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TODAY I LEARNED FROM THJE MEMORIAL PLACE THAT STORES MY MOM'S ASHES THEY CONTACTED ME AND SAID WE TRYIED TO CONTACT MY DAD BNUT THEY COULDNT AS HE WAS DEAD. I WAS TOLD NOTHING BY MY BIO FAMILY WHO I DONT AND NEVER DID GET ALONG WITH,EVEN THOUGH THEY HAD MY CONTACT DETAILS. THAT FUCKING SUCKS BUT IT IS WHAT IT IS. I WAS SHOCKED THAT I FELT ALL THESE EMOTIONS AS MY DAD SEXUALLY PHYSICALLY AND EMOTIONALLY AND WORST OF ALL HE KILLED TWO OF MY DOGS AND ABUSED ONE OF MY CHILD HOOD FRIENDS SO BAD SHE KILLED HERSELF AT 14.I AM STILL TRYING TO FIGURE THIS ALL OUT.RIGHT NOW I AM NUMB WITH ALL MY EMOTIONS SWIRLING THRU MY MIND LIKE A BLOODY TORNADO.I JUST DONT REALLY UNDERSTAND MY EMOTIONS RIGHT NOW.OR WHY PART OF ME IS HAPPY SAD ANGRY SCARED CONFUSED.I SHOULD HATE HIM SO MUCH BUT YET I DONT KNOW HOW I FEEL.
I DIDNT WRITE THIS, IT CAM FROM ONE OF THE MANY DIGITAL NEWSPAPERS I AM SUBSCRIBED TO.
11 things no millennial wedding should be without
Mitchell Toy, Herald Sun
September 17, 2018 9:20am
Subscriber only
THE spring wedding season is fast approaching and thousands of bridesmaids across the state are just about ready to murder their brides.
Millennials are getting married and from hay bales to hashtags, here are 11 things no modern wedding should be without.
INSIDE MELBOURNE SECRET SOCIETIES
12 COMMUTERS TO AVOID
WHY MELBOURNE BEATS VIENNA
HAY BALES
Especially at a rural or outdoor wedding, hay bales are an absolute must.
If you can have a chalkboard sign resting on a hay bale, that’s extra good.
Not only are they rustic and quaint, but as a mega cheap alternative to hiring proper chairs, your wallet with thank you for it, even if your guests won’t.
Nine out of ten chiropractors agree that using hay bales instead of chairs is a lot cheaper.
OVER-THE-TOP BRIDESMAID PROPOSALS
However the groom proposed, times it by ten and that’s how exciting it should be when someone is asked to be a bridesmaid.
And once they accept, they are signing over their whole lives to be told what to do and when, through vicious and expensive shoe and dress shopping to pretty much picking up the bride’s groceries for the length of the engagement.
A PHOTO BOOTH
The photographer will do a great job at capturing guests as they are.
But that’s not enough.
It’s won’t be fun unless people are photographed holding props.
Guests should also be obliged to put a hat on to prove they’re having a good time.
Go on. Prove it. Put the hat on. Hold a little sign.
The photo booth owner has to get the machine back by 9pm so he can get it to an 18th or high school graduation.
FINGER FOOD
Understandably the bride and groom have spent a lot of money making sure this wedding looks as good on the internet as possible.
Naturally the fat will have to be cut on the food and naturally guests won’t mind making that sacrifice.
So it’s standing up and eating little quiches.
If elderly guests struggle to find somewhere to rest, they can be told this isn’t really a sit-down thing.
This is all you will be eating.
WHY WEDDING VENUES ARE SO PRICEY
TEN EVENTS BEFORE THE ACTUAL WEDDING
In your lifetime you only get married like three times max, so why not make the most of it.
It’s not enough to just have a ceremony and reception. You’ve really got to pile it on.
Guests can bring a present to each if they like. Thanks.
If you have any friends left after that, they’ll also try and make it to the actual wedding.
TIERS
It’s a big problem: You have about 500 too many close friends and not all of them can be beckoned to the inner sanctum with a wedding invitation.
So it’s only sensible you invite only your closest friends and family.
All the other plebs can be invited just to the ceremony or post-ceremony drinks.
Gifts on the table, please.
And if you’ve still got too many friends who you can’t possibly squeeze into any of the guest lists, that’s what engagement parties are for.
STUBBLE
It’s only right and decent that the bride try on two dozen dresses and have seven dry runs of hair and makeup before the big day.
As for the groom, a shower and a shave an hour before the ceremony will suffice.
Actually just a shower is fine, stubble is edgy.
And forget about wearing a tie, it’s not like this is a formal occasion.
Prince Harry has set the ultimate precedent for millennial grooms to never feel obliged to shave, especially on their wedding day.
THE VAIN HASHTAG
“We ask that any photos you wish to share of our special day on social media be accompanied by this #VainHashtag.”
That way anyone who wasn’t invited, like all those poor schmucks at the engagement party, can see what they’re missing out on.
And all the couple’s friends abroad can feverishly refresh their feeds every three seconds to stay up to date.
In truth, nobody is searching for the vain hashtag.
THE PHOTO DUMP
Facebook’s servers can hold billions and billions of photos. That storage space will be pushed to its very limit when the happy couple unleash a flood worthy of Genesis. In an age when wedding photographers have long abandoned rolls of film and can keep shooting until they bleed from their nail beds, you are going to be tagged in all 537 images featuring your likeness.
Don’t forget to have your wedding in the middle of nowhere. It will enhance your marriage and people who don’t make the trip will expose themselves as false friends.
GENERIC THANK-YOU CARDS
Not even Einstein could possibly remember who fronted up at his own wedding and who gave him which present.
It’s perfectly reasonable to send generic thank-you cards that don’t mention anyone by name and keep it all about the bride and groom.
