Stroke – CVA

Introduction

A stroke or a “brain attack” is an emergency medical condition. It occurs when the blood supply to the brain is stopped or reduced for a period of time. Your brain controls the life sustaining functions of your body. It also controls the way you think, act, and feel. A lack of oxygen rich blood causes brain cells to become damaged or die. Without oxygen, the section of the brain containing the affected cells can temporarily or permanently lose function. It can also result in coma or death.

Emergency medical treatments may sustain life and prevent disability, if they are received in the first few hours following the onset of stroke symptoms. A stroke can result in temporary or permanent disability and impairments. Recovery from stroke can take a long time, usually over a year.

Rehabilitation therapists help people to regain skills and live as functionally independent as possible. Many people with stroke never fully recover, but with assistance and adjustments, they can lead full and happy lives.

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Anatomy

Your brain is the control center of your body. Your brain controls the way you think, behave, and feel. It communicates with the nerves in your body for functions you can control, such as moving your arms and legs. Your brain also controls the life-sustaining functions that you cannot control. This includes your heartbeat, body temperature, blood pressure, and body metabolism.

The cells in your brain, like all your cells, need oxygen to function and survive. Oxygen is carried to your brain by red blood cells. Your red blood cells travel to your brain in tubes called arteries.

The main arteries to your brain branch off to transport blood to areas throughout your brain. The branches of the internal carotid artery supply blood to the front and top areas of your brain. These branches include the anterior cerebral, anterior communicating, middle cerebral, and posterior communicating arteries.

The vertebral artery branches into the anterior spinal artery and supplies blood to your brain and spinal cord. The junction of your two vertebral arteries forms your basilar artery. Your basilar artery branches into the cerebellar and posterior cerebral arteries that supply blood to the lower and back areas of your brain.

The arterial branches form a circular formation in the center of your brain called the Circle of Willis. The Circle of Willis and small branches of the middle cerebral arteries, near the internal carotid arteries, are common sites of strokes. These areas are especially vulnerable to strokes at places where the arteries join each other.

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Causes

A stroke occurs when the blood flow to the brain is stopped or reduced. When the blood flow is impaired, the brain cells do not receive oxygen for nourishment. Without oxygen, brain cells can be damaged in just a few seconds. Brain cells can die in a few hours without oxygen. This can cause the section of the brain containing the affected cells to temporarily or permanently lose function. It can also result in death.

During a stroke, the brain may not receive blood for a couple of reasons. The brain cannot get blood if an artery is blocked or if an artery has broken open. An ischemic stroke results when an artery is blocked. A transient ischemic attack (TIA) is a “mini stroke” that occurs when the blood supply is briefly interrupted. A hemorrhagic stroke happens when the artery wall bursts and leaks blood.

An ischemic stroke is the most common type of stroke. An ischemic stroke results when an artery is clogged or blocked, and blood cannot flow through it. A clot that forms and remains in the brain is called a cerebral thrombus. A clot may form in other parts of the body and travel to the brain. This type of clot is called a cerebral embolism.

Atherosclerosis, “hardening of the arteries” is the most frequent cause of blood clots and ischemic stroke. High blood pressure, diabetes, and high cholesterol cause atherosclerosis. Atherosclerosis results when fat and blood platelets stick to the wall of the arteries. This causes the build-up of a sticky substance called plaque. Plaque causes blood to flow abnormally through the arteries, which can result in blood clots.

There are several other causes for cerebral embolisms. Atrial fibrillation is a cause of cerebral embolisms. Atrial fibrillation is a condition that causes a fast and irregular heart beat. Embolisms may also result from endocarditis, a disease that affects the lining of the heart. Heart valve problems are another source of cerebral embolisms. People with artificial heart valves, repaired heart valves, heart valve disease, or narrowed heart valves are at risk for blood clots. Blood-clotting disorders and blood vessel inflammation can also cause blood clots. Further, a heart attack can contribute to an ischemic stroke.

A TIA is a stroke that usually lasts for a few minutes. A TIA occurs when the blood flow to an area of the brain is briefly and temporarily blocked. Atherosclerosis and blood clots most commonly cause TIAs. TIAs can be an indicator that a person is at risk for a more serious stroke.

