title: Pacific War

text: A widely publicized example of institutionalized sexual slavery are "comfort women", a euphemism for the 200,000 women and girls, mostly from Korea and China, who were forced to serve in the Imperial Japanese Army's camps during World War II. Some 35 Dutch comfort women brought a successful case before the Batavia Military Tribunal in 1948. During his statement in 1993, Chief Cabinet Secretary Yōhei Kōno said that women were coerced into brothels run by Japan's wartime military.


title: Pacific War

text: The firebombing of Tokyo on 9–10 March 1945, overseen by Curtis LeMay, has been described by some post-war scholars as an unpunished war crime. A United States Strategic Bombing Survey estimation that 84% of the attacked area was residential areas inhabited by non-combatants, mostly women, children and the elderly, and the victims of this raid — over 100,000 people — constitute the deadliest aerial bombing raid in history.


title: Pacific War

text: Over the course of the war, it became common for American soldiers to collect the body parts of dead Japanese soldiers as war trophies. This mutilation was widespread enough to be commented upon by Allied military authorities and the US wartime press, "on a scale large enough to concern the military authorities as soon as the first living or dead Japanese bodies were encountered."


title: Pacific War

text: Due to testimony accounts, American soldiers are alleged to have committed numerous rapes during the Battle of Okinawa. An unknown number of rapes by Allied troops had also occurred during the initial stages of the Occupation of Japan.


title: Pacific War

text: Following the surrender of Japan, the International Military Tribunal for the Far East took place in Ichigaya, Tokyo from 29 April 1946 to 12 November 1948 to try those accused of the most serious war crimes. Meanwhile, military tribunals were also held by the returning powers throughout Asia and the Pacific for lesser figures.


title: Galaxy

text: A galaxy is a system of stars, stellar remnants, interstellar gas, dust, dark matter, bound together by gravity. The word is derived from the Greek "" (), literally 'milky', a reference to the Milky Way galaxy that contains the Solar System. Galaxies, averaging an estimated 100 million stars, range in size from dwarfs with less than a hundred million stars, to the largest galaxies known – supergiants with one hundred trillion stars, each orbiting its galaxy's center of mass. Most of the mass in a typical galaxy is in the form of dark matter, with only a few percent of that mass visible in the form of stars and nebulae. Supermassive black holes are a common feature at the centres of galaxies.


title: Galaxy

text: Galaxies are categorized according to their visual morphology as elliptical, spiral, or irregular. Many are thought to have supermassive black holes at their centers. The Milky Way's central black hole, known as Sagittarius A*, has a mass four million times greater than the Sun. As of March 2016, GN-z11 is the oldest and most distant galaxy observed. It has a comoving distance of 32 billion light-years from Earth, and is seen as it existed just 400 million years after the Big Bang.


title: Galaxy

text: In 2016, using 20 years of images from the Hubble space telescope, it was estimated that there were in total two trillion () or more galaxies in the observable universe, and as many as an estimated stars (more stars than all the grains of sand on all beaches of the planet Earth).


title: Galaxy

text: In 2021, data from NASA's "New Horizons" space probe was used to revise the earlier estimate to roughly 200 billion galaxies (),


title: Galaxy

text: Most galaxies are 1,000 to 100,000 parsecs in diameter (approximately 3,000 to 300,000 light years) and are separated by distances on the order of millions of parsecs (or megaparsecs). For comparison, the Milky Way has a diameter of at least 26,800 parsecs (87,400 ly) and is separated from the Andromeda Galaxy (with diameter of about 152,000 ly), its nearest large neighbor, by 780,000 parsecs (2.5 million ly.)


title: Galaxy

text: The space between galaxies is filled with a tenuous gas (the intergalactic medium) with an average density of less than one atom per cubic meter. Most galaxies are gravitationally organized into groups, clusters and superclusters. The Milky Way is part of the Local Group, which it dominates along with Andromeda Galaxy. The group is part of the Virgo Supercluster. At the largest scale, these associations are generally arranged into sheets and filaments surrounded by immense voids. Both the Local Group and the Virgo Supercluster are contained in a much larger cosmic structure named Laniakea.


title: Galaxy

text: The word "galaxy" was borrowed via French and Medieval Latin from the Greek term for the Milky Way, "" () 'milky (circle)', named after its appearance as a milky band of light in the sky. In Greek mythology, Zeus places his son born by a mortal woman, the infant Heracles, on Hera's breast while she is asleep so the baby will drink her divine milk and thus become immortal. Hera wakes up while breastfeeding and then realizes she is nursing an unknown baby: she pushes the baby away, some of her milk spills, and it produces the band of light known as the Milky Way.


title: Galaxy

text: In the astronomical literature, the capitalized word "Galaxy" is often used to refer to the Milky Way galaxy, to distinguish it from the other galaxies in the observable universe. The English term "Milky Way" can be traced back to a story by Chaucer :


title: Galaxy

text: Galaxies were initially discovered telescopically and were known as "spiral nebulae". Most 18th- to 19th-century astronomers considered them as either unresolved star clusters or anagalactic nebulae, and were just thought of as a part of the Milky Way, but their true composition and natures remained a mystery. Observations using larger telescopes of a few nearby bright galaxies, like the Andromeda Galaxy, began resolving them into huge conglomerations of stars, but based simply on the apparent faintness and sheer population of stars, the true distances of these objects placed them well beyond the Milky Way. For this reason they were popularly called "island universes", but this term quickly fell into disuse, as the word "universe" implied the entirety of existence. Instead, they became known simply as galaxies.


title: Galaxy

text: Tens of thousands of galaxies have been catalogued, but only a few have well-established names, such as the Andromeda Galaxy, the Magellanic Clouds, the Whirlpool Galaxy, and the Sombrero Galaxy. Astronomers work with numbers from certain catalogues, such as the Messier catalogue, the NGC (New General Catalogue), the IC (Index Catalogue), the CGCG (Catalogue of Galaxies and of Clusters of Galaxies), the MCG (Morphological Catalogue of Galaxies), the UGC (Uppsala General Catalogue of Galaxies), and the PGC (Catalogue of Principal Galaxies, also known as LEDA). All the well-known galaxies appear in one or more of these catalogs but each time under a different number.


title: Galaxy

text: For example, Messier 109 (or "M109") is a spiral galaxy having the number 109 in the catalog of Messier. It also has the designations NGC 3992, UGC 6937, CGCG 269-023, MCG +09-20-044, and PGC 37617 (or LEDA 37617). Millions of fainter galaxies are known by their identifiers in sky surveys such as the Sloan Digital Sky Survey, in which M109 is cataloged as SDSS J115735.97+532228.9.


title: Galaxy

text: The realization that "we live in a galaxy that is one among many" parallels major discoveries about the Milky Way and other nebulae.


title: Galaxy

text: Greek philosopher Democritus (450–370 BCE) proposed that the bright band on the night sky known as the Milky Way might consist of distant stars.


title: Galaxy

text: Aristotle (384–322 BCE), however, believed the Milky Way was caused by "the ignition of the fiery exhalation of some stars that were large, numerous and close together" and that the "ignition takes place in the upper part of the atmosphere, in the region of the World that is continuous with the heavenly motions." Neoplatonist philosopher Olympiodorus the Younger (–570 CE) was critical of this view, arguing that if the Milky Way was sublunary (situated between Earth and the Moon) it should appear different at different times and places on Earth, and that it should have parallax, which it did not. In his view, the Milky Way was celestial.


title: Galaxy

text: According to Mohani Mohamed, Arabian astronomer Alhazen (965–1037) made the first attempt at observing and measuring the Milky Way's parallax, and he thus "determined that because the Milky Way had no parallax, it must be remote from the Earth, not belonging to the atmosphere." Persian astronomer al-Bīrūnī (973–1048) proposed the Milky Way galaxy was "a collection of countless fragments of the nature of nebulous stars." Andalusian astronomer Ibn Bâjjah ("Avempace", 1138) proposed that it was composed of many stars that almost touched one another, and appeared to be a continuous image due to the effect of refraction from sublunary material, citing his observation of the conjunction of Jupiter and Mars as evidence of this occurring when two objects were near. In the 14th century, Syrian-born Ibn Qayyim proposed the Milky Way galaxy was "a myriad of tiny stars packed together in the sphere of the fixed stars."


title: Galaxy

text: Actual proof of the Milky Way consisting of many stars came in 1610 when the Italian astronomer Galileo Galilei used a telescope to study it and discovered it was composed of a huge number of faint stars.


title: Galaxy

text: In 1750, English astronomer Thomas Wright, in his "An Original Theory or New Hypothesis of the Universe", correctly speculated that it might be a rotating body of a huge number of stars held together by gravitational forces, akin to the Solar System but on a much larger scale, and that the resulting disk of stars could be seen as a band on the sky from a perspective inside it. In his 1755 treatise, Immanuel Kant elaborated on Wright's idea about the Milky Way's structure.


title: Galaxy

text: The first project to describe the shape of the Milky Way and the position of the Sun was undertaken by William Herschel in 1785 by counting the number of stars in different regions of the sky. He produced a diagram of the shape of the galaxy with the Solar System close to the center. Using a refined approach, Kapteyn in 1920 arrived at the picture of a small (diameter about 15 kiloparsecs) ellipsoid galaxy with the Sun close to the center. A different method by Harlow Shapley based on the cataloguing of globular clusters led to a radically different picture: a flat disk with diameter approximately 70 kiloparsecs and the Sun far from the center. Both analyses failed to take into account the absorption of light by interstellar dust present in the galactic plane; but after Robert Julius Trumpler quantified this effect in 1930 by studying open clusters, the present picture of the Milky Way galaxy emerged.


title: Galaxy

text: A few galaxies outside the Milky Way are visible on a dark night to the unaided eye, including the Andromeda Galaxy, Large Magellanic Cloud, Small Magellanic Cloud, and the Triangulum Galaxy. In the 10th century, Persian astronomer Al-Sufi made the earliest recorded identification of the Andromeda Galaxy, describing it as a "small cloud". In 964, he probably mentioned the Large Magellanic Cloud in his "Book of Fixed Stars" (referring to "Al Bakr of the southern Arabs", since at a declination of about 70° south it was not visible where he lived); it was not well known to Europeans until Magellan's voyage in the 16th century. The Andromeda Galaxy was later independently noted by Simon Marius in 1612.


