c



 
 


  



  

A
     



 ) occurs when the   supply to a part of the

 is suddenly interrupted by occlusion (called an ischemic stroke -- approximately 90% of strokes),
by  
 (called a  

  -- about 10% of strokes) or other causes. 

is a
reduction of   flow most commonly due to occlusion (an obstruction). On the other hand,
 

  (or intracranial  
), occurs when a   vessel in the 
 bursts,
spilling   into the spaces surrounding the 
 cells or when a  

 
 ruptures. The
mortality and long-term morbidity prognosis is generally worse for  

 s than for
ischemic strokes. A small proportion of strokes are

 strokes caused by hypoperfusion (usually
due to hypotension) or other vascular problems including 


.

A stroke is a 
 . It generally presents with loss of function of the area of the
body controlled by the affected part of the brain, e.g. 
, loss of speech or vision, impaired
swallowing reflex or altered sensation. The immediate and long-term results lead to marked  
and  
.







 

Ischemic stroke is usually caused by




(fatty lumps in the artery wall),
 
 (obstruction of blood vessels by blood clots from elsewhere in the body), or

 
 (small artery disease, the occlusion of small cerebral vessels).

Risk factors (for atherosclerosis and small vessel disease) are age,  
  (high
blood pressure), 

 
, 
  
  levels and 

 . High
blood pressure is the most important modifiable risk factor of stroke.  
 ! 
  and
other

s can lead to clot formation in the heart, which embolize to the brain. Some
forms of   
(increased coagulation tendency) have a predilection for arterial
thrombosis and stroke; these include  
 
and the rare 
"

   

   
. 

predisposes to strokes.

# 

 

# 
  increases the risk of cerebral bleeding. Other causes include

   

! 
  ( 
$),  

 
s, cerebral arteriosclerosis,
brain injury, head injury,   
 
, congenital artery defects and  
 .


V


 

As opposed to hemorrhagic stroke or embolic (or other atherogenic) stroke, watershed

strokes occur in parts of the brain that lie at the boundary between zones of arterial distribution
from different arteries. When there is hypotension from any cause, these watershed areas are
more susceptible to damage than other areas of the brain.




 

The symptoms of stroke are usually easy to spot:

ëY sudden numbness or weakness, especially on one side of the body;

ëY reflexes can initially be decreased on the affected side, but are often livelier than on the
other side
ëY the face is normally spared (as this is served by both hemispheres), but the corner of the
mouth can be affected on the same side as the limb symptoms
ëY sudden confusion or aphasia (trouble speaking) or understanding speech;
ëY sudden trouble seeing in one eye (or rarely both);
ëY unequal pupils
ëY sudden trouble walking, dizziness, or loss of balance or coordination.

A subgroup loses consciousness as part of the initial presentation. This occurs

more often in bleeding than in thrombosis.

A sudden-onset severe 

 can denote


  
, which
is a stroke-like clinical entity. Some other forms of stroke can feature 

s.

If the symptoms resolve within an hour, or maximum 24 hours, the diagnosis is



 


 (TIA), and not a stroke. This syndrome may be a warning
sign, and a proportion of patients develop strokes in the future. The chances of suffering a
stroke can be reduced by using

 , which inhibits platelets from aggregating and
forming obstructive clots.

%



Stroke is diagnosed through several techniques: a neurological examination,  
s,
&

s (without contrast enhancements) or $

s, %   

, and

  
. The most important risk factors for stroke are hypertension, 
 


,


, and cigarette smoking. Other risks include heavy alcohol consumption, high blood
cholesterol levels, illicit drug use, and genetic or congenital conditions. Some risk factors for
stroke apply only to women. Primary among these are pregnancy, childbirth, menopause and the
treatment thereof (#&). Stroke seems to run in some families. Family members may have a
genetic tendency for stroke or share a lifestyle that contributes to stroke.