A hemorrhagic stroke occurs when an artery bursts, causing bleeding in or around the brain. The outflow of blood damages the brain cells. Blood pools can build up and increase the pressure inside of the brain. Because the brain is enclosed in the skull, it does not have room to swell or expand. This can compress and damage brain tissue.

The most common cause of hemorrhagic stroke is long-term high blood pressure. It can also be caused by a ruptured aneurysm, head injuries, radiation treatment for cancer in the neck or brain, and blood vessel disorders. Bleeding inside the brain is called an intracerebral hemorrhage. Bleeding outside of the brain is called a subarachnoid hemorrhage.

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Symptoms

The symptoms of a stroke begin suddenly. The symptoms may be more severe at the beginning of a stroke. The symptoms may get continually worse or fluctuate for the first couple of days. Some symptoms may go away, however you should not ignore the signs of a stroke even if your symptoms go away. A stroke is considered complete when the symptoms stop getting worse.

You may experience one or more symptoms. You may have a severe headache. One side of your body or one part of your body — the face, an arm or a leg may feel weak or paralyzed. The affected body parts may feel numb or tingly. It may be hard to walk. You may lose your balance or coordination. It may feel like the room is spinning, and you may feel dizzy. You may feel tired all of the time. A stroke can also cause a person to lose consciousness.

You may experience uncontrollable eye movements, changes in vision, such as double vision, blurred vision, or loss of vision. Your eyelid may droop. You may drool and have difficulty swallowing.

You may have trouble thinking and feel confused. You may have difficulty remembering things that you could before. It may be difficult to understand what others are saying, and you may have problems talking. A stroke can cause personality and behavioral changes. You may feel depressed, agitated, or apathetic.

Symptoms of a TIA are similar to that of a stroke. They may include one or more of the symptoms described above. However, the symptoms of a TIA last less than 24 hours.

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Diagnosis

A stroke is a medical emergency. You should call 911 for ambulance transport to a hospital emergency room. It is important that you receive treatment immediately after you start experiencing the symptoms of a stroke – ideally within the first three hours of when your symptoms began. You should not ignore your condition if some of your symptoms go away—you should still seek immediate emergency medical treatment. Doctors can provide treatments to reduce disability and save lives.

Your doctor can diagnose a stroke by reviewing your medical history and performing an examination. You or the person accompanying you should tell your doctor all of the symptoms that you experienced, even if the symptoms have gone away. Your doctor will order tests to help determine the cause, type, location, and severity of the stroke that you had. Your blood will be tested for immune conditions and abnormal blood clotting conditions. Your doctor may also order tests to rule out other conditions with similar symptoms.

Your doctor will examine you to look for signs that an area of your brain has been affected by the stroke, since certain areas of the brain control certain functions. Your doctor will perform a neurological evaluation to see how the nerves in your body and your brain are communicating. Your doctor will test the strength, sensation, coordination, and movement of your muscles. Your doctor will assess your cognitive or “thinking skills” by asking you simple questions or to follow simple directions. Your doctor will also check your vision and eye movements. A stethoscope, the instrument that allows the doctor to hear your heartbeat, will be placed over the carotid arteries at the front of your neck. Your doctor will listen for abnormal sounds or signs of atrial fibrillation.

Imaging tests help your doctor determine if bleeding or a clot caused your stroke. Imaging tests can identify the location and magnitude of the stroke. Computed Tomography (CT) scans and Magnetic Resonance Imaging (MRI) scans are used to provide a picture of the brain. These imaging scans evaluate brain structures, but do not directly assess brain functioning.

CT scans provide a view of the brain in layers, like the slices that make up a loaf of bread. The CT scan shows the structures in your brain. A CT scan is useful for identifying large clots or areas of bleeding. The MRI scan is very sensitive. It provides detailed images of the brain structures. Both scans are painless procedures.

Heart tests will help your doctor determine if an underlying heart condition caused your stroke. An electrocardiogram (EKG) assesses the electrical activity of the heart. It can identify if a heart attack has occurred, what part of the heart is damaged, irregular heartbeats, and if there is a lack of blood and oxygen in the heart. The test is simple to conduct. Sticky patches attached to electrodes are placed on your skin. The electrodes transmit records to a machine for your doctor to interpret. This test is painless and only takes about 5-10 minutes to conduct.