title: Galaxy

text: In 1734, philosopher Emanuel Swedenborg in his "Principia" speculated that there might be other galaxies outside that were formed into galactic clusters that were minuscule parts of the universe that extended far beyond what could be seen. These views "are remarkably close to the present-day views of the cosmos."


title: Galaxy

text: In 1745, Pierre Louis Maupertuis conjectured that some nebula-like objects were collections of stars with unique properties, including a glow exceeding the light its stars produced on their own, and repeated Johannes Hevelius's view that the bright spots were massive and flattened due to their rotation.


title: Galaxy

text: In 1750, Thomas Wright correctly speculated that the Milky Way was a flattened disk of stars, and that some of the nebulae visible in the night sky might be separate Milky Ways.


title: Galaxy

text: Toward the end of the 18th century, Charles Messier compiled a catalog containing the 109 brightest celestial objects having nebulous appearance. Subsequently, William Herschel assembled a catalog of 5,000 nebulae. In 1845, Lord Rosse constructed a new telescope and was able to distinguish between elliptical and spiral nebulae. He also managed to make out individual point sources in some of these nebulae, lending credence to Kant's earlier conjecture.


title: Galaxy

text: In 1912, Vesto Slipher made spectrographic studies of the brightest spiral nebulae to determine their composition. Slipher discovered that the spiral nebulae have high Doppler shifts, indicating that they are moving at a rate exceeding the velocity of the stars he had measured. He found that the majority of these nebulae are moving away from us.


title: Galaxy

text: In 1917, Heber Curtis observed nova S Andromedae within the "Great Andromeda Nebula" (as the Andromeda Galaxy, Messier object M31, was then known). Searching the photographic record, he found 11 more novae. Curtis noticed that these novae were, on average, 10 magnitudes fainter than those that occurred within this galaxy. As a result, he was able to come up with a distance estimate of 150,000 parsecs. He became a proponent of the so-called "island universes" hypothesis, which holds that spiral nebulae are actually independent galaxies.


title: Galaxy

text: In 1920 a debate took place between Harlow Shapley and Heber Curtis (the Great Debate), concerning the nature of the Milky Way, spiral nebulae, and the dimensions of the universe. To support his claim that the Great Andromeda Nebula is an external galaxy, Curtis noted the appearance of dark lanes resembling the dust clouds in the Milky Way, as well as the significant Doppler shift.


title: Galaxy

text: In 1922, the Estonian astronomer Ernst Öpik gave a distance determination that supported the theory that the Andromeda Nebula is indeed a distant extra-galactic object. Using the new 100-inch Mt. Wilson telescope, Edwin Hubble was able to resolve the outer parts of some spiral nebulae as collections of individual stars and identified some Cepheid variables, thus allowing him to estimate the distance to the nebulae: they were far too distant to be part of the Milky Way. In 1936 Hubble produced a classification of galactic morphology that is used to this day.


title: Galaxy

text: In 1944, Hendrik van de Hulst predicted that microwave radiation with wavelength of 21 cm would be detectable from interstellar atomic hydrogen gas; and in 1951 it was observed. This radiation is not affected by dust absorption, and so its Doppler shift can be used to map the motion of the gas in this galaxy. These observations led to the hypothesis of a rotating bar structure in the center of this galaxy. With improved radio telescopes, hydrogen gas could also be traced in other galaxies.


title: Galaxy

text: In the 1970s, Vera Rubin uncovered a discrepancy between observed galactic rotation speed and that predicted by the visible mass of stars and gas. Today, the galaxy rotation problem is thought to be explained by the presence of large quantities of unseen dark matter.


title: Galaxy

text: Beginning in the 1990s, the Hubble Space Telescope yielded improved observations. Among other things, its data helped establish that the missing dark matter in this galaxy could not consist solely of inherently faint and small stars. The Hubble Deep Field, an extremely long exposure of a relatively empty part of the sky, provided evidence that there are about 125 billion () galaxies in the observable universe. Improved technology in detecting the spectra invisible to humans (radio telescopes, infrared cameras, and x-ray telescopes) allows detection of other galaxies that are not detected by Hubble. Particularly, surveys in the Zone of Avoidance (the region of sky blocked at visible-light wavelengths by the Milky Way) have revealed a number of new galaxies.


title: Galaxy

text: A 2016 study published in "The Astrophysical Journal," led by Christopher Conselice of the University of Nottingham, used 20 years of Hubble images to estimate that the observable universe contained at least two trillion () galaxies. However, later observations with the New Horizons space probe from outside the zodiacal light reduced this to roughly 200 billion ().


title: Galaxy

text: Galaxies come in three main types: ellipticals, spirals, and irregulars. A slightly more extensive description of galaxy types based on their appearance is given by the Hubble sequence. Since the Hubble sequence is entirely based upon visual morphological type (shape), it may miss certain important characteristics of galaxies such as star formation rate in starburst galaxies and activity in the cores of active galaxies.


title: Galaxy

text: The Hubble classification system rates elliptical galaxies on the basis of their ellipticity, ranging from E0, being nearly spherical, up to E7, which is highly elongated. These galaxies have an ellipsoidal profile, giving them an elliptical appearance regardless of the viewing angle. Their appearance shows little structure and they typically have relatively little interstellar matter. Consequently, these galaxies also have a low portion of open clusters and a reduced rate of new star formation. Instead, they are dominated by generally older, more evolved stars that are orbiting the common center of gravity in random directions. The stars contain low abundances of heavy elements because star formation ceases after the initial burst. In this sense they have some similarity to the much smaller globular clusters.


title: Galaxy

text: First described in 1964 by a paper by Thomas A. Matthews and others, they are a subtype of the more general class of D galaxies, which are giant elliptical galaxies, except that they are much larger. They are popularly known as the supergiant elliptical galaxies and constitute the largest and most luminous galaxies known. These galaxies feature a central elliptical nucleus with an extensive, faint halo of stars extending to megaparsec scales. The profile of their surface brightnesses as a function of their radius (or distance from their cores) falls off more slowly than their smaller counterparts.


title: Galaxy

text: The formation of these cD galaxies remains an active area of research, but the leading model is that they are the result of the mergers of smaller galaxies in the environments of dense clusters, or even those outside of clusters with random overdensities. These processes are the mechanisms that drive the formation of fossil groups or fossil clusters, where a large, relatively isolated, supergiant elliptical resides in the middle of the cluster and are surrounded by an extensive cloud of X-rays as the residue of these galactic collisions. Another older model posits the phenomenon of cooling flow, where the heated gases in clusters collapses towards their centers as they cool, forming stars in the process, a phenomenon observed in clusters such as Perseus, and more recently in the Phoenix Cluster.


title: Galaxy

text: A shell galaxy is a type of elliptical galaxy where the stars in its halo are arranged in concentric shells. About one-tenth of elliptical galaxies have a shell-like structure, which has never been observed in spiral galaxies. These structures are thought to develop when a larger galaxy absorbs a smaller companion galaxy—that as the two galaxy centers approach, they start to oscillate around a center point, and the oscillation creates gravitational ripples forming the shells of stars, similar to ripples spreading on water. For example, galaxy NGC 3923 has over 20 shells.


title: Galaxy

text: Spiral galaxies resemble spiraling pinwheels. Though the stars and other visible material contained in such a galaxy lie mostly on a plane, the majority of mass in spiral galaxies exists in a roughly spherical halo of dark matter which extends beyond the visible component, as demonstrated by the universal rotation curve concept.


title: Galaxy

text: Spiral galaxies consist of a rotating disk of stars and interstellar medium, along with a central bulge of generally older stars. Extending outward from the bulge are relatively bright arms. In the Hubble classification scheme, spiral galaxies are listed as type "S", followed by a letter ("a", "b", or "c") which indicates the degree of tightness of the spiral arms and the size of the central bulge. An "Sa" galaxy has tightly wound, poorly defined arms and possesses a relatively large core region. At the other extreme, an "Sc" galaxy has open, well-defined arms and a small core region. A galaxy with poorly defined arms is sometimes referred to as a flocculent spiral galaxy; in contrast to the grand design spiral galaxy that has prominent and well-defined spiral arms. The speed in which a galaxy rotates is thought to correlate with the flatness of the disc as some spiral galaxies have thick bulges, while others are thin and dense.


title: Galaxy

text: In spiral galaxies, the spiral arms do have the shape of approximate logarithmic spirals, a pattern that can be theoretically shown to result from a disturbance in a uniformly rotating mass of stars. Like the stars, the spiral arms rotate around the center, but they do so with constant angular velocity. The spiral arms are thought to be areas of high-density matter, or "density waves". As stars move through an arm, the space velocity of each stellar system is modified by the gravitational force of the higher density. (The velocity returns to normal after the stars depart on the other side of the arm.) This effect is akin to a "wave" of slowdowns moving along a highway full of moving cars. The arms are visible because the high density facilitates star formation, and therefore they harbor many bright and young stars.


title: Galaxy

text: A majority of spiral galaxies, including the Milky Way galaxy, have a linear, bar-shaped band of stars that extends outward to either side of the core, then merges into the spiral arm structure. In the Hubble classification scheme, these are designated by an "SB", followed by a lower-case letter ("a", "b" or "c") which indicates the form of the spiral arms (in the same manner as the categorization of normal spiral galaxies). Bars are thought to be temporary structures that can occur as a result of a density wave radiating outward from the core, or else due to a tidal interaction with another galaxy. Many barred spiral galaxies are active, possibly as a result of gas being channeled into the core along the arms.


title: Galaxy

text: Our own galaxy, the Milky Way, is a large disk-shaped barred-spiral galaxy about 30 kiloparsecs in diameter and a kiloparsec thick. It contains about two hundred billion (2×10) stars and has a total mass of about six hundred billion (6×10) times the mass of the Sun.


