Stroke is the
clogging or rupture of the vessels that carry blood to the brain, causing
paralysis of the affected area in the brain. It is also called cerebral
vascular accident, stroke, or cerebrovascular accident (CVA).
Types
Depending on the cause of the
stroke it can be hemorrhagic or ischemic. Understand each type better:
Hemorrhagic Stroke
A hemorrhagic stroke is a
stroke in which a cerebral vessel ruptures, causing bleeding (hemorrhage)
somewhere in the nervous system.
The bleeding can happen
inside the brain tissue (intraparenchymal hemorrhagic stroke), which is the
most common and accounts for 15% of all stroke cases. However, bleeding can
also occur near the brain surface, between the brain and the meninges, known as
subarachnoid hemorrhagic stroke.
Although hemorrhagic stroke
is not as common as ischemic stroke, it can cause death more often than
ischemic stroke.
Ischemic Stroke
Ischemic stroke is stroke with
obstruction of the artery, preventing the passage of oxygen to the brain cells,
which die - this condition is called cardiac ischemia.
The obstruction of the artery
can be caused by a thrombus, which is a blood clot that forms in the wall of
the blood vessel; or by an embolus, which is nothing more than a thrombus that
moves through the bloodstream until it gets stuck in a blood vessel smaller
than its length.
Causes
Causes of
Hemorrhagic Stroke
When we talk about a
hemorrhagic stroke, the bleeding can be caused by factors such as:
- Hypertension
- Inflammation in the blood vessels, which can develop from diseases such as syphilis, Lyme disease, vasculitis, and tuberculosis
- Blood clotting disorders, such as hemophilia
- Head or neck injuries that result in damage to blood vessels in the head or neck
- Radiation treatment for cancer of the neck or brain
- Cerebral amyloid angiopathy (a degenerative disease of the blood vessels)
- Atherosclerosis
- Cardiac arrhythmias
- Diseases of the heart valves, such as mitral valve prolapse or stenosis of a heart valve
- Endocarditis
- Patent foramen ovale, which is a congenital heart defect
- Blood clotting disorders
- Vasculitis (inflammation of the blood vessels)
- Heart failure
- Acute myocardial infarction
Causes of Ischemic
Stroke
An ischemia causing a stroke can occur due to factors such as:
- Atherosclerosis: vascular condition where the accumulation of lipids (such as cholesterol and triglycerides), platelets and other substances occurs inside the vessels, leading to a gradual thickening of their walls and generating their obstruction.
- Formation of thrombi: small clotted blood clumps, of various sizes, that when in circulation, find a vessel smaller than its diameter, causing its obstruction.
- Inflammations: local responses that our body produces to combat some undesirable situation. In stroke, the most common inflammations are those caused by antibodies (autoimmune diseases) and infections that attack the interior of the arteries.
Risk Factors
The best-known risk factors for stroke of any type are:
- Hypertension
- Type 2 diabetes
- High cholesterol
- Overweight and obesity
- Smoking
- Excessive use of alcohol
- Old age
- Sedentarism
- Family history (close relative, such as father, mother or brother, had a stroke)
- Being male
In addition, cardiovascular diseases that influence blood flow can increase the risk of ischemic strokes, such as:
- Cardiac arrhythmias, such as atrial fibrillation
- Heart valve diseases, such as mitral valve prolapse or heart valve stenosis
- Endocarditis, which is an infection of the heart valves
- Patent foramen ovale, which is a congenital heart defect
- Heart failure
- Acute myocardial infarction
Symptoms
Symptoms of Stroke
The main symptoms of stroke
are:
- Sudden decrease or loss of strength in the face, arm or leg on one side of the body.
- Sudden change in sensation with tingling sensation in the face, arm or leg on one side of the body.
- Sudden loss of vision in one eye or both eyes.
- Acute alteration of speech, including difficulty articulating, expressing, or understanding language.
- Sudden, severe headache with no apparent cause.
- Instability, sudden intense dizziness and unsteadiness associated with nausea or vomiting.
How to
Differentiate Hemorrhagic and Ischemic Stroke?
In some cases, hemorrhagic
stroke may have rapidly worsening symptoms (such as progressive lowering of
consciousness and sudden deterioration of neurological reflexes).
Also, if the person has more
impactful and severe symptoms early on, such as fainting, seizure and so on, it
is also more likely to be a hemorrhagic stroke.
But there is no definite
clinical way to ascertain this separation. The best alternative is rapid
imaging.
Seeking Medical
Help
In the presence of any of the
stroke symptoms mentioned above, it is important to go to an emergency room
immediately. This is because the faster treatment is given, the less sequelae
resulting from the stroke.
The most correct is to call
the rescue (ambulance) to make the removal instead of taking the patient to the
hospital by car or bus, because some procedures, such as oxygenation, can
already be started in the ambulance.
