Stroke
A stroke is a condition when there is insufficient blood supply to the brain, which results in cell death. Strokes can be ischemic or hemorrhagic, which refers to a lack of blood flow or bleeding, respectively. Both freeze certain brain functions in their tracks.
The inability to move or feel on one side of the body, difficulties comprehending or speaking, dizziness, or loss of vision to one side are all potential signs and symptoms of a stroke.
After a stroke, symptoms and signs frequently start to show very quickly. Transient ischemic attack (TIA), often known as a mini-stroke, is the type of stroke that occurs when symptoms last less than one or two hours. A strong headache might potentially be a symptom of a hemorrhagic stroke. A stroke may leave behind lasting symptoms. Pneumonia and a lack of bladder control are examples of long-term consequences.
High blood pressure is by far the major risk factor for stroke. Other risk factors include atrial fibrillation, high blood pressure, smoking, obesity, diabetes, a prior TIA, and end-stage renal disease. Although there are other, less frequent causes of ischemic strokes, blood vessel obstruction is frequently the culprit. Either bleeding into the brain itself or into the space between the membranes of the brain might result in a hemorrhagic stroke.
An aneurysm in the brain that has ruptured may cause bleeding. A physical examination is often used to make a diagnosis, which is then confirmed by imaging tests like a CT or MRI. Although ischemia, which early on often does not show up on a CT scan, can be ruled out by a CT scan, bleeding can still be ruled out by the scan. To identify risk factors and rule out other potential causes, further procedures such as blood tests and electrocardiograms (ECGs) are performed. The symptoms of low blood sugar may be similar.
Reduced risk factors, surgery to widen the brain arteries in individuals with significant carotid stenosis, and warfarin for those with atrial fibrillation are all methods of prevention. Doctors could advise statins or aspirin for prophylaxis.
TIAs and strokes frequently necessitate emergency care. If an ischemic stroke is identified in the first three to four and a half hours, it could be treated with a drug that dissolves the clot. Surgery is beneficial in some hemorrhagic stroke cases. Stroke rehabilitation is a type of treatment used to try to regain lost function; it is preferable to get this kind of care in a stroke unit, but these facilities are rare in many parts of the globe.
A total of 6.9 million ischemic strokes and 3.4 million hemorrhagic strokes were reported in 2013 respectively. About 42.4 million persons who had previously experienced a stroke and were still living in 2015 were estimated to be. The number of strokes that occurred annually between 1990 and 2010 fell by around 10% in the developed world and grew by 10% in the developing world.
With 6.3 million fatalities (11%) in 2015, stroke was the second most common cause of death after coronary heart disease. Hemorrhagic stroke caused 3.3 million fatalities, whereas ischemic stroke caused about 3.0 million deaths. The average lifespan of someone who has had a stroke is less than a year. Two-thirds of strokes, on average, happened to people over 65.
Stroke Classification.
Ischemic and hemorrhagic strokes fall into two main groups. Hemorrhagic strokes are brought on by the rupture of a blood artery or an aberrant vascular structure, whereas ischemic strokes are brought on by the cessation of the blood supply to the brain. Strokes are mostly ischemic (around 87%) and hemorrhagic (the remaining 3%). Hemorrhagic transformation, or bleeding inside ischemic regions, is a medical term for this phenomenon. How often hemorrhagic strokes actually begin as ischemic strokes is uncertain.
Stroke History
From the second millennium BC forward, there have been reports of stroke episodes and family strokes in ancient Mesopotamia and Persia. The first person to describe the abrupt paralysis that is frequently linked to ischemia was Hippocrates (460–370 BC). Hippocratic literature is where the term "apoplexy," which means "struck down with violence," originally arose to describe this condition.
The word stroke is a reasonably precise translation of the Greek phrase and was first used as a synonym for an apoplectic seizure in 1599. An old-fashioned, general word for a cerebrovascular accident followed by bleeding or a hemorrhagic stroke is "apoplectic stroke." Shortly before his death in 1546, Martin Luther is said to have suffered an apoplectic stroke that left him unable to speak.
When Johann Jacob Wepfer (1620-1695) proposed that patients who had died of apoplexy had bleeding in their brains, he identified the etiology of hemorrhagic stroke in his 1658 book Apoplexia. When Wepfer proposed that apoplexy may be brought on by a blockage to those blood vessels, he also identified the primary arteries supplying the brain, the vertebral and carotid arteries, as well as the origin of a form of ischemic stroke known as cerebral infarction. It was Rudolf Virchow who initially identified thromboembolism as a significant issue.
As a result of "growing awareness and acceptance of vascular theories and recognition of the consequences of a sudden disruption in the vascular supply of the brain," the phrase "cerebrovascular accident" was first used in 1927. Numerous neurology textbooks now oppose its usage on the grounds that the word accident's connotation of fortuitousness fails to emphasize the modifiability of the underlying risk factors. The terms "cerebrovascular insult" are interchangeable.
