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Overview of Stroke

by Elias A. Giraldo, MD, MS

A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction) and causing sudden symptoms.

  • Most strokes are ischemic (usually due to blockage of an artery), but some are hemorrhagic (due to rupture of an artery).

  • Transient ischemic attacks resemble ischemic strokes except that no permanent brain damage occurs and the symptoms typically resolve within 1 hour.

  • Symptoms occur suddenly and can include muscle weakness, paralysis, abnormal or lost sensation on one side of the body, difficulty speaking, confusion, problems with vision, dizziness, loss of balance and coordination, and, in one type, a sudden, severe headache.

  • Diagnosis is based mainly on symptoms, but imaging and blood tests are also done.

  • Recovery after a stroke depends on many factors, such as the location and amount of damage, the person’s age, and the presence of other disorders.

  • Controlling high blood pressure, high cholesterol levels, and high blood sugar levels and not smoking help prevent strokes.

  • Treatment may include drugs to make blood less likely to clot or to break up clots and sometimes surgery or angioplasty.

A stroke is called a cerebrovascular disorder because it affects the brain (cerebro-) and the blood vessels (vascular).

Supplying the Brain with Blood

Blood is supplied to the brain through two pairs of large arteries:

  • Internal carotid arteries, which carry blood from the heart along the front of the neck

  • Vertebral arteries, which carry blood from the heart along the back of the neck

In the skull, the vertebral arteries unite to form the basilar artery (at the back of the head). The internal carotid arteries and the basilar artery divide into several branches, including the cerebral arteries. Some branches join to form a circle of arteries (circle of Willis) that connect the vertebral and internal carotid arteries. Other arteries branch off from the circle of Willis like roads from a traffic circle. The branches carry blood to all parts of the brain.

When the large arteries that supply the brain are blocked, some people have no symptoms or have only a small stroke. But others with the same sort of blockage have a massive ischemic stroke. Why? Part of the explanation is collateral arteries. Collateral arteries run between other arteries, providing extra connections. These arteries include the circle of Willis and connections between the arteries that branch off from the circle. Some people are born with large collateral arteries, which can protect them from strokes. Then when one artery is blocked, blood flow continues through a collateral artery, sometimes preventing a stroke. Other people are born with small collateral arteries. Small collateral arteries may be unable to pass enough blood to the affected area, so a stroke results.

The body can also protect itself against strokes by growing new arteries. When blockages develop slowly and gradually (as occurs in atherosclerosis), new arteries may grow in time to keep the affected area of the brain supplied with blood and thus prevent a stroke. If a stroke has already occurred, growing new arteries can help prevent a second stroke (but cannot reverse damage that has been done).

In Western countries, strokes are the fourth most common cause of death and the most common cause of disabling neurologic damage in adults. In the United States, over 795,000 people have a stroke, and about 130,000 die of stroke each year. Strokes are much more common among older people than among younger adults, usually because the disorders that lead to strokes progress over time. Over two thirds of all strokes occur in people older than 65. Slightly more than 50% of all strokes occur in men, but more than 60% of deaths due to stroke occur in women, possibly because women are on average older when the stroke occurs. Blacks are more likely than whites to have a stroke and to die of it.

Types

There are two types of strokes:

About 80% of strokes are ischemic—usually due to a blocked artery, often blocked by a blood clot. Brain cells, thus deprived of their blood supply, do not receive enough oxygen and glucose (a sugar), which are carried by blood. The damage that results depends on how long brain cells are deprived of blood. If they are deprived for only a brief time, brain cells are stressed, but they may recover. If brain cells are deprived longer, brain cells die, and some functions may be lost, sometimes permanently. How soon brain cells die after being deprived of blood varies. They die after only a few minutes in some areas of the brain but not until after 30 minutes or more in other areas. In some cases, after brain cells die, a different area of the brain can learn how to do the functions previously done by the damaged area.

