Content

Introduction

Stroke is a serious disease that occurs following the reduction or interruption of the blood supply to the brain (meaning the brain, cerebellum, and brainstem enclosed in the skull) and the consequent brain cell death.

There are two forms: the most common, ischemic stroke, occurs when a blood clot blocks an artery that carries blood to the brain; hemorrhagic stroke is caused by the rupture of an artery.

We speak of a transient ischemic attack (TIA) when the blood supply to the brain is interrupted for a short time.

Stroke is a serious medical emergency and requires immediate treatment: rapid intervention can minimize brain damage and possible complications. If you are assisting a person and suspect a possible stroke in progress, you must immediately call 112 or 118 for transport to the hospital. Upon arrival at the hospital, you will be immediately subjected to:

  • specialist neurological visit
  • computed tomography (CT scan) or magnetic resonance (MRI) to see images of the brain and evaluate them as quickly as possible
  • admission to a "stroke unit", a structure specialized in the "detection and treatment of strokes
  • specific rehabilitation

Subsequently, the person will be given the plan of care, rehabilitation and clinical checks to be carried out and will be transferred from the hospital to the community guaranteeing long-term support.

The risk factors for stroke are: high blood pressure (arterial hypertension), high blood cholesterol level (hypercholesterolemia), diabetes, obesity, smoking (read the hoax), abuse alcohol consumption.

The "increase in the level of risk factors largely depends on the" adoption of incorrect lifestyles, therefore, stroke can be effectively prevented by adopting:

  • proper nutrition, low in fats of animal origin (saturated fats) and cholesterol, low in salt and sugar
  • regular and daily physical activity
  • give up smoking and excessive consumption of alcoholic beverages

Symptoms

The disorders (symptoms) caused by stroke begin suddenly and depend on the portion of the brain affected and the extent of the damage. The main ones are:

  • face, the left or right side of the face may be drooping, the person may not be able to laugh, or the mouth or eyelid may be drooping
  • armssudden weakness or numbness, especially on one side of the body, whereby a person with a stroke may not be able to lift one arm or keep it raised to the same level as the other
  • language, it can be altered, or absent because the person is unable to speak

Quickly recognizing these signs is essential, especially when you are living with (or know well) a person at risk (for example, an elderly, diabetic, or hypertensive individual). Sometimes other disorders may also appear, including:

  • total paralysis of half of the body, with sudden difficulty walking
  • sudden loss or blurring of vision, from one or both eyes
  • dizziness (dizziness)
  • confusion
  • difficulty understanding what is said by close people
  • problems in stability and coordination
  • difficulty swallowing (dysphagia)
  • sudden and severe headache culminating in pain so strong it has never been experienced
  • loss of consciousness

These symptoms may also depend on causes other than stroke but still require attention and a differential diagnosis.

Transient Ischemic Attack (TIA).

The signs of a transient ischemic attack are the same as for a stroke but, generally, they last from a few minutes to a few hours before they disappear completely. Although the symptoms (symptoms) are progressively reduced, a TIA should never be ignored as it a serious warning of reduced blood flow to the brain and the possible onset of a stroke in the following months. If you suspect you have a TIA you should contact your doctor, call the emergency telephone number 118 (or 112 in some regions ) or go to the emergency room as soon as possible. Even if the complaints (symptoms) disappear while waiting for the ambulance, it is still necessary to go to the hospital to be examined. Symptoms that disappear soon (in less than 24 hours) can lead to suspicion of the presence of a TIA and indicate the possible occurrence, in the short term, of a stroke. After the initial evaluation, hospitalization may be necessary for further information and , if necessary, to initiate specific treatment.

Causes

Ischemic stroke and hemorrhagic stroke can be caused by various causes.

Ischemic stroke is the most common; occurs when a clot blocks the flow of blood, and therefore, the transport of oxygen to the brain. Blood clots usually form in areas where arteries thin or are blocked with lipid and cholesterol deposits known as atherosclerotic plaques. The main risk factors of atherosclerosis are:

  • high blood pressure (hypertension)
  • obesity
  • high cholesterol levels (hypercholesterolemia)
  • diabetes
  • smoking habit
  • excessive consumption of alcoholic beverages

Another possible cause of stroke is atrial fibrillation. It occurs when the heart, beating irregularly, does not contract enough to push all the blood into the arteries. The amount that remains in the atria can form clots that passing through the left ventricle can reach the arteries that supply the brain and obstruct them. Atrial fibrillation can be due to lung disease, heart valve disease, alcohol abuse, coronary heart disease, hyperthyroidism.

