A stroke is a serious and sometimes life-threatening condition. It is a leading cause of disability and the fourth leading cause of death among Americans. Until recently, if you were to experience a stroke, supportive care was all that was available. But now, stroke management has progressed to a point where a stroke can be stopped in its path.
There are treatments available that can prevent or limit disability caused by a stroke as well as saving many lives. The success of such treatments is dependent upon how much time has passed since the stroke symptoms appeared. Therefore, the early recognition of a stroke by the patient or their family is of the utmost importance. This article will attempt to give you the information you need to recognize a stroke and respond accordingly.
What is a Stroke?
There are blood vessels that are dedicated to providing each and every region of the brain with the nutrients and oxygen that it needs to function. Over the years, a plaque from cholesterol and other lipid substances can start to build up in the blood vessels causing them to narrow, and if that plaque ruptures producing damage to the vessel wall, the body tries to heal it. Clot-forming molecules will reach the site and clot off the vessel. Once the blood vessel is closed, there is no blood flow to the tissue beyond the blockage. Sometimes, the clot will dislodge, travel in the blood and block a smaller vessel downstream. Without oxygen and nutrition, the tissue beyond the blockage will begin to die.
A stroke due to such an underlying mechanism is referred to as ischemic, and the severity of it will depend upon the location of the blood clot. This is the predominant form of stroke, at least 8 out of every 10 cases of stroke are ischemic strokes.
Another less frequent type of stroke occurs when a blood vessel ruptures and causes bleeding into or around the brain. This type of stroke is called a hemorrhagic stroke. Although not impossible to treat, this type of stroke tends to be more serious and difficult to handle.
Review the healthcare provider algorithm for response to stroke which includes the Cincinnati Prehospital Stroke Scale and take our online quiz for stroke response.
Why Me? Causes of Stroke
Stroke risk is increased by the same factors that increase the risk of suffering a heart attack: smoking, obesity, diabetes, hypertension, sedentarism, and high cholesterol, all contribute to the risk of stroke. Anything that you can do to change these risk factors will decrease your chances of having a stroke. There can be a genetic component to stroke risk, as well as drug-related factors.
An important note is that the hemorrhagic stroke can often appear without any kind of risk associated, as it is a stroke that can appear due to an aneurysm or congenital issues.
Recognizing a Stroke by Signs and Symptoms
Since the medical management of a stroke varies depending on the length of time since symptoms first appeared, and due to the fact that this will affect prognosis, a prompt recognition of a stroke is extremely important.
Keep in mind that stroke symptoms usually start quite suddenly and get worse over time. You may be sitting at a table and suddenly be unable to hold your coffee cup or get your words out correctly. Signs and symptoms of stroke include sudden onset of weakness on one side of the body and slurred speech or dysarthria, meaning, the inability to make your words come out right. A sudden change in the way you walk or feeling that one leg is not “acting right” can be a sign of stroke. Some patients also notice changes in their ability to see. Loss of balance is another common sign of stroke. Patients who have blood around their brain may complain that “they have the worst headache of their life”.
A useful acronym to recognize and respond to stroke is FAST:
- Drooping of one side of the face. Ask the person to smile and note if it is uneven.
- Weakness or numbness in one arm. Ask the person to lift both arms. Does one extremity drift downward or is the person unable to lift it?
- Difficulty in speech, is it slurred? Ask the person to repeat a phrase and note any changes in speech.
- If any of these symptoms are present, it’s time to call 911 immediately. Also, take note of the time since symptoms onset, which will be required by doctors to decide on appropriate treatment.
In the case of a hemorrhagic stroke, the symptoms appear in a more abrupt way and varies from the ischemic one, the headache is the first thing to appear, it consists of a very severe pain which makes the patient feel like “his head is gonna explode”, then the rest of the symptoms start to appear.
Nausea and vomiting are common along with dizziness and a very stiff neck, usually accompanied by confusion and even seizures, this set of symptoms are called “meningeal syndrome” due to the inflammation of the meninges (a set of membranes that cover the brain and spinal chord), thanks to a severe and sudden hemorrhage in the brain.
It is important to remember though, that the only and best way to ascertain the type of stroke along with the adequate treatment for it, is through imaging studies, for example, a CT scan or an MRI, this last one uses magnets and radio waves in order to create pictures of the organs and structures of the body. This test can detect changes or damage to the brain tissue. All of this is done in the confines of a medical center, so it’s important to take note that we have to act fast in order for the adequate treatment to be given.