There are various types of ultrasound devices that can provide your doctor with pictures of your heart and arteries. A stroke can occur if pieces of a blood clot in the heart break away and travel to the brain. An echocardiogram can determine if a blood clot is in your heart. An echocardiogram takes an image of the heart using ultrasound. A transthoracic echocardiogram uses a device that is placed on your chest. The device transmits images of your heart. A transesophageal echocardiogram uses a scope that is placed inside of your esophagus to take pictures. You will receive a light sedative for the test. A carotid duplex ultrasound can determine if the carotid arteries are blocked by plaque, clots, or narrowing of the arteries. For this test, an ultrasound device is gently placed on your neck to take images.

A cerebral angiography or arteriography is a medical imaging test that provides views of the arteries and veins in your brain. It is considered the gold standard for identifying vascular conditions in the brain. For this test, a catheter is passed through a large artery and advanced through the carotid artery. A fluid is injected that travels throughout the vasculature. The fluid enhances the images and provides a good depiction of the blood supply routes.

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Treatment

Treating a TIA or stroke is a medical emergency. You should call 911 for ambulance transport to a hospital. The emergency room doctors will assess what type of stroke is occurring or has occurred and provide treatments to sustain life and achieve medical stability. Treatments for stroke differ and depend on the type of stroke, the severity of a person’s condition, and any associated medical conditions.

It may be difficult for emergency personnel to determine if a person is having a TIA or a stroke. However, prompt evaluation and treatment is necessary for both. Ideally, TIAs need to be treated within 60 minutes from the start of symptoms. Doctors can use medication or surgery to reduce the risk of stroke for people experiencing a TIA.

If a clot causes a stroke, thrombolytic medication to break up clots can be provided—but this medication has strict administration criteria. The clot dissolving medication should be given within three hours of when the stroke symptoms started. This can save your life and help prevent disability. Other blood thinning medications may be used for people that are not candidates for thrombolytic medication.

If bleeding in the brain causes a stroke, the emergency room team will carefully monitor a person’s vital signs and pressure in the brain. They will provide medical treatments to control blood pressure, blood sugar levels, brain swelling, and seizures. In some cases, surgery may be required to remove the excess blood in the brain, repair a brain aneurysm, and repair blood vessels.

Sometimes a stroke results in a coma, a condition when a person is not alert and does not respond to stimuli. Some people may not be able to breathe on their own and will require a respirator, a machine that breathes for them. Other people may remain alert, but be medically fragile. In most cases, people are transferred from the emergency room department to the Intensive Care Unit (ICU) of a hospital. The ICU staff carefully monitor individuals for vital signs and brain swelling. The goals of the ICU staff are to maintain life and medical stability, while preventing further medical complications.

Occupational and physical therapists may work with people in the ICU to provide preventive treatments. The therapists use passive range of motion (PROM) exercises to gently move and stretch a person’s muscles to improve circulation and to keep the muscles healthy. This prevents the muscles from contracting, which can result in deformities. The therapists may also provide splints or casts to help maintain body positioning.

Recovery from stroke is different for everyone. It depends on many factors including the severity of the stroke, the location of the stroke, the functions of the brain area affected by the stroke, the condition of your brain and nervous system at the time of the stroke, and your other medical conditions.

Treatment and rehabilitation will differ for everyone. It takes a long time to recover from a stroke. Generally, the fastest progress takes place within the first year, although healing continues to take place after that. Many people never fully recover from a stroke, but with assistance and adjustments, they can lead full and happy lives.

It is common for people to have partial or complete impairments following a stroke. Depending on the deficit, they may need assistance, such as a cane to help them walk or another person to help them figure out their bills. Some people may be able to return to living in their home or others may need the help of others at a care facility. It is common for people to transfer from various facilities and levels of care during their recovery process.

When a person is medically stable and able to remain alert and follow simple instructions, they are transferred from the hospital to an acute inpatient rehabilitation unit for therapy. People typically stay in an inpatient rehabilitation center for days to several weeks. Because a stroke can affect how a person thinks, acts, moves, and feels, rehabilitation may be necessary to help a person attain abilities that were lost or impaired by a stroke.