By this stage everyone should understand the couple are exhausted and need a break from all the hard work.
POST-WEDDING BLUES
The party’s over, everyone’s gone home and the attention well has dried up.
That videographer really sucked the funds out of the honeymoon and, waiting on the tarmac for their delayed budget flight to depart for Hobart, the newlyweds realise the curtains have closed and they must now begin a lifetime of conversation for which they are ill prepared.
HAPPY 21ST BIRTHDAY SWEET FANGS MY PRECIOUS RESCUE CAT
11:52 Sep 15 2018 Times Read: 1,590
DEAR SWEET FANGS,
TODAY YOU HAVE BEEN WITH ME AND MY FAMILY NEARLY 3 YEAR. 21 IN CAT YEARS OR 3 YEARS IN MORTAL YEARS. HAPPY 21ST CAT BIRTHDAY! IF YA'LL WERE 21 IN HUMAN YEARS YA'LL WOULD BE ABLE TO MARRY WORK VOTE DRTIVE A CAR SMOKE DRINK ALCOHOL AND OWN PROPERTY! MAY EVERY BIRTHDAY AND YEAR YA'LL ARE ALIVE BECOME HAPPIER AND BETTER FOR YA'LL AND MAY ALL YA'LL HAPPIEST CAT WISHES COME TRUE! THANK YOU FOR THE HAPPINESS YOU HAVE GIVEN AND CONTINUE TO GIVE ME, AND MY FAMILY. I AM SO BLESSED TO HAVE YOU IN MY LIFE. KNOEW THE DAY YA'LL WAS BORN ADN CAME INTO MY LIFE WAS THE BEST DAY EVER. I AM SORRY YOU SUFFERED SO BADLY AS A KITTEN BEFORE YA'LL CAME INTO MY LIFE. ETERNAL LOVE MY PRECIOUS CAT LOVEF FROM YOUR CAT MOM LINDSAY.XX
THIS WAS NOT WRITTEN BY ME IT WAS TAKEN FROM ONE OF THE MANY DIGITAL NEWSPAPERS THAT I AM SUBSCRIBE TO AND READ DAILY.
How top Melbourne chefs use Vegemite to add some zing to their dishes
Dan Stock, Herald Sun
September 3, 2018 2:54pm
Subscriber only
IT’S Australia’s favourite thing to put on toast, but Vegemite isn’t just for the breakfast table.
Top chefs are having fun using the black stuff in all manner of ways, delivering Vegemite-inspired dishes to the best tables in the land. You’ll be served a take on a Vegemite scroll at Australia’s best restaurant, Attica, as well as in the breadbasket at Highline in Windsor.
It’s used to brush a buttery croissant served like “damper on a stick” at Vue de monde.
Roti with Vegemite curry Sunda, Punch Lane, CBD
Young gun chef Khanh Nguyen blends it with curry oil and serves it with flaky roti at this year’s hit restaurant, Sunda, while it took chef Ashley Palmer-Watts many months
of development before he was happy to unveil his “Vegemite ice cream” created especially for the menu at Dinner by Heston.
THE BEST LOOKING PLACES TO EAT AND DRINK
A NEWCOMER WITH BOOKED-OUT BANG
REGIONAL VICTORIA’S DAY TRIP TREATS
“The biggest fear was for us to use Vegemite in a new way and for it not to be received well by our guests,” the British chef says. “We added it to various mixes, biscuits, sponges, chocolates and caramels, noting that when it was diluted, it really showed other flavours (such as) chocolate, salted caramel and a slight fruitiness. Working it into an ice cream dish, other than just spreading it on a warm buttered crumpet has been a great experience.”
The Vegemite ice cream at Dinner by Heston.
But slathered on buttered toast is how Vegemite has mainly been enjoyed since it first hit Australia’s shelves in 1923.
The loved spread is turning 95 and to mark the occasion three Aussie artists — David Bromley, Mitch Revs and Claudia Moodoonuthi — have created large-scale artworks that will adorn limited edition Vegemite jars available over the next few months.
The artists will unveil their works at a special event on Thursday held at David Bromley’s Prahran studio, where Vegemite-inspired dishes created by Charlie Carrington from Altas Dining will be served. Each large-scale piece will be up for online auction at vegemite.com.au/store, with proceeds donated to each artist’s chosen charity.
Artist David Bromley has created a new label for Vegemite's 95th anniversary. Picture- Nicole Cleary
“My concept for the Vegemite 95th anniversary event showcases the six states and two territories of Australia by sourcing an ingredient from each place and pairing it into a Vegemite-based snack,” Charlie says, who has shared two of the recipes with Taste.
VEGEMITE’S NEW LOOK FOR 95TH BIRTHDAY
Chefs like using Vegemite for the umami characteristics it lends to a dish — umami being the fifth basic taste that adds savoury to sweet, salty, sour and bitter. Think of parmesan cheese, caramelised onions, roasted tomato and shiitake mushrooms, which all add umami to dishes.
Here are great new ways to enjoy Vegemite for breakfast, lunch and tea that’s sure to put
a rose in every cheek.
1 St Ali head chef Daniel Dobra is a self-confessed aficionado of adding Vegemite to dishes, using it to create vegetarian jus (“Vegemite has all the similar flavour profiles and components of a meat jus — strong, bold and concentrated”), a vegetable consommé that was used as an accompaniment to one of the first vegetarian dishes served by Dan Hunter at the Royal Mail Hotel in Dunkeld back in the day, and even in the classic after-school snack: cheese and vegemite microwave sandwich.
Daniel Dobra, St Ali head chef
2 Daniel uses it to create a powerful barbecue sauce (mix 200g Vegemite with 100g tomato sauce, 10g cracked black pepper, 2g ground coffee and 20g maple syrup) to serve with avocado on toast.
