By Dr. Clementine E. Karageorgiou, MD, PhD, Director Neurologist – Psychiatrist, Athens Medical Center.
What is a Cerebrovascular Accident or stroke?
A cerebrovascular accident (CVA) or stroke describes a heterogeneous group of disorders having as a predominant feature the presence of central nervous system signs and symptoms either as a result of ischemia or bleeding. The term cerebrovascular accident underlines the sudden onset of symptoms, which most often leave a lasting physical and cognitive disability. This concerns a sudden disruption of the brain's blood supply, resulting in brain damage and disruption.
The cerebrovascular accident is the third leading cause of death after cardiovascular events and cancer, while being the leading cause of long-term disability, as well as an important cause of chronic disability and the most common neurological condition requiring hospitalization.
There are two types of cerebrovascular accident: ischemic and hemorrhagic.
About 80% - 85% of strokes are ischemic. Out of the 750,000 new cerebrovascular accidents that occur in the US each year, 85% are due to a cerebral infarction.
Ischemic Stroke occurs when the blood supply to a part of the brain stops. This is due to obstruction of the large vessels to the brain, or of small vessels within the brain.
The obstruction is caused either by a clot in a narrowed artery (thrombosis) or by a clot formed elsewhere in the body, usually the heart, and moved along the arteries of the brain by blood flow (invasion).
A hemorrhagic episode occurs after bleeding inside (Hematoma), or around the brain (Subarachnoid Hemorrhage). There are many possible causes of brain bleeding. The most common are:
- Ruptured brain aneurysm or fibromuscular dysplasia
- Rupture of small vessels within the brain.
What is the mechanism of the Cerebrovascular Accident?
In cerebrovascular accidents, the blood supply of one area of the brain, sometimes of another extent, stops abruptly, either because of blocked blood flow to the vessel (thrombotic episode), or because there is a rupture of the vessel and the blood circulates around it.(hemorrhagic episode). As a result, the damaged brain cells either stop functioning or they die. When this occurs, the function of body parts regulated by these cells is disrupted or interrupted.
Depending on the area of the brain affected by the stroke, patients may lose speech, sensation, muscle strength, movement, vision, and memory. These symptoms in some patients subside and they are cured, but in others they remain as residues that cause permanent disability, while some patients lose their life.
In ischemic strokes, immediate treatment is needed to prevent damage to a larger area of the brain where blood flow has decreased but has not stopped.
In hemorrhagic strokes, immediate treatment, when necessary, prevents a second hemorrhage.
What is a Transient Ischemic Attack?
A transient ischemic attack is a temporary disruption of blood flow to a part of the brain. It may take a few seconds, or a few hours, but usually takes less than 24 hours. It is an important warning sign of a future stroke in the coming hours, or days. It is an indication that the blood flow to the brain is impaired and should be evaluated with the same urgency as for a stroke.
What are the symptoms of a Cerebrovascular Accident?
The symptoms of the cerebrovascular accident may vary. Sometimes they appear in a slow pace and sometimes in a very fast one. It is even possible to wake up to the symptoms.
Immediate medical help should be sought if suddenly one of the following symptoms occurs:
- Numbness or weakness in the face, hand, foot, mainly on one side of the body
- Confusion, or disorder of speech or of perception
- Vision disorder in one or both eyes
- Walking and coordinating movement disorder, vertigo, instability
- Severe headache
Unfortunately, from the onset of symptoms of a cerebrovascular accident, there is a very limited time frame within which effective treatment can be applied. In the event of delays, the possibility of intervention is lost.
The stroke is progressing rapidly, which means that the patient should be taken care of by doctors as soon as possible.
How is the Cerebrovascular Accident diagnosed?
Evaluation by a Neurologist or another physician will help diagnose CVA and provide information for understanding the cause.
