Stroke

 www.stroke.ie | The IHF's STROKE ACTION website
Take a look at the Irish Heart Foundation's STROKE ACTION website
What is a stroke and how is it caused?
The commonest form of stroke occurs when a blood vessel bringing oxygen and nutrients to the brain is suddenly clogged by a blood clot or some other particle. Because of this blockage, part of the brain doesn't get the flow of blood it needs. Without a proper flow of blood, part of the brain is deprived of oxygen, nerve cells in the affected area of the brain can't function and many die within minutes. When nerve cells can't function, the part of the body controlled by these cells stops working. The devastating effects of stroke often do not recover well because the dead brain cells aren't replaced.

There are four main types of stroke: two caused by blood clots or other particles, and two by brain haemorrhage. Cerebral thrombosis and cerebral embolism are by far the most common, accounting for about 70-80 percent of all strokes. They're both caused by clots or particles that plug an artery. Cerebral and subarachnoid haemorrhages are caused by ruptured blood vessels in the brain.

What is a Cerebral thrombosis?
Cerebral thrombosis is the most common type of stroke. It occurs when a blood clot (thrombus) forms and blocks blood flow in an artery which bring blood to part of the brain. Blood clots usually form in arteries damaged by atherosclerosis (fatty deposits).

What is a Cerebral embolism?
This type of stroke occurs when a wandering clot (an embolus - EM'bo-lus) or some other particle forms in a blood vessel away from the brain, usually in the heart. The clot is carried by the bloodstream until it lodges in an artery leading to or inside the brain, blocking the flow of blood.

The most common cause of these emboli are blood clots which form in people who have a particular type of irregular pulse known as atrial fibrillation. Blood isn't pumped completely out of the heart when the heart beats, allowing some blood to pool and eventually clot. About 15 percent of strokes occur in people with atrial fibrillation.

What types of brain haemorrhage cause strokes?
1. A subarachnoid haemorrhage occurs when a blood vessel on the surface of the brain ruptures and bleeds into the space between the brain and the skull. Subarachnoid haemorrhages account for about seven percent of all strokes.

2. Another type of stroke occurs when a defective artery in the brain bursts, flooding the surrounding brain tissue with blood. This is a cerebral haemorrhage. About 10 percent of all strokes result from cerebral haemorrhages.

When a cerebral or subarachnoid haemorrhage occurs, the loss of a constant blood supply means some brain cells can no longer function. Another problem is that accumulated blood from the burst artery may put pressure on surrounding brain tissue and interfere with how the brain functions. Severe or mild symptoms can result, depending on the amount of pressure.

Effects of Stroke
The after effects of stroke range from very mild to severely devastating . Strokes affect different people in different ways, depending on the type of stroke, the area of the brain affected and the extent of the brain injury. Paralysis with weakness on one side of the body is a common after effect. Brain injury from a stroke can affect the senses of seeing and feeling, the ability to speak and understand speech, and less commonly behavioural patterns, thought patterns, memory and emotions.

How does a stroke affect your emotions?
A stroke survivor may cry easily, often for no apparent reason. This is called emotional lability. Laughing uncontrollably may also occur but is not as common as crying. Depression is common, as people who have experienced stroke may feel less than "whole."

What is loss of awareness after a stroke?
Stroke often causes people to lose mobility and/or feeling in an arm and/or leg, or suffer dimness of sight on one side. The loss of feeling or sight to one side can lead to loss of awareness, so some stroke survivors may forget or ignore their weaker side. This problem is called "neglect." As a result, any or all of the following problems may emerge: they ignoring items put on the affected side, trouble reading, dressing only one side of their body and thinking they're completely dressed. Bumping into furniture or doorjambs when walking or using the wheelchair is also common with stroke survivors who have neglect. One-sided neglect is most common on the left side when it is due to injury to the right side of the brain.

How does a stroke affect your perception?
A stroke can also affect seeing, touching, moving and thinking, so that a person's perception of everyday objects may be changed. Stroke survivors may not be able to recognise and understand the purpose of familiar objects the way they did before. When vision is affected, objects may look closer or farther away than they really are, making people appear clumsy when they cause spills at the table or collide into a doorjamb when walking.

How does a stroke affect hearing and speech?
There is usually no hearing loss after a stroke, although people may have problems understanding speech so that it appears that they haven’t heard properly. They also may have trouble saying what they're thinking. This is called aphasia, which affects the ability to talk, listen, read and write. Problems with speech are most common when a stroke also weakens the right side of the body.