3 Melbourne chef Tracey Lister has recently returned home after spending 13 years in Vietnam, where she ran a cooking school and conducted food tours of her adopted city, Hanoi.
“The cooking centre was popular with Vietnamese school groups and I would always start the class with a blind tasting to get everyone thinking about flavours. I included Vegemite for a bit of fun and the reaction from most of the students was one of, to put it in diplomatic terms, surprise,” she says. “The Vietnamese chefs at the school would call (Vegemite) Australian fish sauce: strong flavour, salty and something you need to grow up with to fully appreciate. One chef even went as far as to suggest the addition of a small amount of vegemite to pho bo (beef pho) could enhance the broth.
James Saunders of Industry Beans Fitzroy
4 Industry Beans’ head chef James Saunders says adding Vegemite to a beef patty adds “a delicious umami flavour” — use about 20g Vegemite for 500g beef — while incorporating it into a chilli con carne adds “delicious richness
to the dish”.
5 Rueben Davis from The Press Club says he’s a big fan of using Vegemite with fish. He suggests melting a dollop of butter with equal part Vegemite and brushing this over a fish such as rockling. Dust it in flour, dip in egg wash, flip through breadcrumbs and deep fry.
6 Use Vegemite in a classic spaghetti bolognaise recipe. “After you have finished the sauce using your go-to recipe, while it is still piping hot, fold through a tablespoon of Vegemite for that umami kick,” George Calombaris
says.
7 For a salty/sweet treat, James says Vegemite caramel brownies are hard to beat. In a bowl, combine 75g cocoa, 450g sugar and 280g dark choc. In a separate bowl combine 6 eggs and 1/3 cup of Vegemite, while in another bowl combine 75g self-raising flour and 75g almond meal. Melt 300g butter in a pan, then add the cocoa, sugar and dark choc mix and combine. Whisk in the Vegemite and egg until it becomes glossy, then take off heat. With a rubber spatula, fold in self-raising flour and almond meal until well combined. Pour into lined baking tray and bake at 160 degrees for about 30 mins or until it stops wobbling.
8 “My first memory of Vegemite is mum using it in a glaze and spreading it onto her meat loaf,” says James Cornwall from Footscray’s Victoria Hotel. He suggests making an Aussie croque madam by smearing Vegemite to taste on sourdough topped with ham and béchamel made using a good aged cheddar. Pan fry in butter until crisp, top with more béchamel and grated cheese and grill until golden. Finish with a runny fried egg.
9 “I once made a Thai red curry but didn’t have any gabi (fermented prawn paste) so I substituted Vegemite as it has similar characteristics — salty, strong, bold and punchy,” Daniel says. “I haven’t looked back since. It’s in all honesty one of my finer cooking moments
at home.”
Trinket’s Vegemite parfait with salt and vinegar chips on brioche.
10 Telina Menzies from Trinket uses Vegemite in an ice cream parfait that she serves with salt and vinegar chips on brioche.
“As a kid in school I used to put crisps in my Vegemite sandwich and this brings back so many good memories.”
Whip 300g whipping cream with 1 tbsp Vegemite until soft peaks form. Set aside in the fridge. Separate 4 small eggs and beat the whites until it stands in firm peaks. Mix in 150g sugar and a dash of vanilla and continue beating with a whisk until it’s smooth and shiny. Fold in the egg yolks, then the whipped cream. Fill a takeaway container and freeze for at least 5 hours.
Remove from freezer 5 mins before serving. Slice thickly, add to a slice of brioche along with some salt and vinegar crisps. Fold in half and enjoy.
“Trust me, you will love it,” Telina says.
11 “A friend of my mum’s swears by rubbing an eye fillet with Vegemite before it goes on the barbecue, it’s actually delicious in all its salty yeastiness,” says Sophie Cookes from Cookes Food catering. “And maybe this is boring but a macaroni and cheese jaffle with a generous schmear of Vegemite on the inside of both bread layers is definitely the hangover cure I turn to when life seems hopeless.”
Charlie Carrington's Kangaroo with Vegemite mustard
12 “A favourite for me is when making a trusty mushroom stock a touch of Vegemite just nails the umami, giving that yeasty edge,” says WonderPies’ Ray Capaldi. “Or for those who are handy with desserts and know how to handle a souffle, add a touch of Vegemite to the chocolate and yours will stand out from the rest.”
13 “My Vegemite escargot walks out the door,” says Lisa van Zanten of Mill & Bakery. “Although the home cook may not make the pastries from scratch, picking up your favourite pastry and dousing it in cheese and splashes of Vegemite and then baking it off til crispy with a cup of hot coffee … YES!”
14 Barbecue pit master Mike Patrick from Fancy Hank’s slow roasts mushrooms with some Vegemite until soft and browned, and then uses these to create a vegan risotto. “It’s so rich, it really doesn’t need any animal products.”
15 Gerard Phelan from Montalto says dehydrating Vegemite and turning it into a salt is an innovative way to add interest to breakfast. Spread a baking sheet with Vegemite and dry in a low oven (60C) overnight. “Once it’s dry I blend it with some coarse salt flakes — Vegemite salt for your smashed avo on toast. Your hipster mates will love it.”
16 Dani Zeini from Royal Stacks says making a Vegemite fondue is fun and easy. Place some Pure Dairy American sliced cheese in saucepan with a bit of hot water and simmer. Stir frequently until cheese is melted and add a little Vegemite. “Dip some fries in it for Cheesy-mite fries,” he suggests.
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Vegemite isn't just for toast.
