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Lupus and the Risk of Stroke

It is estimated that those with SLE have 8 times the risk for stroke compared to the general public.  The following describes what these risks entail and how you can reduce them as much as possible!

 

Introduction

Constantly processing the input and output of data, your brain is your most precious – and potentially vulnerable – asset. Responsible for storing family vacation memories, recalling your best friend’s birthday, and reciting the words of your favorite songs and poems, your brain is continually at work, almost like having a highly-efficient personal assistant who is responsible for organizing the inner-workings of your mind.

What if, however, your personal assistant decided to take a hike without notice? Bills may not get paid, you may forget today is your wedding anniversary, and the memories of your kids’ first trip to Disneyland may vanish. You may even forget how to tie your shoes – or worse – walk and talk. That’s what could happen when an individual experiences stroke … and the potential for stroke increases for individuals with lupus.

It’s important to understand what exactly stroke is, how it affects your brain, what the symptoms may look like, and how stroke can be prevented. There are key factors that may put you at greater risk for stroke, making it imperative that you have open and honest conversations with a trusted healthcare practitioner, which in turn may lead to lifestyle modifications that can help you be your healthiest you.

What is a stroke?

A stroke can occur when blood flow to the brain is somehow restricted or disrupted and portions of the brain are damaged. There are two general types of stroke that can occur: ischemic strokes are caused by a blockage of arteries by clots while hemorrhagic strokes are caused by broken or leaking blood vessels.

Ischemic Strokes

These are the far more common type of stroke and involve the blockage of arteries in the brain.  This prevents oxygen and other nutrients from getting to areas of the brain and can cause either limited damage or widespread cell death.  The size and location of this damage determines the type and severity of symptoms.

Ischemic strokes can be caused by the chronic narrowing of arteries, a process called atherosclerosis, to the point that the blood flow is dangerously slowed or stopped.  Ischemic strokes can also occur if a blood clot detaches suddenly from somewhere upstream in the circulatory system and travels to the arteries of the brain.  When this embolism reaches a brain artery that is too small for it to pass, it blocks the flow of blood in an artery and causes the stroke.   This type of stroke can be significant and long-lasting or it can be temporary and termed a transient ischemic attack.

Transient Ischemic Attack (TIA)

TIA’s, as the name suggests, are temporary artery blockages and are sometimes referred to as “mini strokes.” They mimic full ischemic strokes but with much less severity and last only a few minutes without causing permanent damage. A TIA can serve as a precursor to stroke as about one in three people who experience TIA will eventually experience stroke as well.

Symptoms of TIA’s include:

  • Weakness, numbness, or even paralysis on one side of your face and/or body.
  • Slurred and garbled speech and the inability to understand what others are saying to you.
  • Double vision or blindness.
  • Dizziness or loss of balance and coordination.
  • The sudden onset of severe headache for apparently no reason.

Hemorrhagic Stroke

Hemorrhagic stroke occurs when either a brain aneurysm bursts or blood vessels that are weakened leak. Blood spills in and around the brain causing swelling and pressure, which is damaging to the tissues and cells of the brain.  These account for approximately 13% of all strokes, and they come in two types: intracerebral and subarachnoid.

Intracerebral Hemorrhaging is the most common type of stroke and occurs when blood vessels within the brain itself burst or leak causes brain cells to die.   Subarachnoid Hemorrhaging is less common and occurs when the bleeding takes place between the brain and the tissue which covers the brain – the subarachnoid space.

There is no question that someone experiencing stroke needs immediate medical attention. Studies have shown that individuals who receive treatment within an hour of experiencing stroke and receive the right medications within that time (clot-busting tPA drugs) have a much better chance at minimizing or even eliminating the long-term effects of this potentially life-changing event. Never ever hesitate to call 911!

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What are the risk factors for stroke in individuals with SLE?

Whether due to medication, inflammation, or other medical conditions, individuals with SLE are at a higher risk of experiencing stroke. As SLE is also more common in nonwhites than whites, if you are a person of color, that increased risk of stroke is even greater. A recent study showed that black individuals with lupus have a 34% increased risk for any stroke, while Hispanics had a 25% increased risk of stroke, mainly hemorrhagic stroke. Stroke risk is also greater in younger people with lupus due to conditions like premature atherosclerosis, the existence of comorbid conditions such as vasculitis and rheumatoid arthritis, and even the use of immunosuppressant drug therapy. Here is just a glimpse of how various medical conditions in individuals with lupus can increase stroke risk:

      • Vasculitis – inflammation and damage to blood vessels or blood vessel walls.
      • Antiphospholipid Syndrome (APS) – an autoimmune disease, which can cause clotting in veins and arteries and even result in miscarriage.
      • Hypertension – otherwise known as high blood pressure, has many causes, but is a function of the force of the heart pumping blood in the arterial system and the ability of those vessels to remain flexible and lessen this pressure or resist and allow this pressure to increase.
      • Premature Atherosclerosis – a hardening and narrowing of the arteries that occurs at a young age. Arteries silently and slowly become blocked, inhibiting – or prohibiting – normal blood flow.
      • Chronic Inflammatory Diseases such as Rheumatoid Arthritis – can occur throughout the body making individuals with lupus more susceptible to the conditions that may increase the chance of stroke.
      • Immunosuppressant drug therapy – can cause infection throughout the body.
      • Libman-Sacks Endocarditis – this is the most characteristic cardiac manifestation of Sjörgren-Larsson Syndrome. It is the non-bacterial inflammation of the inner layer of the heart, the endocardium.
      • The presence of immune deposits – when your immune system reacts to an antigen and creates the antibodies to attack and destroy it, the antibody and antigen form an immune complex. These complexes are often deposited in organs, causing illnesses like vasculitis.