title: Galaxy

text: Recently, researchers described galaxies called super-luminous spirals. They are very large with an upward diameter of 437,000 light-years (compared to the Milky Way's 87,400 light-year diameter). With a mass of 340 billion solar masses, they generate a significant amount of ultraviolet and mid-infrared light. They are thought to have an increased star formation rate around 30 times faster than the Milky Way.


title: Galaxy

text: Despite the prominence of large elliptical and spiral galaxies, most galaxies are dwarf galaxies. They are relatively small when compared with other galactic formations, being about one hundredth the size of the Milky Way, with only a few billion stars. Ultra-compact dwarf galaxies have recently been discovered that are only 100 parsecs across.


title: Galaxy

text: Many dwarf galaxies may orbit a single larger galaxy; the Milky Way has at least a dozen such satellites, with an estimated 300–500 yet to be discovered. Dwarf galaxies may also be classified as elliptical, spiral, or irregular. Since small dwarf ellipticals bear little resemblance to large ellipticals, they are often called dwarf spheroidal galaxies instead.


title: Galaxy

text: A study of 27 Milky Way neighbors found that in all dwarf galaxies, the central mass is approximately 10 million solar masses, regardless of whether it has thousands or millions of stars. This suggests that galaxies are largely formed by dark matter, and that the minimum size may indicate a form of warm dark matter incapable of gravitational coalescence on a smaller scale.


title: Galaxy

text: Interactions between galaxies are relatively frequent, and they can play an important role in galactic evolution. Near misses between galaxies result in warping distortions due to tidal interactions, and may cause some exchange of gas and dust.


title: Galaxy

text: Collisions occur when two galaxies pass directly through each other and have sufficient relative momentum not to merge. The stars of interacting galaxies usually do not collide, but the gas and dust within the two forms interacts, sometimes triggering star formation. A collision can severely distort the galaxies' shapes, forming bars, rings or tail-like structures.


title: Galaxy

text: At the extreme of interactions are galactic mergers, where the galaxies' relative momentums are insufficient to allow them to pass through each other. Instead, they gradually merge to form a single, larger galaxy. Mergers can result in significant changes to the galaxies' original morphology. If one of the galaxies is much more massive than the other, the result is known as cannibalism, where the more massive larger galaxy remains relatively undisturbed, and the smaller one is torn apart. The Milky Way galaxy is currently in the process of cannibalizing the Sagittarius Dwarf Elliptical Galaxy and the Canis Major Dwarf Galaxy.


title: Galaxy

text: Stars are created within galaxies from a reserve of cold gas that forms giant molecular clouds. Some galaxies have been observed to form stars at an exceptional rate, which is known as a "starburst". If they continue to do so, they would consume their reserve of gas in a time span less than the galaxy's lifespan. Hence starburst activity usually lasts only about ten million years, a relatively brief period in a galaxy's history. Starburst galaxies were more common during the universe's early history, but still contribute an estimated 15% to total star production.


title: Galaxy

text: Starburst galaxies are characterized by dusty concentrations of gas and the appearance of newly formed stars, including massive stars that ionize the surrounding clouds to create H II regions. These stars produce supernova explosions, creating expanding remnants that interact powerfully with the surrounding gas. These outbursts trigger a chain reaction of star-building that spreads throughout the gaseous region. Only when the available gas is nearly consumed or dispersed does the activity end.


title: Galaxy

text: Starbursts are often associated with merging or interacting galaxies. The prototype example of such a starburst-forming interaction is M82, which experienced a close encounter with the larger M81. Irregular galaxies often exhibit spaced knots of starburst activity.


title: Galaxy

text: A radio galaxy is a galaxy with giant regions of radio emission extending well beyond its visible structure. These energetic radio lobes are powered by jets from its active galactic nucleus. Radio galaxies are classified according to their Fanaroff–Riley (FR) classifications. The FR I class are a minority class – low-luminosity sources exhibiting structures usually known as "plumes" which are much more elongated. The FR II class are by far the most common, exhibiting large-scale structures are called "lobes": these are double, often fairly symmetrical, roughly ellipsoidal structures placed on either side of the active nucleus.


title: Galaxy

text: Radio galaxies can also be classified as giant radio galaxies (GRGs), whose radio emissions can extend to scales of megaparsecs (3.26 million light-years). Alcyoneus is an FR II class low-excitation radio galaxy which has the largest observed radio emission, with lobed structures spanning 5 megaparsecs (16×10 ly). For comparison, another similarly sized giant radio galaxy is 3C 236, with lobes 15 million light-years across. It should however be noted that radio emissions are "not" always considered part of the main galaxy itself, and is usually not used as a standard in measuring the physical diameter of a galaxy. For insight on how physical diameters of galaxies are measured, see section "Physical diameters" below.


title: Galaxy

text: A giant radio galaxy is a special class of objects characterized by the presence of radio lobes generated by relativistic jets powered by the central galaxy's supermassive black hole. Giant radio galaxies are different from ordinary radio galaxies in that they can extend to much larger scales, reaching upwards to several megaparsecs across, far larger than the diameters of their host galaxies.


title: Galaxy

text: Some observable galaxies are classified as "active" if they contain an active galactic nucleus (AGN). A significant portion of the galaxy's total energy output is emitted by the active nucleus instead of its stars, dust and interstellar medium. There are multiple classification and naming schemes for AGNs, but those in the lower ranges of luminosity are called Seyfert galaxies, while those with luminosities much greater than that of the host galaxy are known as quasi-stellar objects or quasars. AGNs emit radiation throughout the electromagnetic spectrum from radio wavelengths to X-rays, though some of it may be absorbed by dust or gas associated with the AGN itself or with the host galaxy.


title: Galaxy

text: The standard model for an active galactic nucleus is based on an accretion disc that forms around a supermassive black hole (SMBH) at the galaxy's core region. The radiation from an active galactic nucleus results from the gravitational energy of matter as it falls toward the black hole from the disc. The AGN's luminosity depends on the SMBH's mass and the rate at which matter falls onto it.


title: Galaxy

text: In about 10% of these galaxies, a diametrically opposed pair of energetic jets ejects particles from the galaxy core at velocities close to the speed of light. The mechanism for producing these jets is not well understood.


title: Galaxy

text: Blazars are believed to be active galaxies with a relativistic jet pointed in the direction of Earth. A radio galaxy emits radio frequencies from relativistic jets. A unified model of these types of active galaxies explains their differences based on the observer's position.


title: Galaxy

text: Possibly related to active galactic nuclei (as well as starburst regions) are low-ionization nuclear emission-line regions (LINERs). The emission from LINER-type galaxies is dominated by weakly ionized elements. The excitation sources for the weakly ionized lines include post-AGB stars, AGN, and shocks. Approximately one-third of nearby galaxies are classified as containing LINER nuclei.


title: Galaxy

text: Seyfert galaxies are one of the two largest groups of active galaxies, along with quasars. They have quasar-like nuclei (very luminous, distant and bright sources of electromagnetic radiation) with very high surface brightnesses; but unlike quasars, their host galaxies are clearly detectable. Seyfert galaxies account for about 10% of all galaxies. Seen in visible light, most look like normal spiral galaxies; but when studied under other wavelengths, their cores' luminosity is equivalent to the luminosity of whole galaxies the size of the Milky Way.


title: Galaxy

text: Quasars (/ˈkweɪzɑr/) or quasi-stellar radio sources, are the most energetic and distant members of active galactic nuclei. Extremely luminous, they were first identified as high redshift sources of electromagnetic energy, including radio waves and visible light, that appeared more similar to stars than to extended sources similar to galaxies. Their luminosity can be 100 times that of the Milky Way.


title: Galaxy

text: Luminous infrared galaxies (LIRGs) are galaxies with luminosities—the measurement of electromagnetic power output—above 10 L☉ (solar luminosities). In most cases, most of their energy comes from large numbers of young stars which heat surrounding dust, which reradiates the energy in the infrared. Luminosity high enough to be a LIRG requires a star formation rate of at least 18 M☉ yr. Ultra-luminous infrared galaxies (ULIRGs) are at least ten times more luminous still and form stars at rates >180 M☉ yr. Many LIRGs also emit radiation from an AGN. Infrared galaxies emit more energy in the infrared than all other wavelengths combined, with peak emission typically at wavelengths of 60 to 100 microns. LIRGs are uncommon in the local universe but were much more common when the universe was younger.


title: Galaxy

text: Galaxies do not have a definite boundary by their nature, and are characterized by a gradually decreasing stellar density as a function of increasing distance from their center, making measurements of their true extents difficult. Nevertheless, astronomers over the past few decades have made several criteria in defining the sizes of galaxies. As early as the time of Edwin Hubble in 1936, there have been attempts to characterize the diameters of galaxies. With the advent of large sky surveys in the second half of the 20th century, the need for a standard for accurate determination of galaxy sizes has been in greater demand due to its enormous implications in astrophysics, such as the accurate determination of the Hubble constant. Various standards have been adapted over the decades, some more preferred than others. Below are some of these examples.


title: Galaxy

text: The "isophotal diameter" is introduced as a conventional way of measuring a galaxy's size based on its apparent surface brightness. Isophotes are curves in a diagram - such as a picture of a galaxy - that adjoins points of equal brightnesses, and are useful in defining the extent of the galaxy. The apparent brightness flux of a galaxy is measured in units of magnitudes per square arcsecond (mag/arcsec; sometimes expressed as "mag arcsec"), which defines the brightness depth of the isophote. To illustrate how this unit works, a typical galaxy has a brightness flux of 18 mag/arcsec at its central region. This brightness is equivalent to the light of an 18th magnitude hypothetical point object (like a star) being spread out evenly in a one square arcsecond area of the sky. For the purposes of objectivity, the spectrum of light being used is sometimes also given in figures. As an example, the Milky Way has an average surface brightness of 22.1 B-mag/arcsec, where "B-mag" refers to the brightness at the B-band (445 nm wavelength of light, in the blue part of the visible spectrum).


