Stroke

The medical term of stroke is "cerebral vascular disease". It occurs when blood supply to the brain is reduced or blocked for certain reasons leading to a sudden lack of oxygen in the brain cells. In a few minutes, the brain cells may be damaged and lose their function. As a result, it affect the body functions controlled by that part of brain cells.

A stroke is a serious medical emergency. Some 30% of the sufferers die in three months’ time. However, more than 50% of the survivors can fully resume self-care ability and less than 20% suffer from severe disability. The factors affecting recovery depend on the severity of brain damage (including the type of stroke and the area and site affected), the complications developed and the self-care ability of the patient before the stroke. Besides, the attitude of patients and the support from their families/carers as well as the appropriate rehabilitation treatments may also have decisive effects.

Many risk factors may lead to a stroke. If you are within any one of the following categories, please be aware and take precautions promptly.

• Family history of stroke
• Aged over 55: the older the age, the higher the chance
• High blood pressure: 70% of stroke patient had preexisting high blood pressure
• High cholesterol: higher chance of atherosclerosis (an accumulation of cholesterol and other deposits (plaques) on the walls of your arteries. Plaques can reduce blood flow through your arteries) and narrowing of cerebral vessels
• Cigarette smoking: increasing the chance of stroke by 3 times for male and 4.7 times for female
• Diabetes mellitus: increasing the chance of stroke by 4 times
• Obesity
• Cardiovascular disease: much higher chance of stroke for people with history of  heart attack (myocardial infarction) and abnormal heart rhythm (atrial fibrillation)
• Vascular Malformation or aneurysm (a balloon-like swelling) of blood vessels in the brain: relatively higher chance of bleeding
• Mini-stroke, i.e. Transient Ischemic Attack (TIA): having symptoms similar to a stroke but lasting for a shorter time, persisting approximately 2 to 15 minutes and not more than 24 hours. Mini-stroke can be a warning sign that a stroke will be coming.
• Alcoholics: increasing the chance of stroke occurrence

To prevent stroke, the most important aspect is to slow down the speed of vascular atherosclerosis (blood vessel hardening). You may take following precautions to prevent stroke:

1. Controlling high blood pressure
   • life style modification: reducing sodium taken from diet, adhering to the "low-sodium, low-sugar, low-fat, high-fiber" dietary principle, controlling weight, taking exercise regularly and avoid addicted to alcohol
   • Medication: taking medicine according to doctor's instructions
2. Quit smoking immediately
3. Controlling diabetes mellitus
4. Lowering cholesterol: through diet and exercise, where necessary, taking medicine according to doctor's instructions
5. Handling pressure and learning to relax

The following medicines are useful to patients having suffered from ischemic stroke (stroke due to lack of blood supply)：

1. Anti-platelet drugs (such as Aspirin or similar drugs) –
   Aspirin can prevent platelet from clotting and is a common drug for preventing a stroke. Comparing with taking placebo (taking no medicine), it can prevent 22% of stroke recurrence. It is inexpensive. Most people will not feel unwell for taking a small dose of Aspirin (50-300 mg). The most common side effect is gastrointestinal upset. A small number of people may have gastrointestinal bleeding, especially those suffering from gastric ulcer. Aspirin users should let the doctor know if they have persistent stomachache, blood spitting or black excrements.
2. Anticoagulant (Warfarin) (a kind of drug to thin your blood) – mainly for patients suffering from heart disease and atrial fibrillation. Through its effect of restraining vitamin K, the body’s blood clotting function is reduced so as to prevent clotting in the heart or vessels. Warfarin can effectively prevent ischemic stroke from patient with underlying atrial fibrillation. Its side effects include cerebral bleeding (bleeding from a ruptured blood vessel in the brain), gastrointestinal bleeding (bleeding of digestive organs) and bleeding in other parts of the body.
   • When taking Warfarin, attention should be paid to the following::  
     • Do not take Aspirin or non-steroid anti-inflammatory drugs simultaneously unless you get doctor's instruction
     • Be aware of diet, avoid food that are rich in vitamin K)
     • Must not take Chinese medicine, to avoid possible drug interaction
     • In case of having bleeding over a long period or without reason, contact the doctor immediately. The symptoms include:
       • black stool
       • blood in urine
       • persistent nose bleeding, oral cavity and gums bleeding
       • a large area of bruise appearing on the skin without reason
       • severe or persistent headache, dizzy
     • Regular follow-up consultation and blood taking to monitor the INR value (normal range should be between 2-3)
       • If blood clotting ability is excessively reduced, the risk of bleeding will greatly increase.
       • If blood clotting ability is too high, stroke cannot be prevented.
3. Novel Anticoagulant: the following drugs should be available in the market
   • Dabigatran
   • Rivoraxaban
   • Apixaban
   • Edoxaban

