STROKE

Dr Arulita Ika Fibriana M.Kes

DEFINITION

Stroke is a rapidly developing loss of brain function(s) disturbance in the blood supply to the brain.

This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood).

As a result, the affected area of the brain is unable to function  inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field.

DEFINITION

World Health Organisation (WHO) definition of stroke :

Stroke is defined as ‘rapidly developing clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24 hour or longer, or leading to death, with no apparent cause other than of vascular origin’

Time window of 24 hour distinguishes stroke from Transient Ischaemic Attack (TIA), which has the same definition but is defined as a neurological deficit lasting less than 24 hour.

CLASSIFICATION

Stroke is classified into two major types: Brain ischemia thrombosis, embolism, or

systemic hypoperfusion (cardiac pump failure from cardiac arrest or arrhythmias, or from reduced cardiac output as a result of myocardial infarction)

Brain hemorrhage due to intracerebral hemorrhage or subarachnoid hemorrhageAbout 87% of strokes are caused by ischemia, and the remainder by hemorrhage.

ISCHEMIC STROKE

EPIDEMIOLOGY

The second leading cause of death in the Western world (after heart disease and before cancer), and causes 10% of deaths worldwide.

The incidence of stroke increases  from 30 years of age.

Advanced age is one of the most significant stroke risk factors also increases a person's risk of dying.

95% of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65.

However, stroke can occur at any age, including in childhood.

EPIDEMIOLOGY

Family members may have a genetic tendency for stroke or share a lifestyle contributes to stroke.

Having had a stroke in the past greatly increases one's risk of future strokes.

Men are 25% more likely to suffer strokes than women,

60% of deaths from stroke occur in women (women live longer, they are older when they have their strokes and thus more often killed)

SIGN & SYMPTOMS

The symptoms depend on the area of the brain that has been affected and the amount of brain tissue damage.

Small strokes may not cause any symptoms, but can still damage brain tissue. Strokes that do not cause symptoms silent strokes. 

SIGN & SYMPTOMS

According to The U.S. National Institute of Neurological Disorders and Stroke (NINDS), these are the five major signs of stroke:

Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. The loss of voluntary movement and/or sensation may be complete or partial. Try to raise both arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your mouth may droop when you try to smile. 

Sudden trouble walking, dizziness, loss of balance or coordination.

SIGN & SYMPTOMS

Sudden confusion or trouble speaking or understanding. Sometimes weakness in the muscles of the face can cause drooling You may slur your words or be unable to find the right words to explain what is happening to you (aphasia). Try to repeat a simple sentence. If you can't, you may be having a stroke.

Sudden trouble seeing in one or both eyes You may suddenly have blurred or blackened vision, or you may see double.

Sudden, severe headache with no known cause which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke.

NEUROLOGICAL IMPACT

Potentially affected neurological domains are : Motor: Motor impairments (the most prevalent of

all deficits ) face, arm, and leg, alone or in various combinations. Motor functions  include cranial nerve function (including speech and swallowing), muscle power and tone, reflexes, balance, gait, coordination.

Sensory: Sensory deficits (numbness, tingling, or altered sensitivity). The more complex sensory losses include astereognosis, agraphia, and extinction to double simultaneous stimuli.

Vision: Stroke can cause monocular visual loss.

NEUROLOGICAL IMPACT

Language: Dysphasia may be exhibited by disturbances in comprehension, naming, repetition, fluency, reading, or writing.

Cognition: impairments in memory, attention, orientation, calculation abilities, and construction assess ability to learn and retain new information in the cognitive evaluation.

Affect: Depression is the most common affective disturbance . It tends to be observed more often in the months after stroke than during the acute event. Symptoms include loss of energy, lack of interests, loss of appetite, and insomnia.

RISK FACTORS

Controllable Risk Factors: High Blood Pressure Atrial Fibrillation High Cholesterol Diabetes Atherosclerosis Circulation Problems Tobacco Use and Smoking Alcohol Use Physical Inactivity Obesity

RISK FACTORS

Uncontrollable Risk Factors: Age Gender Race Family History Previous Stroke or TIA Fibromuscular Dysplasia Patent Foramen Ovale (PFO or Hole in the Heart)

DIAGNOSIS

A physical examination, including taking a medical history of the symptoms and a neurological status.

CT scans or MRI scans, Doppler ultrasound, and arteriography.

Determine the underlying etiology (an ultrasound of the carotid arteries (to detect carotid stenosis) or an electrocardiogram (ECG) and echocardiogram (to identify arrhythmias and resultant clots in the heart which may spread to the brain vessels through the bloodstream), blood tests to determine hypercholesterolemia, anemia, kidney and liver function, electrolyte abnormalities and blood clotting function.

IMPACT OF STROKE

The third largest cause of death (behind heart disease and all forms of cancer).

Lost in work, hospitalization, and the care of survivors in nursing homes disability affects 75% of stroke survivors enough to decrease their employability.

Lose most of the quality of life after a stroke The major cost or impact of a stroke is the loss of independence that occurs in 30% of the survivors.

Family members and friends may have their lives altered as they find themselves in the new role as caregivers.

TREATMENT OF A STROKE

Tissue plasminogen activator (TPA) Alteplase (TPA) as a clot-buster drug to dissolve the blood clot that is causing the stroke.

Anticoagulation for example, heparin are also sometimes used in treating stroke patients in the hopes of improving the patient's recovery.

Managing other Medical Problems :- Blood pressure controlled often using intravenous

medication to prevent stroke symptoms from progressing.

- In patients with diabetes controlling the glucose level in these patients may minimize the size of a stroke.

TREATMENT OF STROKE

Rehabilitation :- speech therapy to relearn talking and

swallowing;- occupational therapy to regain as much

function dexterity in the arms and hands as possible;

- physical therapy to improve strength and walking;

- family education to orient them in caring for their loved one at home and the challenges they will face.

PROGNOSIS

is related to the severity of the stroke and how much of the brain has been damaged.

Some patients return to a near-normal condition with minimal defects.

Many stroke patients are left with permanent problems such as hemiplegia (weakness on one side of the body), aphasia (difficulty or the inability to speak), or incontinence of the bowel and/or bladder. A significant number of persons become unconscious and die following a major stroke.

PREVENTION

Risk factor reduction :- High blood pressure: Managing high blood

pressure so that it is well controlled and in the normal range decreases the chances of a stroke.

- Smoking: Chemicals in cigarettes are associated with developing atherosclerosis or narrowing of the arteries in the body.

- Diabetes: Diabetes causes the small vessels to close prematurely. When these blood vessels close in the brain, small (lacunar) strokes may occur. Good control of blood sugar is important in decreasing the risk of stroke in people with diabetes.

PREVENTION

- High cholesterol: Elevated cholesterol and/or triglycerides in the bloodstream are risk factors for a stroke due to the eventual blockage of blood vessels (atherosclerosis) and plaque formation. A healthy diet and medications can help normalize an elevated blood cholesterol level.

- Blood thinner/warfarin:  blood clots can break off and travel or embolize to blood vessels in the brain blocking blood flow and causing a stroke. Warfarin (Coumadin) is a blood "thinner" that prevents the blood from clotting.

- Antiplatelet therapy: act on platelets to decrease their stickiness and reduce the tendency to clot blood.