Cerebrovascular Accident (CVA)
What is a stroke?
A stroke is a medical emergency in which the blood supply to the brain is interrupted or reduced. When a blood vessel carrying oxygen and nutrients to the brain is either blocked by a clot or breaks, a stroke occurs (or ruptures). When this happens, a section of the brain lacks the blood (and oxygen) it requires, which can lead to cell death. Brain ischemia symptoms can be transitory, lasting seconds to minutes, or they can endure for hours or days (MedLinePlus, 2021). If the brain is irreparably harmed and infarction occurs, symptoms and indicators will last indefinitely. Unfortunately, neurologic symptoms do not correctly represent the existence or absence of infarction, and the speed with which symptoms manifest does not identify the exact area of ischemia. This is a major issue since correct diagnosis of the symptoms is essential for effective treatment.
According to Kaiser Stroke Comprehensive Center in Sacramento (Kaiser, 2022): “Stroke is the fifth leading cause of death in the United States and the primary cause of adult disability. Up to 80 percent of strokes are preventable.”
Stroke is the third leading cause of death in the United States
Every year 600,000 people will suffer a new or recurrent stroke, and of those, 160,000 die.
Non-modifiable risk factors
A stroke can happen to anyone. You have no control over some risk factors. Others are linked to medical conditions and/or lifestyle choices.
Risk factors that you cannot control are:
Age: The risk for stroke increases with age and doubles every decade after 55.
Race: African Americans and Hispanics are at greater risk of stroke compared to other races. Young African Americans are 2 to 3 times more likely to experience ischemic stroke and are more likely to die from stroke compared to Caucasians.
Gender: Stroke is more common in men than women. However, stroke is more severe in women at all ages, and more women than men die of stroke.
Family history: You’re at greater risk for stroke if you have a parent or sibling who has had a heart attack or stroke.
Prior history of stroke or TIA: About 14 percent of people who have a stroke have another one within 1 year; 25 percent have a second stroke within 5 years.
Risk factors you can control are (Kaiser, 2022) (CDC, 2022):
Carotid artery disease
Atrial fibrillation: This is a type of irregular heart rhythm in which blood clots form inside the heart. Clots can get stuck in the brain’s blood arteries.
Sleep apnea (sleep-related breathing disorder) has recently been linked to increasing risk of stroke.
Other heart conditions, including endocarditis, heart valve conditions, and cardiomyopathy
Other rarer disease and conditions such as lupus, syphilis, hemophilia, pneumonia, high levels of homocysteine, and periodontal disease
Birth control pills: Because their risk of stroke is very low, young healthy women (less than 35 years old, nonsmoking, and without high blood pressure) can utilize hormonal birth control. We recommend using the lowest dose of hormonal birth control if you’re older, smoke, or have hypertension. You could also use a nonhormonal birth control option such as condoms or an intrauterine device (IUD).
The prognosis of a patient will be better if they can get a diagnosis and treatment for a stroke as soon as possible. As a result, it’s critical to learn and recognize the signs and symptoms of a stroke.
Symptoms of a stroke include (Ellis, 2018):
dizziness and trouble walking
loss of coordination and balance
difficulties communicating or understanding what others are saying
numbness or paralysis in the face, leg, or arm on only one side of the body, most frequently on one side of the body distorted or clouded vision
a severe headache, especially when nausea, vomiting, or disorientation accompany it
The symptoms of a stroke vary based on the person and the location of the stroke in the brain. Even if the symptoms aren’t severe, they usually develop suddenly and can get worse with time.
Depending on the kind, severity, location, and number of strokes, the effects differ from person to person. The brain is a complicated organ. Each part of the brain is in charge of a certain function or skill. When a section of the brain is destroyed by a stroke, it is possible that a component of the body will lose its usual function. This could lead to a handicap.
Anatomy & Physiology
One of several pathophysiologic processes involving the blood arteries of the brain causes cerebrovascular disease (Caplan, 2021), they are: atherosclerosis, lipohyalinosis, inflammation, amyloid deposition, arterial dissection, developmental deformity, aneurysmal dilation, and/or venous thrombosis. Those mentioned are all processes that are inherent to the vessel. The process can start from afar, for example when an embolus from the heart or extracranial circulation lodges in an intracranial channel. Inadequate cerebral blood flow due to decreased perfusion pressure or increased blood viscosity may also cause ischemia. The rupture of a vessel in the subarachnoid space or intracerebral tissue may cause a hemorrhagic stroke.
Types of Strokes
Hemorrhagic strokes occur when a blood vessel in the brain leaks or ruptures. Blood can then seep into the brain, killing brain cells. They can result from many conditions that affect your blood vessels. Symptoms develop out of nowhere. Severe headaches, nausea, and vomiting are possible symptoms.