MACADAMIA, CARROT & VEGEMITE BUTTER
Serves 6. Recipe: Charlie Carrington
Ingredients
300g macadamias
50g flour
75g Vegemite
75g softened butter + another 25g
6 carrots
1/8 bunch chives
1 medium shallot
Juice of one lemon
Method
1: First, wash the carrots and rub them very lightly with vegetable oil.
2: Place them in a pan and cook them on the lowest heat possible. This should take about 2-3 hours. They’ll start to cook then begin to dehydrate and have a chewy exterior and a crunchy interior. Chop into small pieces, then give them a rough dice and place them back in the pan with 25g of butter, the juice of one lemon and salt. Keep in a warm place.
3: Next, blitz 220g of the macadamias with flour and water. It should come together like a semi wet dough. Place it in between two baking sheets and roll it about 2mm thick. Then, quickly pull off the top sheet (some will stick to the top sheet) but you will be left with a textured cracker. Bake at 170 degrees for 20 minutes.
4: Using a small whisk, combine butter and Vegemite together.
5: Using a mandolin, thinly shave the remaining macadamias so they curl, or use a Microplane to shave them over the cracker. Heat the carrots with the chives and shallots to just above room temperature.
Presentation
6: Break the crackers into random shapes that will fit easily into the mouth.
7: Place a small amount of the Vegemite butter onto the cracker followed by the carrot mix and then the shaved macadamias on top.
Stroke is a medical emergency. If you or someone near you is having, or may be having, a stroke or transient ischaemic attack (TIA) you should go to hospital immediately.
Here you will find information on how to tell if you are having a stroke, stroke prevention, children and stroke.
What is a Stroke?Does Stroke Affect Many Australians?Stroke Risk Self Assessment ChartAm I Having a Stroke?What are the Effects of Stroke?Treatment of StrokeRecovery from StrokeLife After StrokeHow Can I Avoid Another Stroke?One Man’s Stroke StoryLatest Australian research papers on Stroke.
WHAT IS A STROKE?
A stroke occurs when a blood clot blocks a blood vessel (artery) and interrupts blood flow to the brain region supplied by that artery, or when a blood vessel breaks and bleeding occurs into an area of the brain.
Every stroke is different. The symptoms and effects vary according to the type of stroke, the part of the brain affected and the size of the damaged area. For some people the symptoms are severe, for some mild. Nevertheless, people with mild symptoms should also seek urgent attention, since a “mini stroke” can be a warning for a severe one. Also, the intensity of the symptoms can fluctuate within the first time period. Usually, the symptoms of stroke come on suddenly, but in a quarter of cases they may come on during sleep, and the symptoms will only be noticed at the time of waking.
There are two major types of stroke - Ischaemic and Haemorrhagic:
An Ischaemic (clot) Stroke occurs when an artery carrying blood to part of the brain is blocked. The brain needs the constant supply of oxygen and glucose that the blood brings. If this blood supply is blocked for more than a few minutes then that part of the brain stops working properly and the brain tissue begins to die. If the blockage is not cleared within a few hours, all the part of the brain supplied by the blocked vessel may die; that is, it permanently ceases to work properly, leaving a scar in the brain. This is called brain infarction. Ischaemic strokes are the most common type of stroke, occurring more than five times as often as haemorrhagic stroke.A Haemorrhagic Stroke (Cerebral Haemorrhage / bleed) occurs when a blood vessel ruptures within the brain (intracerebral haemorrhage) or into the space surrounding the brain (subarachnoid haemorrhage). Blood in the artery is under pressure and so, as it spurts out, it damages some of the soft brain tissue, the extra pressure, swelling and inflammation from the blood within the brain may cause further injury.
In most cases it is not possible to differentiate an ischemic stroke from a haemorrhagic stroke based on the symptoms; the presentation is usually very similar. If you think that you are suffering a stroke, don’t self-medicate with blood thinners; seek urgent medical advice.
A mini (clot) stroke is called a Transient Ischaemic Attack (TIA).
About 30% of patients who subsequently have an ischaemic stroke have a small warning episode termed a transient ischaemic attack.TIA is like an ischaemic stroke, in that it is results in the sudden loss of function of a particular part of the body because of a sudden lack of blood flow to a part of the brain.TIA is like an ischaemic stroke, in that it is results in the sudden loss of function of a particular part of the body because of a sudden lack of blood flow to a part of the brain.The main difference between a TIA and an ischaemic stroke is that in a TIA the symptoms disappear completely within 24 hours. In 75% of cases the symptoms clear within one hour, often within only a few minutes, because the blockage in the artery clears itself very quickly before the affected brain tissue has died.A TIA is a very important warning that the person is at increased risk of a future stroke. It is essential that proper medical treatment is sought so that this risk can be significantly reduced.
DOES STROKE AFFECT MANY AUSTRALIANS?
Stroke is the third most common cause of death in Australia and a leading cause of disability. About 55,000 Australians have strokes annually, 73% of these being first-ever strokes.
Of 100 stroke patients:
about 30 will die in the first year after their stroke, most (15-20) within the first 30 daysabout 70 will survive* of whom 35 remain permanently disabled at 1 year after a stroke, 10 of whom require care in a nursing home or other long term facility35 are not disabled to the point of affecting their independence in activities of daily living; 10 will have recovered completely and 25 will not be able to do everything they could previously, but will be able to care for themselves independently.
*85% with ischaemic stroke survive, 50% with haemorrhagic stroke.
Of all the neurological disorders stroke is the largest single cause of adult disability.
For a 45 year old, the risk of having a stroke by age 85 is:
one in four for menone in five for women
The risk of having a stroke may increase for:
People with a family history of strokeSome ethnic groups (such as African Americans and Hispanics)Those with risk factors: high blood pressure, high cholesterol, or with an irregular pulse due to atrial fibrillation.People who smoke, or consume excessive alcohol, or get insufficient exercise
A middle-aged man who has high blood pressure, high cholesterol, smokes and has uncontrolled diabetes increases his risk of stroke by TWENTY times.