According to the American Stroke Association, which has been using the word since 1990 and uses it colloquially to refer to both ischemic and hemorrhagic stroke, the term "brain attack" was created to emphasize the sudden character of stroke.
Early identification
Different systems have been suggested to improve stroke identification. To varying degrees, many results can indicate whether a stroke would occur or not. The signs that are most likely to correctly identify a stroke case are sudden-onset face weakness, arm drift (when asked to raise both arms, a person involuntarily lets one arm drift downward), and abnormal speech. The likelihood that at least one of these signs is present increases by 5.5. Similarly, the risk of stroke is reduced (- likelihood ratio of 0.39), when all three of them are missing. Even though these results are not ideal for stroke diagnosis, they are particularly useful in the acute environment due to how quickly and readily they can be assessed.
As recommended by the Department of Health (United Kingdom), the Stroke Association, the American Stroke Association, the National Stroke Association (US), the Los Angeles Prehospital Stroke Screen (LAPSS), and the Cincinnati Prehospital Stroke Scale (CPSS), a mnemonic to remember the warning signs of stroke is FAST (facial droop, arm weakness, speech difficulty, and time to call emergency services). Professional recommendations advise using these scales. When it comes to diagnosing posterior circulation strokes, FAST is less accurate.
Early stroke diagnosis is considered crucial for patients who are sent to the emergency room since it can speed up diagnostic procedures and therapies. For this, a score system called ROSIER (recognition of stroke in the emergency department) is advised; it is based on characteristics from the physical examination and medical history.
Diagnosis
A neurological examination (such as the NIHSS), CT scans (often without contrast enhancements), MRI scans, Doppler ultrasonography, and arteriography are some of the methods used to diagnose stroke. Imaging methods are used to aid in the clinical diagnosis of stroke. Finding the subtypes and causes of stroke is also aided by imaging methods. Although blood tests may be useful in determining the likely etiology of a stroke, there is currently no widely accepted blood test for the diagnosis of stroke itself. An autopsy of a stroke in a deceased person may be able to determine how long after the stroke the person died.
Symptoms
The following symptoms might occur if one of the three major routes of the central nervous system—the dorsal column-medial lemniscus pathway, the corticospinal tract, or the spinothalamic tract—is involved in the damaged part of the brain:
hemiplegia and facial numbness due to muscular weakness
diminished sensory or vibratory perception
Initially decreased muscular tone and flaccidity, followed by spasticity, excessive reflexes, and necessary synergy.
The symptoms are often unilateral, meaning they only affect one side of the body. The abnormality in the brain is often on the opposite side of the body, depending on the area of the brain that is afflicted. The existence of any one of these symptoms, however, does not always signify a stroke because these pathways also go through the spinal cord, and any damage there can also result in these symptoms.
The majority of the twelve cranial nerves, in addition to the CNS channels mentioned above, are derived from the brainstem. As a result, a brainstem stroke that affects both the brain and the brainstem may result in the following symptoms:
changed (totally or partially) senses of smell, taste, hearing, or vision
weakening of the ocular muscles and ptosis of the eyelid
diminished gag, swallow, and light sensitivity responses
reduced feeling and facial muscle weakness
issues with balance and nystagmus
changed heart and breathing rates
inability to move the head to one side due to sternocleidomastoid muscle weakening
tongue weakness (inability to extend or move the tongue from side to side)
The CNS pathways may once again be disrupted if the cerebral cortex is damaged, and the following symptoms may again appear:
Aphasia (difficulty speaking, understanding speech, reading, and writing; usually affects Wernicke's or Broca's region)
Dysarthria (a neurologically induced motor speech problem)
a visual field issue
Memory problems (temporal lobe involvement)
(Parietal lobe involvement) Hemineglect
Thinking erratically, being confused, and making hypersexual gestures (frontal lobe involvement)
lack of understanding of their impairment, which is often caused by a stroke
Ataxia may be present if the cerebellum is affected, and this includes
changed walking style
disturbed coordination of movement, vertigo, and/or disarray
risk elements
High blood pressure and atrial fibrillation are the two most significant modifiable risk factors for stroke, albeit their combined effect is minimal and would require the treatment of 833 people for a full year to avert just one stroke. Other risk factors that can be changed include high blood cholesterol, diabetes mellitus, end-stage renal disease, cigarette smoking (both active and passive), heavy alcohol and drug use, inactivity, obesity, intake of processed red meat, and poor nutrition.
Even one cigarette smoked each day more than triples the risk. Alcohol consumption may increase the risk of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage through a variety of processes, including hypertension, atrial fibrillation, rebound thrombocytosis and platelet aggregation, and coagulation issues. Drugs, most frequently cocaine and amphetamines, can cause stroke by rupturing the blood arteries in the brain and causing severe hypertension. An aura-accompanied migraine increases the risk of an ischemic stroke. Whether or not there are symptoms, untreated celiac disease has been linked to stroke in both children and adults.
