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StrokeAlso known as Brain stroke, Brain attack, Cerebrovascular accident (CVA), Transient ischemic attack (TIA), Ischemic stroke and Hemorrhagic stroke
Stroke is a condition in which the blood supply to the brain is disrupted. This mainly occurs due to either blockage in any of the blood vessels that supply blood to the brain (known as ischemic stroke) or due to rupture or leaking of the blood vessels in the brain (known as hemorrhagic stroke).
Stroke often occurs suddenly. However, symptoms that can help in identifying a stroke are face drooping, arm & leg weakness, lethargy, slurred speech, and loss of balance. There are several factors that can increase your risk of stroke. These include old age, sedentary lifestyle, stress, obesity, smoking, uncontrolled hypertension, uncontrolled diabetes and coronary artery disease.
The treatment approach consists of medications such as statins, anticoagulants, and procedures like thrombectomy. Recovery after stroke depends on severity of stroke, which part of the brain is affected, extent of damage and how quickly the treatment was initiated.
A stroke is a medical emergency and there is a better chance of recovering from a stroke if emergency treatment is started right away. Remember, during a stroke, every minute counts.
- Adults above 65 years of age
- Both men and women but more common in men
- Blood vessels
- India: 44.54 to 150/100000
- Transient ischemic attack (TIA)
- Cerebral neoplasm
- Hemiplegic migraine
- Brain abscess
- Conversion disorder
- Hepatic encephalopathy
- Bell's palsy
- Hypertensive encephalopathy
- Fibrinolytics: Alteplase & Reteplase
- Antiplatelets: Aspirin & Clopidogrel
- Anticoagulants: Warfarin, Apixaban & Rivaroxaban
- Anti-hypertensives: Angiotensin receptor blockers, Calcium channel blockers, Beta-blockers & ACE inhibitors
- Statins: Atorvastatin, Rosuvastatin & Pitavastatin
- Carotid endarterectomy
- Speech therapist
Symptoms Of Stroke
Following are the common signs & symptoms one may experience during a stroke:
Sudden dizziness & loss of balance: A person suffering from stroke tends to lose balance and might feel dizziness or lightheadedness.
Visual disturbances: Vision troubles in one or both eyes are common with stroke.
Face drooping: If you suspect someone in your family is having a stroke, ask them to smile. If the face droops to one side, it could be a potential sign of a stroke.
Paralysis (weakness in the arms & legs): If the arms drift downwards after raising, it can be a sign of stroke.
Slurred speech: The person having a stroke finds it difficult to pronounce a simple sentence.
Confusion: The person might have confusion or difficulty in understanding others while having a stroke.
Headache: A sudden severe headache with no known cause could be a warning sign of stroke.
Causes Of Stroke
The cause of a stroke depends on the type of stroke. Stroke is broadly classified into 3 major types namely:
1. Ischemic stroke: Most of the strokes are ischemic strokes. These types of strokes occur when the oxygen-rich blood supply to some parts of the brain gets blocked or severely restricted. As a result of the deprived blood and oxygen, the cells of that part of the brain die, and the part of the body that it controls stops working. Restriction of blood supply can happen by the following:
- Clogged arteries: Fat, cholesterol, and other deposits can accumulate on the walls of blood vessels. With time, these deposits calcify or harden and this build up is called plaque. The plaque clogs the blood vessels thereby narrowing the passage for blood.
- Blood clots: When a clot forms in a blood vessel of the brain that is already very narrow, it leads to a thrombotic stroke. When a blood clot that has formed somewhere else in the body, breaks away and travels to a blood vessel in the brain, the result is an embolic stroke or cerebral embolism. An embolic stroke can also result from an air bubble or other foreign substance in the blood that moves and blocks a blood vessel in the brain.
2. Hemorrhagic stroke: In hemorrhagic stroke, a weakened blood vessel in the brain gets ruptured allowing blood to leak into the brain. This blood accumulates and compresses the surrounding brain tissue. Two types of weakened blood vessels which usually cause hemorrhagic stroke are aneurysms (balloon-like bulges in an artery that can stretch and burst) and arteriovenous malformations (tangles of blood vessels).
