Cerebrovascular accident

A stroke or cerebrovascular accident (CVA) occurs when the blood supply to a part of the brain is suddenly interrupted by occlusion (called an ischemic stroke -- approximately 90% of strokes), by hemorrhage (called a hemorrhagic stroke -- about 10% of strokes) or other causes. Ischemia is a reduction of blood flow most commonly due to occlusion (an obstruction). On the other hand, hemorrhagic stroke (or intracranial hemorrhage), occurs when a blood vessel in the brain bursts, spilling blood into the spaces surrounding the brain cells or when a cerebral aneurysm ruptures. The mortality and long-term morbidity prognosis is generally worse for hemorrhagic strokes than for ischemic strokes. A small proportion of strokes are watershed strokes caused by hypoperfusion (usually due to hypotension) or other vascular problems including vasculitis.

Treatment

Early assessment

It is important to identify that a patient is having a stroke as early as possible because recovery can be improved for patients treated earlier. The term "brain attack" is used to underline the urgency of early assessment and treatment similar in intensity to the management of a patient with a heart attack.

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If a patient is suspected of having a stroke, emergency services should be contacted immediately, so he or she can be transported to the nearest hospital that can provide a rapid evaluation and treatment with the latest available therapies targeted to the type of stroke. The faster these therapies are started for hemorrhagic stroke (caused by bleeding into or around the brain) and ischemic stroke (due to a blood clot that blocks blood flow), the chances for recovery from each type improves greatly. Immediate decisions about medication and the need for surgery have been shown to improve outcome.

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Only detailed physical examination and medical imaging provide information on the type of stroke (ischemic or hemorrhagic) and the extent, or whether the symptoms may be due to an unrelated condition.

Related Topics:
Physical examination - Medical imaging

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Long-term studies show that patients treated in hospitals with a dedicated Stroke Team or Stroke Unit, and that have a specialized care program for stroke patients, have improved odds of recovery.

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Ischemic stroke

As ischemic stroke is due to a thrombus (blood clot) occluding a cerebral artery, a patient is commenced on anticoagulant medication (aspirin and/or clopidogrel or warfarin, dependant on the cause) when this type of stroke has been demonstrated. As such treatment would be dangerous in hemorrhagic stroke, it is essential that this form of stroke is ruled out with medical imaging.

Related Topics:
Thrombus - Anticoagulant - Aspirin - Clopidogrel - Warfarin

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In increasing numbers of specialist centers, thrombolysis ("clot busting") is used to dissolve the putative clot. As this treatment is expensive, quite experimental, potentially dangerous and often contraindicated, the decision to thrombolyse can often only be made by an expert. There is also a time constraint: studies indicate that after three hours of symptom onset the damage to the brain is irreversible ("time is brain"), and that thrombolysis would provide no benefit. These various requirement prevent routine thrombolysis of ischemic stroke in most hospitals, especially out of working hours when no stroke expert may be available.

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Whether thrombolysis is performed or not, the following investigations are required:

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• Stroke symptoms are documented, often using scoring systems such as the National Institutes of Health Stroke Scale, the Cincinnati Stroke Scale, and the Los Angeles Prehospital Stroke Scale. The latter is used by emergency medical technicians (EMTs) to determine whether a patient needs transport to a stroke center.
• A CT scan is performed to rule out hemorrhagic stroke (or other specific forms of cerebral hemorrhage, such as subarachnoid hemorrhage)
• Blood tests, such as a full blood count, coagulation studies (PT/INR, APTT), electrolytes, renal function, liver function tests and glucose levels.

Other immediate strategies to protect the brain during stroke include ensuring that blood sugar is as normal as possible (such as commencement of an insulin sliding scale in known diabetics), and that the stroke patient is receiving adequate oxygen and intravenous fluids. The patient may be positioned so that their head is flat on the stretcher, rather than sitting up, since studies have shown that this increases blood flow to the brain. Additional therapies for ischemic stroke include aspirin (50 to 325 mg daily), clopidogrel (75 mg daily), and combined aspirin and dipyridamole extended release (25/200 mg twice daily).

