Communication Problems

After having a stroke, many people experience problems with speaking and understanding, as well as with reading and writing. This is called aphasia and is sometimes also known as dysphasia.

Aphasia can be caused by damage to the parts of the brain that are responsible for language, or be due to the muscles that are involved in speech being affected. You should see a speech and language therapist as soon as possible for an assessment, and to start therapy to help you with your communication skills.

Visual Problems

Stroke can sometimes damage the parts of the brain that receive, process and interpret information sent by the eyes. Some people may have double vision, or lose half of their field of vision in one eye. This means that they are able to see everything that is on one side of the eye, but are blind on the other side.

Sex after Stroke

The damage that a stroke causes to your brain can impact on many aspects of your life and wellbeing, and depending on your individual circumstances, you may require a number of different treatment and rehabilitation methods.

Psychological Impact

The two most common psychological conditions found in people after a stroke are:

• depression: many people experience intense bouts of crying and feel hopeless and withdrawn from social activities
• anxiety disorder: where people experience general feelings of fear and anxiety, often punctuated by intense, uncontrolled feelings of anxiety (anxiety attack)

You will receive a psychological assessment from a member of your healthcare team within the first month after your stroke.

Feelings of anger, anxiety, depression, frustration and bewilderment are all common, although they may fade over time. Your healthcare team, family, friends can all provide you with support and care you need.

The person with stroke and their relatives and carers should be given some advice and help about dealing with the psychological impact of stroke. This includes the impact on relationships with other family members and any sexual relationship. There should also be a regular review of any problems of depression and anxiety, and psychological and emotional symptoms generally.

These symptoms tend to settle down over time but if symptoms are severe or last a long time, GPs can refer people for expert healthcare from a psychiatrist or clinical psychologist. For some people, medicines and psychological therapies, such as counselling or cognitive behavioural therapy (CBT) can help. CBT is a therapy that aims to change the way you think about things in order to produce a more positive state of mind.

Cognitive Impact

Effective treatment of stroke has been found to prevent long-term disability and save lives. Stroke experts have set out standards which define good stroke care, including:

• a rapid response to a 999 (UK) or 911 (USA) call for suspected stroke
• prompt transfer to a hospital providing specialist care
• an urgent brain scan (for example, computerised tomography [CT] or magnetic resonance imaging [MRI]) undertaken as soon as possible
• immediate access to a high quality stroke unit
• early multidisciplinary assessment, including swallowing screening
• stroke specialised rehabilitation
• planned transfer of care from hospital to community and longer term support

Initial treatment for a stroke happens in the hospital. The sooner you get treatment, the better. The worst damage from a stroke often occurs within the first few hours. The faster you receive treatment, the less damage will occur.

In the hospital

Your treatment will depend on whether the stroke is caused by a blood clot (ischemic) or by bleeding in the brain (hemorrhagic). Treatment focuses on restoring blood flow for an ischemic stroke or controlling bleeding for a hemorrhagic stroke.

Before starting treatment, your doctor will use a computed tomography (CT) scan or magnetic resonance imaging (MRI) of your head to diagnose the type of stroke you’ve had.

The treatment of hemorrhagic stroke aims to stop bleeding, and to remove blood which might lead to swelling and increased pressure inside the brain.

Below are the two most common causes of hemorrhagic strokes and their treatments

Ruptured Aneurysm

Aneurysms are weak portions along the wall of a blood vessel which balloon out until they rupture. Aneurysms usually rupture because of high blood pressure. Ruptured aneurysms require brain surgery to repair the damaged blood vessel.

Abnormal Brain Blood Vessels

Examples of these include arterio-venous malformations or AVMs, and cavernous malformations. Typically these are blood vessels that are connected to one another in an abnormal way that causes them to bleed into the brain. When these abnormal vessels bleed into the brain, surgery is often needed to remove the abnormal blood vessels.

The treatment of ischemic stroke aims to dissolve, remove, or shatter a blood clot that is preventing blood from reaching an area of the brain. The most common treatments for ischemic stroke are the following:

Intravenous TPA

This is the first line of treatment against ischemic stroke. Tissue plasminogen activator or TPA is injected into the bloodstream through an intravenous line. TPA travels in the blood until it reaches the clot that is causing the stroke. Once there it begins to break up the clot until blood can flow past it toward the affected areas.

