Stroke: definition, causes or risk factors, types, signs and symptoms and management

STROKE

STROKE: Definition, types , causes, signs and symptoms, prevention, management; medical and physiotherapy managements.

INTRODUCTION
Stroke is one of the conditions that remain a major cause of morbidity and mortality. It is the third cause of mortality worldwide.
Stroke in the previous years, affected the elderly but recently, numerous people as young as twenty years are affected.
The most common cause of stroke in the elderly is mostly attributed to hypertension.
However, diabetes, obesity and other factors increase one's risk of getting stroke.

With early intervention, stroke patient shall be returned back to functional independence. The type of stroke would depend on the aetiology. The signs and symptoms may also depend on the area of brain lesion and its severity or the extent of damage caused to the brain. The brain is divided into two hemispheres which controls the body; the left and right hemispheres. The right hemisphere controls the left part of the body and the left controls the right part of the body.
Depending on which hemisphere affected would indicate the presentation and deficits the patient may show.
Stroke should be of vascular origin. For stroke to exist, there should be interruption of blood flow thorough the vessel to the brain. Any damage to the brain not of vascular origin, would not be diagnosed as stroke.

Every part indicated on each of the hemisphere plays a vital role and their affectation would have adverse sequels on these roles, hence affecting bodily functions.

What is stroke?
The term stroke can be explained in different forms by certain authors and organization including WORLD HEALTH ORGANISATION.

According to Medicinenet, Stroke Is
defined as a sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain.
The World Health Organization (WHO) definition of stroke is: “rapidly developing
clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin”.
By applying this definition transient ischemic attack (TIA), which is defined to last less than 24 hours, and patients with stroke symptoms caused by subdural hemorrhage, tumors, poisoning, or trauma are excluded.
Both definition share common thing attributed to blood vessels and it associated problem causing interruption of blood flow to the brain before stroke can be caused.

In simple, terms, stroke is a condition that occurs when blood flow to the brain is interrupted whether by a clot or rapture of the blood vessel leading to death of brain cells causing functional deficits on the body structures.

In every 3.1 minutes, a person die of stroke. Stroke has therefore become a global burden which needs to curbed as soon as possible. More often the main cause of stroke is unknown, but environmental and genetic factors have been implicated in the cause of stroke.

CAUSES/RISK FACTORS OF STROKE

The cause of stroke is unknown, but certain factors may increase one's risk. These risk factors have been divided into modifiable and non modifiable risk factors.

Modifiable risk factors

Hypertension
Diabetes
Arteriosclerosis
Atherosclerosis
Sedentary lifestyle
Alcohol consumption and smoking
Heart disease
Obesity and
Aneurysm

Non modifiable risk factors

Age
Race and
Family history

HOW DO THESE RISK FACTORS CAUSE STROKE?

HYPERTENSION: Hypertension is the common cause of stroke. When blood pressure increases, the artery walls weakens with time, which could rupture should the pressure remains high for a prolonged period of time restricting blood flow to the brain leading to stroke.

Most people with hypertension stand the risk of haemorrhagic stroke.

DIABETES: Diabetes also remains one of the conditions that increases one's risk of getting stroke. Too much sugar content in the blood has negative impact on the blood vessels. There could be increased risk of developing plague in the blood vessels which can create a blockage in the blood flow. Too much blood sugar content can also causes the blood vessels to harden in response to high sugar content in the body.

ARTERIOSCLEROSIS : The hardening of blood vessels due to this condition will narrow the lumen of the blood vessels. Should it be a vessel which conveys blood to the brain, blood flow becomes insufficient or less. This can deprive the brain of adequate oxygen leading to neuron cells death.

ARTHEROSCLEROSIS: A condition which occurs when there is clot formation in the blood vessel reducing the lumen and limiting blood flow through it. This clot can be dislodged (Embolism) and travel from somewhere in the body and create a blockage in a cerebral artery, restricting blood flow leading to stroke.

ALCOHOL CONSUMPTION AND SMOKING

Both alcohol consumption and smoking may contribute to the risk of developing stroke. Alcohol consumption may increase one's risk for hypertension and smoking of cigarettes or tobacco use, would generate plaques in the vessel which would all reduce the flow of blood through an artery.

RACE : Study has shown that stroke affect the blacks than the whites people.

FAMILY HISTORY: Study shows that when one of your parents ever had stroke, you stand the risk of getting stroke.

AGE : Most people diagnosed of stroke fall within the ages of 60-65 years but recently due to certain factors, people as young as twenty years may be affected.

TYPES OF STROKE
TWO MAIN TYPES OF STROKE HAVE BEEN SPOTTED.
The type of stroke depends on the cause of your stroke.

ISCHEMIC STROKE
HAEMORRHAGIC STROKE.

ISCHEMIC STROKE: This is a type of stroke caused by interruption of blood flow to the brain either by a thrombus or an embolus.

It is divided into two subdivision as Thrombotic and embolic stroke.

Each of these types causes interruption of blood flow because of clot formation. With the Thrombotic, the clot is stagnant whereas with the embolic stroke, blood clot travels through the vessel.

