Stroke

Following are the common signs and symptoms one may experience during a stroke:

• Sudden dizziness and loss of balance: A person suffering from a stroke may lose balance and experience dizziness or lightheadedness.
• Visual disturbances: Vision problems in one or both eyes are common during a stroke.
• Face drooping: If you suspect someone in your family is having a stroke, ask them to smile. If the face droops to one side, it could indicate a potential stroke.
• Paralysis (weakness in the arms and legs): If the arms drift downward after raising, it can be a sign of a stroke.
• Slurred speech: A person experiencing a stroke may find it difficult to pronounce simple sentences.
• Confusion: The person may exhibit confusion or have difficulty understanding others during a stroke.
• Headache: A sudden severe headache with no known cause could be a warning sign of a stroke.

The cause of a stroke depends on the type of stroke. Stroke is broadly classified into three major types:

• Ischemic stroke: Most strokes are ischemic strokes. These occur when the oxygen-rich blood supply to parts of the brain is blocked or severely restricted. As a result of the deprived blood and oxygen, the cells in that part of the brain die, and the body functions it controls stop working. Restriction of blood supply can happen due to:
• Clogged arteries: Fat, cholesterol, and other deposits can accumulate on the walls of blood vessels. Over time, these deposits calcify or harden, forming plaque, which clogs the blood vessels and narrows the passage for blood.
• Blood clots: A clot that forms in a narrow blood vessel in the brain leads to a thrombotic stroke. If a blood clot forms elsewhere in the body and travels to a blood vessel in the brain, it results in an embolic stroke or cerebral embolism. An embolic stroke can also occur from an air bubble or other foreign substance in the blood that blocks a blood vessel in the brain.
• Hemorrhagic stroke: In this type of stroke, a weakened blood vessel in the brain ruptures, allowing blood to leak into the brain. This accumulation of blood compresses the surrounding brain tissue. Two types of weakened blood vessels that usually cause hemorrhagic strokes are:
• Aneurysms: Balloon-like bulges in an artery that can stretch and burst.
• Arteriovenous malformations: Tangles of blood vessels.

There are two types of hemorrhagic strokes:

• Intracerebral hemorrhage: The most common type, occurring when a blood vessel in the brain bursts, flooding the surrounding tissue with blood. It is usually caused by high blood pressure.
• Subarachnoid hemorrhage: A less common type referring to bleeding in the space between the brain and the skull. Factors such as head injury, overtreatment with blood thinners, and bleeding disorders can cause subarachnoid hemorrhage.
• Transient ischemic attack (TIA): Also known as a “mini-stroke” or “warning stroke,” it usually lasts for only a few minutes. A TIA is a warning sign of a future stroke and should be treated as a medical emergency, similar to a major stroke. Like ischemic strokes, TIAs are often caused by blood clots. More than a third of individuals who experience a TIA without treatment will have a major stroke within one year. Recognizing and treating TIAs can significantly lower the risk of a major stroke in the future.

Some of the common risk factors of stroke are:

• Age: Aging tends to narrow the arteries, thereby increasing the risk of stroke.
• Gender: Stroke occurs more commonly in men, but more casualties are seen in women due to stroke.
• Family history: Heredity or genetics can influence the risk of having a stroke.
• Sedentary lifestyle: Long sitting hours with minimal movement or exercise is a major risk factor for stroke.
• Excessive alcohol consumption: Consuming more than 2 drinks per day raises blood pressure, and uncontrolled drinking can lead to stroke.
• Obesity: Excessive weight is a significant risk factor for stroke and other cardiovascular complications.
• Tobacco: Chronic use of tobacco narrows blood vessels, and nicotine increases blood pressure, raising the risk of stroke.
• Diabetes: Diabetes can lead to pathological changes in blood vessels, increasing the risk of stroke.
• Uncontrolled hypertension: Blood pressure of 140/90 mmHg or higher can damage blood vessels that supply blood to the brain.
• Elevated red blood cell (RBC) count: High levels of red blood cells thicken the blood and predispose to clot formation, raising the risk for stroke.
• Elevated blood cholesterol and lipids: High cholesterol levels can increase plaque buildup and lead to atherosclerosis, decreasing blood flow to the brain and causing a stroke.
• Heart conditions: Heart valve defects and arrhythmias can cause long-term damage to the heart, thereby increasing the risk of a stroke.
• Birth control pills: These oral contraceptives can increase the risk of stroke.
• Extreme weather conditions: Stroke casualties occur more often during extreme temperatures or weather conditions.
• History of prior stroke: The risk of a second stroke increases if someone has had a stroke in the past.
• History of transient ischemic attacks (TIAs): TIAs, known as mini-strokes, significantly raise the risk of suffering from a stroke.

