Stroke

Source: Adapted from Knowing Your Options: The Definitive Guide to Choosing The Medical Treatments, Reader’s

What is a stroke?

A stroke occurs when oxygen-rich blood is suddenly unavailable to your brain. It’s so much like when the heart is deprived of blood during a heart attack, a stroke is often called a ‘brain attack.’ Blockages, usually clots, inside tiny arteries in the brain cause ischemic strokes. A clot that forms in or near the brain in an artery narrowed by the buildup of cholesterol and other fatty substances is known as a cerebral thrombosis. One that forms in another part of the body, travels to the brain, and gets lodged there is known as a cerebral embolism. Ischemic strokes are treated very differently than hemorrhagic strokes, in which a vessel bursts, allowing blood to seep into the brain. While they are often more deadly, hemorrhagic strokes are far less common.

Whatever the cause, when stroke cuts off blood supply, brain cells die. Parts of the body controlled by the affected part of the brain no longer function. This is often temporary, but can be permanent. Common results of a serious stroke include weakness, paralysis, numbness, problems with understanding and speech, and emotional difficulties. Because such damage can cause major disabilities, just getting through the day can become challenging. Strokes tend to affect only one side of the brain. If it’s the side that controls speech, your ability to speak may be imperiled, even though your thoughts and emotions remain intact. If the stroke occurs in the part of your brain that controls movement, muscle activity on the other side of your body may suffer.

Treatment for strokes

Brain cells perish quickly when deprived of oxygen-rich blood. Irreversible damage can occur in as little as 30 minutes, so urgent treatment is essential when you (or someone else) appear to be having a stroke. The most effective treatments need to be started right away, ideally within the first few hours after a stroke. Once you’re at the hospital, doctors will determine if the stroke is ischemic or hemorrhagic and begin the appropriate treatment. A neurological exam, blood tests, CT and MRI scans, Doppler ultrasound, and arteriography can help distinguish one type of stroke from the other. If the stroke is ischemic, you’ll get a drug to dissolve the clot and literally stop the stroke. If it’s hemorrhagic, doctors will first try to lower your blood pressure to minimize bleeding. Then they may perform surgery.

After the stroke, if you’ve had considerable brain damage, you’ll have to stay in an intensive care unit so the functions of your brain, heart, and other organs can be monitored until your condition stabilizes. Life-support machines will supply oxygen, medicines, and nutrition. If your stroke caused relatively little brain damage, you might be able to go home in just a few days. However, you’ll probably need daily rehab therapy in the hospital or a special stroke center. Recouping lost functions is one goal. Preventing a second stroke is another. Initially, the most dramatic improvements will occur after physical, occupational, or speech therapy. Disabilities lingering beyond a few months are harder to fix.

Medications for strokes

If you get to a hospital at the first signs of an ischemic stroke, you may be given powerful clot-busters called thrombolytics‘the only drug therapy approved for an ongoing stroke. Thrombolytics dissolve existing clots, open blocked arteries, and restore blood flow to the brain. The main thrombolytic medication is called tissue plasminogen activator (tPA), though others are used and several are under investigation. If you arrive within three hours of the start of stroke symptoms, you’ll get thrombolytics through a vein. Within six hours, they may be infused directly into a brain artery. In experienced hands, thrombolytics can dramatically reduce risk of permanent disability from a stroke. Thrombolytics affect blood clotting, so they also increase your risk of bleeding’which in itself can be dangerous. The bottom line is that most people get to the hospital too late for thrombolytic therapy. Only 2% of stroke victims ever receive tPA.

If you’re among the majority of stroke patients not receiving thrombolytics, you’ll be started on an antiplatelet drug to prevent another clot from developing. Acetylsalicylic acid (Aspirin) is a top choice. You’re far less likely to die or suffer a disability if you start acetylsalicylic acid (ASA) therapy within 48 hours of an ischemic stroke. ASA affects the blood’s ability to form a clot, and this has two very positive benefits: ASA will make your current stroke less severe and will reduce your chances of developing another. If you’ve had a hemorrhagic stroke, take ASA only on a doctor’s recommendation.

Your doctor may recommend a drug that combines ASA with another antiplatelet agent called dipyridamole. Named Aggrenox, the blend is more effective than ASA alone for preventing a second stroke, especially if you’re at high risk. While relatively safe, it’s more costly than ASA tablets. Also slightly more protective against stroke than ASA tablets alone (and also somewhat costly) are thienopyridine drugs such as Ticlid and Plavix. If you don’t respond to ASA or can’t tolerate it, antiplatelet medications might be recommended. The potent anticlotting drug warfarin (Coumadin) is sometimes prescribed, but bleeding risk is high.

