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Stroke - symptoms, diagnosis, treatment, prevention

 
A stroke is a disruption of blood flow to a part of the brain, which causes brains cells to be damaged or die because of a lack of oxygen. A stroke is a medical emergency that requires immediate treatment. Symptoms usually occur suddenly but will vary depending on the part of the brain that is affected.
 
Brain scan 1
Approximately 9000 New Zealanders have a stroke each year – it is the second biggest killer (approximately 2500 deaths per year) and a major cause of disability in New Zealand . The best means to prevent a stroke are to manage related medical conditions (notably high blood pressure) and lifestyle factors.

Types of stroke  

Ischaemic strokes:
Ischaemic strokes occur when a blood clot completely blocks an artery in or to the brain. They are the most common type of stroke, occurring in about 85% of cases. Ischaemic strokes can be either thrombotic or embolic.  Thrombotic strokes occur when a blood clot (thrombus) blocks an artery that supplies blood to the brain, which has been narrowed by the build-up of fatty deposits (plaques) during a process known as atherosclerosis.  Embolic strokes are due to a clot that has formed outside the brain and travels to the brain in the blood stream. When this occurs the clot is known as an embolus (plural = emboli).
 
Haemorrhagic Strokes:

Haemorrhagic strokes occur when an artery within the brain ruptures (bursts) and leaks blood into the brain. The presence of this extra blood causes pressure to build within the area of the brain where the bleed has occurred. This causes damage to the brain tissue in that area. Haemorrhagic strokes are less common than ischaemic strokes but their effects are generally more severe.

Rupture of an artery can be due to factors such as an aneurysm (where a weakened section of an artery balloons out), a congenitally abnormal connection of blood vessels, or extremely high blood pressure.
 
Mini stroke (transient ischaemic attack):
Mini strokes, or transient ischaemic attacks (TIA), occur when there is a temporary disruption in the blood flow to the brain. This can be due to a narrowing in an artery in or to the brain, or as a result of a blood clot that quickly dislodges itself allowing blood to flow again.
 
Symptoms of a TIA can be similar to those of a stroke and can include sudden weakness and/or numbness of face, arm and/or leg, sudden blurred or loss of vision in one or both eyes, sudden difficulty speaking or understanding what others are saying, sudden dizziness, loss of balance or difficulty controlling movements. Symptoms may last for only a few minutes or up to a few hours and resolve within 24 hours. If symptoms last longer than 24 hours the condition is diagnosed as a stroke.
 
Suffering a TIA increases the risk of having a full-blown stroke and having a TIA should be a clear warning that a more severe stroke might follow. Immediate medical attention should be sought if a TIA is suspected as they can be a warning sign that a more severe stroke might follow. 
 
The Stroke Foundation recommends a person with a suspected TIA should go directly to hospital for medical assessment. 

Stroke risk 

People of all ages and genders can suffer a stroke. In New Zealand, approximately 24 people have a stroke each day. 
Risk factors multiply and the greater the number, the greater the chance of a stroke. High blood pressure (hypertension) is the leading risk factor for stroke.
 
Seventy-five percent of strokes occur in people over 65 years of age. Ischaemic strokes make up the majority of strokes in older people while younger people are more likely to suffer a haemorrhagic stroke.
Ethnicity is a factor and Maori and Pacific Island New Zealanders are more likely to suffer a stroke than European New Zealanders. Men are more likely to suffer a stroke than women. Pregnant women also have a slightly increased risk of haemorrhagic stroke.
 

There are controllable and uncontrollable factors that increase the risk of stroke.   Uncontrollable risk factors (ie: risks you cannot reduce through treatment or lifestyle changes)  include:

  • Age
  • Male gender
  • Family history
  • Ethnicity
  • Previous TIA.

Early detection and effective management of controllable stroke risk factors can greatly reduce the possibility of stroke.  Controllable risk factors for TIA and stroke include:

Signs and symptoms

Signs and symptoms of a stroke usually occur suddenly. The type of symptoms experienced will depend on what area of the brain is affected. The areas of the brain that control function on one side of the body are often located in the opposite side of the brain. Therefore, lack of blood to one side of the brain can often result in signs and symptoms on the opposite side of the body.   Common initial symptoms of a stroke include:

  • Severe headache
  • Impairment or loss of vision
  • Memory loss
  • Confusion
  • Loss of balance or co-ordination
  • Poor balance and dizziness
  • Sudden numbness, paralysis or weakness of an arm, leg or side of the face
  • Slurred or abnormal speech
  • Loss of consciousness
  • Incontinence.

Complications

A stroke can cause permanent loss of function. The type and degree of this loss of function is determined by which area of the brain has been affected and the speed and success of treatment given.   Permanent effects of a stroke can include:  

  • Impaired vision
  • Difficulty understanding or forming speech
  • Severe weakness or paralysis of the affected side (hemiplegia)
  • Numbness, strange sensations or pain - sometimes made worse by movement or temperature change
  • Swallowing difficulties
  • Depression
  • Emotional problems, such as difficulty controlling emotions or expressing inappropriate emotions.
Stoke may also cause problems with thinking, awareness, attention, learning, judgement and memory. 

