Brain Attack

What is a brain attack? What to do to prevent? What to do if someone is having a stroke? Who is in risk? What causes a brain attack? These and other questions are answer by Dr. Bernell Baldwin in this article.

By Bernell E. Baldwin, PhD

Bernell E. Baldwin, PhD, neurophysiologist, and TV lecturer for The Home School of Health at 3ABN Television, first started lecturing in Physiological Psychology at The George Wash¬ington University, then at Loma Linda Univer¬sity. Currently he is Applied Physiologist at Wildwood Lifestyle Center & Hospital, and Science Editor of The Journal of Health & Healing. This article originally appeared in The Journal of Health and Healing and is used with their permission.

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Dorothy Carlson hit the door clumsily, trying to open it. Then she hit it again. And again. Her eyes turned wildly to the right-then stuck. Hour by hour she got worse. Paralysis, crippled, then diapered, iso¬lated, and largely finished. What hap¬pened? A brain attack!

Mr. Jim, leader of a large organiza¬tion, was so identified, so married to his work that morning, noon, and night it weighed him down. He refused to ac¬cept counsel to be moderate in work and take a break. Finally, one morning on a walk with his wife by a garden he pulled open an ear of corn. Suddenly, a brain attack like a shock paralyzed his right arm and marred his speech. This is the way brain attacks work. They may take years to build up, but strokes can fell them, like a giant tree, in seconds.

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One of these larger strokes happens every 50 seconds in America!—over 600,000 strokes every year. Each year over 160,000 of these attacks end in death. Brain attacks are the third cause of death in America, after heart attacks and can¬cer.1 However, these strokes are the com¬monest cause of disability because thou¬sands of people are permanently disabled, crippled, dumb, even incontinent or de¬mented—and many linger on for years.
What is a Brain Attack?
Like a heart attack, a brain attack is a sudden, unexpected interruption of blood supply to a portion of the brain. It may be from an atherosclerotic plaque that has been silently diminishing the channel for blood flow until it is nearly or completely stopped. It may be from a bit of traveling clot (embolus) that has broken from a larger clot, probably in the heart, and lodges in a brain artery too small to let it continue its journey. On the other hand, it may be the even more serious blow-out in a weak spot in the wall of a brain artery, causing a hemor¬rhage that floods the surrounding brain tissue with blood. This can be fairly slow leakage or sudden gushing like water pouring from a broken pipe.
What are the Warning Signs of a Brain Attack?
•    Sudden numbness or weakness of the face, arm or leg, especially on only one side of the body
•    Sudden confusion, trouble speaking or understanding
•    Sudden trouble walking, dizziness, loss of balance or coordination
•    Sudden trouble seeing in one or both eyes
•    Sudden severe headache with no known cause2

What Causes Brain Attacks?
Obstruction of brain vessels accounts for 80 percent of brain attacks. Ten per¬cent are caused by blowout (hemorrhage) bleeding inside of the brain; hemorrhage inside the skull but outside of the brain, causes another 10 percent.3

Two thirds of all brain attacks are caused by emboli lodging on the surface of atherosclerotic plaques. People don't realize that either the finest coronary by¬pass operation or angioplasty in the world can't stop atherosclerosis from develop¬ing again and blocking a brain artery a few years later.

