Stroke: causes, symptoms, therapy and rehab

What is a stroke?

"Stroke - an emergency!" Surely you have read this statement before on an ambulance. This emergency services campaign is intended to alert the population to the potential mortal danger of stroke. It would be better if the emergency number 112 were chosen too much than too little. Further projects and events on site aim to raise awareness of the possible risk factors and signs of disease and to inform them of the correct action in the event of an emergency.

The high number of strokes makes the issue of the topic clear: Every year over 200,000 people suffer a stroke in Germany. The risk of being confronted with such a situation in one's own family, in the circle of friends or acquaintances, or simply on the street, is correspondingly high.

Acute deficiency of the brain

With stroke or apoplex (griech.apoplezia: "Blow") is a sudden - "sudden" - circulatory disorder of the brain meant. The consequence is an undersupply of brain areas with the oxygen necessary for a normal function. A distinction is made between two different forms: cerebral infarction (ischemic form) and cerebral hemorrhage (hemorrhagic form).

In cerebral infarction (ischemic form), there is a vascular occlusion in a vein. Mostly deposits, so-called plaques, from the large cervical vessels with the blood stream are flushed into the brain. There they move a cerebral vessel largely to completely. The underlying parts of the brain, which were supplied by the vessel, are now cut off from the blood and oxygen supply. They are significantly impaired in their function or even die completely, which is equivalent to a total failure of the brain functions located there.

Another form of stroke is cerebral hemorrhage (hemorrhagic form). This tears a blood vessel in the brain itself or within the skull. It comes to the escape of blood into the brain tissue or in the most subtle spaces between the brain, meninges and skull bones. The underlying parts are also reduced blood circulation. The pressure of the leaked blood can also cause brain damage as in ischemic stroke.

A rare form (about 0.5% of all strokes) is the thrombosis of cerebral vessels. As with leg vein thrombosis after surgery or long air travel while a venous vessel is blocked. The cause is usually an (unknown) tendency to thrombosis in women in temporal connection with childbirth.

causes

Much is homemade

The causes of stroke are largely due to the prosperity of our society. The metabolic or "prosperity syndrome" is a dangerous combination of cardiovascular disease and metabolic disorders, coupled with mental overload and bad habits. High blood pressure and arteriosclerosis strain the cardiovascular system. The diabetes mellitus diabetes damages the vessels additionally. The situation is often made even more difficult by pronounced obesity.

Stress in work and family ensures that we do not sufficiently allow ourselves the necessary relaxation phases for our health. Stimulants such as alcohol, nicotine, caffeine and drugs as well as a lack of exercise and a wrong, high-fat and high-calorie diet are other risk factors. Similarly, people at risk with obstructive sleep apnea syndrome.

Other risk factors

Vascular damage in the head, as Ausackünungen or thinning of the vessel wall can also occur in people with a healthy lifestyle. However, they are not always known to have a "bloody" stroke.

An ischemic stroke can also be triggered by atrial fibrillation. In this form of cardiac arrhythmia, small blood clots can form in the heart. From there they are flushed to the brain with the blood stream and relocate the vessels there.

Read also:
Questions and Answers on Causes & Risk Factors

symptoms

Typical: hemiplegia and speech disorders

Recognizing the symptoms of a stroke can save lives. One of the most common signs are half-sided paralysis. These can occur in the arm or leg, but also in the face. The person affected can no longer smile, a corner of his mouth hangs down.

Also the speech production and the speech comprehension can be disturbed. A fluent, understandable speech is impossible. The language sounds washed out, "like drunk", or "the words are missing".What has been said may not be understood, the person concerned can therefore not comply with requests or behave inappropriately. Along with speech disorders, swallowing disorders are common.

Vision problems and general complaints

If the circulatory disorders affect certain areas of the brain or the eye itself, visual disturbances can also occur. The person concerned no longer sees anything in one eye or sees double images, or the left or right half of the visual field is no longer perceived.

General symptoms may also include headache, increased blood pressure, nausea and dizziness. Eventually, the person concerned loses consciousness. Sometimes, however, the neurological symptoms and deficits are not so concise, but are limited only to mild emotional disorders and a loss of strength in the arm or leg.