It is important to note that intravenous TPA cannot be given to people who come into the emergency room more than three hours after the onset of their symptoms for two important reasons: First, three hours after the onset of symptoms TPA is no longer effective; second: Three hours after the onset of symptoms TPA can increase the risk of bleeding inside the brain. This is one of the most important reasons why you should call 999 (UK) or 911 (USA) immediately after you feel stroke-like symptoms.

Intra-Arterial Thrombolysis

This treatment, which depending on the location of the stroke in the brain can be given for up to 6 hours after the onset of symptoms, consists of the injection of TPA, or a similar agent, directly into the blood clot that is causing the stroke. To do this, a special small catheter is inserted into one of the major blood vessels in the leg, and is strategically advanced towards the brain using a special video system. Once the blood clot is found, the small catheter is passed into its center where the injection is delivered. After sometime, the TPA, or similar agent, begins to dissolve the blood clot until blood can flow past the clot towards the area of the stroke. Unfortunately, because this treatment requires special equipment and technical expertise, it is only available in selected hospitals around the country.

The MERCI Retriever

The Mechanical Embolus Retrieval in Cerebral Ischemia, or MERCI retriever, is a recently developed approach to remove or break up blood clots that have wandered into a small blood vessel causing it to become occluded. This is done by carefully passing a special device from a blood vessel in the leg all the way into the blood vessel in the brain where the blood clot is trapped. The retriever captures the clot and pulls it out of the body, thus returning blood flow to the affected area.

Although this technique is still experimental, its results are often miraculous. However, as it is true with most technical procedures, the results of the MERCI retriever are limited by the experience of the people performing the procedure, and by the quality of the equipment used.

The main complication of the MERCI procedure is bleeding from an accidentally ruptured blood vessel.

Surgery is an accepted way of preventing stroke for patients with certain conditions. There are a number of conventional surgical techniques that have been in use for some time, including “clipping” aneurysms to prevent further bleeding and removing AVMs.

Carotid Endarterectomy

Carotid endarterectomy is a procedure used to remove atherosclerotic plaque from the carotid artery when this vessel is blocked. It has recently been proven that for certain patients with minor strokes or TIAs, carotid endarterectomy is highly beneficial in preventing future strokes. This procedure is also beneficial for some patients with blockage of the carotid arteries who have not had previous symptoms.

Stereotactic Microsurgery for AVMs and Aneurysms

Stereotactic microsurgery is one of the most dramatic new surgical procedures for AVMs and certain aneurysms that were once considered untreatable. It employs sophisticated computer technology and geometric principles to pinpoint the precise location of the AVM. During the procedure, a custom-fitted frame is attached to the patient’s head and three-dimensional reference points are established using CT or MRI. This technique allows neurosurgeons to locate the AVM within one or two millimeters so they can operate, using microscope-enhanced methods and delicate instruments, without affecting normal brain tissue.

Stereotactic Radiosurgery for AVMs

Stereotactic radiosurgery is a minimally invasive, relatively low-risk procedure, that uses the same basic techniques as stereotactic microsurgery to pinpoint the precise location of the AVM. Once located, the AVM can be obliterated by focusing a beam of radiation that causes it to clot and then disappear. Due to the precision of this technique, normal brain tissue usually is not affected. This procedure is generally performed on an outpatient basis.

Hypothermia

During surgical treatment of aneurysms and AVMs, there is a certain inherent risk that the patient may have a stroke while on the operating table. Physicians are using a technique known as hypothermia (cooling of the body), to prevent stroke during surgical treatment of giant and complex aneurysms or difficult AVMs. Dropping the brain temperature gives the surgeon the necessary time to operate with minimal risk of surgery-induced stroke. Special equipment known as a cardiopulmonary bypass machine is sometimes used to completely shunt blood flow away from the brain while the body is placed under deep hypothermia.

Revascularization of the Blood Supply

Revascularization is a surgical technique for treating aneurysms or blocked cerebral arteries. The technique essentially provides a new route of blood to the brain by grafting another vessel to a cerebral artery or providing a new source of blood flow to the brain.

What is a stroke?

Put simply, a stroke happens when blood can’t get to the brain and brain cells are damaged and die.

Are there any warning signs before a stroke happens?

For most people stroke happens suddenly, without warning. However, sometimes people do experience symptoms before the stroke occurs, such as dizziness, headache and/or loss of balance. A transient ischaemic attack (TIA) or mini stroke is a clear warning of an increased risk of a stroke and requires medical attention.

Who is most at risk of stroke?