STROKE RISK SELF ASSESSMENT CHART
Instructions: Score each line and then add up your total score. The lower your score, the better. The higher your score, the greater your risk of having a stroke. An approximate guide to the risk is:
0 - 4 : Very low risk
5 - 9 : Moderate risk
10 - 13 : High risk
14+ : Very high risk
This is just a guide, but it demonstrates measures you can take to decrease your risk of stroke.
Risk Factors
0
1
2
3
Score
Smoking
never smoked
quit after smoking for less than 5 years
current smoker less than 20/day
current smoker more than 20/day
Exercise
1 hour strenuous activity at least 3 times per week
very active once or twice a week
moderately active once or twice a week
very little physical activity
Diabetes
none known
n/a
family history
diabetic
Blood Pressure
normal
mild high blood pressure
moderate high blood pressure
severe high blood pressure
Age
0 - 44
45 - 64
65 - 74
75 +
Alcohol (male)
0-4 standard drinks/week
up to 4 drinks/day
more than 4 drinks a day 2 or more days a week
more than 6 drinks, 4 or more days a week
Alcohol (female)
0-2 standard drinks a week
up to 2 drinks a day
more than two drinks a day, 2 or more days a week
more than 4 drinks, 4 or more days a week
Weight
about average for height
slightly overweight
moderately overweight
obese
Family History
no strokes known
a relative has had a stroke
a relative has had a stroke while younger than 65
several relatives have suffered from stroke
Cholesterol
below average
average
moderately raised
severely raised
Brain Foundation (c)
Reviewed by Dr Alastair Corbett, Consultant Neurologist, Concord Hospital, Australia
AM I HAVING A STROKE?
A STROKE OR A TIA IS AN EMERGENCY
GO TO HOSPITAL - DIAL 000 - IMMEDIATELY
TIME LOST IS BRAIN LOST
SYMPTOMS OF STROKE
The symptoms of stroke usually come on suddenly. The suddenness of onset distinguishes stroke from other conditions such as migraine, seizure or brain tumour. Every patient is affected differently, but one easy way to recognise and remember the signs of stroke is the FAST test:
Using the FAST test involves asking these simple questions:
Face – Check their face. Has their mouth drooped?
Arms – Can they lift both arms?
Speech – Is their speech slurred? Do they understand you?
Time – Time is critical. If you see any of these signs, call 000 straight away.
Other symptoms that may also occur in stroke are:
Loss of vision in one eye, loss of vision in half the visual field of each eye, or double vision.Sudden onset of dizziness or loss of balance.Sudden severe headache with no known cause:Drowsiness or loss of consciousness.
SYMPTOMS OF TRANSIENT ISCHAEMIC ATTACK (TIA)
The symptoms of a TIA are indistinguishable from a stroke, but in a TIA the symptoms resolve completely within 24 hours. There is a high risk of stroke following TIA, particularly in the first few days. So, even if symptoms have resolved completely, urgent medical attention should be sought, since rapid investigation and treatment reduces the risk of future stroke.
Treatments to prevent future stroke are the same as for after a completed stroke (see below)
TREATMENT OF ISCHAEMIC STROKE - IMMEDIATE
Currently, there are two immediate treatments for ischemic (clot) strokes: clot-dissolving medication and endovascular treatment (clot retrieval). Both need to be given within hours from the start of symptoms.
Clot-dissolving medication (alteplase, also known as tPA):
Treatment aiming to dissolve the blood clot.Only suitable for carefully selected patients: It can only be given in the 4.5 hours after the onset of stroke symptoms (=time last known to be well). Patients with wake up stroke symptoms are normally excluded because of uncertainty about when the symptoms started. Not suitable for patients with a high risk of bleed, such as patients with recent surgery, trauma, or on strong blood thinning medications (e.g. Warfarin, Heparin or the direct oral anticoagulants such as apixaban (Eliquis), dabigatran (Pradaxa) or rivaroxaban (Xarelto).Generally not used in pregnant patientsLimited effectiveness for large clots blocking main arteries.Alteplase treatment carries a risk of causing bleeding, sometimes this may be life-threatening. In carefully selected patients, the potential benefits far outweigh the risks, but this balance of benefit versus risk needs to be assessed by the treating doctor for each patient. N.b. Potentially more effective / safer medications, are being tested as part of ongoing clinical trials in many leading stroke centres in Australia.
Endovascular clot retrieval (or mechanical thrombectomy):
This is a surgical procedure, done via a catheter inserted into an artery in the groin, similar to the procedure used to perform a coronary angiogram or stent.It is most suitable for patients with large clots in big arteries, usually resulting in more severe symptoms.The procedure may be performed under either local anaesthetic with sedation or under general anesthesia, depending on the individual circumstances.The catheter is threaded up to the brain through the large arteries and a device is then used to trap and retrieve the clot. This treatment is successful at retrieving the clot in 80-85% of the cases.It is a very complex and delicate procedure, and major complications may occur in up to 5% of people (including potential perforation of a brain vessel or causing another stroke).The degree of recovery after removal of clot is dependent on how much damage was done to the affected brain region from lack of blood supply before the clot could be removed. Recent clinical trials showed that, in patients with large clots and candidates for this treatment, on average about 1 in 3 recover almost completely, being independent 3 months after the stroke.
Definite evidence that this procedure was effective was only obtained in 2015. Extensive training is required, therefore it is not yet available in many centres. Additionally, because of the need to treat sufficient numbers of patients to maintain skill levels, it is generally available only in large, city or regional hospitals.
