feel hopeless and discouraged. The depression can be caused by the devastating disease, and the recovery process can be difficult (Bhandari 2008).The signs of depression include crying, sleep disorders, fatigue, and boredom. Family members can try to put some efforts to solve the issue of depression. Problems such as low self-esteem, sexual disorders, and family relationships dysfunction can be solved by trained medical personnel (Adams Hachinski 2011)

There are various researches that are carried out to find an effective stroke therapy. Some clinical testing in animals and human beings are still being carried out. Thrombolytic therapy is one of the investigation approaches that is being carried out. It involves the use of t-PA to remove a clot and reopen the blocked vessels that were causing a stroke (Abela 2010). The therapy has been found to good in the treatment of heart diseases. The therapy also shows some promising results in the stroke patient. The major limitation is that it may result to increase bleeding. Restorative neurology is the most recent investigation which tries how the repair of damaged nerves and brain occur.

Conclusion

Various researchers have indicated that Neurology can be used for the treatment of stroke by drastically reducing the effects of stroke. This therapy is in the last stages of development. However, prevention remains the most effective way despite the advancement in the treatment of stroke. The patients are advised to seek medical attention so that stroke cannot progress to an extent where they become paralyzed. Management of blood sugars and change of the lifestyles have been found to be effective in controlling stroke. Old age has also been identified to be one of the causes of stroke. Patients should undergo various treatment therapies which can help to reduce the number of stroke deaths.

Obesity and Inactivity

References

Abela, G. S. (2010). Peripheral vascular disease: basic diagnostic and therapeutic approaches. Philadelphia,Pa. [u.a.], Lippincott Williams & Wilkins, viewed 21 March 2017.

Adams, H. P., Hachinski, V., & Norris, J. W. (2011). Ischemic cerebrovascular disease. Oxford, Oxford University Press, viewed 21 March 2017, https://site.ebrary.com/id/10269022.

Baltan, S. (2014). White matter injury in stroke and CNS disease, viewed 21 March 2017, https://site.ebrary.com/id/10811519.

Basson, C. T. (2009). Topics in Structural Heart Disease. New York, Demos Medical Pub., LLC, Viewed 21 March 2017,https://public.eblib.com/choice/publicfullrecord.aspx?p=533094.

Bhandari, P. K. (2008). Heal & prevent stroke & heart disease. New York, iUniverse, Inc.

Bhatt, D. L. (2016). Cardiovascular intervention: a companion to Braunwald's heart disease, viewed 21 March 2017,https://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=980927.

Biller, J. (2011). Stroke in children and young adults. Oxford, Butterworth-Heinemann, viewed 21 March 2017, https://www.engineeringvillage.com/controller/servlet/OpenURL?genre=book&isbn=9780702038839.

Black, H. R., & Elliott, W. J. (2013). Hypertension: a companion to Braunwald's heart disease. Philadelphia, Elsevier/Saunders, viewed 21 March 2017, https://www.clinicalkey.com/dura/browse/bookChapter/3-s2.0-C20090633894.

Black, H. R., & Elliott, W. J. (2013). Hypertension: a companion to Braunwald's heart disease. Philadelphia, Elsevier/Saunders, viewed 21 March 2017, https://www.clinicalkey.com/dura/browse/bookChapter/3-s2.0-C20090633894.

Bogousslavsky, J. (2009). Uncommon causes of stroke. Cambridge [u.a.], Cambridge Univ. Press, Viewed 21 March 2017.

Culebras, A. (2013). Sleep, stroke and cardiovascular disease. Cambridge, Cambridge University Press.

Demos Medical Pu , viewed 21 March 2017https://public.eblib.com/choice/publicfullrecord.aspx?p=807366.

Edwards, N. M., Maurer, M. S., & Wellner, R. B. (2009). Aging, heart disease, and its management: facts and controversies. Totowa, N.J., Humana Press, Viewed 21 March 2017,  https://site.ebrary.com/id/10181344.

Escandari, M. K., Pearce, W. H., & Yao, J. S. T. (2010). Carotid artery disease. Shelton, Conn, People's Medical Pub. House-USA, viewed 21 March 2017.

Ferro, J. M. (2013). Neuropsychiatric symptoms of cerebrovascular diseases. London, Springer, viewed 22 March 2017, https://public.eblib.com/choice/publicfullrecord.aspx?p=1387205.