What is aphasia?
Aphasia is a total or partial loss of the ability to speak and/or understand what is being said. It is most often caused by a stroke that damages the brain's language centre. Some people recover from aphasia after a stroke quickly and completely. Others may have permanent speech and language problems.

  • Speech problems can range from having some trouble finding words to being unable to speak at all apart from frustrated cursing.
  • Some people have problems understanding what others are saying and may also have trouble with reading, writing or simple arithmetic, such as counting change.
  • In other cases, someone with aphasia may have trouble talking but can understand what others say quite well.

Each person's speech and language problem is unique. A speech therapist can help set up a treatment plan and help others understand an aphasic person's wishes.

A related problem is that a stroke can affect muscles used in talking (those in the tongue, palate and lips), and speech can be slowed, slurred or distorted. Some stroke survivors thus also can be hard to understand for this reason. This is called dysarthria and may require the help of a speech therapist.

How can a stroke affect chewing and swallowing food?
Up to 50% of stroke survivors have difficulty swallowing just after their stroke. This problem, called dysphagia, can occur when one side of the mouth is weak. One or both sides of the mouth can lack feeling, increasing the risk of choking when trying to swallow liquids or food.

How can a stroke affect the ability to think clearly?
Planning and carrying out even simple activities may be hard. Stroke survivors may not know how to start a task because they confuse the sequence of logical steps in tasks, and can forget how to do tasks they've done many times before.

STROKE REHABILITATION

Besides stroke being the third leading cause of death in Ireland, stroke is a leading cause of serious, long-term disability. Many stroke survivors have problems with thinking as well as their physical disabilities.

When should rehabilitation start?
In stroke we used to divide up care into the acute care of stroke, rehabilitation and finally continuing care. People used to see rehabilitation only as physical therapy eg; physiotherapy, speech therapy, occupational therapy. However, rehabilitation should be looked on as the process of minimising the effects of the stroke and reducing the impact of the stroke on the person’s and their family’s lives. So rehabilitation starts on the first day of the stroke. Treatment of depression, proper bed and wheelchair positioning following a stroke, are all regarded as part of rehabilitation.

When percentages are quoted in talking about recovery we are really talking about average rates, that is, what would happen say if one took 100 patients who had suffered a stroke. These averages often don’t take into account the type of stroke, the severity of the stroke or the age of the person. That is, they are not directed specifically to the individual, so the percentages should be taken as a rough guide only as each person is different and doesn’t conform to an average.

Does early rehabilitation lead to more recovery of speech and movement?
Remember that part of ‘rehabilitation’ is aimed at helping the person adapt to physical weakness or other problem caused by the stroke. There is some evidence that parts of the brain which are not damaged in the stroke can take over some of the functions which have been damaged (neuroplasticity). Some of the physiotherapy, speech therapy and occupational therapy treatments are based on this possibility, but it probably doesn’t happen to a great extent. There is evidence that more intensive ‘rehabilitation’ can lead to a more rapid recovery of function within the first six months compared with people who receive less rehabilitation, but after six months the amount of recovery between those who have received intensive rehabilitation and those who have received less intensive rehabilitation evens out.

The amount of therapy given and the time when it starts is governed by the effects of the stroke and the amount of recovery that takes place over the weeks and months following the stroke and obviously the availability of a full rehabilitation team. The intensity of therapy will be a matter for the person, his/her therapists and the doctor to discuss. One cannot force speech or movement to return by working 18 hours a day at it! Part of the therapists role is to assess recovery and tailor the rehabilitation to the person. In hospital, or at home, there usually comes a time when a ‘plateau’ is reached in recovery and the amount of therapy is reduced or discontinued. Certainly, if rehabilitation is completely neglected, recovery of function and adaptation to the residual effects of the stroke will be worse.

Early therapy may be unsuitable in some patients eg, there is little point in doing standing practice when the person still cannot yet sit up without considerable support. It is very important that correct posture and movement of limbs and joints occurs from Day One to try and prevent spasticity with limb and trunk contractures which will interfere with future rehabilitation. Therapists often set ‘goals’ along with the patient so everyone knows what is aimed for. Some people recover better than others, usually by about 3 months after the stroke the doctor will have a clear idea of the amount of recovery, but slower recovery can continue up to two years, each person is different.

