Stroke

Definition
A stroke is the sudden death of brain cells in a localized area due to inadequate blood flow.

Description
A stroke occurs when blood flow is interrupted to part of the brain. Without blood to supply oxygen and nutrients and to remove waste products, brain cells quickly begin to die. Depending on the region of the brain affected, a stroke may cause paralysis, speech impairment, loss of memory and reasoning ability, coma, or death. A stroke also is sometimes called a brain attack or a cerebrovascular accident (CVA). Some important stroke statistics include: more than one-half million people in the United States experience a new or recurrent stroke each year stroke is the third leading cause of death in the United States and the leading cause of disability stroke kills about 160,000 Americans each year, or almost one out of three stroke victims three million Americans are currently permanently disabled from stroke in the United States, stroke costs about $30 billion per year in direct costs and loss of productivity two-thirds of strokes occur in people over age 65 but they can occur at any age strokes affect men more often than women, although women are more likely to die from a stroke strokes affect blacks more often than whites, and are more likely to be fatal among blacks

Stroke is a medical emergency requiring immediate treatment. Prompt treatment improves the chances of survival and increases the degree of recovery that may be expected. A person who may have suffered a stroke should be seen in a hospital emergency room without delay. Treatment to break up a blood clot, the major cause of stroke, must begin within three hours of the stroke to be effective. Improved medical treatment of all types of stroke has resulted in a dramatic decline in death rates in recent decades. In 1950, nine in ten died from stroke, compared to slightly less than one in three in the twenty-first century. However, about two-thirds of stroke survivors will have disabilities ranging from moderate to severe.

Causes and symptoms

Causes There are four main types of stroke. Cerebral thrombosis and cerebral embolism are caused byblood clots that block an artery supplying the brain, either in the brain itself or in the neck. These account for 7080% of all strokes. Subarachnoid hemorrhage and intracerebral hemorrhage occur when a blood vessel bursts around or in the brain. Cerebral thrombosis occurs when a blood clot, or thrombus, forms within the brain itself, blocking the flow of blood through the affected vessel. Clots most often form due to "hardening" (atherosclerosis) of brain arteries. Cerebral thrombosis occurs most often at night or early in the morning. Cerebral thrombosis is often preceded by a transient ischemic attack, or TIA, sometimes called a "mini-stroke." In a TIA, blood flow is temporarily interrupted, causing short-lived stroke-like symptoms. Recognizing the occurrence of a TIA, and seeking immediate treatment, is an important step in stroke prevention. Cerebral embolism occurs when a blood clot from elsewhere in the circulatory system breaks free. If it becomes lodged in an artery supplying the brain, either in the brain or in the neck, it can cause a stroke. The most common cause of cerebral embolism is atrial fibrillation, a disorder of the heart beat. In atrial fibrillation, the upper chambers (atria) of the heart beat weakly and rapidly, instead of slowly and steadily.

Blood within the atria is not completely emptied. This stagnant blood may form clots within the atria, which can then break off and enter the circulation. Atrial fibrillation is a factor in about 15% of all strokes. The risk of a stroke from atrial fibrillation can be dramatically reduced with daily use of anticoagulant medication. Hemorrhage, or bleeding, occurs when a blood vessel breaks, either from trauma or excess internal pressure. The vessels most likely to break are those with preexisting defects such as an aneurysm. An aneurysm is a "pouching out" of a blood vessel caused by a weak arterial wall. Brain aneurysms are surprisingly common. According to autopsy studies, about 6% of all Americans have them. Aneurysms rarely cause symptoms until they burst. Aneurysms are most likely to burst when blood pressure is highest, and controlling blood pressure is an important preventive strategy. Intracerebral hemorrhage affects vessels within the brain itself, while subarachnoid hemorrhage affects arteries at the brain's surface, just below the protective arachnoid membrane. Intracerebral hemorrhages represent about 10% of all strokes, while subarachnoid hemorrhages account for about 7%. In addition to depriving affected tissues of blood supply, the accumulation of fluid within the inflexible skull creates excess pressure on brain tissue, which can quickly become fatal. Nonetheless, recovery may be more complete for a person who survives hemorrhage than for one who survives a clot, because the blood deprivation effects usually are not as severe. Death of brain cells triggers a chain reaction in which toxic chemicals created by cell death affect other nearby cells. This is one reason why prompt treatment can have such a dramatic effect on final recovery. Risk factors Risk factors for stroke involve age, sex, heredity, predisposing diseases or other medical conditions, use of certain medications, and lifestyle choices: Age and sex. The risk of stroke increases with age, doubling for each decade after age 55. Men are more likely to have a stroke than women. Heredity. Blacks, Asians, and Hispanics have higher rates of stroke than do whites, related partly to higher blood pressure. People with a family history of stroke are at greater risk. Diseases. Stroke risk is increased for people with diabetes, heart disease (especially atrial fibrillation), high blood pressure, prior stroke, or TIA. Risk of stroke increases tenfold for someone with one or more TIAs. Other medical conditions. Stroke risk increases with obesity, high blood cholesterol level, or high red blood cell count. Hormone replacement therapy. In mid-2003, a large clinical trial called the Women's Health Initiative was halted when researchers discovered several potentially dangerous effects of combined hormone replacement therapy on postmenopausal women. In addition to increasing the risk of some cancers and dementia, combined estrogen and progesterone therapy increased risk of ischemic stroke by 31% among study participants. Lifestyle choices. Stroke risk increases with cigarette smoking (especially if combined with the use of oral contraceptives), low level of physical activity, alcohol consumption above two drinks per day, or use of cocaine or intravenous drugs.

