Stroke

Stroke
Read more at Virtual Medical Centre

Stroke is a medical emergency. If you or someone near you is having, or may be having, a stroke or transient ischaemic attack (TIA) you should go to hospital immediately. Here you will find information on how to tell if you are having a stroke, stroke prevention, children and stroke. What is a Stroke? Does Stroke Affect Many Australians? Stroke Risk Self Assessment Chart Am I Having a Stroke? What are the Effects of Stroke? Treatment of Stroke Recovery from Stroke Life After Stroke How Can I Avoid Another Stroke? One Mans Stroke Story Latest Australian research papers on Stroke.

What is a Stroke?

Two major types of stroke - ischaemic and haemorrhagic

A stroke occurs when a blood clot blocks a blood vessel or artery, or when a blood vessel breaks and interrupts blood flow to an and bleeding occurs into an area of the brain.

Every stroke is different. The symptoms and effects vary according to the type of stroke, the part of the brain affected and the size of the damaged area. For some people the effects are severe, for some mild. Usually the symptoms come on suddenly but they may come on during sleep. Usually injury to one side of the brain affects the opposite side of the body.

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There are two major types of stroke: - An Ischaemic Stroke occurs when an artery carrying blood to part of the brain is blocked. The brain needs the constant supply of oxygen and glucose that the blood brings. If this blood supply is blocked for more than a few minutes then that part of the brain stops working properly and brain tissue at the centre of the area affected begins to die. If the blockage is not cleared within a few hours then that all the part of the brain supplied by the blocked vessel may die; that is, it permanently ceases to work properly. This is called brain infarction. Ischaemic strokes are the most common type of stroke, occurring more than five times as often as haemorrhagic stroke cerebral haemorrhages. - A Haemorrhagic Stroke Cerebral Haemorrhage occurs when a blood vessel ruptures within the brain (called an intracerebral haemorrhage) or into the space surrounding the brain (called a subarachnoid haemorrhage). Blood in the artery is under pressure and so, as it spurts out, it tears some of the soft brain tissue and forms a large clot (or haematoma) that squashes the surrounding brain. Brain tissue on the rim of thein and around the clot may therefore die.

A mini stroke is called a Transient Ischaemic Attack (TIA). - About 30% of patients who subsequently have an ischaemic stroke have a small warning episode termed a transient ischaemic attack. - A TIA is like an ischaemic stroke in that it is results in the sudden loss of function of a particular part of the body because of a sudden lack of blood flow to a part of the brain. - The difference between a TIA and an ischaemic stroke is that in a TIA the symptoms disappear completely within 24 hours. In 75% of cases the symptoms clear within one hour, often within only a few minutes, because the blockage in the artery clears itself very quickly before the affected brain tissue has died. 30% of people have damage evident on sensitive brain imaging techniques such as MRI after a TIA. - A TIA is a very important warning that the person is at increased risk of a future stroke. It is essential that proper medical treatment is sought so that this risk can be significantly reduced.

Does Stroke Affect Many Australians?

Stroke is the third most common cause of death in Australia

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About 40,000 Australians have strokes annually, 73% of these being first-ever strokes.

Of 100 stroke patients: - about 30 die in the first year after their stroke, most (15-20) within the first 30 days - about 70 survive* of whom - 35 remain permanently disabled at 1 year after a stroke, 10 of whom require care in a nursing home or other long term facility - 35 are not disabled to the point of affecting their independence in activities of daily living 10 will have recovered completely and 25 with non-disabling impairments.

*85% with ischaemic stroke survive, 50% with haemorrhagic

A GP with a list of 200 patients will: - see at least one new acute stroke patient every three months - be caring for at least 16 survivors of stroke.

Of all the neurological disorders stroke is the largest single cause of adult disability.

For a 45 year old, the risk of having a stroke by age 85 is: - one in four for men - one in five for women

The risk of having a stroke may increase for:

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- People with a family history of stroke - Some ethnic groups (such as African Americans and Hispanics)

The most common cause of stroke is high blood pressure.

