stroke syndrome


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stroke syndrome

 
a symptom complex caused by a disorder of the blood vessels serving the brain, with impaired blood supply and ischemia. Called also stroke, cerebral vascular accident, and cerebrovascular accident.

Types. There are four neurological events associated with stroke: transient ischemic attack (TIA), reversible ischemic neurologic deficit (RIND), stroke in evolution (SIE), and completed stroke (CS).

TIAs are temporary attacks that come on suddenly and last only a few minutes to not more than 24 hours; although they often are not recognized as such, they are a warning that a completed stroke can occur. During the attack the person may feel a weakness or numbness on one side of the body, slurring of speech or inability to talk, visual disturbances such as blindness or double vision, and staggering or uncoordinated walking. These symptoms are short-lived and reversible; unless the person knows about them and their significance, the episode is often ignored. It is important that lay people be educated about TIAs because the probability of a completed stroke occurring at some time after a TIA is 25 to 35 per cent.

RIND is an event similar to TIA except that the symptoms last for several days to a week; there is complete or nearly complete recovery. Like TIA, RIND is an indication that the person is at high risk for a completed stroke.

A person with a stroke in evolution (SIE) experiences gradual weakness on one side of the body. The diagnosis of SIE is confirmed when the progressive changes are witnessed by the health care provider. The person with a completed stroke (CS) exhibits symptoms associated with severe cerebral ischemia resulting from an interrupted blood supply to the brain.

Persons most at risk for any of the four types of stroke include those with hypertension, atherosclerosis, and heart disease and other cardiovascular disorders. Obese persons, heavy smokers, and those with diabetes mellitus are also at increased risk.
Causes. There are three main causes of stroke syndrome, all of which are related to a pathological condition of the arteries and associated with cerebral infarction, i.e., a necrotic area in the brain tissue. They are cerebral embolism, cerebral thrombosis, and cerebral hemorrhage. Other causes of strokelike symptoms include compression of cerebral vessels, as from tumor or edema, and arterial spasm.
Cerebral Embolism. An embolus is a small mass of material circulating in the blood vessels. It can consist of air, fat, or other material introduced into the circulatory system; or, as is most often the case, it is a detached portion of a thrombus that settles in a cerebral vessel. Damage from cerebral embolism is often less extensive and recovery more rapid than in strokes from thrombosis and cerebral hemorrhage.
Cerebral Thrombosis. A thrombus, or clot, in a blood vessel of the brain is by far the most common cause of stroke. Most often the thrombosis occurs where there is narrowing of the lumen of a vessel, usually caused by atherosclerosis. The thrombosis produces ischemia, edema, and congestion of the brain tissues surrounding the area. Symptoms appear more gradually in this type of stroke.
Cerebral Hemorrhage. This is a rupturing of a blood vessel, usually an artery, within the brain, frequently associated with preexisting hypertension. There often is weakening of the vessel wall as well. Healthy arteries can withstand considerable pressure because of their elasticity, but in persons with arteriosclerosis this elasticity is lost and the blood vessel may rupture from the increased pressure within it. In other situations the cerebral vessel wall may be weakened by an aneurysm, and thus is susceptible to rupture and hemorrhage into the brain tissues. Stroke from cerebral hemorrhage is most common after age 50 and usually produces more extensive neurologic defects with slower recovery than does stroke from other causes.
Symptoms. The symptoms of stroke syndrome vary widely, depending on its cause, location of ischemia, and extent of damage to brain cells. The onset is sudden in cerebral hemorrhage and cerebral embolism because the interruption of blood flow happens quickly. Its effects are noticed almost immediately. Strokes from cerebral hemorrhage occur most often in the daytime while the person is active. In cerebral thrombosis the clot gradually occludes the blood vessels, therefore the onset is gradual. A stroke caused by thrombosis tends to occur while the patient is sleeping or within an hour after arising.



There may be preliminary symptoms, particularly with thrombosis. The patient may experience dizziness, headache, mental confusion, and poor coordination. More often there is a sudden and dramatic onset with loss of consciousness; convulsions may occur. The unconsciousness may last for a few minutes or continue for weeks; it can terminate in a slow recovery or death. Sudden death rarely occurs as a result of stroke.

There usually are neurologic symptoms related to the site of ischemia, such as hemiplegia, loss of sensation, and reflex changes. The area of paralysis is directly related to the area of cerebral ischemia. If the left side of the brain is affected, the paralysis of the face, arm, and leg will be present on the right side. Speech disturbances also are related to the area of brain cell damage; if the left side of the brain is affected (the location of the speech center in right-handed persons), then a right-handed person will have aphasia along with the hemiplegia.

Involvement of the region of the thalamus produces a sensation of pain in the hemiplegic area, especially the hand, beginning several weeks after the stroke. Emotional disturbances also accompany thalamic involvement. The patient has difficulty controlling emotions and may laugh or cry with little provocation.

The symptoms of stroke are almost unlimited in type, severity, and duration. Some may eventually subside, while others are never completely eliminated. Anyone concerned with the care of the stroke victim should be alert to all signs and symptoms that occur. These can be extremely helpful in establishing a definite diagnosis and planning a regimen of patient care.
Prevention and Treatment. Medical and surgical preventive measures have significantly reduced the incidence of stroke in the United States. Medical preventive measures are aimed at eliminating or controlling atherosclerosis and other conditions that predispose a person to stroke. Effective control of hypertension and treatment of rheumatic and atherosclerotic heart disease have significantly reduced the incidence of stroke. Efforts to control diabetes mellitus, reduce cholesterol levels by diet and exercise, manage obesity, and encourage cessation of smoking are all examples of measures that have been successful in preventing stroke in significant numbers of people at risk.