Transient ischemic attacks (TIAs—see Transient Ischemic Attacks), sometimes called ministrokes, are often an early warning sign of an impending ischemic stroke. They are caused by a brief interruption of the blood supply to part of the brain. Because the blood supply is restored quickly, brain tissue does not die, as it does in a stroke, and brain function quickly returns.

The other 20% of strokes are hemorrhagic—due to bleeding in or around the brain. In this type of stroke, a blood vessel ruptures, interfering with normal blood flow and allowing blood to leak into brain tissue or around the brain. Blood that comes into direct contact with brain tissue irritates the tissue and, over time, can cause scar tissue to form in the brain, sometimes leading to seizures.

Risk factors

The major risk factors for both types of stroke are

  • Atherosclerosis (narrowing or blockage of arteries by patchy deposits of fatty material in the walls of arteries)

  • High cholesterol levels

  • High blood pressure

  • Diabetes

  • Smoking

Atherosclerosis is a more important risk factor for ischemic stroke, and high blood pressure is a more important risk factor for hemorrhagic stroke. These risk factors can be controlled to some extent.

Other risk factors include

  • Having relatives who have had a stroke

  • Consuming too much alcohol

  • Using cocaine or amphetamines

  • Having an abnormal heart rhythm called atrial fibrillation

  • Having another heart disorder, such as a heart attack or infective endocarditis (infection of the heart's lining)

  • Having inflamed blood vessels (vasculitis)

  • Being overweight, particularly if the excess weight is around the abdomen

  • Getting too little physical activity

  • Eating an unhealthy diet (such as one that is high in saturated fats, trans fats, and calories)

  • Having a clotting disorder

For hemorrhagic stroke, risk factors also include using anticoagulants (drugs that inhibit blood clotting), using cocaine or amphetamines, and having a bulge (aneurysm) in arteries or an abnormal connection between arteries and veins (arteriovenous malformation) within the skull.

The incidence of strokes has declined in recent decades, mainly because people are more aware of the importance of controlling high blood pressure and high cholesterol levels and stopping cigarette smoking. Controlling these factors reduces the risk of atherosclerosis (which is a risk factor for stroke). Other risk factors for stroke cannot be controlled. They include being older, being male, having had a stroke, and having relatives who have had a stroke.

Symptoms

Symptoms of a stroke or transient ischemic attack occur suddenly. They vary depending on the precise location of the blockage or bleeding in the brain (see Brain Dysfunction by Location and When Specific Areas of the Brain Are Damaged). Each area of the brain is supplied by specific arteries. For example, if an artery supplying the area of the brain that controls the left leg’s muscle movements is blocked, the leg becomes weak or paralyzed. If the area of the brain that senses touch in the right arm is damaged, sensation in the right arm is lost.

Why Strokes Affect Only One Side of the Body

Strokes usually damage only one side of the brain. Because nerves in the brain cross over to the other side of the body, symptoms appear on the side of the body opposite the damaged side of the brain.

Warning symptoms

Because early treatment can help limit loss of function and sensation, everyone should know what the early symptoms of stroke are. People who have any of the following symptoms should see a doctor immediately, even if the symptom goes away quickly :

  • Sudden weakness or paralysis on one side of the body (for example, half of the face, one arm or leg, or all of one side)

  • Sudden loss of sensation or abnormal sensations on one side of the body

  • Sudden difficulty speaking, including difficulty coming up with words and sometimes slurred speech

  • Sudden confusion, with difficulty understanding speech

  • Sudden dimness, blurring, or loss of vision, particularly in one eye

  • Sudden dizziness or loss of balance and coordination, leading to falls

One or more of these symptoms are typically present in both hemorrhagic and ischemic strokes. Symptoms of a transient ischemic attack are the same, but they usually disappear within minutes and rarely last more than 1 hour.