Related Topics:
Insulin sliding scale - Diabetics - Oxygen - Intravenous fluid - Aspirin - Clopidogrel - Dipyridamole

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It is common for the blood pressure to be elevated immediately following a stroke. Studies indicated that while high blood pressure causes stroke, it is actually beneficial in the emergency period to allow better blood flow to the brain.

Related Topics:
Blood pressure - Elevated

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If studies show carotid stenosis, and the patient has residual function in the affected side, carotid endarterectomy (surgical removal of the stenosis) may decrease the risk of recurrence.

Related Topics:
Carotid stenosis - Carotid endarterectomy

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If the stroke has been the result of cardiac arrhythmia (such as atrial fibrillation) with cardiogenic emboli, treatment of the arrhythmia and anticoagulation with warfarin or high-dose aspirin may decrease the risk of recurrence.

Related Topics:
Cardiac arrhythmia - Atrial fibrillation - Anticoagulation - Warfarin

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Hemorrhagic stroke

Patient's with bleeding into (intracerebral hemorrhage) or around the brain (subarachnoid hemorrhage), require neurosurgical evaluation. Neurosurgeons use specialized examinations for hemorrhagic stroke patients, such as the Hunt & Hess scale, that can help determine the appropriate treatment. Strategies to protect the brain during this type of stroke include blood sugar and blood pressure control, adequate oxygen and intravenous fluids, detection and treatment of the cause of bleeding, and constant surveillance (e.g. with the Glasgow Coma Scale) and immediate treatment for complications from bleeding into or around the brain.

Related Topics:
Subarachnoid hemorrhage - Neurosurgical - Blood sugar - Glasgow Coma Scale

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Cerebral arteriography may be used to determine the cause for bleeding, since some causes may be surgically corrected to reduce the risk of future bleeding. Selected patients with subarachnoid hemorrhage due to a ruptured aneurysm require emergency surgery to "clip" the aneurysm off from the normal brain blood circulation, and they receive nimodipine, a drug shown to reduce incidence of vasospasm, a complication of this type of stroke.

Related Topics:
Aneurysm - Nimodipine - Vasospasm

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Care and rehabilitation

Good nursing care is fundamental in maintaining skin care, feeding and hydration and positioning as well as the monitoring of vital signs such as temperature, pulse and blood pressure. Stroke rehabilitation begins almost immediately.

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Stroke rehabilitation is the process by which patients 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 is multidisciplinary in the fact that it involves a team with different skills working together to help the patient. These include nursing staff, physiotherapy, occupational therapy, speech and language therapy and usually a physician trained in rehabiliation medicine. Some teams may also include psychologists and social workers and pharmacists.

Related Topics:
Physiotherapy - Occupational therapy - Speech and language therapy - Physician - Rehabiliation medicine - Psychologists - Social work - Pharmacist

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For most stroke patients, physical therapy is the cornerstone of the rehabilitation process. Another type of therapy involving relearning daily activities is occupational therapy (OT). OT involves exercise and training to help the stroke patient relearn everyday activities sometimes called the Activities of daily living (ADLs) such as eating, drinking and swallowing, dressing, bathing, cooking, reading and writing, and toileting. Speech and language therapy is appropriate for patients with problems understanding speech or written words, or problems forming speech.

Related Topics:
Physical therapy - Occupational therapy - Activities of daily living - Speech and language therapy

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Patients may have particular problems such as an inability to swallow or a swallow that is not safe such that swallowed material may pass into the lungs and cause an aspiration pneumonia. The swallow may improve with time but in the interim a nasogastric tube may be passed which enables liquid food to be given directly into the stomach. If after a week the swallow is still not safe then a PEG tube is passed and this can remain indefinitely.

Related Topics:
Aspiration pneumonia - PEG

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The team have regular meetings at which the patient and family may be present to discuss the current situation and to set goals and to ensure effective communication. In most cases the desired goal is to enable the patient to return home to independent living though this is not always possible.

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Stroke rehabilitation can last anything from a few days up to several months. Most return of function is seen in the first few days and weeks and then falls off. It is unusual that there is complete recovery but not impossible. Most patients will improve to some extent.

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