Stroke -Sudden, unexplained and life changing for family

Stroke is a serious life-threatening medical condition. Stroke occurs when the blood supply to part of the skull is cut off or when blood vessel within the brain bursts and bleeds into and around the brain.

Ischaemic 

This is the most common type of Stroke. It occurs when a blood clot typically forms in areas where the arteries have been narrowed or blocked, over time, by fatty deposits (known as plaques/atherosclerosis) that block the flow of blood and oxygen to the brain.

Another possible cause of ischaemic stroke is a type of irregular heartbeat called (Atrial Fibrillation or AF). This can cause blood clots in the heart that break up and escape from the heart and become lodged in the blood vessels supplying the brain.

Haemorrhagic

It occurs when a blood vessel within the skull bursts and bleeds into and around the brain. These are often called cerebral haemorrhages or intracranial haemorrhages.

· The main cause of haemorrhagic stroke is high blood pressure. High blood pressure weakens the arteries in the brain and make them prone to split or rupture.

· A bleed might also result if a balloon-like expansion of an abnormally formed blood vessel (aneurysm), in the brain, ruptures.

· An arteriovenous malformation (AVM) is a tangle of abnormal and poorly formed blood vessels that have an associated higher rate of bleeding than normal vessels. As such brain AVMs are possible candidates for haemorrhagic Stroke.

· Another possible cause of stroke would be bleeding in the brain caused by a brain tumour. Symptoms for such a tumour vary from a simple headache to life-threatening paralysis 

Risks

High blood pressure, obesity, excessive amounts of alcohol and smoking are risk factors. Lack of exercise and a sedentary lifestyle may also hint at potential poor vascular health. This can be compounded by job roles that involve a lot of standing. 

Family problems, bereavement and stress can be a factor that can cause a temporary rise in blood pressure that can bring about Stroke. Undiagnosed Diabetes or a heart condition like Atrial Fibrillation are also dangerous.

The use of stimulants (such as amphetamines, cocaine or phencyclidine) can also cause a sympathetic surge in blood pressure that results in an arterial spasm (vasospasm) which then produces a constriction in a blood vessel.

Stroke is caused by either a blood clot that restricts blood flow to brain (ischaemic/infarct) or a bleed within the brain (haemorrhagic). The treatment depends on how quickly stroke is diagnosed and on the outcome of the CT/MRI result.

· If it is a Transient Ischaemic Attack (or mini-stroke) it is recommended to treat it with aspirin (antiplatelet) which reduces the chances of another clot forming for 2 weeks. Other antiplatelet medicines such as clopidogrel (long-term) or, alternatively, dipyridamole can be used.

· If it is an Ischaemic stroke treatment depends on joint medical decisions and following strict clinical guidelines. A thrombolysis or "clot-busting" injection (called Alteplase) is most effective if started as soon as possible after the stroke occurs. Alteplase is NOT generally recommended if more than 4.5 hours have passed since the stroke occurred (as clinical evidence suggests it is no longer of benefit after this point). If the ischaemic stroke is caused by a blood clot in a large artery, in the brain, a thrombectomy can be performed under local or general anaesthetic. Following the thrombolysis, and thrombectomy, treatment will be with antiplatelets (as discussed).

· To help avoid/reduce the risk of further ischaemic strokes anticoagulation agents like warfarin, apixaban, dabigatran, edoxaban and rivaroxaban may be prescribed for long-term use.

· To maximise ischaemic stroke prevention statins will be prescribed, even if your cholesterol level isn't particularly high, as these should help reduce your risk of stroke (whatever your cholesterol level is) as they reduce the level of cholesterol in your blood by blocking a chemical (enzyme) in the liver that produces cholesterol.

· If the ischaemic stroke is the result of a narrowing of an artery in the neck (called the carotid artery), a surgical intervention called carotid endarectomy will be performed by a vascular surgeon. This operation opens the carotid artery to allow the surgeon to remove the fatty deposits that are limiting the blood flow. It is worth mentioning that there is a risk of damage to the vocal cord during the surgery but usually recovery is expected.

· The treatment of haemorrhagic stroke differs from that of an ischaemic stroke. Anticoagulants will be stopped. You may also need treatment to reverse the effects of medication to reduce your risk of further bleeding. Blood pressure medications will be offered to lower blood pressure gradually to prevent further strokes. Statins will be stopped, at least for a couple of weeks, and then restarted only by the stroke consultant.

· Haemorrhagic stroke is difficult to treat as the blood vessels in the brain are difficult to get to. Treatment generally requires observation. 

· Surgery to treat complications of haemorrhagic stroke, called hydrocephalus (shunt surgery), might be needed. The aim of this surgery is to drain the cerebrospinal fluid away to reduce the symptoms such as throbbing headaches, sickness, drowsiness, vomiting and loss of balance. This operation takes around one to two hours and is performed under general anaesthetic by a neurosurgeon (a specialist in brain and nervous system surgery).

Although some people may recover quite quickly, many people who have a stroke need long-term support to help them regain as much independence as possible.

About 80% of stroke survivors experience some degree of 

cognitive difficulties such as depression, anxiety, or anger and possibly emotional lability (which is rapid, often exaggerated changes in mood, emotions or feelings like uncontrollable laughing or crying or heightened irritability or temper).

The ability to plan, solve problems and reason about situations (poor executive function) might result.

The ability to carry out skilled physical activities such as getting dressed or making a cup of tea (poor praxis) might occur.

Many people experience problems with communication – verbal - speaking, understanding, reading, writing & calculating.

Two in three carers report experiencing difficulties in their relationship with the stroke survivor (with 1 in 10 considering a breaking up). 50% of carers experience some degree of mental health problems.

Stroke also increases the risk of developing vascular dementia. This may happen immediately after a stroke or may develop some time layer.

Lack of spatial awareness (not having a natural awareness of where your body is in relation to your immediate environment) can lead to accidents and injuries.

Low energy or a feeling of fatigue might result and affect some people’s ability to keep on top of daily chores which may mean they become dependent on care or on family.

Difficulty with bladder control or bowel movements can result in incontinence and the need to wear a ‘pad’, long-term.

Some people experience problems with their swallowing (dysphagia) reflex which can lead to damage to lungs and trigger a lung infections (pneumonia). To avoid complication percutaneous endoscopic gastrostomy (PEG) can be inserted, under local anaesthetic, to manage nutritional needs.

Poor posture and muscle wastage, or contraction, may become an issue that requires some degree of ongoing pain management.

Poor mobility might require providing wheel chair access, adding stair lifts or converting a living, or dining, room into a bedroom. If family members are unable to cope with the levels of care needed, moving the stroke survivor to a care home may need to be considered (and financed). 

Carbon dioxide is colour and odourless gas that is heavier than air. When bathing (to chest height) in a “dry carbon dioxide” the gas is absorbed through the hair follicles and skin into the capillaries and connective tissues. This (vasodilation) expands the blood vessel’s diameter which improves blood flow and the removal of waste products as well as increasing the transport of oxygen, nutrients and glucose to the tissues.

Effects:

Within the first couple of minutes a client experiences pleasant heat and perspiration.

Blood pressure is decreased typically by 15-20mmHg Systolic and 10-15mmHg Diastolic.

 Benefits last up to six months:

· Helps to alleviate Stroke related Neuropathic pain

· Better blood flow increases energy levels alleviates fatigue and improves mood

· Cognition may improve

· Eyesight may improve

· Alleviates wheezing

· Helps to improve independence and improves quality of life

· Helps improve lymphatic fluid drainage (gravitational oedema) - meaning shoes fit properly

Gradually walking distance will improve