Following a stroke, you may also need other medications to treat various complications. Depression is very common, and antidepressants, such as Prozac, Pamelor, and Elavil, can really be of benefit. They also help ease any crying episodes and increase your mental sharpness. A brain stimulant such as Ritalin may boost speech and motor skills when combined with physical therapy. The muscle relaxant baclofen can help with painful muscle spasms. When speech difficulties occur after a stroke, Parlodel, a drug used for Parkinson’s disease, can enhance the formation of sentences and multisyllable words.

Related Procedures for Strokes

With speedy drug treatment, there’s a good chance that problems such as numbness, weakness, and difficulties with speech, vision, and swallowing will improve on their own over the following weeks. Your powerful brain will also reassign tasks previously performed by non-damaged parts, but months of therapy may await you. Strokes are very individual, affecting different areas of each person’s brain, so what you’ll want from rehabilitation may be very different from someone else’s needs. You may have to learn how to strengthen an arm and hand, while someone else may require speech therapy or help with swallowing. One or more of the following therapies may be right for you:

• Physical therapy (PT). It’s best to start intensive rehabilitation as soon as your blood pressure, pulse, and breathing have stabilized’as early as two days post-stroke, if possible. The aim is to keep your muscles strong and prevent them from stiffening and developing tight contractions. Passive movements initiated by the therapist eventually give way to more active exercises on your part. Moving around may also prevent painful pressure sores.
• Neurodevelopmental treatment (NDT). Rehabilitation methods once taught people to compensate for lost function by working with their unaffected side and adding canes, braces, and walkers for support. Introduced by the British in the 1970s, NDT concentrates on enhancing residual function in nerves and muscles on the stroke-damaged side of the body.
• Constraint-induced movement therapy. Researchers are finding this approach can help retrieve a person’s ability to move a limb, even years after a stroke. In one study, stroke victims with right-side paralysis had their nonparalyzed arm immobilized, forcing them to use the paralyzed one. Most (11 of 13) participants experienced real improvement in their impaired arms, making daily basics such as brushing teeth and combing hair possible again.
• Occupational therapy (OT). During these sessions, the therapist helps you retrain your brain to control certain small muscle groups so you can resume daily basics (swallowing, using the toilet, cooking, writing). This helps not only your motor skills but also your independence and morale.
• Speech therapy. When you’re having trouble forming words and sentences, but the thoughts are right there in your head, dramatic results can be realized with speech therapy. Pantomime, sign language, and pen and paper can also help get your point across.

Once you’ve had a stroke, there’s little a surgeon can do. Brain tissue has died; even if a clot is removed, restored blood flow can’t bring it back to life. There are times when surgery makes sense. If you’ve had a cerebral thrombosis (or a prestroke TIA) caused by an internal carotid artery blockage (responsible for about 9% of strokes), a carotid endarterectomy to clean out this large artery in the neck can reduce risk of a future stroke. It’s commonly done if the artery is more than 70% blocked.

Mixed results have been had with a decades-old procedure called extracranial-intracranial bypass (EC-IC), in which surgeons reroute a healthy scalp artery to an area that was deprived of blood because of an artery blockage. There’s hope that with new imaging techniques and refinements in surgery, this type of bypass will become safer and more effective. Carotid angioplasty, based on the same principles as angiography for heart disease, is being investigated as an EC-IC alternative.

Questions for Your Doctor

• Will I ever be the same person again?
• Is there someone who can help make my home more ‘stroke friendly’ after I get out of the hospital?
• Will I be able to return to work after my stroke?
• Do I have to worry about having another stroke when I have sex?
• After I recover, can I be tested to see if I can drive safely?

After a Stroke

If you’ve suffered from a stroke, here are a few ways you can be proactive and take control of your situation:

• Inspect your local hospital. If you’ve had a stroke, you’re at high risk for another. Familiarize yourself with services nearby. Does your hospital have a 24-hour stroke team? A stroke expert?
• Make your family stroke savvy. Do they know the major signs of stroke and when to call 911? Key alerts: one-sided weakness or numbness, vision loss, sudden balance problems, difficulty speaking or understanding, severe headache.
• Review the rehab team’s resume. You want pros with extensive experience in treating strokes’as well as a hefty dose of patience and perseverance. An inspiring cheerleading squad is key.
• Do a medications check. Certain drugs can interfere with your recovery from a stroke. Take all your medicine bottles to the doctor for review. Common culprits: anticonvulsants, antipsychotics, antianxiety medications, and blood pressure drugs.
• Try biofeedback. Physical therapy combined with biofeedback techniques has helped some stroke sufferers re-orient themselves to body sensations. If you have difficulty swallowing, for example, biofeedback training of key muscles may accelerate your ability to relearn this action. Working with the wrists and fingers shows similar promise.
• Seek support from family, friends, or an outside group. A stroke generates unique stresses, from dependence on others to mood changes. Don’t try to deal with these problems alone.