What is Acute Stroke (Stroke)?
An acute stroke is often called a “cerebrovascular accident,” but it’s not really an accident. It’s more accurately described as a “brain attack,” similar to a “heart attack.” Yet, strokes can vary more widely than heart diseases. We mainly categorize strokes into two types: ischemic, where a blood vessel gets blocked and cuts off blood supply to the brain, and hemorrhagic, where a blood vessel ruptures, causing blood to spill into the brain. Hemorrhagic strokes can be further classified into two types: spontaneous intracerebral hemorrhage and spontaneous aneurysmal subarachnoid hemorrhage.
According to the American Heart Association and The American Stroke Association, simply put, a stroke is a sudden episode of brain dysfunction that lasts for more than 24 hours. It’s the second leading cause of death worldwide and a leading cause of disability. It also causes a considerable financial burden given the costs of medical care required before, during, and after hospitalization.
It’s vital to understand that the chance of a full neurological recovery decreases with each passing minute in an untreated acute stroke. This idea forms the basis of the “time is brain” concept, stressing the need for quick diagnosis and treatment of an acute stroke. Early specific treatments, along with rehabilitation programs and long-term lifestyle changes, can significantly improve outcomes for someone experiencing an acute stroke. Hopefully, these measures can optimize the recovery for each patient and lessen the global impact of strokes.
What Causes Acute Stroke (Stroke)?
Ischemic strokes happen in various ways, with over 100 linked conditions. According to a classification system used in a stroke treatment study, the main causes of ischemic stroke fall into three categories: large vessel disease, small vessel disease, and clots formed in the heart.
Large vessel disease includes conditions such as hardening of the arteries, tearing in the artery wall, and clots passing from one artery to another. If a clot or blockage occurs in a major artery, it can result in specific symptoms due to reduced blood flow to certain parts of the brain. Major arteries include those within the brain and those leading to the brain from the neck.
Strokes related to small vessel diseases, or “lacunar strokes”, are often associated with diseases causing thickening of the walls of smaller blood vessels, which can block the smaller arteries penetrating the brain. Hardened deposits, known as plaques, formed in larger arteries can also cause such blockages.
Clots forming in the heart, or “cardioembolism”, can lead to stroke. These can come about through various heart-related issues, including irregular heart rhythms, valve disease, and heart muscle disease.
Key risk factors for Ischemic stroke hit close to home for many people. They include old age, high blood pressure, diabetes, high cholesterol, cigarette smoking, irregular heart rhythms, and heart disease.
Intracerebral Hemorrhage is the second most common stroke form. It usually occurs when small arteries in the brain burst, often due to high blood pressure, a disease that causes deposits to form in the brain’s blood vessels, coagulation disorders, and other blood vessel diseases. Several factors can lead to this, including getting older, high blood pressure, smoking, heavy drinking, certain medications, and drugs that constrict blood vessels.
Lastly, Subarachnoid Hemorrhage is responsible for about 5% of all strokes. In most cases, it happens when an aneurysm, a bulge in a blood vessel that can rupture, in the brain breaks open. Other potential causes include drug use, coagulation disorders, a rupture in an abnormal connection between arteries and veins, as well as a blood clot in the veins covering the brain. Risk factors include smoking, high blood pressure, heavy alcohol consumption, getting older, a personal or family history of aneurysms or this type of stroke.
Risk Factors and Frequency for Acute Stroke (Stroke)
Stroke is the second primary cause of death around the globe and contributes significantly to disability. The most common type of stroke is ischemic stroke, which makes up about 62% of all strokes. Following this, Intracerebral hemorrhage (ICH) makes up 28%, and subarachnoid hemorrhage (SAH) accounts for 10%. Even though ischemic strokes occur more frequently, hemorrhagic strokes often result in more deaths and contribute to a higher number of disability-adjusted life years (DALYs).
Between the years 1990 and 2019, there was a notable decrease worldwide in the rates of ICH and SAH strokes per year, in comparison to ischemic strokes. These changes include the number of strokes happening, current strokes, deaths from stroke, and DALYs because of stroke.
- Both men and women across the globe have roughly a 25% risk of having a stroke, starting from the age of 25.
- This risk is particularly high in East Asia and Central and Eastern Europe.
Signs and Symptoms of Acute Stroke (Stroke)
When a person comes in with signs of a sudden neurological issue, a fast and focused evaluation of their medical history and current physical state is necessary. This assessment helps in distinguishing if the case is an actual stroke or something that just appears to be a stroke, and if it’s a stroke, determining the type and subtype. Sometimes, conditions like low blood sugar, seizures, or migraines can mimic a stroke.
