Video : First Aid for Stroke

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What is Stroke?

A stroke, also known as cerebrovascular accident (CVA), is the rapid loss of brain functions due to the lack of blood flow caused by blockage such as thrombosis, arterial embolism and hemorrhage. When the blood vessels get clogged, the brain cells become deprived from nutrients and oxygen as there is no blood supply. Eventually, that part of the brain starts to die. A stroke occurs. The results of having stroke are impairments in memory, speech ability and physical mobility.

 According to National Stroke Association of Malaysia, stroke is the third largest cause of death in Malaysia.

The types of stroke is divided into three:

• Ischemic stroke-It is main type of stroke. It is due to blockage of blood vessels supplying the brain.
• Hemorrhagic stroke-It is due to bleeding into or around the brain.
• Transient ischemic stroke(TIA)- A mini-stroke

Images are from Google Images
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Stroke is the third largest cause of death in Malaysia. Only heart diseases and cancer kill more. It is considered to be the single most common cause of severe disability, and every year, an estimated 40,000 people in Malaysia suffer from stroke. Anyone can have a stroke, including children, but the vast majority of the cases affect adults. - National Stroke Association Malaysia

References:

1. http://www.strokeassociation.org/STROKEORG/AboutStroke/Types-of-Stroke_UCM_308531_SubHomePage.jsp
2. http://en.wikipedia.org/wiki/Stroke

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Video : Stroke Animation

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Risk factors for strokes

Controllable risk factors

• High blood pressure

The arteries wall will weaken when high blood pressure constantly passes through it because it puts unnecessary strains on the blood vessels of the circular system. Eventually, it bursts. It will bleed into the brain tissues and spaces between skull and brain. This affects the brain and causes strokes. If a person has an untreated hypertension, he will have 4 times the risk of getting a stroke. High blood pressure also leads to aneurysm. Aneurysm is a ballooning of a portion of a blood vessel due to the weakening part of its wall. When the pressure is too high, it burst and leads to stroke again.

• Diabetes mellitus

Uncontrolled diabetic mellitus causes an increase in the systolic blood pressure. This increases the blood pressure and leads to stroke.

• Cigarette smoking

 

Smoking doubles the risk of stroke. It causes artherosclerosis, which is hardening of blood vessels. When it hardens, the blood vessels become narrow. This also leads to high blood pressure, another main risk factor of stroke. The atherosclerotic plaque that dislodges increases the likelihood of blood clotting. This reduces the amount oxygen passed to the brain. Eventually some brain cells die due to lack of oxygen which leads to stroke.

• High blood cholesterol and lipids

High blood cholesterol and lipids causes artherosclerosis. The formation of plaques on the wall of blood vessels decreases the amount of blood flow to the brain. At severe condition, the blood vessel is blocked and the blood supply to the brain is cut off. This causes stroke.

• High red blood cell count

 

Excessive amount of red blood cell thickens the blood which increases the chance of blood clotting.

Other controllable risk factors include heart disease, history of transient ischemic attacks, lack of exercise and physical inactivity, obesity, substance abuse, abnormal heart rhythm and cardiac structural abnormalities.

Uncontrollable risk factors

• Age

 

After the age of 55, the risk of getting stroke may be more than double.

• Race

 

Africans, south Asians, Hispanic and people from first nations have higher rates of diabetes mellitus and high blood pressure. This two are the major risk factors of stroke.

• Gender

 

Female before menopause has lower possibility of getting stroke compared to male. However, the survival rate of female patients with stroke is lower than that of males.

Other uncontrollable risk factors include history of prior stroke and heredity.

References :

http://cholesterol.about.com/lw/Health-Medicine/Conditions-and-diseases/Cholesterol-and-Stroke-Risk.htm

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Treatment for Stroke

Investigation of acute stroke is to confirm the vascular nature of the lesion, distinguish cerebral infarction from haemorrhage and identify the underlying vascular disease and risk factors.

Initial investigations includes simple blood tests, an electrocardiogram and brain imaging. When there is uncertainty about the nature of stroke, further investigations are carried out. This usually applied to younger patient who are less likely to have atherosclerotic disease.

Brain imaging using CT scan or MRI should be carried out in all patients with stroke. CT  is widely available and the most practical method of imaging the brain. It will usually exclude non-stroke lesions like subdural haematomas and brain tumours. CT scan is used to look for bleeding within the brain that may cause symptoms that mimic a stroke, but are not treated with thrombolytic therapy with TPA.

MRI is not as widely available as CT, scanning times are longer and it cannot be used in some individuals with contraindications. However, MRI diffusion weighted imaging can detect ischaemia earlier than CT and other MRI sequences can also be used to demonstrate abnormal perfusion. MRI is more sensitive than CT in detecting strokes that affects the brain stem and cerebellum. An MRI scan can also be used to specifically view the blood vessels non-invasively (without using tubes or injections), a procedure called an MRA (magnetic resonance angiogram).

Stroke can also be investigated by computerised tomography with angiography. This can be done by using dye and inject it into a vein in the arm. Images of the blood vessels in the brain can give information regarding aneurysms or arteriovenous malformations. Besides, other abnormalities of brain blood flow may be evaluated.