If a stroke is confirmed on imaging, various other studies may be performed to determine

whether there is a peripheral source of emboli:

ëY an ultrasound/doppler study of the carotid arteries (to detect carotid stenosis)

 ëY an electrocardiogram (ECG) and echocardiogram (to identify arrhythmias and resultant
clots in the heart which may spread to the brain vessels through the bloodstream)
ëY a Holter monitor study to identify intermittent arrhythmias
ëY an angiogram of the cerebral vasculature (if a bleed is thought to have originated from an
aneurysm or arteriovenous malformation)

[
 
  
 
and 
die when they no longer receive " and  s from the blood
or when they are damaged by sudden bleeding into or around the brain. These damaged cells can
linger in a compromised state for several hours. With timely treatment, these cells can be saved.
Intriguingly, when the brain cells suffer the ischemia, they begin to fill up with free zinc ions
which are released from some of their proteins, especially metallothionein, which can release 7
zinc ions per molecule. This released zinc is a major player in the ensuing death of the brain
cells. Drugs that buffer the zinc and reduce the level of free zinc are already being tested to
reduce brain cell death after stroke.

[  
Prevention is an important public health concern. Identification of patients with treatable
risk factors for stroke is paramount. Treatment of risk factors in patients who have already had
strokes (secondary prevention) is also very important as they are at high risk of subsequent
events compared with those who have never had a stroke. Medication or drug therapy is the most
common method of stroke prevention. Surgery such as 

   can be used to
remove significant narrowing of the neck (internal) 

  which supplies blood to the
brain and this operation has been shown to be an effective way to prevent stroke in particular
groups of patients.

Some brain damage that results from stroke may be secondary to the initial death of brain
cells caused by the lack of blood flow to the brain tissue. This brain damage is a result of a toxic
reaction to the primary damage. Researchers are studying the mechanisms of this toxic reaction
and ways to prevent this secondary injury to the brain. Scientists hope to develop neuroprotective
agents to prevent this damage. Another area of research involves experiments with vasodilators,
medications that expand or dilate blood vessels and thus increase the blood flow to the brain.
Basic research has also focused on the genetics of stroke and stroke risk factors. One area of
research involving genetics is  
. One promising area of stroke animal research
involves hibernation. The dramatic decrease of blood flow to the brain in hibernating animals is
extensive enough that it would kill a non-hibernating animal. If scientists can discover how
animals hibernate without experiencing brain damage, then maybe they can discover ways to
stop the brain damage associated with decreased blood flow in stroke patients. Other studies are
looking at the role of hypothermia, or decreased body temperature, on metabolism and
neuroprotection. Scientists are working to develop new and better ways to help the brain repair
itself and restore important functions to the stroke patients. Some evidence suggests that







  (TMS), in which a small magnetic current is delivered to an
area of the brain, may possibly increase brain plasticity and speed up recovery of function after
stroke.


& 

'







It is important to identify that a patient is having a stroke as early as possible because

recovery can be improved for patients treated earlier. The term "brain attack" is used to underline
the urgency of early assessment and treatment similar in intensity to the management of a patient
with a heart attack.

If a patient is suspected of having a stroke, emergency services should be contacted

immediately, so he or she can be transported to the nearest hospital that can provide a rapid
evaluation and treatment with the latest available therapies targeted to the type of stroke. The
faster these therapies are started for hemorrhagic stroke (caused by bleeding into or around the
brain) and ischemic stroke (due to a blood clot that blocks blood flow), the chances for recovery
from each type improves greatly. Immediate decisions about medication and the need for surgery
have been shown to improve outcome.

Only detailed 


 "

  and 
 
 provide information on the
type of stroke (ischemic or hemorrhagic) and the extent, or whether the symptoms may be due to
an unrelated condition.

Long-term studies show that patients treated in hospitals with a dedicated Stroke Team or
Stroke Unit, and that have a specialized care program for stroke patients, have improved odds of
recovery.



 

As ischemic stroke is due to a  
(blood clot) occluding a cerebral artery, a

patient is commenced on


 medication (

  and/or     or
!
,
dependant on the cause) when this type of stroke has been demonstrated. As such treatment
would be dangerous in hemorrhagic stroke, it is essential that this form of stroke is ruled out with
medical imaging.

In increasing numbers of specialist centers, thrombolysis ("clot busting") is used to

dissolve the putative clot. As this treatment is expensive, quite experimental, potentially
dangerous and often contraindicated, the decision to thrombolyse can often only be made by an
expert. There is also a time constraint: studies indicate that after three hours of symptom onset
the damage to the brain is irreversible ("time is brain"), and that thrombolysis would provide no
benefit. These various requirement prevent routine thrombolysis of ischemic stroke in most
hospitals, especially out of working hours when no stroke expert may be available.

