Helping Others Understand: All Strokes Are Not the Same

Helping Others Understand is an open-ended, intermittent series designed to support stroke survivors and family caregivers with helping friends and family better understand the nuances, complications and realistic expectations for common post-stroke conditions. If there is a specific post-stroke condition you’d like to see us address in future issues, we invite you to let us know:

illustration of man with caneAlthough stroke is not uncommon, it is possible for people to go through life and never know a stroke survivor. And those who do know a survivor may only know one. When it comes to stroke, knowing one is definitely not knowing all.

Stroke is an interruption of blood flow to the brain, which produces unique consequences in the bodies, brains and lives of those who survive. Every stroke and recovery journey is different — and there are many reasons why that is the case. They include:

  • How quickly the person having a stroke gets medical attention and the quality of medical care they receive
  • The type of stroke and the area and extent of the brain injury
  • Stroke-caused conditions that may negatively affect recovery
  • The quality and quantity of stroke rehabilitation available
  • The patient’s general health: Are they otherwise in shape? Are they managing other conditions?
  • Medications (and side effects)
  • The kind of family, friends and community support available
  • And, of course, the survivor’s own attitude and commitment to their recovery

Each of the above contain a wide range of varying possibilities. The number of potential combinations of these variables is vast. It becomes easy to see how Aunt Mary’s stroke and recovery can look completely different than neighbor Jim’s.

We talked with physiatrist Richard Zorowitz, chief medical informatics officer at MedStar National Rehabilitation Network, and professor of clinical rehabilitation medicine, Georgetown University, in Washington, D.C., about the many variables that affect stroke survivors and their recovery.

The Survivor’s Age

Age increases risk, but does it affect recovery? “Theoretically, age shouldn’t affect recovery,” Zorowitz said. “But of course, it all depends upon what survivors were doing prior to their stroke. If they were very active, they have a good shot at getting back to that. If you’re older and more debilitated, the chances of recovery are not going to be as good.”

The Area & Extent of the Injury

Perhaps more defining than age — and what makes every stroke different — is where it happens in the brain. “It is as the real estate people like to say, ‘Location, location, location,’” Zorowitz said. “Certainly, size [of the brain injury] can matter, but I think the location actually can matter even more. A small stroke in just the wrong place can be just as devastating as a much larger stroke. It’s a matter of what neural pathways are affected. You can actually have a fairly large subcortical (below the brain’s cortex) stroke and not do too badly. On the other hand, if you have a little stroke that hits one of the very critical areas where motor pathways travel, that could be very, very devastating.”

To understand more about the effects of stroke on different areas of the brain, see our ongoing series “When Stroke Affects …,” on our Stroke Connection website.

The Quality & Quantity of Rehab

Yet another way survivors can differ is in the rehab they receive — how soon, how much and how good.

How soon rehab starts after stroke makes a difference. “The rate of improvement actually occurs faster earlier on, so it’s important to get going with rehab as early as possible,” Zorowitz said. “Although, doing rehab months or even years afterwards can be very, very helpful.”

Dr. Richard Zorowitz

Dr. Richard Zorowitz

The quality of therapy is not uniform. How much rehab and how good the rehab is both make a difference as well. “Rehabilitation helps the brain reorganize itself,” Zorowitz said. “Intensive rehabilitation can actually help the patient to improve functionally to a much better degree than if you don’t have it.”

Patients need to be properly matched with therapists who have the skills to give them appropriate therapy. Intensity and repetition make a big difference. “Repetition really is the key to the brain reorganizing itself,” Zorowitz said. “It comes down to that old adage, ‘How do you get to Carnegie Hall? Practice, practice, practice.’ The more survivors do and the more appropriate are the things they do in rehab, the more likely they’re going to have a better outcome.”

Co-occurring Conditions & Recurrent Stroke

Co-occurring diseases, such as diabetes, unstable hypertension, other forms of cardiovascular disease and cancer, complicate recovery for stroke survivors. According to a 2017 study, unstable hypertension can prevent transfer to rehabilitation or may stop rehabilitation as high blood pressure raises the risk of a new stroke. Coronary artery disease or heart failure can limit participation in therapies, as can asthma. Diabetes can cause mental status problems that affect participation in therapies. While co-occurring conditions can affect a survivor’s stroke treatment, those diseases also need to be treated.

