Stroke: 2nd Most Common Cause of Death Worldwide

Across the globe, stroke is the second most common cause of death. During a stroke, there is a disruption of blood supply to one or more areas of the brain due to blockage or rupture of the brain artery.

Types of Stroke

A stroke can arise primarily through two mechanisms

Ischemic stroke: which is more common, among the two occurs when there is a reduction in blood flow to the brain due to blood clots resulting in a decreased supply of oxygen and nutrients.

Hemorrhagic stroke occurs when there is a bleed into the brain tissue due to High Blood pressure or aneurysm rupture.

Risk Factors for Stroke

• Hypertension
• Diabetes Mellitus
• Elevated cholesterol
• Smoking
• Physical Inactivity
• Atrial Fibrillation
• Family History of stroke
• Illegal drugs such as cocaine
• Aneurysms or abnormalities in blood vessels in the brain
• Hole in the heart ( Patent Foramen Ovale, Atrial Septal Defect)

Symptoms and Signs of Stroke

A stroke can manifest in a multitude of ways depending on the size and site of the brain affected ranging from ‘silent’ strokes which are asymptomatic to complete paralysis and loss of sensation at the other extreme. Most frequently, the symptoms noted are localized weakness or loss of sensation, abnormal vision, and difficulty with speaking or swallowing. Sometimes the individual may have a seizure or experience loss of consciousness.

In the acute setting, it is helpful to remember the mnemonic FAST to look out for a stroke

F for Face – facial asymmetry from weakness and vision problems

A for Arm – sudden weakness, numbness, or drift in the arms

S for Speech – slurring of words and difficulty speaking

T for Time – it is important to get urgent treatment to increase the chances of saving brain tissue. Call the local emergency services immediately when you notice someone showing the signs described above (911 in the US and Canada)

Diagnosis of Stroke

In addition to reviewing the patient’s history and performing a physical exam, the doctors would require additional tests to diagnose a stroke and to help plan management.

Imaging is performed with Non-Contrast CT of the head or MRI brain. These tests help doctors identify if the stroke is secondary to a bleed or a blood clot.

Blood tests are also done to estimate blood glucose, complete blood count including platelets, and tests of bleeding and clotting such as Prothrombin Time and INR (International Normalised Ratio).

Echocardiogram: It is an ultrasound of the heart to evaluate heart function, blood clot or hole in the heart.

Carotid Ultrasound: To identify any blockage in carotid arteries.

Treatment of Stroke

This depends on the type of stroke and the time of presentation. The sooner one can get to the hospital, there are better chances for recovery.

Treatment of Ischemic Stroke

Intravenous thrombolytic therapy: This is the first-line treatment to breakdown clots blocking the blood vessels. This can however only be administered within four and a half hours from symptom onset as its benefit wanes with time.

Mechanical thrombectomy: This is a procedure requiring expertise to manually remove the clot obstructing the vessel and can be performed within 24 hours.  Not everyone is eligible as there are specific situations where the benefit is seen.

Medications: Antiplatelet medications (blood thinners) such as aspirin  or clopidogrel

Anticoagulants in case of Atrial Fibrillation: warfarin, Xarelto, Eliquis, Pradaxa.

Lipid-lowering with high-intensity statin therapy.

Treatment of Hemorrhagic Stroke

Reversal of anticoagulation: For patients on any blood thinners such as aspirin or warfarin, these need to be stopped immediately with close monitoring of bleeding and clotting parameters. Occasionally, reversal agents may be required to rapidly bring the patients’ ability to clot blood back to normal.

Management of Hypertension: Blood pressure-lowering medications may be administered to reduce highly elevated pressures though a close eye is kept to ensure that low pressures do not result in decreased perfusion to the brain.

Surgical Hematoma Evacuation: This is done through decompression which helps to reduce the pressure building up within the skull.

Prognosis of Stroke

Stroke is a leading cause of death and disability. After surviving a stroke, depending on the location and amount of brain matter affected, the individual may recover completely or left with residual symptoms like difficulty in speaking, feeding, and movement. Stroke can greatly affect independence and quality of life. Long term physical therapy and rehabilitation are frequently required and some may recover lost function with specialist care.

Prevention of Stroke

Prevention of a second stroke is also important to keep in mind which requires effective control of risk factors such as management of high blood pressure and diabetes, cessation of smoking, increasing physical activity, and adopting a Mediterranean diet. Some patients may require surgery to close the hole in the heart to reduce the risk of further stroke.

Resources:

• American College of Neurology
• American Heart Association