Surgical procedures employed to prevent stroke or lessen the severity of its effects once it has occurred include (1) endarterectomy to remove thickened areas from the inner lining of the carotid or vertebral arteries in the neck, (2) using a graft to patch a section of artery in which there is an aneurysm, or removing the section of artery so affected, and (3) removal of a blood clot within the artery.

The choice of prevention and treatment is governed by the conditions which predispose the patient to having a stroke and, in the event one has already occurred, the potential of the individual patient to benefit from the treatment. anticoagulant therapy is used only when hemorrhage has been ruled out as a possibility and clot formation has been found to be either the potential or actual cause of decreased blood flow. Antihypertensive drugs are used to reduce pressure within the blood vessel and thereby avoid rupture.
Emergency and Acute Care. Emergency care consists of loosening all constricting clothing, especially around the neck, to improve respiration and circulation to the head. The patient's head should be turned to the affected side to prevent aspiration of saliva and mucus. Oxygen is administered, and the patient is kept calm and quiet and reassured of being cared for. If conscious, he or she may sit up or the head may be elevated to lessen blood pressure within it.



After admission and during the acute stage of stroke syndrome, it is extremely important to assess the patient's condition frequently to determine the neurologic effects and to ascertain whether there is evidence of recurrent strokes. Observations of the patient are valuable in determining the cause of the stroke and the choice of treatment. Maintenance of a patent airway and adequate oxygenation are critical. suctioning may be necessary if paralysis prevents normal swallowing of saliva. An artificial airway is inserted if the patient cannot maintain an adequate airway on his own. In severe cases a tracheostomy may be required. The vital signs are taken and recorded at frequent intervals until stable. An elevated temperature, with decrease in the pulse and respiratory rates, indicates a poor prognosis.
General Care. To avoid complications that can develop quickly in a stroke victim with partial paralysis, it is necessary to attend to proper positioning, good body alignment, and frequent turning.
Causes of stroke. From Ignatavicius and Workman, 2000.
The patient is turned at least every two hours. Because of poor circulation to the affected area, a stroke patient should not be left to lie on the affected side for more than 20 minutes four times a day.



The amount of activity allowed will depend on the cause of the stroke and the stage of illness. Those who have increased intracranial pressure from hemorrhage and edema will be placed on complete bed rest. Others who are comatose will require continuous care to avoid complications arising from inactivity (see also coma).

Complications to be avoided in the patient who has suffered a stroke include pressure ulcers, hypostatic pneumonia, thrombosis and other conditions resulting from circulatory stasis, kidney stones and urinary infections, and such orthopedic deformities as footdrop, wristdrop, and contractures. Unless contraindicated, the joints are put through their full range of motion at least once a day (see also therapeutic exercise). A program of physical therapy, along with occupational therapy and speech therapy is planned and started as soon as possible to assure maximum rehabilitation.

Nutrition is maintained by whatever means necessary, depending on the patient's ability to chew, handle food in the mouth, and swallow. In some cases tube feeding may be the only method by which food is administered. If the patient is able to swallow, but has some dysphagia, food should be cut into small pieces and the patient instructed to chew it thoroughly and to make a conscious effort to swallow. Liquids should be sipped rather than gulped down; thickened liquids are easier than thin ones to swallow. Tilting the head to the unaffected side may make swallowing easier and gagging less likely. Rinsing the mouth after meals and frequent mouth care help eliminate accumulation of food in the mouth and halitosis. The lips should be kept lubricated with cold cream or mineral oil to keep them from drying and cracking.

Incontinence of urine and feces sometimes accompanies a stroke. A regular schedule of offering the bedpan, especially after each meal, may help establish a routine of elimination. It is also helpful to get the patient up to the bathroom or to a bedside commode whenever this is possible. In any event the patient must be kept clean and dry and skin care must be given frequently to avoid pressure areas and decubitus ulcers. Fecal impaction and urinary retention may occur and can be avoided by intelligent observation and recording of bowel movements and urinary output. (See also bladder training and bowel training.)

Stroke victims sometimes experience a lack of proprioception; that is, they are unaware of the location and position of an affected extremity unless they are looking directly at it. This predisposes them to falls and other injuries unless special care is taken to assist them. Other common problems include those associated with decreased sensitivity to touch, pressure, heat, and cold.

Rehabilitation of the patient begins upon entrance to the hospital. This means that all measures taken to maintain bodily functions and to avoid complications are aimed at the ultimate goal of getting the patient back to a state as near normal as possible. Reaction to the illness by the patient and the family, the quality of care received, and the attitude of caregivers will greatly affect the eventual outcome of the illness. There may be a tendency on the part of the hospital staff and the patient's family to do everything for someone who seems so helpless and handicapped. Certainly the patient should be helped with the things he or she absolutely cannot do, but total dependence on others can become very demoralizing; for the patient's sake he or she must be encouraged in self care. This may be a slow and demanding process, requiring much patience and optimism. One can begin by providing the means by which the patient can gradually begin activities such as bathing, feeding, and dressing.

Special equipment, such as an overbed table made of cardboard or plywood, can be used so that the patient can reach bath water, toilet articles, and other needed things. Food should be prepared and arranged on the tray so that the patient can handle it without great difficulty. If the first movements are awkward and messy, no mention should be made of this; the patient must never be made to feel that he or she has caused an inconvenience to anyone through efforts to do things independently.

There has been much interest in the rehabilitation of stroke patients in recent years and there is a wealth of information and help available for the patient and family. Pamphlets dealing with the special problems of this illness are available from the American Heart Association and the American Red Cross. Centers for speech therapy, vocational rehabilitation, and homemaker services are located in many communities. The local health department can provide information as to the location of these centers and services they provide.
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