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Stroke

 

Like angina and heart attacks, strokes can be caused by a blockage in a blood vessel, only in this case the blockage is in one of the arteries that supply blood to the brain. In a thrombotic stroke,a blood clot (thrombus) forms in a carotid artery narrowed by arteriosclerosis. Four of every five strokes are of this type. In hernorrhagic stroke, the artery leaks or bursts, interrupting the brain’s blood supply. The least common type of stroke is an embolic stroke, in which a blood clot travels to the brain from the heart or other vessels and lodges in a small vessel in the brain.

Symptoms

Symptoms of a stroke may include
sudden weakness or numbness of the face, arm, and leg on one side of the body;
loss of speech, or trouble talking or understanding speech;
dimness or loss of vision, especially in one eye;
unexplained dizziness, unsteadiness, or sudden falls.

These are all the result of a lack of oxygen in ceils that make up various parts of the brain. About 10 percent of strokes are preceded by transient ischemic attacks (TIAs), sometimes called ministrokes. In these cases, blood vessels may go into spasm but are not usually closed off, or a small embolus may close off a small branch of a vessel. The symptoms may be similar to those of a stroke but last an average of only a few minutes or so. When the ministroke is over, the symptoms usually recede within 24 hours, whereas in a full-blown stroke they do not.

Intravenous anticoagulants can sometimes combat a stroke in progress, although this procedure is still somewhat experimental. Later, as with a blocked coronary artery, surgeons may be able to bypass a blocked carotid artery or remove a plaque under direct vision, in a procedure called a carotid endarterectomy, to prevent further strokes.

People who have had one stroke are at risk for having another; thus, preventing subsequent strokes is a major priority in treatment. Some of the preventive measures are the same as those recommended for preventing heart disease: use of aspirin or other anticoagulants, measures to keep blood pressure and cholesterol levels low, and smoke-free living. About 500,000 Americans have strokes each year, and almost 3 million Americans alive today have had strokes in the past. Stroke is a major cause of disability and is th e third leading cause of death in the United States—about 150,000 die of stroke each year. About 85,000 to 90,000 fewer stroke deaths are recorded each year than in the early 1970s—largely the result of earlier treatment of hypertension.

Risk factors and Prevention

Given the devastating deficits often associated with a stroke, the need for prevention is obvious. Many of the risk factors for stroke these and other vascular risk factors. Routine checkups should begin at age 20 and be repeated at least every five years, more frequently in later years or if warranted by the results of the initial screening. Blood pressure should be checked more frequently.

HIGH BLOOD PRESSURE
A major risk factor common to both coronary heart disease and stroke, high blood pressure is present in 50 to 70 percent of stroke cases, depending primarily on the type of stroke. The long-term effects of the increased pressure damage the walls of the arteries, making them more vulnerable to thickening or narrowing (atherosclerosis) or rupture.

There is no specific blood pressure reading that is considered normal, but rather a range. Most experts agree, however, that a reading greater than 140/90 mm Hg is abnormal, and anyone with such a reading should see a physician. But even mild elevations in blood pressure are associated with an increased risk for stroke. Sometimes mildly elevated blood pressure can be controlled by life-style modification, but medication is often needed. Although the patient may feel no different, control of blood pressure is associated with a marked decrease in the occurrence of stroke.

HEART DISEASE
Just as strokes area strong risk factor for heart disease, heart disease is a strong risk factor for stroke,although only for one type of stroke, ischemic strokes. Heart disease is associated with stroke in two ways.First, damage to the heart (as, for example, from a heart attack) may make it more likely that clots will form within the heart. These clots can break loose and travel to the brain, causing a cardioembolic stroke. Heart disease and stroke are also associated because they are both manifestations of atherosclerotic disease in the blood vessels. If the blood vessels feeding the heart (the coronary arteries) are diseased, it is likely that arteries to the brain are also affected. Patients with evidence of coronary artery disease, congestive heart failure, left ventricular hypertrophy (enlargement of the left side of the heart), disease of the heart valves, or arrhythmias (irregular heart rhythms) have a several-fold increase in the risk of stroke.

Several recent studies suggest that people with atrial fibrillation who take daily doses of either aspirin or warfarin (Coumadin) have a reduction of up to 80 percent in their risk of stroke. These findings suggest that an estimated 20,000 to 50,000 strokes might be prevented each year if all people with this condition had prophylactic drug treatment.