title: Galaxy

text: R.O. Redman in 1936 suggested that the diameters of galaxies (then referred to as "elliptical nebulae") should be defined at the 25.0 mag/arcsec isophote at the B-band, which is expected to cover much of the galaxy's light profile. This isophote then became known simply as D (short for "diameter 25"), and corresponds to at least 10% of the normal brightness of the night sky, which is very near the limitations of blue filters at that time. This method was particularly used during the creation of the Uppsala General Catalogue using blue filters from the Palomar Observatory Sky Survey in 1972.


title: Galaxy

text: This conventional standard, however, is not universally agreed upon. Erik Holmberg in 1958 measured the diameters of at least 300 galaxies at the isophote of about 26.5 mag/arcsec (originally defined as where the photographic brightness density with respect to plate background is 0.5%). Various other surveys such that of the ESO in 1989 use isophotes as faint as 27.0 mag/arcsec. Nevertheless, corrections of these diameters were introduced by both the Second and Third Reference Catalogue of Galaxies (RC2 and RC3), at least to those galaxies being covered by the two catalogues.


title: Galaxy

text: The half-light radius (also known as "effective radius"; R) is a measure that is based on the galaxy's overall brightness flux. This is the radius upon which half, or 50%, of the total brightness flux of the galaxy was emitted. This was first proposed by Gérard de Vaucouleurs in 1948. The choice of using 50% was arbitrary, but proved to be useful in further works by R. A. Fish in 1963, where he established a luminosity concentration law that relates the brightnesses of elliptical galaxies and their respective R, and by J.L. Sérsic in 1968 that defined a mass-radius relation in galaxies.


title: Galaxy

text: In defining R, it is necessary that the overall brightness flux galaxy should be captured, with a method employed by Bershady in 2000 suggesting to measure twice the size where the brightness flux of an arbitrarily chosen radius, defined as the local flux, divided by the overall average flux equals to 0.2. Using half-light radius allows a rough estimate of a galaxy's size, but is not particularly helpful in determining its morphology.


title: Galaxy

text: Variations of this method exist. In particular, in the ESO-Uppsala Catalogue of Galaxies values of 50%, 70%, and 90% of the total blue light (the light detected through a B-band specific filter) had been used to calculate a galaxy's diameter.


title: Galaxy

text: First described by V. Petrosian in 1976, a modified version of this method has been used by the Sloan Digital Sky Survey (SDSS). This method employs a mathematical model on a galaxy whose radius is determined by the azimuthally (horizontal) averaged profile of its brightness flux. In particular, the SDSS employed the Petrosian magnitude in the R-band (658 nm, in the red part of the visible spectrum) to ensure that the brightness flux of a galaxy would be captured as much as possible while counteracting the effects of background noise. For a galaxy whose brightness profile is exponential, it is expected to capture all of its brightness flux, and 80% for galaxies that follow a profile under de Vaucouleurs's law.


title: Galaxy

text: Petrosian magnitudes have the advantage that it is redshift and distance independent, allowing the measurement of the galaxy's apparent size since the Petrosian radius is defined in terms of the galaxy's overall luminous flux.


title: Galaxy

text: A critique of an earlier version of this method has been issued by IPAC, with the method causing a magnitude of error (upwards to 10%) of the values than using isophotal diameter. The use of Petrosian magnitudes also have the disadvantage of missing most of the light outside the Petrosian aperture, which is defined relative to the galaxy's overall brightness profile, especially for elliptical galaxies, with higher signal-to-noise ratios on higher distances and redshifts. A correction for this method has been issued by Graham "et al." in 2005, based on the assumption that galaxies follow Sersic's law.


title: Galaxy

text: This method has been used by 2MASS as an adaptation from the previously used methods of isophotal measurement. Since 2MASS operates in the near infrared, which has the advantage of being able to recognize dimmer, cooler, and older stars, it has a different form of approach compared to other methods that normally use B-filter. The detail of the method used by 2MASS has been described thoroughly in a document by Jarrett "et al.", with the survey measuring several parameters.


title: Galaxy

text: The standard aperture ellipse (area of detection) is defined by the infrared isophote at the K band (roughly 2.2 μm wavelength) of 20 mag/arcsec. Gathering the overall luminous flux of the galaxy has been employed by at least four methods: the first being a circular aperture extending 7 arcseconds from the center, an isophote at 20 mag/arcsec, a "total" aperture defined by the radial light distribution that covers the supposed extent of the galaxy, and the Kron aperture (defined as 2.5 times the first-moment radius, an integration of the flux of the "total" aperture).


title: Galaxy

text: Galaxies have magnetic fields of their own. They are strong enough to be dynamically important, as they:


title: Galaxy

text: The typical average equipartition strength for spiral galaxies is about 10 μG (microgauss) or 1nT (nanotesla). By comparison, the Earth's magnetic field has an average strength of about 0.3 G (Gauss or 30 μT (microtesla). Radio-faint galaxies like M 31 and M33, the Milky Way's neighbors, have weaker fields (about 5μG), while gas-rich galaxies with high star-formation rates, like M 51, M 83 and NGC 6946, have 15 μG on average. In prominent spiral arms, the field strength can be up to 25 μG, in regions where cold gas and dust are also concentrated. The strongest total equipartition fields (50–100 μG) were found in starburst galaxies—for example, in M 82 and the Antennae; and in nuclear starburst regions, such as the centers of NGC 1097 and other barred galaxies.


title: Galaxy

text: Current models of the formation of galaxies in the early universe are based on the ΛCDM model. About 300,000 years after the big bang, atoms of hydrogen and helium began to form, in an event called recombination. Nearly all the hydrogen was neutral (non-ionized) and readily absorbed light, and no stars had yet formed. As a result, this period has been called the "dark ages". It was from density fluctuations (or anisotropic irregularities) in this primordial matter that larger structures began to appear. As a result, masses of baryonic matter started to condense within cold dark matter halos. These primordial structures eventually became the galaxies we see today.


title: Galaxy

text: Evidence for the appearance of galaxies very early in the Universe's history was found in 2006, when it was discovered that the galaxy IOK-1 has an unusually high redshift of 6.96, corresponding to just 750 million years after the Big Bang and making it the most distant and earliest-to-form galaxy seen at that time.


title: Galaxy

text: While some scientists have claimed other objects (such as Abell 1835 IR1916) have higher redshifts (and therefore are seen in an earlier stage of the universe's evolution), IOK-1's age and composition have been more reliably established. In December 2012, astronomers reported that UDFj-39546284 is the most distant object known and has a redshift value of 11.9. The object, estimated to have existed around 380 million years after the Big Bang (which was about 13.8 billion years ago), is about 13.42 billion light travel distance years away. The existence of galaxies so soon after the Big Bang suggests that protogalaxies must have grown in the so-called "dark ages". As of May 5, 2015, the galaxy EGS-zs8-1 is the most distant and earliest galaxy measured, forming 670 million years after the Big Bang. The light from EGS-zs8-1 has taken 13 billion years to reach Earth, and is now 30 billion light-years away, because of the expansion of the universe during 13 billion years. On 17 August 2022, NASA released a large mosaic image of 690 individual frames taken by the Near Infrared Camera (NIRCam) on the James Webb Space Telescope (JWST) of numerous very early galaxies. Some early galaxies observed by JWST, like CEERS-93316, a candidate high-redshift galaxy, has an estimated redshift of approximately z = 16.7, corresponding to 235.8 million years after the Big Bang.


title: Galaxy

text: The detailed process by which the earliest galaxies formed is an open question in astrophysics. Theories can be divided into two categories: top-down and bottom-up. In top-down correlations (such as the Eggen–Lynden-Bell–Sandage [ELS] model), protogalaxies form in a large-scale simultaneous collapse lasting about one hundred million years. In bottom-up theories (such as the Searle-Zinn [SZ] model), small structures such as globular clusters form first, and then a number of such bodies accrete to form a larger galaxy.


title: Galaxy

text: Once protogalaxies began to form and contract, the first halo stars (called Population III stars) appeared within them. These were composed almost entirely of hydrogen and helium and may have been more massive than 100 times the Sun's mass. If so, these huge stars would have quickly consumed their supply of fuel and became supernovae, releasing heavy elements into the interstellar medium. This first generation of stars re-ionized the surrounding neutral hydrogen, creating expanding bubbles of space through which light could readily travel.


title: Galaxy

text: In June 2015, astronomers reported evidence for Population III stars in the Cosmos Redshift 7 galaxy at . Such stars are likely to have existed in the very early universe (i.e., at high redshift), and may have started the production of chemical elements heavier than hydrogen that are needed for the later formation of planets and life as we know it.


title: Galaxy

text: Within a billion years of a galaxy's formation, key structures begin to appear. Globular clusters, the central supermassive black hole, and a galactic bulge of metal-poor Population II stars form. The creation of a supermassive black hole appears to play a key role in actively regulating the growth of galaxies by limiting the total amount of additional matter added. During this early epoch, galaxies undergo a major burst of star formation.


title: Galaxy

text: During the following two billion years, the accumulated matter settles into a galactic disc. A galaxy will continue to absorb infalling material from high-velocity clouds and dwarf galaxies throughout its life. This matter is mostly hydrogen and helium. The cycle of stellar birth and death slowly increases the abundance of heavy elements, eventually allowing the formation of planets.


title: Galaxy

text: The evolution of galaxies can be significantly affected by interactions and collisions. Mergers of galaxies were common during the early epoch, and the majority of galaxies were peculiar in morphology. Given the distances between the stars, the great majority of stellar systems in colliding galaxies will be unaffected. However, gravitational stripping of the interstellar gas and dust that makes up the spiral arms produces a long train of stars known as tidal tails. Examples of these formations can be seen in NGC 4676 or the Antennae Galaxies.


title: Galaxy

text: The Milky Way galaxy and the nearby Andromeda Galaxy are moving toward each other at about 130 km/s, and—depending upon the lateral movements—the two might collide in about five to six billion years. Although the Milky Way has never collided with a galaxy as large as Andromeda before, evidence of past collisions of the Milky Way with smaller dwarf galaxies is increasing.


title: Galaxy

text: Such large-scale interactions are rare. As time passes, mergers of two systems of equal size become less common. Most bright galaxies have remained fundamentally unchanged for the last few billion years, and the net rate of star formation probably also peaked about ten billion years ago.


