Stroke

The brain needs a constant supply of oxygen and nutrients in order to function. A stroke, also called cerebrovascular accident (CVA), occurs when blood flow to the brain is disrupted. Even a brief interruption in blood supply can cause problems; brain cells begin to die after just a few minutes without blood or oxygen.

Patients who come in through our emergency rooms are quickly examined and given priority in all testing and diagnosis. Within minutes of a stroke code, our team performs a full patient assessment, rushes the patient to CT/MRI imaging and develops a treatment plan. After the initial treatment, patients are monitored around the clock for neurological changes.

Several Northwell hospitals utilize Telestroke. Telestroke uses a computer screen and video camera to allow neurologists (doctors who have special training and experience in stroke care) to evaluate you even if they are not in the hospital. Telestroke lets you to receive a fast brain evaluation by a stroke specialist. This evaluation helps the doctor know if you are able to receive “clot-busting” drug or other ways to treat your stroke. The faster you have your stroke treated, the more likely you are to reduce stroke-related disabilities. Telestroke neurologists are available to you any time, day or night, every day of the year.

The following are the most common symptoms of stroke. However, each individual may experience symptoms differently.

Symptoms may be sudden and include:

• Weakness or numbness of the face, arm or leg, especially on one side of the body
• Confusion or difficulty speaking or understanding
• Problems with vision, such as dimness or loss of vision in one or both eyes
• Dizziness or problems with balance or coordination
• Problems with movement or walking
• Severe headaches with no other known cause
• Brief loss or change of consciousness such as fainting, confusion, seizures or coma
• Sudden nausea, vomiting or fever not caused by a viral illness
• Transient ischemic attack (TIA), or "mini-stroke"

If any of the above symptoms are present, call 911 (or your local ambulance service) immediately. Treatment is most effective when started immediately. Note that all of the above warning signs may not occur with each stroke. Do not ignore any of the warning signs, even if they go away—take action immediately. The symptoms of stroke may resemble other medical conditions or problems. Always consult your doctor for a diagnosis.

A stroke happens when blood flow to the brain is disrupted. This disruption is caused by a blood clot that blocks one of the vital blood vessels in the brain (ischemic stroke) or when a blood vessel bursts, spilling blood into surrounding tissues (hemorrhagic stroke).

A transient ischemic attack (TIA), or "mini-stroke," can cause many of the same symptoms as a stroke, but TIA symptoms are fleeting and last for a few minutes or up to 24 hours. Call for medical help immediately if you suspect a person is having a TIA, as it may be a warning sign that a stroke is about to occur. Not all strokes, however, are preceded by TIAs.

Stroke is the fourth leading cause of death, ranking behind diseases of the heart, lungs and all forms of cancer. According to the National Stroke Association (NSA), strokes kill more than 137,000 Americans each year.

Strokes can be classified into two main categories: ischemic and hemorrhagic strokes.

Ischemic stroke

An ischemic stroke occurs when a blood vessel that supplies the brain becomes blocked or "clogged" and impairs blood flow to part of the brain. The brain cells and tissues begin to die within minutes from lack of oxygen and nutrients. The area of tissue death is called an infarct. About 87% of strokes fall into this category. Ischemic strokes are further divided into groups, including the following:

• Thrombotic strokes: Thrombotic strokes are strokes caused by a thrombus (blood clot) that develops in the arteries supplying blood to the brain. This type of stroke is usually seen in older individuals, especially those with high-cholesterol levels and atherosclerosis (a buildup of fat and lipids inside the walls of blood vessels). Sometimes, symptoms of a thrombotic stroke can occur suddenly and often during sleep or in the early morning. At other times, it may occur gradually over a period of hours or even days. This is called a stroke-in-evolution. Thrombotic strokes may be preceded by one or more "mini-strokes," called transient ischemic attacks, or TIAs. TIAs may last from a few minutes to a few days and are often a warning sign that a stroke may occur. Although usually mild and transient, the symptoms caused by a TIA are similar to those caused by a stroke.
• Lacunar infarct: Another type of stroke that occurs in the small blood vessels in the brain is called a lacunar infarct. The word lacunar comes from the Latin word meaning "hole" or "cavity." Lacunar infarctions are often found in people who have diabetes or hypertension (high blood pressure).
• Embolic strokes: These strokes are caused by blood clot or plaque debris that develops elsewhere in the body and then travels to one of the blood vessels in the brain via the bloodstream. Embolic strokes often result from heart disease or heart surgery and occur rapidly and without any warning signs. About 15 percent of embolic strokes occur in people with atrial fibrillation, a type of abnormal heart rhythm in which the upper chambers of the heart do not beat effectively.

Hemorrhage stroke

About 13 percent of strokes are hemorrhagic strokes caused by bleeding.

• Intracerebral hemorrhage is usually caused by hypertension (high blood pressure), and bleeding occurs suddenly and rapidly. There are usually no warning signs and bleeding can be severe enough to cause coma or death.
• Subarachnoid hemorrhage results when bleeding occurs between the brain and the meninges (the membrane that covers the brain) in the subarachnoid space. This type of hemorrhage is often due to an aneurysm or an arteriovenous malformation (AVM).

