After Stroke

Enhancing Quality of Life

Wallace Sife

• Editore: Routledge
• Anno: 2020
• ISBN:
  9781317971535
• Edizione: 1
• Argomento: Medicina
• Categoria: Teoria, pratica e riferimenti medici

After Stroke: Enhancing Quality of Life brings together an extraordinary selection of advice, practical survivor techniques, information about resources, and personal stories of triumph. It is designed to help those who have experienced a stroke attain the highest quality of life possible, under their new physical restrictions. Recuperating from a stroke is an arduous process that has only just begun when the survivor is released from the hospital. This book shows anyone interested how to create an effective climate for healing and how to help the survivor realize his/her fullest recovery potential. It offers varied perspectives of everyone involved with a stroke: the patient, the family, and friends as well as the team of specialized physicians, nurses, psychologists, physical therapists, speech pathologists, and diverse therapists. Through its interesting and varied essays, After Stroke: Enhancing the Quality of Life offers the reader a clearer understanding of the injuries that the body as well as the mind have sustained. This anthology is carefully designed to present enhanced perspectives into all aspects of the healing and recovery processes that follow the personal tragedy of a stroke.

Part I
Clinical Perspectives

Pathophysiology of Stroke

Fletcher McDowell

The term “stroke” is an ancient one. If you look it up in the Oxford English Dictionary it has 20 different meanings. These include: a stroke of lightning, a stroke of the pen, a stroke of an oar, a stroke of luck. But it also came to mean any kind of cataclysmic event that occurred to a human being. In ancient times it included everything that we now recognize as stroke but also included seizures and fainting spells.

It has been only in the last hundred years that stroke has become understood and sorted out into its various entities. It’s not a unified diagnosis as there are a number of different causes, each of which has a different pathology, different treatments and different frequencies, incidence and prevalence. These include cerebral infarction or ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage. These names do not imply causation but provide a useful clinical classification.

The most common reason for stroke is cerebral infarction, which is due to death of brain tissue caused by decreased or absent blood supply to a part or all of the brain for a long enough period so that brain tissue dies. Cerebral hemorrhage means that a blood vessel has broken inside of the brain, and caused bleeding into the brain, usually with formation of a large clot creating a hematoma within the brain. This can destroy and compress brain tissue and cause dysfunction. Subarachnoid hemorrhage, is bleeding over the surface of the brain, usually from a rupture of an aneurysm on one of the large arteries at the base of the brain. The frequencies of these diagnoses is quite different. Cerebral infarction causes about 80% of all strokes, cerebral hemorrhage 12% and subarachnoid hemorrhage 8%. The clinical characteristics of these particular entities of stroke are quite unique.

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Fletcher McDowell, MD, is Executive Medical Director, Burke Rehabilitation Hospital, 785 Mamarinack Avenue, White Plains, NY 10605.

[Haworth co-indexing entry note]: “Pathophysiology of Stroke.” McDowell, Fletcher. Co-published simultaneously in Loss, Grief & Care (The Haworth Press, Inc.) Vol. 8, No. 1/2, 1998, pp. 7-13; and: After Stroke: Enhancing Quality of Life (ed: Wallace Sife) The Haworth Press, Inc., 1998, pp. 7-13. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-342-9678, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

For cerebral infarction, the brain is deprived of blood flow, either total or locally. If this continues 10 minutes or longer, there is conspicuous change in nervous system function. After 10 seconds of decreased blood supply in the entire brain individuals faint. If the decrease is local and if the blood supply is not restored quickly, the area the brain supplies dies. Most strokes are due to local impairment of blood supply on one side of the brain or another on the posterior portion of the brain. This is most commonly due to obstruction of an artery supplying the brain. Obstruction is most often due to atherosclerosis. This is an extremely common condition, and is almost universal. In fact the evidence suggests that less than 4% of the people in our population die without some evidence of extensive atherosclerotic disease. It is common, but not everybody with atherosclerosis has a stroke. In addition to atherosclerotic obstruction of arteries, clots can form in the heart or in the vessels leading to the brain. These can break off and travel downstream and plug vessels. This is probably as common a cause for stroke as mechanical obstruction of arteries by atherosclerosis.

When a stroke occurs from decreased blood supply to a particular portion of the brain, the most common result is weakness, loss of sensation, and sometimes visual impairment on the side of the body opposite to the brain infarction. The victim has paralysis or weakness of the face, hand, arm and leg as well as a sensation of numbness and sensory loss on the same side. Strokes that are due to impairment of blood supply of the posterior portion of the brain have a wide variety of clinical possibilities. They most often cause some degree of paralysis on one side or both sides of the body, with loss of sensation, changes in the ability of controlling movements, and often some impairment of eye movement. If brain infarction occurs in the dominant hemisphere, which in most people is the left cerebral hemisphere, stroke victims will have some difficulty in understanding language or speaking. Combinations of impaired speech production and understanding are most common. With a large stroke, which involves the right cerebral hemisphere, victims may have major problems with awareness of the world on one side of the body or another. They also may be unaware of being paralyzed or that the left side of their body exists.