HAEMORRHAGIC STROKE : This type of stroke is mostly caused by hypertension.
Spontaneous intracerebral hemorrhages (as opposed to traumatic ones) are mainly due
to arteriolar hypertensive disease, and more rarely due to coagulation disorders,
vascular malformation within the brain, and diet (such as high alcohol consumption, low blood cholesterol concentration, high blood pressure, etc.). Cortical amyloid angiopathy (a consequence of hypertension) is a cause of cortical hemorrhages especially occurring in elderly people and it is becoming increasingly frequent as populations become older.

Subarachnoid hemorrhage

This group of strokes is mainly due to the rupture of aneurysms at the bifurcations of
large arteries at the inferior surface of the brain. Often they do not cause direct
damage to the brain and some studies of stroke have therefore excluded them. However, patients with subarachnoid hemorrhage may develop symptoms that are in accordance with the stroke definitions and should as such be regarded as a stroke.

TRANSCIENT ISCHEMIC ATTACK: This refers to as a mini stroke. It is a neurological deficit with symptoms lasting less than 24 hours. Transchient ischemic attack should be treated as soon as possible to prevent major stroke which comes with lot of complications.

SIGNS AND SYMPTOMS OF STROKE

The signs and symptoms a stroke patient may show will depend on the area of brain lesion and its severity or the extent of brain areas affected.
Most of the symptoms come earlier before the condition itself is spotted. These symptoms create an awareness that stroke is approaching you.

Feeling of tingling sensation
Throbbing head pain
Numbness in some parts of your body especially finger tips, toes etc
Sudden Confusion
Visual disturbances such as blur vision

All these acute symptoms should be given much attention as soon as possible to prevent the condition.

General signs and symptoms may include:
1. One side weakness
2. Contracture
3. Hypersentivity to touch Eg severe pain to touching.
4. Impaired gait (circumduction often)
5. Spasticity of muscles to passive movement
6. Loss of sensation
7. Fecal and urinary incontinence
8. Disorientation
9.Speech problem.
10. Impaired balance and coordination
11. Joint Contractures
12. Sublaxation
13.Facial paralysis

HOW CAN YOU PREVENT STROKE?

1.Reduce alcohol intake
2.Take salt in modulation
3.Avoid smoking
4. Eat balance diet including vegetables and fruits and avoid too much intake of fatty foods.
5. Sticking to prescribed medication especially diabetic and hypertensive patients.
6.Regular daily exercise.

MANAGEMENT

The treatment of stroke requires multidisciplinary approach. Different specialised professional interventions are needed. These multidisciplinary team may include;

Patient
Patient's relatives
Physicians
Speech therapist
Occupational therapist
Physiotherapist/ Physiotherapy Technicians or Assistant
Nurses and
Social worker

Medical management of stroke target the cause of your stroke and wholly rely on drug prescription to limit most of your symptoms.

ISCHEMIC STROKE : Doctors may prescribe anticoagulants to dissolve your clot

HAEMORRHAGIC STROKE : Doctors may prescribe antihypertensive drugs to manage your blood pressure.

Surgery : Doctors also find means of removing the lesion from your brain and also suture the ruptured cerebral artery.

PHYSIOTHERAPY AND STROKE

Stroke management cannot be successful only with medical management. There's the need for physiotherapy intervention as long as functional independence is of much concern to us. After medical diagnosis is done and your conditions is ascertained, your doctor will refer you to physiotherapy for continual treatment.

Physiotherapy Assistant or Techincian will do an assessment to determine your deficit in terms of strength, sensation, ROM, Muscular tone, and others.
Goals would be set which will depend mostly on your symptoms or your presenting complaints.

These goals will include;

Increase muscular strength
Improve sensation
Improve joint flexibility
Enhancing balance and coordination
Ensuring clear airways
Avoiding comorbidities or other complications
Gait retraining and others

Physiotherapy apply numerous techniques in achieving these aims and this may be done differently based on acute and chronic stages.
Those for inpatient and those for outpatient.

IN-PATIENT

Frequent turning of patient on bed
Passive mobilization of all joints
Deep breathing exercise
Tense relax technique
Teaching patient how to sit from lying and from lying to sitting and also bed standing is necessary depending on patient strength.
Teach patient some facial exercises in case facial palsy is present.

OUT PATIENT TECHNIQUES

These are performed as soon as patient gain some strength and is stable enough for exercise.

Weight bearing exercises is done to improve strength in the Lower extremity
Gait training exercise incorporating the normal gait pattern
Balance and coordination training
Strengthening exercises for upper and lower extremities.
Apply various textures to facilitate sensation
Use of heating modalities can also help perform stretching and helps in pain reduction
Use of Orthotics devices such as arm sling to stabilize shoulder in the case of sublaxation
Training of certain functional skills.
Assistive devices such as Zimmer frame and wheel chairs are needed
Teach transfers from wheel chair to bed and bed to wheel chair

Patient transfer from bed to wheel chair and vice versa

Educate patients relatives on some exercise regime to be done in the home.
Provision of disability friendly environment
Train task specific exercises

LONG TERM REHABILITATION

Environmental modification:

It is always important that the recovered patient remains within the vicinity with the condition and still function independently. Certain modifications would help ensure this particular goal.

Below are pictures showing some of the environmental modifications that can be made to help stroke patient in terms of long term rehabilitation.