Tissue plasminogen activator (TPA). Alteplase (TPA) is used  to dissolve the blood clot that is causing the stroke. The earlier it is given, the better the result. TPA must be given within four and a half hours after the onset of symptoms. For patients who waken from sleep with symptoms of stroke, it counts when they were last seen in a normal state.TPA is injected into a vein in the arm but the time frame for its use may be extended to six hours if it is dripped directly into the blood vessel that is blocked requiring angiography, which is performed by an interventional radiologist. This technology is not availble in all hospitals.TPA may reverse stroke symptoms in most patients but it may also cause bleeding in some patients, causing stroke to become worse.

Heart tests are often performed in stroke patients to search for the source of an embolism. Electrocardiograms (EKG or ECG) can be used to detect abnormal heart rhythms .

Blood tests are done to check for kidney and liver function, electrolyte abnormalities, blood clotting function and anaemia.

Heparin

Formal anticoagulation with heparin has been widely used in treating stroke in the past. This does improve the patient’s recovery. However, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes.

Aspirin

Aspirin should be started immediately after an ischaemic stroke unless  rt-PA has been given, in which case it should be withheld for at least 24 hours. Aspirin reduce the risk of early recurrence and has a small but measurable effect on long-term outcome.

Corticosteroids, haemodilution, vasodilators and ‘neuroprotective’ agents

Routine use of these agents should be avoided because they may have adverse effects. None of it has been shown to improve patient outcomes.

Managing other Medical Problems

• Patient will be given fluids because if the patient is having a stroke, he or she may often be dehydrated.
• Patients who have difficulty in breathing will be assessed and treated.
• Oxygen may be given to make sure that the brain is getting the maximal amount.
• Patients are not allowed to eat or drink until his or her ability to swallow is assessed.
• Medicine including pills, nitroglycerin paste or IV injections can be used to lower the blood pressure. However,  blood pressure should not be too low so that the brain can get enough oxygen. If the blood pressure is very high, patients would be placed on a continuous IV flow of medication.
• The blood sugars level of patients with diabetes is often elevated after a stroke. The glucose level in patients should be controlled to minimise the size of strokes.
• Patients who have ischemic attacks  may undergo  blood pressure and cholesterol medications even if the blood pressure and cholesterol levels are within acceptable levels.
• No smoking .

Management is aimed at minimising the volume of brain that is irreversibly damaged, preventing complications , reducing the patient’s disability and handicap through rehabilitation, and reducing the risk of recurrent episodes.

The rehabilitation process is shown in the following:

1. occupational therapy - To regain the  function in the arms and hands .
    
2. physical therapy-  To improve strength  and help in walking.
3. speech therapy -  To relearn talking and swallowing. 
4.  family education - To help them in facing and coping with types of challenges in life.

However, total recovery is not really possible in many cases but  many stroke patients can return to their independent lives.

Patients who have more severe stroke are transferred from the acute care hospital setting to a skilled nursing facility to be monitored and continue physical and occupational therapy.

Reducing the risk of further strokes and other vascular problems

The average risk of having a further stroke is 5-10% within the first week of stroke or TIA, perhaps 15% in the first year and 5% per year thereafter.  Patients with ischaemic events should be put on long-term antiplatelet drugs and statins to lower down cholesterol level. The risk of recurrence after strokes can be reduces by blood pressure reduction,even for those with blood pressure in the normal range.

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Signs and Symptoms of Stroke

Brain cells will not be able to function well when the brain is lack of oxygen. So this causes the person who is having stroke unable to do things properly. The symptoms of stroke depend on the amount of brain tissue damage and also the area of brain that has been affected. Small stroke may not cause any symptom but it can still damage brain tissue.

Stroke symptoms usually come suddenly. This is because they are caused by an abrupt interruption of blood flow to an area of the brain.  It only takes a few seconds for that part of the brain to stop functioning.

The symptoms include the following :

• Sudden numbness or weakness of the face, arm or leg on one side of the body.
• Sudden confusion,  trouble speaking or understanding.
• Double vision or sudden trouble seeing in one or both eyes.
• Sudden trouble walking, dizziness, loss of balance or coordination.
• Sudden trouble writing.
• Sudden and unusually severe headache . However, only a small proportion of strokes produce headache symptoms. But because of  the sudden onset of  severe headache, doctors may suspect that there is internal bleeding of the brain that will cause death. So  people who go  into the emergency room complaining of severe headache are immediately sent to screen for  the presence of blood in the brain.

How long the symptoms last  is depends on how long the affected part of the brain remains without blood flow.  Short  events of poor blood flow  lead to a complete recovery  while longer events can leave permanent deficits.

Strokes usually affect only one side of the body. The right side of the brain controls the left side of the body while the left side of the brain controls the right side of the body . When a blood vessel carries blood to a part of the brain and is blocked, only the side of the brain where the blood vessel is located is affected. This causes symptoms in the opposite side of the body.

If you think you are having a stroke, you should call 911 immediately. It is better that you get to the emergency room quickly to get earlier treatment. You should also get ready to answer the following question to help the doctors choose the best treatment.

