Although better surveillance and control of high blood pressure has led to a decreased incidence of stroke, it remains the third leading cause of death in the United States. Risk factors for stroke include the aforementioned hypertension, as well as diabetes, high cholesterol, smoking, heart disease, alcoholism and drug usage. Additionally, family history is a key risk factor. In women, migraines and the use of oral contraceptives are also implicated.
A stroke (also known as a cerebrovascular accident or CVA) is either a blockage or significant disturbance of blood flow to an area of the brain resulting in a permanent neurological effect or deficit. The diminished blood flow causes decreased oxygenation to the brain and either a motor or sensory deficit occurs, which persists for a period of time, often indefinitely. The deficit depends on which area of the brain is involved. A motor area may result in paralysis of a limb or an inability to speak. A mental deficit or weakness of a particular body area are also common presentations.
Strokes are generally defined by their causes. A lacunar infarct is a small lesion that most often occurs when blood pressure is so high as to interrupt circulation in a small blood vessel, or from poorly controlled diabetes. A cerebral infarction occurs when a small blood clot or fat or cholesterol embolus obstructs a vessel. Cardioemboli are small blood clots thrown from the circulation and pooling of blood in the heart. Strokes can also happen from hemorrhage, where a blood vessel bursts and there is bleeding into the brain.
Onset of a stroke is abrupt and may range from having sensory deficits to paralysis of a side of the body, or even to coma and death. The findings can be localized to where the interruption of blood flow occurred and how much certain parts of the body are supplied by the affected area. Virtually all of those who are affected should be admitted to the hospital and undergo neuroimaging with a CT scan or MRI. The cause of stroke is important to identify, and chest x-ray and heart echo (for cardiac causes), cholesterol and blood analysis (for thrombosis and blood clots/cholesterol emboli) and carotid artery studies are done. Conditions that may mimic stroke, such as seizure, low blood sugar, migraine and even structural abnormalities such as a brain tumor all have to be considered as well.
Transient ischemic attacks (TIAs) are temporary interference of cerebral blood flow, the effects of which reverse within 24 hours, and generally in the first hour or two. TIAs are associated with development of future strokes as well as an increased mortality risk. Treatment for both stroke and CVA are completely related to their cause and may include blood thinners, medications to dissolve blood clots, blood pressure lowering agents, and supportive care in the hospital, often in a stroke care unit.
A stroke is a serious medical impairment that has to be accounted for in underwriting. Most important is treatment of the cause so that a subsequent stroke doesn’t occur. Fibrillation in the heart causing blood to pool may need either eradication or blood thinners to prevent it from happening again. Narrowed circulation in the carotid arteries supplying the brain may have to be surgically treated. Blood pressure may have to be optimally controlled, as well as blood sugar. Smoking is a direct contributor to narrowing of blood vessels and must be permanently discontinued.
A second consideration is what is called “post stroke level of function.” Many strokes can be reversed when adjoining areas of the brain take over function for inactive or dead neurons and there are no permanent motor or sensory deficits. When the deficit is persistent the mortality risk is much greater. When ambulation is affected it is generally most severe, and the inclusion of mental impairment makes the condition likely uninsurable.
The most favorable considerations given to stroke are with TIAs (when the reversible deficit does not reoccur) and when the cause of a stroke can be directly remediated, or a one-time event, such as the use of the birth control pill. A six-month waiting period is usually in effect to see how the insured progresses and if contributors to the stroke are well controlled, such as blood pressure, blood sugar and cholesterol. Strokes are more seriously rated at younger ages, and the absence of permanent deficits generally coincides with the most favorable offers or lower mortality impairment ratings.
