Stroke

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Stroke, also known as cerebrovascular accident (CVA), cerebrovascular insult (CVI), or brain attack, is when poor [3]

The main [7]

Prevention includes decreasing risk factors as well as possibly [2]

In 2010 approximately 17 million people had a stroke and 33 million people had previously had a stroke and were still alive. Between 1990 and 2010 the number of strokes which occurred each year decreased by approximately 10% in the [8]

Classification

A slice of brain from the autopsy of a person who suffered an acute middle cerebral artery (MCA) stroke

Strokes can be classified into two major categories: ischemic and hemorrhagic.[2]

Definition

In the 1970s the [12]

Ischemic

Main articles: Brain ischemia

In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen:

  1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally)
  2. Embolism (obstruction due to an embolus from elsewhere in the body, see below),[2]
  3. Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)[13]
  4. Venous thrombosis.[14]

Stroke without an obvious explanation is termed “cryptogenic” (of unknown origin); this constitutes 30-40% of all ischemic strokes.[15]

There are various classification systems for acute ischemic stroke. The Oxford Community Stroke Project classification (OCSP, also known as the Bamford or Oxford classification) relies primarily on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as [19]

Hemorrhagic

Main articles: Cerebral hemorrhage

CT scan of an intraparenchymal bleed (bottom arrow) with surrounding edema (top arrow)

An pia mater).

A head injury).

Signs and symptoms

Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage.

Early recognition

Various systems have been proposed to increase recognition of stroke. Different findings are able to predict the presence or absence of stroke to different degrees. Sudden-onset face weakness, arm drift (i.e., if a person, when asked to raise both arms, involuntarily lets one arm drift downward) and abnormal speech are the findings most likely to lead to the correct identification of a case of stroke increasing the likelihood by 5.5 when at least one of these is present). Similarly, when all three of these are absent, the likelihood of stroke is significantly decreased (– likelihood ratio of 0.39).[20] While these findings are not perfect for diagnosing stroke, the fact that they can be evaluated relatively rapidly and easily make them very valuable in the acute setting.

Proposed systems include [24]

For people referred to the [25]

Subtypes

If the area of the brain affected contains one of the three prominent medial lemniscus), symptoms may include:

In most cases, the symptoms affect only one side of the body (spinal cord and any lesion there can also produce these symptoms, the presence of any one of these symptoms does not necessarily indicate a stroke.

In addition to the above CNS pathways, the cranial nerves. A stroke affecting the brain stem and brain therefore can produce symptoms relating to deficits in these cranial nerves:

  • altered smell, taste, hearing, or vision (total or partial)
  • drooping of eyelid (ocular muscles
  • decreased reflexes: gag, swallow, pupil reactivity to light
  • decreased sensation and muscle weakness of the face
  • nystagmus
  • altered breathing and heart rate
  • weakness in sternocleidomastoid muscle with inability to turn head to one side
  • weakness in tongue (inability to protrude and/or move from side to side)

If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the following symptoms:

If the cerebellum is involved, the patient may have the following:

  • altered walking gait
  • altered movement coordination
  • vertigo and or disequilibrium

Associated symptoms

Loss of consciousness, headache, and vomiting usually occurs more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing the brain.

If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke.

Causes

Thrombotic stroke

Illustration of an embolic stroke, showing a blockage lodged in a blood vessel.

In thrombotic stroke a thrombus[27] (blood clot) usually forms around atherosclerotic plaques. Since blockage of the artery is gradual, onset of symptomatic thrombotic strokes is slower. A thrombus itself (even if non-occluding) can lead to an embolic stroke (see below) if the thrombus breaks off, at which point it is called an “embolus.” Two types of thrombosis can cause stroke:

[32]

Embolic stroke

An embolic stroke refers to an arterial embolism (a blockage of an artery) by an embolus, a traveling particle or debris in the arterial bloodstream originating from elsewhere. An embolus is most frequently a thrombus, but it can also be a number of other substances including fat (e.g., from bone marrow in a broken bone), air, cancer cells or clumps of bacteria (usually from infectious endocarditis).[33]

Because an embolus arises from elsewhere, local therapy solves the problem only temporarily. Thus, the source of the embolus must be identified. Because the embolic blockage is sudden in onset, symptoms usually are maximal at start. Also, symptoms may be transient as the embolus is partially resorbed and moves to a different location or dissipates altogether.

