Stroke, also called brain attack, occurs when blood flow to the brain is disrupted. Disruption in blood flow is caused when either a blood clot blocks one of the vital blood vessels in the brain (ischemic stroke), or when a blood vessel in the brain bursts, spilling blood into surrounding tissues (hemorrhagic stroke).
The brain needs a constant supply of oxygen and nutrients in order to function. Even a brief interruption in blood supply can cause problems. Brain cells begin to die after just a few minutes without blood or oxygen. The area of dead cells in tissues is called an infarct. Due to both the physical and chemical changes that occur in the brain with stroke, damage can continue to occur for several days. This is called a stroke-in-evolution.
A loss of brain function occurs with brain cell death. This may include impaired ability with movement, speech, thinking and memory, bowel and bladder, eating, emotional control, and other vital body functions. Recovery from stroke and the specific ability affected depends on the size and location of the stroke. A small stroke may result in only minor problems such as weakness in an arm or leg. Larger strokes may cause paralysis (inability to move part of the body), loss of speech, or even death.
According to the National Stroke Association (NSA), it is important to learn the three R's of stroke:
- Reduce the risk.
- Recognize the symptoms.
- Respond by calling 911 (or your local ambulance service).
Stroke is an emergency and should be treated as such. The greatest chance for recovery from stroke occurs when emergency treatment is started immediately.
Stroke is the third largest cause of death, ranking behind diseases of the heart and all forms of cancer. Strokes kill more than 160,000 Americans each year. About 5.8 million US adults live today with the effects of a stroke.
Strokes can be classified into two main categories:
- 83 percent are ischemic strokes - strokes caused by blockage of an artery.
- 17 percent are hemorrhagic strokes - strokes caused by bleeding.
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An ischemic stroke occurs when a blood vessel that supplies the brain becomes blocked or "clogged" and impairs blood flow to part of the brain. The brain cells and tissues begin to die within minutes from lack of oxygen and nutrients. The area of tissue death is called an infarct. About 88 percent of strokes fall into this category. Ischemic strokes are further divided into two groups, including the following:
- thrombotic strokes - caused by a blood clot that develops in the blood vessels inside the brain.
- embolic strokes - caused by a blood clot or plaque debris that develops elsewhere in the body and then travels to one of the blood vessels in the brain via the bloodstream.
Thrombotic strokes are strokes caused by a thrombus (blood clot) that develops in the arteries supplying blood to the brain. This type of stroke is usually seen in older persons, especially those with high-cholesterol levels and atherosclerosis (a build-up of fat and lipids inside the walls of blood vessels).
Sometimes, symptoms of a thrombotic stroke can occur suddenly and often during sleep or in the early morning. At other times, it may occur gradually over a period of hours or even days. This is called a stroke-in-evolution.
Thrombotic strokes may be preceded by one or more "mini-strokes," called transient ischemic attacks, or TIAs. TIAs may last from a few minutes to a few days and are often a warning sign that a stroke may occur. Although usually mild and transient, the symptoms caused by a TIA are similar to those caused by a stroke.
Another type of stroke that occurs in the small blood vessels in the brain is called a lacunar infarct. The word lacunar comes from the Latin word meaning "hole" or "cavity." Lacunar infarctions are often found in people who have diabetes or hypertension (high blood pressure).
Embolic strokes are usually caused by an embolus (a blood clot that forms elsewhere in the body and travels through the bloodstream to the brain). Embolic strokes often result from heart disease or heart surgery and occur rapidly and without any warning signs. About 15 percent of embolic strokes occur in people with atrial fibrillation, a type of abnormal heart rhythm in which the upper chambers of the heart do not beat effectively.
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Hemorrhagic strokes occur when a blood vessel that supplies the brain ruptures and bleeds. When an artery bleeds into the brain, brain cells and tissues do not receive oxygen and nutrients. In addition, pressure builds up in surrounding tissues and irritation and swelling occur. About 17 percent of strokes are caused by hemorrhage. Hemorrhagic strokes are divided into two main categories, including the following:
- intracerebral hemorrhage - bleeding from the blood vessels within the brain.
- subarachnoid hemorrhage - bleeding in the subarachnoid space (the space between the brain and the membranes that cover the brain).