SMOKING
Smoking facilitates atherosclerosis and appears to be an independent risk factor for strokes that result from a clot. It also seems to be a risk for strokes that result from cerebral hemorrhage.A study shows extensively for cardiovascular disease, who smoked more than 40 cigarettes a day had twice the stroke risk of men who smoked fewer than 10. The number of cigarettes smoked was found to be directly related to stroke risk. Women smoking more than 25 cigarettes a day had a 2.7 times greater risk of stroke from a clot or embolus and a 9.8 times greater risk of a hemorrhagic stroke. Datas indicate that one can significantly reduce stroke risk by stopping smoking. Five years after they stop, exsmokers have a stroke risk equal to that of nonsmokers.

DIABETES
People with diabetes are at greater risk for stroke, just as they are for heart disease. Women with diabetes are at an even greater risk than men. High blood pressure compounds the risk. Although treatment of diabetes has not been conclusively shown to reduce risk, it is known that control of high blood sugar (hyperglycemia) can reduce the severity of cerebral damage during a stroke. For this and other reasons, diabetics should keep their blood glucose levels under strict control.

CHOLESTEROL
Studies have found a link between high blood lipid levels and atherosclerosis in cerebral arteries, but it is still unclear whether high cholesterol levels significantly increase stroke risk. They do, however, increase heart disease risk, so efforts should be made to reduce them.

OBESITY AND INACTIVITY
Obesity and a sedentary life-style are risk factors for stroke primarily because they increase the risk of high blood pressure, heart disease, and diabetes. They may also be independent stroke risk factors. Losing weight and following a moderate exercise regimen can help reverse these risks.

ORAL CONTRACEPTIVES AND ESTROGEN REPLACEMENT THERAPY
The role of oral contraceptives in stroke risk is still inconclusive, primarily because most research has looked at the effects of high-dose estrogen pills, and most women now use lower-dose preparations. Estrogen is believed to promote blood clotting; lowerdose estrogen preparations are thought to minimize this effect. Because studies have found no increase in current risk of stroke or heart attack in women who previously used oral contraceptives, it is believed that the pill does not promote atherosclerosis.

Several retrospective studies have suggested that oral contraceptive use is associated with an increase in stroke risk, while other studies have only found a significant risk of brain hemorrhage in women over age 35 who take the pill and smoke. Smokers who have migraine headaches and take oral contraceptives may be at a particularly high risk of stroke. Experts usually advise women who smoke not to use oral contraceptives—or better, to quit smoking. In contrast, there is evidence to suggest that estrogen replacement therapy for postmenopausal women may slow the atherosclerotic process. In this group the use of estrogens may actually lower the risk of stroke (and heart disease).

HISTORY OF TRANSIENT ISCHEMIC ATTACKS (TIAs)
Researchers are learning that these “ministrokes” may be the most reliable warning of an imminent “full” stroke. Between 10 and 50 percent of strokes, depending on the type, are preceded by TIAs; if not treated, about one-third of all people who have a TIA goon to have a stroke within five years, TIAs are also indicators of potential coronary heart disease: Each year, 5 percent of those who have had at least one TIA have a heart attack. Anyone who has had a TIA should do whatever possible to reduce other risk factors. Drug therapy or surgery may be warranted to reduce the risk of subsequent TIAs, . stroke, or heart attack.

HEREDITY AND FAMILY HISTORY
The chance of having a stroke is higher for people who have a family history of this disease. Part of the risk is due to inherited risk factors and part to family life-styles (eating and exercise habits, for example). The presence of inherited risk factors does not mean that risk cannot be lowered. In one study, for instance, the hereditable risk for vascular disease was mostly due to a susceptibility to the effects of cigarette smoking. When cigarette smoking was eliminated, the hereditable effect was significantly lowered. The risk of stroke rises significantly with age. After 55, it more than doubles with each passing decade. Each year, about 1 percent of people between ages 65 and 74 have a stroke—and 5 to 8 percent of people in that age group who have had a TIA go on to stroke. Although risk associated with advancing age cannot be changed, it is an important factor in assessing stroke risk and planning preventive therapies.

AN EARLIER STROKE
Because the same factors that caused a first stroke are likely to cause a subsequent one, the risk of stroke for someone who has already had one is increased.