Emboli most commonly arise from the heart (especially in atrial fibrillation) but may originate from elsewhere in the arterial tree. In paradoxical embolism, a deep vein thrombosis embolizes through an atrial or ventricular septal defect in the heart into the brain.[33]

Cardiac causes can be distinguished between high and low-risk:[34]

  • High risk: atrial fibrillation and coronary artery bypass graft (CABG) surgery.
  • Low risk/potential: calcification of the annulus (ring) of the mitral valve, patent foramen ovale (PFO), atrial septal aneurysm, atrial septal aneurysm with patent foramen ovale, left ventricular aneurysm without thrombus, isolated left atrial “smoke” on ascending aorta or proximal arch.

Cerebral hypoperfusion

watershed stroke refers to the condition when blood supply to these areas is compromised. Blood flow to these areas does not necessarily stop, but instead it may lessen to the point where brain damage can occur.

Venous thrombosis

Cerebral venous sinus thrombosis leads to stroke due to locally increased venous pressure, which exceeds the pressure generated by the arteries. Infarcts are more likely to undergo hemorrhagic transformation (leaking of blood into the damaged area) than other types of ischemic stroke.[14]

Intracerebral hemorrhage

It generally occurs in small arteries or arterioles and is commonly due to hypertension,[2]).

Silent stroke

A [39]

Pathophysiology

Ischemic

Micrograph of the superficial cerebral cortex showing neuron loss and reactive astrocytes in a person that suffered a stroke. H&E-LFB stain.

Ischemic stroke occurs because of a loss of blood supply to part of the brain, initiating the [42]

As oxygen or glucose becomes depleted in ischemic brain tissue, the production of citation needed]

Ischemia also induces production of citation needed]

These processes are the same for any type of ischemic tissue and are referred to collectively as the ischemic cascade. However, brain tissue is especially vulnerable to ischemia since it has little respiratory reserve and is completely dependent on aerobic metabolism, unlike most other organs.

In addition to injurious effects on brain cells, ischemia and infarction can result in loss of structural integrity of brain tissue and blood vessels, partly through the release of matrix metalloproteases, which are zinc- and calcium-dependent enzymes that break down collagen, citation needed]

Hemorrhagic

Bleeding within the skull cavity can occur from various causes. [45]

Diagnosis

A CT showing early signs of a middle cerebral artery stroke with loss of definition of the gyri and grey white boundary

Dens media sign in a patient with middle cerebral artery infarction shown on the left. Right image after 7 hours.

Stroke is diagnosed through several techniques: a neurological examination (such as the NIHSS), CT scans (most often without contrast enhancements) or MRI scans, Doppler ultrasound, and arteriography. The diagnosis of stroke itself is clinical, with assistance from the imaging techniques. Imaging techniques also assist in determining the subtypes and cause of stroke. There is yet no commonly used blood test for the stroke diagnosis itself, though blood tests may be of help in finding out the likely cause of stroke.[46]

Physical examination

A NIH stroke scale.

Imaging

For diagnosing ischemic stroke in the emergency setting:[47]

  • CT scans (without contrast enhancements)
sensitivity= 16%
specificity= 96%
  • MRI scan
sensitivity= 83%
specificity= 98%

For diagnosing hemorrhagic stroke in the emergency setting:

  • CT scans (without contrast enhancements)
sensitivity= 89%
specificity= 100%
  • MRI scan
sensitivity= 81%
specificity= 100%

For detecting chronic hemorrhages, MRI scan is more sensitive.[48]

For the assessment of stable stroke, nuclear medicine scans SPECT and PET/CT may be helpful. SPECT documents cerebral blood flow and PET with FDG isotope the metabolic activity of the neurons.

Underlying cause

12-lead ECG of a patient with a stroke, showing large deeply inverted T-waves. Various ECG changes may occur in people with strokes and other brain disorders.

When a stroke has been diagnosed, various other studies may be performed to determine the underlying cause. With the current treatment and diagnosis options available, it is of particular importance to determine whether there is a peripheral source of emboli. Test selection may vary, since the cause of stroke varies with age, comorbidity and the clinical presentation. Commonly used techniques include:

Prevention

Given the disease burden of strokes, [54]

Risk factors

The most important modifiable risk factors for stroke are high blood pressure and atrial fibrillation (although magnitude of this effect is small: the evidence from the Medical Research Council trials is that 833 patients have to be treated for 1 year to prevent one stroke[65]

No high-quality studies have shown the effectiveness of interventions aimed at weight reduction, promotion of regular exercise, reducing alcohol consumption or carotid endarterectomy can be a useful surgical method of preventing stroke.

