Stroke
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Stroke or CVA or Cerebral Vascular Accident is a major cause of morbidity and loss of independence especially in the elderly.

There are two major categories of stroke: embolic and hemorrhagic. Embolic mechanisms result in too little blood flow to brain tissue and a resultant death of the cells commonly referred to as infarction. Hemorrhagic mechanisms result in the replacement of the space occupied by brain cells by blood. The pressure of the blood on the brain cells results in destruction.

Embolic strokes can be caused by a variety of types of embolus including air but the the two major causes are small blood clots and fragments of lipid plaques that break off blood vessel walls. The lipid plaques are the same problem that occurs in coronary vessels in coronary artery disease. Thus the cholesterol and lipid risk factor in coronary artery disease is also present in embolic stroke. One facet of stroke prevention is to manage cholesterol and lipid abnormalities. The small blood clots that also can be involved in embolic strokes can be made up of small aggregates of platelets. In this instance stroke prevention can involve the use of anti-platelet drugs (Aspirin, Plavix...). In some cases anticoagulation with coumadin is necessary for treatment and subsequent protection. Artificial valves in valvular heart disease are a site for embolus production. Stroke prevention in people with artificial valves means lifetime anticoagulation with coumadin. Atrial fibrillation causes an increase in embolus production. Stroke prevention in people with atrial fibrillation, especially new onset fibrillation, is to treat to revert to normal sinus rhythm and /or lifetime anticoagulation.

Hemorrhagic stroke depends on the condition of the blood vessels of the brain and on the patient's blood pressure. Stroke prevention is dependent on appropriate control of the blood pressure. The state of the brain blood vessels can depend on hereditary factors such as a strong family history of Berry Aneurysm or on concurrent disease such as Diabetes or Atherosclerotic Vessel Disease. Stroke prevention means good Diabetic control and management and treatment of Atherosclerosis by cholesterol and lipid management. If an aneurysm can be identified hopefully before it ruptures and if it is in an easily accessed part of the brain, stroke prevention can be "clipping" of an appropriate aneurysm.

TIA or Transient Ischemic Attack:

A TIA is a neurological change that lasts for 24 hours or less and completely resolves. Commonly it can present as slurred speech or as weakness or numbness affecting only one side of the body. TIA is an early warning system for stroke. It is very important to heed these warnings and to rigorously search for treatable causes. Some of the investigations stimulated by TIA are (1) carotid ultrasound to rule out plaques and obstruction in the carotid arteries leading from the heart to the brain, (2) echocardiogram to rule out valvular heart disease and ventricular malfunction, (3) 24 hour Holter Monitor to detect intermittent cardiac arrhythmias such as atrial fibrillation and flutter. CT scan and MRI should also be ordered.

Evolving Stroke:

What can you do for someone who is in the process of developing neurological changes consistent with stroke?

The best response is to get them to the nearest center that has a CT scan and Neurologist/ Neurosurgeon team. It must be determined quickly what basic type of stroke is occurring: hemorrhagic or embolic. If the stroke is caused by a blood clot, anticoagulation and clot breakdown techniques can be started immediately. This can reduce the extent of the stroke and any subsequent disabilities. If the stroke is hemorrhagic ( bleeding involved), then it is absolutely contra-indicated to use anticoagulation or anti-platelet medication. The optimum outcome results if there is an experienced neurosurgeon involved. In some specialized centers there are teams and protocols set up to administer thrombolytic therapy for acute ischemic stroke. Tissue Plasminogen Activator (TPA) was approved in the U.S. in 1996 and in Canada in 1999 for the treatment of acute ischemic stroke. There is a three hour window from symptom to treatment to apply TPA. If the patient can be transported to a specialized stroke center, have a CT scan and get TPA in this time frame, the outcomes for ischemic stroke can be improved.

 

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