CAROTID BRUIT
A bruit is a noise made by turbulent flow in a blood vessel that usually can be heard only with a stethoscope. The most common cause is a narrowing of an artery because of atherosclerosis. Bruits tend to occur in the large arteries of the body, including the carotid artery in the neck. Even in patients without other symptoms, carotid stenosis (narrowing) and carotid bruits are associated with an increased stroke rate of 5 percent each year. Over the course of a lifetime, the cumulative stroke risk may be quite high. The increased risk associated with the presence of a carotid bruit has prompted some physicians to recommend a surgical procedure called carotid endarterectomy to open the narrowing. Initial results of this procedure have proved disappointing in terms of preventing strokes. Patients with asymptomatic bruit should, if possible, be considered for referral to a medical center that has special expertise in cerebrovascular disease and is participating in a welldesigned clinical trial.

OTHER RISK FACTORS Other factors influence stroke risk, although to a lesser extent. These include an elevated hematocrit (number of red cells in the blood), geographic location (especially the southeastern United States, which is sometimes called the “stroke belt"), lower socioeconomic status, use of cocaine and amphetamines, and high alcohol consumption. Stroke deaths seem to occur more often during periods of extreme heat or cold.

Transient Ischemic Attacks (TIAs)

A transient ischemic attack is a localized neurological problem caused by ischemia (decreased blood flow) that completely resolves within 24 hours. Most last only a few minutes. People who suffer a TIA often pass it off as nothing, especially when it goes away almost as quickly as it came. The more neurologists learn about the cause of TIAs, the more clear it becomes that a TIA presents a unique opportunity to prevent a stroke. The importance of a TIA is not in its neurological symptoms-by definition, they disappear. Rather it is that a third of all patients will go on to have a stroke. TIAs represent about 10 percent of all cerebrovascular disease. Up to half of patients who suffer an ischemic stroke will report having had a TIA, and may never have sought treatment. TIAs also identify a group of people at high risk for heart attack. It is imperative that anyone who experiences a TIA consult a doctor for both neurological and cardiovascular evaluation. The key is to make the diagnosis and work to lower the risk. The symptoms of a TIA are similar to those of a stroke-weakness or numbness on one side of the body, inability to speak or understand language, or lack of coordination-except they don’t last as long. Any combination of the symptoms described for stroke,lasting more than a few seconds, should be considered as a possible TIA. One additional common symptom of a TIA is transient monocular blindness, also called amaurosis fugax (flight of darkness). This is a brief change or distortion of vision in one eye that is often described as a misting, clouding, blurring, spottiness, or the sensation that a blind is being drawn down over the eye. The evaluation of a patient for a TIA is similar to that for a stroke. Most patients will be hospitalized because of the concern of a subsequent stroke and the need for immediate treatment should one occur. Patients at low risk of stroke and those whose general medical condition precludes aggressive treatment may be followed on an outpatient basis. The first step is to consider, and exclude, other disease that can mimic a TIA. Many of these diseases are serious neurological problems that also may require urgent treatment. After other diseases have been excluded, the physician will try to determine the mechanism of the TIA in order to help guide decisions about treatment. Most TIAs are due to either an embolus (blood clot) or restricted blood flow-often caused by a narrowing in the carotid artery. Brief TIAs (lasting less than 10 minutes) are commonly associated with carotid stenosis (artery narrowing), while longer-duration TIAs (lasting more than one hour) are more often caused by embolism. If a TIA is due to restricted blood flow because of a carotid artery stenosis, surgery may be indicated. If it is due to an embolus from the heart (as may occur with various abnormal heart rhythms), even if there is a carotid stenosis, surgery may not be appropriate.

Diagnosing and Assessing Stroke

Anyone experiencing symptoms of a stroke requires immediate medical help. Even if the ultimate diagnosis is not stroke, many diseases that can mimic a stroke are also medical emergencies.

If a physician cannot be contacted by telephone, the person should be taken to the nearest hospital emergency department at once. Many types of stroke require immediate treatment, and most of the promising new therapies for stroke are effective only if started within a few hours of the onset of symptoms. A variety of diagnostic tools are available to the physician, from history-taking and trained observation to sophisticated radiologic imaging studies. The tests performed will vary with the type of stroke, its severity, and the planned therapies. Regardless of the tests used, the goals are the same: to exclude nonvascular reasons for the neurological symptoms and to pinpoint the cause, location, and extent of the stroke.

