Stroke (Brain Attack)

Stroke is a feared disease because it is the leading cause of long term disability in the United States. Say the word stroke and you are likely to picture people who need help completing life’s daily tasks—eating, dressing, walking, and grocery shopping. And, unfortunately, this is not far from the truth. Of those who survive a first stroke, fully 30 percent of stroke victims die within one year after the event nearly a third lose much of their personal independence, and over two thirds experience problems on the job over the long term.

A stroke or “brain attack” occurs when a blood clot blocks the blood flow in a vessel or artery or when a blood vessel breaks, interrupting blood flow to an area of the brain. When either of these things happens, brain cells begin to die. When brain cells die during a stroke, abilities controlled by that area of the brain are lost. These include functions such as speech, movement, and memory. The specific abilities lost or affected depend on the location of the stroke and on its severity (i.e., the extent of brain cell death). For example, someone who has a small stroke may experience only minor effects such as weakness of an arm or leg. Someone who has a larger stroke may be paralyzed on one side or lose his/her ability to speak. Some people recover completely from less serious strokes, while other strokes can be fatal.

Types of  Stroke:

There are two main types of stroke: ischemic and hemorrhagic. Ischemic strokes are by far the most common in the United States accounting for 70 to 80 percent of all strokes-and occur when there is an interruption in the flow of blood to the brain, almost always due to a clot blocking a blood vessel. The remaining 20 to 30 percent are hemorrhagic strokes, which occur when a blood vessel in the brain ruptures and bleeds.

Ischemic strokes:

In everyday life, blood clotting is beneficial. When you are bleeding from a wound, blood clots work to slow and eventually stop the bleeding. In the case of stroke, however, blood clots are dangerous because they can block arteries and cut off blood flow to the brain, a process called ischemia.

Ischemic stroke occurs when there is a blockage in one of the arteries that supplies blood  to the brain. If the blockage lasts longer than about two hours, the part of the brain nourished by the artery dies. The exact effects of a stroke depend on the part of the brain that is affected and how long the blood vessel is blocked. There are two main types of ischemic strokes: thrombotic and embolic. Like a heart attack, thrombotic stroke most often occurs when a buildup of fat and cholesterol (plaque) in a brain artery ruptures and a blood clot (thrombus) forms that blocks the blood supply to brain tissue. Embolic stroke is the result of a blockage in an artery by a clot or fragment of plaque that is formed elsewhere in the body, often in the heart, and travels with the blood until it lodges in a small blood vessel in the brain. Clots and other debris that travel through the blood are called emboli. Embolic strokes are often linked to atrial fibrillation, a condition in which one of the chambers of the heart beats rapidly and irregularly. The fluttering motion allows blood to pool in the heart and form clots that can travel to the brain. Other heart diseases also greatly increase the risk of emboli, including coronary heart disease, valve disease, and congestive heart failure.

Transient Ischemic Attacks: Strokes are often preceded, from days to months, by events called transient ischemic attacks (TIAs). Often referred to as mini strokes or precursors to stroke, Transient ischemic attacks, or TIAs, are brief episodes of stroke symptoms resulting from temporary interruptions of blood flow to the brain. TIAs can last anywhere from a few seconds up to 24 hours. Unlike actual strokes, TIAs do not kill brain cells, and therefore, do not result in permanent brain damage. However, they can be warning signs of an impending stroke.The symptoms of a TIA are the same as for a stroke:

• Sudden numbness of face, arm or leg, especially on one side of the body
• Sudden trouble seeing in one or both eyes
• Sudden confusion, trouble speaking or understanding
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause

If a person experiences any of these symptoms, for even the briefest amount of time, he or she should seek medical attention immediately. Urgent response to symptoms is important for two reasons:

• If you are having an actual stroke, emergency medical attention could save your life and greatly improve your chances for successful rehabilitation and recovery.
• If you are having a TIA, your doctor will evaluate and treat the underlying causes. Unfortunately, most people who have TIAs neglect to seek treatment, either because the symptoms are painless or because they choose to attribute their symptoms to old age, fatigue, etc.

Hemorrhagic Stroke:

A hemorrhagic stroke  also called a brain hemorrhage or cerebral hemorrhage, occurs when a blood vessel in the brain ruptures, causing bleeding (hemorrhaging) into or around the brain. Brain damage can result from a hemorrhagic stroke because of lack of blood and oxygen to the tissues, as well as a buildup of pressure from the bleeding. Although every stroke is serious, brain hemorrhages are often devastating because they are more likely to cause death.