A middle-aged man who has high blood pressure, high cholesterol, smokes and has uncontrolled diabetes increases his risk of stroke by TWENTY times.

Stroke Risk Self Assessment Chart

Instructions: Score each line and then add up your total score. The lower your score, the better. The higher your score, the greater your risk of having a stroke. An approximate guide to the risk is:

0 - 4 : Very low risk 5 - 9 : Moderate risk 10 - 13 : High risk 14+ : Very high risk

This is just a guide, but it demonstrates measures you can take to decrease your risk of stroke.

0 1 2 3

Risk Factors

Score
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Smoking never smoked

quit after smoking for less than 5 years

current smoker less than 20/day

current smoker more than 20/day Exercise 1 hour strenuous activity at least 3 times per week

very active once or twice a week

moderately active once or twice a week

very little physical activity Diabetes none known

n/a

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family history

diabetic Blood Pressure normal

mild high blood pressure moderate high blood pressure severe high blood pressure Age 0 - 44

45 - 64

65 - 74

75 + Alcohol (male) 0-4 standard drinks/week

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up to 4 drinks/day

more than 4 drinks a day 2 or more days a week

more than 6 drinks, 4 or more days a week Alcohol (female) 0-2 standard drinks a week

up to 2 drinks a day

more than two drinks a day, 2 or more days a week

more than 4 drinks, 4 or more days a week Weight about average for height

slightly overweight

moderately overweight

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obese Family History no strokes known

a relative has had a stroke

a relative has had a stroke while younger than 65

several relatives have suffered from stroke Cholesterol below average

average

moderately raised

severely raised

Brain Foundation (c)

Reviewed by Dr Alastair Corbett, Consultant Neurologist, Concord Hospital, Australia

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Am I Having a Stroke?
A STROKE OR A TIA IS AN EMERGENCY

GO TO HOSPITAL IMMEDIATELY

TIME LOST IS BRAIN LOST

Symptoms of Stroke
The symptoms of stroke usually come on suddenly. The suddenness of onset distinguishes stroke from other conditions such as migraine or brain tumour. Every patient is affected differently and the most common symptoms are: - Sudden numbness or weakness of face, arm or leg, often one side of the body. - A lack of muscle strength in any group of muscles, most commonly those on the face, hand, arm and leg on one side (called hemiparesis). At least half of patients suffer some form of hemiparesis, some with a mild form that involves difficulty in controlling movement, rather than weakness. - A loss of sensation or feeling in any part of the body. Numbness of the skin of the face, hand, arm, and leg on one side (hemiananaesthia) is most common.

- Sudden confusion, trouble speaking or understanding. - Difficulty in speech - slurring of speech (from weakening of face, mouth, throat muscles) may be accompanied by swallowing difficulty. There may be difficulty understanding others speech, finding the right words, understanding written words or in writing (aphasia).

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- Sudden trouble seeing in one or both eyes. - Difficulty with vision - may take the form of total loss of vision in one eye, or loss of vision in half the visual field of each eye, or double vision.

- Sudden trouble walking, dizziness loss of balance or co-ordination. - Dizziness - injury to inner ear nerves may cause loss of balance, a spinning feeling, of the world moving (vertigo). May cause nausea, unsteadiness on the feet, a tendency to veer to one side or the other, or an unexplained fall.

- Sudden severe headache with no known cause. - Headache - stroke and TIA do not usually cause headache, but headache may result from stretching or irritation of the membrane covering the brain (meninges) or the blood vessels in the brain. - Subarachnoid haemorrhage may be preceded by the sudden (within seconds) onset of an extremely severe thunderclap headache (the most intense the patient has ever felt), together with neck stiffness. Irritation from light may also be a problem. After minutes to hours the headache spreads to the back of the head, neck and back as blood tracks down the spinal subarachnoid space. Subarachnoid hemorrhage may be associated with drowsiness or loss of consciousness and with other stroke symptoms.