If any of these happens to a member of your family, a friend, or a contact, CALL 911 FAST! Time is of the essence, for im¬mediate appropriate care of a blood clot can prevent loss of function as circulation is restored to the damaged area. Get to the best hospital available within reason-able distance because more than three hours delay can ruin your chances of dis¬solving a clot in the brain. While the am¬bulance is coming, phone ahead, and be sure the closest hospital does brain scans and is ready for brain attacks. If this hos¬pital does not have this facility, find one quickly that is prepared to handle brain attacks, now. Accurate immediate diag¬nosis is imperative, because clot-dissolv¬ing intervention is disastrous in a hemorrhaging brain.
TIAs, Transient Ischemic Attacks
A short term stroke that fades away within 24 hours is called a transient ischemic attack (TIA). The symptoms and signs may be similar to a more serious stroke but TIAs involve the critically deficient supply of blood and oxygen to a spot in the brain that usually clears up, within one hour, but must clear within 24 hours to be called a TIA. About one-third of people who have a TIA will later have a fully developed brain attack. About 80 to 90 percent of people who get a stroke related to atherosclerosis will have had one or more TIAs previously. These dangerous episodes are more common in men and in black people. Risks for TIAs are similar to those for brain attacks.
Silent Strokes
At the stroke meetings in Fort Lauder¬dale, Florida, in 2001, Dr. Leary, of the University of California at Los Angeles, reported on new data from over 5,000 brain scans, showing that by far most strokes are silent. They are not dramatic enough to put people in the hospital. From these brain scans, the researchers estimate that each year 11 million Americans have one of these clinically silent strokes, while each year 750,000 other Americans are having big strokes. These silent strokes can be serious because they tend to recur, and tiny deficits recurring year by year add up to ruined memory, depression, inability to walk, or other brain-related deficits—even severe personality changes. Also, these small strokes tend to precede big strokes.

Silent strokes are uncommon before one is 30 years old, but they double every 10 years thereafter. The data indicate that each year one in three people 70 years old or older has a silent stroke. Some people have more than one each year. Dr. Leary says that both silent and symptomatic strokes can be prevented by the measures mentioned below. Dr. Sacco, of Columbia University, says that recognized, conventionally diagnosed strokes may be just the tip of a murderous iceberg. In a separate study from Holland, Dutch doctors did brain scans on more than 1,000 elderly people. They confirmed the evidence showing that 80 percent of these had had silent strokes.4
Implications
Obviously, strokes are much more common than has been previously recog¬nized. They come in all sizes. The West¬ern world is experiencing an epidemic of strokes and we need to be very vigorous about thorough prevention and care. Af¬ter all, our brains are us, and our elder years can be lived abundantly instead of endured painfully.

High Blood Pressure or Hypertension (HT) is a Major Cause

The healthiest brain arteries in the world are in people with systolic* blood pressure (BP) of 110 or lower. Henry and Meehan of UCLA5 have studied and reported on 10 societies with low, low blood pressures, 110 that is. They have discovered that the more stressful the society, and the more the values of children clash with those of their parents, the more hy¬pertension there is. Pressing, grinding, pushing STRESS is bad news for blood pressure. Hypertension is a complicated problem with more than one cause and more than one cure. In biophysics it is known that through nerves and hormones the brain can whip the heart faster, and clamp down the small arteries (arterioles) in three key areas: the kidneys, the viscera (abdominal organs), and the skin. Physi¬ologists have known for 50 years that brain stimulation can shrink the kidneys in four seconds! I have records from my brain lab at The George Washington University of doubling the blood pressure in 10 seconds by electrical stimulation of stress centers in the brain.

* The pressure while the heart is beating—recorded as the upper number of blood pressure.
If this happens often enough and long enough in a genetically primed person, especially with one or more of the risk factors discussed below, the BP control system can be reset, and higher BPs become established. In HT the kidneys commonly are deranged by thickening of the casings—the inner membranes—of the blood vessels themselves. This can help perpetuate the abnormal blood pressure by squeezing down the arteriolar openings, thus contributing dangerously, even to malignant HT.6

Almost 40 percent of all black adults and more than half of the en¬tire population over age 60 have HT. It is the most prevalent cardio¬vascular disorder in the United States. Over 60 million people in America have it.3

The hypertension expert, Dr. Kaplan, writes, "Over half of all heart attacks and two-thirds of all strokes occur in individuals who were previously hypertensive."7 It is also a major risk factor not only for stroke but also for coronary, ce¬rebral, and renal (kidney) vascular disease, which, combined, cause over half of all deaths. Hyperten¬sion is the most important modifi¬able risk factor for coronary heart disease, stroke, congestive heart failure, and end-stage renal dis-ease8. In the world famous Framingham health studies, brain attacks occurred 5 to 30 times more commonly in hypertensive people than in controls.7

