A stroke or cerebrovascular accident is any alteration that occurs temporarily or permanently, in one or more areas of our brain as a result of a disorder in cerebral blood flow (Martínez-Vila et al., 2011).
At present, in the scientific literature we find a wide variety of terms and concepts that refer to this type of disorders. The older term is stroke, was used widely when an individual was affected by paralysis, however, it did not involve a specific cause (National Institute of Neurological Disorders and Stroke, 2015)
Among the most commonly used terms, we may recently find: cerebrovascular disease (CVD), cerebrovascular disorder (CVD), cerebrovascular accident (CVA), or generic use of the term stroke. Generally, these terms are often used interchangeably. In the case of English, the term used to refer to strokes is “Stroke.”
Diseases of the brain in numbers
The World Health Organization (WHO) in January 2015 has highlighted cardiovascular diseases as the leading cause of death worldwide. Approximately 17.5 million people (31%) died worldwide due to this type of cause and 6.7 million deaths were due to strokes (WHO, 2015).
In Spain, stroke is the leading cause of death in women and the second in men, according to the Spanish Society of Neurology. More specifically, every six minutes a new case of stroke is occurring. (FEI, 2012).
It is the most frequent pathology in the population from 55 years of age. These pathologies follow a progression with age. Most of the strokes occur in the population over 65 years of age (75% of the total stroke), (Martínez-Vila et al., 2011). Approximately 21% of citizens over 60 years of age have a very high risk of stroke (FEI, 2012).
In addition, WHO estimates that there will be a significant 27% increase in the incidence of stroke cases up to 2025, mainly due to population aging (Martínez-Vila et al., 2011).
If we consider that approximately in the year 2050 approximately 46% of the total population will be over 65 years of age, almost half of these could have a somewhat risk of suffering a cerebrovascular accident (FEI, 2012).
In relation to the mortality rate of individuals suffering from an Ictus, there has been a drastic decrease due to an improvement in both primary and secondary prevention measures, as well as a significant technical advance in care protocols. In Spain, it is estimated that between 16.7% and 25% of intrahospital mortality due to stroke (Martínez-Vila et al., 2011).
Regarding the impact of this disease, approximately 30% of the patients who have suffered a stroke will present a serious problem of paralysis, cognitive and linguistic deficits. In addition, the direct costs of these accidents are estimated between 1% and 4% of total health expenditure. However, controlling for risk factors could prevent almost 80% of stroke cases (FEI, 2012).
Definition of cerebrovascular accident
An accident or cerebrovascular disorder occurs when the blood supply to an area of the brain is suddenly interrupted or when a blood leak occurs (National Institute of Neurological Disorders and Stroke, 2015).
The oxygen and glucose that circulate in our bloodstream are essential for the efficient functioning of our brain, since it does not accumulate its own energy reserves. In addition, the cerebral blood flow passes through the cerebral capillaries without coming into direct contact with the neuronal cells.
At baseline, the required cerebral blood perfusion is 52ml / min / 100g. Therefore, any reduction in blood supply below 30ml / min / 100g will seriously interfere with cerebral cell metabolism (Leon-Carrión, 1995; Balmesada, Barroso and Martín y León-Carrión, 2002).
When areas of the brain stop receiving oxygen (Anoxia) and glucose due to inadequate blood flow or a massive influx of blood, many brain cells are severely damaged and can die immediately (National Institute of Neurological Disorders and Stroke, 2015).
Types of Stroke
The most widespread classification of diseases or cerebrovascular accidents is performed according to its etiology, and is divided into two groups: cerebral ischemia and cerebral hemorrhage (Martínez-Vila et al., 2011).
The term ischemia refers to the irruption of blood supply to the brain as a result of blockage of a blood vessel (National Institute of Neurological Disorders and Stroke, 2015).
It is usually the most common type of stroke, ischemic attacks account for 80% of total occurrence (National Institute of Neurological Disorders and Stroke, 2015).
Depending on the extent, we can find: focal ischemia (affects only one specific area) and global ischemia (which may simultaneously affect different areas), (Martínez-Vila et al., 2011).
In addition, depending on its duration we can distinguish:
- Transient ischemic attack (TIA): when symptoms completely disappear in less than one hour (Martínez-Vila et al., 2011).
- Cerebral infarction: the set of pathological manifestations will present a duration greater than 24 hours and will result from a tissue necrosis due to deficiency of blood supply (Martínez-Vila et al., 2011).
- The blood supply through the cerebral arteries can be interrupted by several causes:
- Thrombotic stroke: an occlusion or narrowing of a blood vessel occurs due to an alteration of its walls. The alteration of the walls may be due to the formation of a blood clot in one of the arterial walls, which remains fixed by reducing the blood supply or by a process of arteriosclerosis , narrowing of the blood vessel by an accumulation of fatty substances (cholesterol and Other lipids) (National Institute of Neurological Disorders and Stroke, 2015).