Symptoms Symptoms of an embolic stroke usually come on quite suddenly and are at their most intense right from the start, while symptoms of a thrombotic stroke come on more gradually. Symptoms may include: blurring or decreased vision in one or both eyes severe headache, often described as "the worst headache of my life" weakness, numbness, or paralysis of the face, arm, or leg, usually confined to one side of the body dizziness, loss of balance or coordination, especially when combined with other symptoms

Diagnosis

The diagnosis of stroke is begun with a careful medical history, especially concerning the onset and distribution of symptoms, presence of risk factors, and the exclusion of other possible causes. A brief neurological exam is performed to identify the degree and location of any deficits, such as weakness, incoordination, or visual losses. Once stroke is suspected, a computed tomography scan (CT scan) or magnetic resonance imaging (MRI) scan is performed to distinguish a stroke caused by blood clot from one caused by hemorrhage, a critical distinction that guides therapy. Blood and urine tests are done routinely to look for possible abnormalities. Other investigations that may be performed to guide treatment include an electrocardiogram,angiography, ultrasound, and electroencephalogram.

Treatment
Emergency treatment Emergency treatment of stroke from a blood clot is aimed at dissolving the clot. This "thrombolytic therapy" currently is performed most often with tissue plasminogen activator, or t-PA. t-PA must be administered within three hours of the stroke event. Therefore, patients who awaken with stroke symptoms are ineligible for t-PA therapy, as the time of onset cannot be accurately determined. t-PA therapy has been shown to improve recovery and decrease long-term disability in selected patients. t-PA therapy carries a 6.4% risk of inducing a cerebral hemorrhage, and is not appropriate for patients with bleeding disorders, very high blood pressure, known aneurysms, any evidence of intracranial hemorrhage, or incidence of stroke, head trauma, or intracranial surgery within the past three months. Patients with clot-related (thrombotic or embolic) stroke who are ineligible for t-PA treatment may be treated with heparin or other blood thinners, or with aspirin or other anti-clotting agents in some cases. Emergency treatment of hemorrhagic stroke is aimed at controlling intracranial pressure. Intravenous urea or mannitol plus hyperventilation is the most common treatment. Corticosteroidsalso may be used. Patients with reversible bleeding disorders, such as those due to anticoagulant treatment, should have these bleeding disorders reversed, if possible. Surgery for hemorrhage due to aneurysm may be performed if the aneurysm is close enough to the cranial surface to allow access. Ruptured vessels are closed off to prevent rebleeding. For aneurysms that are difficult to reach surgically, endovascular treatment may be used. In this procedure, a catheter is guided from a larger artery up into the brain to reach the aneurysm. Small coils of wire are discharged into the aneurysm, which plug it up and block off blood flow from the main artery. Rehabilitation Rehabilitation refers to a comprehensive program designed to regain function as much as possible and compensate for permanent losses. Approximately 10% of stroke survivors are without any significant disability and able to function independently. Another 10% are so severely affected that they must remain institutionalized for severe disability. The remaining 80% can return home with appropriate therapy, training, support, and care services. Rehabilitation is coordinated by a team of medical professionals and may include the services of a neurologist, a physician who specializes in rehabilitation medicine (physiatrist), a physical therapist, an occupational therapist, a speech-language pathologist, a nutritionist, a mental health professional, and a social worker. Rehabilitation services may be provided in an acute care hospital, rehabilitation hospital, long-term care facility, outpatient clinic, or at home.

A hemorrhagic stroke (left) compared to a thrombotic stroke (right). (Illustration by Hans & Cassady, Inc.)