A high degree of physical exercise around 26% lowers the risk of stroke. Studies that examine advertising campaigns intended to change lifestyle characteristics are often of low quality. Nevertheless, given the substantial amount of circumstantial data, recommendations on food, exercise, smoking, and alcohol use constitute the best medical care for stroke. The most popular means of avoiding strokes is medication, while carotid endarterectomy is a surgical procedure that can be effective.
the heart rate
Stroke risk is attributed to high blood pressure in 35–50% of cases. A 10% systolic or 5% diastolic blood pressure drop lowers the risk of stroke by around 40%. It has been clearly demonstrated that lowering blood pressure prevents both ischemic and hemorrhagic strokes. In secondary prevention, it is as crucial. Antihypertensive medication has positive effects on persons of all ages, including those over 80 and those with isolated systolic hypertension. Since there aren't many differences between antihypertensive medications in terms of preventing strokes, other aspects like cost and protection from other types of cardiovascular disease should be taken into account. There is no evidence to support the advantages of routinely taking beta-blockers after a stroke or transient ischemic attack.
Plasma lipids
Uncertain correlations exist between high cholesterol levels and (ischemic) stroke. It has been demonstrated that statins can cut the risk of stroke by 15%. Statins could exert their benefits via mechanisms other than their lipid-lowering properties, as past meta-analyses of other lipid-lowering medications failed to demonstrate a lowered risk.
sweet diabetes
Diabetes mellitus doubles to triple the risk of stroke. Stroke has not been proven to be reduced by strict blood sugar management, despite the fact that it has been shown to lessen minor blood vessel problems such as kidney damage and damage to the retina of the eye.
Stroke Management
Surgery
The carotid artery's atherosclerotic narrowing can be treated via carotid endarterectomy or carotid angioplasty. In certain circumstances, there is evidence to support this practice. It has been demonstrated that endarterectomy for severe stenosis can help those who have already experienced a stroke from having another one. The effectiveness of carotid artery stenting has not been established. Age, gender, degree of stenosis, length of time since symptoms began, and personal preferences all play a role in who has surgery.
Surgery is most effective when not postponed for too long; endarterectomy lowers the risk of recurrent stroke to around 5% in patients with 50% or higher stenosis after 5 years. Five operations were required for early surgery (within two weeks of the first stroke), but 125 if the treatment was postponed for more than 12 weeks.
The general population has not been demonstrated to benefit from screening for carotid artery narrowing. Studies on surgical treatment for asymptomatic carotid artery stenosis have only marginally reduced the incidence of stroke. The surgery's complication rate has to be less than 4% to be effective. Even yet, for every 100 operations, 5 people will gain by avoiding stroke, 3 will still have a stroke despite the procedure, 3 will have a stroke or pass away because of the procedure, and 89 will avoid stroke but would have done so even without the procedure.
vascular endoscopy
A possible therapy for the obstruction of a big artery, such as the middle cerebral artery, is mechanical thrombectomy, which involves physically removing the blood clot that is the cause of the ischemic stroke. One study from 2015 showed that this operation is safe and effective if carried out within 12 hours of the beginning of symptoms. Compared to the use of intravenous thrombolysis, which is often used in patients who are being assessed for mechanical thrombectomy, it decreased disability without changing the risk of mortality. Up to 24 hours following the beginning of symptoms, thrombectomy may be beneficial in some circumstances.
Craniectomy
Large-scale brain injuries from strokes can result in severe brain edema and consequent brain damage to the surrounding tissue. This event, which mostly affects brain tissue that depends on the middle cerebral artery for blood flow and is known as "malignant cerebral infarction" because it has a poor prognosis, is seen in strokes that harm brain tissue. It is possible to try to relieve the pressure with medicine, but for certain people, hemicraniectomy—a temporary surgical removal of the skull on one side of the head—is necessary. Despite the fact that some people who would have otherwise died live with disabilities, the chance of mortality is reduced as a result.
Rehabilitation
Stroke rehabilitation is the process through which people who have had incapacitating strokes receive therapy to enable them to lead as normal a life as possible by recovering and relearning daily living skills. Additionally, it seeks to avoid further issues, educate family members so they may provide support, and assist the survivor in understanding and adjusting to challenges.
Social workers and psychologists may also be part of certain teams because at least one-third of those afflicted exhibit post-stroke depression. When determining whether a stroke victim can manage at home on their own or with assistance after being released from the hospital, validated tools like the Barthel scale may be employed.
Rehabilitation after a stroke should begin as soon as feasible and might run for a few days to more than a year. However, other individuals claim that their condition improves with time, allowing them to regain and hone skills like writing, walking, running, and conversing.[Required medical citation] People who have suffered a stroke should continue to include regular rehabilitative activities in their daily routine. Although a full recovery is uncommon, it is not impossible, and the majority of individuals will see some improvement. A healthy diet and regular exercise are thought to aid in brain rehabilitation.
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