Below is the comparison between Novel Anticoagulant and Warfarin:

Warfarin	Novel Anticoagulant
Interactions with food / drug	Less likely to interact with food / drug
Require regular follow-up and monitoring of INR via blood test for necessary dosage adjustment	No specific monitoring parameters No regular blood test required Fixed dosage, thus lower the risk of taking wrong dosage
Slower onset time	Faster onset time, but last for a shorter period of time. It is of vital importance to take medicine as prescribed
	Not indicated to renal failure patient)
	Not indicated to patient with prosthetic valve implantation
	A lower risk in bleeding complication)
	More expensive

 There is no study conducted for a direct comparison between the Novel Anticoagulants on their efficacy and risk.

Patients suffering from severe carotid arteries sclerosis (hardening of the arteries in the neck) may consider to have surgery performed to remove the sclerotic part or carotid angioplasty/stenting to widen the narrowed carotid arteries and improve the blood flow so as to promptly lower the risk of having a stroke again.

Depending on its causes, stroke is mainly divided into two types:

• Ischemic stroke: it is caused by cerebral thrombosis (a blood clot forms inside the vessels of the brain) and is relatively common, more than 70% of strokes belong to this type.  Also cerebral atherosclerosis causes formation of blood clot in the cerebral artery or the blood clots can be formed with the hearts or carotid artery in the neck. The clot can travel up to the cerebral vessels distally and block the flow of blood. Those cardiac diseases including arrhythmia (abnormal heart beat), cardiac valve problems and coronary heart disease could cause the stroke.

• Hemorrhagic stroke: it is caused by the bursting of a blood vessel inside the brain.  Most often, it is associated with persistent high blood pressure. There are also cases in which a blood vessel on the surface of the brain tissue bursts. This is associated with congenital cerebral vascular diseases e.g. cerebral artery aneurysm or arteriovenous malformation. The blood would be released below the arachnoid space (the space between the brain tissue and the skull) pressing the brain tissue.  Moreover, the blood vessel will contrict after bleeding, further reducing the flow of blood.

Both ischemia (inadequate flow of blood to a part of the body, caused by blockage of the blood vessels) and bleeding may prevent the brain tissue from receiving adequate nutrition and oxygen. The affected neurons will therefore die, giving rise to various neurologic symptoms.

The causes of TIA are similar to those of Ischemic stroke .

For most people, there is no sign before a stroke occurs. As a stroke may lead to very profound impacts, on the occurrence of the following warning signals, doctor should be consulted immediately in order to minimize the stroke sequelae (deficits that result from a preceding disease or accident):

Inability to speak clearly or having speech difficulties Sudden and transient numbness, weakness or paralysis of one arm, one leg or half of the face (usually in the same side) Sudden blurring of vision or decreased vision on one eye Sudden severe headache Difficulties in body balance and coordination of hands and feet or falling over suddenly without reason Dizziness or faintness without reason Incontinence (inappropriate involuntary passage of urine, resulting in wetting) The symptoms of TIA are the same as those of a stroke but only persist a few minutes and will not lead to permanent disability. A patient may have TIA once or several times and this may mean a real stroke is coming. In any event, doctor should be consulted immediately upon occurrence of the warning signals.

