Stroke: symptoms, causes, treatments and rehabilitation.

It is important to watch out for the following signs and symptoms and to pay attention to when they begin. Their duration can have an impact on the choice of treatment.

• Trouble speaking and understanding: the person may experience confusion; words may be slurred and they may have difficulty in understanding speech.
• Paralysis or numbness in the face, arm or leg: the person may experience sudden numbness, weakness or paralysis in the face, arm or leg. This often occurs only on one side of the body. If the person attempts to raise both arms above their head at the same time and one arm begins to fall, the person may have experienced a stroke. In addition, one side of the mouth may droop when attempting to smile.
• Problems with vision in one or both eyes: vision may be suddenly blurred or blackened in one or both eyes or the person may experience double vision.
• Headache: a sudden severe headache, perhaps accompanied by vomiting, dizziness or altered consciousness, may indicate that the person is having a stroke.
• Trouble walking: the person may trip or experience sudden dizziness, loss of balance or coordination.

At the first signs or symptoms of stroke, you must seek immediate medical attention, even if the symptoms seem to rise and fall in intensity or disappear altogether. Check for the following signs of stroke, even called FAST warning signs:

• Facial Droping – Ask the person to smile. Is one side of their face drooping?
• Arm Weakness – Ask the person to raise both arms. Does one arm fall? Are they unable to raise one arm?
• Speech difficulties – Ask the person to repeat a simple sentence. Is their speech garbled or strange?
• Time – If any of the symptoms above are showing, time is of the essence.

If you notice any one of these signs, call 112 (the European emergency number) or the local emergency number immediately, without waiting to see if the symptoms stop. The longer a stroke goes untreated, the greater the potential for brain damage and disability.

A stroke can be caused by a blocked artery (ischemic stroke) or by a leaking or burst blood vessel (hemorrhagic stroke).

Some individuals may experience only a temporary interruption of blood flow to the brain (transient ischemic attack, or TIA), which does not cause permanent damage.

About 80% of strokes are ischemic. These occur when the arteries supplying blood to the brain narrow or become blocked, severely reducing blood flow (ischemia).

The most common types of ischemic stroke are:

• Thrombotic stroke: occurs when a blood clot (thrombus) forms in one of the arteries that supplies blood to the brain.
• Embolic stroke: occurs when a blood clot or other debris forms far from the brain (usually in the heart) and is then carried by the bloodstream to the brain, where it gets stuck in the brain’s narrower arteries. This type of blood clot is called an embolus.

A hemorrhagic stroke occurs when a blood vessel in the brain leaks blood or ruptures. Many different conditions that affect the blood vessels can cause a brain hemorrhage:

• high blood pressure
• excessive treatment with anticoagulants
• aneurysm

One less common cause for a hemorrhage is the rupturing of an abnormal tangle of thin-walled blood vessels, a congenital defect called an arteriovenous malformation.

Types of hemorrhagic stroke include:

• Intracerebral hemorrhage: a blood vessel in the brain bursts and bleeds into the surrounding brain tissue, damaging the brain cells. The same cells are also deprived of blood, meaning that the damage is doubled.

High blood pressure, trauma, blood vessel malformation, the use of blood thinners, and other conditions may cause an intracerebral hemorrhage.

• Subarachnoid hemorrhage (SAH): an artery on or near the surface of the brain bursts, bleeding into the intracranial space. A common symptom of such a bleed is a sudden, severe headache.

A subarachnoid hemorrhage is usually caused by the rupture of a small saccular, or berry, aneurysm. Following the hemorrhage, the blood vessels in the brain may dilate and contract in an irregular fashion (vasospasm), causing damage to the brain cells by further reducing blood flow.

Many factors may elevate stroke risk and some of these factors may also increase risk of heart attack.

Potentially treatable stroke risk factors:

• lifestyle (being overweight or obese, lack of exercise, smoking, alcohol use, drug use)
• medical risk (blood pressure, cholesterol level, diabetes, sleep apnea, cardiovascular disease, family history)
• Other risk factors:
  • age
  • ethnicity
  • gender
  • hormone therapy

Occasionally a stroke can cause temporary or permanent disability, depending on how long the brain remains deprived of blood and which part of the brain is affected.

The effects of a stroke may include:

• Paralysis or loss of muscular movement: the person may remain paralyzed on one side of their body or lose control of certain muscles. Rehabilitation can help them to regain movement in the limbs affected by the stroke, and thus the ability to walk, eat or dress themselves.
• Difficulty in talking or swallowing: a stroke can affect control of the muscles in the mouth and throat, making it difficult to speak clearly (dysarthria), swallow (dysphagia) or eat.
• Memory loss or difficulty in thinking.
• Emotional problems: the person may have difficulty in controlling their emotions or may develop depression.
• Pain: the person may experience pain, numbness or other strange sensations in the parts of the body affected by the stroke.
• Behavioral changes and changes in the ability to take care of oneself.