Intracerebral hemorrhage is usually caused by hypertension (high blood pressure), and bleeding occurs suddenly and rapidly. There are usually no warning signs and bleeding can be severe enough to cause coma or death.
Subarachnoid hemorrhage results when bleeding occurs between the brain and the meninges (the membrane that covers the brain) in the subarachnoid space. This type of hemorrhage is often due to an aneurysm or an arteriovenous malformation (AVM).
- An aneurysm is a weakened, ballooned area on an artery wall and has a risk for rupturing. Aneurysms may be congenital (present at birth), or may develop later in life due to such factors as hypertension or atherosclerosis.
- An AVM is a congenital disorder that consists of a disorderly tangled web of arteries and veins. The cause of AVM is unknown.
The following are the most common symptoms of stroke. However, each individual may experience symptoms differently. If any of these symptoms are present, call 911 (or your local ambulance service) immediately. Treatment is most effective when started immediately.
Symptoms may be sudden and include:
All of the above warning signs may not occur with each stroke. Do not ignore any of the warning signs, even if they go away - take action immediately. The symptoms of stroke may resemble other medical conditions or problems. Always consult your physician for a diagnosis.
- weakness or numbness of the face, arm, or leg, especially on one side of the body
- confusion or difficulty speaking or understanding
- problems with vision such as dimness or loss of vision in one or both eyes
- dizziness or problems with balance or coordination
- problems with movement or walking
- severe headaches with no other known cause
Other, less common, symptoms of stroke may include the following:
- sudden nausea, vomiting, or fever not caused by a viral illness
- brief loss or change of consciousness such as fainting, confusion, seizures, or coma
- transient ischemic attack (TIA), or "mini-stroke"
A TIA can cause many of the same symptoms as a stroke, but TIA symptoms are transient and last for a few minutes or up to 24 hours. Call for medical help immediately if you suspect a person is having a TIA, as it may be a warning sign that a stroke is about to occur. Not all strokes, however, are preceded by TIAs.
Rehabilitation of the patient with a stroke begins during the acute treatment phase. As the patient's condition improves, a more extensive rehabilitation program is often begun.
The outlook for stroke patients today is more hopeful than ever due to advances in both stroke treatment and rehabilitation. Stroke rehabilitation works best when the patient, family, and rehabilitation staff works together as a team. Family members must learn about impairments and disabilities caused by the stroke and how to help the patient achieve optimal function again.
The goal of stroke rehabilitation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally, and socially. Rehabilitation is designed to meet each person's specific needs; therefore, each program is different. Some general treatment components for stroke rehabilitation programs include the following:
- treating the basic disease and preventing complications
- treating the disability and improving function
- providing adaptive tools and altering the environment
- teaching the patient and family and helping them adapt to lifestyle changes
It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence. The success of stroke rehabilitation depends on many variables, including the following:
- cause, location, and severity of stroke
- type and degree of any impairments and disabilities from the stroke
- overall health of the patient
- family support
Areas covered in stroke rehabilitation programs may include:
Self-care skills, including activities of daily living (ADLs)
Feeding, grooming, bathing, dressing, toileting, and sexual functioning
Walking, transfers, and self-propelling a wheelchair
Speech, writing, and alternative methods of communication
Memory, concentration, judgment, problem solving, and organizational skills
Interacting with others at home and within the community
Medications and alternative methods of managing pain
Identifying problems and solutions with thinking, behavioral, and emotional issues
Assistance with adapting to lifestyle changes, financial concerns, and discharge planning
Patient and family education and training about stroke, medical care, and adaptive techniques
The stroke rehabilitation team revolves around the patient and family and helps set short- and long-term treatment goals for recovery. Many skilled professionals are part of the pulmonary rehabilitation team, including any/all of the following:
- critical care nurse
- rehabilitation nurse
- physical therapist
- occupational therapist
- speech/language pathologist
- social worker
- case manager
- recreation therapist
- vocational counselor
There are a variety of stroke treatment programs, including the following:
- acute rehabilitation programs
- subacute rehabilitation programs
- long-term care rehabilitation programs
- home health rehabilitation programs
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