TREATMENT OF ISCHAEMIC STROKE – PREVENTING ANOTHER STROKE
People who have had a stroke or TIA are at increased risk of having another stroke. However with close monitoring and preventive therapies (medications and lifestyle changes) rates of secondary stroke can be lowered dramatically.
Medication – Blood thinners. There are two main kinds:1-Anti-clotting (antiplatelet) medication, such as aspirin, or clopidogrel (for those patients who have had an ischaemic stroke caused by a clot forming on an area of hardening of the arteries). Sometimes dipyridamole is used in combination with aspirin.2-Anti-coagulant medication (such as warfarin or the direct oral anticoagulants – apixaban, dabigatran and rivaroxaban). Used when the ischaemic stroke has been caused by a blood clot forming in the heart, breaking off and lodging in the brain. These medications are powerful blood thinners, and must be carefully supervised by the doctor.Blood pressure lowering medication: Lowering blood pressure reduces the risk for a second stroke. Many different blood pressure lowering medications can be used. Most people with high blood pressure will need more than one medication to lower their blood pressure to the target range.Cholesterol lowering tablets also lower the risk of a second strokeDiabetes medications to ensure excellent blood sugar control may be also prescribed.Taking all these medications regularly, as prescribed, is very important for preventing another stroke. Ongoing monitoring and addition of further treatment if necessary is particularly important for blood pressure and diabetes. Carotid surgery / stenting: one in ten stroke patients have a very narrow artery in the front of the neck on one side (the carotid artery) that restricts the flow of blood to the brain. Surgery to open and clear the artery or to place a small cylinder (stent) in it to increase the flow can be considered.Changes to lifestyle Diet: a recent trial showed significantly lower stroke rates in patients assigned to a Mediterranean-style diet. Diet should be varied, high in fibre, fruit, nuts and vegetables, and healthy fats such as olive or canola oil; but low in saturated fat, and salt. Alcohol should be drunk in moderation (1-2 standard drinks), preferably with food.Avoidance of smoking - this is absolutely essential.Regular exercise – which will help to regulate weight and improve circulation.
COMMON TESTS AFTER STROKE OR TIA
Tests to determine the nature, precise location and extent of the injury to the brain will be performed. These are likely to include Brain scans: Computer Tomography) and/or MRIs (Magnetic Resonance Imaging). Later, tests to investigate possible causes of the stroke may be performed. These may include Doppler ultrasound or computer tomography angiography to look for narrowing of the carotid arteries, a cardiograph or holter monitor to look for heart rhythm abnormalities, an ultrasound of the heart (echocardiograph) and blood tests.
HEMORRHAGIC STROKE
Immediate treatment
A stroke caused by bleeding into the brain (haemorrhagic stroke) is treated in the first hours by intensive blood pressure control in a specialized stroke unit or intensive care bed. If the patient is taking blood thinners, some medications to reverse their effect may be given. In selected cases, surgery to drain the blood or to reduce swelling may be considered.
Subarachnoid haemorrhage is usually caused by rupture of an aneurysm (ballooning of the artery wall). Repair of this vessel (with open surgery or through the vessels with catheters and coils) will usually be performed. The timing of this surgery is dependent on several factors, which will be taken into account by the treating doctors.
Regular medical supervision Particularly regular monitoring of blood pressure, with changes to treatment as needed. Changes to lifestyle Avoidance of smoking - this is absolutely essential.Healthy diet, which should be varied, but low in saturated fat, and salt, and high in fibre, fruit and vegetables. Avoidance of excess alcohol intake is particularly relevant in haemorrhagic types of stroke, since excess alcohol puts someone at particular risk of this type of stroke.Regular aerobic exercise (walking, cycling, running, swimming) – which will help to regulate weight and improve circulation. Avoid heavy lifting / straining in the first few months after haemorrhagic strokes.
REHABILITATION
Recovery from stroke takes time
Recovery from stroke can be remarkable and inexplicable.
Much is still not known about how the brain compensates for the damage caused by stroke. Some brain cells may be only temporarily damaged, not killed, and may resume functioning. In some cases, the brain can reorganize its own functioning: another part of the brain ‘takes over’ for a damaged part.
Recovery after stroke is greatest in the first few months, and gradually plateaus, although further gains may be made for some years. The rate of recovery will vary greatly amongst patients.
Rehabilitation starts in the hospital some days after the stroke. In patients who are stable, rehabilitation may begin two-three days after the stroke has occurred, and should be continued as necessary after release from the hospital. A conference with hospital staff regarding future care, supervision and rehabilitation will usually be held before discharge.
Rehabilitation treatments vary enormously depending on the particular problems experienced by the stroke survivor. Both ischaemic and haemorrhagic strokes are treated with rehabilitation therapies. Care requirements will usually be agreed upon in consultation with a rehabilitation specialist or specialist geriatrician, the acute stroke treatment team, therapists and the family. Exactly what therapy may be needed is very variable, depending on the capacities and goals of the stroke survivor and their usual living arrangements. Depending on the severity of the effects of the stroke, rehabilitation options include:
A rehabilitation unit in the hospitalA rehabilitation hospitalHome therapyHome with outpatient therapyA long-term care facility that provides therapy and skilled nursing care.
In any of these locations, therapists may include:
Physiotherapists – for help with mobility and daily functioningOccupational Therapists – also for help with daily functioning, particularly hand function, and some types of visual and thinking problems due to stroke.Speech Pathologists, for communication and swallowing trainingNeuropsychologists, for help with thinking (cognition) and social interactions after strokePsychologists, for help with mood problems (depression/anxiety)WHAT ARE THE EFFECTS OF STROKE?