Besides examining the clinical symptoms, doctor will check the status of various risk factors such as blood pressure, cholesterol, blood sugar and will also take blood to check hemoglobin (oxygen-carrying proteins in blood), platelets and blood clotting time in order to identify anemia, bleeding tendency and blood viscosity. An electrocardiogram test (a medical test that detects heart abnormalities by measuring the electrical activity generated by the heart as it contracts) will also be done to check for the occurrence of heart attack simultaneously. Other examinations may include:

Computerized Tomography (CT Scan): it may help to differentiate stroke due to lack of blood supply from hemorrhagic stroke Magnetic Resonance Imaging (MRI): it can show the status of the brain tissue and the patency/narrowing of blood vessels Ultrasonic imaging of cervical blood vessels: using image to detect whether the cervical blood vessels have been narrowed or been blocked Transcranial Doppler: to detect whether the cerebral vessels have been narrowed or been blocked

No medication has yet been identified to address a stroke in an absolutely safe, reliable and effective way. Many treatments in fact are still under study. Surgery is of help to only a few stroke types. Modern treatments mainly focus on prevention and treatment of complications and starting planned rehabilitation program as soon as possible.
 
Treatments in acute stage

1. Medication
   • Thrombolytic therapy
     Thrombolytic agent could dissolve the thrombus and restore the blood flow to the brain, reducing damage to the brain cells and thereby disability caused by stroke, having said that the patients must receive the agent within three to four and a half hours of onset. Nevertheless, receiving thrombolytic therapy does not guarantee complete recovery. The thrombolytic agent would also increase the risk of developing intracerebral heamorrhage by ten times, and limited the use of this therapy.
     Moreover, the thrombolytic therapy is not applicable to all stroke patients. Patients are required to conduct a treatment eligibility assessment, by neurologist. If the degree of stroke is mild, the risk of bleeding in thrombolytic therapy might outweigh the benefit of recanalization.
     Therefore, timely medical attention and medical team's clinical assessment are very important. After the thrombolytic therapy, patients would be closely monitored, and their blood pressure would be managed to reduce the risk of intracerebral haemorrhage.
   • Other medications
     • anti-platelet drugs: e.g. Aspirin. These drugs could prevent formation of blood clot via platelet coagulation, thereby reduce the risk of re-occurrence of ischaemic stroke. If these drugs could be taken within 48 hours after stroke, functional dependency of stroke patients could be reduced by 1%.)
     • Anticoagulants: e.g. Warfarin and Novel Anticoagulant. These drugs could reduce formation of blood clot and vessel occlusion, thus would reduce the chance of stroke for patients with atrial fibrillation. However, the use of anticoagulants in acute stroke treatment is still controversial.)
     • For patients suffering from cerebral edema (swelling of brain tissue) caused by a severe stroke, the doctor may prescribe drugs such as Mannitol and Glycerol to decrease intracranial pressure
     • Certain drugs in clinical trial may protect the cerebral cells from dying in large volume but for the time being no drugs in clinical trial have been proved effective.
   • Edovascular mechanical thrombectomy
     Recent studies found that patients with large vessel occlusion stroke received endovascular mechanical thrombectomy within 6 hours of onset, could have better recovery. However, outcome of this procedure will be subject to the skill-mix of respective unit, and whether safe and emergent intervention could be provided. Given the resource limitation, this procedure is not yet widely adopted in local setting.
2. Surgery
   Not every patient suffering from hemorrhagic stroke needs to undergo surgery. It depends on the size, location and depth of the hematoma (collection of blood outside the blood vessels) and whether the stroke is complicated by swelling of brain tissue and the overall condition of the patient etc. Surgery can remove the hematoma to decrease intracranial pressure (pressure inside the skull) in patient with haemorrhagic stroke. Surgery can also clip the aneurysm (a balloon-like swelling of blood vessels in the brain) to prevent its from further bleeding. For ischemic stroke (stroke due to lack of blood supply), surgery can also be done to remove part of the intima of the carotid artery in order to prevent stroke recurrence. With the advance in non-invasive technology, catheter-based treatment can be perform to dilate the narrowing of the neck vessels or to seal up the aneurysm of the vessels inside the brain. 
3. Integrated treatment in Acute Stroke Unit
   A medical team comprising a number of different professionals provides acute treatment, rehabilitation care, physical therapy, occupational therapy, speech therapy, medical social work services and clinical psychological services etc for the purpose of preventing complications and preparing the patient for receiving rehabilitation treatments after the condition of the patient stabilizes.