Success in treating these post-stroke complications varies from person to person.

Knowing the stroke risk factors, following your physician’s advice and adopting a healthy lifestyle form the basis of prevention, including for those who have already suffered a stroke or a transient ischemic attack (TIA).

Many stroke prevention strategies are the same as those for heart disease.

In general, recommendations for a healthy lifestyle include:

• Control high blood pressure (hypertension). Exercise, stress management, maintaining a healthy body weight and limiting sodium and alcohol intake can help to keep high blood pressure under control. In addition to recommending lifestyle changes, your physician may prescribe drugs to treat high blood pressure.
• Reduce the amount of cholesterol and saturated fats in your diet. If you are unable to control your cholesterol through diet, your physician may prescribe a drug to lower cholesterol.
• Quit smoking.
• Control diabetes. Diabetes can be managed through diet, exercise, body weight management and medications.
• Maintain a healthy body weight. Losing just 10 kilos can lower blood pressure and improve cholesterol levels.
• A diet rich in fruits and vegetables. A diet containing five or more portions of fruit or vegetables per day can reduce stroke risk. Following the Mediterranean diet, with olive oil, fruit, nuts, vegetables and whole grains, can be helpful.
• Regular physical exercise. Aerobic, or “cardio,” exercise reduces stroke risk because it lowers blood pressure, increases levels of high-density lipoprotein (“good”) cholesterol and improves the overall blood vessel and heart health.
• Drink alcohol in moderation. Drinking excessive amounts of alcohol increases the risk of high blood pressure, ischemic stroke and hemorrhagic stroke. However, drinking small or moderate amounts of alcohol can help to prevent ischemic stroke and decrease blood coagulation. Keep in mind that alcohol can interact with other drugs being taken. It is a good idea to talk about it with your physician.
• Treat obstructive sleep apnea (OSA). OSA treatment involves the administration of oxygen during the night or a small oral appliance that helps the person to breathe.
• Avoid using illicit drugs. Some drugs, such as cocaine and methamphetamines, are risk factors for TIA or stroke. Cocaine reduces blood flow and can narrow the arteries.

If you have had an ischemic stroke or a TIA, your physician may prescribe drugs for secondary prevention of stroke.

• Antiplatelet drugs: Platelets are the blood cells that form clots. The most commonly used antiplatelet drug is aspirin and your physician can help you to determine the correct dosage. If aspirin does not prevent a transient ischemic attack or you cannot take aspirin, your physician may prescribe an antiplatelet drug such as clopidogrel (Plavix) as an alternative.

• Anticoagulants: These drugs, which include heparin and warfarin (Coumadin, Jantoven) reduce blood coagulation (clotting). Warfarin is a powerful blood thinner and must be taken exactly as instructed.

Every year in the world, around 18,000,000 people experience a stroke. Roughly two-thirds of these require stroke rehabilitation to become as independent as possible and achieve an improved quality of life.

Although rehabilitation cannot “cure” the effects of a stroke, because it cannot repair damage to the brain, it can help individuals to improve their life after stroke.

Rehabilitation helps to recover abilities lost due to damage to a part of the brain, such as coordination and leg movement.

Rehabilitation also teaches new ways to perform tasks in a manner that works around or compensates for any residual disability, for example learning to take a bath or dress oneself with only one hand or to communicate effectively when language skills have been affected.

Experts agree on the fact that the most important component of any stroke rehab plan is consistent, well-focused and direct repetition, the same type of practice used when learning a new skill.

Rehabilitation treatment begins in the hospital, in intensive care, once the patient’s overall condition has stabilized, often within 24-48 hours of the stroke’s occurrence.

The first step consists of encouraging independent movement, because many individuals are paralyzed or severely weakened.

Stroke rehabilitation exercises:

Patients are asked to change position frequently when lying in bed and to engage in passive exercises (the therapist actively helps the patient to move a limb repeatedly) or active exercises (performed by the patient without physical assistance) to strengthen the limbs affected by the stroke.

Nurses and rehabilitation therapists help patients to perform increasingly complex actions, like bathing themselves, dressing themselves and using the bathroom; they encourage patients to use the limbs affected by the stroke while performing those tasks.

Stroke recovery plans aimed to maintain and refine skills can require the assistance of specialists for months or years after the stroke itself.

The type and degree of disability after stroke depends on the area of the brain that has been damaged.

Generally, strokes can cause five main types of disability:

• paralysis or problems controlling movement
• sensory disturbances, including pain
• problems using or understanding language
• problems with thinking and memory
• emotional disturbances

 

Paralysis or problems controlling movement (motor control)

Paralysis is one of the most common disabilities caused by stroke. It usually occurs on the side of the body opposite to the side of the brain damaged by the stroke and may involve the face, an arm, a leg or the entire side of the body.