Currently, around 56,000 Australians have a stroke each year; more than 100 every day. The rates of people dying from stroke have dropped significantly over the last 30 years, however still around 10,600 Australians die of stroke each year. There are around 475,000 stroke survivors alive today, and of these, around ½ suffer from a disability affecting their daily life.
Effects of Stroke
The most common problems in daily life are likely to be caused by:
Weakness or lack of movement (paralysis) in legs and/or armsTrouble speaking, reading or writingChanges to the way things are felt when touched (sensory problems)Problems thinking or remembering (cognitive problems)Changes to way things are seen or felt (perceptual problems)Shoulder painTrouble swallowingIncontinenceFeeling depressedProblems controlling feelingsTiredness / fatigue
The specific abilities that will be lost or affected by stroke depend on the extent of the brain damage and, most importantly, where, in the brain, the stroke occurred: the right hemisphere (or half), the left hemisphere, the cerebellum or the brain stem.
Effects of Strokes on the Right Side of the Brain
The right hemisphere of the brain controls the movement of the left side of the body. A stroke in the right hemisphere often causes paralysis in the left side of the body. The paralysis can vary from a mild weakness to a complete loss of strength in the left limbs. If the stroke is toward the back of the brain on the right, vision to the left may also be impaired (reduced vision to the left in both eyes, called a hemianopia).
Survivors of right-hemisphere strokes may also have problems with their spatial and perceptual abilities. This may cause them to misjudge distances (leading to a fall) or be unable to guide their hands to pick up an object, button a shirt or tie their shoes. They may also experience left-sided neglect or inattention, in which they tend to be unaware of the left side of their body, or anything to their left. This can cause them to neglect their new disability, seeming unaware of its existence. This can be dangerous. It may lead them to try to walk or drive a car even when they have a clear impairment.
Along with these physical effects, survivors of right-hemisphere strokes often have judgment difficulties that show up in their behaviour. They often act impulsively, unaware of their impairments and certain of their ability to perform the same tasks as before the stroke.
Effects of Strokes on the Left Side of the Brain
The left hemisphere of the brain controls the movement of the right side of the body. It also controls speech and language abilities for most people. A left-hemisphere stroke often causes paralysis of the right side of the body, and may also cause impairment of vision to the right. Inattention and neglect are only rarely seen with left hemisphere strokes.
Someone who has had a left-hemisphere stroke may also develop aphasia. Aphasia is the term used to describe a wide range of speech and language problems. These problems can be highly specific, affecting only one part of the patient's ability to communicate. Some patients can experience troubles with understanding language after stroke, other patients can have normal comprehension, but can experience problems finding words or creating correct sentences. The language difficulties typically affect both spoken/heard and written/read language.
In contrast to survivors of right-hemisphere stroke, patients who have had a left-hemisphere stroke often become slower or more cautious. They may need frequent instruction and feedback to finish tasks.
Patients with left-hemisphere stroke may develop memory problems similar to those of right-hemisphere stroke survivors.
Effects of Strokes in the Cerebellum
The cerebellum is the small roundish part of the brain behind and below the larger brain hemispheres. It controls many of our reflexes and much of our balance and coordination. A stroke that takes place in the cerebellum can cause coordination and balance problems, dizziness, nausea and vomiting.
Effects of Brainstem Strokes
The brainstem is a small (but vital) part of the brain that connects the brain hemispheres with the spinal cord. It runs in front of the cerebellum. The brainstem is the area of the brain that controls all of our involuntary functions, such as breathing rate, blood pressure and heart beat. Strokes that occur in the brainstem are especially devastating. The brainstem also controls abilities such as eye movements, hearing, speech and swallowing. Since impulses generated in the brain's hemispheres must travel through the brain stem on their way to the arms and legs, patients with a brain stem stroke may also develop paralysis in one or both sides of the body.
The brainstem is a small structure, all the brain cells carrying information to the body travel very close to each other at this level. Therefore, even small strokes in the brainstem can have major effects, and strokes in this region are more commonly fatal.
Other Effects of Stroke
Depression is quite common amongst people who have had a stroke. It can affect both the survivor and his/her family. A depressed person may refuse or neglect to take medications, may not be motivated to take part in physical rehabilitation or may be irritable with others. This in turn makes it difficult for those who wish to help, and tends to deprive the survivor of valuable social contacts that could help dispel the depression. Mild depression may resolve spontaneously, but counselling and appropriate medication may be necessary.Apparent changes in personality following a stroke may be very disturbing to the survivor’s family. Stroke affected people may not seem the same person as before. The way in which they think, feel and react may be altered. Problems and activities once tackled easily may be difficult or impossible, while other tasks are unaffected. Sudden laughing or crying for no apparent reason and difficulty controlling emotional responses also affects many stroke survivors. There may be little happiness or sadness involved, and the excessive emotional display will end as quickly as it started. The way in which the person affected by stroke reacts to these changes will affect their personality, and may cause changes in control of emotions and behaviour. People affected by stroke may become confused, self-centred, uncooperative and irritable.Fatigue is also commonly described after stroke. The mechanisms that produces fatigue after stroke are still unclear, but it is consistently described by stroke survivors, and survivors of other forms of brain injury. The intensity of the fatigue is not related to the severity of the initial stroke, a minor stroke can cause excruciating fatigue. Fatigue has a huge impact on the quality of life of stroke survivors; it can affect the ability to concentrate, to the point where the patients can’t do everyday tasks. It tends to improve progressively within months, nevertheless some patients may experience problems with fatigue and lack of concentration years after the stroke. Recently, some medications have shown promising results in early phase trials, and this is an area of ongoing clinical trials.
Often problems such as fatigue and depression do not become very apparent until after discharge from hospital, or when returning to previous work or other activities. These problems can be very disabling, even though they may not be as apparent to others as weakness or language difficulties. However it is important to realise that these are just as much consequences of stroke, and to seek medical attention if needed.
