What is a stroke?
A stroke (acute cerebrovascular accident) is a medical condition in which poor blood flow to the brain results in cell death.
What is the cause of the disease?
It can be developed due to two principal causes: blood can’t reach a brain area due to vascular blockage or rapture. If it is vascular blockage with a thrombus or embolus (a vesicle of complex origin), we have ischemic stroke. In case of rapture of an extended arterial part (aneurysm) or rapture due to high blood pressure, we have hemorrhagic stroke.
What types of strokes are known?
Depending on causes of stroke, there are ischemic stroke or cerebrovascular accident and hemorrhagic stroke or brain hemorrhage. If stroke signs resolve within 24 hours, we have a transitory ischemic attack or transient cerebrovascular disease.
How is stroke manifested?
The brain can be divided into two hemispheres, brain stem and cerebellum. Symptoms can depend on the site and volume of lesion. For instance, if a cerebral hemisphere is damaged, neurological symptoms will affect the opposite side. Thus, in damage to the right hemisphere, decreased strength, disturbed movements in the limbs and disturbed sensitivity will be left-sided.
A stroke can be accompanied by impairment of consciousness varying from mild disorientation, when a patient doesn’t understand where he is and what’s happening to him, to coma (complete loss of consciousness). Craniocerebral nerves can be damaged. Facial nerve damage can result in drooping of facial features (mouth or cheek). Vision disturbances can be manifested as loss of right half or left half of vision. Swallowing disorders and voice changes can be developed. Slurred or indistinct speech, difficulty understanding speech or struggle to say words, global aphasia (the patient can’t speak and doesn’t understand speech). In a stroke, motor skills can be damaged as well (decreased muscular strength, mild restricted movements (varying degrees of pareses) or complete loss of movements in the limbs (plegia)). Sensitivity disturbances: reduction or lack of pain or temperature perceptions, most obvious in the limbs. Balance disturbances: dizziness, balance problems, sometimes the patients are not able to stand or walk. Urogenital or intestinal disturbances: urine retention, fecal retention or incontinence.
How is a stroke treated?
If there is a first suspicion for a stroke, you need to call an ambulance immediately as this diagnosis requires compulsory hospitalization. The sooner the patient arrives in a specialized department, the greater are chances for his/her good recovery. There is a so-called therapeutic window of 3–6 hours. When a portion of the brain is damaged, some nervous tissue is immediately destroyed (ischemic event) and is not subject to restoration. The penumbra is the area surrounding an ischemic event. Here, cells can preserve their functions within 3–6 hours. Timely treatment can completely restore the area. It is necessary to determine the type of a stroke and select a respective therapeutic approach within this period.
During the first days from the disease onset the patients are hospitalized to a specialized intensive care unit where vital functions of body (respiration, cardiac functioning, arterial blood pressure, etc.) are controlled on a constant basis and where an intense drug therapy aimed at elimination of the basic cause of stroke is initiated. This is the first stage of treatment. Therapy will depend on the type of a stroke. Thus, a patient with an ischemic stroke requires agents that inhibit the process of blood clot formation. These agents are not used when there is a hemorrhage at the first stage of the disease. Intense neurometabolic therapy with peptides that launch all internal mechanisms of pathological process compensation and have an antioxidant and neuroprotective effect, nootropics (substances that can be taken to improve mental performance), antioxidants (agents that bind free radicals and inhibit oxidation which is favorable for brain metabolism), and vasoactive agents (increase blood flow to the brain) is given.
If patients are weak or have disturbed swallowing, they sometimes need therapeutic nutrition with protein supplements. If no swallowing is possible, a nasogastric tube (a special tube running to the stomach through your nose) is used. A weak patient has the supplements as basic food or food additive.
At the second stage of treatment, patients are transferred to the neurological department where the previous therapy and early rehabilitation started at the neuroresuscitation department are continued. Exercise therapy is an important component of the early restorative period. A set of exercises depends on the lesion degree and volume and is selected by an exercise therapist on the individual basis. The therapist shows the patients and their relatives how the exercises need to be performed with daily lessons. Massage which is rather sparing in the beginning of the rehabilitation period is useful as well. Mechanotherapy with training simulators is applied.
More active exercise therapy, massage, especially that of the affected limbs, recurrent courses of neurometabolic and vasoactive therapy up to 4 times a year are conducted in the remote rehabilitation period. Intellectual exercises are necessary.
K. R. Badalyan
Department of Neurology, Faculty of Additional Professional Education
of Pirogov Russian National Research Medical University
It must be remembered that the principal task is not only to restore the lost function, but also to prevent the recurrent stroke. For this purpose, the patients need to follow doctor’s recommendations strictly.
Blood pressure levels must be monitored. Arterial hypertension needs a respective therapy selected by a therapist or cardiologist. It is necessary to take antiplatelet agents (medicines that inhibit the formation of blood clots). It must be understood that the agents will be taken for life. That’s why discuss the desirable intake and dosage regimen with your treating physician.
Patients who survived a stroke need to control the levels of blood cholesterol and sugar. If the values are increased, nutrition must be corrected. In case of no progress drug management is required.
Remember that bad habits are detrimental to your health. Smoking and drinking must be avoided as they, among other things, result in atherosclerosis. Food must be rich in vitamins and microelements. Limit sodium chloride, fats, easily digestible carbohydrates (sugar, confectionery) and have more vegetable food.
A patient’s wish and help of relatives will make restoration more effective. It is known that maximum improvement of motor functions in the paralyzed limbs is optimal within the first 6 months. Exercise therapy must be continued at home daily. More elaborated methods can be selected in specialized rehabilitation institutions. Different types of physiotherapy (electrostimulation of the paralyzed limb, neurofeedback provided when using gamified computer programs and implemented as sound or visual signals) and massage are possible.
It takes 2–3 years to restore speech following a stroke. It is impossible to restore speech without communication. So, relatives will have to talk to the patient much even if he/she doesn’t comprehend the meaning of the words at some stage. A specialist (aphasiologist) will select an individual program and assign drug therapy if needed.
Restoration of the intellectual activity and mood normalization are also important in stroke-related rehabilitation. It is necessary to restore memory and confidence and struggle depression in order to lead normal social (and labor) life again. It is depression that often prevents from restoration. Psychotherapeutic rehabilitation is aimed at overcoming depression with the help of a psychotherapist and special agents.
Walking though the past day events, learning new words, rhymes and different intellectual games are useful for memory restoration.
Bed-bound patients must have even mattresses, seamless and unfolded bedlinen. Change the patient’s position, place rollers under bony prominences and air pillow under the sacrum. Wash the patient’s skin regularly, clean it daily with warm water and baby soap and soak thoroughly with a cotton towel. This is how decubitus can be avoided.
To prevent pulmonary engorgement, respiratory gymnastics and preventive massage of the chest must be done regularly.
Oral care is especially important in swallowing disorders.
Those predisposed to constipation need to have more vegetable food. Purgative agents will make the diet more effective.
Timely and well-organized rehabilitation of patients who survived a stroke promotes health restoration, return to a productive life and reduces the risk of recurrent strokes.
K. R. Badalyan
Department of Neurology, Faculty of Additional Professional Education
of Pirogov Russian National Research Medical University