Ischemic Stroke
This kind of stroke happens when blood flow to the brain gets blocked. When checking for this, we should know about when the person was last seen as being fine, how the symptoms started, the patient’s risk factors, their current medications, and other relevant information that could suggest an underlying disease. A targeted neurological examination should be conducted using the National Institutes of Health Stroke Scale.
Intracerebral Hemorrhage (ICH)
This condition involves bleeding within the brain and can happen at any time, even during normal activities or physical exertion. The symptoms usually get worse within a few minutes to hours. During hospital stay, further worsening of symptoms is often observed due to the growing bleed and its effects. Symptoms can vary and may include nausea, vomiting, and headache. Some people may experience seizures at the start of bleeding or within 24 hours. Adequate brain imaging is necessary to distinguish ICH from other conditions.
Subarachnoid Hemorrhage (SAH)
Similar to ICH, this type of bleed often occurs during everyday activity or rest, but can also happen during physical activity. A common symptom of SAH is a severe and sudden headache, often described as the worst headache ever experienced. Other symptoms can include neck pain or stiffness, sensitivity to light, vomiting, changes in mental state, and loss of consciousness. Some may report a severe headache days or weeks before the bleed happens. Seizures could also occur. In terms of physical signs, there may be one-sided vision loss, difficulty in recognizing spatial relations, eye movement disorders, and internal bleeding in the eye. Other possible findings include muscle weakness on one side, difficulty with language, and a loss of initiative. For a neurological assessment, the Hunt-Hess scale or the World Federation of Neurological Surgeons scale can be used.
Testing for Acute Stroke (Stroke)
If someone is suspected to have had a stroke, neuroimaging – using methods like computed tomography (CT) scans or magnetic resonance imaging (MRI) – plays a vital role in managing the patient’s condition. According to the 2019 guidelines for stroke management, every patient suspected of having a stroke should have an emergency brain scan as soon as they arrive at a hospital. This step is important for ruling out hemorrhage (bleeding within the brain) before giving certain treatments.
If a patient has stroke symptoms that started within the last 6 hours and shows a small area of dead brain tissue from lack of blood supply, a CT angiography (CTA) or MR angiography (MRA) is suggested. These tests can help decide if removing a blood clot, a process known as mechanical thrombectomy, is appropriate. However, for stroke symptoms that began between 6 to 24 hours prior, and shows a large-vessel occlusion (a blockage in the major brain arteries), diffusion-weighted MRI (DW-MRI) or CT perfusion are recommended for further assessment.
For patients who wake up with stroke symptoms or where the time of the stroke onset is unknown, an MRI is necessary. If the MRI shows positive results on the diffusion scan and negative results on the fluid-attenuated inversion recovery (FLAIR) scan, the patient could benefit from thrombolytic therapy, which involves using medication to break down blood clots.
In patients with an intracranial hemorrhage (bleeding within the brain), a CT angiography during the first hours of noticing symptoms can spot those at risk of hematoma expansion (enlargement of the blood clot). Moreover, having a CT scan within the first 24 hours can watch out for any expansion of the blood clot.
If a subarachnoid hemorrhage (bleeding into the space surrounding the brain) is suspected, non-contrast CT imaging is usually the first step. If the CT scan doesn’t find anything but the suspicion remains high, a lumbar puncture (a procedure to collect fluid from the spine) is recommended. In this situation, interpreting CT scans using the Ottawa subarachnoid hemorrhage rule showed high accuracy in diagnosing the condition. If the CT angiography can’t confirm the presence of an aneurysm (a bulge in a blood vessel caused by a weakness in the vessel wall), the best test is the digital subtraction catheter angiography with 3-dimensional reconstruction.
According to the 2019 guidelines, for patients suspected to have had a stroke, it’s important to check their blood sugar level before initiating certain treatments, as both low and high blood sugar levels can mimic stroke symptoms. An electrocardiogram (ECG) is also advised for patients to identify possible heart problems but it should not delay administering time-sensitive treatments. Similarly, checking the troponin level, a protein released into the bloodstream during a heart attack, is recommended but should not stall initiating treatments.
Treatment Options for Acute Stroke (Stroke)
Every minute that a stroke is left untreated reduces the chances of a full recovery. This is why it’s crucial to evaluate and treat a stroke quickly.