- Less common symptoms include: - Nausea and vomiting- can be associated with vertigo or involvement of the vomiting centre (the medulla) of the brain; common at the outset of subarachnoid haemorrhage. - Drowsiness or unconsciousness - also not common, but may occur, often briefly, depending on the location of the injury in the brain. - Epileptic seizures (10% of patients with subarachnoid haemorrhage).

Symptoms of Transient Ischaemic Attack (TIA)

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The symptoms of TIA are not easily distinguished from those of stroke, except that they do not last as long. They may include: - Short term blindness, blurred vision, double vision, other visual disturbances - Speech disturbance often an inability to put thoughts into words, or the substitution of a similar word for another of different meaning (I bent on the ball for I leant on the wall), or slurring of speech - Vertigo a spinning sensation usually in conjunction with other symptoms - Facial numbness or weakness - Swallowing difficulty - Arm or leg weakness or paralysis - Loss of balance - Nausea and vomiting

A TIA is significant and must not be ignored. Advice must be sought immediately.

A TIA may be the start of a stroke that can follow the TIA within hours.

A TIA can warn of a future stroke and rapid investigation and treatment can reduce the risk of having a stroke.

If the symptoms disappear quickly, a TIA may be diagnosed and the patient discharged with appropriate instructions for medical follow-up, investigation and treatment to minimise the risk of recurrence.

If the symptoms persist, tests to determine the nature, precise location and extent of the injury to the brain will be started. These are likely to include Brain scans (Computer Tomography) and MRIs (Magnetic Resonance Imaging).

Treatment to may be started to rescue damaged brain tissue, to prevent complications such as difficulty swallowing, and to minimise the chance of further strokes.

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Reviewed by Professor Alastair Corbett, Consultant Neurologist, Concord Hospital, Australia

Of 40,000 Australians having strokes annually, 28,000 survive, of these 14,000 make a complete recovery, 14,000 are left with some form of disability

What are the Effects of Stroke?

Effects of Stroke

The most common problems in daily life are likely to be caused by: Weakness or lack of movement (paralysis) in legs and/or arms Shoulder pain Trouble swallowing Changes to way things are seen or felt (perceptual problems) Changes to the way things are felt when touched (sensory problems) Problems thinking or remembering (cognitive problems) Trouble speaking, reading or writing Incontinence Feeling depressed Problems controlling feelings Tiredness

The specific abilities that will be lost or affected by stroke depend on the extent of the brain damage and, most importantly, where, in the brain, the stroke occurred: the right hemisphere (or half), the left hemisphere, the cerebellum or the brain stem.

Effects of Right Hemisphere Strokes

The right hemisphere of the brain controls the movement of the left side of the body so stroke in the right hemisphere often causes paralysis in the left side of the body. This is known as left hemiplegia.

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Survivors of right-hemisphere strokes may also have problems with their spatial and perceptual abilities. This may cause them to misjudge distances (leading to a fall) or be unable to guide their hands to pick up an object, button a shirt or tie their shoes. They may even be unable to tell right side up from upside-down when trying to read. Along with these physical effects, survivors of right-hemisphere strokes often have judgment difficulties that show up in their behaviour. They often act impulsively, unaware of their impairments and certain of their ability to perform the same tasks as before the stroke. This can be extremely dangerous. It may lead them to try to walk without aid or to try to drive a car. Survivors of right-hemisphere strokes may also experience left-sided neglect. This is a result of visual difficulties that cause them to "forget" or "ignore" objects or people on their left side.

Some survivors of right-hemisphere strokes will experience problems with short-term memory. Although they may be able to recall a visit to the seashore that took place 30 years ago, they may be unable to remember what they ate for breakfast that morning.