Blood pressure

[78]

Blood lipids

High cholesterol levels have been inconsistently associated with (ischemic) stroke.[80]

Diabetes mellitus

[83]

Anticoagulation drugs

Oral anticoagulants such as [53]

Those with [89]

In primary prevention however, antiplatelet drugs did not reduce the risk of ischemic stroke while increasing the risk of major bleeding.[93]

Surgery

[98]

Screening for carotid artery narrowing has not been shown to be a useful [67]

Diet

Nutrition, specifically the [104]

Women

A number of specific recommendations have been made for women including: taking aspirin after the 11th week of pregnancy if there is a history of previous chronic high blood pressure, blood pressure medications in pregnancy if the blood pressure is greater than 150 mmHg systolic or greater than 100 mmHg diastolic. In those who have previously had preeclampsia other risk factors should be treated more aggressively.[105]

Previous stroke or TIA

Keeping blood pressure below 140/90 mmHg is recommended.[106]

Anticoagulants, when used following stroke, should not be stopped for dental procedures.[109]

If studies show carotid stenosis, and the person has residual function in the affected side, carotid endarterectomy (surgical removal of the stenosis) may decrease the risk of recurrence if performed rapidly after stroke.

Management

Ischemic stroke

Definitive therapy is aimed at removing the blockage by breaking the clot down ([111]

Tight control of blood sugars in the first few hours does not improve outcomes and may cause harm.[113]

Thrombolysis

[121]

Its use is endorsed by the [126]

Hemicraniectomy

Large territory strokes can cause significant edema of the brain with secondary brain injury in surrounding tissue. This phenomenon is mainly encountered in strokes of the middle cerebral artery territory, and is also called “malignant cerebral infarction” because it carries a dismal prognosis. Relief of the pressure may be attempted with medication, but some require hemicraniectomy, the temporary surgical removal of the skull on one side of the head. This decreases the risk of death, although some more people survive with disability who would otherwise have died.[127]

Hemorrhagic stroke

People with citation needed]

Stroke unit

Ideally, people who have had a stroke are admitted to a “stroke unit”, a ward or dedicated area in hospital staffed by nurses and therapists with experience in stroke treatment. It has been shown that people admitted to a stroke unit have a higher chance of surviving than those admitted elsewhere in hospital, even if they are being cared for by doctors without experience in stroke.[128]

When an acute stroke is suspected by history and physical examination, the goal of early assessment is to determine the cause. Treatment varies according to the underlying cause of the stroke, thromboembolic (ischemic) or hemorrhagic.

Rehabilitation

Stroke rehabilitation is the process by which those with disabling strokes undergo treatment to help them return to normal life as much as possible by regaining and relearning the skills of everyday living. It also aims to help the survivor understand and adapt to difficulties, prevent secondary complications and educate family members to play a supporting role.

A rehabilitation team is usually multidisciplinary as it involves staff with different skills working together to help the patient. These include physicians trained in rehabilitation medicine, Barthel scale may be used to assess the likelihood of a stroke patient being able to manage at home with or without support subsequent to discharge from hospital.

Good vital signs such as temperature, pulse, and blood pressure. Stroke rehabilitation begins almost immediately.

For most people with stroke, dysphagia (problems with swallowing).

Patients may have particular problems, such as percutaneous endoscopic gastrostomy (PEG) tube is passed and this can remain indefinitely.

Treatment of spasticity related to stroke often involves early mobilizations, commonly performed by a physiotherapist, combined with elongation of spastic muscles and sustained stretching through various positionings.[26]

Stroke rehabilitation should be started as quickly as possible and can last anywhere from a few days to over a year. Most return of function is seen in the first few months, and then improvement falls off with the “window” considered officially by U.S. state rehabilitation units and others to be closed after six months, with little chance of further improvement. However, patients have been known to continue to improve for years, regaining and strengthening abilities like writing, walking, running, and talking. Daily rehabilitation exercises should continue to be part of the stroke patient’s routine. Complete recovery is unusual but not impossible and most patients will improve to some extent: proper diet and exercise are known to help the brain to recover.

Some current and future therapy methods include the use of [134]

Other novel non-invasive rehabilitation methods are currently being developed to augment physical therapy to improve motor function of stroke patients, such as [136]

A stroke can also reduce people’s general fitness.[137]

Prognosis

Disability affects 75% of stroke survivors enough to decrease their employability.[140] Dysfunctions correspond to areas in the brain that have been damaged.

Some of the physical disabilities that can result from stroke include muscle weakness, numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform learned movements), difficulties carrying out daily activities, appetite loss, speech loss, vision loss and pain. If the stroke is severe enough, or in a certain location such as parts of the brainstem, coma or death can result.