Here are a few key guidelines when it comes to treating strokes, according to health organizations:
- In patients suffering an ischemic stroke, those with high blood pressure should have their blood pressure carefully reduced. The target is to maintain their blood pressure below 180 over 105 for at least 24 hours following treatment.
- Oxygen should be supplemented to these patients to maintain their oxygen levels above 94%. However, this is not recommended for patients whose oxygen levels are already normal.
- Body temperatures above 38°C or 100.4°F, high or low blood glucose levels should be treated accordingly.
- Intravenous alteplase, a type of drug, is highly recommended for eligible patients within 4.5 hours from when symptoms begin to show or when the patient last appeared healthy.
- Patients are encouraged to undergo mechanical thrombectomy, a procedure that involves the removal of a blood clot, if they fulfill certain specific criteria. This is also recommended for patients within 24 hours of symptom onset.
- Aspirin should be administered within 24 to 48 hours after the onset of symptoms. Other patients may also require dual antiplatelet therapy with aspirin and clopidogrel within 24 hours of symptom onset.
For patients suffering a hemorrhagic stroke, initiating treatment for elevated blood pressure within 2 hours of symptom onset and reaching the target blood pressure within 1 hour may decrease the risk of hemorrhage and improve outcomes. In patients with mild-to-moderate hemorrhagic stroke, the target is to maintain their blood pressure between 130 and 150 mm Hg.
Surgical management can also be useful in certain patients. This may involve minimal surgical intervention to remove the blood clot.
For patients suffering from subarachnoid hemorrhage, intervention should ideally be carried out within 72 hours of symptom onset to decrease the risk of rebleeding. Blood pressure should be maintained below 160 mm Hg until the ruptured aneurysm has been coiled or clipped. Any seizures associated with this condition should be treated with antiepileptic drugs. Other treatment goals include pain control, maintaining a balanced fluid level in the body, normal body temperature, and normal blood glucose levels.
What else can Acute Stroke (Stroke) be?
In diagnosing a suspected stroke, doctors take into account a list of 20 common conditions that might share similar symptoms. These conditions together account for almost all of the cases where patients thought to have a stroke, were eventually ruled out as having either a confirmed mini-stroke (transient ischemic attack) or an actual stroke. The top 5 conditions seen most frequently in these cases are seizures (19.6%), fainting spells (syncope, 12.2%), severe infections (sepsis, 9.6%), general non-dangerous headaches (9%), and brain tumors (8.2%).
What to expect with Acute Stroke (Stroke)
Studies have emphasized the huge impact of acute stroke, regardless of its specific type, and the importance of joint efforts to improve care for stroke patients, prevent secondary strokes, and enhance long-term outlooks.
According to a 2019 analysis for the Global Burden of Diseases, the number of strokes and deaths caused by stroke increased significantly between 1990 and 2019.
A research study conducted in the United Kingdom found that five years after their first stroke, almost half of patients had passed away and about 39% were living with disabilities.
In a Swedish study, survival rates differed between patients with ischemic stroke and those with a type of stroke called ICH. Thirty days after their first stroke, about 90% of patients with ischemic stroke were alive, compared to about 70% of patients with ICH. Overall, after five years, survival rates were higher for ischemic stroke patients (about 50%) than ICH patients (about 38%). This study observed a trend: five years after their first stroke, over 65% of patients with ischemic stroke and over 75% of patients with ICH were either deceased or dependent due to impairments.
An Australian study found that survival rates for hospitalised stroke patients were 52.8% at five years and 36.4% at ten years. There was also a significant chance (19.8% at five years and 26.8% at ten years) of having a second stroke.
A Dutch study focused on young stroke survivors aged 18-49, found that the risk of death remained higher than the general population for up to 15 years after the stroke.
In another UK study, it was observed that the recurrence rate of stroke within five years decreased from 18% between 1995-99 to 12% between 2000-05. However, since 2005, there has been no further reduction in stroke recurrence rates.
A Danish study showed that the risk of a recurrent stroke after a first one was 4% within a year and 13% after 10 years for ischemic stroke, with almost similar rates for ICH. Moreover, the overall risk of death after a first stroke was 17% at one year and 56% at ten years, increasing after repeated strokes. As for ICH, the mortality risks were also high and increased after recurrent strokes.
Possible Complications When Diagnosed with Acute Stroke (Stroke)
Medical complications following a stroke can greatly affect a person’s health and survival chances if not correctly predicted, prevented, and taken care of.