Blood pressure is the most powerful risk factor for brain attacks. Even within the BP ranges of what average physicians call normal or tolerable, an increase of only 5 mm of diastolic blood pressure (the lower number, that of pressure in the heart between beats) throughout the range of 70 to 110 mm of mercury (Hg), increases the risk of stroke by approximately 50 percent! The risk for stroke is about 4 times above normal for a BP of 160/ 95. The risk is two times higher for those in the borderline range. Aggressive therapy that lowers and keeps the BP down—even 6 mm of Hg reduces stroke risk by nearly one quarter.6 Framingham data show that reducing BP in the eighth and ninth decades of life is beneficial in reducing stroke risk. All adults should know their BP. It is as important as oil pressure for airplane pilots. Crashes are caused; they don't just "happen." The autonomic nerves are involved in hypertension.

Usually the sympathetic nervous sys¬tem squeezes the blood vessels of the body and makes blood pressure go up. The parasympathetic nervous system should balance this by putting the brakes on. There is evidence that in patients with early HT, diminished resting parasympa¬thetic nervous system activity follows. (The brakes are off).
•     Sympathetic nervous system activity is enhanced (The accelerator is ON).
•     Blood (plasma) level of the hormone Noradrenaline, which increases blood vessel constriction, is commonly high.
•     Enhanced vascular response to stress
•     Exaggerated response also to relax¬ation—blood pressure falls during meditation and other states of relax¬ation. This lowers blood pressure.
•     Mental stress such as mental arithmetic produces greater rises of blood pres¬sure in hypertensive people.
•     Physical stress, like isometric exercise, produces a greater rise of increased blood pressure.
•     Impressive falls of blood pressure oc¬cur when patients are removed from stressful home environments and brought into safe, supportive, hospital settings.
• Increased prevalence of hypertension is found in cities, as compared with that found in quieter country environments.
• Increased levels of hypertension prevail in societies where value systems are in disarray, contrasted with lower levels of blood pressure in stable societies.6

Many other factors in the environment, in the family, in genetics, and in the individual are also thought to contribute to the current epidemic of hypertension. What makes most hypertension?

Years ago Hans Selye, that pioneer of understanding stress, realized and stated correctly, "The organism has only two correlating systems—the nervous and the hormonal—and both are involved in the development of hypertension." 9**
What About Salt?
One of the cheapest ways to jazz up flavor is with more salt! So, guess what? We are assaulted with salt—in baby foods, in restaurants, in cans, in snacks, in baked goods, in almost everything. Millions of people get far too much salt in their diet. So what? By direct meticulous labo¬ratory measurement on blood vessels, under strict control of everything, the more salt in the blood the more spasm of blood ves¬sels you get, with exactly the same norepinephrine dose. It is not quasi-politi¬cal guesswork. High salt is dangerous, period. Don't throw this article aside just yet—we are quite aware of salt insensitive people.

Formerly, in the salt-fish eating islands of Japan, 30 percent of the fishermen would "stroke out" (die) with massive strokes. When war was declared on ex¬cess salt, down, down went the problem. Eating far too much SODIUM is not mod¬eration!

Too much salt is also a risk factor for cancer of the stomach, especially when combined with nitrosamine formation, as after eating bacon or luncheon meats. Salt appetite is a learned behavior. It is also a taste habit. We must make up our minds— is our taste for salt in charge, or is our informed will? The fact that some people can get away with excess salt is no rea¬son to swallow excess sodium (in the salt) in chronic presumption. The American Heart Association draws a line in the sand of salt intake at 6 grams per day.10 Millions of people eat 10 or more grams (two tea spoons full) per day. Fortunately, inclusion of foods—fruits and vegetables—with more potassium, magnesium, and calcium in the diet can help balance sodium.