In rehabilitation, a team of healthcare professionals with expertise in stroke care help people achieve their highest level of independent functioning for Activities of Daily Living (ADLs). ADLs include basic tasks such as walking, dressing, swallowing, and talking. It also includes behavioral and thinking skills necessary for independent living and socialization. The rehabilitation team works together on goals and meets regularly to monitor a person’s progress.

A rehabilitation team includes several healthcare professionals. The team is usually lead by a Physiatrist, a doctor who specializes in physical rehabilitation medicine. Physical Therapists work on improving muscle strength, flexibility, and coordination. They focus on skills such as walking and balance. Occupational Therapists use purposeful activities to help people obtain independent and meaningful daily living. They focus on physical, emotional, and cognitive challenges, including feeding, dressing, thinking skills, and visual training. Speech Language Pathologists work to improve a person’s ability to talk and comprehend what is seen or heard. Speech Language Pathologists or Occupational Therapists work with people to improve swallowing abilities.

Other rehabilitation team members include Rehabilitation Nurses, Recreational Therapists, Neuropsychologists, and Case Managers or Social Workers. Rehabilitation Nurses work with people on goals to improve functioning and monitor their medical status.

Recreational Therapists provide goal oriented leisure activities to improve social skills, muscle movement skills, and enhance self-esteem. They regularly plan activities in the community where people may apply the skills they learn in rehabilitation. Types of recreational therapy include pet therapy, wheelchair sports, and special social functions.

Neuropsychologists focus on the way the brain functions. They assess the way the brain processes thoughts, emotions, and behavioral information. They work with people to help them improve brain functioning and adjust to setbacks. Their reports are important for discharge planning, return to school, and return to work.

Case Managers or Social Workers communicate with individuals and their families regarding treatment goals and planning. They work with individuals and their insurance companies to assure cost-effective treatment. Case Managers or Social Workers also facilitate discharge planning.

The discharge destination from rehabilitation varies and depends on an individual’s skill level, safety awareness, and the level of care that they need. Some people may return to their homes to live independently or with supervision or a little help from their family or friends. Other people may need more time to heal and are discharged to a subacute rehabilitation center to continue to work on therapy. For people that need assistance or are completely dependent on the aid of healthcare professionals, discharge destinations may include skilled nursing homes, nursing homes, assisted living centers, supervised living centers, or Veterans’ homes.

In addition to rehabilitation after a stroke, your doctor will manage your health to help prevent another stroke. This may include monitoring and treating atrial fibrillation, high blood pressure, diabetes, and cholesterol. Your doctor may also monitor and treat you for depression. Depression is common for people that have experienced a stroke. Depression is a real medical condition that is treatable. Depression may cause you to feel sad, irritable, tired, and uninterested in activities that you used to find enjoyable. You may also experience appetite changes, sleeping problems, and have trouble remember things or concentrating. You should discuss any symptoms of depression with your doctor. Your doctor will be able to provide you with medications or a counseling referral to help you.

The experience of stroke can be an emotional process for the patient and their loved ones. It is important that you receive support. Some people find comfort in their family, friends, co-workers, and place of worship. Stroke support groups are another good option. They can be a good source of information and support from people who understand what you are experiencing. Ask your doctor for stroke support group locations in your area.

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Prevention

You should seek immediate emergency medical care if you suspect you are having a stroke. It is important to be evaluated by a doctor as soon as possible. Prompt treatment can save lives and reduce disability.

You should eliminate the risk factors for stroke that you can control. Have regular physical examinations to check for high blood pressure, high cholesterol, diabetes, and atherosclerosis. Learn what you can do to prevent these conditions. Ask your doctor to check your medications to see if any of them promote blood clotting or blood thinning. Women that take birth control pills should talk with their doctors about the risk of associated blood clots.

It is helpful to maintain a healthy weight and eat a balanced diet. It is also important to quit smoking and limit alcohol. You should not use illegal drugs.

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Am I at Risk

Risk factors may increase your likelihood of developing a stroke. People with all of the risk factors may never develop a stroke; however, the chance of developing a stroke increases with the more risk factors you have. You should try to eliminate the risk factors that you can control to help prevent a stroke. You should tell your doctor about your risk factors and discuss your concerns.

