What is a stroke and what

causes it?

A stroke means that the blood
supply to a part of the brain is
suddenly cut off. The brain cells
need a constant supply of oxygen
from the blood. Soon after the
blood supply is cut off, the cells in
the affected area of brain become
damaged, or die.

Stroke is the primary cerebrovascular disorder in
the United States, and it is the third leading
cause of death after heart disease and cancer.
Strokes can be divided into two major categories:
Ischemic (85%)
- There is vascular occlusion and a significant
hypoperfusion
Hemorrhagic (15%)
- There is extravasations of blood into the brain or
subarachnoid space (Hinkle & Guanci, 2007).

Increasing Age
Sex
Heredity
Hypertension
Cigarette Smoking
Diabetes Mellitus
Heart Disease
High RBC Count
Season and Climate
Socioeconomic Factors
Excessive Alcohol Intake
Certain kinds of Drug Abuse

1. Ischaemic stroke
- caused by a blood clot.
In an ischemic stroke, blood supply to part of the
brain is decreased, leading to dysfunction of the
brain tissue in that area.
There are four reasons why this might happen:
Thrombosis (obstruction of a blood vessel by a
blood clot forming locally)
Embolism (obstruction due to an embolus from
elsewhere in the body)
Systemic hypoperfusion (general decrease in
blood supply, e.g., in shock)
Venous thrombosis


2. Hemorrhagic stroke
- caused by bleeding. Primarily intracranial or
subarachnoid hemorrhage.
- A damaged or weakened artery may burst
and bleed:

The pathophysiology of hemorrhagic stroke
depends on the cause and type of
cerebrovascular disorder.

Intracerebral Hemorrhage
Intracranial Aneurysm
Arteriovenour Malformations
Subarachnoid Hemorrhage

CLINICAL MANIFESTATIONS
Deficits Manifestations
Visual Field Deficits
Homonymous hemianopsia
(loss of half of the visual field)


Loss of peripheral vision


Diplopia

Unaware of persons or objects on side
of visual loss
Neglect of one side of the body
Difficulty judging distances
Difficulty seeing at night
Unaware of objects or the borders of
objects
Double vision
Motor Deficits
Hemiparesis

Hemiplegia


Ataxia


Dysarthria
Dysphagia
Weakness of the face, arm, and leg on
the same side (due to a lesion in the
opposite hemisphere)
Paralysis of the face, arm, and leg on
the same side (due to a lesion in the
opposite hemisphere)
Staggering, unsteady gait
Unable to keep feet together; needs a
broad base to stand
Difficulty in forming words
Difficulty in swallowing









Sensory Deficits
Paresthesia (occurs on the side
opposite the lesion)

Numbness and tingling of extremity
Difficulty with proprioception
Verbal Deficits
Expressive aphasia


Receptive aphasia

Global (mixed) aphasia

Unable to form words that are
understandable; may be able to speak in
single-word responses
Unable to comprehend the spoken word;
can speak but may not make sense
Combination of both receptive and
expressive aphasia
Cognitive Deficits Short- and long-term memory loss
Decreased attention span
Impaired ability to concentrate
Poor abstract reasoning
Altered judgment
Emotional Deficits Loss of self-control
Emotional lability
Decreased tolerance to stressful situations
Depression
Withdrawal
Fear, hostility, and anger
Feelings of isolation
A quick guide for the general
public to remember:
As a way of helping the general public to become more aware of
the symptoms of a stroke, a simple symptom checklist to remember
has been devised and publicized. This is to think of the word FAST.
That is:
F - Facial weakness. Can the person smile?
Has their mouth or eye drooped? A - Arm
weakness. Can the person raise both
arms? S - Speech disturbance. Can the
person speak clearly? Can they understand
what you say? T - Time to call the nearest
emergency department.
Long-term effects from having a stroke?


Careful history taking
Complete physical and neurologic
examination
- Glasgow Coma Scale
- Summary Of National Institutes Of
Health Stroke Scale (NIHSS)

Brain scan (CT scan or MRI scan). This can
determine the type of stroke (ischemic or
hemorrhagic) and may detect rarer
conditions which may have caused the
stroke, or which may mimic a stroke.
Blood tests to check on such things as blood
sugar level and cholesterol level. High levels
can increase the risk of a further stroke.
Chest X-ray and ECG (a heart tracing) to
check for heart or lung conditions which
may be a cause of stroke (e.g, atrial
fibrillation).
Ultrasound scan of the carotid arteries in the
neck to check if there are large patches of
atheroma in these arteries.

Medical Management

Further early treatment
A plan for any other treatments should be
devised and started as soon as possible.
Treatments should be tailored to the
particular need of the individual. The
treatment plan can depend on factors such
as the severity of the stroke, the effects it
has, the cause of the stroke, and other
diseases that may be present. Treatments
that may be considered include the
following:

Antiplatelet medication
Antiplatelet medication is usually advised if
you have had an ischemic stroke (due to a
blood clot). Antiplatelet medication reduces
the stickiness of platelets. This helps to
prevent blood clots forming inside arteries,
which helps to prevent a further stroke.
Aspirin (low-dose) immediate
Clopidogrel - given long-term after
the initial treatment.

Thrombolytic Therapy
Thrombolytic agents are used to treat
ischemic stroke by dissolving the blood
clot that is blocking blood flow to the
brain. Recombinant t-PA is a
genetically engineered form of t-PA, a
thrombolytic substance made naturally
by the body. It works by binding to fibrin
and converting plasminogen to plasmin,
which stimulates fibrinolysis of the
atherosclerotic lesion.
Medications and therapy to
reduce or control brain
swelling

Corticosteroids and special types of
intravenous (IV) fluids are often used to
help reduce or control brain swelling,
especially after a hemorrhagic stroke (a
stroke caused by bleeding into the
brain).