The rehabilitation program is based on the patient's individual deficits and strengths. Strokes on the left side of the brain primarily affect the right half of the body, and vice versa. In addition, in left brain dominant people, who constitute a significant majority of the population, left brain strokes usually lead to speech and language deficits, while right brain strokes may affect spatial perception. Patients with right brain strokes also may deny their illness, neglect the affected side of their body, and behave impulsively. Rehabilitation may be complicated by cognitive losses, including diminished ability to understand and follow directions. Poor results are more likely in patients with significant or prolonged cognitive changes, sensory losses, language deficits, or incontinence. PREVENTING COMPLICATIONS. Rehabilitation begins with prevention of stroke recurrence and other medical complications. The risk of stroke recurrence may be reduced with many of the same measures used to prevent stroke, including quitting smoking and controlling blood pressure. One of the most common medical complications following stroke is deep venous thrombosis, in which a clot forms within a limb immobilized by paralysis. Clots that break free often become lodged in an artery feeding the lungs. This type of pulmonary embolism is a common cause of death in the weeks following a stroke. Resuming activity within a day or two after the stroke is an important preventive measure, along with use of elastic stockings on the lower limbs. Drugs that prevent clotting may be given, including intravenous heparin and oral warfarin. Weakness and loss of coordination of the swallowing muscles may impair swallowing (dysphagia), and allow food to enter the lower airway. This may lead to aspiration pneumonia, another common cause of death shortly after a stroke. Dysphagia may be treated with retraining exercises and temporary use of pureed foods. Depression occurs in 30-60% of stroke patients. Antidepressants and psychotherapy may be used in combination. Other medical complications include urinary tract infections, pressure ulcers, falls, and seizures. TYPES OF REHABILITATIVE THERAPY. Brain tissue that dies in a stroke cannot regenerate. In some cases, the functions of that tissue may be performed by other brain regions after a training period. In other cases, compensatory actions may be developed to replace lost abilities.

Physical therapy is used to maintain and restore range of motion and strength in affected limbs, and to maximize mobility in walking, wheelchair use, and transferring (from wheelchair to toilet or from standing to sitting, for instance). The physical therapist advises on mobility aids such as wheelchairs, braces, and canes. In the recovery period, a stroke patient may develop muscle spasticity and contractures, or abnormal contractions. Contractures may be treated with a combination of stretching and splinting. Occupational therapy improves self-care skills such as feeding, bathing, and dressing, and helps develop effective compensatory strategies and devices for activities of daily living. A speech-language pathologist focuses on communication and swallowing skills. When dysphagia is a problem, a nutritionist can advise alternative meals that provide adequate nutrition. Mental health professionals may be involved in the treatment of depression or loss of thinking (cognitive) skills. A social worker may help coordinate services and ease the transition out of the hospital back into the home. Both social workers and mental health professionals may help counsel the patient and family during the difficult rehabilitation period. Caring for a person affected with stroke requires learning a new set of skills and adapting to new demands and limitations. Home caregivers may develop stress, anxiety, and depression. Caring for the caregiver is an important part of the overall stroke treatment program. Support groups can provide an important source of information, advice, and comfort for stroke patients and for caregivers. Joining a support group can be one of the most important steps in the rehabilitation process.

Prognosis
Stroke is fatal for about 27% of white males, 52% of black males, 23% of white females, and 40% of black females. Stroke survivors may be left with significant deficits. Emergency treatment and comprehensive rehabilitation can significantly improve both survival and recovery. A 2003 study found that treating people who have had a stroke with certain antidepressant medications, even if they were not depressed, could increase their chances of living longer. People who received the treatment were less likely to die from cardiovascular events than those who did not receiveantidepressant drugs.

Prevention
Damage from stroke may be significantly reduced through emergency treatment. Knowing the symptoms of stroke is as important as knowing those of a heart attack. Patients with stroke symptoms should seek emergency treatment without delay, which may mean dialing 911 rather than their family physician. The risk of stroke can be reduced through lifestyle changes: quitting smoking controlling blood pressure getting regular exercise keeping body weight down avoiding excessive alcohol consumption getting regular checkups and following the doctor's advice regarding diet and medicines, particularly hormone replacement therapy.

Treatment of atrial fibrillation may significantly reduce the risk of stroke. Preventive anticoagulant therapy may benefit those with untreated atrial fibrillation. Warfarin (Coumadin) has proven to be more effective than aspirin for those with higher risk. A new drug called ximelagatran (Exanta) with fewer side effects has been introduced in Europe. The drug's manufacturer was applying for FDA approval to market the drug for use in preventing stroke and other thromboembolic complications in early 2004. In 2003, physicians at the Framingham Heart Study derived new risk scores to help physicians determine which patients with new onset of atrial fibrillation are at higher risk for stroke alone or for stroke or death. Screening for aneurysms may be an effective preventive measure in those with a family history of aneurysms or autosomal polycystic kidney disease, which tends to be associated with aneurysms.