Everything you need to know about stroke.

Let’s jump right into the middle of the topic, that is the most important: the survival of stroke patients largely depends on how quickly they receive medical care. Everyone should know at what symptoms to call an ambulance immediately.

Stroke is the second most common cause of death and the third most common cause of disability. The 350 million inhabitants of the Eastern European states, i.e. the former socialist bloc, are particularly at risk, since the risk factors of the disease – high blood pressure, smoking and obesity – are much more present in this population than in western states. According to estimates, this region currently per million inhabitants approx. 4-5 thousand patients are hospitalized due to stroke. Throughout history, such well-known people as Lenin, Ramses the II., Handel, Stalin, Goya, Dickens, Pasteur, Churchill, Berlioz, Voltaire and Fellini.

Calamity, of the worst kind

Stroke was already known to the ancient Greeks: it was considered an unexpected, uncontrollable event. That is why Hippocrates gave the disease the name „plesso”, which means: struck by lightning. The current name of the disease dates back to the 16th. century, when a stroke was considered as a stroke of God. Today, this is how we collectively call cerebrovascular accidents in the brain, i.e. the dysfunction resulting from a disruption of the blood supply to the brain. In 80-85 percent of stroke cases, blood flow to a part of the brain is reduced due to blood vessel blockage, as a result of which a certain area of ​​the brain dies.

A stroke – according to the current definition – is a rapidly developing set of clinical symptoms characterized by a global or focal (focal) disorder caused by a blood supply disorder in the brain, which can last for more than 24 hours and means a disfunction in the cerebral vascular system. If the neurological symptoms disappear within 24 hours, we are talking about a temporary cerebrovascular accident (transient ischemic attack, TIA).

At the beginning of the 21st century, approx. 1.1 million Europeans suffered a stroke, an ischemic stroke approx. in 80% of cases. Although the incidence of stroke is decreasing globally, the rates are increasing in young adults, so it is necessary to develop prevention strategies.

The importance of stroke in terms of public health is also very high in Hungary: 40-50 thousand stroke cases occur every year, compared to 16 thousand heart attacks. 70-80 percent of those who have had a heart attack have a chance to lead a normal life. This number in case of stroke is 10%, which is a serious value, so we have to take it seriously. This is why the profession believes that it is easier to prevent a stroke than to survive. That is why stroke prevention is of great importance, the cornerstones of which are:

• regular exercise,
• avoid smoking,
• effective treatment of hypertension
• proper treatment of cardiac arrhythmias.

Causes 

As with ischemic heart disease, stroke is caused by atherosclerosis. Plaques deposited in the carotid artery, which supplies large areas of the brain with blood, obstruct the path of blood flow, and a blood clot breaking off from the vessel wall can even block blood flow completely. A stroke can also occur when blood clots formed in the heart or on the heart valves break off and get blocked when they reach the brain vessels with the blood. This process mainly occurs in patients who have undergone heart surgery or have a heart rhythm disorder – atrial fibrillation. Infarction in the brain and the heart are therefore related diseases that belong to one „family” and arise from a common root, the atherosclerosis. Although stroke begins suddenly and unexpectedly and develops rapidly, its development is the result of many decades of pathological changes. There are more than two hundred risk factors behind an ischemic stroke (caused by blockage of a cerebral artery), the most important of which are high blood pressure, high cholesterol due to a disorder of fat metabolism, diabetes, obesity and smoking. The more risk factors accumulate, the greater the likelihood of a stroke.

Time = brain tissue

How can you tell if someone has a stroke? Before the appearance of a stroke, patients often notice a temporary speech or vision disorder, limb numbness, which disappears after a few minutes. This temporary circulatory disturbance – in medical language: transient ischemic attack (TIA) – is the „hallway” of a stroke. If patients with these complaints were to consult a doctor immediately, strokes could be prevented with appropriate intervention – for example, surgical dilation of carotid artery stenosis or treatment of heart rhythm disorders. Unfortunately, in most cases, patients do not take these threatening symptoms seriously enough, and because of this, they fall victim to a stroke soon after.

The symptoms of cerebrovascular accident are quite telling. Weakness or paralysis on one side of the limb, temporary loss of vision in one eye, double vision, visual field-loss, speech comprehension disorders, difficulty forming words, confusion, dizziness, headache, or sudden loss of consciousness can all raise the suspicion of a stroke. If a member of our family or someone in our environment smiles strangely – half-heartedly -, finds it difficult to repeat even a simple sentence, or is unable to raise both arms, then the ambulance should be called immediately.

