Stroke (insult)

The term stroke (med.: insult) refers to a symptom caused by an abrupt circulatory disturbance. Since the cells of the brain (neurons) are very sensitive, they perish after a few minutes without sufficient oxygen supply.

The risk of suffering an insult increases steadily with age. The annual incidence rate for people between 55 and 65 years of age is approximately 250 per 100,000 inhabitants, and for people over 65 the incidence rate increases almost threefold. In rare cases, people of younger age or even children can suffer an insult. Men generally suffer a stroke slightly more often than women. A stroke can be caused by different changes, which is why it can be divided into different types:

• Ischemic infarction: this is the most common cause of stroke, accounting for 80 percent. Atherosclerosis or blood clots can lead to a blockage of the afferent vessels.
• Cerebral haemorrhage: Vascular injuries can cause bleeding in the brain, which is responsible for almost 20 percent of insults.
• In rare cases, circulatory disorders are caused by inflammatory diseases of the vessels.

Insults are the number one cause of permanent disability worldwide and the number two cause of death. This makes it clear that strokes also play an important economic role. The care and support of those affected not only takes up a lot of time, but also incurs high costs. The lifelong costs for a stroke patient amount to approximately 45,000 euros in Europe.

Ischemic infarction:

As mentioned earlier, this cause is responsible for about 80 percent of strokes. Ischemic infarction, in turn, can be caused by various changes. For example, the vessels can be blocked by atherosclerosis, a calcification of the arteries, or they can be blocked by carried-over blood clots (thrombi).

These changes in blood supply lead to a lack of oxygen and nutrient supply to the affected areas of the brain. Since the nerve cells cannot survive for long without oxygen, irreversible destruction of these occurs after a few minutes.

In the course of a sleep attack, the vessels in the area of the vascular occlusion can be damaged, which can lead to bleeding into the infarct tissue. This can lead to a steady increase of the symptoms in the following days.

A number of factors have been identified that can significantly promote the occurrence of an insult:

• Arterial high blood pressure (hypertension)
• elevated blood sugar (diabetes mellitus)
• Adiposity (obesity)
• Smoking
• increased alcohol consumption
• elevated blood cholesterol or triglyceride levels
• oral contraceptives containing oestrogen

Other conditions that may result in a stroke include:

• atrial fibrillation
• heart arrhythmia
• heart attacks
• heart valve disease

Cerebral hemorrhages

Cerebral haemorrhages are caused by various reasons, such as damage to vessels in the brain and haemorrhaging into the nerve tissue. Here, a cerebral mass haemorrhage can be distinguished from a subarachnoid haemorrhage. The brain is protectively surrounded by a fluid (i.e. cerebrospinal fluid) and the meninges. If hemorrhage occurs into the cerebrospinal fluid space, it is called subarachnoid hemorrhage. In cerebral mass haemorrhage, brain tissue is displaced and compressed by the blood.

A number of risk factors have also been identified for cerebral hemorrhage:

• Arterial hypertension (high blood pressure).
• Diseases of the bone marrow as well as coagulation disorders (e.g. thrombocyte aggregation disorders, haemophilia A and B, Von Willebrandt syndrome)
• Taking blood-thinning medicines (e.g. Marcumar or heparin)
• Liver disease that limits the protein synthesis function of the liver, such as cirrhosis of the liver
• Vascular deformations, such as circumscribed dilatations of the arteries (aneurysm) or tumor-like vascular neoplasms (angiomas)
• Damage to the blood vessels due to increased deposition of so-called amyloid proteins (amyloidosis) or inflammation of the vessel walls (vasculitis)

It is extremely important to recognise a stroke quickly in order to take the appropriate steps at an early stage. Until the affected person receives the appropriate therapy, more and more nerve tissue can be lost. If you suspect an insult, you should therefore call an emergency doctor immediately. In any case, it is not advisable to drive to the hospital yourself or with a friend, as the condition of the affected person can quickly worsen and become life-threatening.