Fisher, M., & Bogousslavsky, J. (2010). Current Review of Cerebrovascular Disease. London, Current Medicine Group, viewed 21 March 2017,  https://dx.doi.org/10.1007/978-1-4684-0001-4.

Fuster, V., Topol, E. J., & Nabel, E. G. (2010). Atherothrombosis and coronary artery disease. Philadelphia, PA, Lippincott Williams & Wilkins, viewed 21 March 2017.

Gillum, R. F., Gorelick, P. B., & Cooper, E. S. (2010). Stroke in blacks: a guide to management and prevention. Basel, Karger, viewed 21 march 2017.

Hennerici, M. (2012). Stroke. Oxford, Oxford University Press, viewed 22 March 2017.

Hreib, K. K. (2009). 100 questions and answers about stroke: a Lahey Clinic guide. Sudbury, Mass, Jones and Bartlett Publishers, viewed 21 March 2017.

Kamal, A. (2010). Color atlas of cerebrovascular disease and its management. [London], [Wolfe Medical Publications], viewed 22 March 2017.

Lapchak, P. A., & Zhang, J. H. (2017). Neuroprotective therapy for stroke and ischemic disease, viewed 22 march 2017, https://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=1331454.

Mackay, J., & Mensah, G. A. (2009). The atlas of heart disease and stroke. Geneva, World Health Organization, viewed 21 March 2017.

Mohr, J. P. (2011). Stroke: pathophysiology, diagnosis, and management. Philadelphia, PA, Elsevier/Saunders, viewed 22 March 2017,  https://www.clinicalkey.com/dura/browse/bookChapter/3-s2.0-C20090405567.

Norrving, B. (2014). Oxford textbook of stroke and cerebrovascular disease, viewed 21 March 2017.

Ottoboni, F., & Ottoboni, M. A. (2009). The modern nutritional diseases: heart disease, stroke, type-2 diabetes, obesity, cancer : and how to prevent them. Sparks, Nev, Vincente Books, viewed 22 March 2017.

Roach, S. E., Lo, W. D., & Heyer, G. (2011). Pediatric Stroke and Cerebrovascular Disorders, viewed 21 March 2017.

 New York, BRAUNWALD, E., & BONOW, R. O. (2012). Braunwald's heart disease: a textbook of cardiovascular medicine. Philadelphia, Elsevier Saunders, viewed 21 March 2017,  https://www.123library.org/book_details/?id=112744.

Robinson, K. (2010). Homocysteine and Vascular Disease. Dordrecht, Springer Netherlands, viewed 22 March 2017, https://dx.doi.org/10.1007/978-94-017-1789-2.

Schweizer, T. A., & Macdonald, R. L. (2013). The behavioral consequences of stroke, viewed 22 March 2017, https://public.eblib.com/choice/publicfullrecord.aspx?p=1694246.

Seshadri, S., & Debette, S. (2016). Risk factors for cerebrovascular disease and stroke, viewed 21 March 2017,  https://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=1159833.

Slevin, M. (2011). Therapeutic angiogenesis for vascular diseases: molecular mechanisms and targeted clinical approaches for the treatment of angiogenic disease. Dordrecht, Springer, viewed 21 March 2017,  https://dx.doi.org/10.1007/978-90-481-9495-7.

Spencer, M. P. (2009). Ultrasonic Diagnosis of Cerebrovascular Disease: Doppler Techniques and Pulse Echo Imaging. Dordrecht, Springer Netherlands, viewed 21 March 2017,  https://public.eblib.com/choice/publicfullrecord.aspx?p=3101577.

Toyoda, K. (2013). Brain, stroke, and kidney. Basel, Karger, viewed 22 March 2017.

Welch, K. M. A. (2011). Primer on cerebrovascular diseases. San Diego, Academic Press, viewed 21 March 2017, https://site.ebrary.com/id/10225030.

Wiebers, D. O., Feigin, V. L., & Brown, R. D. (2008). Handbook of stroke. Philadelphia, Lippincott Williams & Wilkins, viewed 22 March 2017,  https://gateway.ovid.com/ovidweb.cgi?T=JS&NEWS=N&PAGE=booktext&D=books&AN=01257010/2nd_Edition/2&XPATH=/OVIDBOOK%5b1%5d/METADATA%5b1%5d/TBY%5b1%5d/AUTHORS%5b1%5d.