Symptoms of a hemorrhagic stroke may also include the following:

  • Sudden severe headache

  • Nausea and vomiting

  • Temporary or persistent loss of consciousness

  • Very high blood pressure

Other symptoms

Other symptoms that may occur early include problems with memory, thinking, attention, or learning. People may be unable to recognize parts of the body and may be unaware of the stroke’s effects. The peripheral field of vision may be reduced, and hearing may be partially lost. Difficulty swallowing, dizziness, and vertigo may develop.

People may have difficulty controlling their bowels or bladder beginning several days or more after the stroke occurred. Loss of control may be permanent.

Later symptoms may also include involuntary stiffening and spasms of the muscles (spasticity) and inability to control emotions. Many people become depressed because of the stroke.

In most people who have had an ischemic stroke, loss of function is usually greatest immediately after the stroke occurs. However, in about 15 to 20%, the stroke is progressive, causing greatest loss of function after a day or two. This type of stroke is called an evolving stroke. In people who have had a hemorrhagic stroke, function usually is lost progressively over minutes to hours.

Over days to months, some function is usually regained because even though some brain cells die, others are only stressed and may recover. Also, certain areas of the brain can sometimes switch to the functions previously done by the damaged part—a characteristic called plasticity. However, the early effects of a stroke, including paralysis, can become permanent. Muscles that are not used usually become permanently spastic and stiff, and painful muscle spasms may occur. Walking, swallowing, physically saying words clearly, and doing daily activities may remain difficult. Various problems with memory, thinking, attention, learning, or controlling emotions may persist. Depression, impairments in hearing or vision, or vertigo may be continuing problems. Control of bowel or bladder function may be permanently impaired.

Complications

When a stroke is severe, the brain swells, increasing pressure within the skull. Increased pressure can damage the brain directly or indirectly by forcing the brain downward in the skull. The brain may be forced through the rigid structures that separate the brain into compartments, resulting in a serious problem called herniation (see Figure: ). The pressure affects areas that control consciousness and breathing in the lower part of the brain (brain stem) and can cause irregular breathing, loss of consciousness, coma, and death.

The symptoms caused by a stroke can lead to other problems. If swallowing is difficult, people may inhale food, fluids, or saliva from the mouth. Such inhalation (called aspiration) can cause aspiration pneumonia, which may be serious. Difficulty swallowing can also interfere with eating, resulting in undernutrition and dehydration. People may have difficulty breathing. Over time, not being able to move can result in pressure sores, muscle loss, permanent shortening of muscles (contractures), and the formation of blood clots in deep veins of the legs and groin (deep vein thrombosis). Clots can break off, travel through the bloodstream, and block an artery to a lung (pulmonary embolism). If bladder control is impaired, urinary tract infections are more likely to develop.

Diagnosis

Symptoms suggest the diagnosis, but tests are needed to help doctors determine the following:

  • Whether stroke has occurred

  • Whether it is ischemic or hemorrhagic

  • Whether immediate treatment is required

  • What the best way to prevent strokes is

  • Whether rehabilitation therapy is needed and, if so, what it should include

Computed tomography (CT—see Computed Tomography) or magnetic resonance imaging (MRI—see Magnetic Resonance Imaging) of the brain is done. These tests can detect most hemorrhagic strokes, except for some subarachnoid hemorrhages. These tests can also detect many ischemic strokes but sometimes not until several hours after symptoms appear. If needed to confirm the diagnosis, a specialized type of MRI, called diffusion-weighted MRI, can show areas of brain tissue that are deprived of blood. This test can thus help doctors diagnose an ischemic stroke or a transient ischemic attack. However, diffusion-weighted imaging is not always available.

The blood sugar level is measured immediately because a low blood sugar level (hypoglycemia) can cause symptoms similar to those of stroke.

Doctors evaluate people who have had a stroke for problems that can contribute to or cause a stroke, such as infection, a low blood oxygen level, and dehydration. Tests are done as needed. People are asked about depression, which often occurs after a stroke. The ability to swallow is evaluated, sometimes with x-rays taken after a radiopaque dye such as barium is swallowed. Depending on the type of stroke, more tests are done to identify the cause.