Warning signs

Symptoms can often appear before the actual stroke, but these are reversible, i.e. not associated with permanent damage to the brain. Symptoms include speech difficulties, sensitivity problems, weakness in the limbs or even paralysis and memory loss. This may be a TIA (transient ischemic attack), which can cause symptoms similar to a stroke, but resolves completely within 24 hours without secondary damage. Although such an attack does not cause massive damage, a hospital should be visited immediately in order to differentiate the symptoms from a stroke or to determine the cause of the TIA.

Typical symptoms

The symptoms of a stroke strongly depend on the affected brain area and its function:

• Very often, a half-side paralysis (hemiparesis) can be observed in the affected person. On one side, one corner of the mouth usually hangs down and the arm and leg of the affected side can be moved to a very limited extent or not at all.
• In many cases, slurred speech and sensory disturbances can be observed.
• Especially with aneurysm bleeding, many people report whiplike, massive headaches.
• Some patients also report nausea and vomiting.
• If large areas of the brain are affected, consciousness may be severely impaired or even unconsciousness may occur.

While the symptoms in men are often accompanied by typical symptoms, a stroke in women can often be very uncharacteristic.

• Nausea with vomiting
• Pain in the limbs, as well as pain in the face
• Palpitations with chest pain
• Shortness of breath
• Hiccups

Medical history

At the beginning, the attending physician will ask some questions about the symptoms and their course and possibly check whether there are risk factors for a stroke. Sometimes the patients themselves can no longer give any information because they are too impaired or can no longer speak clearly. In these cases, an interview is often conducted with the patient's relatives (external history) in order to find out more about the symptoms and the course of the disease.

Examinations

Neurological examination:

This is a physical examination that primarily tests the neurological functions of the body. This can determine whether neurological deficits are present and a rough assignment to an affected area of the brain can be made.

However, before therapy can be initiated, it is essential to clarify whether the stroke is an infarction or a haemorrhage, because the two are treated very differently.

Imaging techniques are usually used for this purpose:

CT: This is the most commonly used procedure in the workup of stroke due to its rapid feasibility. A cerebral haemorrhage can be seen on CT immediately after the first symptoms appear, whereas an infarction can pass the first four hours without any abnormalities on CT. Furthermore, the CT can show the affected area of the brain and the size of the restricted area.

MRI: Due to lower availability and longer examination times, magnetic resonance imaging (MRI) is used less frequently. However, changes in the brainstem area can be better detected with MRI.

Doppler ultrasound: This form of ultrasound can be used to examine the patency of the vessels that supply the brain with blood. Furthermore, the degree of calcification, which can lead to arterial occlusion, can be assessed.

Angiography: Depending on the type of stroke, a radiological examination of the brain vessels (angiography) may be necessary. This can show narrowings (stenoses), occlusions, vessel ruptures and malformations particularly well.

ECG: Since atrial fibrillation or other cardiac arrhythmias can often be the cause of a stroke, an ECG is routinely performed. In addition, a cardiac ultrasound may be performed to see if blood clots in the heart are responsible for the stroke.

In addition, a blood draw may be done supplementally to assess the patient's condition and to determine other risk factors, such as clotting disorders or elevated blood lipids.

Emergency

If a stroke is suspected, action must be taken quickly, so an emergency doctor should be called immediately. The best care can be provided in specialised care units (stroke units), which are available in every larger hospital.

Cerebral haemorrhage: While it is often possible to wait for localised haemorrhages to disappear, surgery is usually necessary for major haemorrhages.

Cerebral infarction: The appropriate treatment for a vessel occlusion is the so-called lysis therapy, in which the occluding clot is dissolved by special medication. However, good results can only be achieved by lysis therapy in the first few hours. Furthermore, a cerebral haemorrhage must be excluded as the cause of the stroke. If lysis therapy is not an option, acetylsalicylic acid is usually administered to counteract progression of the insult.