Types of hemorrhagic stroke:
Subarachnoid Hemorrhage: When a blood vessel breaks and bleeds into the space between the brain and the skull, it is known as a SAH. A burst aneurysm induced by elevated blood pressure is the most common cause. An aneurysm is a blood-filled pouch that forms on the inside of an arterial wall and swells outward. It is an artery on or near the surface of the brain , bursts and spill into the space between the surface of the brain and the skull.
Intracerebral Hemorrhage: When a blood artery in the brain spills into the tissue, it is known as an ICH. The main reasons are high blood pressure and aging blood vessels. This occurs when a blood vessel in the brain bursts and spills into the surrounding brain tissue, damaging brain cells.
When a blood clot stops an artery for a brief period of time, it is known as a transient ischemic attack also known as a “ministroke.” This is when there is a temporary decrease in blood supply to part of the brain. The symptoms are similar to those of a stroke, but they last only a few minutes to hours, and there is no permanent brain damage. Having a TIA raises your chances of having a stroke.
Types of Strokes
Ischemic strokes are caused by a shortage of blood supply to a portion of the brain (American Stroke Association, n.d.). It’s caused by blood arteries in the brain becoming narrowed or clogged, cutting off blood flow:
• Ischemic strokes account for roughly 87 percent of all strokes.
• Symptoms may appear suddenly or gradually worsen over time.
• Loss of strength or sensation on one side of the body, trouble speaking, or changes in vision or balance are all possible symptoms of a TIA, which can occur before an ischemic stroke..
• Low blood flow results in systemic hypoperfusion.
When the heart stops working, not enough blood reaches the brain. A heart attack can lead to a stroke in this way.
The cause of up to 40% of ischemic strokes is unknown.
Ischemic Strokes are classified as follows:
• Thrombotic strokes are caused by a blood clot (thrombus) in a cerebral artery. The clot prevents blood from flowing to a portion of the brain. Typically, blood clots occur in arteries that have been injured by plaque build-up (atherosclerosis).
• Embolic strokes are caused by a blood clot that has moved around in the heart (embolus). Clots travel through the bloodstream and obstruct a blood artery in or near the brain.
Treatment of the stroke depends on what kind of stroke you have had. If it is an ischemic stroke it is imperative that they get medical help as soon as possible. The instant emergency medical services (EMS) arrives to transport you to the hospital; your stroke treatment begins. You may receive emergency care, treatment to prevent another stroke, rehabilitation to treat stroke-related side effects, or all three after you arrive at the hospital (CDC, 2021). Stroke is a life-threatening condition. If you arrive within 4.5 hours of when you were last normal you can receive Alteplase (Vega, 2022).Your medical team in the emergency room will (Kaiser, 2022):
Examine you to determine the extent of the stroke and its consequences.
Examine your medical history and inquire about your symptoms. If you are unable to communicate, we will contact a family member or friend on your behalf.
Testing such as blood tests, an electrocardiogram (EKG or ECG), and a CT (computed tomography) scan are performed. Other tests may be performed, such as an MRI, cerebral angiography, carotid ultrasonography (carotid doppler or duplex ultrasound), and/or an echocardiography (heart ultrasound).
tPA increases the likelihood of a stroke recovery. Individuals with ischemic strokes who receive tPA are more likely to fully recover or have less disability than patients who do not receive the medication, according to studies. Patients who get tPA are also less likely to require long-term nursing home care. Many stroke sufferers, unfortunately, do not arrive at the hospital in time for tPA treatment. This is why it’s critical to detect the signs and symptoms of a stroke as soon as possible.
For those who are past the 4.5 hours mark, but within 24 hours may be considered for treatment. They would have a procedure done through Interventional radiology. This is where they go through the femoral artery and retrieve the clot.
Carotid Artery Surgery (Endarterectomy) (Kaiser, 2022) may be used to help prevent a stroke. A vascular surgeon removes plaque (fatty deposits) from the carotid arteries in your neck during a carotid endarterectomy. The blood supply to your brain is provided by these arteries. The surgery’s timing will be determined by a number of factors, including:
The severity of the brain injury
your general well-being.
Craniotomy is used when the hemorrhage is so big that it puts pressure on the brain, causing a shift, which lead to deterioration. Removing part of the skull allows for swelling.
Injected into vein in arm
Given 4.5 hours after onset of symptoms
Dissolves the blood clot and restores blood flow
Retrieves the clot
Opens the artery to resore blood flow
Can be done up to 24 hours after onset of symptoms
Incision in neck
Open crotid artery
Remove fatty acids
Small section of skull is cut away
Remove blood clot/repair burst in blood vessel
It is important for both the patient and family members know that prevention is number one. Knowing your blood pressure, taking Statins to control hypercholesterolemia, quit smoking and taking anticlotting agents are things everyone can work on to help prevent future strokes.