The one-sided symptoms always occur in the opposite side of the body stroke. This can be explained by the fact that important nerve tracts intersect to stimulate the various parts of the body at the level of the spinal cord.

The symptoms may be self-evident within 24 hours (so-called transient attack, TIA). Even then, the situation must be taken seriously and evaluated as a clear warning signal. Often there are serious underlying diseases that were previously unrecognized.

You'll find more about it here:
All about the symptoms of stroke

diagnosis

In a classic symptom picture, a stroke is often seen by the ambulance or ambulance by "eye diagnosis" and a simple neurological Basischeck.

CT to exclude bleeding

Immediately after arriving at the clinic, a computed tomography of the head (CT) is carried out as one of the first examinations. Here it is checked if there is a bleeding in the head. If the symptoms are typical for a classic stroke and the CT shows no bleeding, then in the next step, if necessary, a strong blood-thinning therapy can be given (lysis therapy).

A complete physical and neurological examination, the acceptance of many different laboratory values ​​and an electrocardiogram (ECG) from the heart are also performed in the first few minutes and hours.

Magnetic resonance imaging (MRI) and / or computed tomography with contrast agents help to diagnose and help differentiate between vascular occlusion and cerebral hemorrhage. Even complications such as reactive bleeding and brain swelling can be detected quickly.

Investigations in the course

In the following days of the hospital stay, the doctors carry out further special examinations to find out what has caused the stroke. Only then can they begin appropriate treatment to prevent future strokes in the future.

With an ultrasound, for example, the neck vessels are displayed. If a vessel section is severely calcified and closed, it may need to be surgically reopened, depending on the degree of severity.

Cardiac arrhythmias can also cause a stroke. Not infrequently there is atrial fibrillation. It is responsible for 15-20% of all strokes. In addition to the resting ECG, therefore, a 24-hour long-term ECG and an ultrasound of the heart (echocardiography) are performed.

In special constellations also takes a special form of cardiac ultrasound, a so-called swallowing echo. As with gastroscopy, the ultrasound probe is brought in from very close to the heart chambers. Since the esophagus and heart are directly behind each other, so individual chambers can be particularly well and accurately examined.

Read more about this topic here:
Important questions about diagnostics and examinations

therapy

1. Treatment in acute case

The motto in the treatment of acute stroke is "Time is brain!" ("Time is brain!"). There is only a small time window of a few hours after the onset of the symptoms, in which it is still possible to treat successfully. Symptom detection, hospitalization and initial examinations must therefore be carried out as soon as possible. Only in this way can as much as possible brain tissue be saved and brain damage minimized.

Well taken care of in a stroke unit

The experience of the clinic also plays an important role in therapy. Ideally, the person is treated in a stroke unit, a special ward for stroke patients. This is comparable to an intensive care unit equipped, but has a special know-how in dealing with neurologically ill people and a correspondingly specialized team of doctors, nurses and staff of different therapeutic areas.

Medication or catheter make the way again

In ischemic stroke, it is possible to dissolve the blood clot in the brain by means of medication (lysis therapy). The aim is to restore blood circulation to downstream brain areas as quickly as possible.The drugs are usually administered via an infusion and act at the site of the vascular occlusion. Rarely, other substances are given directly into a closed artery. Possible side effects of lysis therapy include bleeding and swelling of the brain tissue.

With newer therapies, clots can be aspirated through a gauzy catheter or captured in a tiny wire basket and removed. However, these methods are regularly carried out mainly in specialized centers.

In the rare case of cerebral venous thrombosis, heparin is mainly treated with the active substance. Similar to lysed drugs, this drug is also administered via the vein. It dissolves the vascular occlusion by making the blood thinner.

With a bleeding is waited

If there is a hemorrhagic stroke, ie a cerebral hemorrhage, the affected persons are primarily treated conservatively. A surgical procedure is often not necessary, the bleeding usually stops by itself. The treatment is then exclusively by speech therapy, occupational and physiotherapy.

Complaints are medically relieved. Rarely does an increased pressure within the skull have to be reduced by an emergency operation or a bruise removed.

How it goes on

After the acute therapy, the treatment is still ongoing. A stroke can be repeated at any time. In order to minimize the risk, it is important to identify appropriate risk factors and underlying diseases and to treat them early.

