In Belgium, stroke is the second most common cause of death and the leading cause of disability in adults. A stroke is a medical emergency, and prompt treatment is crucial. The faster a stroke is recognized, the faster treatment can be started, thus lowering the risk of brain damage and disability.
A stroke occurs when a blood vessel, that carries nutrients and oxygen to the brain, is blocked by a clot or ruptures. When that happens, a part of the brain cannot get the blood and oxygen it needs, leading to brain damage and cell death. The effects of a stroke depend on several factors, including the location and how much brain tissue is affected.
Types of stroke
An ischemic stroke is caused by a clot or other blockage within an artery leading to the brain, causing oxygen loss and tissue damage. It is the most common type of stroke, accounting for almost 80 percent of all strokes.
A TIA (transient ischemic attack) is when the blood supply to the brain is only temporarily interrupted (less than 24 hours), so no brain tissue is damaged and symptoms resolve without treatment. Nevertheless, a TIA is often a warning sign of an ischemic stroke, so prompt treatment is warranted.
An intracerebral hemorrhage is caused by the sudden rupture of an artery within the brain. Blood is then released into the brain compressing brain structures and causing secondary tissue damage.
A subarachnoid hemorrhage differs from an intracerebral hemorrhage in that the location of the rupture leads to blood filling the space surrounding the brain rather than within the brain.
How do we recognize a stroke?
Marie arrived home after driving her children to school, when she found her husband Eric sitting on the couch. She had difficulty understanding what Eric was saying. She also noticed that the right corner of his mouth was drooping. She immediately recognized “possible stroke” symptoms and called 112. A few minutes later, the ambulance arrived.
In recent years, stroke treatment has considerably improved, giving patients better chance to achieve independence. To minimize the risk of long-term disability, treatment must be initiated as fast as possible. Recognizing stroke symptoms is key to stroke care.
Symptoms suggesting a stroke are:
- Weakness or paralysis of an arm or a leg
- Non-fluent or slurred speech, difficulty to understand others
- Facial droop or deviation of the mouth
- Numbness of an arm, a leg or one side of the face
- Brutal loss of vision or double vision
- Imbalance, gait disturbances (drunk-like gait)
- Sudden dizziness and/or loss of coordination.
- A sudden, severe headache (like a thunderclap), which may be accompanied by vomiting, dizziness or altered consciousness.
- Sudden confusion.
As Marie did, one should promptly call 112 when recognizing one or several of these symptoms.
How do we treat stroke ?
Eric arrived in the emergency room of the local hospital. A large team of staff was already awaiting him, as the ambulance had informed them about his arrival. Faster than a Formula-1 pit stop, two nurses placed an intravenous catheter in each arm, while the stroke neurologist did a quick neurological evaluation. Within minutes of his admission, Eric was on his way to the brain CT-Scan.
Obtaining a brain imaging (through CT-Scan or MRI) is the first step of in-hospital stroke care. This allows the medical team to know the type of stroke they are dealing with and to rule out other conditions.
In case of ischemic stroke, the main goal is opening the occluded vessel as fast as possible. Depending on the location of the clot and time after symptom onset, two acute treatments can be proposed:
- Intravenous thrombolysis: intravenous medication aimed at dissolving the clot.
- Mechanical thrombectomy: and endovascular technique aimed at removing the clot mechanically through a device inserted by inguinal puncture.
Currently, intravenous thrombolysis may be used within 9 hours following stroke onset, and mechanical thrombectomy may be used within 24 hours, in selected cases. Although these time intervals seem long, the basic principle is “TIME IS BRAIN”. The faster these treatments are given, the better the functional outcome after treatment will be.
Causes of stroke
Certain conditions increase the risk of having a stroke, including:
- high blood pressure (hypertension)
- high cholesterol
- diabetes mellitus
- drug abuse (cocaine, amphetamine, cannabis)
- presence of atherosclerosis/atheromatous plaque, leading to narrowing of the vessels
- atrial fibrillation or other cardiac sources of clot
- cerebral small vessel disease (different pathological processes that affect the small vessels of the brain)
- familial history of stroke
Further, some rare causes of stroke include:
- inflammation of vessel walls
- tear of the vessel wall (dissection)
- congenital heart defects including a PFO (patent foramen ovale) in certain conditions
- vascular malformations: aneurysm (arterial blood vessel wall ballooning at a weak spot), arteriovenous malformation (AVM)
- hereditary causes of stroke
How do we prevent another stroke?
The first step consist of understanding the stroke mechanisms.
During the hospital stay, different investigations will be carried out to find out the underlying cause of the stroke. Risk factors also need to be treated to reduce the risk of further stroke or other cardio-vascular disease.
The medical treatment could contain:
- a treatment preventing clot formation (antiplatelet treatment, anticoagulation treatment)
- a lipid-lowering treatment (usually statins)
- an anti-hypertensive treatment (if present)
- an anti-diabetic treatment (if present)
Several lifestyle modifications are needed to reduce the risk of another stroke:
- diet: the Mediterranean diet is recommended, consisting of a lot of fruit and vegetables, whole grain cereals, vegetable oil, nuts, seeds, fish and water
- salt intake should be limited to 6gr/day
- red meat consumption should be limited
- tobacco use: should be promptly stopped
- alcohol: should be limited to 10 alcoholic consumptions per week
- physical exercise is highly recommended, 3 to 4 times a week for at least 30 minutes, intense enough to induce sweat production or increase heart rate
- reduce stress
Thanks to Marie’s prompt response, Eric was treated with intravenous thrombolysis. One week after presentation, his speech difficulties improved considerably.
During hospitalization, he was diagnosed with an atheromatous plaque narrowing the left carotid artery, caused by smoking, but also previously unknown high blood pressure and raised blood cholesterol. A surgical procedure to remove the plaque was performed to reduce the risk of stroke recurrence.
He is now ready to go back at home with preventive drugs, including antiplatelet, anti-hypertensive and lipid-lowering medication, and speech reeducation.