Early recovery is probably due to recovery of function of less damaged and swollen areas of the brain - it can take up to a month for swelling to go out of the brain. Later recovery, probably develops as the person learns techniques to compensate for their impairments. Changes to the environment can help in this eg, adaptations in the house.

The ‘pattern’ of the recovery depends on a host of factors, so it can be difficult to predict the full extent of an individual’s functional recovery. As a general rule the rate of recovery is greatest in the first few months following a stroke.

Does a person need rehabilitation to recover from a stroke?
Most gains in a person's ability to function in the first 30 days after a stroke are due to spontaneous recovery. Still, rehabilitation is important. For the most part, successful rehabilitation depends on

  • the extent to which the brain is affected
  • the survivor's attitude
  • the rehabilitation team's skill
  • the support of family and friends

People with the least severe strokes are likely to recover the most. But even when improvement is limited, rehabilitation may still enable the person to return home from hospital.

What is the goal of rehabilitation?
The goal of rehabilitation is to reduce dependence and improve physical ability. Often old skills have been lost and new ones are needed in the early weeks of post severe stroke. It's also important to maintain and improve a person's physical condition as much as possible.

Rehabilitation begins early when nurses and other hospital staff work to prevent such complications as stiff joints, bedsores and pneumonia, which can result from being confined to bed for a long time.

How can a stroke survivor's family help?
The role of the stroke survivor's family in rehabilitation is significant. A caring and able spouse or partner can be one of the most important positive factors in rehabilitation. The skills of family members matters a great deal. Family members need to understand what the stroke survivor has been through and how disabilities can affect the person. The effects of the stroke will be easier to handle if the family knows what to expect and how to handle problems that arise after the person leaves the hospital.

For a stroke survivor, their goal for rehabilitation is to be as independent and productive as possible, within the limitations resulting from their stroke.

STROKE RISK FACTORS

Several factors have been identified that increase the risk of stroke. The more risk factors a person has, the greater the risk that he or she will have a stroke. Some of these risk factors are inevitable, such as increasing age, others cannot be changed such as; family health history and gender. But you can change, treat or modify other factors to lower your risk. Factors resulting from lifestyle or environment can be modified to good effect.

What are the risk factors for stroke?
Increasing age - The chance of having a stroke more than doubles for each decade of life after age 55. While stroke is common among the elderly, substantial numbers of people under 65 also have strokes.

High blood pressure - High blood pressure is the most important risk factor for stroke. In fact, stroke risk rises directly with higher blood pressure. Many people believe the effective treatment of high blood pressure is a key reason for the decline in the death rates for stroke.

Male sex - Overall, men have about a 19 percent greater chance of stroke than women. Among people under age 65, the risk for men is even greater when compared to that of women.

Heredity (family history) - The risk of stroke is greater in people who have a family history of stroke.

Prior stroke - The risk of stroke for someone who has already had a stroke is many times that of a person who has never had a stroke.

Cigarette smoking - In recent years studies have shown cigarette smoking to be an important risk factor for stroke. The nicotine and carbon monoxide in cigarette smoke damage the circulation system in many ways. The use of oral contraceptives combined with cigarette smoking greatly increases stroke risk. Smoke 20 cigarettes per day increases the risk of stroke six fold.

Diabetes mellitus - Diabetes is an additional risk factor for stroke and is strongly linked with high blood pressure. While diabetes is treatable, having diabetes still increases a person's risk of stroke. People with diabetes often also have high cholesterol or can be overweight, increasing their risk even more.

Carotid artery disease - The carotid arteries in your neck carry blood to your brain. A carotid artery damaged by atherosclerosis (a fatty build-up of plaque in the artery wall) may become blocked by a subsequent blood clot, which may result in a stroke.

Heart disease - A diseased heart increases the risk of stroke. In fact, people with heart problems have more than twice the risk of stroke as those with hearts that work normally. Atrial fibrillation (the rapid, uncoordinated beating of the heart's upper chambers), in particular, raises the risk for stroke. Subsequent heart attack has been found to be a major cause of death among survivors of stroke.

Transient ischaemic attacks (T.I.A.s) - TIA’s are "mini strokes" that produce stroke-like symptoms but no lasting damage. They are strong predictors of future permanent stroke. A person who's had one or more TIAs is almost 10 times more likely to have a stroke than someone of the same age and sex who hasn't had a TIA.

