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STROKE
INTRODUCTION
The brain controls our body movements, processes information from the outside
world and allows us to communicate with others. The brain is also one of the
most delicate parts of the body and, tragically, even a short time without a good
blood supply can be disastrous, the brain is damaged within minutes.
Having a stroke is one of the more alarming and devastating things that can
happen to a person, and will happen to a quarter of us over the age of 45.
The symptoms of a ‘stroke’ usually come on quickly and can be very severe. A
stroke occurs when part of the brain stops working because of problems with its
blood supply. This leads to the classic symptoms of a stroke, such as a sudden
weakness affecting the arm and leg on the same side of the body.
'Stroke' or 'brain attack' are lay terms used to describe the disruption of blood
flow to the brain. This may be caused by cerebral haemorrhage (haemorrhagic
stroke) or by blockage of an artery (ischemic stroke).
Keeping abreast of emerging evidence in a field such as stroke is a difficult task
for busy practitioners. High quality treatment may save a patient’s life or result
in reduce disability. Guidelines can never provide the answers for every
situation and do not replace sound clinical judgement and common sense. The
guidelines do, however, provide a framework for such care and are intended to
be just as practical and relevant for non-specialists as for specialists.
There have been a number of developments in stroke medicine over the past
years. Stroke medicine is now a recognised specialty within medicine and all
hospitals have been advised by their national government that they should have
a dedicated stroke unit. The roles of the nurse, physiotherapist, occupational
therapist and speech therapist are also developing and companion publications
drawing from guidelines provide each profession with specific guidance.
A stroke patient is likely to be treated during the course of their illness by many
different people, ranging from the doctors and nurses in the emergency
department, a wide array of professionals on the stroke unit, to therapists,
doctors, nurses and social services staff in the community.
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WHAT IS A STROKE?
A stroke occurs when the blood supply to the brain is disturbed in some way. As
a result, brain cells are starved of oxygen causing some cells to die and leaving
other cells damaged.
The most common cause of a stroke is a thrombosis – when a blood vessel
supplying vital nutrients to the brain becomes blocked with a blood clot.
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CAUSES, INCIDENCE, AND RISK FACTORS
Every 45 seconds, someone in the world has a stroke. A stroke can happen
when:


A blood vessel carrying blood to the brain is blocked by a blood clot. This
is called an ischemic stroke.
A blood vessel breaks open, causing blood to leak into the brain. This is a
hemmorhagic stroke.
If blood flow is stopped for longer than a few seconds, the brain cannot get
blood and oxygen. Brain cells can die, causing permanent damage.
ISCHEMIC STROKE
This is the most common type of stroke. Usually this type of stroke results from
clogged arteries, a condition called atherosclerosis. Fatty deposits and blood
platelets collect on the wall of the arteries, forming a sticky substance called
plaque. Over time, the plaque builds up. Often, the plaque causes the blood to
flow abnormally, which can cause the blood to clot.
There are two types of clots:


A clot that stays in place in the brain is called a cerebral thrombus.
A clot that breaks loose and moves through the bloodstream to the brain
is called an cerebral embolism.
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Another important cause of cerebral embolisms is a type of arrhythmia called
atrial fibrillation. Other causes of ischemic stroke include endocarditis and the
use of a mechanical heart valve. A clot can form on the artificial valve, break
off and travel to the brain. For this reason, those with mechanical heart valves
must take blood thinners.
HEMORRHAGIC STROKE
A second major cause of stroke is bleeding in the brain hemorrhagic stroke. This
can occur when small blood vessels in the brain become weak and burst. Some
people have defects in the blood vessels of the brain that make this more likely.
The flow of blood after the blood vessel ruptures damages brain cells.
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STROKE RISKS
High blood pressure is the number one reason that you might have a stroke. The
risk of stroke is also increased by age, family history of stroke, smoking,
diabetes, high cholesterol, and heart disease. Certain medications increase the
chances of clot formation, and therefore the chances for a stroke. Birth control
pills can cause blood clots, especially in woman who smoke and who are older
than 35. Men have more strokes than women. But, women have a risk of stroke
during pregnancy and the weeks immediately after pregnancy. Cocaine use,
alcohol abuse, head injury, and bleeding disorders increase the risk of bleeding
into the brain.
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Warning Signs of Stroke
The most common sign of stroke is sudden weakness of the face, arm or leg,
most often on one side of the body.
Other warning signs can include:
- Sudden numbness of the face, arm, or leg, especially on one side of the
body
- Sudden confusion, trouble speaking or understanding speech
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden severe headache with no known cause
The signs of a stroke depend on the side of the brain that's affected, the part of
the brain, and how severely the brain is injured. Therefore, each person may
have different stroke warning signs. Stroke may be associated with a headache,
or may be completely painless.
Even if the symptoms pass quickly, they could be an important warning that
requires prompt medical attention.
TYPES OF STROKE
Transient ischemic attack (TIA)
Cerebral thrombosis
Cerebral embolism
Cerebral haemorrhage
Transient ischemic attack (TIA):
 Is a short-term stroke that lasts for less than 24 hours.