Rehabilitation

After a stroke has occurred, early and consistent rehabilitation is very important. Early exercise therapy, for example, helps to counteract complications of an insult. These include pneumonia, which can develop due to inhaled food residues, thrombosis in the legs or skin damage due to bed confinement.

By means of a wide variety of therapy methods, rehabilitation attempts to improve many physical functions that may be severely restricted by the stroke, thus enabling reintegration into everyday life and possibly even into working life.

Speech disorders should be largely eliminated, movement patterns, memory and the ability to concentrate should be improved.

It is also important to strengthen the autonomy of those affected. It may be necessary to relearn basic everyday tasks such as washing or changing clothes. Unfortunately, however, not all stroke patients can achieve success through exercise therapy. In these cases, new ways must be found with the affected person in order to deal with the physical deficits in the best possible way. When eating, for example, certain postures can prevent the inhalation of food in order to prevent pneumonia.

The rehabilitation of a stroke is very extensive and requires the cooperation of a number of professional groups. For example, physical therapists, speech therapists, nurses, and even family are necessary for the most successful rehabilitation. In addition, the success of rehabilitation depends on starting as early as possible and on the extent of the stroke.

The course of the disease after a stroke varies greatly, which is why it is difficult to give an individual prognosis. Some affected people can lead a comparatively normal life again after just a few weeks, while others will never be able to perform some everyday activities again despite intensive physiotherapy. However, the family and relatives can be an essential support for those affected and have a positive influence on the prognosis.

The size of the affected brain area and the localization of the infarct are also decisive for the prognosis. The prognosis can be significantly improved by efficient and early rehabilitation. In some cases, the affected brain areas are so small that the patients hardly experience any restrictions. In these cases, however, it is very important to prevent a further stroke by means of blood-thinning medication (e.g.: acetylsalicylic acid, ThromboAss).

The survival rate of a stroke is about 80 percent. Complete rehabilitation of mental and physical deficits is achieved in about one third of all survivors. One third, on the other hand, remain chronically impaired after an insult, and one third are no longer able to lead an independent life and are dependent on nursing care. The probability of dying from a stroke increases with the number of sleep attacks that have occurred.

In the prevention of a stroke, a distinction must be made between primary prevention and secondary prevention. Primary prevention refers to measures that prevent the occurrence of a stroke. Secondary prevention refers to the prevention of a new insult after a stroke has already occurred.

Primary prevention of a cerebral infarction

The most effective way to prevent a cerebral infarction is to reduce the risk factors to a large extent. Above all, vascular calcification (atherosclerosis) should be counteracted, as this is the greatest risk factor.

• Elevated blood pressure is a major risk factor. The risk of suffering an insult can be reduced by about 40 percent by efficiently adjusting the blood pressure.
• Smoking increases the risk of stroke by 2-3 times. Therefore, it is advisable to quit smoking.
• Proper diet, which should preferably be very rich in vegetables and fruits, can also reduce the risk by about 30 percent.
• The extent of vascular calcification (atherosclerosis) is strongly related to the level of cholesterol in the blood. That is why you should eat a low-fat diet and have your cholesterol level checked by a doctor if necessary.
• Diabetics should regularly check their blood sugar and have their therapy readjusted if necessary.
• Furthermore, severely overweight people can reduce their risk of stroke by reducing their weight. But people who are not affected by obesity should also make sure they get regular exercise.

In about one fifth of all cases, cardiac arrhythmias, especially atrial fibrillation, can be identified as the cause of a stroke. Irregular contractions of the heart muscles during atrial fibrillation can cause blood clots (thrombi), which can travel through arteries into the small vessels of the brain, where they can lead to blockage. In many cases, atrial fibrillation can be symptom-free, but blood thinning should be carried out in order to prevent a stroke.