High red blood cell count - A moderate or marked increase in the red blood cell count is a risk factor for stroke. The reason is that more red blood cells thicken the blood and make clots more likely.

Socio-economic factors - There's some evidence that people of lower income and educational levels have a higher risk for stroke.

Excessive alcohol intake - Excessive drinking (an average of more than one drink per day for women and more than two drinks per day for men) and binge drinking can raise blood pressure, contribute to obesity, produce high fat levels in the blood stream, cause heart failure.

Certain kinds of drug abuse - e.g.; Intravenous drug abuse carries a high risk of stroke from cerebral embolism. Cocaine use has been closely related to strokes, heart attacks and a variety of other cardiovascular complications.

How are heart disease risk factors related to stroke?
Some heart disease risk factors are also risk factors for stroke. They raise the risk of stroke indirectly by increasing the risk of heart disease due to:

  • High blood cholesterol and lipids
  • Physical inactivity
  • Being overweight

STROKE SYMPTOMS/WARNING SIGNS

  • Stroke should be regarded as a medical emergency requiring urgent medical attention.
  • The Irish Heart Foundation says the symptoms of stroke are
  • Sudden numbness or weakness of face, arm or leg, especially on one side of the body.
  • Sudden confusion, trouble speaking or understanding.
  • Sudden trouble seeing in one or both eyes.
  • Sudden trouble walking, with dizziness, loss of balance or co-ordination.
  • Sudden, severe headache with no known cause.

What is a TIA or transient ischaemic attack?
Any of the above signs may be only temporary, last only a few minutes, and be due to a "mini-stroke" called a transient ischaemic attack or T.I.A. About 10 percent of strokes are preceded by TIA’s. A person who has had one or more TIAs is about 10 times more likely to have a stroke that someone of the same age and sex who has not.

TIA’s are important stroke warning signs. Don't ignore them! SEEK MEDICAL ADVICE.

Can stroke be prevented?
In some circumstances yes. In high risk individuals the risk of major stroke can be reduced considerably by the following treatments on advice from your doctor:

  • Use of aspirin to stop more blood clots forming after a mini-stroke (TIA- Transient Ischaemic Attack).
  • Surgical operation (carotid endarterectomy) to unblock arteries in the neck after a TIA
  • Use of Warfarin to prevent blood clots forming in the heart in people with a certain type of irregular heart beat (atrial fibrillation).
  • Modification of risk factors (eg, high blood pressure, smoking, lack of exercise).

Can stroke be cured?
Once the stroke has occurred, the short answer is "no". There is no known drug which can completely eliminate the risk of having a stroke or offer a guaranteed ‘cure’. However, early diagnosis and quick action after a stroke can reduce its severity.

For stroke patients suffering loss of speech, movement, impaired thought processes or loss of feeling, rehabilitation is possible with the assistance of physiotherapists, speech and language therapists, occupational and other therapists.

Remember, a stroke should be regarded as a medical emergency and must be seen to as soon as possible. Prevention and treatment is the key!

What risks exist after a stroke?
After a stroke the risk of a further stroke is increased by ten-fold over five years. 80% of patients survive the first month, 70% survive the first year, after which the risk of dying from a heart attack is greater than the risk of dying from a stroke. While some types of stroke have a worse outcome than others, it is important to remember that half of all stroke survivors regain independence.

It is important that as well as trying to reduce the possibility of a further stroke that other vascular diseases, including heart disease are checked into.

What is a CAT scan?
Computerised axial tomographic scan (C.T. or CAT scan) is a computerised x-ray which helps to show the brain structure. If bleeding (brain haemorrhage) has occurred this can be seen immediately on the CT scan but the signs of a thrombus or embolism may take several days to show up clearly in a CT scan. Doctors use CT to determine whether a stroke has occurred and to identify the type of stroke: ischaemic (result of blockage) or haemorrhagic (result of bleeding).

What tests show blood flow?
Doppler (Duplex) ultrasound tests - In this safe and painless test, ultrasound waves are used to detect blockages in the carotid artery. The probe is placed on the neck, very close to the carotid artery. Ultrasound waves generated from the probe travel through the neck, bounce off the moving blood cells and detects whether the artery is partially or completely blocked. This type of ultrasound test can help a vascular surgeon advise people with either TIA or mild stroke whether surgery to the carotid artery in the neck would further protect against further TIA or stroke.