 Is caused by a temporary state of reduced blood flow in a portion of the
brain. This is most frequently caused by tiny blood clots that temporarily
occlude a portion of the brain. During a TIA, the temporary disturbance of
blood supply to an area of the brain results in a sudden, brief decrease in
brain function.
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 Refers to temporary brain dysfunction due to a shortage of blood and
oxygen. It sometimes is referred to as a "mini-stroke." TIA is a serious
condition that serves as a warning for a stroke. The chance of suffering a
stroke is greatest in the first few months after the initial TIA.
 The oxygen supply to the brain is restored quickly, and symptoms of the
stroke disappear completely. A transient stroke needs prompt medical
attention as it is a warning of serious risk of a major stroke
Blood Supply to the Brain
A primary blood supply to the brain is through two arteries in the neck (the carotid arteries) that branch off
within the brain to multiple arteries that supply specific areas of the brain.
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Cerebral Thrombosis is a formation or development of a blood clot within a
blood vessel. A clot in an artery supplying the brain gradually cuts off the blood
supply to that particular area of the brain and causes a stroke. The clot usually
develops because of damage to the wall of the blood vessel.
Cerebral Embolism is a blockage that has entered the bloodstream. This
blockage can be air, fat or some other material that has found its way into the
circulatory system. Most often it is a piece of thrombus that has broken up and
lodged in one of the arteries of the brain.
Cerebral haemorrhage is a bleeding from a ruptured blood vessel in the brain
that can be fatal without prompt medical treatment. A person who survives may
be left with permanent disabilities, depending on the location and severity of the
brain damage.
The blood is supplied to the brain from the front of the neck and
the backbone. The arteries join in a rough circle which helps to
maintain an adequate supply of blood if one artery is blocked.
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- Causes
A temporary blockage of the blood supply to the brain results in a TIA; build up
of plaque in the arteries and hardening of the arteries usually is present. Reasons
for the blockage may include:
 A blood clot or a piece of plaque from inside the wall of an artery breaks
off and blocks blood flow to a portion of the brain.
 A blood clot dislodges from the heart and moves to the brain.
 Temporary low blood pressure in the brain may occur due to narrowed
arteries in the neck.
Blood and blood clotting disorders may predispose to TIAs, such as:




Anemia
Polycythemia
Hyperviscosity
Vasculitis or blood vessel inflammation
- Risk Factors
A risk factor is something that increases your chance of getting a disease or
condition:
-
Atrial fibrillation, an irregular heart rhythm
Family history of stroke
Age: 45 or older (highest risk is in the 7th and 8th decades)
Diabetes
Heart disease
Smoking
High blood pressure
Excessive alcohol use
Sex: male
High cholesterol
Obesity
Sedentary lifestyle
Sleep apnoea
AIDS
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- Symptoms
TIA's symptoms usually last less than 10 minutes, but may persist for up to 24
hours. The effects differ depending on the location of the blockage. The
following is a list of possible problems and are similar to those of a stroke and
warrant immediate medical care:
- Blindness in one eye, often described as a window shade dropping
- Other vision problems
- Weakness, numbness, or tingling of the face, arm, leg, or one side
of the body (Usually affects one side of the body, but there are
exceptions)
- Difficulty speaking or understanding words
- Dizziness, unsteadiness, or a fall
- Difficulty walking or unsteady gait
- Trouble with balance or coordination
- Loss of consciousness
- Nausea
- Vomiting
- Sudden confusion or memory problems
Stroke symptoms are typically of sudden onset and may quickly become worse.
-
Weakness or inability to move a body part
Numbness or loss of sensation
Decreased or lost vision (may be partial)
Speech difficulties
Inability to recognize or identify familiar things
Sudden headache
Vertigo (sensation of the world spinning around)
Dizziness
Loss of coordination
Swallowing difficulties
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- Sleepy, stuporous, lethargic, comatose, or unconscious
- pain
 may occur prior to other neurologic deficits
 may be in neck
 may radiate into eye
- pulsating noises may be present in the ear (pulsatile tinnitus)
- weakness or total inability to move a body part
- abnormal sensations
 numbness, loss of sensation
 tingling or other
- Horner's syndrome
 eyelid drooping (ptosis)
 abnormal pupil
 abnormal facial sweating
- decreased or lost vision, partial or temporary
- language difficulties (aphasia)
- inability to recognize or identify sensory stimuli (agnosia)
- loss of memory
- vertigo (abnormal sensation of movement)
- personality changes
- mood and emotion changes
- consciousness changes
- sleepy
- stuporous, somnolent, lethargic
- comatose, unconscious
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- Diagnosis
The doctor will ask about the symptoms and medial history, and perform a
physical exam. A primary goal is to determine your stroke risk.