HISTORY AND EXAMINATION
Perhaps the most important diagnostic tool is the initial history and physical examination of the patient. Critical details about the medical history may have to be obtained from a family member if the patient is disoriented or unable to speak.

During the examination, the physician will test a variety of neurological functions: orientation, memory, emotional control, motor skills, tactile sensation, hearing, vision, and the ability to read, write, and speak. Using knowledge of brain anatomy and function, a neurologist can usually identify the area of the brain that is damaged by noting the specific symptoms. For example, difficulty with walking and balance is likely due to damage to the cerebellum. Specific deficits on one side of the body point to damage in the opposite cerebral hemisphere. The general examination should also include a search for evidence of high blood pressure, coronary heart disease, or disease in other parts of the vascular system. Using findings from the history, neurological examination, and general examination, the physician will formulate an initial opinion about the location and type of stroke. Laboratory and radiological tests will then be ordered to help confirm or exclude the physician’s initial suspicions.

LABORATORY TESTS
Tests are usually done on samples of blood, urine,and, occasionally, cerebrospinal fluid (fluid around the brain and spinal cord). They focus initially on excluding conditions that can mimic or worsen a stroke, such as infection or low levels of blood sugar. Screening may also be done for diabetes, elevated blood cholesterol, bleeding disorders, and abnormalities in blood proteins

IMAGING STUDIES
Computed tomography (CT) scans and magnetic resonance imaging (MRI) are techniques that produce anatomic pictures of the brain. Computed tomography scans use multiple X-rays and computer reconstruction to create cross-sectional images of internal structures. Magnetic resonance imaging uses magnetic fields to create images. Each has advantages in different circumstances. Because these scans can delineate (and thus help exclude) such conditions as tumors, abscesses, and bleeding from trauma, they are often done early after a stroke. They can usually differentiate ischemic strokes from those that are due to bleeding. The studies are often repeated several days after the onset of a stroke to determine its size and because the full extent of the damage may not be seen until then. If a patient’s condition worsens, the tests may be repeated in order to help determine the cause of the deterioration. Magnetic resonance devices are also capable of spectroscopically (based on spectrums of light) measuring chemicals within the brain. These measurements may be important in determining the mechanism of a stroke and the prognosis and best therapy for a particular stroke victim.

CARDIAC EVALUATION
An electrocardiogram (ECG) is usually the first step in a cardiac evaluation. An ultrasound examination (echocardiogram) of the heart may help pinpoint a source of an embolus.

ANGIOGRAPHY
Angiography involves the injection of a dye or contrast medium into an artery in order to study the blood vessels via X-ray pictures. It can be used to detect many of the abnormalities that cause stroke, including narrowing or occlusion of a blood vessel, embolus, atherosclerosis, dissections, arteriovenous malformations, and aneurysms. Because angiography is an invasive technique, in that it introduces instruments and substances into the body, it may be associated with serious complications. These include inducing or worsening a stroke, allergic reactions to the contrast medium, and, very rarely, death. Newer techniques using magnetic resonance imaging can be used to produce an angiogram noninvasively. As these images continue to improve in quality, they may replace conventional angiography.

ULTRASOUND
Ultrasound is a noninvasive technique that uses sound waves and their echoes to visualize structures and blood flow within the body. Two types of ultrasound are used in stroke diagnosis carotid ultrasound (to measure flow in the carotid arteries) and transcranial Doppler (to measure flow in the intracranial arteries). Although the anatomical information it produces is not as precise as that obtained through angiography, ultrasound has the advantages of being painless and risk-free. It is often used to screen patients before invasive studies are done.

BLOOD-FLOW STUDIES
Blood-flow techniques-such as positron emission tomography (PET), single-photon-emission computed tomography (SPECT), and xenon inhalation-provide information on blood flow in the brain. These tests may show changes immediately after the onset of stroke symptoms, while computed tomography or magnetic resonance imaging may remain negative for several hours or days after a stroke. The role of these tests is still being defined, and they are generally available only in large medical centers. They may be useful in determining the mechanism of a stroke (e.g., carotid stenosis) or determining prognosis early in the hospitalization.