It is also important to give
preference to hospitals that are known to be prepared to receive a patient in
acute stroke situations.
Diagnosis and Exams
At the Doctor's
Appointment
Specialists who can diagnose
stroke are:
- General practitioner
- Intensive Care Physician
- Neurologist
Since stroke is an emergency
diagnosis, the consultation usually occurs without any preparation on the part
of the patient and his or her companions.
Stroke Diagnosis
First Aid
If you suspect that a person is having a stroke, the pre-hospital stroke scale should be applied to recognize the most frequent signs if the patient does not have a clear picture. Of the three items assessed, a positive sign (with sudden onset) is enough to suspect a hemorrhagic stroke:
- Face: the rescuer will ask the patient to give a smile, to check for deviation of the mouth.
- Strength: he will ask the patient to raise both arms and see if one of them falls because of lack of strength.
- Speech: The patient will be asked to say any phrase, such as "the sky is blue", to check if there is any alteration.
Diagnosis and Emergency
Treatment
Once the patient arrives at
the hospital, emergency clinical care includes:
- Check vital signs, such as blood pressure and axillary temperature.
- Position the head of the bed at 0°, except if vomiting is present (in this case keep it at 30 degrees).
- Place peripheral venous access in non-paralyzed upper limb.
- Administer oxygen by nasal catheter or mask, if the patient needs it.
- Check capillary blood glucose
- Determine the time of symptom onset by questioning the patient or caregiver.
Examination
Some exams can be done, during hospitalization, to help diagnose the type of stroke (ischemic or hemorrhagic), as well as what caused it:
- Computed tomography
- Magnetic resonance
- Angiography
- Ultrasonography
- Echocardiogram
Stroke Treatment
Emergency Treatment
in The Hospital
When the stroke patient
arrives at the hospital and it is determined what type of stroke he has,
emergency treatments are performed.
If the time of onset of
symptoms is less than four hours, with no intracranial hemorrhage present, an
attempt can be made to clear the arteries using an intravenous medication,
rt-PA.
This procedure is known as
intravenous thrombolysis, and can be performed if the patient is included in
the inclusion and exclusion criteria for the procedure and has no
contraindications.
These inclusion and exclusion
criteria are determined by institutional protocols that must follow the most
modern international recommendations in the area.
If the presence of a thrombus
in the cerebral arteries is observed in the imaging exam, the preference is for
mechanical removal or local dissolution of the thrombus. This procedure is
performed by the Neuroradiology team, which must be called immediately.
Through advanced endovascular
procedures (such as catheterization), it is possible to remove the thrombus or
to infuse on site medications that remove the obstruction (including rt-PA).
This enables the immediate unblocking of the blocked artery. This procedure is
indicated for patients with up to 8 hours event.
If the history is longer than
4 hours, with no evidence of the presence of thrombus in the intracerebral
arteries detected by imaging, all that is left is clinical treatment and
support to reduce damage and prevent further events.
After the emergency, the
patient is taken to the Intensive Care Unit (ICU), where he or she will be
closely observed and monitored, in addition to continuing diagnostic
investigation tests and prevention of new events.
All the patient's controls
must be stabilized (blood pressure, glycemia, metabolic and hydro-electrolytic
balance).
Clinical Treatment
After the Patient's Recovery
The treatment and
rehabilitation of a stroke victim will always depend on the particularities
surrounding each case. There are therapeutic resources that can help restore
the affected functions.
For the patient to have a
better recovery and quality of life, it is fundamental that he/she is analyzed
and treated by a multidisciplinary team of health professionals,
physiotherapists, physicians, psychologists, and other professionals.
Whatever the type of
accident, the consequences are very harmful. Besides being among the main
causes of death worldwide, stroke is one of the pathologies that most
incapacitate people to perform their daily activities.
Types of
Rehabilitation Technique
During rehabilitation it is
important that the patient is accompanied by:
- Physical therapists
- Occupational therapists
- Speech therapists
Medications for
Stroke
The medications used in
stroke treatment are generally indicated to prevent future complications, such
as cardiovascular diseases. For cases like this, simvastatin is usually the
drug most often prescribed by specialists.
However, always keep in mind
that only a doctor can tell you which medication is best for you, as well as
the correct dosage and duration of treatment. Always follow your doctor's
instructions to the letter and never treat yourself.
Do not discontinue use of the
drug without consulting a doctor first, and if you take it more than once or in
much larger amounts than prescribed, follow the directions on the package
insert.
Is There A Cure for
Stroke?
When a person is attended to
quickly after a stroke, his or her chances of surviving and having fewer
sequelae are lower.
If the patient has survived
and is left with sequelae, the recovery time varies from case to case and
depends on several factors.