The hemorrhagic stroke (cerebral or intracranial hemorrhage) occurs when an artery located inside the head (intracranial) breaks and blood leaks into the brain. The main cause of hemorrhagic stroke is high blood pressure which, in turn, is caused by:

  • excessive consumption of salt in the diet
  • overweight / obesity
  • excessive use of alcoholic beverages
  • smoking habit
  • Sedentary life
  • stress, which can lead to a temporary rise in blood pressure

Hemorrhagic stroke can occur from a rupture of a brain aneurysm, which is the abnormal dilation of a blood vessel in the brain.

Diagnosis

Strokes are ascertained (diagnosed) by subjecting the person to a thorough examination of physical functions (paralysis, speech disorders, difficulty swallowing) and by analyzing images of the brain obtained through computerized axial tomography (CT) or nuclear magnetic resonance (MRI) ).

In addition, various clinical investigations are available to help identify the causes of stroke: a blood sample to check the level of cholesterol and glycemia, an electrocardiogram to check the frequency and regularity of the heart rhythm and blood pressure control.

Computed Axial Tomography (CT)

Even if the physical signs of a stroke are obvious, a computed tomography scan of the brain is needed to determine:

  • whether the stroke was caused by the obstruction (ischemic stroke) or from the rupture of an artery (hemorrhagic stroke)
  • the affected part of the brain
  • the extent of the damage

CT is like an x-ray, it uses multiple images (scans) to build a detailed, three-dimensional picture of the brain to help identify affected areas. Contrast can be administered before or during the scan, by intravenous injection, which improves the clarity of the images and the vision of the blood vessels supplying the brain. Since hemorrhagic strokes and ischemic strokes require different treatments, the faster the assessment of the type of stroke present is, the more effective the therapy will be.

Nuclear Magnetic Resonance (MRI)

Nuclear magnetic resonance uses a powerful magnetic field and radio waves to reproduce a detailed image of the brain.
In the presence of multiple complex disorders (symptoms), when the magnitude and location of the damage is unknown or a TIA has occurred, MRI is more appropriate. It allows, in fact, a detailed analysis of the brain tissue, allowing the localization of smaller areas affected by the "stroke. As in the CT scan, the contrast medium can also be used in magnetic resonance imaging to improve the quality of the images.

Swallowing examination

It is important for anyone who has had a stroke to investigate whether the ability to swallow is impaired; in fact, if altered, there is a risk that food and drink can enter the trachea and lungs causing the so-called pneumonia ab ingestis. Typically, the person affected by stroke may have difficulty swallowing normally, it is the doctor who decides whether to give fluids or nutrients intravenously or through a tube to the stomach.

Investigations should be carried out to confirm the possible cause of the stroke. They include:

  • carotid doppler echo, ultrasound examination that allows to highlight the reduction in the width or obstruction of the arteries located in the neck, the carotids, which carry blood to the brain. This non-invasive examination involves the passage on the skin of the neck, in correspondence with the arteries, of a small probe (transducer) that emits high-frequency sound waves and records the echo of the waves that bounce off the tissues and blood cells. A computer connected to the probe allows you to see sound waves on a monitor in real time. Information on the blood flow rate is then displayed in a graph.

In some cases, another type of ultrasound examination, the echocardiogram, can be used to obtain images of the heart. It consists in the use of an ultrasound probe to pass over the chest to receive detailed images of the heart's functioning.

Therapy

Rapid and effective treatment (therapy) of stroke can avoid death and long-term disability; the specific treatment depends on the type of stroke (ischemic / haemorrhagic) and consists in taking drugs; for some people surgery is necessary.

Treatment of ischemic stroke

It consists of the administration of a combination of drugs that, in addition to treating the stroke, are able to prevent its possible recurrence (relapse); some medicines must be given within a short period of time after symptoms appear (acute phase); others can only be used after the acute phase and for a long time thereafter.

Ischemic stroke is treated with the administration of a drug fibrinolytic, that is, it dissolves blood clots and restores the blood supply to the brain. This type of therapy, called thrombolysis, it is effective if used as soon as possible after the onset of the stroke while it is generally not recommended if more than four and a half hours have elapsed since the onset of the disorders (or if there are exclusion criteria correlated with an increased risk of bleeding) . After this period of time, in fact, there is no certainty that the drug will be beneficial. However, before using thrombolysis, it is important to perform a CT scan or MRI scan to confirm that it is an ischemic stroke : in fact, if it were a hemorrhagic stroke, the use of thrombolysis is contraindicated.