For individuals of color with SLE, the risk factor is even greater due to increased occurrences of:

      • Lupus Nephritis – inflammation of the kidneys which can result in hypertension (high blood pressure).
      • Hypertension – see above.
      • Dyslipidemia – blood lipid levels that are either too high or too low. Lipids are fatty substances such as triglycerides and cholesterol. Dyslipidemia can lead to coronary artery disease (CAD) and peripheral artery disease (PAD).

These risk factors increase the onset of cerebrovascular disease (problems related to the blood vessels of the brain), which can result in a cerebrovascular accident (CVA), or in other words, stroke.

How does stroke affect the brain?

Cerebrovascular disease that leads to stroke can adversely affect the brain by decreasing the blood supply to various parts of the brain. Outcomes differ depending on which part of the brain is ultimately affected. It’s important to keep in mind that each side of the brain affects the opposite side of the body (the right side of the brain affects the sensing and motor control of the left side of the body and vice versa).

      • Back of brain – vision may be impaired.
      • Right side of brain – there may be numbing or paralysis on the left side of the body, vision problems, memory loss, and the person may develop an inquisitive behavioral style.
      • Left side of brain – there may be numbness and paralysis on the right side of the body, speech and language problems, memory loss, and the person may develop a more cautious behavioral style.
      • Brain stem (lower part of the brain) – both sides of the body may be adversely affected resulting in a “locked-in” state where the person is unable to speak and is paralyzed from the neck down.

If stroke does occur, it is really important to remember that along with the physical implications, there are huge emotional implications as well. The person who has experienced stroke may experience mood and personality changes and their overall outlook on life may change due to the chemical responses that are occurring in the brain. Once again, it’s imperative to treat the person holistically as they are more than just the sum of their physical organs.  Stroke not only affects the individual – it affects their loved ones as well. Not only is immediate medical attention imperative to mitigating the long-term effects of stroke, patience and compassion with each other are of equal importance when helping those overcome this potentially debilitating medical event.

Decreasing the Risk of Stroke

There are several steps that can be taken to keep healthy and help prevent instances of stroke. Work with your medical practitioner to develop a plan that you can easily work into your lifestyle to help you feel your best and achieve good health.

Diet and Achieving Healthy Weight

A diet targeted at keeping a healthy weight and atherosclerosis at bay is essential and should include foods low in fat and cholesterol yet high in omega-3 fatty acids, fiber, fruits and vegetables. It’s also important to maintain a healthy weight to avoid the onset of type 2 diabetes. Avoid other unhealthy ingredients such as high-fructose corn syrup and really anything that decreases a food’s nutritional value (excess salt, preservatives, excess refined sugars, trans fats, etc.).  This doesn’t mean taste needs to go away, just the awful ingredients that tend to hide in some of our favorite foods!

Managing Alcohol Intake

While in some studies, alcohol has been shown to increase “good” cholesterol (HDL) and decreases complications from cardiovascular disease, drinking alcohol should always be done in moderation. The actual recommended amount is still hotly debated and depends upon an individual’s metabolism, body weight, etc., so you should find the most reputable source of advice for yourself.

Exercising

Regular exercise has proven invaluable in mitigating the risk of atherosclerosis and cardiovascular disease. Aerobic exercise can help individuals maintain a healthy weight, decrease blood pressure, elevate “good” cholesterol levels (HDL), and decrease glucose levels. It’s even been shown that strengthening exercise can be equally as beneficial. Exercise of any kind can also improve mood, which results in a win-win for body and mind.

Quitting smoking

Smoking significantly increases the risk of cardiovascular disease such as stroke. While quitting smoking can be incredibly tough – and there’s the potential for experiencing pretty nasty withdrawal symptoms and weight-gain – there are many programs, including behavior modification, medications and support groups that can help.  Many hospitals offer these programs, and many insurance providers offer incentive programs to help make these healthier lifestyle choices.

Taking hydroxychloroquine

Frequently given to individuals with lupus to decrease disease symptoms, hydroxychloroquine (brand name Plaquenil), has been shown to decrease cholesterol levels as well as decrease the chances of getting blood clots.

Avoiding Hypertension

Avoiding hypertension (high blood pressure) may be achieved by regular exercise and a healthy diet (as mentioned above) as well as low caffeine intake. An individual whose blood pressure is not easy to control may be prescribed medications to help achieve better results. A healthy blood pressure target is typically around 140/90, or 130/80 if there are kidney complications. Complementary practices such as cognitive behavioral therapy, meditation, gentle yoga, tai chi, etc. may also help an individual achieve more favorable blood pressure results and improve overall well-being.