This paralysis on one side of the body is called hemiplegia (weakness on one side of the body is called hemiparesis). Stroke patients with hemiparesis or hemiplegia may have difficulty in performing everyday tasks such as walking or grasping objects.

Some stroke patients have trouble swallowing (dysphagia) due to damage to the part of the brain that controls the muscles used for swallowing.

Damage to the lower section of the brain, the cerebellum, can impact the body’s ability to coordinate movement, a disability called ataxia, which leads to problems with body posture, walking and balance.

Stroke recovery involves physicians, rehabilitation nurses, physical therapists, occupational therapists, educators, speech and language therapists and psychotherapists.

 

Physicians

Physicians’ primary responsibility is to manage and coordinate patients’ long-term care and to recommend the best rehabilitation plans to address their individual needs.

Neurologists usually lead acute-care teams specialized in stroke, which guide patient care during hospitalization. Other specialists, especially PM&Rs (physical medicine and rehabilitation physicians, or physiatrists) lead the rehabilitation phase of treatment.

 

Rehabilitation nurses

Nurses specialized in rehabilitation teach patients how to perform basic everyday activities, educate them about routine health treatments, how to take care of their skin, how to get out of bed, how to get into a wheelchair, and about the special needs of people with diabetes.

Rehabilitation nurses also work to reduce the risk factors that could lead to a second stroke occurring.

 

Physical therapists

Physical therapists (also known as physiotherapists) are specialized in the treatment of sensory and motor disabilities. They evaluate the strength, resistance, range of movement, gait abnormalities and sensory impairments of stroke patients in order to plan personalized rehabilitation programs that aim to help patients recover control of their motor functions.

Physical therapists help patients to regain the use of limbs affected by the stroke, teach them compensatory strategies to reduce the impact of any remaining impairments and, as time goes on, determine exercise regimens to help them maintain the skills they have just learned.

Persons with disabilities tend to avoid using affected limbs, a behavior called learned non-use. However, repetitive use of the affected limbs promotes neuroplasticity and helps to reduce disability. Therefore, physical therapists employ strategies to encourage use of affected limbs, including selective sensory stimulation, like tapping or stroking, active and passive range-of-motion exercises, and temporarily restraining healthy limbs when practicing motor exercises.

People too weak to bear their own weight can still practice repetitive movements during hydrotherapy (where water provides sensory stimulation and supports the patient’s weight) or while partially supported by a harness.

Physical therapists often use selective sensory stimulation to encourage the use of impaired limbs and help patients to regain awareness of stimuli on the neglected side of the body.

 

Occupational and recreational therapists

Occupational therapists are also concerned with improving motor and sensory abilities and ensuring patient safety post-stroke.

They often teach patients how to break a complex activity down into smaller steps, practice each part, and eventually perform the action in its entirety. This strategy can improve coordination and help people with apraxia relearn how to perform planned actions.

Occupational therapists also teach people how to develop compensatory strategies and change those things that limit their activities of daily living. 

 

Speech and language therapists

Speech and language therapists help stroke survivors with aphasia to relearn how to use language or to develop alternative means of communication. They also help patients to improve their ability to swallow.

Rehabilitation should begin as soon as the patient is stable, sometimes within 24-48 hours of the stroke occurring. This first stage of rehabilitation can occur in the hospital, in acute care. However, this varies greatly from patient to patient.

The largest stoke rehabilitation study, recently conducted in the United States, compared two common techniques for helping stroke patients to improve their walking: training on a body-weight supported treadmill or working on strength and balance exercises at home with a physical therapist. Both resulted in equal improvements in the patient’s ability to walk up to one year after stroke.

The study showed that 52% of participants made significant improvements in walking, everyday activities and quality of life, regardless of how severe their impairment was or whether they began training at 2 or 6 months after the stroke.

Upon discharge from the hospital, most patients return home, but some move into medical facilities such as those listed below.

 

Inpatient hospital units

Inpatient facilities can be freestanding or part of larger hospital complexes. Patients usually remain in these facilities for 2-3 weeks, where they engage in a coordinated and intensive rehabilitation program.

 

Outpatient facilities

Outpatient facilities are often part of a larger hospital structure and provide access to physicians and therapists specialized in stroke rehabilitation.

While patients spend nights at home, they generally spend several hours per day at these facilities, often 3 days a week, engaging in coordinated therapy sessions.

 

Nursing facilities

The rehabilitation services available at nursing facilities are more varied than those in inpatient hospital units and outpatient facilities.

Specialized nursing facilities usually place an emphasis on rehabilitation, while traditional nursing homes focus more on residential care.

 

Home-based rehabilitation programs

Home-based rehabilitation offers a high degree of flexibility. Stroke patients can participate in an intensive level of therapy several hours per week or follow a less demanding regimen.

The main disadvantage of these programs is their lack of specialized equipment. Nevertheless, undergoing home-based treatment has the advantage of allowing patients to put their skills into practice and to develop compensatory strategies in the context of their own living environments.