Most people are given a dose of so-called drugs anti-aggregants, to reduce the risk of a new clot forming. Various medicines are available with this action, starting with aspirin. Some patients are prescribed anticoagulant drugs to reduce the risk of new blood clots such as warfarin (OTA: oral anticoagulant therapy), or rivaroxaban, dabigatran and apixaban. oral anticoagulants for long-term use (NAO: new oral anticoagulants). There are also other anticoagulants called heparins which can only be used by injection and are used for a short time.

The anticoagulants they can be used for stroke prevention in case of:

  • atrial fibrillation
  • people at risk of blood clots (deep vein thrombosis) in the veins of the legs (lower limbs) due to immobility caused by a previous stroke or other cause (tumors)

If blood pressure is high, drugs can be given to lower it. Commonly used medicines include:

  • angiotensin converting enzyme inhibitors (ACE inhibitors)
  • calcium channel blockers
  • beta blockers
  • angiotensin II receptor antagonists (or sartans)
  • direct-acting vasodilators
  • thiazide diuretics

If the level of cholesterol in the blood is too high, medicines called statins may be given. These are substances that reduce the level of cholesterol in the blood by blocking the enzyme that produces it present in the liver.

Some ischemic strokes are caused by the reduction in the width of the carotid artery, the artery in the neck that carries blood to the brain. Such a narrowing, called stenosis, is caused by the formation of one, or more, thickenings in the artery wall. If carotid stenosis is particularly severe, surgery is required to reduce it and widen the artery. It is performed via a technique called carotid endarterectomy which consists of "incision of the carotid artery to remove the plaque (s).

Treatment of hemorrhagic stroke

As in the case of ischemic stroke, medicines, such as ACE inhibitors, to lower blood pressure and prevent further strokes. If the person affected by the stroke previously used anti-coagulants, it may be necessary to administer drugs that reverse their effects, reducing the risk of worsening of the bleeding.

Emergency surgery is used to remove blood from the brain and repair blood vessels. Generally, in these cases we proceed with the craniotomy: it consists in the removal of a section of the skull to allow the surgeon to access the bleeding area. The surgeon repairs the damaged artery and makes sure that there are no blood clots that could impede the blood supply to the brain. Once the bleeding is stopped, the removed part of the skull is replaced by a metal plate.

Supportive care

In addition to the treatments already outlined, additional short-term care may be needed to address some of the problems that plague people who have had a stroke. Between these:

  • Power supply, using the nasogastric tube in case of difficulty in swallowing (dysphagia)
  • supplementation of nutrients, in case of malnutrition
  • liquids, administered directly intravenously in case of risk of dehydration
  • oxygen, supplied via nasal tubes or mask in case of low oxygen levels in the blood

Prevention

Some relevant risk factors for stroke cannot be changed. They include:

  • age, you are more likely to have a stroke after age 65
  • family history, if a first degree relative (parents, siblings, children) has had a stroke at a young age (before age 55), the risk of having it is higher
  • personal medical historyif you have had a stroke, TIA or ischemic heart disease in your life, the risk of having a stroke is higher

However, it is possible to effectively combat the onset of stroke or the occurrence of a second episode by modifying one's lifestyle, preventing the formation of lipid and cholesterol deposits in the arteries (atherosclerotic plaques) and keeping blood pressure below the values ​​of 140/90 mmHg (read the Hoax). Since even an irregular heartbeat (atrial fibrillation) can significantly increase the risk of stroke, those who suffer from it should consult the specialist to evaluate whether or not , to take anticoagulant drugs that reduce the likelihood of this happening.

Diet

A varied and balanced diet, made up of modest portions, with low consumption of saturated fats and cholesterol, low in salt and sugar, rich in vegetables and fruit, whole grains, legumes and fish decreases the risk of developing cardiovascular diseases. Fruits and vegetables are rich in vitamins, minerals and fiber, and they help keep the body healthy. The ideal is to eat at least five 80g portions of fruit and vegetables every day.

An important risk factor for the onset of cardiovascular disease is cholesterol, of which there are two types:

  • with low density lipoproteins (LDL), consisting mainly of fat and a small amount of protein; this type of cholesterol is deposited in the wall of the arteries and can obstruct them, therefore it is often referred to as "atherogenic cholesterol" or "bad cholesterol"
  • with high density lipoproteins (HDL), composed mainly of proteins plus a small amount of fat; this type of cholesterol is not deposited in the arteries and is therefore often referred to as "good cholesterol"

The increase in LDL cholesterol is favored by the intake of foods containing saturated fats and cholesterol, such as:

  • sausages, red meats and fatty meats, lard and bacon
  • butter and cream
  • egg yolk (yolk)
  • cheeses
  • sweets and cookies
  • foods that contain palm or coconut oil (rich in saturated fat)

On the other hand, including polyunsaturated fats in your diet lowers blood cholesterol levels and increases HDL cholesterol levels, helping to reduce atherosclerotic plaque in the arteries. Foods rich in polyunsaturated fats include:

  • blue fish
  • avocado
  • nuts and seeds
  • sunflower and rapeseed oil

Extra virgin olive oil is rich in monounsaturated fats; even monounsaturated fats have the peculiarity of lowering LDL cholesterol levels and increasing HDL cholesterol levels.