- Embolic stroke: Occlusion occurs as a consequence of the presence of a plunger, that is, a foreign material of cardiac or non-cardiac origin, which originates at another point in the system and is transported through the arterial system to a smaller area in which it is able to impede blood flow. The embolus may be a blood clot, an air bubble, fat, or tumor-like cells (Leon-Carrión, 1995).
- Hemodynamic cerebrovascular accident: may be caused by the occurrence of low cardiac output, hypotension or a phenomenon of “theft of flow” in some arterial area by occlusion or stenosis (Martínez Vila et al., 2011).
The cerebral haemorrhages or haemorrhagic stroke represents between 15 and 20% of all strokes (Martinez-Vila et al., 2011).
When blood enters the intra- or extra-cerebral tissue, it will disrupt both normal blood supply and neural chemical balance, both of which are essential for brain function (National Institute of Neurological Disorders and Stroke, 2015).
Also Read: What are Consciousness Disorders?
Therefore, with the term cerebral hemorrhage we refer to blood shedding within the cranial cavity as a consequence of rupture of a blood vessel, arterial or venous (Martínez-Vila et al., 2011).
There are different causes of cerebral hemorrhage, among which we can highlight: arteriovenous malformations, rupture of aneurysms , hematological diseases and traumatic brain injury (Leon-Carrión, 1995).
Among these, one of the most common causes are aneurysms, it is the appearance of a weak or dilated area that will lead to the formation of a bag in an arterial wall, venous or cardiac. These bags can weaken and break up (León-Carrión, 1995).
On the other hand, a rupture of an arterial wall may also occur due to the loss of elasticity due to plaque (arteriosclerosis) or hypertension (National Institute of Neurological Disorders and Stroke, 2015).
Among arteriovenous malformations, angiomas are a conglomerate of defective blood vessels and capillaries that have very thin walls that may also present ruptures. National Institute of Neurological Disorders and Stroke, 2015).
Depending on the site of cerebral hemorrhage, we can distinguish several types: intracerebral, deep, lobar, cerebellar, brainstem, intraventricular and subarachnoid (Martínez-Vila et al., 2011).
Symptoms of stroke
Strokes are usually present suddenly. The National Institute of Neurological Disorders and Stroke suggests a series of symptoms that appear acutely:
- Lack of sensation or sudden weakness in the face, arm, or leg, especially on one side of the body.
- Confusion, problem of speech or compression of language.
- Difficulty of vision in one or both eyes.
- Difficulty walking, dizziness, loss of balance or coordination.
- Severe and severe headache.
Consequences of LCA
When these symptoms occur as a result of a stroke, the essential thing is urgent medical attention. Identification of the symptoms by the patient or close people will be essential .
When a patient arrives at an emergency presenting a picture of stroke, emergency and primary care services will be coordinated through the activation of the “Ictus Code”, which will facilitate diagnosis and initiation of treatment (Martínez-Vila et al., 2011) .
In some cases, it is possible for the individual to die in the acute phase when a major accident occurs, although it has been significantly reduced due to the increase in technical measures and the quality of medical care.
When the patient overcomes complications, the severity of the sequelae will depend on a number of factors related to the lesion as well as to the patient, being some of the most important the location and extent of the lesion (León-Carrión, 1995). In general, recovery occurs in the first three months in 90% of cases, but there is no exact time criterion (Balmesada, Barroso and Martín y León-Carrión, 2002).
The National Institute of Neurological Disorders and Stroke (2015) highlights some of the likely sequels:
- Paralysis: A paralysis of one side of the body (Hemiplegia) frequently appears on the contralateral side of the brain injury. There may also be weakness on one side of the body (Hemiparesis). Both paralysis and weakness can affect a circumscribed part of the body or everything. Some patients may also suffer from other motor deficits such as gait problems, balance and coordination.
- Cognitive deficits: In general deficits may appear in different cognitive functions in attention, memory, executive functions, etc.
- Language deficits: Problems in language production and understanding may also arise.
- Emotional deficits: difficulties may be encountered in controlling or expressing emotions . A common occurrence is the onset of depression.
- Pain: Individuals may experience pain, numbness, or strange sensations, due to either sensory regions, inflexible joints, or impaired extremities.
The development of new diagnostic techniques and life support methods, among other factors, has allowed the exponential growth in the number of survivors in stroke.
At present, a wide variety of therapeutic interventions specifically designed for the treatment and prevention of stroke are found (Spanish Society of Neurology, 2006).