There are two types of hemorrhagic strokes:
- Intracerebral hemorrhage is the most common type of hemorrhagic stroke. “Intracerebral” means “within the brain”, it occurs when a blood vessel in the brain bursts, flooding the surrounding tissue with blood. Intracerebral strokes are usually caused by high blood pressure.
- Subarachnoid hemorrhage is a less common type of hemorrhagic stroke. It refers to bleeding in the space between the brain and the skull. Factors like head injury, overtreatment with blood thinners, and bleeding disorders can cause subarachnoid hemorrhage.
3. Transient ischemic attack (TIA): Also known as “mini-stroke” or a “warning stroke”, it usually does not occur for more than a few minutes. A TIA is a warning sign of a future stroke, so should be considered a medical emergency, just like a major stroke. Like ischemic strokes, blood clots often cause TIAs. More than a third of people who have a TIA and don’t get treatment have a major stroke within 1 year. Recognizing and treating TIAs can lower the risk of a major stroke in the future.
Risk Factors For Stroke
Some of the common risk factors of stroke are:
Age: Aging tends to narrow down the arteries, therefore increasing the risk of stroke.
Gender: Stroke occurs more commonly in men, but more casualties are seen in women than men due to a stroke.
Family history: Heredity or genetics can influence the risk of getting a stroke.
Sedentary lifestyle: Long sitting hours with very little movement or exercise is a major risk factor for stroke
Excessive alcohol consumption: Excessive consumption of alcohol with more than 2 drinks per day raises blood pressure. Uncontrolled drinking can lead to stroke.
Obesity: Obesity or excessive weight is a major risk factor for stroke or other cardiovascular complications.
Tobacco: Narrowing of blood vessels is a common consequence of chronic use of tobacco in any form. Nicotine also increases blood pressure, which also increases the risk of stroke.
Diabetes: Diabetes can lead to pathological changes in the blood vessels, therefore increasing the risk of stroke.
Uncontrolled hypertension: Blood pressure of 140/90 mmHg or higher can damage blood vessels that supply blood to the brain.
Elevated red blood cell (RBC) count: High levels of red blood cells thicken the blood and predispose to formation of clots. This raises the risk for stroke.
Elevated blood cholesterol and lipids: High cholesterol levels can increase buildup of plaque and lead to atherosclerosis or thickening or hardening of the arteries. This can decrease the amount of blood flow to the brain and cause a stroke.
Heart conditions: Heart conditions like heart valve defects and arrhythmias (irregular heart rhythm) can cause long term damage to the heart thereby increasing risk of a stroke.
Birth control pills: Also known as oral contraceptives, these drugs can also increase the risk of stroke.
Extreme weather conditions: Stroke casualties occur more often during extreme temperatures or weather conditions.
History of prior stroke: The risk of a second stroke increases if someone already had a stroke in the past.
History of transient ischemic attacks (TIAs): TIAs are called mini-strokes. If someone has had one or more TIAs, they are at a very high risk of suffering from a stroke.
ABCD2 score is a prediction rule used to determine the risk for stroke after a transient ischemic attack. The ABCD2 score is based on five parameters - age, blood pressure, clinical features, duration of TIA, and presence of diabetes. Scores for each item are added together to produce an overall result ranging between zero and seven. People found to have a high score often need to visit a specialist sooner.
Interpretation of ABCD2 score is
Score 1-3 (low)
Score 4-5 (moderate)
Score 6–7 (high)
Higher the score, the higher the risk of stroke in the near future.
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Diagnosis Of Sroke
When a patient arrives at the hospital with the suspicion of stroke, the first step is the stabilization of airways, breathing, and circulation. Complete medical history is recorded and a physical exam is done.