Treatment

The primary goals of stroke treatment have changed, thanks to new drug therapy. Doctors now attempt to halt the progression of the stroke and to prevent recurrence. In years past, when it was believed that all brain cells died after about four minutes without blood flow, stroke was considered to be largely untreatable. Spurred on by observations in animals that at least partial recovery can occur after even an hour of complete ischemia (lack of oxygen), researchers have discovered that regions of the brain with very minimal blood flow can survive-although they do not function normally-for several hours or perhaps days. These viable cells surrounding an infarct, called the “ischemic penumbra," are the focus of numerous experimental drug therapies aimed at restoring blood flow or preserving cell function. As researchers learn more about the mechanisms of stroke, they are realizing that it is not simply a lack of blood flow that causes death of tissue; a progression of other processes (including inflammation and toxic buildup), called the ischemic cascade, may play an even greater role in causing lasting necrologic damage. Doctors believe that if they can interrupt this cascade, they may be able to prevent the devastating brain damage that was once the inevitable consequence of stroke.

TREATMENT OF ACUTE STROKE
Most treatment of stroke during the acute phase centers on maintaining fluids and electrolytes (chemical substances in the blood, such as sodium and potassium), avoiding low blood pressure (hypotension), and avoiding the secondary complications of stroke and paralysis. The latter includes pneumonia, urinary tract infections, muscle contractures, and pressure breakdown of the skin (bedsores). The physician will also attempt to anticipate and avert deterioration after a stroke. This will require constant monitoring and evaluation and may necessitate a number of laboratory tests. Anticoagulant medications such as heparin are sometimes used to treat an acute ischemic stroke. While heparin does not dissolve existing clots, it can prevent the formation of new ones. Thus it may help prevent subsequent strokes, which occur in up to 20 percent of ischemic stroke cases. Because heparin can increase some patients’ tendency to bleed, its use is often restricted to those with the highest risk of recurrent stroke: patients with a progressing stroke, more than one TIA, or a cardiac source of embolism (often seen with myocardial infarction, atrial fibrillation, or valvular diseases). Related drugs known as heparinoids are now being evaluated and appear to be at least as effective, with a lower risk of bleeding. Surgery is usually not used to treat an acute stroke, although it maybe indicated for a hemorrhagic stroke (subarachnoid and brain hemorrhages) or a recent blockage of a carotid artery.

LONG-TERM TREATMENT OF TIA AND STROKE
After the acute phase of a TIA or stroke has passed, emphasis is placed not only on recovery and rehabilitation but also on preventing further vascular events, including ischemic stroke and myocardial infarction. Therapy may include modification of risk factors, drugs, or surgery, or a combination. Risk factors are discussed earlier in this chapter. Treatment of high blood pressure and diabetes, along with smoking cessation, are probably the most important. The effects on stroke risk of modifying other factors–controlling weight, lowering cholesterol, and moderating alcohol intake—are not as well studied, but these modifications are generally recommended. Treatment of additional risk factors is best considered on an individual basis in consultation with a physician.

ANTIPLATELET MEDICATIONS
Platelets are cell fragments that circulate in the blood and play a key role in the formation of clots. Medications that inhibit platelet function, such as aspirin, lessen the tendency of blood to clot. Patients at high risk of stroke are known to benefit in several ways from taking aspirin daily. Aspirin therapy lowers the risk of stroke and stroke-related death. Unfortunately, aspirin therapy is complicated by the fact that the optimal dose is unknown. If the dose is too low, the aspirin will not have an effect on the platelets; if it is too high, it may cause the blood vessel walls to release chemicals, resulting in the formation of more clots. Most authorities recommend between 325 and 1,200 mg aspirin per day (one to four tablets), a higher dose than that usually recommended to prevent a heart attack. More recent evidence suggests that doses as low as 80 mg per day may also have a protective effect.

Although aspirin has been shown to reduce the risk of stroke, it may not’ be appropriate for all patients, For example, it should not be used in patients whose blood pressure is not normal. Before beginning any treatment, even as simple as aspirin therapy, a patient should consult his or her physician. Aspirin should always be part of a larger program directed at all aspects of vascular disease prevention. Ticlopidine, a relatively new antiplatelet medication, appears to be about 15 percent more effective than aspirin in reducing the risk of stroke in people who have had a TIA or minor stroke. This slight improvement in efficacy must be weighed against more serious side effects such as rash, diarrhea, and lowered white cell counts, and higher cost.

