STROKES - Full extract 

Mrs.Peterson and her family had been patients of our practice for many years. I looked after her late husband when he was ill with lung cancer, but she attended very infrequently. On one occasion her son brought her to the surgery after she had sprained her ankle in the garden. At the time I checked her blood pressure and suggested that she come in for a check-up. 

Although I sometimes saw her carrying home groceries from the supermarket, I heard no more for a couple of years. Several weeks ago her son gave me a call to say that he had found her slumped next to her bed. " She's talking strange too", he said. " I can't even understand what she's saying." By the time I arrived, Mrs Peterson's son had helped her on to the bed. She was quite cool and may have been lying on the floor for a few hours. She had an obvious facial weakness with marked drooping of the right corner of her mouth. She tried to speak but made no sense. It was obvious that she knew what to say but just could not get the words out properly. This made her very exasperated and upset. 

Mrs.Peterson's right arm was quite lifeless and hung at her side. She had no movement in the limb at all. She was able to bend her right knee and ankle but could not bear any weight. Her blood pressure was normal, but a listen to the carotid arteries in her neck revealed signs of narrowing, most marked on the left. Her son mentioned that she had a funny turn a few weeks earlier, when her right hand became clumsy for a few hours and she had difficulty preparing her dinner. 

I explained to Mrs Peterson that she had suffered a stroke and that she needed to be taken by ambulance to the hospital. She immediately had extensive investigations performed, including a CT brain scan. It appeared that a piece of clot had dislodged from her left carotid artery and travelled upwards blocking a branch of a cerebral artery. This caused damage to an area of the brain that is responsible for speech and controls the movement of muscles on the right side.  

She has had intensive physiotherapy and other rehabilitation but unfortunately progress has been very slow. She is able to walk and can speak a little more clearly but there are several residual disabilities. In view of her general condition, it was decided not to investigate her neck arteries at this stage. She has been put on low-dose aspirin permanently. It is hoped that with further rehabilitation she will improve to a degree where she will be able to move into a special accomodation unit not far from her home.

Having a stroke is some people's worst fear; nearly everyone has a relative or a friend who has had one. About 37,000 strokes occur annually in Australia. After heart attacks and cancer, strokes are the third most common cause of death. But they are the highest cause of continuing disability. 

A stroke is a sudden injury to the brain caused by an interference to its blood supply. This may be an artery that has become blocked with clot or one that has ruptured and begun to haemorrhage. The effect of a stroke depends on the size and location of the area involved. Some people suffer only a transient mild disturbance. Others may lapse into a coma and die. Most people do survive but may suffer disabilities like paralysis of limbs, difficulty with speech, memory loss, and coordination problems. 

On the positive side, the mortality rate from strokes has dropped by more than 60% in recent years. This has been due mainly to better control of blood pressure in our community. 

There are factors that clearly predispose to stroke, for instance high blood pressure, smoking, obesity, diabetes, family history and high blood cholesterol. Quite simply, people with one or more of these risk factors are more likely to suffer a stroke. These are the same risk factors that increase the likelihood of heart attack and vascular disease. 

Some strokes are caused by an irregular heart rhythm called atrial fibrillation, which predisposes to a thrombus, or clot, forming within the heart. A piece of clot may dislodge and travel up one or other carotid artery in the neck to the brain. The presence of atrial fibrillation may require treatment to slow the heart rate down or restore the rhythm to normal. Nowadays many patients with atrial fibrillation are given an anticoagulant medication called warfarin to reduce the likelihood of strokes. This medication always requires careful monitoring and regular blood tests. 

About 50% of people who suffer strokes experience brief warning symptoms beforehand, called T.I.A's or transient ischaemic attacks. The symptoms vary and may last from a few minutes to several hours. They occur if a small piece of clot flicks off the lining of a narrowed carotid artery in the neck, flows into a branch of an artery in the brain and temporarily blocks it off. The person might experience transient weakness or clumsiness of the hand, difficulty speaking properly or partial loss of vision. 

Sometimes it is difficult to be sure whether the symptoms are due to T.I.A's or some other condition like migraine. Urgent assessment and investigation is required. Low-dose aspirin is usually started because it makes clotting particles in the blood called platelets less sticky, thereby reducing the risk of a subsequent major stroke. A CT brain scan and an ultrasound of the carotid arteries in the neck are also usually arranged. If there is significant narrowing of a carotid artery, prompt referral to a vascular specialist is necessary, in case surgery is required to widen the artery. Other investigations like an ECG (heart tracing) may also be requested. In some patients a new medication called clopidogrel may be advised as an alternative to aspirin.

In contrast to TIA's, a true stroke is characterized by more pronounced and persistent symptoms. Weakness affecting one side of the body may occur. Difficulty speaking is another common feature; the person often knows exactly what to say but just cannot get the words out properly. Marked dizziness and unsteadiness can be another symptom. Sometimes collapse and loss of consciousness can be the very first sign that a stroke has occurred. 

Currently there is a major therapeutic trial in Australia to assess the efficacy of a clot-dissolving medication called Streptokinase. It can only be used in strokes caused by an artery blocked with clot, not for those caused by haemorrhage. To be effective in limiting the size of a stroke, it must be administered within four hours of the onset of symptoms. If there is concern that a stroke has occurred urgent transport to a major hospital is advised, by ambulance if necessary. 

Subarachnoid haemorrhage is a particular type of stroke with a specific presentation. Leaking from an aneurysm, or bubble on an artery, is a common cause. Sudden onset of very severe headache and neck pain is the usual pattern. Any possibility of a subarachnoid haemorrhage needs immediate investigation in case surgery is required for the aneurysm. 

Once in hospital, the person suspected of having had a stroke can have baseline tests and monitoring performed. If the blood pressure is elevated it can be controlled with medications. Investigations like a CT brain scan can be arranged and any specialized treatments can be commenced. Early assessment and treatment by the rehabilitation team can also be started. Physiotherapy, speech and occupational therapy play a major role in the degree of eventual recovery. 

Although there is a more positive and optimistic outlook for people who have suffered strokes, it is more important to try to prevent strokes in the first place. With careful attention to individual risk factors like smoking and high blood pressure, the number of people who suffer strokes should be able to be drastically reduced. 

Health Tips:
* Recognize those T.I.A early warning signs. Prompt treatment can prevent a major stroke from occurring. 

* A suspected stroke should be regarded as a medical emergency. Always seek urgent medical attention because early diagnosis and treatment leads to a better degree of recovery.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: December 11, 2004