To evaluate the type of stroke that you may be having and the areas of your brain affected, you will need a complete evaluation. Your medical team will want to rule out other possible causes of your symptoms, such as a brain tumor or a drug reaction. You will likely undergo a variety of tests to determine the cause of your symptoms, including:

• Physical examination
• Blood tests
• Computerized tomography (CT) scan
• Magnetic resonance imaging (MRI)
• Carotid ultrasound
• Cerebral angiogram
• Echocardiogram

Receiving treatment at a state-designated stroke center can mean the difference between life and death. Using medications like tissue plasminogen activator (tPA), known as a “clot-buster,” help our stroke teams improve the outcome of stroke patients. tPA has been shown to significantly reduce the effects of stroke and lessen the chance of permanent disability when given intravenously in the first three hours after the start of stroke symptoms. Patients with very large strokes due to large vessel occlusion (LVO) diagnosed within eight hours may be candidates for treatments using intra-arterial thrombolysis or clot-removal devices, both of which are aggressive and effective treatments not widely available.

Rehabilitation is also an important part of treatment and begins during the acute treatment phase. As the patient's condition improves, a more extensive rehabilitation program is often begun. There are a variety of stroke treatment programs, including acute rehabilitation programs, subacute rehabilitation programs, long-term care rehabilitation programs and home health rehabilitation programs.

The goal of stroke rehabilitation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life—physically, emotionally and socially. Stroke rehabilitation can help you recover from the effects of stroke and relearn skills and new ways to perform tasks. Rehabilitation is designed to meet each person's specific needs; therefore, each program is different. Some general treatment components for stroke rehabilitation programs include the following:

• Treating the basic disease and preventing complications
• Treating the disability and improving function
• Providing adaptive tools and altering the environment
• Teaching the patient and family and helping them adapt to lifestyle changes

The stroke rehabilitation team revolves around the patient and family and helps set short- and long-term treatment goals for recovery. Many skilled professionals are part of the neurology rehabilitation team, including any or all of the following:

• Neurologist/neurosurgeon
• Physiatrist
• Critical care nurse
• Internist
• Other specialty doctors
• Rehabilitation specialists
• Physical therapist
• Occupational therapist
• Speech/language pathologist
• Audiologist
• Registered dietitian
• Social worker
• Psychologist/neuropsychologist/psychiatrist
• Case manager
• Orthotist
• Recreation therapist
• Vocational counselor
• Chaplain

Areas covered in stroke rehabilitation programs may include:

• Self-care skills, including activities of daily living (e.g., feeding, grooming, bathing, dressing and using the bathroom)
• Mobility skills (e.g., walking, transfers and self-propelling a wheelchair)
• Communication skills (e.g., speech, writing)
• Cognitive skills (e.g., memory, concentration, judgment, problem solving and organizational skills)
• Socialization skills (interacting with others at home and within the community)
• Vocational training (work-related skills)
• Pain management (e.g., medications, alternative methods of managing pain)
• Psychological testing (identifying problems and solutions for thinking, behavioral and emotional issues)
• Family support (assistance with adapting to lifestyle changes, financial concerns and discharge planning)
• Education (patient and family education and training about stroke, medical care and adaptive techniques)

Stroke is an emergency and should be treated as such. According to the NSA, it is important to learn the 3 R's of stroke:

• Reduce the risk.
• Recognize the symptoms.
• Respond by calling 911 (or your local ambulance service).

A loss of brain function occurs when there is brain cell death. This may include impaired ability with movement, speech, thinking and memory, bowel and bladder, eating, emotional control, sensory (ability to feel touch, pain, temperature and position) and other vital body functions. Recovery from stroke and the specific ability affected depends on the size and location of the stroke. A small stroke may result in problems such as weakness in an arm or leg. Larger strokes may cause paralysis (inability to move part of the body), loss of speech or even death. The greatest chance for recovery from stroke occurs when emergency treatment is started immediately.

The outlook for stroke patients today is more hopeful than ever due to advances in both stroke treatment and rehabilitation. Stroke rehabilitation works best when the patient, family and rehabilitation staff works together as a team. Family members must learn about impairments and disabilities caused by the stroke and how to help the patient achieve optimal function again.

The best way to reduce the risk of another stroke is to live a healthy lifestyle. You can do this by eating right, not smoking, reducing the amount of alcohol you drink and following your doctor’s advice.

Some medications can also help prevent blood from clotting:

• Anticoagulants are “blood thinners” that help stop blood from clotting. When blood clots occur they can become stuck in an artery of the brain and cause a stroke. An example of an anticoagulant is warfarin, also known as Coumadin®.
• Antiplatelets are medicines that also stop clotting. They prevent platelets from sticking together and forming clots. The goal is to keep the blood flowing and decrease the risk of stroke and heart attack. Some examples are aspirin, Clopidogrel (Plavix®) and aspirin combined with extended release dipyridamole (Aggrenox®).