LIFE AFTER STROKE
Patients are generally encouraged to return to their normal lives - depending on the effects persisting from stroke
Some aspects of life after stroke include:
Resuming work
How soon this is possible depends partly on remaining disability, the type of work involved, and the feelings about returning to work. Some people experience fatigue and tiredness after a stroke, and have difficulty carrying out any kind of physical activity for any length of time. Part-time work at least in the early stages may be a good idea. Unless the stroke has reduced awareness of impairment, it is probable that the person who had the stroke is the best judge of when to return to work.Driving
Even someone who appears to have made a full recovery after stroke should not drive a car for at least a month as the risk of another stroke is greatest at this time. To drive again involves being cleared by the doctor (who will be aware of relevant government regulations) as the stroke may have left subtle impairments, not always apparent, such as poor coordination, lack of awareness on one side, difficulties in judging distance, changes in vision (as visual field defects), difficulties in concentration and confusion between left and right.Sexual activity
Resumption of sexual activity after stroke is encouraged. Many couples experience some difficulty in their sex life after stroke, but this is more commonly caused by fears and concerns about the stroke, rather than physical disability resulting from the stroke. A doctor can advise on any difficulty such as erectile problems in men.Sport and Exercise
Resumption of physical activity and hobbies is an important part of rehabilitation- normal activity should be resumed as soon as physically possible.Patients who have experienced a haemorrhagic stroke are generally advised against heavy lifting.Drinking Alcohol
The intake of excessive amounts of alcohol should be avoided after stroke as it may interact adversely with medication, raise blood pressure, and affect judgement resulting in injury. Moderate consumption (one-two standard drinks per day) should not cause problems, and may in fact have a small beneficial effect in terms of preventing further stroke or heart attack.Flying Generally, patients can fly with no restriction after stroke, however it is wise to consult your doctor first. General advice for avoiding clots in the legs may be advised, such as wearing long compression stockings or perform regular walks on the plane. ONE MAN’S STROKE STORY Peter Doyle (of the famous Sydney icon Doyle’s Fish Restaurant) suffered a massive stroke in October 1995 “It’s been a hard road back since the massive stroke I suffered on 18th October 1995. My bloody oath it’s been hard. Still is. You try undoing buttons and going to the toilet with one hand. You can’t even do up a belt. Your lifestyle alters altogether and you get so cranky with people. And no matter how much money you’ve got, you can’t buy your way out of it. Rich or poor, this thing can strike you down – there’s no defining line in terms of wealth – or of age. I’m sorry to be the bearer of such confronting news, but this could happen to you, and it’s important to understand this and to take precautions. I see myself as one of the lucky ones, in that I was hit on the right side of the brain, and even though it was tough, I was soon able to speak again. I’m left with constant pain on the left side, reduced independence; a lifetime of medication, occasional giddy turns, and depression comes in waves. As well, I’m still restricted with what I can eat, and I have to supplement my food intake with a high protein liquid, fed via a tube into my stomach. It’s no picnic. After a stroke, you’re buggered unless you’ve got someone to help you. I’m fortunate in having a retired merchant mariner, Pat Moss, to assist me. He’s my driver, and pushes me in the wheelbarrow! In 1997, on the flight to Perth for a friend’s wedding, I suffered another cerebral haemorrhage. They take you to hospital, drill a hole, and drain it. And they tell me I could face this again if I let stress get to me. It’s ironic … I used to thrive on stress! The funny thing is that I never thought of packing it in. When I first woke up in Sydney’s St Vincent’s Hospital after the stroke, I looked down and saw a Catholic brother I know, standing at the foot of the bed. I thought, God, I must be on the dying list, and then I thought, “bugger it, I’m not going to die.” You know, I look back and recall that like all Aussie men, I believed I was bulletproof. But I’m here to tell you that this is not so for any of us. Superman is a fictional character. If you want to end up like me, well that’s fine, but if you’re not a masochist and you value your well-being and the independence that goes with it, I urge you to pick up the phone now and make an appointment with your GP to have your blood pressure and other risk factors checked. Do it immediately. No excuses. During the months I spent in rehabilitation, I met so many people who had ignored the effect stress was having on their lives, and they ended up having a stroke or cerebral haemorrhage.
I’ll tell you something else: you don’t have to be a high-powered executive to fall victim to stress. Now I understand the importance of a low fat diet, drinking alcohol in moderation only – and avoiding cigarettes like the plague. I used to smoke, and gave it up 18 years ago – but I should never have taken it up in the first place. And another thing: eat more fish! For those of you who have already suffered a stroke – and that is 40,000 Australians a year – I want to hold out my hand and tell you that you’re not alone. We’re in this together, and help is out there, beginning with the Brain Foundation. The Foundation aims to work for the prevention and treatment of brain disorders in this country through community education, support programs, and the promotion of research. And if you’ve got a spare few bucks – or better still, a spare million – I can think of no more worthwhile organization to give it to. Thanks for listening; I’ve enjoyed chatting to you, and I have just one thing to add … I keep reminding myself of Joan Collins’ philosophy: “What doesn’t kill us, makes us stronger”. Further sources of information and support Australia Read more at Virtual Medical Centre. www.strokensw.org.au www.strokefoundation.org.au https://enableme.org.au/ www.mydr.com.au Overseas www.strokeaha.org www.americanstroke.org www.intelihealth.com
Reviewed October 2017 by Professor Neil Spratt and Dr Carlos Garcia-Esperon, Department of Neurology, University of Newcastle and Hunter Medical Research Institute, Australia
DISCLAIMER: The information provided is designed to support, not replace, the relationship that exists between a patient / site visitor and his / her existing health care professionals.
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