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Stroke

— 2015-08-19

stroke

A stroke is known as a cerebrovascular accident or a brain attack. Blood supply is interrupted to part of the brain, causing brain cells to die; this results in the patient losing brain function in the affected area. Interruption is usually caused by an obstruction of arterial blood flow (ischemic stroke), such as formation of a blood clot, but can also be caused by a leaking or ruptured blood vessel (hemorrhagic stroke). A blood clot may develop from a piece of unstable plaque lining a vessel wall that breaks free, or an embolus that travels from elsewhere in the body and lodges within the vessel. The bleeding may occur as a result of trauma or spontaneously, as in the setting of uncontrolled hypertension. Ischemia occurs when insufficient blood is getting to the brain tissue. This leads to lack of available oxygen (hypoxia) and glucose (hypoglycemia) for the brain. When these nutrients are not available for a sustained period, the brain cells die, causing an area of infarction.
Permanent deficits result from infarction.
There is increased risk for stroke in patients with a medical history of hypertension, diabetes mellitus, high cholesterol, atrial fibrillation, obesity, smoking, or oral contraceptive use. Patients may also experience a transient ischemic attack in which the symptoms result from a temporary problem with blood flow to a specific area of the brain. The symptoms have a duration between a few minutes and 24 hours.

PROGNOSIS

The degree of damage and location of the stroke will determine the outcome for the patient. Strokes occur suddenly and patients should seek immediate treatment for the best possible outcome. The majority of strokes are ischemic. Rapid entry into the healthcare system and treatment with thrombolytic agents to break up a clot that has caused the ischemia gives the patient the best chance for recovery without permanent disability. Patients with hemorrhagic stroke may need surgery to relieve intracranial pressure or stop the bleeding. A large area of damage may lead to significant permanent disability or death.

HALLMARK SIGNS AND SYMPTOMS

• Mental impairment
• Disorientation, confusion
• Emotional changes, personality changes
• Aphasia (difficulty with speech; may be receptive, expressive)
• Slurring of words
• Sensory changes (paresthesia, visual changes, hearing changes)
• Unilateral numbness or weakness in face or limbs
• Seizure
• Severe headache due to increased intracranial pressure from hemorrhage
• TIA symptoms are similar but have a shorter duration and resolve

DIAGNOSTIC CHECK

• CT scan identifies area of bleeding (usually for emergency use).
• MRI (magnetic resonance imaging) identifies location of ischemic areas (slower than CT scan).
• MRA (magnetic resonance angiography) can identify abnormal vasculature or vasospasm.
• Diffusion/perfusion MRI or MRA will show areas that are not getting adequate blood supply, but have not yet suffered an infarction.
• SPECT (single photon emission computed tomography) will show an area that is not perfusing adequately

TREATMENT

It is most important to determine whether the patient has suffered an ischemic or hemorrhagic stroke as the treatment is different. Giving a thrombolytic agent to the patient who has had a hemorrhagic stroke will only cause further bleeding into the brain. Caution is also recommended in patients with head trauma, uncontrolled hypertension, hemorrhagic retinopathy, gastrointestinal bleeding, recent surgery, recent MI, or pregnancy.

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