title: Galaxy

text: Spiral galaxies, like the Milky Way, produce new generations of stars as long as they have dense molecular clouds of interstellar hydrogen in their spiral arms. Elliptical galaxies are largely devoid of this gas, and so form few new stars. The supply of star-forming material is finite; once stars have converted the available supply of hydrogen into heavier elements, new star formation will come to an end.


title: Galaxy

text: The current era of star formation is expected to continue for up to one hundred billion years, and then the "stellar age" will wind down after about ten trillion to one hundred trillion years (10–10 years), as the smallest, longest-lived stars in the visible universe, tiny red dwarfs, begin to fade. At the end of the stellar age, galaxies will be composed of compact objects: brown dwarfs, white dwarfs that are cooling or cold ("black dwarfs"), neutron stars, and black holes. Eventually, as a result of gravitational relaxation, all stars will either fall into central supermassive black holes or be flung into intergalactic space as a result of collisions.


title: Galaxy

text: Deep-sky surveys show that galaxies are often found in groups and clusters. Solitary galaxies that have not significantly interacted with other galaxies of comparable mass in the past billion years are relatively scarce. Only about 5% of the galaxies surveyed are truly isolated; however, they may have interacted and even merged with other galaxies in the past, and may still be orbited by smaller satellite galaxies. Isolated galaxies can produce stars at a higher rate than normal, as their gas is not being stripped by other nearby galaxies.


title: Galaxy

text: On the largest scale, the universe is continually expanding, resulting in an average increase in the separation between individual galaxies (see Hubble's law). Associations of galaxies can overcome this expansion on a local scale through their mutual gravitational attraction. These associations formed early, as clumps of dark matter pulled their respective galaxies together. Nearby groups later merged to form larger-scale clusters. This ongoing merging process (as well as an influx of infalling gas) heats the intergalactic gas in a cluster to very high temperatures of 30–100 megakelvins. About 70–80% of a cluster's mass is in the form of dark matter, with 10–30% consisting of this heated gas and the remaining few percent in the form of galaxies.


title: Galaxy

text: Most galaxies are gravitationally bound to a number of other galaxies. These form a fractal-like hierarchical distribution of clustered structures, with the smallest such associations being termed groups. A group of galaxies is the most common type of galactic cluster; these formations contain the majority of galaxies (as well as most of the baryonic mass) in the universe. To remain gravitationally bound to such a group, each member galaxy must have a sufficiently low velocity to prevent it from escaping (see Virial theorem). If there is insufficient kinetic energy, however, the group may evolve into a smaller number of galaxies through mergers.


title: Galaxy

text: Clusters of galaxies consist of hundreds to thousands of galaxies bound together by gravity. Clusters of galaxies are often dominated by a single giant elliptical galaxy, known as the brightest cluster galaxy, which, over time, tidally destroys its satellite galaxies and adds their mass to its own.


title: Galaxy

text: Superclusters contain tens of thousands of galaxies, which are found in clusters, groups and sometimes individually. At the supercluster scale, galaxies are arranged into sheets and filaments surrounding vast empty voids. Above this scale, the universe appears to be the same in all directions (isotropic and homogeneous)., though this notion has been challenged in recent years by numerous findings of large-scale structures that appear to be exceeding this scale. The Hercules–Corona Borealis Great Wall, currently the largest structure in the universe found so far, is 10 billion light-years (three gigaparsecs) in length.


title: Galaxy

text: The Milky Way galaxy is a member of an association named the Local Group, a relatively small group of galaxies that has a diameter of approximately one megaparsec. The Milky Way and the Andromeda Galaxy are the two brightest galaxies within the group; many of the other member galaxies are dwarf companions of these two. The Local Group itself is a part of a cloud-like structure within the Virgo Supercluster, a large, extended structure of groups and clusters of galaxies centered on the Virgo Cluster. And the Virgo Supercluster itself is a part of the Pisces–Cetus Supercluster Complex, a giant galaxy filament.


title: Galaxy

text: The peak radiation of most stars lies in the visible spectrum, so the observation of the stars that form galaxies has been a major component of optical astronomy. It is also a favorable portion of the spectrum for observing ionized H II regions, and for examining the distribution of dusty arms.


title: Galaxy

text: The dust present in the interstellar medium is opaque to visual light. It is more transparent to far-infrared, which can be used to observe the interior regions of giant molecular clouds and galactic cores in great detail. Infrared is also used to observe distant, red-shifted galaxies that were formed much earlier. Water vapor and carbon dioxide absorb a number of useful portions of the infrared spectrum, so high-altitude or space-based telescopes are used for infrared astronomy.


title: Galaxy

text: The first non-visual study of galaxies, particularly active galaxies, was made using radio frequencies. The Earth's atmosphere is nearly transparent to radio between 5 MHz and 30 GHz. (The ionosphere blocks signals below this range.) Large radio interferometers have been used to map the active jets emitted from active nuclei. Radio telescopes can also be used to observe neutral hydrogen (via 21 cm radiation), including, potentially, the non-ionized matter in the early universe that later collapsed to form galaxies.


title: Galaxy

text: Ultraviolet and X-ray telescopes can observe highly energetic galactic phenomena. Ultraviolet flares are sometimes observed when a star in a distant galaxy is torn apart from the tidal forces of a nearby black hole. The distribution of hot gas in galactic clusters can be mapped by X-rays. The existence of supermassive black holes at the cores of galaxies was confirmed through X-ray astronomy.


title: Stroke

text: A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functioning properly.


title: Stroke

text: Signs and symptoms of a stroke may include an inability to move or feel on one side of the body, problems understanding or speaking, dizziness, or loss of vision to one side. Signs and symptoms often appear soon after the stroke has occurred. If symptoms last less than one or two hours, the stroke is a transient ischemic attack (TIA), also called a mini-stroke. A hemorrhagic stroke may also be associated with a severe headache. The symptoms of a stroke can be permanent. Long-term complications may include pneumonia and loss of bladder control.


title: Stroke

text: The main risk factor for stroke is high blood pressure. Other risk factors include high blood cholesterol, tobacco smoking, obesity, diabetes mellitus, a previous TIA, end-stage kidney disease, and atrial fibrillation. An ischemic stroke is typically caused by blockage of a blood vessel, though there are also less common causes. A hemorrhagic stroke is caused by either bleeding directly into the brain or into the space between the brain's membranes. Bleeding may occur due to a ruptured brain aneurysm. Diagnosis is typically based on a physical exam and supported by medical imaging such as a CT scan or MRI scan. A CT scan can rule out bleeding, but may not necessarily rule out ischemia, which early on typically does not show up on a CT scan. Other tests such as an electrocardiogram (ECG) and blood tests are done to determine risk factors and rule out other possible causes. Low blood sugar may cause similar symptoms.


title: Stroke

text: Prevention includes decreasing risk factors, surgery to open up the arteries to the brain in those with problematic carotid narrowing, and warfarin in people with atrial fibrillation. Aspirin or statins may be recommended by physicians for prevention. A stroke or TIA often requires emergency care. An ischemic stroke, if detected within three to four and half hours, may be treatable with a medication that can break down the clot. Some hemorrhagic strokes benefit from surgery. Treatment to attempt recovery of lost function is called stroke rehabilitation, and ideally takes place in a stroke unit; however, these are not available in much of the world.


title: Stroke

text: In 2013, approximately 6.9 million people had an ischemic stroke and 3.4 million people had a hemorrhagic stroke. In 2015, there were about 42.4 million people who had previously had a stroke and were still alive. Between 1990 and 2010 the number of strokes which occurred each year decreased by approximately 10% in the developed world and increased by 10% in the developing world. In 2015, stroke was the second most frequent cause of death after coronary artery disease, accounting for 6.3 million deaths (11% of the total). About 3.0 million deaths resulted from ischemic stroke while 3.3 million deaths resulted from hemorrhagic stroke. About half of people who have had a stroke live less than one year. Overall, two thirds of strokes occurred in those over 65 years old.


title: Stroke

text: Strokes can be classified into two major categories: ischemic and hemorrhagic. Ischemic strokes are caused by interruption of the blood supply to the brain, while hemorrhagic strokes result from the rupture of a blood vessel or an abnormal vascular structure. About 87% of strokes are ischemic, the rest being hemorrhagic. Bleeding can develop inside areas of ischemia, a condition known as "hemorrhagic transformation." It is unknown how many hemorrhagic strokes actually start as ischemic strokes.


title: Stroke

text: In the 1970s the World Health Organization defined stroke as a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours", although the word "stroke" is centuries old. This definition was supposed to reflect the reversibility of tissue damage and was devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. The 24-hour limit divides stroke from transient ischemic attack, which is a related syndrome of stroke symptoms that resolve completely within 24 hours. With the availability of treatments that can reduce stroke severity when given early, many now prefer alternative terminology, such as brain attack and acute ischemic cerebrovascular syndrome (modeled after heart attack and acute coronary syndrome, respectively), to reflect the urgency of stroke symptoms and the need to act swiftly.


title: Stroke

text: In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen:


title: Stroke

text: A stroke without an obvious explanation is termed cryptogenic (of unknown origin); this constitutes 30–40% of all ischemic strokes.


title: Stroke

text: There are various classification systems for acute ischemic stroke. The Oxford Community Stroke Project classification (OCSP, also known as the Bamford or Oxford classification) relies primarily on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) or posterior circulation infarct (POCI). These four entities predict the extent of the stroke, the area of the brain that is affected, the underlying cause, and the prognosis. The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is based on clinical symptoms as well as results of further investigations; on this basis, a stroke is classified as being due to (1) thrombosis or embolism due to atherosclerosis of a large artery, (2) an embolism originating in the heart, (3) complete blockage of a small blood vessel, (4) other determined cause, (5) undetermined cause (two possible causes, no cause identified, or incomplete investigation). Users of stimulants such as cocaine and methamphetamine are at a high risk for ischemic strokes.