However, remember that fats are very caloric, therefore it is recommended to use them in moderate quantities.

Smoke

Smoking is a major risk factor for cardiovascular disease, contributing to the development of atherosclerosis and arterial hypertension. Smoking significantly increases the risk of having a stroke, as it narrows the arteries and makes blood clots more likely. Quitting smoking reduces the likelihood of it happening.

In Italy there is a Green Telephone against Smoking (TVF): 800 554 088, an anonymous and free national service that carries out consultancy activities on issues related to the phenomenon of smoking (for more information, consult the website of the Green Telephone against smoking of the Institute Superior of Health).

High blood pressure (arterial hypertension)

Consistently high blood pressure (high blood pressure) can place excessive strain on the heart, increasing the risk of heart attack. Arterial hypertension can be reduced by moderating the consumption of alcoholic beverages, reducing weight and keeping it within the normal range, carrying out regular and daily physical activity and following a varied and balanced diet, with modest portions, low in salt, saturated fat, cholesterol Salt increases blood pressure and it is therefore recommended to use little, both for cooking and for seasoning, less than 5g (about a teaspoon) per day, also considering the salt contained in packaged foods.

Alcohol

Alcohol does not contain any vitamins or other nutrients, it only gives calories. Drinking wine or other alcohol on a regular basis increases blood pressure and weight. Both men and women should not drink more than 14 units of alcohol per week (in men it is recommended not to drink more than two glasses of wine in the whole day, in women, only one glass). If you drink 14 units of alcohol a week it would be better if they were spread over three or more days, and that they accompany the meal.

Excess alcohol consumption can lead to increased blood pressure (hypertension) and an irregular heartbeat (atrial fibrillation): both of these factors can increase the risk of having a stroke.

Weight

Being overweight forces the heart to work harder to circulate blood in the body, and this can cause blood pressure to rise.
If you are overweight or obese, losing even a few pounds can make a big difference in your blood pressure and overall health.

Exercise

Staying active and practicing physical activity regularly lowers blood pressure, keeping the heart and blood vessels in good condition. Regular physical activity also helps to lose weight, reduce blood pressure and control emotional tension.

Low-impact activities such as walking, swimming, and cycling are recommended. More demanding activities, such as soccer and tennis, may not be suitable; it is advisable to consult your doctor to make choices suitable for your state of health.

If you are recovering from a stroke, you should discuss with your doctor what physical activity plan you can do. In fact, it may not be possible to do it in the first weeks or months after the stroke, but it should be feasible to start exercising once rehabilitation is well under way.

Control your stress

Avoid unnecessary stress and learn techniques for dealing with and managing everyday stress.

Living with

The brain damage caused by stroke can be extensive; although some people recover quickly, others need long-term support to manage difficulties and regain more independence. The path to recovery (rehabilitation) is specific and disease-dependent ( symptoms) and their severity Often starts in the hospital and then continues home or to the clinic.

The team of specialists is indispensable to help the rehabilitation process: physiotherapists, psychologists, occupational therapists, speech therapists, specialist nurses and doctors. During this period it is useful to set goals that will help the person in complete recovery.

It is also necessary to manage the main psychological problems that can affect people after a stroke:

  • depression, many people experience intense crying spells and feel hopeless and excluded from social activities
  • anxiety, sense of fear and insecurity accompanied by panic attacks

Feelings such as anger, frustration, and bewilderment are also common.

The person affected by a stroke should receive a psychological evaluation from the health care team to see if any emotional problems are present.

It is important to provide the patient with advice aimed at better coping with the psychological impact of stroke. In particular, the effect it could have on relationships with other family members and with the partner. It is desirable that evaluations be carried out at regular intervals of time to check for any psychological problems.

These problems can resolve over time, but if they are serious or last for a long time, your GP may suggest that you consult with experienced specialists (psychiatrists or clinical psychologists).

Medicines and psychological therapies (such as counseling or cognitive-behavioral therapy) are helpful. Cognitive-behavioral therapy aims to change the way we see things, inducing and encouraging positive moods.

In-depth link

Heart Project (ISS)

Association for the Fight against Cerebral Stroke (ALICe)

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