The ABCD2 score is a prediction rule used to determine the risk for stroke after a transient ischemic attack. The ABCD2 score is based on five parameters: age, blood pressure, clinical features, duration of TIA, and presence of diabetes. Scores for each item are added together to produce an overall result ranging from zero to seven. Individuals with a high score often need to visit a specialist sooner.

Interpretation of ABCD2 score:

• Score 1-3 (low)
• Score 4-5 (moderate)
• Score 6-7 (high)

ABC Monitoring

Initial Evaluation

• Score 0: No stroke symptoms
• Score 1 to 4: Minor stroke
• Score 5 to 15: Moderate stroke
• Score 16 to 20: Moderate to severe stroke
• Score 21 to 42: Severe stroke

Diagnostic Tests

1. Blood Tests

• Blood sugar levels to detect hyperglycemia and hypoglycemia
• Presence of any infections
• Platelet counts
• Blood coagulation profile
• Lipid profile
• Cardiac markers

2. Imaging Tests

• Cranial (head) CT scan: This imaging technique is usually the initial test used to diagnose stroke, providing clear, detailed images of the brain. It can reveal bleeding or damage caused by a stroke and detect abnormalities.
• Computed Tomographic Angiography: This test uses CT technology to visualize detailed images of blood vessels.
• Magnetic Resonance Imaging (MRI): MRI uses magnetic fields to identify small changes in brain tissue, making it more sensitive than CT for detecting stroke.
• Magnetic Resonance Angiography: This technique uses MRI technology and is considered the gold standard for assessing blood flow through involved vessels.
• Carotid Doppler or Doppler Sonography: This test uses ultrasound waves to visualize blood flow in the carotid arteries, detecting plaque and fatty deposits.
• Electrical Activity Tests: Tests such as electroencephalography (EEG) or evoke tests measure electrical impulses in the brain.

Heart Tests

• Electrocardiography (ECG): An ECG records the heart's electrical activity and can identify conditions such as atrial fibrillation or irregular heart rhythms that may lead to a stroke.
• Echocardiogram: This test uses sound waves to locate clots in the heart that may have traveled to the brain, and it also assesses heart valve function.

Prevention is essential, especially for individuals who have previously suffered a stroke, as they are at a higher risk of experiencing another stroke in the future. The following measures can be taken to prevent stroke:

• Dietary modifications: Eat a wholesome diet rich in green leafy vegetables, fruits, and nuts. Consume foods low in saturated fats, trans fats, and cholesterol, and high in fiber to prevent high cholesterol. Limiting salt in the diet can also lower blood pressure. Avoid red meat and greasy, fatty junk foods to reduce the risk of stroke.
• Maintain a healthy weight: If you are overweight or obese, or have high cholesterol levels, it is advisable to lose weight to achieve a body mass index (BMI) between 18.5 and 24.9. This can lower the risk of stroke in the future.
• Stay active: A sedentary lifestyle is a major factor in the progression of cardiovascular and cerebrovascular complications. It is recommended to move as much as possible and engage in some form of exercise most days of the week. For adults, 2 hours and 30 minutes of moderate-intensity aerobic physical activity, such as a brisk walk, is recommended each week.
• Keep your blood pressure in check: High blood pressure can increase your risk of having a stroke. Since high blood pressure usually has no symptoms, ensure regular check-ups. If you have high blood pressure, proper medication, lifestyle changes, and foods with lower sodium can help manage the condition.
• Control diabetes: Uncontrolled diabetes can significantly increase the risk of stroke. It is crucial to monitor your blood sugar levels. If you have diabetes, your doctor may recommend lifestyle changes, such as increased physical activity or healthier food choices, along with necessary medications to help maintain good blood sugar control.
• Cut down on alcohol: If you consume alcohol, it is advisable to either quit or minimize intake to reduce the risk of stroke. Men should not exceed two drinks per day, and women should limit themselves to one drink.
• Quit smoking: Smoking significantly increases the risk of stroke. If you do not smoke, do not start. If you do smoke, quitting will greatly reduce your risk of stroke. Your doctor can provide guidance on how to quit smoking.
• Evaluation of risk factors: If you are at high risk for stroke, appropriate lifestyle changes along with biannual health check-ups can go a long way in prevention.

Additionally, here are a few tips to prevent another stroke:

• Work with your doctor to identify the cause of the stroke.
• Always keep up with follow-up appointments.
• Consult your doctor if you are changing or stopping any medications.
• Do not ignore the warning signs and symptoms of stroke.

The treatment of stroke depends upon the type of stroke.

A. Treatment for Ischemic Stroke

1. Fibrinolytics/thrombolytic medications: Medications that break down or dissolve the clot can restore blood flow to the brain. Common examples include:
   • Alteplase
   • Reteplase
   Note: Citicoline, a neuroprotective drug, is approved for the treatment of acute ischemic stroke. However, its efficacy over currently used fibrinolytics is not known. Piracetam has shown potential to improve learning and memory, and may facilitate recovery and rehabilitation after a stroke.
2. Antiplatelet medications: These medications help prevent the formation of a clot in the blood vessels, aiding in the management and prevention of stroke. Examples include:
   • Aspirin
   • Clopidogrel
3. Anticoagulants: Anticoagulants prevent clot formation by altering the chemical composition of the blood. Novel oral anticoagulants (NOACs) are alternatives to warfarin for high-risk patients, including those with a history of stroke and atrial fibrillation. These drugs do not require frequent monitoring like warfarin. Examples of NOACs include:
   • Apixaban
   • Rivaroxaban
   • Dabigatran
   • Edoxaban
4. Blood pressure medications: Antihypertensives are administered in stroke to maintain normal blood pressure. Commonly prescribed drugs include:
   • Angiotensin receptor blockers (ARBs)
   • Calcium channel blockers (CCBs)
   • Diuretics
   • Beta-blockers
   • Angiotensin-converting enzyme (ACE) inhibitors
5. Statins: This class of drugs is known to aid in the treatment of stroke and prevention of a second attack by reducing cholesterol levels in the blood. Examples include:
   • Atorvastatin
   • Rosuvastatin
   • Pitavastatin
6. Thrombectomy: Thrombectomy refers to the procedure of removing the clot to ensure normal blood flow to the brain.
7. Carotid endarterectomy: This surgical procedure addresses carotid stenosis or narrowing of the carotid artery due to fatty substance deposition. An incision is made on the carotid artery to remove the deposited substances.

B. Treatment for Hemorrhagic Stroke

1. Surgery: Surgery is necessary in a hemorrhagic stroke to access the source of bleeding. Sometimes, a catheter or small tube is inserted in the arm or leg artery, guiding it to the brain tissue for evaluation.
2. Endovascular procedures: These procedures may be used to treat certain hemorrhagic strokes. A long tube is inserted through a major artery in the leg or arm, guided to the site of the weak spot or break in a blood vessel. The tube is then used to install a device, such as a coil, to repair the damage or prevent bleeding. Details include:
   • Surgical clipping: A surgeon places a tiny clamp at the base of the aneurysm to stop blood flow to it, preventing the aneurysm from bursting.
   • Coiling (endovascular embolization): Using a catheter inserted into an artery in the groin and guided to the brain, the surgeon places tiny detachable coils into the aneurysm to fill it.
3. Surgery for hydrocephalus: In hydrocephalus, fluid accumulates around the brain. This can be treated with a tube, called a shunt, to drain the excess fluid.

