Stroke is most devastating and serious medical emergency and often leaves some residual damage to body and mind. In US, every one out of 4 deaths is claimed by stroke, killing about 130000 Americans every year.
Stroke’s risk increases exponentially, someone who has had a stroke in past is 4 times more likely to get another stroke. Not only this, but morbidity following stroke is very high compared to any other disease, making it much more disabling disease relative to other diseases.
In older times stroke was referred as “apoplexy” a greek term meaning “a striking away” as patients with stroke often lose consciousness or use of his/her limbs within a matter of seconds. Even now the situation is not much different, In local terms, it is still known as being “struck down by the hands of gods”.
Study of stroke started with Hippocrates – A renowned physician and father of medicine, and is still going on but now that we know what is stroke, how strokes happen, types of stroke there is a fair chance to recover from a stroke, even if it’s worse there are rehabilitation centers for people affected with stroke. Let’s try to learn what stroke is and if we can prevent or minimize the disability that follows stroke.
What is Stroke?
In simpler terms, stroke is a brain attack. When blood supply to the heart is hampered it is called heart attack or myocardial infarct similarly, when such scenario presents in the brain it is called a stroke. Blood supply to brain is compromised in stroke leading to death of cells in brain, Except in brain it is somewhat different from heart attack and have a wide range of symptoms.
For many brain disorders often present with similar symptoms, WHO devised a definition of stroke to avoid confusion with other cerebrovascular incidents. It says stroke is a “neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours”.
To break it down in understandable terms – stroke is a disorder of brain, it is of vascular origin i.e. related to blood supply of brain and most importantly its symptoms last beyond 24 hours period anything less than that can not be defined as stroke. This last bit is especially for transient ischemic attacks TIA which often presents with similar symptoms as a stroke but usually resolves by the end of 24 hours.
Although TIA is not a stroke as per WHO guidelines still some physician consider it a type of stroke. Stroke or not it poses a great risk of stroke for future life.
How to Recognize Stroke?
As I mentioned above, it is like being struck down by hands of gods. Within seconds you will start having symptoms even if you won’t comprehend, it is the bystanders who will need to be careful and look for these symptoms.
Our whole body is governed by brain. Everything we do, feel and say is a function of brain. So, it will be childish to limit stroke symptoms to bunch of no.s because symptoms will be present depending on the area of brain whose blood supply is being hampered. Still, there are a few symptoms which are commonly seen in stroke patients.
Hemipresis is the weakness of one side of body – right side or left side, which may or may not be with sensory loss of same side or opposite side. Patient loses his ability to use his limbs due to extreme muscular weakness. This may also be present as paralysis due to complete loss of movement on affected side. It is called motor impairment. He/she will not be able to lift his arm or leg, even won’t be able to perform day to day work. Sensory loss means the patient won’t be able to feel touch, temperature or pain on affected limb. He also might lose his vibration sense. Hemipresis is the most common presentation of stroke, being present in about 85% patients of stroke. But it often improves with time and rehabilitation.
Headache is a commonly seen complaint in stroke patients, usually in stroke due to bleeding inside brain. This headache is sudden and severe in this hemorrhagic stroke due to bleeding in subarachnoid space. Important about this is, migraine can also present similar headache. In migraine, usually other symptoms of stroke are absent and patient is usually exhausted.
Loss of vision
Loss of vision can happen in stroke, may present as smaller field defects or full-fledged vision loss. Although stroke usually affects one half on brain but as ophthalmic nerve from both eyes runs together in brain it presents in both eyes. Vision loss is not fully recovered ever in stroke patients though some recovery is possible. Hemianopia and quadrantanopia are commonly associated field defects with stroke.
Inability to speak
Patient may develop something called slurred speech. He may try to speak words but won’t be able to say them. His words may seem mumble jumble to a normal person. Or he may use unknown words to express himself. He may completely lose his ability to speak. This all is typically seen when Broca’s area is affected by stroke.