• What time did your symptoms start?
• What is your complete medical history?
• Have you ever had a stroke or  had bleeding  inside of your brain?
• Do you have any metal inside your body? ( to decide whether MRI can be used for imaging.)
• What medications and supplements do you take on a regular basis?
• Do you have bleeding disorder?

Take note : You should not wait for the symptoms to go away and you should not take aspirin on your own . Besides, do not drive to the hospital on your own.

Patients will be admitted to the hospital for monitoring and further testing to figure out the cause of the stroke and ways to prevent a future stroke.

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Prevention and control of stroke

Control through food intake

• Eat a lot of vegetables and fruits.
• High intake of vegetables and fruits reduces the percentage of sodium in our blood. Less sodium means lower risk of getting high blood pressure, which is one of the risk factors of stroke. Vegetables and fruits also are rich sources of antioxidant vitamins and minerals, which reduces the risk of getting stroke.
• Eat low-sodium food to reduce your blood pressure.
• Reduce the intake of food containing high cholesterol and polyunsaturated fat. This reduces the chances of getting artherosclerosis.
• Eat food with high omega 3 fatty acids. Do not exceed the intake of 3 grams of omega 3 fatty acids daily. Omega 3 fatty acids increase our HDL blood cholesterol and reduce the fats in our blood. This helps in reducing our blood pressure. Example of food rich in omega 3 fatty acids are whole grains, walnuts, salmons, sardines, olive oil and garlic.
• Reduce sugar intake to prevent diabetes mellitus, another risk factor of stroke.

Drink plentiful of plain water

• Do drink more than 8 cups of water a day.
• Do not consume alcohol. If you do, try to reduce it to 2-3 days of alcohol consumption days in a week. Large consumption of alcohol raises the blood pressure immediately, which will lead to stroke.
• Drink tea daily. Based on a report in 2009, researchers have found out that drinking black or green tea reduces the stroke risk by around 20 percent.
• Avoid the temptations of drinks with high sugar content.

Be more physically active

• Exercise for at least 30 minutes twice each week. 
• Take the stairs instead of the elevator. 
• Exercising reduces our blood cholesterol and blood pressure. it also improves the ability of your body to control the insulin. Exercise intensively to reduce body fat for those that are obese as obesity is one of the risk factors of stroke.

Stop smoking

• Quit smoking immediately if you are a smoker. Smoking causes artherosclerosis and increases the possibility of blood clotting. 
• Try nicotine gum which is an antidepressant as one of the way to quit smoking.

Manage medical condition

• Blood pressure should be checked every year. For those who are already having high blood pressure, do check regularly.
• Check for atria fibrillation which is irregular electric pulse in the heart. This will causes blood clots that can lead to stroke.
• Check blood sugar daily for those that have diabetes mellitus. Consume medicine as told by the doctor.
• Cholesterol level should be maintained at less than 240 mg/dL, with LDL below 160 mg/dL and HDL above 40 mg/dL. However, people with the risk factors should maintain their cholesterol level at level below 200 mg/dL, with LDL below 100 mg/dL, and HDL above 60 mg/dL.

*If you are experiencing any symptoms of stroke such as sudden weakening of limbs, sudden dizziness, blurring of vision or sudden severe headache, seek for medical assistance immediately.

References :

http://altmedicine.about.com/od/healthconditionsdisease/a/stroke_prevention.htm

Medical reference from university of Maryland medical centre’s website

Natural Approaches to Stroke Prevention, By Cathy Wong, About.com Guide, Updated September 21, 2009

Stroke Prevention, From Marian Anne Eure, former About.com Guide, Updated August 21, 2005

http://www.cdc.gov/heartdisease

http://seniorhealth.about.com/cs/stroke/a/stroke_002700a.htm

http://www.ninds.nih.gov/disorders/stroke/preventing_stroke.htm

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A History of Stroke

The father of medicine, Hippocrates was the first to recognized stroke many years ago. However, it was not known as stroke, instead it was called apoplexy, which means “struck down by violence” in Greek. This is because it causes people to develop sudden paralysis and change in well being. Doctors have little knowledge about it.

Around mid 1600, Jacob Wepfer found out that patients who died due to apoplexy were having bleeding in the brain. He discovered that a blockage in the brain’s blood vessels could cause apoplexy.

Studies on causes, symptoms and treatments of apoplexy were carried out. In 1928, apoplexy was divided to different categories based on the cause of the blood vessels problem. The term stroke or “cerebral vascular accident (CVA) come from this.

In this century, there is a lot of information available on the cause, prevention, risk and treatment of stroke. Most stroke patients have a goof chance to survival and recovery though there is no cure for it.  

Facts: 1.According to WHO, 17 million people suffer stroke worldwide every year.

          2. 5 million out of 15 million died and another 5 million are permanently disabled.

          3. High blood pressure is one of the main contributors to stroke.

References :
http://www.yalemedicalgroup.org/stw/Page.asp?PageID=STW022874
http://www.who.int/cardiovascular_diseases/resources/atlas/en/

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