The physical impairment caused by stroke tends to improve over time. Generally, the improvement that occurs is most evident in the first three months after stroke, and is most evident in the lower extremities. Skilled hand and finger movements rarely return to normal, and most persons with a stroke report that despite near normal return of function they are never really back to the level of function they had before. If a concert pianist has a stroke, regardless of how much recovery occurs, it is unlikely that performance will return to the prestroke level. Virtually anyone who has had a stroke, and can talk about their experience, will tell you that they are never the same person following the stroke. Generally, infarction occurs rather abruptly, sometimes with warning signs briefly suggesting that a stroke is going to happen. These warning signs may last for ten to twenty minutes. They are strong indications that a stroke may occur.

Patients with intracerebral hemorrhage usually have a rather abrupt change in function, with headache and weakness developing on one side of the body. If the hemorrhage is large enough to compress of the brain stem, patients will lose consciousness. The sequence of events is sometimes not always abrupt, and symptoms may gradually develop over a period of hours. Generally intracerebral hemorrhage, when it occurs, produces an acute event over a period of a few hours. It almost never has warning signs suggesting that it’s going to happen. The diagnosis of intracerebral hemorrhage is easily made by the CT scan, which clearly displays bleeding into the brain. CT scanners are now available in about 90% of the hospitals, in the United States.

Determining whether a stroke is due to changes in cerebral blood flow or hemorrhage is vitally important because treatment of cerebral infarction often involves medication, which increases the chances of bleeding. The mortality of intracerebral hemorrhage is extremely high, depending on how large the hemorrhage is and whether the victim loses consciousness. Mortality from intracerebral hemorrhage can be as high as 70-80%. Small hemorrhages in the brain are not associated with high mortality but they do cause impairment of function. Some hemorrhages resolve without permanent changes in nervous system function.

Subarachnoid hemorrhage is a unique kind of stroke and easily identified if information about the onset is available. Usually, a victim of subarachnoid hemorrhage will report the abrupt onset of a severe headache, usually described as the most severe headache they have ever had. It is so intense that it stops a patient’s normal daily function. Many people have headache and manage it with aspirin and go to work, but usually not the headache of subarachnoid hemorrhage. At times the onset of subarachnoid hemorrhage may be associated with a brief period of loss of consciousness. If there is bleeding from the aneurysm into the brain there may be weakness on one side of the body or another. Because blood is an irritant around the outside of the brain, after several hours patients will have a stiff neck. On CT scanning which should be done for all patients suspected of having a subarachnoid hemorrhage, there will be evidence of bleeding over the surface of the brain. If that is found, the next procedure is to perform cerebral angiography to determine the source of the bleeding. Most commonly, it is a ruptured aneurysm found on one of the large cerebral arteries at the base of the brain, including the internal carotid, the middle cerebral or the anterior cerebral artery. The mortality of subarachnoid hemorrhage is high. It varies from 30 to 40% for the initial hemorrhage. A serious problem for victims of subarachnoid hemorrhage is recurrent bleeding. And each recurrence carries the same risk of mortality. Recurrence occurs in about 35-40% of patients. Because blood is an irritant and is found over the surface of the brain in contact with cerebral arteries, it often reduces the caliber of arteries supplying the brain or vasospasm. This occurs several days after the onset and is associated with another increase in mortality. It can decrease cerebral blood flow, and often causes cerebral infarction. It is extremely important to deal with the bleeding source, to be sure that recurrent bleeding is prevented. This should be done as quickly as possible. Unfortunately, many of those who survive subarachnoid hemorrhage have enough brain destruction to suffer permanent impairment, both in intellect and motor function.

Mortality in cerebral infarction is generally about 20%, but the frequency of disability is as high as about 40%, in stroke survivors. For intracerebral hemorrhage, mortality can vary from 45-70% and the disability can be very high. Subarachnoid hemorrhage mortality is high, but disability can be moderate. Many victims of subarachnoid hemorrhage survive without evidence of neurological impairment.

An important question is how frequently stroke occurs. This is done by calculating its incidence and prevalence. Incidence is an important determination for epidemiologists, and indicates how many individuals in a given population have a stroke in a given period of time. This is expressed as the annual number of strokes occurring in a population of 100,000 per year. There is difficulty getting this kind of information because it is nece...

Indice dei contenuti

• Cover
• Halftitle Page
• Title Page
• Copyright Page
• About the Editor
• Table of Contents
• Introduction
• PART I. CLINICAL PERSPECTIVES
• PART II. PROFESSIONAL CONTRIBUTIONS
• PART III. PERSONAL REFLECTIONS
• PART IV. HEALING DIMENSIONS
• Index