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troke is probably one of the most feared words in the English language. The catastrophic onset and debilitating damage of stroke evoke dread. Stroke is the third most common cause of death in the United States. More than a quarter of those who have a stroke die as a direct result. Many of the others are plagued by severe disability and other complications.
Stroke occurs when one of the blood vessels to the brain or in the brain is clogged or starts bleeding. The exact symptoms are based on which area of the brain is deprived of blood flow. For instance, one of the classic syndromes is caused by blocking the left middle cerebral artery. This can cause paralysis of the right side of the body and loss of speech.
However, there are many other types of stroke syndromes, that is, patterns of neurologic damage and loss. For example, when the left side of the body is paralyzed, speech and language problems are uncommon. Blindness can accompany one-sided weakness or paralysis. Disorders of balance might be more predominant than paralysis. Loss of sensation can accompany paralysis in some cases. In few cases, all four extremities are sticken.
Most stokes are embolic. That means a small clot forms within an artery and obstructs the flow of blood. Less common are hemorrhagic strokes, where a blood vessel ruptures and bleeds into the substance of the brain itself. This often occurs at a site of weakness in the vessel, such as an aneurysm or arteriovenous malformation.
Those who are at highest risk for stroke are people with established risk of cardiovascular disease, or who already have cardiovascular disease. This includes people with hypertension, elevated cholesterol levels, heart disease, diabetes, chronic kidney disease, and smokers.
Also at risk are those with a particular kind of irregular heart rhythm called atrial fibrillation. With this irregularity, the heart is prone to forming clots within its walls, which can then fly through the circulation and lodge in the brain. In addition, users of illegal drugs such as cocaine and heroin are likely to get strokes. Women taking oral contraceptives are at increased risk as well.
There might be a warning. TIA, or transient ischemic attack, signals a high risk of stroke within the next year, just as angina pectoris suggests risk for heart attack. In TIA, a person has a neurologic loss similar to stroke, but the symptoms last less than 24 hours, and resolve completely. But the warning is for real.
Stroke
is an emergency. As soon as the signs are recognized, emergency care must begin. Patients need intensive care. Larger hospitals are now forming special units for “brain attack”, just as they did for heart attack a generation ago. Cardiac and neurologic monitoring is essential. Blood pressure must be controlled. Specialists must decide whether or not to use blood thinners, or to attempt angioplasty of the carotid arteries, the brain’s major blood supply, as is done with the coronary arteries in heart attack.
Antiplatelet therapy with aspirin remains central in the treatment and prevention of stroke. Of course, blood pressure control and lowering cholesterol are also important. If a clot is found in one of the brain’s major arteries within the first three hours after symptoms occur, aggressive intervention with clot busting drugs might be warranted, if a patient is at a center with such capabilities. Sometimes, the acute damage causes swelling in the brain, cerebral edema. This may require intensive management with mechanical breathing machines and medications to reduce the swelling. Those patients with atrial fibrillation require long term treatment with the blood thinner warfarin.
After the stroke, rehabilitation becomes of paramount importance. It is difficult to predict how much recovery any particular individual can have after stroke, and rehab can be difficult. But aggressive rehab, begun as soon as possible, is the best hope to get return of function after stroke.
AnestaMed, Inc. Real Health. Real Simple.
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Created by Christopher Green R.N. B.A.
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Dr. Samuel Snyder is Associate Professor and Chair of Internal Medicine at Nova Southeastern University College of Osteopathic Medicine. He is a Fellow of the American College of Physicians, the American Society of Nephrology, and the American College of Osteopathic Internists. He is board certified in both Internal Medicine and Nephrology. He writes scientific and popular articles and lectures widely on a wide range of medical subjects.