Effects of Left Hemisphere Strokes

The left hemisphere of the brain controls the movement of the right side of the body. It also controls speech and language abilities for most people. A left-hemisphere stroke often causes paralysis of the right side of the body. This is known as right hemiplegia.

Someone who has had a left-hemisphere stroke may also develop aphasia. Aphasia is a catch all term used to describe a wide range of speech and language problems. These problems can be highly specific, affecting only one part of the patient's ability to communicate, such as the ability to move their speech-related muscles to talk properly. The same patient may be completely unimpaired when it comes to writing, reading or understanding speech.

In contrast to survivors of right-hemisphere stroke, patients who have had a left-hemisphere stroke often develop a slow and cautious behaviour. They may need frequent instruction and feedback to finish tasks.

Patients with left-hemisphere stroke may develop memory problems similar to those of right-hemisphere stroke survivors. These problems can include shortened retention spans, difficulty in learning new information and problems in conceptualising and generalising.

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Effects of Cerebellum Strokes

The cerebellum controls many of our reflexes and much of our balance and coordination. A stroke that takes place in the cerebellum can cause abnormal reflexes of the head and torso, coordination and balance problems, dizziness, nausea and vomiting.

Effects of Brain Stem Strokes

Strokes that occur in the brain stem are especially devastating. The brain stem is the area of the brain that controls all of our involuntary functions, such as breathing rate, blood pressure and heart beat. The brain stem also controls abilities such as eye movements, hearing, speech and swallowing. Since impulses generated in the brain's hemispheres must travel through the brain stem on their way to the arms and legs, patients with a brain stem stroke may also develop paralysis in one or both sides of the body.

Other Effects of Stroke

Depression is very common amongst people who have had a stroke. It can be quite severe, affecting both the survivor and his/her family. A depressed person may refuse or neglect to take medications, may not be motivated to take part in physical rehabilitation or may be irritable with others. This in turn makes it difficult for those who wish to help, and tends to deprive the survivor of valuable social contacts that could help dispel the depression. In time the depression may lift gradually, but counselling and appropriate medication may be necessary. In the past, researchers speculated that some of the older anti-depressant drugs might interfere with a person's mental performance but recent studies suggest that anything that can effectively treat post-stroke depression, whether an old or new treatment, may also improve mental ability and enhance rehabilitation.

Sudden laughing or crying for no apparent reason and difficulty controlling emotional responses also affects many stroke survivors. There may be little happiness or sadness involved, and theexcessive emotional display will end as quickly as it started.

Apparent changes in personality following a stroke may be very disturbing to the survivors family. Stroke affected people may not seem the same person as before. The way in which they think, feel and react may be altered. Problems and activities once tackled easily may be difficult or impossible, while other tasks are unaffected.

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The way in which the person affected by stroke reacts to these changes will affect their personality, and may cause changes in control of emotions and behaviour. People affected by stroke may become confused, self-centred, uncooperative and irritable, and may have rapid changes in mood. They may not be able to adjust easily to anything new and may become anxious, annoyed or tearful over seemingly small matters.

Reviewed by Professor Alastair Corbett, Consultant Neurologist, Concord Hospital

Treatment of Stroke

Regular medical supervision, medication and lifestyle changes

Medical advice will be given on continuing care for stroke survivors and may include: - Regular medical supervision - Regular checks of blood pressure, and cholesterol levels leading to appropriate medication - Carotid surgery -one in ten stroke patients have a very narrow artery in the front of the neck on one side (the carotid artery) that restricts the flow of blood to the brain. Surgery to open and clear the artery or to place a small cylinder (stent) in it will increase the flow.

- Medication two kinds of tablets are prescribed: clot-busters and blood-thinners - Anti-clotting (antiplatelet) medication, such as aspirin, probably in combination with another drug such as clopidogrel or dipyridamole (for those patients who have had an ischaemic stroke caused by a clot forming on an area of hardening of the arteries). - Anti-coagulant medication (such as warfarin) where an ischaemic stroke has been caused by a blood clot forming in the heart, breaking off and lodging in the brain. These drugs are very powerful, may have significant side effects and must be carefully supervised by the doctor.