Therefore, next follows the diagnostics described above. Depending on what she shows, further therapies follow. In order to avoid long-term repeated strokes, a permanent treatment with medication is usually unavoidable. This is where the broad field of prevention begins.

You'll find more about it here:
Frequently asked questions about acute treatment

2. Rehabilitation

The rehabilitation after a stroke is very important. It is an essential part of the therapy. To achieve the best possible results and improvements, it must start already in the acute phase of the disease (Phase A). The affected person is therefore still in the hospital, ideally on a specialized stroke station.

A neurological rehabilitation differs fundamentally from rehabilitation procedures for other illnesses and injuries in which rehab or follow-up treatment takes place only after discharge from the hospital. The neurological rehab is therefore also referred to as so-called "early rehab".

With much practice, the brain recovers

Background of the timely start of rehabilitation is the fact that the brain is still capable of learning even in advanced to high adulthood. Going lost due to the destruction of brain tissue functions, other brain areas can partially take over these. This is called the plasticity of the brain.

As in a circuit new interconnections can be created, so also nerve fibers can make new connections. However, this does not happen from now on the same, but requires a lot of time, patience and consistent training. In fact, there are months in which, with regular implementation of active and passive measures, improvements can still be achieved.

Training your own body perception

A fundamental stimulus for the brain to create new nerve connections is the care, storage and possibly mobilization of the mobility impaired or bedridden sufferer according to special neurophysiological concepts.

By way of example, the Bobath concept is mentioned here. The applied techniques are adapted to the individual disturbance picture. The goal of the Bobath concept is to relax strongly stressed (spastic) muscle groups, to restore the interaction between the two halves of the brain - that is, from the affected and unaffected side - and to improve the perception of the restricted body side. Paralyzed (paretic) muscles are exposed to special external stimuli. So slowly physiological movement patterns can be initiated again.

These goals are achieved through the influence of passive head movements on the muscles of the trunk and extremities. A large contact surface when sitting or lying down relaxes, while a smaller or selective support surface stimulates certain muscle groups.

Structured rehabilitation program

Due to the high relevance of rehabilitation measures in the field of neurology, the requirements in Germany in terms of requirements, content and scope as well as the duration of the rehabilitation programs were laid down years ago. Neurological rehabilitation relies on a phase model.

Phase A, as mentioned above, already takes place in the acute disease situation in the clinic. In phase B, only passive measures will continue to be carried out, and the seriously ill can not actively participate. Phase C already describes further measures. The person concerned is largely conscious and is able to participate in 30-minute therapy sessions several times a day. In phase D self-employment is further trained and stabilized in the activities of daily life (mobility, body care, excretion, food preparation and intake, etc.).

Phase E relates to aftercare services (egPhysiotherapy and speech therapy in local practices) and - in younger people - vocational rehabilitation in specialized centers or reintegration at work. In the case of persistent need for care, Phase F, which relates to long-term care, such as those in the wake coma, follows instead.

The neuro-rehab is based on three pillars:

  • practicing procedures
  • Learn strategies to compensate for missing or restricted functions
  • Dealing with necessary aids

Physiotherapy will get you going again

Practical exercises include physiotherapy, speech therapy, occupational therapy and neuropsychological procedures. With the various methods of physiotherapy - similar to the Bobath concept - by certain stimuli from the outside relaxes the spastic muscles and the use of previously paralyzed muscles are made possible again.

Special emphasis must be placed on the training of the affected arm. In paralysis, the functions of the arm and the hand are much harder to restore than those of the leg and foot.

Often the situation is complicated by a paralysis of the trunk and shoulder muscles, which can lead to poor posture of the arm with a painful train on the joint capsule to shoulder dislocation (so-called painful shoulder or shoulder-arm syndrome). Not to be underestimated is the effect on the trunk, with which the arm is connected like a kind of abutment. Together with the rehabilitation of the arm so must always be a treatment of the trunk muscles.

Useful aids in everyday life

If necessary, in the physiotherapy also walking is trained. Often this aids are needed, for example, stabilizing rails or walking aids such as a walker or walker. The aids can be individually selected and adjusted in cooperation with the occupational therapists.

A special task is occupational therapy in the rehabilitation of the arm and the hand. Their functions are so complex that there are already specially trained hand therapists. The main task of occupational therapy is the restoration of the greatest possible independence and ability to act in everyday situations.