It is important for family members to know that surviving a stroke puts the survivor at increased risk of having another stroke — nearly a quarter of the 795,000 strokes that happen each year are recurrent strokes. Zorowitz said, “I think in terms of recurrent stroke, it’s very important for survivors to make sure that their risk factors and co-occurring conditions are being treated appropriately because otherwise, it will raise their risk of having another stroke.”

Post-stroke Conditions

illustration of woman sitting in chair with dog in her lapBeyond the physical, speech and cognitive deficits stroke leaves, survivors also differ in the conditions they experience post-stroke. For instance, it is not unusual for a survivor to experience post-stroke depression, but that is not universal. The same with pain and aphasia. “Any post-stroke condition like pain or depression or pseudobulbar affect can certainly affect the ability of patients to participate in therapy, and participation really is the key to making sure that patients can get better,” Zorowitz said. “It is very, very important that these conditions be identified and treated as soon as possible.”

Medications & Side Effects

Another variable among survivors is medications. Survivors may be discharged with a number of drugs they need to take. These can range from simple aspirin and anticoagulants like warfarin, which can put a survivor at risk of bleeding, to statins and high blood pressure meds. Survivors with diabetes may require medication for that. Pain, spasticity or depression are other post-stroke conditions that may require medication, each of which has its own side effects. “I think the major thing for patients and family members to understand is what medications are for and what are their potential side effects so that you can look out for them and be able to reverse them if needed,” Zorowitz said.

Social & Emotional Support

illustration of senior couple holding handsSocial support is another element that is unique to every survivor. “Does the patient have strong caregivers and family support?” Zorowitz asked. “That can make the difference in terms of the types of rehab that the patient will get because some of the regulations require that. For inpatient rehab, for example, the patient needs to have a place to go following their rehab. If they don’t, they probably shouldn’t be going to the inpatient rehab. If a patient has a good, supportive family and a good, supportive set of caregivers, the chances of them going home — even having severe impairments — is going to be much better than a patient who has no support. Studies have shown that the better the support system for the patient, the less likely they’ll experience depression, and the more likely that they’ll be able to go home and have a better quality of life.”

Clearly, given these variables, strokes can impact individual survivors in very different ways. Two strokes in the same brain can also produce very different results.

“For example, the speech centers are typically more in the left hemisphere than the right,” Zorowitz said. “So, if you have a stroke in the lower frontal area in the left hemisphere, the chances are you may end up with speech problems, like a non-fluent Broca’s aphasia. If you have a stroke in the same area on the other side, it may end up producing left hemineglect or problems with visual perceptual deficits. Location really does make a difference.”

Stroke may be one disease, but it does not produce one outcome. Every stroke is different. The deficits it leaves are essentially unique.

The Stroke Connection team knows that it can sometimes be hard for family and friends to understand how one survivor’s stroke experience can be so different from another’s. We encourage you to share this article with the people in your life — and, for those pressed for time, we’ve created a quick-reference sheet that you can print or share via email or social media with family and friends.

Stroke is an interruption of blood flow to the brain, which produces unique consequences in the bodies, brains and lives of those who survive. Every stroke and recovery journey is different — and there are many factors that make that the case.

How quickly the person gets medical attention and the quality of medical care they receive. Different types of strokes require different treatments. Getting immediate medical attention and appropriate treatment may significantly reduce long-term effects of stroke for some.

The area and extent of the brain injury

The location of the brain injury from the stroke is one of the greatest factors in how the survivor is affected and how well they are able to do in rehab. A small stroke in an area of the brain with lots of neural pathways can be more devastating than a larger stroke. To learn more about how different areas of the brain are affected by stroke, visit the Stroke Connection website.

Stroke-caused conditions that may negatively affect recovery

Survivors may experience a variety of conditions post-stroke, including depression, pain, spasticity, fatigue or pseudobulbar affect. Any of these may affect their ability to participate fully in rehab. It is important that these conditions be identified and treated as soon as possible.

The quality and quantity of stroke rehabilitation available

All rehab is not the same. Patients should be properly matched with therapists who have the skills to treat their particular needs. The intensity and repetition of rehab make a difference. Starting rehab early typically results in more and faster improvement. Some survivors have complications or circumstances that prevent them from starting rehab early.