title: Stroke

text: The above two main types of hemorrhagic stroke are also two different forms of intracranial hemorrhage, which is the accumulation of blood anywhere within the cranial vault; but the other forms of intracranial hemorrhage, such as epidural hematoma (bleeding between the skull and the dura mater, which is the thick "outermost" layer of the meninges that surround the brain) and subdural hematoma (bleeding in the subdural space), are not considered "hemorrhagic strokes".


title: Stroke

text: Hemorrhagic strokes may occur on the background of alterations to the blood vessels in the brain, such as cerebral amyloid angiopathy, cerebral arteriovenous malformation and an intracranial aneurysm, which can cause intraparenchymal or subarachnoid hemorrhage.


title: Stroke

text: In addition to neurological impairment, hemorrhagic strokes usually cause specific symptoms (for instance, subarachnoid hemorrhage classically causes a severe headache known as a thunderclap headache) or reveal evidence of a previous head injury.


title: Stroke

text: Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of the brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with a headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage.


title: Stroke

text: Various systems have been proposed to increase recognition of stroke. Different findings are able to predict the presence or absence of stroke to different degrees. Sudden-onset face weakness, arm drift (i.e., if a person, when asked to raise both arms, involuntarily lets one arm drift downward) and abnormal speech are the findings most likely to lead to the correct identification of a case of stroke, increasing the likelihood by 5.5 when at least one of these is present. Similarly, when all three of these are absent, the likelihood of stroke is decreased (– likelihood ratio of 0.39). While these findings are not perfect for diagnosing stroke, the fact that they can be evaluated relatively rapidly and easily make them very valuable in the acute setting.


title: Stroke

text: A mnemonic to remember the warning signs of stroke is FAST (facial droop, arm weakness, speech difficulty, and time to call emergency services), as advocated by the Department of Health (United Kingdom) and the Stroke Association, the American Stroke Association, the National Stroke Association (US), the Los Angeles Prehospital Stroke Screen (LAPSS) and the Cincinnati Prehospital Stroke Scale (CPSS). Use of these scales is recommended by professional guidelines. FAST is less reliable in the recognition of posterior circulation strokes.


title: Stroke

text: For people referred to the emergency room, early recognition of stroke is deemed important as this can expedite diagnostic tests and treatments. A scoring system called ROSIER (recognition of stroke in the emergency room) is recommended for this purpose; it is based on features from the medical history and physical examination.


title: Stroke

text: If the area of the brain affected includes one of the three prominent central nervous system pathways—the spinothalamic tract, corticospinal tract, and the dorsal column–medial lemniscus pathway, symptoms may include:


title: Stroke

text: In most cases, the symptoms affect only one side of the body (unilateral). Depending on the part of the brain affected, the defect in the brain is "usually" on the opposite side of the body. However, since these pathways also travel in the spinal cord and any lesion there can also produce these symptoms, the presence of any one of these symptoms does not necessarily indicate a stroke. In addition to the above CNS pathways, the "brainstem" gives rise to most of the twelve cranial nerves. A brainstem stroke affecting the brainstem and brain, therefore, can produce symptoms relating to deficits in these cranial nerves:


title: Stroke

text: If the "cerebral cortex" is involved, the CNS pathways can again be affected, but also can produce the following symptoms:


title: Stroke

text: Loss of consciousness, headache, and vomiting usually occur more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing the brain.


title: Stroke

text: If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke.


title: Stroke

text: In thrombotic stroke, a thrombus (blood clot) usually forms around atherosclerotic plaques. Since blockage of the artery is gradual, onset of symptomatic thrombotic strokes is slower than that of a hemorrhagic stroke. A thrombus itself (even if it does not completely block the blood vessel) can lead to an embolic stroke (see below) if the thrombus breaks off and travels in the bloodstream, at which point it is called an embolus. Two types of thrombosis can cause stroke:


title: Stroke

text: Anemia causes increase blood flow in the blood circulatory system. This causes the endothelial cells of the blood vessels to express adhesion factors which encourages the clotting of blood and formation of thrombus. Sickle-cell anemia, which can cause blood cells to clump up and block blood vessels, can also lead to stroke. A stroke is the second leading cause of death in people under 20 with sickle-cell anemia. Air pollution may also increase stroke risk.


title: Stroke

text: An embolic stroke refers to an arterial embolism (a blockage of an artery) by an embolus, a traveling particle or debris in the arterial bloodstream originating from elsewhere. An embolus is most frequently a thrombus, but it can also be a number of other substances including fat (e.g., from bone marrow in a broken bone), air, cancer cells or clumps of bacteria (usually from infectious endocarditis).


title: Stroke

text: Because an embolus arises from elsewhere, local therapy solves the problem only temporarily. Thus, the source of the embolus must be identified. Because the embolic blockage is sudden in onset, symptoms usually are maximal at the start. Also, symptoms may be transient as the embolus is partially resorbed and moves to a different location or dissipates altogether.


title: Stroke

text: Emboli most commonly arise from the heart (especially in atrial fibrillation) but may originate from elsewhere in the arterial tree. In paradoxical embolism, a deep vein thrombosis embolizes through an atrial or ventricular septal defect in the heart into the brain.


title: Stroke

text: Among those who have a complete blockage of one of the carotid arteries, the risk of stroke on that side is about one percent per year.


title: Stroke

text: A special form of embolic stroke is the embolic stroke of undetermined source (ESUS). This subset of cryptogenic stroke is defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources. About one out of six ischemic strokes could be classified as ESUS.


title: Stroke

text: Cerebral hypoperfusion is the reduction of blood flow to all parts of the brain. The reduction could be to a particular part of the brain depending on the cause. It is most commonly due to heart failure from cardiac arrest or arrhythmias, or from reduced cardiac output as a result of myocardial infarction, pulmonary embolism, pericardial effusion, or bleeding. Hypoxemia (low blood oxygen content) may precipitate the hypoperfusion. Because the reduction in blood flow is global, all parts of the brain may be affected, especially vulnerable "watershed" areas—border zone regions supplied by the major cerebral arteries. A watershed stroke refers to the condition when the blood supply to these areas is compromised. Blood flow to these areas does not necessarily stop, but instead it may lessen to the point where brain damage can occur.


title: Stroke

text: Cerebral venous sinus thrombosis leads to stroke due to locally increased venous pressure, which exceeds the pressure generated by the arteries. Infarcts are more likely to undergo hemorrhagic transformation (leaking of blood into the damaged area) than other types of ischemic stroke.


title: Stroke

text: It generally occurs in small arteries or arterioles and is commonly due to hypertension, intracranial vascular malformations (including cavernous angiomas or arteriovenous malformations), cerebral amyloid angiopathy, or infarcts into which secondary hemorrhage has occurred. Other potential causes are trauma, bleeding disorders, amyloid angiopathy, illicit drug use (e.g., amphetamines or cocaine). The hematoma enlarges until pressure from surrounding tissue limits its growth, or until it decompresses by emptying into the ventricular system, CSF or the pial surface. A third of intracerebral bleed is into the brain's ventricles. ICH has a mortality rate of 44 percent after 30 days, higher than ischemic stroke or subarachnoid hemorrhage (which technically may also be classified as a type of stroke).


title: Stroke

text: A silent stroke is a stroke that does not have any outward symptoms, and people are typically unaware they have had a stroke. Despite not causing identifiable symptoms, a silent stroke still damages the brain and places the person at increased risk for both transient ischemic attack and major stroke in the future. Conversely, those who have had a major stroke are also at risk of having silent strokes. In a broad study in 1998, more than 11 million people were estimated to have experienced a stroke in the United States. Approximately 770,000 of these strokes were symptomatic and 11 million were first-ever silent MRI infarcts or hemorrhages. Silent strokes typically cause lesions which are detected via the use of neuroimaging such as MRI. Silent strokes are estimated to occur at five times the rate of symptomatic strokes. The risk of silent stroke increases with age, but may also affect younger adults and children, especially those with acute anemia.


title: Stroke

text: Ischemic stroke occurs because of a loss of blood supply to part of the brain, initiating the ischemic cascade. Atherosclerosis may disrupt the blood supply by narrowing the lumen of blood vessels leading to a reduction of blood flow by causing the formation of blood clots within the vessel or by releasing showers of small emboli through the disintegration of atherosclerotic plaques. Embolic infarction occurs when emboli formed elsewhere in the circulatory system, typically in the heart as a consequence of atrial fibrillation, or in the carotid arteries, break off, enter the cerebral circulation, then lodge in and block brain blood vessels. Since blood vessels in the brain are now blocked, the brain becomes low in energy, and thus it resorts to using anaerobic metabolism within the region of brain tissue affected by ischemia. Anaerobic metabolism produces less adenosine triphosphate (ATP) but releases a by-product called lactic acid. Lactic acid is an irritant which could potentially destroy cells since it is an acid and disrupts the normal acid-base balance in the brain. The ischemia area is referred to as the "ischemic penumbra". After the initial ischemic event the penumbra transitions from a tissue remodeling characterized by damage to a remodeling characterized by repair.


title: Stroke

text: As oxygen or glucose becomes depleted in ischemic brain tissue, the production of high energy phosphate compounds such as adenosine triphosphate (ATP) fails, leading to failure of energy-dependent processes (such as ion pumping) necessary for tissue cell survival. This sets off a series of interrelated events that result in cellular injury and death. A major cause of neuronal injury is the release of the excitatory neurotransmitter glutamate. The concentration of glutamate outside the cells of the nervous system is normally kept low by so-called uptake carriers, which are powered by the concentration gradients of ions (mainly Na) across the cell membrane. However, stroke cuts off the supply of oxygen and glucose which powers the ion pumps maintaining these gradients. As a result, the transmembrane ion gradients run down, and glutamate transporters reverse their direction, releasing glutamate into the extracellular space. Glutamate acts on receptors in nerve cells (especially NMDA receptors), producing an influx of calcium which activates enzymes that digest the cells' proteins, lipids, and nuclear material. Calcium influx can also lead to the failure of mitochondria, which can lead further toward energy depletion and may trigger cell death due to programmed cell death.