In terms of initial evaluation, The National Institutes of Health Stroke Scale or NIH Stroke Scale (NIHSS) is the most frequently used score worldwide for assessing the clinical severity and prognosis of a stroke. The NIHSS is composed of 11 items, each of which scores a specific ability between 0 and 4. For each item, a score of 0 typically indicates normal function in that specific ability, while a higher score is indicative of some level of impairment. The maximum possible score is 42, with the minimum score being 0.
- Score 0: No stroke symptoms
- Score 1 to 4: Minor stroke
- Score 5 to 15: Moderate stroke
- Score 16 to 20: Moderate to severe stroke
- Score 21 to 42: Severe stroke
The following blood and imaging tests help in diagnosing the cause of a stroke:
1. Blood tests
Blood tests can help to diagnose the factors that might have disrupted the normal flow of blood and in drafting a proper treatment plan. Blood tests are used to determine the following:
Blood sugar should be detected early and both hyperglycemia and hypoglycemia need be treated accordingly in time
Presence of any infections
2. Imaging tests
- Cranial (head) CT scan: This imaging technique is usually the initial test used to diagnose stroke as it shows clear, detailed images of the brain. It can display bleeding in the brain or damage to brain cells caused by a stroke. It can also detect any abnormalities along with the location or type of stroke.
- Computed tomographic angiography: This test uses CT technology to visualize detailed images of blood vessels.
- Magnetic resonance imaging (MRI): It uses magnetic fields to find small changes in brain tissue that help to detect and diagnose stroke. It is more sensitive than CT to see the soft tissues of the brain and to localize the area of the brain affected.
- Magnetic resonance angiography: This technique uses MRI technology and is regarded as the gold standard for detecting blood flow through the blood vessels involved.
- Carotid doppler or doppler sonography : In this test, ultrasound waves help to visualize blood flow in the carotid arteries. It helps to detect the formation of plaques and fatty deposits in walls of carotid arteries.
- Electrical activity test: Two tests, namely electroencephalography (EEG) or evoke tests show the electrical impulses in the brain.
Electrocardiography (ECG): An ECG records the heart electrical activity and can determine any heart conditions that may have led to a stroke such as atrial fibrillation or irregular heart rhythms.
Echocardiogram: An echocardiogram uses sound waves to find a source of clots in the heart that may have traveled from the heart to the brain and caused a stroke. It also checks the function of the heart valves.
Specialist To Visit
Stroke should be treated as early as possible, ideally within 3 to 4.5 hours of the first symptoms. If you think someone may be having a stroke use the F.A.S.T test.
Face: Check their face. Has their face fallen on one side?
Arms: Can they raise both arms and keep them there?
Speech: Is their speech slurred?
Time: It is critical to act in time. If you notice any of these signs, call the nearby hospital immediately.
Once you spot any signs of stroke, you can consult:
If it is a hemorrhagic stroke, then a neurosurgeon should be consulted as well. Also, during the recovery process post a stroke attack, you may also need help from a physiotherapist and a speech therapist.
Treatment Of Stroke
The treatment of stroke depends upon the type of stroke.
A. Treatment for ischemic stroke
1. Fibrinolytics/thrombolytic medications: Medications that break down or dissolve the clot can restore the blood flow to the brain. Some of the common examples that belong to this class are:
Note: Citicoline, a neuroprotective drug, is approved for the treatment of acute ischemic stroke. However, its efficacy over the currently used fibrinolytics is not known. Also, piracetam has been shown to improve learning and memory, and it may facilitate recovery and rehabilitation after a stroke.
2. Antiplatelet medications: Antiplatelet medications help to prevent the formation of a clot in the blood vessels, thereby aiding in the management and prevention of stroke. Examples are:
3. Anticoagulants: Anticoagulants prevent clot formation by altering the chemical composition of the blood. Novel oral anticoagulants (NOACs) are alternatives to warfarin for high-risk patients (including those with a history of stroke) who have atrial fibrillation. The advantage of these drugs is that they dont require frequent monitoring like warfarin. Examples of NOACs include:
4. Blood pressure medications: Antihypertensives are given in stroke to maintain normal blood pressure. Some of the commonly prescribed drugs that belong to this category include:
5. Statins: This class of drug is known to help in the treatment of stroke and prevention of a second attack by reducing the cholesterol levels in the blood. Examples include:
6. Thrombectomy: Thrombectomy refers to the procedure of removing the clot to ensure normal blood flow to the brain.
7. Carotid endarterectomy: Carotid stenosis or narrowing of the carotid artery may occur due to the deposition of fatty substances. This is a surgical procedure where an incision is made on the carotid artery to remove the deposited fatty substances.