For the treatment of ischemic stroke, using a drug called IV alteplase can have side effects. These may include bleeding within the brain (in 6% of cases), severe body-wide bleeding (2% of cases), and swelling under the skin (5% of cases). It is important for medical practitioners to be ready to manage these potential serious side effects before they administer the drug.
When a large area of the brain is affected by a stroke, it can lead to swelling in the brain. Depending on how severe it is, surgery might be necessary. Such surgery has been shown to help reduce death rates.
If the patient experiences repeated seizures after a stroke, they should be treated in a similar way to seizures triggered by other acute neurological conditions. It’s also important to note that using seizure prevention drugs is not recommended.
For cases of intracerebral hemorrhage (a type of stroke that causes bleeding within the brain), identifying and preventing medical complications early on are crucial during the initial hours and days. It helps to follow standard protocols and have order sets to reduce the chances of disability and death. Additionally, it’s recommended to carry out formal dysphagia screening before allowing oral intake. This screening helps reduce the risk of disability and pneumonia. Treating high body temperature with fever-reducing drugs, standard cooling blankets, water-circulating devices for surface cooling, or tube-shaped devices for cooling is also advised. Also, monitoring and preventing both low and high blood sugar levels is suggested.
In cases of subarachnoid hemorrhage (a type of stroke that causes bleeding in the space surrounding the brain), secondary brain injury can happen due to intracerebral hemorrhage, intraventricular hemorrhage, increased pressure within the skull, water on the brain, bleeding under the skull’s inner layer, or cerebral infarction.
Medical complications are common occurrences and can have a significant effect on a patient’s outcome. Some reported complications include:
- High body temperature
- Serious body-wide infection
- Pneumonia due to inhaling food, stomach acid, or saliva into the lungs
- Heart problems
- Lack of enough healthy red blood cells
- Low sodium levels in the blood
- High blood sugar levels
- Blood clot in a deep vein
Having critical care strategies focussed on preventing these complications, spotting them early on, and treating them effectively, such as maintaining normal body temperature and blood sugar levels, is advisable.
Recovery from Acute Stroke (Stroke)
Rehabilitation therapies are crucial for helping stroke survivors return to their everyday activities and improve their overall quality of life. However, there’s still a lot of discussion about the best time and intensity for these rehabilitation services. Some studies suggest that starting to move around too soon (within 24 hours of having a stroke) might actually be harmful, as it could increase the risk of issues related to blood pressure and falls. However, we need more research to fully understand the implications.
Most studies recommend starting therapy services within 2 weeks after the stroke. Depending on the effects of the stroke, these services often include physical, occupational, and speech therapies. The main goals are to help deter falls, improve walking and balance, avoid cramping and bedsores, enhance daily activities like bathing, feeding, and dressing, and address any speech and cognition issues. There are many different techniques used to address stroke-related challenges, like mirror therapy, electrical stimulation, task-focused training and cognitive exercises. To help manage pain in the shoulder after a stroke, techniques like electrical stimulation on the skin or using tape or straps can be used.
Despite all this, more research is still needed in order to find the best ways to help stroke survivors’ recovery. Many existing studies don’t quite provide a clear cut answer or only use small groups of people, which means their findings may not apply to everyone who’s had a stroke.
Preventing Acute Stroke (Stroke)
Acute stroke, a sudden interruption of blood supply to the brain, can both be prevented and treated. One way to prevent it is through creating awareness and educating people about the risk factors and warning signs. Various public education programs have been successful in guiding people to timely recognize early symptoms of a stroke, thereby ensuring they get to emergency services sooner. This quick response has been shown to reduce the time it takes for diagnosis and treatment.
There are certain risk factors for stroke that we can control or change. These include lack of physical activity, unhealthy cholesterol levels, poor diet and nutrition, high blood pressure (the major and most well-studied risk), obesity, diabetes, smoking, and atrial fibrillation (an irregular, often rapid heart rate). As such, changes in exercise and diet routines, giving up smoking, and medication to control blood pressure, cholesterol levels, and diabetes can be crucial for acute stroke prevention. A special scoring system known as CHA2DS2-VASc score is recommended for patients with atrial fibrillation, to predict the risk of stroke and guide prevention treatment.
Stroke is also a serious complication in individuals with sickle cell disease (SCD), a condition affecting red blood cells, especially in early childhood. Strokes mostly occur in patients with the most severe form of SCD, making this group a primary focus for prevention strategies.
After a person has suffered an acute stroke, it’s important for them to receive thorough information, counseling, and opportunities to talk about their experience. Caregivers also need to be educated, supported, and trained to improve the patient’s and their own quality of life.