Individuals who have had a stroke may have any of the following symptoms (Baptist Health, n.d.):
Problems with bladder and bowel function are typical among stroke survivors, but they can be upsetting. Urinary incontinence and retention, constipation, and bowel incontinence can all complicate “going to the bathroom” after a stroke.
Stroke patients may find it difficult to cope with a barrage of emotions. Some emotions are natural reactions to life changes following a stroke. They should be encouraged to seek help if they are suffering from sadness, anxiety, or overwhelming emotions.
After a stroke, one of the most prevalent complaints is exhaustion. Fatigue affects between 30 percent to 70 percent of survivors, which can be frustrating and hinder recovery.
Communication difficulties are one of the most typical issues following a stroke. Individuals may stutter, slur, or not be able to find their words at all. Stroke survivors and their families may experience distress and frustration as a result of this.
Strokes can range in severity from minor to severe, with a variety of limitations in between. Stroke survivors can find a variety of tools, including in-person and online Stroke Support Group meetings, to help them manage with their new limitations.
Professionals are expected to provide help and associated care information to family caregivers throughout the course of the disease (Pei-Chun Tsai, 2015). In order to comprehend difficulties from the caregivers’ perspective, health care practitioners must assess the requirements of family caregivers. Family caregivers should be given relevant information and counseling to assist them get the aid they need when they need it.
Control high blood pressure
Maintain a healthy weight
Eat a healthy diet
Avoid illicit drugs
Stroke is sudden death of brain cells due to lack of oxygen
Stroke is caused by blockage of blood flow/rupture of artery to the brain
Symptoms: weakness/paralysis on one side of the body, difficulty with balance, speaking, and swallowing
Clot-busting drugs like TPA can be used to reverse a stroke
Prevention – minimizing risk factors
A stroke is known medically as a cerebrovascular accident (CVA). A stroke occurs when blood flow to a portion of your brain is interrupted by a blockage or a blood vessel rupture. Everyone should be educated and aware of the signs and symptoms of a stroke. Especially those with comorbidities such as hypertension, diabetes and hyperlipidemia/hypercholesterolemia. It is critical to seek medical help as soon as possible in order to undergo treatment that will improve the prognosis. If a stroke is not treated promptly, it can lead to lifelong brain damage. It is also important to prevent future strokes or strokes at all by controlling high blood pressure, high cholesterol and diabetes.
American Stroke Association. (n.d.). About Stroke. Retrieved from American Stroke Association: About Stroke
Baptist Health. (n.d.). Patient Education for Stroke. Retrieved from Baptist Health: https://www.baptist-health.com/services/stroke/patient-education-for-stroke/#:~:text=Patient%20Education%20for%20Stroke%20Learn%20more%20about%20the,or%20medically-managed%20to%20decrease%20your%20risk%20of%20stroke.
Caplan, L. R. (2021, August 3). Overview of the evaluation of stroke. Retrieved from UpToDate: https://www.uptodate.com/contents/overview-of-the-evaluation-of-stroke?search=cva&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
CDC. (2021, May 5). Stroke. Retrieved from CDC: https://www.cdc.gov/stroke/treatments.htm
CDC. (2021, May 5). Stroke Facts. Retrieved from CDC: https://www.cdc.gov/stroke/facts.htm
CDC. (2021, August 2). Types of Stroke. Retrieved from CDC.gov: https://www.cdc.gov/stroke/types_of_stroke.htm
Ellis, M. E. (2018, September 29). Cerebrovascular Accident. Retrieved from HealthLine: https://www.healthline.com/health/cerebrovascular-accident
John Hopkins Medicine. (n.d.). Effects of Stroke. Retrieved from John Hopkins Medicine: https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/effects-of-stroke
Kaiser. (2022). Stroke. Retrieved from Kaiser: https://mydoctor.kaiserpermanente.org/ncal/structured-content/#/Condition_Stroke.xml
MedLinePlus. (2021, October 26). Stroke. Retrieved from MedLinePlus: https://medlineplus.gov/stroke.html
Pei-Chun Tsai, P.-K. Y.-F. (2015). Needs of family caregivers of stroke patients: a longitudinal study of caregivers’ perspectives. Retrieved from NIH: https://pubmed.ncbi.nlm.nih.gov/25834409/
Vega, J. (2022, February 23). How Tissue Plasminogen Activator (tPA) Works for Stroke. Retrieved from VeryWellHealth: https://www.verywellhealth.com/tissue-plasminogen-activator-tpa-3146225