It's about trivial things, like opening the button for a toilet, smearing a sandwich or writing a sticky note. However, these and other activities can not be done by many in their current situation. Targeted instructions and consistent training are needed. As an aid in occupational therapy, for example, gripping aids, eating utensils with thicker handles or special pen holders are used.

Learn to speak new

Being able to communicate (in writing) is especially important for those who suffer from a disturbance of the speech and / or speech function (aphasia) after their stroke. In such a situation, the speech therapy comes into play.

In speech disorders alone the process of speech is disturbed, caused by a paralysis of the laryngeal and tongue / mouth muscles. However, the person concerned can express himself in writing and understand what is said. If, on the other hand, there is a speech disorder, the understanding of speech and writing is also limited or suspended. Communication is then possible via interpretations on objects or picture panels.

In addition to the typical speech and speech disorders, there is also the variant of excessive speech production. The affected person speaks "unchecked", but not always correct. It comes to slips, words are omitted or new word creations invented.

In spite of the speech or speech disturbances, however, sufferers really perceive their environment and the everyday life around them and can assess their possibilities accordingly. They can not always communicate this to their fellow human beings and often suffer greatly from the situation.

The prognosis of aphasia depends on the linguistic abilities before the disease event, on the extent and exact location of the stroke, the dominance of the left or right hemisphere on the affected person as well as on age and secondary diseases.

Swallow - a vital mechanism

Also, speech therapists become active if there is a dysphagia. Dysphagia is often associated with a speech disorder. Both are based on paralysis of the musculature in the mouth and larynx area.

The affected individuals are at risk of suffocating from their own saliva. When lying down, the head should therefore be positioned so that the saliva or vomit can flow freely out of the mouth. It may be necessary to administer medications according to medical prescription, which reduce the production of saliva.

Restrictions can of course also exist when eating and drinking. Due to the reduced or reversed oral and tongue motor skills, it is not possible for those affected to properly control the food or liquid in the mouth. Solid food may not be chewed, the porridge (even from passaged food) is not actively transported in the mouth back towards the throat. A correct swallow is not triggered. Spilled fluids as well as saliva spill out of the mouth or possibly into the trachea.

It is not always clear coughing vocal.In many cases, swallowing is recognized retroactively as such even when fever, sputum and other signs of infection occur: the person affected has suffered aspiration pneumonia, pneumonia by unnoticed inhalation or leakage of liquid or food into the lungs (silent aspiration). Like other forms of pneumonia, the worst case scenario can be fatal.

Slow food preparation

Therefore, before swallowing is safe, drinks and food should only be given to trained personnel who can respond properly in the event of an emergency. The basis for a swallowing training, which can be carried out by speech therapists or even trained nurses, is always an upright - swallowing - position, no matter whether the training is sitting in a chair or carried out in bed. The affected person must not be bent down in the abdominal area, but only in the hip, so as not to make swallowing even harder for him.

The swallowing is done primarily with food in pulpy consistency, such as yogurt or porridge. Only when the person concerned can swallow these foods safely, should be transferred to drinks and liquid food such as soups. Liquids are always at the beginning to thicken. For this purpose, various powdery thickening agents (for example locust bean gum) are available, which can be stirred into the liquids or sauces. They are tasteless and facilitate the swallowing test.

Often very stressful: cognitive limitations

In addition to the problems mentioned in the area of ​​mobility and mobility, food intake and communication as well as everyday coping, there may also be difficulties in the area of ​​cognitive performance. This refers to disturbances of attention, ability to remember and to learn, optical and acoustic perception, sense of time, creativity and action planning, spatial imagination and emotional control.

In these cases, additional neuropsychological procedures are used. Extensive battery testing has identified limitations in these areas that were considered secondary in the acute situation, or had not even occurred. However, they require as much attention as the purely physical restrictions, since they can lead to great anxiety and self-doubt among those affected. Previously, some of the tests were quite simple with paper and pencil, but nowadays more and more computer-aided methods are being used.

Halved world: the neglect phenomenon

In addition to neuropsychological tests, there are also appropriate therapy and training approaches. They are used when there is a neglect phenomenon. This means a multi-dimensional neglect of a room side.