Thus, classic stroke treatment is based on both pharmacological (anti-embolic, anticoagulant, etc.) and non-pharmacological therapy (physiotherapy, cognitive rehabilitation , occupational therapy , etc.) (Bragado Rivas and Cano-de la Cuerda, 2016).
However, this type of pathologies continues to be one of the leading causes of disability in Spain and in most industrialized countries,due essentially to the enormous medical complications and deficits secondary to their occurrence (Masjuán et al., 2016).
Thus, more than 50% of people who have had a stroke present as a sequela some form of disability, which causes a significant deterioration in the quality of life of the family and its relatives (Pinedo et al., 2016).
In addition, it has a high social impact, due to the dependency it generates and, in addition, to the permanent need for care in a large number of cases (Bragado Rivas and Cano-de la Cuerda, 2016).
Although the specific consequences of strokes will vary depending on type (Bragado Rivas and Cano-de la Cuerda, 2016), extension or location of brain damage and injuries, strokes are considered a first-line medical emergency Order (Masjuán et al., 2016).
When a blood stroke or oxygen flow occlusion occurs, the life of the affected person is at serious risk, as damage and brain damage develop very quickly.
In this way, the specific treatment of the stroke, can be classified according to the moment of intervention:
When signs and symptoms consistent with the occurrence of a stroke are detected, it is essential that the affected person comes to the emergency department.
Thus, in many hospitals, there are already different protocols specialized for the care of this type of neurological urgency.
The “ictus code” specifically, is an extra and intra-hospital system that allows both the rapid identification of the pathology, medical notification and the hospital transfer of the affected person to the reference hospital centers (Sociedad Española de Neurologia, 2006 ).
The essential objective of all the interventions that are put in place in the acute phase, therefore, is:
– Restore cerebral blood flow.
– Control the vital signs of the patient.
– Avoid the increase of brain injury.
– Avoid medical complications.
– Minimize the probabilities of cognitive and physical deficits.
– Avoid the possible occurrence of another stroke.
Thus, in the emergency phase, the most commonly used treatments include pharmacological and surgical therapies (National Institute of Neurological Disorders and Stroke, 2016):
The majority of drugs used in stroke are administered in parallel to or after the occurrence of stroke. Thus, some of the most common, include:
– Thrombotic agents: they are used to avoid the formation of blood clots that can be housed in a primary or secondary blood vessel. This type of drug, such as aspirin, controls the ability to coagulate through blood platelets and therefore may reduce the likelihood of recurrence of stroke. Other types of drugs used include clopidogrel and ticoplidine. Generally, they are usually given in emergency rooms immediately.
– Anticoagulants: this type of medicine is responsible for reducing or increasing the ability to coagulate the blood. Some of the most commonly used include heparin or warfarin. The specialists recommend the use of this type of drugs within the first three hours of the emergency phase, specifically through intravenous administration.
– Thrombolytic agents: these drugs are effective in restoring cerebral blood flow, since they have the ability to dissolve blood clots, if this is the etiological cause of stroke. Generally, they are usually administered during the onset of the attack or in a period not exceeding 4 hours, after the initial presentation of the first signs and symptoms. One of the drugs most used in this case is tissue plasminogen activator (TPA),
– Neuroprotectors: the essential effect of this type of drugs is the protection of the brain tissue against secondary injuries resulting from the occurrence of a cerebrovascular attack. However, most of them are still in the experimental phase.
Surgical procedures can be used both for the control of stroke in the acute phase and for the repair of secondary injuries to the acute phase.
Some of the most commonly used procedures in the emergency phase may include:
– Catheter: if intravenous or oral administration drugs do not offer the expected results. It is possible to opt for the implantation of a catheter, that is to say, a thin and thin tube, inserted from an arterial branch located in the groin, until reaching the affected cerebral areas, where the drug will be released.
– Embolectomy: A catheter is used to remove or remove a clot or thrombus housed in a specific brain area.
– Decompressive craniotomy: in most cases, the occurrence of a stroke may lead to cerebral edema and, consequently, an increase in intracranial pressure. Thus, the goal of this technique is to reduce pressure through the opening of a hole in the skull or removal of a bony flap.
– Carotid endarectomy: The carotid arteries are accessed through several incisions at the neck level, to eliminate possible fat plaques that occlude or block these blood vessels.
– Angioplasty and stent: In the algioplasty, a balloon was introduced to expand a narrowed blood vessel, through a catheter. While in the case of the use of the stent, a clip is used to prevent bleeding of a blood vessel or arteriovenous malformation.
Once the crisis is controlled, the main medical complications have resulted and, therefore, the survival of the patient is assured, the rest of therapeutic interventions are put into action.