After studying data from 32 countries around the world, Dr. Stamler, of Chicago, calculates that with a lower 100 mmol/day (approximately 6 grams or l 1/4 teaspoon per day from all sources) salt intake over the lifespan, there would be a 23 percent lower risk of stroke death.11
Diabetes Is Another Risk Factor for Brain Attack
The risk for stroke is approximately three times higher for diabetics.
Smoking
Tobacco smoking increases stroke risk twofold to fourfold. And, those who stop smoking forever reduce their risk appre¬ciably.3
Age
The incidence of brain attack approxi¬mately doubles with each decade between ages 45 and 85 years.3
Race
The risk for African Americans is ap¬proximately 1.3 times that for Caucasians. Some think this is a combination of high stress, poor food choices, hypertension, and obesity.
Oral Contraceptives
There continues to be a problem with venous thromboembolism with use of oral contraceptives, and it is thought that even at low dosages these unphysiological hormonal manipulations can combine with other risk factors to produce damage to linings of blood vessel walls and hence promote problems in blood vessels of the brain.12

Homocysteine
A group of scientists from Centers for Disease Control in Atlanta, studied 300 young women for stroke prevention. The blood homocysteine levels ranged from 2.89 to 26.5 micromol/liter; safe range is less than 10. This tell-tale molecule for vascular risk increased with age, cholesterol level, alcohol intake, and number of cigarettes smoked. Thirteen percent of the young ladies had levels over ten micro-mol/L.13

Alcohol
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A group from the National Public Health Institute of Finland studied 14,874 Finnish men and women for risk factors of stroke in 1982 or 1987. In 1994 they were reanalyzed. A new chemical marker named gamma-glutamyl transferase (GGT) was used to estimate actual alcohol use. They found that the higher this marker was—therefore the more alcohol used—the more strokes the people got. They concluded that heavy alcohol use is a risk factor for stroke.14 Remember that 10 percent of people who start drinking end up as problem drinkers.

Genetics
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A Danish team from the Copenhagen City Heart Study, carefully mapped the ex¬act amino acid composition of the low density lipoprotein (LDL) receptors in 345 patients who had a stroke. They found that people with a certain abnormal inherited gene had a 5.4 fold increase in risk of stroke.* This new discovery implies that genetics can be quite significant. Strange¬ly, this mutation was not closely related to atherosclerosis or to lipoprotein lev¬els.15 Stroke is not strikingly related to li¬poprotein levels, either. It is much more highly related to blood pressure.
*a double threonine (an amino acid) homozygosity (same amino acid) at position 370.
Prior Stroke
The risk of another stroke for some¬one who has already had one is about 15 times that of a person who has not.16 Carotid Artery Disease.

Carotid Artery Disease
The carotid arteries, located in the neck on either side of your windpipe, sup¬ply the brain with blood. When either one is narrowed, as by atherosclerosis, the risk for stroke goes up. These atherosclerotic plaques, especially when soft and thin-capped, can break open and precipitate a clot. Dangerous!

Heart Disease
Atherosclerotic arteries, left-sided valve defects, or certain abnormal rhy¬thms of the heart tend to endanger the brain because of clots. Atrial fibrillation, in which the heart quivers rather than beats in coordinated fashion, is a common and especially dangerous condition that must be dealt with immediately.
Drugs
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Intravenous drug use is particularly threatening. Even first-time cocaine users can get strokes from emboli or floating clots. Heavy marijuana use has caused strokes17, as has ephedra18, which often masquerades under the cover of "dietary supplementation."
Obesity
Overeating and under-exercising can gradually add up to obesity. Most risky is the "apple" form, in which the weight cen¬ters in and around one's abdomen. This central obesity is associated with high blood pressure, high blood cholesterol, high triglycerides (blood fat), diabetes, heart disease, and stroke. Women with waistlines of more than 35 inches and men whose waistlines exceed 40 inches, are considered especially vulnerable to these serious diseases.10
Strokes are multifactoral. Though most may start with unremitting stress, other mechanisms like dysfunction of the kidneys, electrolytes, or blood coagulation can push and keep on pushing until the dreadful happens—a brain attack.