There are essentially two types of hemorrhagic stroke: intracerebral hemorrhage and subarachnoid hemorrhage. When bleeding takes place inside the brain tissue, the stroke is called an intracerebral hemorrhage. When a vessel on the surface of the brain bursts, it is called a subarachnoid hemorrhage. While intracerebral hemorrhages usually occur in normal blood vessels that may have been weakened by a factor such as hypertension, subarachnoid hemorrhages tend to occur in abnormally shaped, weak-walled arteries in the brain. Subarachnoid hemorrhages also tend to be more serious than intracerebral hemorrhages. Because a subarachnoid hemorrhage causes bleeding into the area between the brain and the skull (called the subarachnoid space), pressure can build up and press upon a large area of the brain that controls vital functions.

Who are at risk of developing stroke? What are the risk Factors?

1. The chances of having a stroke increase with age. Two-thirds of all strokes happen to people over age 65.
2. Males have a slightly higher stroke risk than females.
3. African Americans have a higher stroke risk than some other racial groups
4. Risk is higher for people with a family history of stroke or TIA
5. People with diabetes have a higher stroke risk, even if diabetics are on medication and have blood sugar under control, they may still have an increased stroke risk simply because they have diabetes
6. Hypertension is a major risk factor for stroke. The increased blood pressure can raise the risk of stroke by injuring and weakening artery walls. An injury to an artery wall can start the process of atherosclerosis, and a weakened artery wall is more likely to burst and bleed, especially when blood pressure isvery high.
7. Excessive alcohol and drug use have been associated with higher incidences of ICH and SAH
8. If you have any type of blood clotting disorder, such as hemophilia or sickle cell anemia
9. Although anti-clotting medication may prevent ischemic stroke, if your blood becomes “too thin,” you may be at risk for an ICH.
10. Smoking can raise the risk of stroke in many ways. It promotes atherosclerosis, increases short-term blood pressure, and makes it more likely that blood will clot.
11. Atrial Fibrillation: Atrial fibrillation greatly increases the risk of stroke approximately 6 times in those with the condition compared to those without. The irregular beating of the atria can cause blood to pool, promoting the formation of clots, which can then travel to the brain and get lodged in an artery, cutting off the blood supply.
12. A heart attack can increase the risk of stroke by weakening the pumping action of the heart or causing an irregular heartbeat, both of which can cause blood clots to form; these clots can then travel to the brain. The risk of a stroke is highest in the first month following a heart attack, but remains elevated for years afterward. A heart attack can also be a sign that a person is prone to atherosclerosis, which increases the likelihood that they will also develop plaque in the large arteries of the neck.
13. Valve disease and congestive heart failure, can also increase the risk of stroke, usually by increasing the likelihood that clots will form and travel through the bloodstream to the brain.

Signs and Symptoms of Stroke:

1. Weakness: Sudden loss of strength or sudden numbness in the face, arm or leg, even if temporary. This may affect the whole side or just the arm or the leg. The weakness or paralysis is on the side of the body opposite the side of the brain injured by the stroke. For example, if the stroke injured the left side of the brain, the weakness or paralysis will be on the right side of the body.
2. Trouble speaking (aphasia and dysarthria): Sudden difficulty speaking or understanding or sudden confusion, even if temporary. A person with aphasia may have trouble understanding speech or writing. Or, the person may understand but may not be able to think of the words to speak or write. A person with dysarthria knows the right words but has trouble saying them clearly.
3. Vision problems—Sudden trouble with vision, even if temporary.
4. Headache: Sudden severe and unusual headache.

The above symptoms are immediate. The symptoms below can occur immediately or later on:

1. Being unaware of or ignoring things on one side of the body (bodily neglect or inattention): Often, the person will not turn to look toward the weaker side or even eat food from the half of the plate on that side.
2. Pain, numbness, or odd sensations: These can make it hard for the person to relax and feel comfortable.
3. Problems with memory, thinking, attention, or learning (cognitive problems): A person may have trouble with many mental activities or just a few. For example, the person may have trouble following directions, may get confused if something in a room is moved, or may not be able to keep track of the date or time.
4. Being unaware of the effects of the stroke: The person may show poor judgment by trying to do things that are unsafe as a result of the stroke.
5. Trouble swallowing: This can make it hard for the person to get enough food. Also, care must sometimes be taken to prevent the person from breathing in food  while trying to swallow it.
6. Problems with bowel or bladder control
7. Getting tired very quickly: Becoming tired very quickly may limit the person's participation and performance in a rehabilitation program.
8. Sudden bursts of emotion, such as laughing, crying, or anger: These emotions may indicate that the person needs help, understanding, and support in adjusting to the effects of the stroke.