 
Treatments in rehabilitative stage
The aim of the rehabilitation treatments is to ensure best recovery of the patients' daily life activity functions. Although not all physical functions can be fully restored, the aim of "self-adaptation" can be attained. It is very important to start rehabilitation training as soon as possible. A multi-professional medical team is responsible for the rehabilitation treatments. The team will assess the physical and psychological functions of the patient, their rehabilitation care needed and the caring ability of the carers. Most important of all is that the stroke patients and their family members should actively participate in the treatments.
 
In the rehabilitation treatments, nurses play an important role in providing 24-hour support to the stroke patients and their family members. They help the patients to maintain physical and psychological functions, improve their ability of living independently and prevent the complications caused by loss of ability. They will also provide professional care in relation to the common problems of stroke patients such as psychological problems involving anxiety and helpless feelings or physical problems such as difficulties in swallowing, difficulties in communication, urinary incontinence, constipation and pressure sore etc.
 
Physiotherapy will help the stroke patients to restore physical functions in various aspects, teach patients and their family members the correct cares and exercises and prevent the complications so that the patients can gain the highest independent ability.
 
Occupational therapy (Chinese version only) will, through different therapeutic programs, enable the stroke patients to gain the highest independent ability in various aspects such as basic self-care, domestic care, vocational and leisure skills.
 
Speech therapy will help the stroke patients to improve their swallowing, communication and verbal expression abilities. If the patients have psychological and/or emotional problems, clinical psychologist may offer assistance. The medical social workers may help the stroke patients and their family members by attending to their needs relating to financial assistance, housing, housework assistance, job arrangement, residential services.

Stroke is a severe disease. Up to 40% of the stroke patients in acute stage have difficulties in speech or swallowing to different extents. A small number of patients suffering a severe stroke, will even fall into coma. More than half of the stroke patients cannot return to work.

Apart from the impairment of physical functions caused by the damaged brain tissue, the common complications caused by a stroke include:

• Pneumonia
• Swallowing disorders
• Pressure sore
• Swelling of brain tissue
• Shoulder problems
• Digestive tract bleeding
• Epilepsy
• Difficulties in urination or urinary incontinence
• Constipation
• Blood clot formation with the vein of lower limbs and sudden blockage in the lung artery
• Depression

Stroke patients and their family members should discuss with the rehabilitation team about drawing up a suitable discharge plan and make proper preparations for domestic rehabilitation and care in the future. Such preparations may include:

• Determine the living place: make sure the residence is suitable and safe for the patient's activities.
• Assess the home facilities: where necessary, the rehabilitation team may visit the patient's home before the patient is discharged and suggest appropriate alterations to the facilities and construction of the patient’s home.
• Select and purchase necessary instruments: such as appropriate walking aids, domestic care aids.
• Advise on the caring skills: the patient and family members have to learn the necessary domestic care knowledge and skills relating to feeding and incontinence etc and the correct way to use the walking aids, suitable domestic exercises and skills in daily care and supporting and carrying the patient etc.
• Test the ability to care: arrangement may be made for the patient to have a brief vacation at home and take this as a practical training.
• Introduce the necessary community services: such as information about elderly homes, financial assistance and home helper arrangements.
• Make follow-up arrangements: such as follow-up consultation, instructions for taking medicine, speech therapist or dietitian for following up the swallowing or nutrition problems, receiving rehabilitation trainings at out-patient clinic or geriatric day hospital, home visit by community nurse to follow up the case.

Home caring and nursing

The main points are as follows:

• Domestic exercises: to improve self-care ability
• Fall and accidents prevention: pay attention to the skills for different activities
• Take medicine on time
• Diet restriction according to the instructions given by the medical professionals
• Prevent and handle constipation
• Pay attention to skin care to prevent pressure sore
• Implement the self-care skills (going to toilet, taking bath and washing up)
• Prevent recurrence of stroke: from various aspects including diet, emotion, living habits and medication.
• Face new life with a positive attitude

Solicitude of family members / carers
Family members' participation is extremely important in the course of the rehabilitation treatment while it is a severe challenges for the carers to live with the recovering stroke patient. When the patient feels depressed and helpless, encouragement and support from family members are something irreplaceable and this requires patience and understanding. But the carers also have to take good care of themselves. They should apply correct skills to avoid injury and give themselves space and time for rest. Sharing feelings with others and seeking help are encouraged. By doing so, they would be able to keep on supporting the patient to recover.