Diagnosis of Kinds of Brain Attacks and Smaller Strokes
Formerly with BRAIN ATTACK symp¬toms, a careful analysis of history, physical and neurological examination, and simple lab tests were standard of care. No longer. An immediate, excellent brain scan is a must. This scan, plus a complete exami¬nation including a neurologic diagnosis must be finished, and if the stroke is caused by obstruction of flow, clot-dis¬solving therapy must be started within three hours for it to do any good. In some cases this will reverse the stroke. In others it should not be tried because hemor¬rhagic or bleeding strokes can be dramati¬cally worsened by clot-dissolving therapy. It would be wise for any older person with even borderline HT, and/or diabetes or history of strokes in the family to get a "baseline examination" before any trouble is manifest at all. Ask that your check-up include a complete neurological exam with an MRI (magnetic resonance image) or scan. If you already have one or several small lesions from silent strokes, ask your doctor what you can do right now to prevent another small or LARGER stroke. If you don't change your patterns of living, most likely more and larger strokes will hasten the decline of your mental, spiritual, and physical functions.
What Can Be Done to Treat Brain Attacks?
Thrombolysis
To treat brain attacks, laymen must be alert and aware of the symptoms of a brain attack. As mentioned previously, when-ever symptoms appear, morning, noon, or night, call 911 or take the person immediately to the best hospital locally available.

Remember, you have only three hours for the whole sequence of diagnosis and the initiation of serious treatment. To repeat: get on the phone to the emergency room of the finest, most-up-to-date hospital in your area. If this hospital is not yet ready with a brain attack program, rush the pa¬tient to a hospital that is ready. Vital func¬tions must be supported while the patient is in transit.

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In most cases a CT (computer assisted tomography) scan without contrast can help determine ischemic (clot-caused) from hemorrhagic strokes. High-speed MRI scan is also most useful in diagnos¬ing stroke. Careful prompt history and neurological examination can often tell which artery is at fault and how serious the stroke is.

Treatment of brain attack is currently under dynamic review. Clot-dissolving therapy is five times more likely to be used in the Midwest than in the South. It takes an entirely new approach to stroke care to do justice to a serious brain attack, es¬pecially in the middle of the night, and on weekends. In a conventional hospital three hours is not very long. Decision to use clot-dissolving (thrombolytic) therapy cannot be taken lightly. If the patient is bleeding or if the stroke is due to a very large clot, then dissolving therapy could make him or her very much worse.
When clot-dissolving (thrombolysis) is indicated, and the sooner recombinant tissue plasminogen activator (rt-PA) therapy is begun, the better the results; there is approximately a 30 percent greater chance of rather complete recovery with this therapy with select patients. But there is about a 6 percent chance of symptomatic hemorrhage developing in the brain within 36 hours.19 The decision to dissolve clots is a techno-judgment decision. Many factors must be taken into account—from the age and pre-stroke condition of the patient, to the probable gains in quality of life for him or her. A mistake here could have legal conse¬quences, even when medical care cannot be faulted.
Fortunately, research and develop¬ment are very active in this area. Goals include saving more brain tissue by deliv¬ering blood and oxygen to the deprived area sooner. Even hypothermia (cooling the brain) is being tried to reduce oxygen demand of the brain tissue until more can be delivered.20
Use of Surgery to Unclog Arteries Supplying the Brain Is Maturing Rapidly
If an artery supplying the brain, es¬pecially a carotid artery, is 70 percent or more plugged up, timely surgery by a team who is very experienced and frequently performs this operation, can be very help¬ful. Fortunately, side effects of this sur¬gery are continually decreasing. Of course, a complete prevention program should then be instituted to keep the arteries open. Early smaller plaques should be addressed by serious lifestyle medicine, and progress precisely monitored by ultra-sound. If there is no regression, clot removal by surgery may be indicated before, not af-ter, a stroke.
An Ounce of Prevention Is Worth a Pound—or a Ton—of Cure
Most strokes can be prevented by the following measures.
Beware of the probability of one's having a brain attack; more than one-half of all Western people get strokes. Al¬though they come in all sizes and several kinds, most silent strokes are predictive of more and bigger clinical ones. Together they can beget depression, ruined memory, ruined mobility, and other preventable handicaps.10
Blood pressure of 120/70 is better and safer than 130/80, and 130 is better than 140. You say your pressure is 165/95? That is bad, dangerous, even deadly. Mathematically, the higher the blood pres¬sure, the more the strokes (and heart at¬tacks) and the worse the prospects are for enjoyable and fulfilling elder years. High BP is dangerous. Any systolic blood pressure over 140 is risky, and any diastolic blood pressure over 90 should be lowered.