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- Changes to lifestyle - Attention to diet, which should be varied, but low in saturated fat, alcohol, and salt, and high in fibre, fruit and vegetables. - Avoidance of smoking - this is absolutely essential. - Stress management - stress in life is unavoidable but can be reduced by various strategies including exercise, changing attitudes to work, meditation and relaxation. - Regular exercise which will help to regulate weight and improve circulation.

Reviewed by Professor Alastair Corbett, Consultant Neurologist, Concord Hospital

Recovery from stroke takes time Recovery from stroke can be remarkable and inexplicable

Recovery from Stroke

Recovery and Rehabilitation

Much is still not known about how the brain compensates for the damage caused by stroke. Some brain cells may be only temporarily damaged, not killed, and may resume functioning. In some cases, the brain can reorganize its own functioning: another part of the brain takes over for a damaged part. Stroke survivors sometimes experience remarkable and unanticipated recoveries that can't be explained.

Recovery after stroke takes time. It is greatest in the first few months, and gradually plateaus, although small gains may be made for the next 1 to 2 years. The rate of recovery will vary greatly amongst patients.

Rehabilitation starts in the hospital as soon as possible after the stroke. In patients who are

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stable, rehabilitation may begin two days after the stroke has occurred, and should be continued as necessary after release from the hospital. Before discharge a conference with hospital staff regarding future care, supervision and rehabilitation is essential.

Depending on the severity of the effects of the stroke, rehabilitation options include: A rehabilitation unit in the hospital A rehabilitation hospital Home therapy Home with outpatient therapy A long-term care facility that provides therapy and skilled nursing care.

Further sources of information and support

Australia http://www.strokensw.org.au/ http://www.strokefoundation.com.au http://www.mydr.com.au

Overseas http://www.strokeaha.org http://www.americanstroke.org http://www.intelihealth.com

Reviewed by Professor Alastair Corbett, Consultant Neurologist, Concord Hospital

Patients are generally encouraged to return to their normal lives depending on the effects persisting from stroke

Life After Stroke

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Some aspects of life after stroke include: - Resuming work How soon this is possible depends partly on remaining disability, the type of work involved, and the feelings about returning to work. Some people feel quite tired after a stroke, and have difficulty carrying out any kind of physical activity for any length of time. Part-time work at least in the early stages may be a good idea. Unless the stroke has reduced awareness of impairment, it is probable that the person who had the stroke is the best judge of when to return to work. - Driving Even someone who appears to have made a full recovery after stroke should not drive a car for at least a month as the risk of another stroke is greatest at this time. To drive again involves being cleared by the doctor (who will be aware of relevant government regulations) as the stroke may have left subtle impairments, not always apparent, such as poor co-ordination, lack of awareness on one side, difficulties in judging distance, changes in vision, difficulties in concentration and confusion between left and right. - Sexual activity Resumption of sexual activity after stroke is encouraged. Most couples experience some difficulty in their sex life after stroke, but this is usually due to psychological factors rather than any disability caused by stroke. A doctor can advise on any difficulty such as erectile problems in men. - Sport and Exercise Resumption of physical activity and hobbies is an important part of rehabilitation- normal activity should be resumed as soon as physically possible. - Drinking Alcohol The intake of excessive amounts of alcohol should be avoided after stroke as it may interact adversely with medication, raise blood pressure, and affect judgement resulting in injury. Moderate consumption (two standard drinks per day) should not cause any problem.

Reviewed by Professor Alastair Corbett, Consultant Neurologist, Concord Hospital

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How Can I Avoid Another Stroke?

Secondary prevention to reduce your risk

Secondary prevention is a very serious matter

40% of stroke survivors have a second stroke within five years with the highest risk being in the first few months after the stroke or TIA.

A repeat stroke is frequently more devastating than the first.

