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STROKE
Stroke, also known as cerebrovascular accident (CVA), involves damage to the brain because of impaired blood supply and causes a sudden, no convulsive malfunction of the brain. In the United States, stroke is the third-ranking cause of death after heart disease and cancer, and about one-fourth of the neurologic patients in nursing homes are stroke victims. The death rate, however, has declined by nearly 50 percent since the late 160s; in the early 10s about 150,000 Americans of the 450,000 each year who suffered a new stroke died as a result. Among the reasons for the decline are earlier detection and treatment of hypertension, better diets (less meat and dairy products and more vitamins), and more exercise.
Stroke victims are generally elderly people with degeneration of blood vessels, but children and young adults also can have a stroke. Some stroke risk factors cannot be changed, such as increasing age, gender (more men have strokes), race (more African-Americans have strokes), prior stroke, and family history of stroke. Other risk factors can be controlled, including hypertension, heart disease, diabetes mellitus, diseases affecting blood vessels, sickle-cell disease, cigarette smoking, alcohol consumption greater than ounces per day, drug abuse, high cholesterol, high red blood cell count, migraine headaches, and transient ischemic attacks (TIAs), or little strokes. Women using oral contraceptives are also at greater risk.
SYMPTOMS
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A stroke may be mildly incapacitating, massive with sudden death, or may involve a sudden coma, followed by headache, nausea, confusion, and stupor. The symptoms of a stroke are sudden weakness or numbness of the face or limbs on one side of the body (hemiplegia); loss of speech or comprehension; dimness or loss of vision, particularly in one eye; and unexplained dizziness, unsteadiness, or sudden falls. Some strokes are preceded by TIAs, with similar effects that may last anywhere from one minute to several hours. Initially, the paralysed muscles of a stroke victim are soft because of central nervous system shock, but spasticity occurs as spinal motor neurons resume function, tightening muscles and causing the limbs to contract.
TYPES OF STROKES
Ischemia
A stroke can be caused by ischemia, which is a narrowing or blockage of an artery by means of atherosclerosis or by an embolus. About 65 percent of strokes are ischemic. Atherosclerosis, or progressive hardening of the arteries, produces ischemia by obstruction of vessels with fat derivatives. Most frequently, cholesterol forms plaques that build up on arterial walls, reducing the passage of blood. A common aging process, atherosclerosis especially afflicts the elderly or people with high cholesterol intake.
Another form of ischemia is thrombosis, or blockage resulting from an embolus. An embolus produced by the carotid artery in the neck, which supplies blood from the heart to the brain, claims about one-third of stroke patients. A clot, or thrombus, can form in this artery and fragment, producing a thromboembolus, which travels to the brain and becomes entrapped in a cerebral artery.
Haemorrhage
About 0 percent of all strokes are caused by cerebral haemorrhage. Causes of spontaneous intracranial haemorrhage are hypertension (10 percent to 15 percent of all cases), aneurysm (5 percent to 7 percent), bleeding into a tumour ( percent to 5 percent), and a generalized bleeding tendency (1 percent to percent). Hypertensive haemorrhages occur in the brain stem or the lateral portion of the cerebral hemisphere near the pathway for motor nerves; if the haemorrhage extends into the motor tract, hemiplegia will result. A massive haemorrhage, however, can result in coma, brain damage, and possibly death. Alcoholics, who bleed more easily, are more likely to have this type of stroke.
Aneurysms--enlargements of small portions of blood vessels--can haemorrhage and cause stroke if present in the brain or arteries of the neck. Rupture of an aneurysm can cause massive bleeding on the surface of the brain and may be fatal. After an aneurysm ruptures, red blood cells degenerate and release products that promote vascular spasm. An aneurysm is usually treated surgically after a two-week waiting period, which allows oedema and vasospasm to subside. Often, however, bleeding begins again and is frequently fatal.
Tumours must have an adequate blood supply to maintain their growth; therefore some tumours secrete an angiogenesis factor that promotes blood-vessel growth. At times a tumour may produce too much of this factor, causing the vessels to enlarge. This enlargement can result in internal haemorrhage and sudden stroke. The stroke, unfortunately, may mask the existence of a tumour and delay a complete diagnosis.
DIAGNOSIS
The most important information is history from the patient or a witness. A neurological examination shows what parts are not functioning properly, which can point to the probable damaged location in the brain, and often the probable cause. Diagnostic techniques for stroke include injecting radiopaque dyes into vessels of the neck and head (arteriogram), using brain scans for defects in the blood/brain barrier, conducting a magnetic resonance scan, and performing computerized tomography (see CAT scan) with image enlargement to search for altered density within the brain. Lumbar puncture (spinal tap) is usually not necessary and may do more damage in some types of strokes.
TREATMENT
The medical team involved in caring for stroke victims includes an internist, a neurosurgeon, a neurologist, a stroke nurse, a physical therapist, an occupational therapist, and a speech therapist. These people also help educate the patients family in long-term care as well as alerting them to problems that may be encountered during rehabilitation.
The type of treatment depends on the type of stroke. For example, a patient with a stroke caused by hypertension needs to have his or her blood pressure reduced significantly. Physiotherapy is an important part of medical treatment for stroke patients, to rehabilitate the damaged functions and preserve the motor abilities of contracted limbs. Speech and occupational therapists can help in the recovery of motor functions. Medical complications are also treated, with an emphasis on preventing a recurrence.
Debility is often severe, and depression may occur. Stroke support groups are an important resource for helping the stroke patient learn ways of coping with disability. Research is focusing on ways to limit brain damage, such as by using drugs to dissolve blood clots in ischemic strokes, and to prevent the death of brain cells.
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