A neglect occurs predominantly in right-sided brain infarcts. The affected person then does not perceive stimuli on the left side of the body or contact from the left side. There is a disturbance of one's own localization in space. The person concerned thinks he is much farther to the right than his objective position.

A neglect shows, for example, that the person concerned is always lying diagonally in bed or - particularly impressive - the fact that only the right half of a plate of food is eaten. The food on the left half of the affected does not perceive. He can see her, however, because there is no visual disturbance.

For the treatment of neglect it is important to offer the affected person a high stimulation frequency and intensity from the left side. The stimuli can consist of speech, running radio, objects or special attention and eye-tracking.

Acute risk of falling in the Pusher syndrome

Sometimes there is additionally a pusher syndrome.to push: "press"). The subjective virtual body axis is shifted by about seven degrees. If the affected person is standing or sitting, he feels he is in a significant incline. The logical consequence is that he wants to work his way out of this abnormal position. So he pushes himself vigorously in the opposite direction to subjectively take an upright position in the room.

Problems arise from the lack of muscle power on the Paretic side and the fact that due to the extreme sideways hardly balance can be maintained. The victims are therefore at the highest risk of falling.

A better perception of the body axis is often only possible after many weeks and requires a special walking training with at least two therapists. Balance, increasing weight on the paretic side and walking as such have to be trained in combination.

Varied offers support you

In addition to the treatment offers already listed, further support and counseling services are often available, such as nutritional advice, social services or pastoral care.

Nutritionists explain a healthy diet to those affected and relatives and help them to implement them in everyday life.

The social service helps to decide whether accommodation in the nursing home or temporarily in a facility for short-term care makes sense and is necessary, or whether a return home is conceivable.Even when looking for a nursing home or in the necessary structural redesigns and purchases for home care provide the employees of the social service information or can establish contact with competent contact persons.

Clinic-own pastors accompany believing people with stroke and their relatives in the for all difficult time.

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Everything about rehab after stroke

prevention

As part of the stroke diagnosis must always be a cause of research in relation to cardiovascular diseases and disorders of blood clotting. Detected diseases must be treated and risk factors eliminated.

Stroke seldom comes alone

Particular attention must be paid to avoiding further strokes. After the first event, the risk of another stroke is 10% in the first month and about 30% in the first year. From these averages, the individual's risk may still differ significantly, depending on his or her personal preconditions and comorbidities, as well as risk factors. Similarly, after a first stroke, the risk of heart attacks and circulatory disturbances in the legs is increased.

What the doctors can do

If, for example, severe deposits and constrictions in the neck vessels have been detected during diagnosis, these must be surgically removed in certain cases. Here are precise rules on the severity of the recommended operation.

If calcification of the carotid artery triggers a stroke, as a rule the administration of aspirin (ASA® 100mg) or alternatively clopidogrel 75mg. Aspirin and clopidogrel are called platelet inhibitors. That is, they prevent platelets from sticking to each other, depositing on the inside of the vessel walls and thereby narrowing them over time.

This therapy is also given if no obvious cause of a stroke can be detected. In addition, most sufferers receive a so-called statin. It lowers cholesterol and has anti-inflammatory and protective effects in the vessel walls.

If the vessel walls are too large, they can undergo preventive surgery. The risk of stroke due to bleeding is thus largely averted, at least at the treated site.

If a cardiac arrhythmia, atrial fibrillation, is diagnosed as part of a stroke, then a strong dilution of the blood with Marcumar® or similar blood thinners. Aspirin is usually insufficient in such cases.

A proven obstructive sleep apnea syndrome should be treated consistently with a respirator, if necessary, discontinue a known tendency to thrombosis by medication.

What you can do yourself

The Prosperity Syndrome described above can not be treated by surgery. Rather, this requires fundamental changes in one's own behavior in order to reduce the individual stroke risk.

Regular exercise and a balanced mixed diet, stress avoidance and if necessary weight reduction and nicotine waiver are the basic measures that can be implemented within a short time and with little effort and expense.

For optimal blood pressure, blood sugar, heart rate, blood lipid and clotting levels and for further weight loss, it is important to work with the attending physician and take regular medication. For nicotine and alcohol abstinence are available on the family doctor supportive contact persons.

More information here:
Worth knowing about prevention