Diagnosis

To diagnose a stroke a doctor will usually make an assessment using several of the following:

  • Examination of current signs and symptoms
  • Review of medical history (including current medications being taken, and head injuries)
  • Review of personal and family history of heart disease, stroke and TIA
  • Electrocardiogram (ECG) - measures electrical activity in the heart
  • Echocardiogram - to assess for any abnormalities in heart function and structure
  • Electroencephalogram (EEG) - measures electrical activity in the brain
  • Cerebral angiogram - provides a detailed view of the arteries in the brain
  • Ultrasound scanning of the neck arteries (carotids)
  • Computerised tomography (CT) scan - specialised x-rays that can provide detailed cross-sectional images of the brain
  • Magnetic resonance imaging (MRI) - a specialised scan that produces a detailed image of the brain
  • Blood tests
  • Chest x-rays. 

Treatment 

Stroke is a medical emergency requiring immediate treatment.  Prompt treatment improves the chances of survival and increases the degree of recovery that might be expected. The treatment given will depend on the type of stroke suffered.

INITIAL TREATMENT

Immediate treatment is aimed at limiting the size of the stroke and preventing further stroke. Acute stroke therapies try to stop a stroke while it is happening by quickly dissolving the blood clot causing an ischaemic stroke or by stopping the bleeding of a haemorrhagic stroke.  This will involve administering medications and may involve surgery in some cases.

Medications 

  • Thrombolytic therapy: These medications dissolve blood clots allowing blood flow to be re-established
  • Anti-platelet drugs (eg: aspirin) and anticoagulants (eg: heparin): These medications help to prevent blot clots getting bigger and prevent new blood clots from forming
  • Antihypertensives:  In cases of haemorrhagic stroke these medications may be prescribed to help lower high blood pressure
  • Medications to reduce swelling in the brain and medications to treat underlying causes for the stroke eg: heart rhythm disorders may also be given.
Surgery
Surgery may be needed to repair blocked or ruptured arteries. For a haemorrhagic stroke this may involve repairing a bleeding aneurysm or AVM. Where an ischaemic stroke has been caused by a blockage in a neck artery surgery to remove the blockage may be performed. This is known as a carotid endarterectomy.

Supportive treatment
Providing adequate fluid and nutrition intake after a stroke is vital, particularly if swallowing has been affected.  This may require the insertion of an intravenous drip into a vein in the hand or arm, or it may involve inserting a feeding tube via the nose into the stomach.  Preventing complications that can occur as a result of immobility eg: pneumonia and bed sores, is also important.
 
LONGER TERM TREATMENT:

Brain cells do not generally regenerate (regrow). Following a stroke, surviving brain cells can take over the function of areas that are dead or damaged, but only to a certain degree. The adaptive ability of the brain requires the relearning of various skills.

As each person who suffers a stroke is affected differently, individual rehabilitation plans are developed in conjunction with the patient, family and healthcare team. These aim to teach skills and maximise function so that the person can achieve maximum independence.

Rehabilitation may involve:

  • Physiotherapy - to improve mobility
  • Speech therapy - to improve communication
  • Occupational therapy - to improve daily functions such as eating, cooking, toileting and washing.
Recovery can take months and it may be several days or weeks after the stroke before doctors are able to give an accurate prediction for recovery.

Long term treatment with medications to treat the underlying cause of the stroke and to minimise the risk of further stroke may be required. This includes long term use of medications to treat high blood pressure, heart rhythm disorders, high cholesterol, heart disease and blood clotting disorders. Common long-term medications prescribed for people who have had a stroke include warfarin and aspirin - both of which aim to prevent the formation of blood clots.

Surgery to treat the underlying cause of the stroke may also be recommended. This can include surgery to damaged heart valve, heart rhythm problems (may involve the insertion of a pacemaker) or carotid endarterectomy.  

Prevention 

Reducing the number of controllable risk factors is the best way to prevent a stroke.  This can include:

If discovered prior to a stroke, some medical conditions may be repaired surgically in order to prevent a stroke occurring in the first place eg: aneurysms, narrowed arteries, heart rhythm disorders, heart valve problems.

Medications (eg: aspirin or warfarin) may be recommended to help prevent another ischaemic stroke or TIA.

Further support 

Stroke Foundation NZ offers information and support and can provide details for regional branches. Contact details are as follows:

Stroke Foundation NZ
Freephone: 0800 STROKE (0800 78 76 53)
E-mail: strokenz@stroke.org.nz
Website: www.stroke.org.nz

References 

Mayo Clinic (2017). Stroke (Web Page). Rochester, NY: Mayo Foundation for Medical Education and Research. http://www.mayoclinic.org/diseases-conditions/stroke/home/ovc-20117264 [Date accessed: 15/08/17]
Ministry of Health (2014). New Zealand Health Survey: Annual update of key results 2013/14 (Report PDF). Wellington: Ministry of Health. https://www.health.govt.nz/system/files/documents/publications/annual-update-key-results-nzhs-2013-14-dec14-v2.pdf
O’Toole, M.T. (Ed.) (2013). Cerebrovascular accident (CVA). Mosby’s Dictionary of Medicine, Nursing & Health Professions (9th ed.). St Louis, MI: Elsevier Mosby.
Stroke Foundation NZ (Date Unknown). Information about stroke (Web Page). Wellington: Stroke Foundation New Zealand. http://www.stroke.org.nz/information-about-stroke [Date accessed: 14/08/17]
 
Last Reviewed – August 2017 

 

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