This phase usually includes interventions from different areas and, in addition, a large number of medical professionals.
Although rehabilitation measures are usually designed based on the specific deficits observed in each patient, there are some common features.
In almost all cases, rehabilitation usually begins in the initial phases, ie after the acute phase, in the first days of hospitalization (Study Group of Cerebrovascular Diseases of the Spanish Society of Neurology, 2003).
In the case of cerebrovascular accidents, health professionals recommend the design of an integrated and multidisciplinary rehabilitation program , characterized by physical, neuropsychological, occupational therapy, among others.
After the crisis, the recovery period should begin immediately, in the first hours (24-48h) with physical intervention, through postural control or mobilization of paralyzed joints or limbs (Diaz Llopis and Moltó Jordá, 2016 ).
The fundamental objective of physical therapy is the recovery of lost skills: coordination of movements with hands and legs, complex motor activities , walking, etc. (Know Stroke, 2016).
Physical exercises often include repetition of motor acts, use of affected limbs, immobilization of healthy or unaffected areas, or sensory stimulation (Know Stroke, 2016).
Neuropsychological rehabilitation programs are designed in a specific way, that is, they must be work-oriented with the deficits and residual capacities presented by the patient.
Thus, in order to treat the most affected areas, which tend to be related to guidance, attention or executive function, this intervention usually follows the following principles (Arango Lasprilla, 2006):
– Individualized cognitive rehabilitation.
– Joint work of the patient, therapist and family.
– Focused on the achievement of the relevant goals at functional level for the person.
– Continuous evaluation.
Thus, in the case of care, strategies are often used to train the care process, environmental support or external aid. One of the most used programs is the Attention Process Training (APT) by Sohlberg and Mateer (1986) (Arango Lasprilla, 2006).
In the case of memory, intervention will depend on the type of deficit, however, it focuses essentially on the use of compensatory strategies and the enhancement of residual capacities through repetition, memorization, recognition, association, Environmental adaptations, among others (Arango Lasprilla, 2006).
In addition, in many cases patients may present significant deficits in the linguistic area, specifically, problems for the articulation or expression of language. Therefore, the intervention of a speech therapist and the development of an intervention program may be required (Arango Lasprilla, 2006).
The physical and cognitive alterations will significantly impair the performance of activities of daily living.
It is possible that the affected person presents a high level of dependence and, therefore, requires the help of another person to cleanse the person, eat, dress, sit, walk, etc.
Thus, there is a wide variety of programs designed for the relearning of all these routine activities.
New therapeutic approaches
Apart from the classic approaches described above, numerous interventions are currently under development that are showing beneficial effects in post-stroke rehabilitation.
Some of the newer approaches include virtual reality, mirror therapy or electrostimulation.
Virtual Reality (Bayón and Martínez, 2010).
The techniques of virtual reality are based on the generation of a perceptual reality in real time through a computer system or interface.
Thus, through the creation of a fictitious scenario, the person can interact with him through the realization of different activities or taras.
Normally, these intervention protocols usually last about 4 months, after which it has been possible to observe an improvement of the capacities and motor skills of the affected ones in phase of recovery.
Thus, it has been observed that virtual environments are capable of inducing neuroplasticity and, therefore, contribute to the functional recovery of people who have suffered a stroke.
Specifically, different experimental studies have reported improvements in gait, grip or balance.
Mental practice (Bragado Rivas and Cano-de la Cuerda, 2016)
The process of metal practice or motor imagery consists of performing a movement at the mental level, ie without physically executing it.
It has been discovered that through this process the activation of much of the musculature related to the physical execution of the imagined movement is induced .
Therefore, the activation of the internal representations can increase muscle activation and, therefore, improve or stabilize the movement.
The technique or therapy of mirror consists, as its name indicates, in the placement of a mirror, in a vertical plane in front of the affected individual.
Specifically, the patient should place the paralyzed or affected limb on the posterior aspect of the mirror and the healthy or unaffected one in front, thus allowing the observation of their reminiscence.
The goal, therefore, is to create an optical illusion, the affected limb in motion. Thus, this technique is based on the principles of mental practice.
Different clinical reports have pointed out that mirror therapy shows positive effects, especially in the recovery of motor functions and pain relief.
Electrostimulation (Bayón, 2011).
Transcranial magnetic stimulation (TMS) is one of the most commonly used approaches in the area of electrostimulation in stroke.
EMT is a non-invasive technique that is based on the application of electrical pulses in the scalp on the areas of affected nervous tissue.
The most recent research, has shown that the application of this protocol is capable of improving motor deficits, aphasia and even heminelect, of people who have suffered a stroke.