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High BP is caused by a number of things, almost all of which can be turned around. The cause should be discovered, so that it can be treated, not just the BP itself. If yours is more than 140/90 get a thorough diagnosis by a prevention-minded physician. Even isolated instances of elevated systolic BP have predictive significance. A small twig is the easiest to bend. Bend it.

Daily low-stress exercise helps pre¬vent or treat high BP. Walking is best be¬cause it is so available, and exercises the whole body. Stressful or competitive ex¬ercise that causes you to pant is danger¬ous.21 It makes the platelets too sticky and reduces plasmin concentration in the blood. This combination makes more clots.22 With your physician's permission, start walking a little and work into more of it gradually. One-half hour of walking each day would be excellent.
Gardening is even better because growing flowers and tomatoes is a beauti¬ful step toward Eden. Swimming is a wel¬come form of low-stress exercise. The old "huff and puff" forms of "no-pain-no-gain" exercise were satisfactory for muscles but not for platelets, the trigger cells for clotting. Clots kill millions.

Faithful STRESS CONTROL is a must for stroke prevention. This means, at the very least, a long weekend every season, away from the grindstone. This means a real two-week vacation every year, away from the grind. This also requires genu¬ine, deep, regular sleep each night, and a day of rest every week. I like the Creator's day. The modern scene is full of gimmicks, drugs, and even surgery to reduce stress, but if you want the best go to the Great Physician. He promised "My peace I give unto you" (John 14:27b) and further, "These things I have spoken unto you, that in Me ye might have peace." John 16:33a

Also, the wonderful gifts given us as explained in Galatians 5:22 and following—love, joy, and peace—are all promised. This makes tremendous sense because the nervous system is run from the frontal lobes down and the spiritual peace lodged there can down-regulate stress throughout the body by electronic and hormonal communication. Remember the Great Physician asleep in that storm? The busier we get the more relevant spiritual peace becomes. Go for it.
More Preventive Medicine

Don't dally with diabetes. Treat it wisely and faithfully.

Excellent nutrition is basic. "Eat for strength and not for drunkenness." Ecclesiastes 10:17. Eating too much of even good food brings trouble eventually, and eating too much of bad food brings big trouble sooner. For instance, eating blood with its clotting chemicals, in meat, is just asking for more clots. All meat—flesh, fish or fowl—has arachadonic acid in it. Eating this, particularly in excess, primes the membranes of the body for inflammation. This we don't want in arteries of the brain or anywhere else.

Go easy on salt. Many people are spe¬cifically sensitive to salt, and respond by abnormally high blood pressure, which decreases when salt is minimal or not added to food.