B. Treatment for hemorrhagic stroke
1. Surgery: Surgery is needed in a hemorrhagic stroke to reach the source of bleeding. Sometimes, a catheter or small tube is inserted in the arm or leg artery, guiding it to reach the brain tissue and to evaluate the problem.
2. Endovascular procedures: Endovascular procedures may be used to treat certain hemorrhagic strokes. The doctor inserts a long tube through a major artery in the leg or arm and then guides the tube to the site of the weak spot or break in a blood vessel. The tube is then used to install a device, such as a coil, to repair the damage or prevent bleeding. These are details of endovascular procedures:
Surgical clipping: A surgeon places a tiny clamp at the base of the aneurysm to stop blood flow to it. This clamp can keep the aneurysm from bursting.
Coiling (endovascular embolization): Using a catheter inserted into an artery in the groin and guided to the brain, the surgeon will place tiny detachable coils into the aneurysm to fill it.
3. Surgery for hydrocephalus: In hydrocephalus, fluid accumulates around the brain. This can be treated with the help of a tube, called a shunt, to drain the excess fluid.
C. Supportive treatment
In some cases, supportive treatment measures might be required to improve the overall condition of the patient such as:
Inserting a feeding tube into your stomach through your nose (nasogastric tube) to provide nutrition, if you have difficulty swallowing.
Intravenous administration of fluids (fluids given directly into a vein), if you're at risk of dehydration.
Prevention Of Stroke
Prevention is a must, especially in people who have suffered from stroke, once as they have a higher chance of having another stroke in the future. The following measures can be taken to prevent stroke:
1. Dietary modifications: Eat a wholesome diet rich in green leafy vegetables, fruits, and nuts. Consume foods low in saturated fats, trans fat, and cholesterol and high in fiber to prevent high cholesterol. Limiting salt in the diet can also lower blood pressure. Also, avoid red meat and other greasy and fatty junk foods to lower the risk of stroke.
2. Maintain healthy weight: If you are overweight/obese or have high cholesterol levels, then it is advised to lose weight to attain body mass index (BMI) between 18.5 and 24.9. This can lower the risk of stroke in the future.
3. Stay active: Sedentary lifestyle is a major factor in progression of cardiovascular and cerebrovascular complications. Hence, it is recommended that you try to move as much as possible and indulge in some form of exercise most days of the week. For adults, 2 hours and 30 minutes of moderate-intensity aerobic physical activity such as a brisk walk is recommended for each week.
4. Keep your blood pressure in check: High blood pressure can increase your risk of having a stroke. High blood pressure usually has no symptoms, so make sure to have it checked on a regular basis. If you have high blood pressure, proper medication, some changes in lifestyle, or foods with lower sodium can help in managing the condition.
5. Control diabetes: Uncontrolled diabetes can lead to higher risk of development of stroke, it is of paramount importance to watch your blood sugar levels. In case you have diabetes, your doctor may recommend some lifestyle changes like more physical activity or choosing healthier foods along with necessary medications. These steps will help keep blood sugar under good control and hence help lower the risk for stroke.
6. Cut down on alcohol: If you consume alcohol, it is advised either to quit or decrease it to a minimum to avoid the risk of stroke. Men should not consume more than two drinks per day, and women should have no more than one drink.
7. Quit smoking: Smoking is a strict no-no when it comes to prevention of stroke. If you don’t smoke, don’t start. If you do smoke, quitting will greatly reduce the risk for stroke. Your doctor can advise ways to help you quit smoking.