STROKE TREATMENT

What are accepted ways to treat stroke or TIA (mini-stroke)?
Surgery, certain drugs, acute hospital care and rehabilitation are all accepted ways to treat stroke.

When a neck artery has become partially blocked, surgery might be used to remove the build-up of the fatty deposits. This procedure called carotid endarterectomy is performed by a vascular surgeon.

What about tissue plasminogen activator (TPA) - the clot dissolving treatment?
This is a major advance in medical therapy for acute strokes caused by blood clots. A risk of brain haemorrhage accompanies use of the drug. TPA is effective only if given promptly. For maximum safety, the therapy should only be started after a CT brain scan has shown that there is no evidence of brain haemorrhage and, for maximum benefit, the TPA needs to be given within three hours after the onset of a stroke. Therefore, it is critical that medical professionals and the public recognise and respond to the urgency of the onset of stroke.

What about treating heart disease?
Sometimes treating a stroke also entails treating the heart, because various forms of heart disease can contribute to the risk of stroke. For example, damaged heart valves may need to be surgically treated or the patient will need to take an anti-clotting drug, ie, Warfarin to reduce the chance of clots forming around the heart valve. Blood clots can also form in patients with atrial fibrillation , a type of irregular (heart and pulse rhythm). If clots form, there's a chance they could travel to the brain and cause a stroke.

Why is return to driving sometimes unsafe and illegal?
A stroke can affect eyesight, co-ordination, limb movement, strength, balance, reaction time, concentration, speed of thought, memory, awareness of space (where objects are in relation to each other) and even awareness that there is anything wrong at all (insight into the disability). Any one of these disabilities carries with it the possibility of making driving unsafe. There are therefore vehicle licensing authority requirements (and insurance company requirements) before a person can restart driving after stroke. Not all people who have suffered a stroke will be able to get back to driving.

If someone has had a stroke or transient ischaemic attack, they should seek advice from their doctor and inform their licensing authority and insurance company.

If a doctor is uncertain whether or not a patient should be allowed to drive he/she can write directly to the Irish Wheelchair Association Driving Service requesting their assessment to the licensing authority for their advice. The motoring advice, assessment and tuition service (MAATS) at the Irish Wheelchair Association is a very useful source of information and assessment.

Can I resume sexual activity after stroke?
Thousands of stroke survivors have learned that having a stroke does not mean an end to a satisfying sex life. After the first phase of recovery is complete, patients usually find that the same forms of lovemaking that were pleasing before can still be rewarding. Many myths surround sex after stroke. The most common one is that resuming sex often brings on further stroke or sudden death. This simply isn’t true. There’s no reason why stroke survivor can’t resume usual sexual activity as soon as they feel ready to do so. Talk with your doctor if you have any concerns.

Fear about performance and general depression are two psychological factors that can greatly reduce sexual interest and capacity. After recovery, stroke survivors may feel depressed. This depression is normal, it disappears within three months. However, it tends to exaggerate whatever previous sexual problems were present between partners.

You and your partner can prepare for sex in several ways. First, you can maintain and improve your physical conditions and personal hygiene. Second, you can become more tolerant of your emotions, if temporary mood swings emerge.

Consider the following general guidelines for couples resuming sex:

  • Choose a time when you are rested, relaxed and free from the stressful feelings brought on by the day’s schedules and responsibilities.
  • Wait one to three hours after eating a full meal, so that that digestion can take place.
  • Select a familiar, peaceful setting that is free from interruptions.
  • Take medicine prior to sexual relations if prescribed by your doctor.
  • Be aware that your feelings about your body may have changed since your brain attack.
  • Try using pillows to help support your affected side during lovemaking.

What is thalamic pain (central post-stroke pain)?
This type of pain can emerge after severe strokes where the person reports numbness or loss of feeling on one side of their body. The pain is often constant, burning or tingling in nature and resistant to routine pain killers including morphine.

The syndrome being described is probably central post stroke pain. This central post-stroke pain can be a difficult problem to deal with. Different treatments include the use of anti-depressants (Amitriptyline) and anti-convulsants (Gapapentin). Acupuncture and transcutaneous nerve stimulation (TENS) may have some place for patients with persistent pain.

What support groups are there?
Volunteer Stroke Scheme
Different Strokes
Irish Wheelchair Association (MAATS)


Stroke Campaign
Call our helpline on 1890 432 787