Anybody can have a stroke: people of any race, any age (including children), either sex and any background. But some parts of the population are at increased risk. Stroke Foundation provides more information about who is at risk.

Is it true that people of certain racial origins are more likely to have a stroke?

Stroke affects all sections of the population, and nobody is exempt from risk. Even children can have a stroke. But it is true that people of South Asian or African-Caribbean origin in the UK are at increased risk.

Does stroke run in families?

If you have a close relative who has had a stroke, you are at an increased risk; however, stroke is not hereditary. Families with a history of stroke, cardiovascular problems or other risk factors are at an increased risk of problems. If you are concerned about stroke in your family, discuss your worries with your doctor.

Why me?

Stroke often happens out of the blue, without warning.  People affected by stroke, and their families, are often left in shock and disbelief.  Stroke can also cause a grief reaction, due to the overwhelming sense of loss.  However, asking “Why me?” is the first step on the process of recovery and learning to cope with the changes a stroke can bring.

How long does it take to recover from a stroke?

There is no simple answer to this question. Just as everybody is affected differently by their stroke, everybody has their own journey of recovery. Some people will make a full recovery and others may not. Most people will experience their fastest period of recovery in the days and weeks immediately after a stroke, and this will be followed by a longer period of slower rehabilitation.

Will I be able to lead a normal life again?

A third of people will make an almost full recovery physically and should be encouraged to lead a normal life

A third of people will have a significant amount of disability. This will vary from the severely disabled, e.g. people who need help getting in and out of bed, to milder things, such as needing help with bathing.

A third of people will be severely affected by stroke and will die within the year. The majority of these people will die in hospital in the first few weeks.

Dysphagia

The damage caused by a stroke can interrupt your normal swallowing reflex, making it possible for small particles of food to enter your respiratory tract (windpipe).

Problems with swallowing are known as dysphagia. Dysphagia can lead to damage to your lungs, which can trigger a lung infection (pneumonia).

To prevent any complications from dysphagia, you may be fed using a feeding tube. The tube is usually put into your nose and then passed into your stomach, but it may be directly connected to your stomach during surgery.

How long you will need a feeding tube can vary from a few weeks to a few months but it is rare to have to use a tube for more than six months.

Hydrocephalus

Hydrocephalus is a condition that occurs when there is too much cerebrospinal fluid in the ventricles (cavities) of the brain. About 10% of people who experience a haemorrhagic stroke will develop hydrocephalus.

Cerebrospinal fluid (CSF) is produced in the brain and protects it and spinal cord and carries away waste from brain cells. CSF flows continuously through the ventricles (cavities inside the brain) and over the surface of the brain and spinal cord. Any excess CSF usually drains away from the brain and is absorbed by the body.

Damage caused by a haemorrhagic stroke can stop the CSF from draining, and an excess of fluid can build up. Symptoms include:

• headaches
• sickness and vomiting
• loss of balance

However, the condition can be treated by placing a tube into the brain to allow the fluid to drain properly.

Deep vein thrombosis

Around 5% of people who have had a stroke will experience a further blood clot in their leg, known as deep vein thrombosis (DVT).

This normally occurs in people who have lost some or all of the movement in their leg, as immobility will slow the blood flow in their veins, increasing blood pressure and the chances of a blood clot.

Symptoms of a DVT include:

• swelling
• pain
• warm skin
• tenderness
• redness, particularly at the back of the leg, below the knee

If you have a DVT, prompt treatment is required because there is a chance that the clot may move into your lungs, which is known as a pulmonary embolism and can be fatal.

DVTs can be treated using anti-clotting medicines. If it is felt that you are at risk of a DVT, your stroke team may recommend that you wear a compression stocking. This is a specially designed stocking that can reduce the blood pressure in your legs.

There are many positive steps that you can take now to reduce your risk of stroke. The most common risk factors for stroke are listed below. These include some conditions that can be changed by lifestyle modification or medical treatment, and some, such as hereditary factors, that cannot be changed.

How to Reduce Your Risk

Most of the controllable risk factors for stroke relate to cardiovascular fitness. Because stroke is a form of cardiovascular disease, it makes sense that keeping your heart and blood vessels as healthy as possible will reduce your risk of stroke. The following are the most important measures you can take to control your stroke risk. These include changing risk factors by medical treatment as well as by positive lifestyle modifications.

Regular Medical Check-Ups

Risk factors such as heart disease, high blood pressure, and elevated blood cholesterol must be monitored by your physician on a regular basis. These risk factors can be changed or, at minimum, controlled by proper medical treatment and appropriate diet and lifestyle modifications.