title: Stroke

text: Ischemia also induces production of oxygen free radicals and other reactive oxygen species. These react with and damage a number of cellular and extracellular elements. Damage to the blood vessel lining or endothelium may occur. These processes are the same for any type of ischemic tissue and are referred to collectively as the "ischemic cascade". However, brain tissue is especially vulnerable to ischemia since it has little respiratory reserve and is completely dependent on aerobic metabolism, unlike most other organs.


title: Stroke

text: Hemorrhagic strokes are classified based on their underlying pathology. Some causes of hemorrhagic stroke are hypertensive hemorrhage, ruptured aneurysm, ruptured AV fistula, transformation of prior ischemic infarction, and drug-induced bleeding. They result in tissue injury by causing compression of tissue from an expanding hematoma or hematomas. In addition, the pressure may lead to a loss of blood supply to affected tissue with resulting infarction, and the blood released by brain hemorrhage appears to have direct toxic effects on brain tissue and vasculature. Inflammation contributes to the secondary brain injury after hemorrhage.


title: Stroke

text: Stroke is diagnosed through several techniques: a neurological examination (such as the NIHSS), CT scans (most often without contrast enhancements) or MRI scans, Doppler ultrasound, and arteriography. The diagnosis of stroke itself is clinical, with assistance from the imaging techniques. Imaging techniques also assist in determining the subtypes and cause of stroke. There is yet no commonly used blood test for the stroke diagnosis itself, though blood tests may be of help in finding out the likely cause of stroke. In deceased people, an autopsy of stroke may help establishing the time between stroke onset and death.


title: Stroke

text: A physical examination, including taking a medical history of the symptoms and a neurological status, helps giving an evaluation of the location and severity of a stroke. It can give a standard score on e.g., the NIH stroke scale.


title: Stroke

text: For the assessment of stable stroke, nuclear medicine scans SPECT and PET/CT may be helpful. SPECT documents cerebral blood flow, whereas PET with an FDG isotope shows cerebral glucose metabolism.


title: Stroke

text: CT scans may not detect an ischemic stroke, especially if it is small, of recent onset, or in the brainstem or cerebellum areas (posterior circulation infarct). MRI is better at detecting a posterior circulation infarct with diffusion-weighted imaging. A CT scan is used more to "rule out" certain stroke mimics and detect bleeding. The presence of leptomeningeal collateral circulation in the brain is associated with better clinical outcomes after recanalization treatment. Cerebrovascular reserve capacity is another factor that affects stroke outcome it is the amount of increase in cerebral blood flow after a purposeful stimulation of blood flow by the physician, such as by giving inhaled carbon dioxide or intravenous acetazolamide. The increase in blood flow can be measured by PET scan or transcranial doppler sonography. However, in people with obstruction of the internal carotid artery of one side, the presence of leptomeningeal collateral circulation is associated with reduced cerebral reserve capacity.


title: Stroke

text: When a stroke has been diagnosed, various other studies may be performed to determine the underlying cause. With the current treatment and diagnosis options available, it is of particular importance to determine whether there is a peripheral source of emboli. Test selection may vary since the cause of stroke varies with age, comorbidity and the clinical presentation. The following are commonly used techniques:


title: Stroke

text: For hemorrhagic strokes, a CT or MRI scan with intravascular contrast may be able to identify abnormalities in the brain arteries (such as aneurysms) or other sources of bleeding, and structural MRI if this shows no cause. If this too does not identify an underlying reason for the bleeding, invasive cerebral angiography could be performed but this requires access to the bloodstream with an intravascular catheter and can cause further strokes as well as complications at the insertion site and this investigation is therefore reserved for specific situations. If there are symptoms suggesting that the hemorrhage might have occurred as a result of venous thrombosis, CT or MRI venography can be used to examine the cerebral veins.


title: Stroke

text: Among people with ischemic strokes, misdiagnosis occurs 2 to 26% of the time. A "stroke chameleon" (SC) is stroke which is diagnosed as something else.


title: Stroke

text: People not having a stroke may also be misdiagnosed as a stroke. Giving thrombolytics (clot-busting) in such cases causes intracerebral bleeding 1 to 2% of the time, which is less than that of people with strokes. This unnecessary treatment adds to health care costs. Even so, the AHA/ASA guidelines state that starting intravenous tPA in possible mimics is preferred to delaying treatment for additional testing.


title: Stroke

text: Women, African-Americans, Hispanic-Americans, Asian and Pacific Islanders are more often misdiagnosed for a condition other than stroke when in fact having a stroke. In addition, adults under 44 years of age are seven times more likely to have a stroke missed than are adults over 75 years of age. This is especially the case for younger people with posterior circulation infarcts. Some medical centers have used hyperacute MRI in experimental studies for persons initially thought to have a low likelihood of stroke. And in some of these persons, strokes have been found which were then treated with thrombolytic medication.


title: Stroke

text: Given the disease burden of strokes, prevention is an important public health concern. Primary prevention is less effective than secondary prevention (as judged by the number needed to treat to prevent one stroke per year). Recent guidelines detail the evidence for primary prevention in stroke. In those who are otherwise healthy, aspirin does not appear beneficial and thus is not recommended. In people who have had a myocardial infarction or those with a high cardiovascular risk, it provides some protection against a first stroke. In those who have previously had a stroke, treatment with medications such as aspirin, clopidogrel, and dipyridamole may be beneficial. The U.S. Preventive Services Task Force (USPSTF) recommends against screening for carotid artery stenosis in those without symptoms.


title: Stroke

text: The most important modifiable risk factors for stroke are high blood pressure and atrial fibrillation although the size of the effect is small; 833 people have to be treated for 1 year to prevent one stroke. Other modifiable risk factors include high blood cholesterol levels, diabetes mellitus, end-stage kidney disease, cigarette smoking (active and passive), heavy alcohol use, drug use, lack of physical activity, obesity, processed red meat consumption, and unhealthy diet. Smoking just one cigarette per day increases the risk more than 30%. Alcohol use could predispose to ischemic stroke, as well as intracerebral and subarachnoid hemorrhage via multiple mechanisms (for example, via hypertension, atrial fibrillation, rebound thrombocytosis and platelet aggregation and clotting disturbances). Drugs, most commonly amphetamines and cocaine, can induce stroke through damage to the blood vessels in the brain and acute hypertension. Migraine with aura doubles a person's risk for ischemic stroke. Untreated, celiac disease regardless of the presence of symptoms can be an underlying cause of stroke, both in children and adults.


title: Stroke

text: High levels of physical activity reduce the risk of stroke by about 26%. There is a lack of high quality studies looking at promotional efforts to improve lifestyle factors. Nonetheless, given the large body of circumstantial evidence, best medical management for stroke includes advice on diet, exercise, smoking and alcohol use. Medication is the most common method of stroke prevention; carotid endarterectomy can be a useful surgical method of preventing stroke.


title: Stroke

text: High blood pressure accounts for 35–50% of stroke risk. Blood pressure reduction of 10 mmHg systolic or 5 mmHg diastolic reduces the risk of stroke by ~40%. Lowering blood pressure has been conclusively shown to prevent both ischemic and hemorrhagic strokes. It is equally important in secondary prevention. Even people older than 80 years and those with isolated systolic hypertension benefit from antihypertensive therapy. The available evidence does not show large differences in stroke prevention between antihypertensive drugs—therefore, other factors such as protection against other forms of cardiovascular disease and cost should be considered. The routine use of beta-blockers following a stroke or TIA has not been shown to result in benefits.


title: Stroke

text: High cholesterol levels have been inconsistently associated with (ischemic) stroke. Statins have been shown to reduce the risk of stroke by about 15%. Since earlier meta-analyses of other lipid-lowering drugs did not show a decreased risk, statins might exert their effect through mechanisms other than their lipid-lowering effects.


title: Stroke

text: Diabetes mellitus increases the risk of stroke by 2 to 3 times. While intensive blood sugar control has been shown to reduce small blood vessel complications such as kidney damage and damage to the retina of the eye it has not been shown to reduce large blood vessel complications such as stroke.


title: Stroke

text: Oral anticoagulants such as warfarin have been the mainstay of stroke prevention for over 50 years. However, several studies have shown that aspirin and other antiplatelets are highly effective in secondary prevention after a stroke or transient ischemic attack. Low doses of aspirin (for example 75–150 mg) are as effective as high doses but have fewer side effects; the lowest effective dose remains unknown. Thienopyridines (clopidogrel, ticlopidine) might be slightly more effective than aspirin and have a decreased risk of gastrointestinal bleeding, but are more expensive. Both aspirin and clopidogrel may be useful in the first few weeks after a minor stroke or high risk TIA. Clopidogrel has less side effects than ticlopidine. Dipyridamole can be added to aspirin therapy to provide a small additional benefit, even though headache is a common side effect. Low-dose aspirin is also effective for stroke prevention after having a myocardial infarction.


title: Stroke

text: Those with atrial fibrillation have a 5% a year risk of stroke, and this risk is higher in those with valvular atrial fibrillation. Depending on the stroke risk, anticoagulation with medications such as warfarin or aspirin is useful for prevention. Except in people with atrial fibrillation, oral anticoagulants are not advised for stroke prevention—any benefit is offset by bleeding risk.


title: Stroke

text: In primary prevention, however, antiplatelet drugs did not reduce the risk of ischemic stroke but increased the risk of major bleeding. Further studies are needed to investigate a possible protective effect of aspirin against ischemic stroke in women.


title: Stroke

text: Carotid endarterectomy or carotid angioplasty can be used to remove atherosclerotic narrowing of the carotid artery. There is evidence supporting this procedure in selected cases. Endarterectomy for a significant stenosis has been shown to be useful in preventing further strokes in those who have already had one. Carotid artery stenting has not been shown to be equally useful. People are selected for surgery based on age, gender, degree of stenosis, time since symptoms and the person's preferences. Surgery is most efficient when not delayed too long—the risk of recurrent stroke in a person who has a 50% or greater stenosis is up to 20% after 5 years, but endarterectomy reduces this risk to around 5%. The number of procedures needed to cure one person was 5 for early surgery (within two weeks after the initial stroke), but 125 if delayed longer than 12 weeks.