Risk factors for stroke:

• Hypertension “high blood pressure” is the top risk factor for stroke.
• Smoking increases the risk of stroke. Smoking can contribute to coronary artery disease and blood clots.
• The risk of stroke increases with age. Most strokes occur after the age of 65.
• African Americans and Hispanics have the highest risk of stroke.
• High cholesterol can contribute to plaque build-up in arteries, coronary artery disease, and heart attacks that can lead to stroke.
• More men than women get stroke; however, women are more likely to die from a stroke.
• Your risk is greater if you have a family history of stroke or TIA.
• People that have had one stroke are at risk for another stroke.
• Diabetes can cause blood circulation problems that lead to stroke.
• Heart conditions such as atrial fibrillation, endocarditis, heart valve conditions, or cardiomyopathy increase the risk of stroke.
• Some medications can increase the risk of blood clots, including birth control pills for females.
• Women have an increased risk of stroke during pregnancy and the weeks immediately following pregnancy.
• A lack of physical activity can increase the risk of stroke.
• Street drugs, such as cocaine, and alcohol abuse contribute to stroke.
• Trauma or a head injury can cause bleeding in the brain.
• Some blood clotting disorders or bleeding disorders can increase the risk of stroke.

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Complications

There are many complications associated with stroke. A stroke can cause disability, coma, or death. People that have had one stroke are at risk for future strokes. People that have had a TIA have an increased risk for more TIAs or stroke. Doctors carefully monitor people that have had a TIA or stroke.

A stroke may require a person to be dependent on others, need some help, or need supervision for living. Functional impairments can affect several parts of the body. Such impairments may be partial, full, temporary, or permanent. Listed below are some main complications resulting from neurological injury to the brain.

A stroke can affect thought processing, emotions, and behavior. People may experience difficulty with thinking skills including memory, problem solving, judgment, and safety awareness. People’s personality may change. They may laugh or cry at inappropriate times. This is called mood lability. They may also be depressed, agitated, apathetic, or be frustrated easily. Behavior may be affected by stroke as well. People may become impulsive, sexually inappropriate, aggressive, and socially inappropriate. People that lack such skills may require 24-hour supervision to prevent harm to themselves and others.

A stroke can affect the way muscles work and move. A stroke can cause partial or complete paralysis. Spasticity can cause muscle to have increased tone and be unable to function. Strokes typically affect one half of the body; however, some people are able to perform tasks with the functioning side of their body. For instance, a person may walk with an assistive device, such as a cane and leg bracing. People can also dress and bathe themselves using assistive devices and one-handed techniques. Cars can even be adapted so people can drive. It is important that you discuss your life goals with your therapists and work on the skills that are priorities for you.

A stroke can affect the way that people communicate. People may not be able to speak or have difficulty forming words. This is called expressive aphasia. People that are unable to speak may use a variety of assistive devices to communicate including picture boards, letter boards, and electronic keyboards. Another type of aphasia, receptive aphasia, is the inability to understand what other people say making it more difficult to compensate.

Vision can be affected by stroke. Stroke can cause “visual neglect.” Visual neglect is a condition that causes a person to only be aware of half of things. Individuals with severe visual neglect may ignore half of their body because they are not aware of it. This leaves them vulnerable to injury, as they may not be aware of their arm or leg placement. A NeuroOptometrist and an occupational therapist with expertise in visual therapy can help people learn to compensate for visual impairments.

A lack of sensation associated with stroke can compound visual impairments. Some people lose the feeling in the affected side of their body. A lack of sensation can also include an impaired or absent temperature awareness. People are vulnerable to injury if they cannot gauge temperatures or detect the placement of their limbs.

A stroke can also affect the senses of taste and smell. People may report that food tastes differently. This can be a safety issue if people cannot smell fire or taste and smell spoiled food. Therapists have many ways to help people compensate for such deficits.

It is very common for people to experience a loss of bladder and bowel control. This condition is typically temporary. In the interim, people generally wear protective undergarments.

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Advancements

Carotid artery stenting is a preventative option for select people. During surgery, a stent, a small metal tube, is placed in the carotid artery. The stent allows for increased blood flow in areas that may be blocked by plaque. In some cases, the stent may be coated with a medication that helps to reduce further blockage.

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