The evaluation includes:
-
- Physical examination
- Neurological examination
- Blood tests
- Brain imaging exams (Computed tomography, MRI)
- Brain Vascular Imaging (Angiography)
- Cardiac function tests ( -Electrocardiogram (ECG)
-Ultrasound cardiogram
-Heart rate tracking)
What doctor can diagnose a Cerebrovascular Accident?
The family doctor (Physician, General Practitioner) may make the first diagnosis of a potential stroke, but Neurologists are doctors who specialize in brain and nerve disorders and are involved in the diagnosis of Cerebrovascular Accident.
To be able to provide the best care, your Neurologist needs to know all your symptoms and medical history.
You need answers to your questions. It will be helpful if there are notes on the patient's condition and few, well-structured, patient questions at each appointment with the physician.
What treatment options are there?
Immediate medical care is important.
For ischemic stroke patients who meet certain criteria, a thrombolytic drug, the tissue plasminogen activator (tPA), can improve the progression when given within 4 hours from the onset of the symptoms. The earlier the treatment is given, the more likely it is to prove helpful.
In some cases there are other ways of removing blood clots from the brain vessels.
The need to expand the temporal, therapeutic window and to treat patients with large vessel obstruction has led to the development of intra-arterial treatments. These are intra-arterial thrombolysis and intra-arterial thrombectomy, or mechanical thrombolysis. The intra-arterial treatments can be applied within 6 hours of the onset of symptoms. After puncturing the femoral artery (the artery of the leg), a microcatheter is advanced to the artery with the blood clot. Through the microcatheter a thrombolytic substance (tPA) is injected directly into the clot, or with the help of a special apparatus the clot is mechanically removed.
The treatment, within the first 24 hours, is aimed at preventing and addressing the potential immediate complications of the episode by improving recovery and preventing future strokes. It includes medicines that liquefy the blood, lower blood pressure and cholesterol, and in some cases invasive methods are used to repair arterial stenosis.
Other treatment aim at reducing the risks of complications immediately by optimizing recovery and preventing future cerebrovascular accidents. They include medicines that liquefy the blood, and medicines that lower blood pressure and cholesterol. In some cases, stents are used to open the inside of blood vessels with stenosis in the neck.
For hemorrhagic Cerebrovascular Accidents the treatment includes:
- Blood pressure lowering drugs
- Surgical treatment for blood drainage of the brain or lowering of the intracerebral blood pressure
- Surgery to repair ruptured blood vessels
- Introduction of a coil to prevent vascular bleeding
- Peripheral brain medicines
- Insertion of a drainage tube to reduce intracerebral pressure
Life after the Cerebrovascular Accident
Although some patients recover after a cerebrovascular accident, others continue to have problems depending on the location and the size of the stroke, such as:
- Memory, concentration and attention problems
- Difficulty of speaking or understanding oral speech
- Difficulty to swallow
- Emotional problems, such as depression
- Vision loss, often on one side
- Loss of power, or sensation of one side of the body
- Loss of balance, or ability to walk
Further physiotherapy helps to regain lost function after a stroke injury, in combination with occupational therapy and speech therapy if needed.
In recovery, most will improve, some not completely.
The brain can learn new ways of working using intact brain cells.
Preventing a Second Cerebrovascular Accident
People who have already had a cerebrovascular accident are at greater risk for another stroke than those who have never had an event.
The patient should discuss with the Neurologist about the ways one can prevent a second stroke, including medications and lifestyle changes such as:
- Diet poor in salt, fat, cholesterol, sugar
- High blood pressure control
- Blood sugar adjustment
- Stopping of smoking
- Regulation of cholesterol medication
- Antiplatelet drugs
Post-stroke rehabilitation is often a major problem for both patients and their caregivers. Continuous support for both the patient and the caregiver is needed, with the help of not only physical but also mental support, to minimize the severe deficit in the quality of daily living created by disability.
Successful achievement of this goal requires simultaneous support from family and carers, with supportive carer and family psychotherapy, guidance for participation in programs and groups for people with stroke, support from social workers with regards to social, legal and bureaucratic issues concerning people who had suffered a cerebrovascular accident.