C. Supportive Treatment

In some cases, supportive treatment measures might be required to improve the overall condition of the patient, such as:

• Inserting a feeding tube into the stomach through the nose (nasogastric tube) to provide nutrition if there is difficulty swallowing.
• Intravenous administration of fluids if there is a risk of dehydration.

The complications of stroke vary from person to person. They depend on the severity of the stroke along with which part of the brain is affected by it. Some of the complications associated with stroke include:

• Vision problems
• Cognitive impairment, including dementia (forgetfulness)
• Reduced mobility or ability to control certain muscle movements
• Sensory changes
• Loss of bladder and bowel control
• Deep venous thrombosis
• Epileptic seizures
• Pneumonia
• Pulmonary embolism
• Shoulder pain
• Mood or emotional changes
• Anxiety and depression
• Pressure or bed sores
• Recurrent stroke

Although it is estimated that 1 in 4 stroke survivors will have another attack, not many know that up to 80% of strokes can be prevented with simple measures. These measures include a combination of medication, a healthy diet, physical activity, and controlling comorbidities.

Here are a few tips for stroke survivors and caregivers to help identify and manage the condition:

• Learn about the condition: Whether it is the warning signs and symptoms, the cause of stroke, or the side effects of medications, it is important to be well aware of the condition and its impact on overall health.
• Control risk factors: If the modifiable risk factors, such as cholesterol, blood pressure, and diabetes, are not controlled, the risk of another stroke is high. Ensure you eat a healthy diet, stay active, take medications as advised, and keep up with follow-up appointments. Avoid smoking and drinking, as they can severely hinder recovery.
• Keep a tab on recovery: Recovery post-stroke is influenced by many factors, such as which part of the brain was affected, the extent of the damage, and the general health of the survivor before the stroke. While most people tend to show improvement within 3-4 months after a stroke, for others, it may take a year or two.
• Maintain regular checkups: Regular checkups help monitor your blood pressure, blood sugar, lipid profile, and overall recovery.
• Do not ignore falls/injury: Falls after a stroke are common. It is important to take measures to prevent falls. If a survivor has had minor falls more than twice in six months or experiences bruising, bleeding, or pain after a fall, consult your doctor promptly.

Rehabilitation: Successful recovery from a stroke often requires specific therapies and support systems, including:

• Speech therapy: A stroke can sometimes cause speech difficulties. A speech and language therapist can assist with problems in producing or understanding speech. If verbal communication is challenging after a stroke, they can help find new and innovative ways to communicate. Regular practice and adjustments in communication style can simplify the process.
• Physical therapy: Loss of muscle tone and strength after a stroke can restrict body movements. A physical therapist can help regain strength and relearn movement and coordination. Finding new ways to adapt to limitations can significantly aid rehabilitation.
• Occupational therapy: A stroke can dull the senses, reducing the sensation of temperature, pressure, or pain. An occupational therapist can assist in adjusting to this lack of sensation and improve the ability to perform daily activities such as bathing, dressing, eating, and reading.
• Cognitive therapy: Many patients may experience changes in thinking or reasoning skills after a stroke, which can lead to behavioral and mood swings. Cognitive therapy can help regain former patterns of behavior and manage emotional responses.

Take care of your mental health: Sound mental health plays a crucial role in recovery and rehabilitation. If needed, seek help.

• Join a support group to cope with any mental health issues. Many find it helpful to share experiences and exchange ideas and information.
• Family, along with close friends and relatives, should provide comfort and practical support after a stroke. Letting them know how they can help is very important.

With the right help and the support of loved ones, achieving a decent quality of life is usually possible, depending on the severity of the stroke.