Emotional problems following a stroke can be due to direct damage to emotional centers in the brain or from frustration and difficulty adapting to new limitations. Post-stroke emotional difficulties include anxiety, panic attacks, flat affect (failure to express emotions), mania, apathy and psychosis. Other difficulties may include a decreased ability to communicate emotions through facial expression, body language and voice.[141]

Disruption in self-identity, relationships with others, and emotional well-being can lead to social consequences after stroke due to the lack of ability to communicate. Many patients who experience communication impairments after a stroke find it more difficult to cope with the social issues rather than physical impairments. Broader aspects of care must address the emotional impact speech impairment has on those who experience difficulties with speech after a stroke.[143]

30 to 50% of stroke survivors suffer post-stroke depression, which is characterized by lethargy, irritability, sleep disturbances, lowered self-esteem and withdrawal.[144] Depression can reduce motivation and worsen outcome, but can be treated with antidepressants.

[145] Emotional lability occurs in about 20% of stroke patients.

Cognitive deficits resulting from stroke include perceptual disorders, hemispatial neglect, a patient is unable to attend to anything on the side of space opposite to the damaged hemisphere.

Cognitive and psychological outcome after a stroke can be affected by the age at which the stroke happened, pre-stroke baseline intellectual functioning, psychiatric history and whether there is pre-existing brain pathology.[150]

Up to 10% of people following a stroke develop [152]

Epidemiology

[153]

  no data
  <250
  250-425
  425-600
  600-775
  775-950
  950-1125
  1125-1300
  1300-1475
  1475-1650
  1650-1825
  1825-2000
  >2000

Stroke was the second most frequent cause of death worldwide in 2011, accounting for 6.2 million deaths (~11% of the total).[8]

It is ranked after heart disease and before cancer.southeastern United States, but causes of these disparities have not been explained.

The [31] A person’s risk of dying if he or she does have a stroke also increases with age. However, stroke can occur at any age, including in childhood.

Family members may have a genetic tendency for stroke or share a lifestyle that contributes to stroke. Higher levels of Von Willebrand factor are more common amongst people who have had ischemic stroke for the first time.[157] The results of this study found that the only significant genetic factor was the person’s blood type. 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,HRT).

History

Hippocrates first described the sudden paralysis that is often associated with stroke.

Episodes of stroke and familial stroke have been reported from the 2nd millennium BC onward in ancient Mesopotamia and Persia.[158] Hippocrates (460 to 370 BC) was first to describe the phenomenon of sudden paralysis that is often associated with ischemia. Apoplexy, from the Greek word meaning “struck down with violence,” first appeared in Hippocratic writings to describe this phenomenon.[159][160] The word stroke was used as a synonym for apoplectic seizure as early as 1599,[161] and is a fairly literal translation of the Greek term.

In 1658, in his Apoplexia, [162]

The term cerebrovascular accident was introduced in 1927, reflecting a “growing awareness and acceptance of vascular theories and (…) recognition of the consequences of a sudden disruption in the vascular supply of the brain”.[167]

The term brain attack was introduced for use to underline the acute nature of stroke according to the [169]

Research

Angioplasty and stenting

Angioplasty and stenting have begun to be looked at as possible viable options in treatment of acute ischemic stroke. Intra-cranial stenting in symptomatic intracranial arterial stenosis, the rate of technical success (reduction to stenosis of <50%) ranged from 90-98%, and the rate of major peri-procedural complications ranged from 4-10%. The rates of restenosis and/or stroke following the treatment were also favorable. This data suggests that a randomized controlled trial is needed to more completely evaluate the possible therapeutic advantage of this preventative measure.[170]

Mechanical thrombectomy

Removal of the clot may be attempted in those where it occurs within a large blood vessel and may be an option for those who either are not eligible for or do not improve with intravenous thrombolytics.[172]

Neuroprotection

Drugs that scavenge [174]

Hyperbaric oxygen therapy has been studied as a possible protective measure, but is currently not thought to be beneficial.[175]

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See also

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Further reading

  • J. P. Mohr, Dennis Choi, James Grotta, Philip Wolf (2004). Stroke: Pathophysiology, Diagnosis, and Management. New York: Churchill Livingstone. 50477349 52990861. 
  • Charles P. Warlow, Jan van Gijn, Martin S. Dennis, Joanna M. Wardlaw, John M. Bamford, Graeme J. Hankey, Peter A. G. Sandercock, Gabriel Rinkel, Peter Langhorne, Cathie Sudlow, Peter Rothwell (2008). Stroke: Practical Management (3rd ed.). Wiley-Blackwell. ISBN 1-4051-2766-X. 

External links

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