8. Evaluation of risk factors: If you are at high risk for stroke, appropriate lifestyle changes along with bi-annual health checkups can go along way in preventing a stroke.
Additionally, here are a few tips to prevent another stroke:
Work with your doctor to identify the cause of it.
Always ensure to keep up with the follow-up appointments.
Consult your doctor if you are changing/stopping any medications.
Do not ignore the warning signs and symptoms of stroke.
Complications Of Stroke
The complications of stroke vary from person to person. They depend on the severity of the stroke along with which part of the brain is affected by it. Some of the complications associated with stroke are as follows:
Cognitive impairment including dementia (forgetfulness)
Reduced mobility or ability to control certain muscle movements
Loss of bladder and bowel control
Deep venous thrombosis
Mood or emotional changes
Anxiety and depression
Pressure or bed sores
Living With Stroke
Although, it is estimated that 1 in 4 stroke survivors will have another attack, not many know that up to 80% of strokes can be prevented with simple measures. These include a combination of medication, healthy diet, physical activity, and controlling comorbidities.
Here are a few tips for stroke survivors as well as caregivers to help identify and handle the condition.
Learn about the condition
Whether it is the warning signs and symptoms, the cause of stroke, or the side effects of medications, it is important to be well aware of the condition & its impact on the overall health.
Control risk factors
If the risk factors, modifiable ones like cholesterol, blood pressure, and diabetes are not controlled, then the risk of stroke striking again is high. So, make sure you eat a healthy diet, stay active, take medications as advised and keep up with the follow-up appointments. Also, avoid any smoking and drinking as they can severely hamper the road of recovery.
Keep a tab on recovery
Recovery post stroke is influenced by many factors like which part of the brain was affected, how much was affected, general health of the survivor before the stroke, etc. Although, most people tend to show improvement 3-4 months after a stroke, for others it may take a year or two.
Maintain regular checkups
This helps to monitor your blood pressure, blood sugar, lipid profile and overall recovery.
Do not ignore falls/injury
It is seen that falls after stroke is a common occurrence. So, it is important to follow measures to prevent the same. Also, if a survivor has had minor falls more than twice in six months or has bruising or bleeding or pain after a fall, then please consult your doctor without fail.
Successful recovery from a stroke often requires some specific therapies and support systems including:
Speech therapy: A stroke can sometimes cause deranged speech. A speech and language therapist can help with problems producing or understanding speech. In case verbal communication is difficult after a stroke, they can help in finding new and innovative ways of communication. Regular practice along with change in communication style can make communicating simpler.
Physical therapy: Loss of muscle tone and strength after a stroke restricts certain movements of the body. A physical therapist can help to regain strength and relearn movement and coordination. New ways to learn to adjust to any limitations can go a long way in rehabilitation.
Occupational therapy: Sometimes, stroke can dull the senses. It means that the sensation of temperature, pressure, or pain are significantly reduced. An occupational therapist can help to adjust to this lack of sensation. They can also help a person improve their ability to carry out daily activities such as bathing, dressing, eating, and reading.
Cognitive therapy: After a stroke, many patients may experience changes in their thinking or reasoning skills. This can also lead to behavioral and mood swings. Cognitive therapy can help to regain former patterns of behavior, along with management of emotional responses.
Take care of your mental health
Sound mental health plays an important role in recovery and rehabilitation. So if needed, seek help.
Joining a support group to cope with any mental health issues. Many people find it helpful to share their experiences and exchange ideas and information.
Family along with close friends and relatives should provide comfort and practical support after a stroke. Letting family and friends know how they can help is very important.
With the right help and the support of loved ones, attaining a decent quality of life is usually possible, depending on the severity of the stroke.
Frequently Asked Questions
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- Hemorrhagic Stroke. American Stroke Association.
- Secades JJ, Alvarez-Sabín J, Castillo J, et al. Citicoline for Acute Ischemic Stroke: A Systematic Review and Formal Meta-analysis of Randomized, Double-Blind, and Placebo-Controlled Trials. J Stroke Cerebrovasc Dis. 2016 Aug;25(8):1984-96.