I’m Having a Stroke! What Should I Do?
It is imperative that you get help and get to a hospital AS SOON AS POSSIBLE following the onset of symptoms of stroke. Treatment for stroke is very time-dependent. A clot-busting medication can be given to clear the clot from the vessel, but only if you are at the hospital within 3 hours (4.5 hours for some patients) of onset of symptoms.Call 911 IMMEDIATELY. Do not wait for relatives to arrive, do not wait while you pack clothing for the hospital or wait for your family to return a call. The amount of damage done by the stroke is subject to how long the blood vessel remains blocked. Keep in mind that TIME IS BRAIN. For every minute you delay getting medical attention, more brain tissue is being damaged.
If you are calling help for a friend or family member, after dialing 911, you should attempt to determine the time since symptoms began. If you arrived at your family member’s house and found them having symptoms, it may be advantageous to phone a neighbor that may have seen them. You are attempting to figure out the time that the patient was “last known well”. This could be a telephone conversation, a neighbor who saw them getting their mail earlier in the day or the report of someone who was with them when their symptoms began. This is important because the clot-busting medication can only be given within a certain timeframe.
It is also important to note that in the case of a hemorrhagic stroke, since this type of stroke does not derive from pressures from a clot or a plaque, an utmost care must be taken if the patient was taking any form of clot-busting medication since these kinds of treatments generally worsen the stroke itself.
What to Expect When the Ambulance Arrives
The paramedics and EMTs will focus on two things: making sure that your vital signs are stable and transporting you quickly and efficiently to a stroke center that is capable of treating you.
Don’t be surprised if EMS encourages you to go to a hospital other than the one that you would prefer. There are certain hospitals that are classified as Stroke Centers of different levels. Comprehensive stroke centers (usually the larger teaching hospitals) are capable of not only giving clot-busting medication but are also able to perform procedures quickly to remove the clot and restore your blood flow.
If you are transported to a hospital that is not a stroke center, valuable time will be wasted while they complete their assessment and diagnostic testing and then transfer you to an appropriate stroke center for treatment. Transporting you directly to the closest stroke center available can save precious time. Most EMS have protocols in place for this purpose.
What Treatments are Available for Stroke?
Since ischemic stroke is the most common type of stroke, its treatment is the one described here. At the end of this section, you will find links to articles on stroke management which include treatment of hemorrhagic stroke. Remember, for any type of emergency treatment, the earlier it’s begun, the better the results.
Clot-Busting Medication: tPA is a clot-busting medication that has been used for many years to treat strokes, heart attacks, and pulmonary embolisms (clots in the blood vessels of the lungs). It is given intravenously and dissolves the clot to restore blood flow. It is, however, not without complications: tPA can cause bleeding in the brain and other parts of the body. So, you will be assessed to make sure that you are not at high risk of bleeding. For example, if you recently had a major injury, surgery or internal bleeding, it would be too dangerous to administer a clot-busting medication for your stroke. Clot-busting medication cannot be administered if more than 3 hours (4.5 hours in some cases) have elapsed since symptom onset. After such time the risks outweigh benefits. That is why it is important to know when symptoms began. The time that your symptoms began is the time when the blood vessel became occluded.
Percutaneous Interventions: just like with a heart attack there are procedures to place a catheter directly into a vessel that feeds the brain and remove the clot that is blocking it. A catheter is placed through the groin and threaded up to the blood vessel that has been blocked. The clot can then be dissolved by directly delivering clot-busting medication or it can be physically removed with the help of a tiny device at the end of the catheter.
The treatment of a hemorrhagic stroke varies from the ischemic one. Due to the fact that a hemorrhagic stroke appears more suddenly and even without previous risks associated (hypertension in the case of an ischemic stroke) the time to act when presented with a hemorrhagic stroke must be faster.
Anticonvulsivants due to the high risk of seizures related to a hemorrhagic stroke, different forms of anticonvulsants are administered, which can then be extended for weeks or even months until the risk is lowered.
Antihypertensive agents and diuretics since most hemorrhagic strokes derive from a sudden high blood pressure, a drug that lowers said blood pressure needs to be administered along with another one that helps the intracranial/meningeal pressure, this kind of treatment is often given with care due to the risks associated with them and with the stroke itself.
Surgical procedures the main objective of a surgical procedure to treat a hemorrhagic stroke is to drain the blood from the meninges, alleviating the pressure done on said areas and helping with the onset of symptoms derived from it.
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