Whether thrombolysis is performed or not, the following investigations are required:

ëY Stroke symptoms are documented, often using scoring systems such as the National
Institutes of Health Stroke Scale, the Cincinnati Stroke Scale, and the Los Angeles
Prehospital Stroke Scale. The latter is used by emergency medical technicians (EMTs) to
determine whether a patient needs transport to a stroke center.
 ëY A CT scan is performed to rule out hemorrhagic stroke (or other specific forms of
cerebral hemorrhage, such as subarachnoid hemorrhage)
ëY Blood tests, such as a full blood count, coagulation studies (PT/INR, APTT), electrolytes,
renal function, liver function tests and glucose levels.

Other immediate strategies to protect the brain during stroke include ensuring that blood
sugar is as normal as possible (such as commencement of an 



 in
known 

), and that the stroke patient is receiving adequate " and

 
 !s. The patient may be positioned so that their head is flat on the
stretcher, rather than sitting up, since studies have shown that this increases blood flow to
the brain. Additional therapies for ischemic stroke include

  (50 to 325 mg daily),
    (75 mg daily), and combined

  and  
  extended release
(25/200 mg twice daily).

It is common for the    

  to be 

 immediately following a stroke.
Studies indicated that while high   

  causes stroke, it is actually beneficial in
the emergency period to allow better blood flow to the brain.

If studies show 



, and the patient has residual function in the affected side,

 
   (surgical removal of the stenosis) may decrease the risk of
recurrence.

If the stroke has been the result of 




(such as
 
! 
 ) with
cardiogenic emboli, treatment of the arrhythmia and


  with
!
 or
high-dose aspirin may decrease the risk of recurrence.

# 

 

Patient's with bleeding into (intracerebral hemorrhage) or around the brain

(


  
), require 
 
 evaluation. Neurosurgeons use specialized
examinations for hemorrhagic stroke patients, such as the Hunt & Hess scale, that can help
determine the appropriate treatment. Strategies to protect the brain during this type of stroke
include  

and blood pressure control, adequate oxygen and intravenous fluids,
detection and treatment of the cause of bleeding, and constant surveillance (e.g. with the


  

) and immediate treatment for complications from bleeding into or around
the brain.

Cerebral arteriography may be used to determine the cause for bleeding, since some
causes may be surgically corrected to reduce the risk of future bleeding. Selected patients with
subarachnoid hemorrhage due to a ruptured
 
 require emergency surgery to "clip" the

 
 off from the normal brain blood circulation, and they receive  , a drug
shown to reduce incidence of 




, a complication of this type of stroke.



 

 

Good nursing care is fundamental in maintaining skin care, feeding and hydration and
positioning as well as the monitoring of vital signs such as temperature, pulse and blood
pressure. Stroke rehabilitation begins almost immediately.
 Stroke rehabilitation is the process by which patients with disabling strokes undergo
treatment to help them return to normal life as much as possible by regaining and relearning the
skills of everyday living. It is multidisciplinary in the fact that it involves a team with different
skills working together to help the patient. These include nursing staff, 
 
,

 
 
,

 

 
 and usually a 

 trained in


  . Some teams may also include 
  

and

 ers and



s.

For most stroke patients, 


 
 is the cornerstone of the rehabilitation
process. Another type of therapy involving relearning daily activities is 
 
 

(OT). OT involves exercise and training to help the stroke patient relearn everyday activities
sometimes called the 
 !
 (ADLs) such as eating, drinking and swallowing,
dressing, bathing, cooking, reading and writing, and toileting. 



 is
appropriate for patients with problems understanding speech or written words, or problems
forming speech.

Patients may have particular problems such as an inability to swallow or a swallow that is
not safe such that swallowed material may pass into the lungs and cause an


 
 
. The swallow may improve with time but in the interim a nasogastric tube may be
passed which enables liquid food to be given directly into the stomach. If after a week the
swallow is still not safe then a [' tube is passed and this can remain indefinitely.

The team have regular meetings at which the patient and family may be present to discuss
the current situation and to set goals and to ensure effective communication. In most cases the
desired goal is to enable the patient to return home to independent living though this is not
always possible.

Stroke rehabilitation can last anything from a few days up to several months. Most return
of function is seen in the first few days and weeks and then falls off. It is unusual that there is
complete recovery but not impossible. Most patients will improve to some extent.