Primary prevention of cerebral haemorrhage

The most important measure to prevent a cerebral haemorrhage is good blood pressure control, because high blood pressure is the most common cause of cerebral haemorrhage. Unfortunately, no preventive measures can be taken against congenital vascular deformities, such as aneurysms (vascular dilatations), which can rupture and cause bleeding, because they usually occur spontaneously.

Secondary prevention of a cerebral infarction

The likelihood of suffering a stroke again increases with every insult that occurs, which is why stroke patients should definitely receive secondary prevention medication. These include, above all, acetylsalicylic acid (e.g. in ThromboAss) or clopidogrel (e.g. in Plavix).

Furthermore, an individual risk scheme can be determined on the basis of age, blood pressure, blood sugar and the presence of certain vascular diseases.

Stroke patients with atrial fibrillation should also take oral blood thinners as secondary prophylaxis.

Secondary prevention of cerebral haemorrhage

Effective blood pressure control is also very important in the secondary prevention of cerebral haemorrhage. If the stroke was caused by a malformation of a blood vessel, surgery may be considered.

Sport

After a stroke, regular exercise can help those affected in many ways. On the one hand, physical and neurological deficits can be improved or even completely eliminated through consistent exercise. On the other hand, sports can also be an important help against the mental stress after a stroke. In contrast to physiotherapy exercises, many people enjoy performing similar movements in the context of a sport. Many patients find it easier to do sports instead of conventional physiotherapy because they are not always reminded of the illness and the movements are more playful. It is important to have enough patience and not to demand full performance from your body right from the start.

The main advantages of sporting activity after an insult are:

• Sport makes the affected person more mobile again, which also makes everyday life much easier. It promotes gross and fine motor movements, increases the condition and brain performance.
• Other secondary or concomitant diseases could be avoided through sport.
• Regular exercise promotes psychological well-being and can be helpful against depressive or anxious moods.

Suitable sports

Which type of sport is most suitable for a stroke patient cannot be said in general terms, but should be determined on an individual basis. The choice depends above all on the physical limitations of the person affected, on interests, on other illnesses as well as on age. It is advisable to discuss this with the doctor treating the patient in order to find a suitable type of sport. There may also be courses or sports groups suitable for rehabilitation that are led by specially trained coaches.

Costs

For some time now, sport has been seen as an important complement to physiotherapy and rehabilitation programmes. For heart attack patients in particular, sporting activity is an important part of secondary prevention, but more and more sporting opportunities are also being created for stroke patients. Health insurance companies cover at least a part of the costs, but it is important that sporting activity is prescribed by a doctor and approved by the insurance company. It should also be mentioned that although sport is an important supportive measure after a stroke, it cannot replace physiotherapy, especially in the case of more severe physical deficits.

Possible sports

Patients who have suffered a stroke should also pay attention to a few things when doing sports:

• Those affected should measure their blood pressure and pulse rate from time to time. It should be discussed with the attending physician which values should not be exceeded and when, if necessary, a break should be taken.
• One should not completely exhaust oneself during sports.
• Furthermore, it is advisable not to do any sports under strong sunlight or in very hot weather.

Very suitable sports are:

• Gymnastics: This type of sport can be performed by a large proportion of patients, whereby initially mainly movements from physiotherapy are performed.
• Water gymnastics: The resistance of the water makes the movements in this form of gymnastics more difficult, which makes water gymnastics quite demanding. This type of sport is particularly recommended for older people with joint problems, as it is gentle on the joints. However, people with diseases of the cardiovascular system should avoid water gymnastics because of the high physical strain.
• Swimming: This sport, especially backstroke, is very suitable for stroke patients. The swimming speed and the distance covered should only be increased slowly from unit to unit.
• Walking: This is another sport that can be done well after a stroke. Again, the pace and distance should be increased only gradually.

Unsuitable sports

Sports that demand a lot of strength from the body, such as weight training or martial arts, are very unsuitable for stroke patients because they can lead to greater fluctuations in blood pressure.