In the case of a stroke, we have to run a race against time, because in a single hour of an untreated stroke, the brain ages three and a half years, 2 million nerve cells die every minute, and approx. 700 kilometres of neural pathways are destroyed. The acute stroke patient should therefore immediately be taken to the hospital – preferably to a so-called a “stroke centre” because, according to international studies, only three hours are available from the first symptoms to dissolve the blood clot. The emphasis is on speed, because any and all intervention can be effective only within this timeframe and can significantly reduce mortality, the severity and number of residual conditions. Every minute counts, because – as they say in medical circles – time equals brain tissue. Therefore, it is extremely important for the patient to be admitted to the nearest stroke centre as quickly as possible after the onset of symptoms, regardless where the patient is in the country.

What happens at the hospital?

In the optimal case, the ambulance takes the stroke patient directly to the stroke centre, because the treatment of acute ischemic stroke is most effective in well-organized stroke wards. At these care facilities, it is possible to minimize the time between the patient’s arrival at the hospital and the start of treatment, which is crucial for special treatment that requires a narrow time window.

During the diagnosis, following the physical examination of the patient, various imaging procedures (ultrasound, CT, MRI) are used to determine the exact location, extent, and type of brain damage, and to isolate the ischemic (caused by cerebral blockage) or haemorrhagic origin of the stroke. In the acute phase, the patient’s nervous system status, blood pressure, heart rate, breathing, fluid and electrolyte balance, blood sugar level, body temperature and other important physiological characteristics are continuously monitored.

Paralysis and other damage caused by stroke can now be optimally prevented or reversed with infusion of blood clotting treatment. We have to mention the so-called mechanical thrombus extraction. The essence of this „high-tech” procedure is to remove the blood clot blocking the vein through a catheter inserted into the brain through the carotid artery.

Life after stroke

After the acute, first stage of the disease and the stabilization of the patient’s condition, the intensive rehabilitation begins immediately. The goal is to achieve a self-sufficient lifestyle, the ability to speak, to move independently, thus the best possible quality of life and to return the patient in the family and the society. This is a very difficult task, as it is a multifaceted activity that requires the creation of a rehabilitation team consisting of physiotherapists, physical therapists, speech therapists, psychologists and other qualified health professionals.

In the early period after the first stroke, the probability of another stroke is very high. Therefore, one of the cornerstones of stroke care is the prevention of recurrent cardiovascular events and other complications. In order to do this, the stroke patient must undergo regular medical check-ups and take certain medications, such as blood pressure and cholesterol-lowering drugs, anti-platelet and anti-coagulant drugs. In addition, the patient must give up his previous harmful habits, most importantly smoking and excessive alcohol consumption. Unfortunately, 22 percent of men and 25 percent of women who have had a stroke die within a year.

Source:

(1) Johnson W, Onuma O, Owolabi M, Sachdev S. Stroke: a global response is needed. Bull World Health Organ. 2016;94(9):634-634A. doi:10.2471/BLT.16.181636.

(2) Dr. Csiba László: A stroke ellátás sikerei és gondjai, avagy merre tart a stroke? IME IX. évf. 8. szám. 2010. okt.

(3) Tsoucalas G, Papaioannou TG, Karamanou M. The Hippocratic Doctrine of „the Acute Brain Suffering” as the Brain Stroke. J Stroke Cerebrovasc Dis. 2019;28(2):412-417. doi:10.1016/j.jstrokecerebrovasdis.2018.10.017.

(4) Knight-Greenfield A, Nario JJQ, Gupta A. Causes of Acute Stroke: A Patterned Approach. Radiol Clin North Am. 2019;57(6):1093-1108. doi:10.1016/j.rcl.2019.07.007.

(5) Abbott AL, Silvestrini M, Topakian R, et al. Optimizing the Definitions of Stroke, Transient Ischemic Attack, and Infarction for Research and Application in Clinical Practice. Front Neurol. 2017;8:537. Published 2017 Oct 18. doi:10.3389/fneur.2017.00537.

(6) Béjot Y, Bailly H, Durier J, Giroud M. Epidemiology of stroke in Europe and trends for the 21st century. Presse Med. 2016;45(12 Pt 2):e391-e398. doi:10.1016/j.lpm.2016.10.003.

(7) Grysiewicz RA, Thomas K, Pandey DK. Epidemiology of ischemic and hemorrhagic stroke: incidence, prevalence, mortality, and risk factors. Neurol Clin. 2008;26(4):871-vii. doi:10.1016/j.ncl.2008.07.003.

(8) Yew KS, Cheng EM. Diagnosis of acute stroke. Am Fam Physician. 2015;91(8):528-536.

(9) Saver JL. Time is brain–quantified. Stroke. 2006;37(1):263-266. doi:10.1161/01.STR.0000196957.55928.ab.

(10) Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2018 Mar;49(3):e138] [published correction appears in Stroke. 2018 Apr 18;:]. Stroke. 2018;49(3):e46-e110. doi:10.1161/STR.0000000000000158.

 (11) Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2017 Feb;48(2):e78] [published correction appears in Stroke. 2017 Dec;48(12 ):e369]. Stroke. 2016;47(6):e98-e169. doi:10.1161/STR.0000000000000098.