Control Blood Pressure

High blood pressure (hypertension) is the single most important risk factor for stroke. Even mild hypertension, if not adequately treated, increases stroke risk. In general, blood pressure should be below 120/80. Elevated blood pressure promotes atherosclerosis and puts abnormal pressure on blood vessel walls, which can cause a rupture at a weak spot. Hypertension is often called the“silent killer” because there may be no obvious symptoms. It is important to check your blood pressure regularly. Controlling blood pressure, whether by a low-sodium diet, weight control, stress management and/or medication will reduce your risk of stroke. Remember: medication to control hypertension is effective only if taken on a regular basis, so it is important to follow your physician’s instructions.

Treatment of hypertension in older adults is also important. However, in elderly individuals, an abrupt fall in blood pressure may actually cause a stroke. Therefore, treatment of high blood pressure in the elderly may need to start with small doses of medication, so that blood pressure is reduced gradually.

Stop Smoking

Studies confirm that smokers have a higher risk of stroke, regardless of other factors such as age, high blood pressure, or heart disease. The risk declines dramatically within a few years of stopping smoking.

Treat Heart Disease

A variety of heart conditions, including irregular heart rhythms (atrial fibrillation), heart attacks and heart valve disorders, can cause stroke. Treatment of these disorders can reduce stroke risk.

Improve Diet

Consumption of foods high in fat, cholesterol and salt increases the risk for stroke. The following recommendations are among the most important for stroke prevention. Ask your doctor for more help in identifying dietary culprits and making appropriate substitutions.

• Avoid excess fat: High intakes of fat, particularly saturated fat, and cholesterol may contribute to atherosclerosis, which is associated with stroke. Dietary fat and cholesterol may be reduced by limiting fat or oil added in cooking, trimming fat and skin from meats and poultry, using low-fat or non-fat dairy products, broiling and baking foods rather than frying, and limiting eggs to no more than three a week
• Avoid excess sodium: Excess sodium in the diet is linked to hypertension. Table salt is the primary source of dietary sodium. There is also “hidden” salt in most processed and canned foods. Disodium phosphate, monosodium glutamate, sodium nitrate, or any similar compounds in the list of ingredients indicate a high sodium content. Try to eat fresh food whenever possible
• Limit alcohol intake: Individuals who drink alcoholic beverages (more than two drinks per day) have an increased risk of stroke. For heavy drinkers, the risk of stroke increases further. Healthy young adults are just as susceptible to the risk of stroke incurred by heavy alcohol consumption as are older persons

Maintain a Healthy Weight

Being overweight strains the heart and blood vessels and is associated with high blood pressure. Obesity also predisposes a person to heart disease and diabetes, both of which increase the risk for stroke. Keeping your weight to recommended levels for your height and build is a prudent preventive measure.

Exercise Regularly

The percentage of fat in our bodies tends to increase with age. Regular exercise helps keep this increase to a minimum. There appears to be an inverse relationship between exercise and atherosclerosis, i.e., more exercise is linked to lower levels of atherosclerosis.

If you have not exercised regularly and would like to start an exercise program, or if you have medical problems or family history of serious disease, consult your physician before beginning an exercise program. Select an exercise program that is most suitable for you. Experts recommend at least 20 to 30 minutes of aerobic exercise three to four times a week in order to achieve and maintain an improved level of fitness.

Treat Diabetes

The association between diabetes and increased stroke risk seems to be related to the circulatory problems caused by diabetes. Good control of diabetes appears to reduce the cardiovascular complications of the disease.

Reduce Stress

Because stress may increase blood pressure, it is linked indirectly to stroke risk. A one-time stressful event rarely causes a stroke, but long-term unresolved stress can contribute to high blood pressure. Stress management, including relaxation techniques, biofeedback, exercise and counseling, appear to be useful in the treatment of high blood pressure, thus lowering the risk of stroke.

Use of Oral Contraceptives

Oral contraceptives, especially those with high estrogen content, appear to increase the risk of blood clots, including clots that cause stroke, especially in women over age 30. The risk is even higher in women who smoke. Consult your physician for advice regarding alternative methods of birth control if you have stroke risk factors and are currently using oral contraceptives.

Post-menopausal Estrogen Use

Recent studies have shown that post-menopausal estrogen resplacement is associated with a small increase in the risk of stroke.

Strokes change lives. About one-third of people who have a stroke are left with physical and mental disabilities.