Inability to comprehend
If Wernicke’s area is affected by stroke, patient may loss his sense of comprehension. He will not understand what we are trying to say to him. He will respond altogether differently to our approach. Neither will he understand any written material. As Broca’s and Wernicke’s areas are linked these symptoms often present together making it difficult for patient to communicate.
Change in gait
Change in gait is noticeable in patients of stroke due to muscle weakness. Gait can be described as a way person walks. If muscle weakness is not too much in stroke and then he will try to walk with a limp, giving him an unusual gait which will help elicit muscle weakness. On examination, we will find decreased muscle tone and power.
Facial weakness is also one of the common symptoms seen in stroke patients and is often limited to one side of face. Affected part of face will be opposite to area affected in brain due to crossing of facial nerve and then reaching to facial nuclei in different hemispheres of brain. Facial weakness is observed as drooping of one eyelid, angle of same side of mouth, tongue deviation to opposite side. If patient tries to blow he won’t be able to do so.
All these symptoms I discussed above are in brief and I can not emphasise enough on this that stroke can be present with much more symptoms than these common symptoms. It may affect cranial nerve and might present symptoms accordingly. There might be decreased heart rate and respiration rate. Vertigo and decreased hearing may be associated with all above symptoms. There may be vomiting, loss of consciousness, confusion and many more.
Often stroke symptoms do not progress further, rather they improve. But other cerebral disorders can mimic these symptoms, so keep a lookout for these disorders. A few of these disorders are migraine, seizures, Intracranial tumour, encephalopathy etc.
Different Type Of Strokes And Causes
As you might have already have guessed by now that there are two major types of stroke and it is important to know about them if we are to recognize them. These types are as described below :
Hemorrhagic stroke is hemorrhage or bleeding inside the brain. When one of the blood vessel supplying to the brain ruptures or bursts, it causes hemorrhagic stroke. Following the hemorrhage, brain tissue beyond the rupture gets devoid of blood supply, this and brain tissue compression by spilled blood causes various symptoms seen in stroke. Hemorrhagic stroke can further be assessed as one of the following:
Subarachnoid hemorrhagic stroke
Subarachnoid hemorrhagic stroke is bleeding outside the brain tissue, but inside the cranial vault. Three layers of meninges work as a cushion for brain in event of trauma from outside.
In subarachnoid hemorrhage, bleeding occurs between the innermost meningeal layer Arachnoid mater and 2nd meningeal layer Pia mater. This stroke is often accompanied with a heavy headache.
Intracerebral hemorrhagic stroke
Intracerebral hemorrhagic stroke is bleeding inside the arachnoid layer i.e. inside the brain tissue, leading to far more devastating symptoms. This is usually associated with uncontrolled hypertension.
Anything which is weakening the blood vessels inside the brain can be considered a cause for hemorrhagic stroke, yet there are few causes which are more likely to result in hemorrhagic stroke than others. Various causes of hemorrhagic stroke:
Aneurysms – An aneurysm is dilation or ballooning of blood vessel at its weak point. This can burst open any second. Aneurysm associated with subarachnoid hemorrhage is called berry’s aneurysm.
Uncontrolled Hypertension – Hypertension can cause hemorrhage inside brain when it is way beyond limit. Usually smaller arteries are involved but effect is just as much devastating.
AV Malformations – Arteriovenous malformations are abnormal tangled network arteries and veins which passes blood directly from arteries to veins. These AV malformations are prone to rupture due to their thin walls.
Ischemic stroke is defined as decreased blood supply to brain. This is far more common compared to its compadre being about in 85% of total stroke incidents. It can be due to some obstruction to large or small vessels inside the brain or it can be generalised cerebral hypoperfusion. Due to decreased blood supply brain cell death occurs which causes symptoms in ischemic stroke. Symptoms are gradual in ischemic stroke if it is due to a thrombus compared to hemorrhagic stroke where symptoms develops suddenly. Causes of ischemic stroke are
Thrombosis – Thrombosis is usually gradual in progression following atherosclerosis. Injury to plaque can expose the endothelium, initiating a chain reaction which ultimately ends in blood clot formation and thereby occluding the blood vessel inside the brain. Thrombus can be present in larger carotid arteries or smaller circle of Willis.