If unable to swallow, you will be given food and
fluids via a tube that is passed into stomach.
(NGT)
Medication may be advised to reduce any risk
factors for having a further stroke. For example,
medication to lower a raised blood pressure,
sugar level, or cholesterol level.
If hemorrhagic (bleeding) stroke and are taking
an anticoagulant medicine such as warfarin,
treatment to reverse the effect of the
anticoagulation is given.



Several types of surgery may be
performed to help treat a stroke, or help
to prevent a stroke from occurring,
including the following:
Carotid Endarterectomy
Carotid endarterectomy is a procedure
used to remove plaque and clots from
the carotid arteries, located in the neck.
These arteries supply the brain with
blood from the heart. Endarterectomy
may help prevent a stroke from
occurring.

Carotid Stenting
A large metal coil (stent) is placed in the
carotid artery much like a stent is placed
in a coronary artery. The femoral artery
is used as the site for passage of a
special hollow tube to the area of
blockage in the carotid artery. This
procedure is often done in radiology
labs, but may be performed in the cath
lab.

Craniotomy

A craniotomy is a type of surgery in the
brain itself to remove blood clots or
repair bleeding in the brain.

Surgery To Repair Aneurysms
And Arteriovenous Malformations
(Avms)
An aneurysm is a weakened, ballooned
area on an artery wall that has a risk for
rupturing and bleeding into the brain. An
AVM is a congenital (present at birth) or
acquired disorder that consists of a
disorderly, tangled web of arteries and
veins. An AVM also has a risk for rupturing
and bleeding into the brain. Surgery may be
helpful, in this case, to help prevent a stroke
from occurring.

Patent Foramen Ovale (PFO)
Closure
The foramen ovale is an opening that occurs in the
wall between the two upper chambers of a baby's
heart before birth. It functions to provide oxygen-rich
blood to the baby from the mother's placenta while in
the womb. This opening normally closes soon after
birth. If the flap does not close, blood flows from the
right atrium directly to the left atrium. It then flows out
to the central circulation of the body. If this blood
contains any clots or air bubbles, they can pass into
the brain circulation causing a stroke or transient
ischemic attack (TIA). PFO closure procedure can be
performed through a percutaneous (through the skin)
approach. Signs and symptoms of a PFO may not
occur until early or middle adulthood and may even go
undetected.


Improving Mobility and Preventing
J oint Deformities
- Preventing shoulder adduction
- Positioning the hand and fingers.
- Changing positions.
- Establishing an exercise program.
- Preparing for ambulation.
- Preventing Shoulder Pain

Enhancing Self-Care
- set realistic goals; if feasible, a new task is
added daily.
- to carry out all self-care activities on the
unaffected side.
Managing Sensory-Perceptual Difficulties
- Approach on the unaffected part
Assisting With Nutrition
- Enteral tubes can be either nasogastric (placed
in the stomach) or nasoenteral (placed in the
duodenum) to reduce the risk of aspiration.
Attaining Bowel and Bladder Control
- intermittent catheterization with sterile
technique

Improving Thought Processes
Improving Communication
Maintaining Skin Integrity
Improving Family Coping
Rehabilitation
The aim of rehabilitation is to maximize activity
and quality of life following a stroke. Hospitals
which deal with stroke patients have various
specialists who help in rehabilitation. These
include: physiotherapists, occupational
therapists, speech therapists, dieticians,
psychologists, specialist nurses and doctors.
One or more of these may be required,
depending on how the stroke has affected you.
Good-quality rehabilitation is vital following a
stroke, and can make a big difference to your
eventual outcome.

PREVENTION
One can reduce the risk of having a
stroke by reducing risk factors.
Smoking. One should make every effort to
stop. The chemicals in tobacco are carried
in the bloodstream and can damage the
arteries.
High blood pressure. Make sure blood
pressure is checked regularly. If it is high it
can be treated. High blood pressure usually
causes no symptoms, but can be damaging
to the arteries.
Diet. Aim to eat a healthy diet. Briefly, a healthy diet
means:
AT LEAST five portions of a variety of fruit and vegetables
per day.
THE BULK OF MOST MEALS should be starch-based
foods (such as cereals, wholegrain bread, potatoes, rice,
pasta), plus fruit and vegetables.
NOT MUCH fatty food such as fatty meats, cheeses, full-
cream milk, fried food, butter, etc. Use low-fat, mono-, or
poly-unsaturated spreads.
INCLUDE 2-3 portions of fish per week. At least one of
these should be oily (such as herring, mackerel, sardines,
kippers, pilchards, salmon, or fresh tuna).
If you eat red meat, it is best to eat lean red meat, or
poultry such as chicken.
If you do fry, choose a vegetable oil such as sunflower,
rapeseed or olive.
Try not to add salt to food, and limit foods which are salty.

If overweight, losing some weight is
advised.
A high cholesterol level. This can
be treated if it is high.
Inactivity. Aim to do some moderate
physical activity on most days of the
week for at least 30 minutes. For
example, brisk walking, swimming,
cycling, dancing, gardening, etc.

Alcohol. Do not drink more than the
recommended limits. That is, men should drink
no more than 21 units of alcohol per week, no
more than four units in any one day, and have
at least two alcohol-free days a week. Women
should drink no more than 14 units of alcohol
per week, no more than three units in any one
day, and have at least two alcohol-free days a
week. Pregnant women should not drink at all.
One unit is in about half a pint of normal
strength beer, or two thirds of a small glass of
wine, or one small pub measure of spirits.
Diabetes. Treatment to keep the blood sugar
as near normal as possible is important.