title: Stroke

text: Screening for carotid artery narrowing has not been shown to be a useful test in the general population. Studies of surgical intervention for carotid artery stenosis without symptoms have shown only a small decrease in the risk of stroke. To be beneficial, the complication rate of the surgery should be kept below 4%. Even then, for 100 surgeries, 5 people will benefit by avoiding stroke, 3 will develop stroke despite surgery, 3 will develop stroke or die due to the surgery itself, and 89 will remain stroke-free but would also have done so without intervention.


title: Stroke

text: Nutrition, specifically the Mediterranean-style diet, has the potential for decreasing the risk of having a stroke by more than half. It does not appear that lowering levels of homocysteine with folic acid affects the risk of stroke.


title: Stroke

text: A number of specific recommendations have been made for women including taking aspirin after the 11th week of pregnancy if there is a history of previous chronic high blood pressure and taking blood pressure medications during pregnancy if the blood pressure is greater than 150 mmHg systolic or greater than 100 mmHg diastolic. In those who have previously had preeclampsia other risk factors should be treated more aggressively.


title: Stroke

text: Keeping blood pressure below 140/90 mmHg is recommended. Anticoagulation can prevent recurrent ischemic strokes. Among people with nonvalvular atrial fibrillation, anticoagulation can reduce stroke by 60% while antiplatelet agents can reduce stroke by 20%. However, a recent meta-analysis suggests harm from anticoagulation started early after an embolic stroke. Stroke prevention treatment for atrial fibrillation is determined according to the CHA2DS2–VASc score. The most widely used anticoagulant to prevent thromboembolic stroke in people with nonvalvular atrial fibrillation is the oral agent warfarin while a number of newer agents including dabigatran are alternatives which do not require prothrombin time monitoring.


title: Stroke

text: If studies show carotid artery stenosis, and the person has a degree of residual function on the affected side, carotid endarterectomy (surgical removal of the stenosis) may decrease the risk of recurrence if performed rapidly after stroke.


title: Stroke

text: Aspirin reduces the overall risk of recurrence by 13% with greater benefit early on. Definitive therapy within the first few hours is aimed at removing the blockage by breaking the clot down (thrombolysis), or by removing it mechanically (thrombectomy). The philosophical premise underlying the importance of rapid stroke intervention was summed up as "Time is Brain!" in the early 1990s. Years later, that same idea, that rapid cerebral blood flow restoration results in fewer brain cells dying, has been proved and quantified.


title: Stroke

text: Tight blood sugar control in the first few hours does not improve outcomes and may cause harm. High blood pressure is also not typically lowered as this has not been found to be helpful. Cerebrolysin, a mixture of pig-derived neurotrophic factors used to treat acute ischemic stroke in many Asian and European countries, does not improve outcomes and may increase the risk of severe adverse events.


title: Stroke

text: Thrombolysis, such as with recombinant tissue plasminogen activator (rtPA), in acute ischemic stroke, when given within three hours of symptom onset, results in an overall benefit of 10% with respect to living without disability. It does not, however, improve chances of survival. Benefit is greater the earlier it is used. Between three and four and a half hours the effects are less clear. The AHA/ASA recommend it for certain people in this time frame. A 2014 review found a 5% increase in the number of people living without disability at three to six months; however, there was a 2% increased risk of death in the short term. After four and a half hours thrombolysis worsens outcomes. These benefits or lack of benefits occurred regardless of the age of the person treated. There is no reliable way to determine who will have an intracranial bleed post-treatment versus who will not. In those with findings of savable tissue on medical imaging between 4.5 hours and 9 hours or who wake up with a stroke, alteplase results in some benefit.


title: Stroke

text: Its use is endorsed by the American Heart Association, the American College of Emergency Physicians and the American Academy of Neurology as the recommended treatment for acute stroke within three hours of onset of symptoms as long as there are no other contraindications (such as abnormal lab values, high blood pressure, or recent surgery). This position for tPA is based upon the findings of two studies by one group of investigators which showed that tPA improves the chances for a good neurological outcome. When administered within the first three hours thrombolysis improves functional outcome without affecting mortality. 6.4% of people with large strokes developed substantial brain bleeding as a complication from being given tPA thus part of the reason for increased short term mortality. The American Academy of Emergency Medicine had previously stated that objective evidence regarding the applicability of tPA for acute ischemic stroke was insufficient. In 2013 the American College of Emergency Medicine refuted this position, acknowledging the body of evidence for the use of tPA in ischemic stroke; but debate continues. Intra-arterial fibrinolysis, where a catheter is passed up an artery into the brain and the medication is injected at the site of thrombosis, has been found to improve outcomes in people with acute ischemic stroke.


title: Stroke

text: Mechanical removal of the blood clot causing the ischemic stroke, called mechanical thrombectomy, is a potential treatment for occlusion of a large artery, such as the middle cerebral artery. In 2015, one review demonstrated the safety and efficacy of this procedure if performed within 12 hours of the onset of symptoms. It did not change the risk of death, but reduced disability compared to the use of intravenous thrombolysis which is generally used in people evaluated for mechanical thrombectomy. Certain cases may benefit from thrombectomy up to 24 hours after the onset of symptoms.


title: Stroke

text: Strokes affecting large portions of the brain can cause significant brain swelling with secondary brain injury in surrounding tissue. This phenomenon is mainly encountered in strokes affecting brain tissue dependent upon the middle cerebral artery for blood supply and is also called "malignant cerebral infarction" because it carries a dismal prognosis. Relief of the pressure may be attempted with medication, but some require hemicraniectomy, the temporary surgical removal of the skull on one side of the head. This decreases the risk of death, although some people – who would otherwise have died – survive with disability.


title: Stroke

text: People with intracerebral hemorrhage require supportive care, including blood pressure control if required. People are monitored for changes in the level of consciousness, and their blood sugar and oxygenation are kept at optimum levels. Anticoagulants and antithrombotics can make bleeding worse and are generally discontinued (and reversed if possible). A proportion may benefit from neurosurgical intervention to remove the blood and treat the underlying cause, but this depends on the location and the size of the hemorrhage as well as patient-related factors, and ongoing research is being conducted into the question as to which people with intracerebral hemorrhage may benefit.


title: Stroke

text: In subarachnoid hemorrhage, early treatment for underlying cerebral aneurysms may reduce the risk of further hemorrhages. Depending on the site of the aneurysm this may be by surgery that involves opening the skull or endovascularly (through the blood vessels).


title: Stroke

text: Ideally, people who have had a stroke are admitted to a "stroke unit", a ward or dedicated area in a hospital staffed by nurses and therapists with experience in stroke treatment. It has been shown that people admitted to a stroke unit have a higher chance of surviving than those admitted elsewhere in hospital, even if they are being cared for by doctors without experience in stroke. Nursing care is fundamental in maintaining skin care, feeding, hydration, positioning, and monitoring vital signs such as temperature, pulse, and blood pressure.


title: Stroke

text: Stroke rehabilitation is the process by which those with disabling strokes undergo treatment to help them return to normal life as much as possible by regaining and relearning the skills of everyday living. It also aims to help the survivor understand and adapt to difficulties, prevent secondary complications, and educate family members to play a supporting role. Stroke rehabilitation should begin almost immediately with a multidisciplinary approach. The rehabilitation team may involve physicians trained in rehabilitation medicine, neurologists, clinical pharmacists, nursing staff, physiotherapists, occupational therapists, speech-language pathologists, and orthotists. Some teams may also include psychologists and social workers, since at least one-third of affected people manifests post stroke depression. Validated instruments such as the Barthel scale may be used to assess the likelihood of a person who has had a stroke being able to manage at home with or without support subsequent to discharge from a hospital.


title: Stroke

text: Stroke rehabilitation should be started as quickly as possible and can last anywhere from a few days to over a year. Most return of function is seen in the first few months, and then improvement falls off with the "window" considered officially by U.S. state rehabilitation units and others to be closed after six months, with little chance of further improvement. However, some people have reported that they continue to improve for years, regaining and strengthening abilities like writing, walking, running, and talking. Daily rehabilitation exercises should continue to be part of the daily routine for people who have had a stroke. Complete recovery is unusual but not impossible and most people will improve to some extent: proper diet and exercise are known to help the brain to recover.


title: Stroke

text: The current body of evidence is uncertain on the efficacy of cognitive rehabilitation for reducing the disabling effects of neglect and increasing independence remains unproven. However, there is limited evidence that cognitive rehabilitation may have an immediate beneficial effect on tests of neglect. Overall, no rehabilitation approach can be supported by evidence for spatial neglect.


title: Stroke

text: The current body of evidence is uncertain whether the use of rehabilitation can improve on-road driving skills following stroke. There is limited evidence that training on a driving simulator will improve performance on recognizing road signs after training. The findings are based on low-quality evidence as further research is needed involving large numbers of participants.


title: Stroke

text: Based on low quality evidence, it is currently uncertain whether yoga has a significant benefit for stroke rehabilitation on measures of quality of life, balance, strength, endurance, pain, and disability scores. Yoga may reduce anxiety and could be included as part of patient-centred stroke rehabilitation. Further research is needed assessing the benefits and safety of yoga in stroke rehabilitation.


title: Stroke

text: The latest scientific evidence indicates that action observation is beneficial in improving upper limb motor function and dependence in activities of daily living in patients with stroke. Thus, action observation therapy is generally associated with better arm and hand function, with no significant adverse events. The findings are based on low to moderate quality evidence.


title: Stroke

text: The current body of scientific evidence is uncertain on the effectiveness of cognitive rehabilitation for attention deficits in patients following stroke. While there may be an immediate effect after treatment on attention, the findings are based on low to moderate quality and small number of studies. Further research is needed to assess whether the effect can be sustained in day-to-day tasks requiring attention.


title: Stroke

text: The latest evidence supports the short-term benefits of motor imagery (MI) on walking speed in individuals who have had a stroke, in comparison to other therapies. MI does not improve motor function after stroke and does not seem to cause significant adverse events. The findings are based on low-quality evidence as further research is needed to estimate the effect of MI on walking endurance and the dependence on personal assistance.