Embolus – Embolus can be a detached thrombus, point of origin being heart. During arterial flutter or fibrillation thrombus in the heart can get detached and reach in cerebral circulation causing obstruction. It can also be a fat or air emboli which usually originate during bony injury and can also result in ischemic stroke.
Cerebral Hypoperfusion and Venous Thrombosis – Cerebral hypoperfusion is seen in heart diseases or hypoxic conditions. Whole of the brain’s blood supply is compromised due to reduction in cardiac output. In theory, brain’s blood supply is almost last to go. So, heart failure needs to be pretty advanced to result in such scenario.
Venous thrombosis in thrombosis is seen in venous sinuses in brain due raised venous pressure. This ischemic stroke later undergoes hemorrhagic changes becoming hemorrhagic stroke.
What To Do To Avoid Stroke
There are only a handful of risk factors for stroke, some of which can easily be avoided in lifestyle. Considering the alternative, I should say you better start modifying yourself as much as you can. Various risk factors for stroke are :
Age – Old age comes with certain disadvantages. One of them is various diseases. Risk of stroke is twice after the age of 55 yrs, heart diseases which come with this age have a risk of their own. Although age is a factor you can not modify, yet you can adopt healthy habits in old age.
Hypertension – Hypertension is most important factor concerning stroke. It is associated with both hemorrhagic and ischemic stroke. Even a fall of 10 mmhg of blood pressure is known to increase the risk of stroke by 40%. So keep your BP in check. Decrease daily salt intake, monitor your BP regularly, and do not forget antihypertensive treatment you are taking.
Diabetes – Diabetes increases blood cholesterol levels along with blood sugar levels. While it is directly increasing the risk of large vessel related stroke by 2 fold, indirectly it also is increasing the risk of atherosclerosis by raising blood cholesterol.
High Cholesterol levels – High cholesterol levels, one which are bad for us i.e. LDL, triglycerides and all non HDL cholesterol increases the risk of atherosclerosis, thereby increasing the risk of thrombotic stroke. Statins have shown to improve blood cholesterol levels. You can also improve your cholesterol by sticking to green diet and avoiding junk food.
Drugs – No, it is not usual substance abuse, not that I am promoting that. But drugs which are associated with stroke are anticoagulant. These are good guys, For a stroke patient, anticoagulant drugs like aspirin, clopidogrel etc. reduce the risk of future stroke by lowering the risk of thrombus formation.
Smoking – Smoking is responsible for high blood pressure – the most important risk factor for stroke. It also has been associated with heart failure and other heart diseases like pericarditis known to cause cerebral hypoperfusion. Smoking also damages blood vessels making them prone for thrombosis. the list goes on but fact is, it is not going to help us in any possible way. So better quit when you can.
Lack Of Physical Activity – It is a risk of omission. Exercise is something you should do on daily basis but you avoid it, making other risk factors more prominent. It will control your blood pressure, lower your blood cholesterol, will also help getting rid of smoking. It is a whole package, by doing one single activity you are avoiding whole lot of pain. I would advise to take it seriously and start improving your life.
Rehabilitation is the process of getting back on with life. Once someone recovers from a stroke, he/ she either regains control all of his body completely or in unfortunate cases do not.
In these unfortunate cases rehabilitation helps. Rehabilitation prepares them mentally and physically to be accepted in society. In physical aspect, rehabilitation helps these patients to maximise the use of whatever little function his/her limb has left, and return to as much normal life as possible. Mentally, it prepare the patients to self manage their condition, and also provides them with a different career choice so that they can take care of themselves in the society.
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