Diagnostic Tests: These are the most common types of brain imaging used for diagnosis of strokes:

1. CT scan (computed tomography) —this can show the kind of stroke you have had (for example, a stroke caused by a blocked or burst blood vessel and how much damage it may have caused.
2. MRI scan (magnetic resonance imaging) — this can give a more detailed picture of your brain. It is sometimes used instead of a CT scan for certain types of strokes, or to make sure what was found in the CT scan is correct.
3. Other tests :

• blood tests;
• chest X-ray;
• electrocardiogram
• doppler ultrasound
• Echocardiogram

Treatment:

Treatment begins in a hospital with "acute care." This first step includes helping the patient survive, preventing another stroke, and taking care of any other medical problems. Your treatment will depend on:

• The type of stroke you have had
• Whether you have any other medical conditions
• The results of your brain scan.

What treatment will I get straight away if my stroke was not hemorrhagic?

1. Thrombolytic (clot busting} drugs:  if these are appropriate you will be given them ASAP.
2. Aspirin: this is given within 48 hours of the stroke and for 14 days after the stroke. After this, you will take a low dose of aspirin for life.
3. Nurses will pay close attention to your body position and will help you move as soon as possible after your stroke, to help protect your limbs and reduce any possible complications such as: blood clots in your legs; chest infections; bed sores and urine infections. This will involve careful positioning and moving of your arms and legs.

Treatment to reduce the risk of having another stroke will be given:

Antiplatelet therapy:  After an ischaemic stroke (caused by a blocked blood vessel) most people will be given antiplatelet therapy to reduce the risk of another stroke. Antiplatelet therapy prevents blood cells called platelets from sticking together to make blood clots.  You may be given:

• low-dose aspirin and dipyridamole;
• clopidogrel; or
• ow-dose aspirin.

Anticoagulation therapy; If you have an irregular heartbeat (atrial fibrillation) and you have had an ischaemic stroke, anticoagulation therapy (warfarin) may be used to reduce the risk of blood clots that could cause another stroke.

Statin therapy: Statins are used to help to reduce the level of cholesterol in your blood. A build-up of cholesterol in your blood can block your arteries and cause you to have a stroke. Two of the most common statins are: atorvastatin and simvastatin.

Anti-hypertensive medication:

Anti-hypertensive medication is used to help reduce high blood pressure and the risk of developing heart failure, heart attacks and strokes. Even if you don't have high blood pressure, you may be given an anti-hypertensive to prevent it from happening. Your blood pressure will be monitored throughout your treatment and the medication will be changed when necessary. The two most common types of medications which also help to lower blood pressure are: ACE inhibitor drugs and thiazide diuretic (a water tablet).

Is surgery right for me?

Not all patients need surgery. You may have a test called doppler ultrasound. This will show if the carotid arteries (which carry blood from your heart to the brain) in your neck have become more narrow. lf the doctor thinks your stroke was caused by the carotid artery narrowing, then they will decide if you should have surgery. The surgery removes the fatty deposits that cause your arteries to become narrow and reduces the risk of having another stroke. Specialist surgeons will perform the surgery. Surgery should be performed as soon as you are stable and fit enough. The best time is within two weeks of your stroke.

Depression After Stroke:

It is normal for a stroke survivor to feel sad over the problems caused by stroke. However, some people experience a major depressive disorder, which should be diagnosed and treated as soon as possible. A person with a major depressive disorder has a number of symptoms nearly every day, all day, for at least 2 weeks. These always include at least one of the following:

1. Feeling sad, blue, or down in the dumps.
2. Loss of interest in things that the person used to enjoy.
3. A person may also have other physical or psychological symptoms, including:
• Feeling slowed down or restless and unable to sit still.
• Feeling worthless or guilty.
• Increase or decrease in appetite or weight.
4. Problems concentrating, thinking, remembering, or making decisions.
5. Trouble sleeping or sleeping too much.
6. Loss of energy or feeling tired all of the time.
7. Headaches.
8. Other aches and pains.
9. Digestive problems.
10. Sexual problems.
11. Feeling pessimistic or hopeless.
12. Being anxious or worried.
13. Thoughts of death or suicide.

How to protect yourself from having a stroke?

1. Know your blood pressure. Have it checked at least annually. If it is elevated, work with your doctor to keep it under control.
2. Find out if you have atrial fibrillation (AF). If you have AF, work with your doctor to manage it. Atrial fibrillation (AF) can cause blood to collect in the chambers of your heart. This blood can form clots and cause a stroke.
3. If you smoke, stop.
4. If you drink alcohol, do so in moderation.
5. Know your cholesterol number. If it is high, work with your doctor to control it. Lowering your cholesterol may reduce your risk for stroke. Having high cholesterol can indirectly increase stroke risk by putting you at greater risk of heart disease – another important stroke risk factor.
6. If you are diabetic, follow your doctor’s recommendations carefully to control your diabetes.
7. Include exercise in the activities you enjoy in your daily routine.
8. Enjoy a lower sodium (salt), lower fat diet.