Doctors often use a standardized set of criteria to determine how severe the stroke is and what the chances of recovery are. It includes evaluation of level of consciousness, the ability to answer questions, the ability to obey simple commands, vision, arm and leg function, and speech.

Prognosis

Certain factors suggest that the outcome of a stroke is likely to be poor. Strokes that impair consciousness or that affect a large part of the left side of the brain (which is responsible for language) may be particularly grave.

Usually, the more quickly people improve during the days after stroke, the more they will ultimately improve. Improvement commonly continues for 6 months after the stroke. In adults who have had an ischemic stroke, problems that remain after 12 months are likely to be permanent, but children continue to improve slowly for many months. Older people fare less well than younger people. For people who already have other serious disorders (such as dementia), recovery is more limited.

If a hemorrhagic stroke is not massive and pressure within the brain is not very high, the outcome is likely to be better than that after an ischemic stroke with similar symptoms. Blood (in a hemorrhagic stroke) does not damage brain tissue as much as an inadequate supply of oxygen (in an ischemic stroke) does.

Prevention

Preventing strokes is preferable to treating them. The main strategy for preventing a first stroke is managing the major risk factors. If people have had a stroke, additional preventive measures are usually needed.

Managing risk factors

High blood pressure (see High Blood Pressure : Treatment) and diabetes (see Diabetes Mellitus : Treatment) should be controlled. Cholesterol levels should be measured and, if high, lowered to reduce the risk of atherosclerosis (see Dyslipidemia : Treatment). Smoking and use of amphetamines or cocaine should be stopped, and alcohol should be limited to no more than 2 drinks a day. Exercising regularly and, if overweight, losing weight help people control high blood pressure, diabetes, and high cholesterol levels.

Having regular checkups enables a doctor to identify risk factors for stroke so that they can be managed quickly.

Antiplatelet drugs

If people have had an ischemic stroke, taking an antiplatelet drug can reduce the risk of another ischemic stroke. Antiplatelet drugs make platelets less likely to clump and form clots, a common cause of ischemic stroke. (Platelets are tiny cell-like particles in blood that help it clot in response to damaged blood vessels.) Aspirin, one of the most effective antiplatelet drugs, is usually prescribed. One adult’s tablet or 1 children’s tablet (which is about one fourth the dose of an adult aspirin) is taken each day. Either dose seems to prevent strokes about equally well. Taking a combination tablet that contains a low dose of aspirin and dipyridamole (an antiplatelet drug) is slightly more effective than taking aspirin alone.

Clopidogrel, another antiplatelet drug, may be given to people who cannot tolerate aspirin. Sometimes taking clopidogrel plus aspirin for a short time after a stroke appears to reduce the risk of future strokes more than taking aspirin alone. Taking clopidogrel plus aspirin increases the risk of bleeding.

Some people are allergic to antiplatelet drugs or similar drugs and cannot take them. Also, people who have gastrointestinal bleeding should not take antiplatelet drugs.

Anticoagulants

If an ischemic stroke or a transient ischemic attack is due to blood clots originating in the heart, warfarin, an anticoagulant, may be given to inhibit blood clotting. Because taking warfarin and an antiplatelet drug greatly increases the risk of bleeding, these drugs are rarely used together for stroke prevention.

Dabigatran, apixaban, and rivaroxaban are new anticoagulants that are sometimes used instead of warfarin.

Treatment

Anyone with symptoms of a stroke should seek medical attention immediately.

Preventing and Treating Problems After a Stroke

Problem

Measures

Blood clots in the legs

To prevent blood clots, doctors may give anticoagulants, such as heparin or low molecular weight heparin, put elastic or air-filled support stockings on the person’s legs to improve blood circulation, or both.

Moving the legs, which improves blood flow, can also help. People, if able, are encouraged to walk or simply move their legs (for example, extending and flexing their ankles). If people cannot move their legs, a therapist or other staff member moves their legs for them (called passive exercise).