Managing Cholesterol

A diet that is low in fat and cholesterol will help decrease overall cholesterol and decrease “bad” cholesterol (LDL). Practicing everything mentioned above may ultimately help with cholesterol, but sometimes it’s not enough especially if high cholesterol is hereditary or there are other risk factors. In these cases, individuals may be prescribed statins (brand names include Lipitor, Crestor, Zocor) to help balance cholesterol levels.

In Conclusion

Stroke may be avoidable so it is important to do what you can to decrease the risk. Even though it may seem scary, it’s a great conversation for individuals with lupus to have with their medical practitioner in order to discuss risk and the development of healthy habits. While avoiding stroke, you may also avoid all kinds of medical implications and achieve greater health overall. Doing something good and healthy for yourself can also boost confidence and a greater sense of well-being because you are doing something positive by being proactive and taking your health into your own hands.

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References

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Arkema, E., Asplund, K., Holmqvist, M., & Simard, J. (2015). Stroke in systemic lupus erythematosus: a meta-analysis of population-based cohort studies. RMD Open. doi:10.1136/rmdopen-2015- 000168
Barbhaiya, M., Costenbader, K., Everett, B., Feldman, C., Fischer, M., Gomez-Puerta, J., Guan, H., & Solomon, D. (2017). Race/ethnicity and cardiovascular events among patients with systemic lupus erythematosus. Arthritis & Rheumatology. doi: 10.1002/art.40174
Boyles, S. (2010). Many stroke patients don’t get quick treatment. Retrieved from: https://www.webmd.com/stroke/news/20100603/many-stroke-patients-dont-get-quick-treatment#1
Cobb, C. (2018). Dyslipidemia: Everything you need to know. Retrieved from: https://www.medicalnewstoday.com/articles/321844.php
Effects of stroke. (2012). Retrieved from: https://www.strokeassociation.org/STROKEORG/AboutStroke/EffectsofStroke/Effects-of-Stroke_UCM_308534_SubHomePage.jsp
Hemorrhagic stroke. (2018). Retrived from: http://www.stroke.org/understand-stroke/what-stroke/hemorrhagic-stroke
https://www.webmd.com/lupus/lupus-nephritis#1
Harrison, P. (2015). Stroke risk high in lupus – risk of all stroke subtypes is elevated, particularly in the young. Retrieved from: https://www.medpagetoday.com/rheumatology/lupus/55475
Krishnan E. (2005). Stroke subtypes among young patients with systemic lupus erythematosus. American Journal of Medicine, 118(12), 1415.e1-1415.e7.  Retrieved from: https://www.sciencedirect.com/science/article/abs/pii/S0002934305004973
Lahita, R. G., & Phillips, R.H. (2014). Lupus: Everything you need to know (3rd ed.). Garden City Park, NY: Avery Pub. Group.
MacGill, M. (2017). Everything you need to know about hypertension. Retrieved from: https://www.medicalnewstoday.com/articles/150109.php
Nabili, S. (2018). Vasculitis. Retrieved from: https://www.emedicinehealth.com/vasculitis/article_em.htm#what_are_the_causes_and_types_of_vasculitis
Ren, X. (2014). Libman-Sacks endocarditis. Retrieved from: https://emedicine.medscape.com/article/155230-overview
Thomas, D. E. (2014). The lupus encyclopedia: A comprehensive guide for patients and families. Baltimore, MD: Johns Hopkins University Press.
Transient ischemic attack (TIA). (2018). Retrieved from: https://www.mayoclinic.org/diseases-conditions/transient-ischemic-attack/symptoms-causes/syc-20355679
Understanding stroke. (2018) Retrieved from: http://www.stroke.org/understand-stroke?gclid=CjwKCAjw5ZPcBRBkEiwA-avvk3ntSjXIE2mJX8VZcglKsSrNk5KD-0Tz1SBIfNjcMWu3x1RdLUZBDBoC3ZQQAvD_BwE
What is atherosclerosis? (2018). Retrieved from: https://www.webmd.com/heart-disease/what-is-atherosclerosis#1

Author:  Liz Heintz

Liz Heintz is a technical and creative writer who received her BA in Communications, Advocacy, and Relational Communications from Marylhurst University in Lake Oswego, Oregon. She most recently worked for several years in the healthcare industry. A native of San Francisco, California, Liz now calls the beautiful Pacific Northwest home.

All images unless otherwise noted are property of and were created by Kaleidoscope Fighting Lupus. To use one of these images, please contact us at [email protected] for written permission; image credit and link-back must be given to Kaleidoscope Fighting Lupus.

 

All resources provided by us are for informational purposes only and should be used as a guide or for supplemental information, not to replace the advice of a medical professional. The personal views do not necessarily encompass the views of the organization, but the information has been vetted as a relevant resource. We encourage you to be your strongest advocate and always contact your healthcare practitioner with any specific questions or concerns.

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