Lifestyle adjustments often need to be made- these seem simple but require commitment and permanence.

Secondary prevention measures include: - Regular checks by your doctor for: - Blood pressure - Cholesterol - High blood pressure and high cholesterol usually respond well to medication taken as prescribed - Diabetes - Control diabetes by following medical advice carefully - Heart beat

- Dont smoke Stopping smoking is not easy for the dedicated smoker but it is vital - it is possible to give up cigarettes. Assistance is available. - Reduce your stress levels

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- Limit your alcohol intake - Manage your weight - Exercise regularly Many forms of exercise are available to suit individual tastes. Walking is easy no special equipment, can be done at any time, in most weather exercise that also provides fun, pleasure and companionship is very valuable. - Eat a balanced diet, avoid food high in salt and fat - Enjoy work and play - Follow medical advice faithfully

One Mans Stroke Story

Peter Doyle (of the famous Sydney icon Doyles Fish Restaurant) suffered a massive stroke in October 1995

Its been a hard road back since the massive stroke I suffered on 18th October 1995. My bloody oath its been hard. Still is. You try undoing buttons and going to the toilet with one hand. You cant even do up a belt. Your lifestyle alters altogether and you get so cranky with people. And no matter how much money youve got, you cant buy your way out of it. Rich or poor, this thing can strike you down theres no defining line in terms of wealth or of age. Im sorry to be the bearer of such confronting news, but this could happen to you, and its important to understand this and to take precautions.

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I see myself as one of the lucky ones, in that I was hit on the right side of the brain, and even though it was tough, I was soon able to speak again. Im left with constant pain on the left side, reduced independence; a lifetime of medication, occasional giddy turns, and depression comes in waves. As well, Im still restricted with what I can eat, and I have to supplement my food intake with a high protein liquid, fed via a tube into my stomach. Its no picnic. After a stroke, youre buggered unless youve got someone to help you. Im fortunate in having a retired merchant mariner, Pat Moss, to assist me. Hes my driver, and pushes me in the wheelbarrow!

In 1997, on the flight to Perth for a friends wedding, I suffered another cerebral haemorrhage. They take you to hospital, drill a hole, and drain it. And they tell me I could face this again if I let stress get to me. Its ironic I used to thrive on stress!

The funny thing is that I never thought of packing it in. When I first woke up in Sydneys St Vincents Hospital after the stroke, I looked down and saw a Catholic brother I know, standing at the foot of the bed. I thought, God, I must be on the dying list, and then I thought, bugger it, Im not going to die.

You know, I look back and recall that like all Aussie men, I believed I was bulletproof. But Im here to tell you that this is not so for any of us. Superman is a fictional character. If you want to end up like me, well thats fine, but if youre not a masochist and you value your well-being and the independence that goes with it, I urge you to pick up the phone now and make an appointment with your GP to have your blood pressure and other risk factors checked. Do it immediately. No excuses.

During the months I spent in rehabilitation, I met so many people who had ignored the effect stress was having on their lives, and they ended up having a stroke or cerebral haemorrhage. Ill tell you something else: you dont have to be a high-powered executive to fall victim to stress. Now I understand the importance of a low fat diet, drinking alcohol in moderation only and avoiding cigarettes like the plague. I used to smoke, and gave it up 18 years ago but I should never have taken it up in the first place. And another thing: eat more fish!

For those of you who have already suffered a stroke and that is 40,000 Australians a year I want to hold out my hand and tell you that youre not alone. Were in this together, and help is out there, beginning with the Brain Foundation. The Foundation aims to work for the prevention and treatment of brain disorders in this country through community education, support programs, and the promotion of research. And if youve got a spare few bucks or better still, a

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spare million I can think of no more worthwhile organization to give it to.

Thanks for listening; Ive enjoyed chatting to you, and I have just one thing to add I keep reminding myself of Joan Collins philosophy: What doesnt kill us, makes us stronger.

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