Fruits and vegetables are proven preventives for strokes.23 Vegetable proteins have excellent balance of arginine, an amino acid that dilates blood vessels by forming nitric oxide. An exclusively plant-based diet is best.
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Omega-3 fat as from flax, walnuts, and all green leafy vegetables, helps lim¬ber up your arteries—they become actually less stiff. This is wiser than fish—no cholesterol or viruses.
If your blood pressure, blood sugar, weight, or smoking is not under steady complete control go to a lifestyle center and win the victory sooner instead of the expensive salvage of your faculties and functions later. You will be glad you did.
If you do get a stroke, don't short-change physical therapy and rehabilitation. They can help very significantly in new skills for new challenges of living. And, do spread the word to your family and friends. Many strokes are prevented, and lives maximized, by an ounce of pre-vention, and that life may be yours!
If you would like to subscribe to The Journal of Health and Healing or order back issues where many more health articles are available, call 706-820-1493, Ext. 407.
REFERENCES:
1.    2001 Heart and Stroke Statistical Update, American Heart Association, c. 2001, http://www.americanheart.org/statistics/ stroke/html
2.    Stroke is a Medical Emergency Call 911! American Heart Association, c. 1999, http://www.strokeassociation.org/
3.    Pulsinelli, W. A. and Levy, David E. Cerebrovascular Diseases-Principles, in, Chap 468, Cecil Textbook of Medicine, 19th ed., Wyngaarden J. B., L. H. Smith and J. C Bennett, 1992, pp. 2145-2170.
4.    American Stroke Association Report. Associated Press Release, Feb. 16, 2001, online.
5.    Henry, J.P. and Meehan, J.P., High Blood Pressure, ch. 11, in The Circulation. An Integrative Physiologic Study. Year Book Med. Pub., Inc., Chicago, 1971, pp. 174-193.
6.    Kaplan, N.M., Systemic Hypertension. Mechanisms and Diagnosis, ch. 25, in Braunwald, E. Heart Disease. W.B. Saun-ders Co., Philadelphia, 1980, pp. 852-921.
7.    Kaplan, N.M., Systemic Hypertension: Mechanisms and Diagnosis, ch. 28, in Braun wald, E., et al., Heart Disease. W.B. Saunders Co., Philadelphia, 2001, pp. 941-971.
8.    He, J. and Whelton, P.K., Epidemiology and prevention of hypertension. Med Clin North Am, 81 (5): 1077-97, abs.
9.    Cort, J. H., et al, Symposium on the Pathogenesis of Essential Hypertension. A Pergamon Press Book, The Macmillan Co., New York, 1962, pp. 168-9.
10.    AHA Scientific Statement, AHA Dietary Guidelines, c. 2000, AHA, Inc., published online 10/05/01. http://circ.ahajournals. org/cgi/content/full/43046355102
11.    Stamler, J., et al, INTERSALT study finds. Public health and medical care implica¬tions. Hypertension, 14(5):570-7, PMID: 2807518, abs.
12.    Godsland, I.F., et al, Occlusive vascular diseases in oral contraceptive users. Epidemiology, pathology and mechanisms. Drugs, 60(4):721-869, 2000, abs.
13.    Giles, W.H., et al, Distribution and correlates of elevated total homosyst(e)ine: the Stroke Prevention in Young Women Study. Ann Epidemiol, 9(5):307-13, 1999, abs.
14.    Jousilahti, P., et al, Serum gamm-glutamyl transferase, self-reported alcohol drinking, and the risk of stroke. Stroke, 31 (8): 1851 -5,2000, abs.
15.    Frikke-Schmidt, R., et al, LDL receptor mutations and ApoB mutations are not risk factors for ischemic cerebrovascular disease of the young, but lipids and lipo¬proteins are. Eur J Neurol, 6(6):691-6, 1999, abs.
16.    Redfern, J., et al, Behavioral risk factor prevalence and lifestyle change after stroke: a prospective study. stroke,31(8):1877-81, 2000, abs.
17.    White, D., et al, Stroke associated with marijuana abuse. Pediatr Neurosurg, 32(2):92-4,2000, abs.
18.    Haller, C.A. and Benowitz, N.L., Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med, 343(25}:1833-8, 2000, abs.
19.    Kelley, R.E., Thrombolytic therapy for actute ischemic stroke. J La State Med Soc, 152(5):253-8, 2000, abs.
20.    Maier, C.M, et al, Delayed induction and long-term effects of mild hypothermia in a focal model of transient cerebral ischemia: neurological outcome and infarct size. J Neurosurg,94(l)-.90-6,2001, abs.
21.    Mittleman, M.A., et al, Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med, 329 (23): 1677-83,1993, abs.
22.    Willich, S.N., et al, Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. N Engl J Med, 329(23): 1684-90, 1993, abs.
23.    Gillman, M.W., et al, Protective effect of fruits and vegetables on development of stroke in men. JAMA, 273(14): 1113-7, 1995, abs.