Tests may include:
Blood Tests - including a complete blood count, blood sugar, cholesterol, fat
levels, clotting levels, and a check of other elements in the blood
Electrocardiogram (EKG) – to measure heart rhythm and check for an
irregular heart beat
Ultrasound– a test that uses sound waves to help determine if there are
blockages in the arteries supplying the brain
MRI Scan – a test that uses magnetic waves to make pictures of structures
inside the head
MRI of Brain Injury
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Magnetic Resonance Angiography– performed prior to carotid artery surgery
to determine how much the artery has narrowed. Gadolinium, a type of dye, may
be injected into your vein for this test.
Arteriogram – during a conventional arteriogram, a contrast dye is injected and
x-ray images are produced to precisely locate the blockage and to determine
how much of the artery is blocked. This test is usually only done to confirm the
need for surgery.
Echocardiogram – an ultrasound test that looks for blood clots and valve
abnormalities within the heart
Electroencephalogram (EEG) – a test that can detect seizures by measuring
brain waves (used only if a seizure is suspected)
- Treatment
A TIA places at greater risk for having a stroke; therefore, treatment aims to
decrease stroke risk through lifestyle changes, medication, and surgery. Any
contributing conditions such as diabetes or high blood pressure should be
brought under control.
Medications: many patients receive aspirin or other drugs to decrease the risk of
clot formation. However, there are situations when these drugs cannot be used.
If the blood cholesterol is high or hypertension, drugs to lower it may be
prescribed.
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Endarterectomy:
If the carotid artery is 70% blocked or more there may recommend
a carotid to remove the plaque deposits
Endarterectomy : a surgical procedure removing plaque material from
the lining of an artery.
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Note: A stroke is a sudden interruption in the blood supply of the brain. A
carotid dissection is when a carotid artery develops a tear in its lining. The flow
of blood in between the various layers of the blood vessel causes the layers to
separate, resulting in the lumen (channel) narrowing.
Stroke secondary to carotid dissection, unlike many other forms of stroke, may
occur in young people, usually under 40 years old. Dissection accounts for less
than 5% of strokes.
Carotid stenosis, X-ray of the left artery
Carotid stenosis, X-ray of the right artery
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CONCLUSION
Stroke is caused by a loss of blood circulation to an area or areas of the brain.
The specific neurologic deficits may vary depending on the location, extent of
the damage, and cause of the disorder. Most strokes occur when a blood clot
blocks one of the arteries (blood vessels) that carries blood to the brain
Most strokes are caused by an abrupt blockage of arteries leading to the brain
(ischemic stroke). Other strokes are caused by bleeding into brain tissue when
a blood vessel bursts (hemorrhagic stroke). Because stroke occurs rapidly and
requires immediate treatment, stroke is also called a brain attack.
When the symptoms of a stroke last only a short time (less than an hour), this is
called a transient ischemic attack (TIA) or mini-stroke. Transient ischemic
attack (TIA) is a short-term stroke that lasts for less than 24 hours. The oxygen
supply to the brain is restored quickly, and symptoms of the stroke disappear
completely. A transient stroke needs prompt medical attention as it is a warning
of serious risk of a major stroke.
Approximately one in 10 strokes is caused by cerebral haemorrhage. This type
of stroke (haemorrhagic stroke) is usually much more severe than ischaemic
stroke.
The effects of a stroke depend on which part of the brain is injured, and how
severely it is injured. Strokes may cause sudden weakness, loss of sensation, or
difficulty with speaking, seeing, or walking. Since different parts of the brain
control different areas and functions, it is usually the area immediately
surrounding the stroke that is affected.
Sometimes people with stroke have a headache, but stroke can also be
completely painless. It is very important to recognize the warning signs of
stroke and to get immediate medical attention if they occur.
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RESOURCES:
www.strokecenter.org/pat/about.htm
http://healthgate.partners.org/browsing/LearningCenter.asp?
http://medlineplus.gov/
http://www.nlm.nih.gov/medlineplus/ency/article/000726.htm
http://healthgate.partners.org
www.netdoctor.co.uk
U.S. National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894
American Heart Association: http://www.americanheart.org/
National Stroke Association: http://www.stroke.org/
SOURCES:
Conn's Current Therapy. W. B. Saunders Co.;2001.
Griffith's 5-Minute Clinical Consult, 1999 ed. Lippincott Williams & Wilkins;1999.
National Institute of Neurological Disorders and Stroke.
Practice of Geriatrics, 3rd ed. W. B. Saunders Co.;1998.
Primary Care Medicine, 4th ed. Lippincott Williams & Wilkins;2000.
National clinical guidelines for stroke - Prepared by the Intercollegiate Stroke Working Party
June 2004 Second edition
Clinical Effectiveness & Evaluation Unit
ROYAL COLLEGE OF PHYSICIANS - UK
Extra: Domains of training materials
http://members.madasafish.com/~shinybeetle/illness/burton.
Film about trunck stability scale after stroke made by the university of Leuven
In map neuroblend
http://www.emedicine.com/neuro/topic9.htm
about acute stroke care: text + tests, management, drugs, …
http://www.emedicine.com/neuro/NEUROVASCULAR_DISEASES.htm
list with all the neurovascular diseases
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