The survivor’s general health before the stroke

Being fit before the stroke may help with recovery in some cases. However, factors such as the area and effects of the brain injury may prevent that. On the other hand, someone who is debilitated before their stroke is likely to have a harder time with recovery. Managing other diseases (diabetes, heart disease, cancer, etc.) may complicate stroke treatment.

Medications and side effects

Survivors may have several prescribed medicines — aspirin, blood thinners, cholesterol and blood pressure medications. Pain, spasticity or depression may also require medication. Each medication has its own side effects. Some may impact the survivor’s ability to work on recovery.

The kind of family, friends and community support available

Social and family support play a big part in recovery. Do your best to understand how the stroke has affected the person you care about, and how those effects may impact their degree of recovery. Your understanding and support can go a long way to bolster one of the most important factors in recovery: The survivor’s own attitude and commitment to their recovery.

This information is provided as a resource to our readers. The tips, products or resources listed or linked to have not been reviewed or endorsed by the American Stroke Association.​

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Stroke Rehabilitation

Making the Best Decisions at Discharge After Stroke

The type of rehabilitation and support systems a survivor receives at discharge can strongly influence health outcomes and recovery. In this, the first part of a two-part series on stroke rehab, we offer guidance for the decision-making process required when it’s time to leave the hospital.

What to Expect from Outpatient Rehab

After stroke, about two-thirds of survivors receive some type of rehabilitation. Outpatient therapy may consist of Several types of therapy. Whether a patient is referred to inpatient or outpatient therapy depends on the level of medical care required.

What to Expect in Stroke Rehab

Following a stroke, about two-thirds of survivors receive some type rehabilitation. In this second of our two-part series, we want to alleviate some of the mystery, fear and anxiety around the inpatient rehab part of the stroke recovery journey.
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AHA-ASA Resources

The Support Network

When faced with challenges recovering from heart disease or stroke, it’s important to have emotional support. That is why we created a network to connect patients and loved ones with others during their journey.

Caregiver Guide to Stroke

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Stroke Support Group Finder

To find a group near you, simply enter your ZIP code and a mile radius. If your initial search does not pull up any groups, try

Tips for Daily Living Library

This volunteer-powered library gathers tips and ideas from stroke survivors, caregivers and healthcare professionals all over the country who’ve created or discovered adaptive and often innovative ways to get things done!

Stroke Family Warmline

The Warmline connects stroke survivors and their families with an ASA team member who can provide support, helpful information or just a listening ear.

Let's Talk About Stroke Patient Information Sheets

Let's Talk About Stroke is a series of downloadable patient information sheets, created by the American Stroke Association, that presents information in a question-and-answer format that's brief, easy to follow and easy to read.

Request Free Stroke Information Packets

Fill out this online form to request free information about a variety of post-stroke topics.
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Stroke & Parts of the Brain

When Stroke Affects the Occipital Lobe

Our occipital lobe, the smallest of the four lobes of the cerebral cortex, controls how we visually interpret our world.

When Stroke Affects the Cerebellum

The cerebellum contains 80 percent of our neurons. Its job seems to be to make things better. We talked with neuroscientist Jeremy Schmahmann about how stroke affects the “little brain.”

When Stroke Affects the Parietal Lobe

The parietal lobe helps us make sense of sensory information, like where our bodies and body parts are in space, our sense of touch, and the part of our vision that deals with the location of objects.

When Stroke Affects the Frontal Lobe

Of the four lobes that make up the cerebral cortex, the frontal lobe is the largest. It plays a huge role in many of the functions that make us human — memory, language, movement, judgment, abstract thinking.

When Stroke Affects the Temporal Lobe

The temporal lobe has several functions, mainly involved with memory, perception and language.

When Stroke Affects the Brain Stem

The brain stem serves as a bridge in the nervous system. It sits at the top of the spinal column in the center of the brain. When a stroke happens there, it can cause a few different deficits and, in the most severe cases, can lead to locked-in syndrome.

When Stroke Affects the Thalamus

The thalamus can be thought of as a "relay station," receiving signals from the brain’s outer regions (cerebral cortex), interpreting them, then sending them to other areas of the brain to complete their job.
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