Some of the factors are: the
extent of the stroke, the patient's age, general health conditions, physical
and speech therapy, nursing care, and psychological and family support after
the stroke.
Time to Recover
from A Stroke
In general, the average
recovery time is around six months to one year.
Possible Complications
See below the types of
rehabilitation for the main sequelae of a stroke:
Motor deficit
It occurs when the area
affected by the stroke is the one responsible for the movements of our body,
being the left side of the brain responsible for the movements of the right
side and vice-versa.
Early physiotherapy and
occupational therapy is important, in order to reinsert the person in
day-to-day activities.
Sensory Deficit
Several areas of the brain
are related to sensitivity. When one of them is damaged, the person can no
longer feel one side of the body.
One activity that can help in
the recovery of sensitivity is to expose the affected area to different
materials, such as sponges, paper, wood, rough sandpaper, etc.
Aphasia
When the stroke occurs in the
area of the brain that corresponds to language (drill and wernicke), it is
common for the patient to suffer from aphasia. The work of a speech therapist
is fundamental.
It can be divided basically
into two large groups: aphasia of expression (when the patient understands what
you say, but is unable to express himself through spoken language) and aphasia
of comprehension (when he can express himself in all forms, but does not
understand what is said to him).
Apraxia
The stroke patient with
apraxia loses the ability to express himself by gestures and mimics, and to
perform motor tasks in sequences.
For example: the inability to
make gestures that have a predefined meaning, such as the silent sign, waving
hello or raising the thumb in a positive sign.
In these cases, the patient
needs to relearn how to do these processes. It is necessary to re-teach this
sequence of movements, which must be remembered and exercised.
Neglect
Resulting from lesions in the
non-dominant cerebral hemisphere, which in the majority of the population is
the right side. This sequel concerns a person who neglects a part or a side of
his or her body, as if that segment did not belong to the person. It is
fundamental to stimulate the affected side of the body to reduce the sequela;
Visual Agnosia
Visual agnosia is understood
as a person's incapacity to recognize objects and people through sight, even
though this has not been compromised. Depending on the degree of the injury,
the person may not even recognize faces anymore.
It is important to exercise
this side of the patient, introducing him/her to new objects, always with a lot
of patience - one tactic is to start with objects that were part of the
patient's daily life before the stroke.
Memory Deficit
This occurs when the temporal
region of the brain is affected. The person usually loses the ability to
remember recent events, recalling only past episodes.
Brainstem Injuries
In the brainstem are located
centers responsible for vital activities, such as breathing. Injuries to this
region can leave serious sequelae and even lead to death.
Patients with this type of
sequelae can also present paralysis on both sides of the body, strabismus, and
difficulty swallowing - each point being treated by its specific specialty.
Behavioral
Alterations
Caused by a lesion in the front part of the brain, behavioral changes are common in stroke victims.
The individual usually goes
through agitation and apathy pictures, passing through symptoms such as loss of
initiative or angry outbursts with no apparent cause.
Caregivers should seek medical advice, as in some cases it may be necessary for the patient to be medicated.
Depression
The illness works exactly
like ordinary depression, but it begins after the stroke.
The symptoms are the same as
those of common depression - sadness, apathy, inadequate sleep, eating
disorders, among others - and it requires specialized treatment with a
psychologist and with a neurologist or psychiatrist.
Post-Traumatic
Stress Disorder (PTSD)
It is common in individuals
with stroke. Symptoms that help identify the problem are persistent nightmares
and the patient's tendency to avoid memories of the event.
Prevention
Many risk factors contribute
to the onset of ischemic stroke. Some of these factors cannot be changed, such
as age, race, genetic makeup, and gender.
Other factors, however, can
be diagnosed and treated, such as hypertension (high blood pressure), diabetes
mellitus, heart disease, migraine, use of hormonal contraceptives, alcoholic
beverages, smoking, sedentary lifestyle (lack of physical activities), and
obesity.
The adequacy of daily life
habits is primordial for the prevention of stroke.
The objective of treatment
after a stroke involves, besides treating the sequels that appear, preventing
possible future events. Therefore, lifestyle changes are an important part of
ischemic stroke follow-up.
Here's what you need to do to
prevent another stroke:
- Do not smoke or do not allow others to smoke near you.
- Maintain a healthy weight.
- Get at least 30 minutes of exercise most days of the week (walking is a good choice).
- Maintain a balanced diet, with less cholesterol, saturated fats, sugar, and salt, according to professional advice.
- Control your blood pressure (if you are hypertensive).
- Control your blood glucose (if you have diabetes).
- Continue taking the medications prescribed by your doctor. After the ischemic stroke the vast majority of patients will have to take an anti-aggregant, medication that thins the blood, such as aspirin (ASA).