Pressure sores

Nurses, other staff members, or caregivers should frequently turn or reposition people who are confined to a bed or wheelchair. Areas likely to develop pressure sores should be inspected every day.

Permanent shortening of muscles that limits movement (contractures)

Moving the limbs can prevent contractures. People, if able, are encouraged to move and change positions regularly. Or a therapist or other staff member moves their limbs for them and makes sure the limbs are placed in appropriate resting positions. Sometimes splints are used to keep the limbs in place.

Difficulty swallowing

People are evaluated for difficulty swallowing. If they have difficulty, care is taken to provide them with enough fluids and nourishment. Sometimes learning simple techniques (for example, how to position the head or how to breathe when swallowing) can help the person swallow safely. Tube feedings may be necessary until the ability to swallow returns.

Difficulty breathing

If people smoke, they are encouraged to stop. Therapists also teach them to do deep breathing exercises and to cough to clear the airways. Therapists may provide a handheld breathing device. If needed, oxygen is provided through a face mask or a tube inserted in the nose or in the mouth.

Urinary tract infections

If possible, a urinary catheter, which can cause urinary infections, is not used. If a catheter is needed, it is removed as soon as possible.

Discouragement and depression

Doctors discuss the effects of the stroke with affected people and their family members or other caregivers. The discussion includes the type of recovery that can be expected and ways to cope with limitations of function. People and their caregivers are put in contact with stroke support groups. Formal counseling or drugs may be necessary to treat depression.

Doctors check the person’s vital functions, such as heart rate, breathing, temperature, and blood pressure, to make sure they are adequate. If they are not, measures to correct them are taken immediately. For example, if people are in a coma or unresponsive (as may result from brain herniation), mechanical ventilation (with a breathing tube inserted through the mouth or nose) may be needed to help them breathe. If symptoms suggest that pressure within the skull is high, drugs may be given to reduce swelling in the brain, and a monitor may be put in the brain to periodically measure the pressure.

Other treatments used during the first hours depend on the type of stroke. These treatments include drugs (such as antiplatelet drugs, anticoagulants, drugs to break up clots, and drugs to control high blood pressure) and surgery to remove blood that has accumulated.

Later and ongoing treatments focus on preventing subsequent strokes, treating and preventing problems that strokes can cause, and helping people regain as much function as possible (rehabilitation).

Rehabilitation

Intensive rehabilitation can help many people overcome disabilities after a stroke (see Rehabilitation After a Brain Injury). The exercises and training of rehabilitation encourage unaffected areas of the brain to learn to perform functions that were done by the damaged area. Also, people are taught new ways to use muscles unaffected by the stroke to compensate for losses in function.

The goals of rehabilitation are the following:

  • To regain as much normal function as possible

  • To maintain and improve physical condition

  • To help people relearn old skills and learn new ones as needed

Success depends on the area of the brain damaged and the person’s general physical condition, functional and cognitive abilities before the stroke, social situation, learning ability, and attitude. Patience and perseverance are crucial. Participating actively in the rehabilitation program can help people avoid or lessen depression.

Rehabilitation is started in the hospital as soon as people are physically able—usually within 1 or 2 days of admission. After discharge from the hospital, rehabilitation can be continued on an outpatient basis, in a nursing home, in a rehabilitation center, or at home. Occupational and physical therapists can suggest ways to make life easier and the home safer for people with disabilities.

Family members and friends can contribute to a person’s rehabilitation by keeping in mind what effects a stroke can have, so that they can better understand and support the person. Support groups can provide emotional encouragement and practical advice for people who have had a stroke and for those who care for them.

End-of-Life Issues

For some people who have had a stroke, quality of life is predicted to remain very poor despite treatment. For such people, care focuses on control of pain, comfort measures, and provision of fluids and nourishment.

People who have had a stroke should establish advance directives (see Advance Directives) as soon as possible because the recurrence and progression of strokes are unpredictable. Advance directives can help a doctor determine what kind of medical care people want if they become unable to make these decisions.

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