ANTICOAGULANTS
Like antiplatelet medications, anticoagulant drugs also interfere with the clotting mechanism, in this case by affecting the action of enzymes necessary for clotting. A commonly used anticoagulant is warfarin (Coumadin). Because it is a more powerful drug than aspirin, it is usually recommended only when aspirin therapy has failed or when it is clear that the source of the clots is the heart (e.g., when the patient has atrial fibrillation or has had a myocardial infarction or valvular heart disease).

Patients taking warfarin must be carefully monitored via periodic blood tests, known as prothrombin time tests, that measure the speed of clotting. Without monitoring, the dosage may be too low, increasing the risk of stroke, or too high, increasing the risk of bleeding complications. Patients also need to be aware that certain medications and foods (leafy green vegetables such as spinach and other foods high in Vitamin C) can alter the effectiveness of warfarin. However, dietary restrictions are not usually advised for patients on anticoagulants.

SURGERY
The goal in surgery is to provide a pathway for blood to get to the brain. This is most commonly done using a procedure known as carotid endarterectomy, in which a stenosis (narrowing) or ulceration of an atherosclerotic plaque in the carotid artery is removed. Similar interim results were released in 1991 from two large studies of carotid endarterectomy. Participants in the study had experienced either a recent TIA or a nondisabling stroke, and each had a carotidartery blockage of more than 70 percent. Participants who underwent endarterectomies showed a sixfold reduction in strokes, compared to those who did not have surgery. This dramatic result suggests that carotid surgery is likely to play a key role in the prevention of recurrent stroke in the coming years.

There are, however, several important points that should be made in interpreting these results. First, the carotid narrowing must be in a particular portion of the artery. For example, if a patient has a small stroke in the left brain hemisphere, this is not an indication for surgery on a narrowed right carotid artery. Secondly, these studies were carried out at leading medical centers that have low complication rates. Thus, the results suggest that carotid surgery, in the best of circumstances, reduces the risk of stroke. Whether this will hold true for all hospitals remains to be demonstrated. Finally, as physicians better understand stroke risk factors, it maybe possible to use even more precise criteria to select patients for surgery. For example, even considering the group of people with the most severe carotid narrowing, there are many who will not have a stroke.

Using risk stratification models and blood flow measurements, it maybe possible to identify people who do not require surgery, even though they may have a carotid-artery blockage of more than 90 percent. Despite the encouraging results of these two studies, there are still no answers for people with a carotid artery narrowing of less than 70 percent or for those who have not yet had a stroke or TIA. These questions are being investigated actively in clinical studies, and results should be available in the next few years. Although conceptually appealing, the removal of a carotid stenosis is not without risk: There is a 10 percent complication rate across the United States. There is evidence to suggest that only medical centers where the complications and mortality rates are less than 6 percent should be performing the procedure. Another way of providing blood to the brain is via a procedure known as extracranial-intracranial bypass, which involves connecting an artery from the scalp to one on the surface of the brain through a surgical opening in the skull. This procedure was recently tested in a large cooperative trial and was not demonstrated to be beneficial; it is not recommended at this time.

Recovery from Stroke

Recovery after a stroke is dependent on many factors.The specific site of the brain injury, the general health of the patient, his or her personality and will, family support, and the care received. The best recovery is usually seen in a patient who has had a small ischemic stroke. Large subarachnoid hemorrhages pose the most difficult challenge for recovery. Nevertheless, there are few solid rules for prognosis, and each case should be considered on an individual basis.

Caring for a patient after a stroke is a multifaceted and often complex process. The care must include helping the patient recover from deficits (such as weakness of an arm or leg or an inability to speak clearly) and learn to function with any losses, dealing with the patient's emotional issues and those of the family, and preventing recurrent strokes.

REHABILITATION
In the immediate poststroke period, medical personnel care for the patient’s physical needs in order to reduce the risk of complications. Patients who have difficulty swallowing, for example, may need to be fed intravenously until they are able to swallow water and food adequately. Most patients will be able to get out of bed for increasingly longer periods within two to three days and be able to leave the hospital in ten days to two weeks.

Planning for rehabilitation should begin as soon after the stroke as possible. Early attention to weak limbs can greatly improve the chances of a successful recovery. Simple measures such as frequent position changes while in bed and exercise of the paralyzed areas (including moving the arms and legs by physical therapists, nurses, and family members) can improve the circulation, maintain joint flexibility, maintain normal muscle tone, and get the family and patient involved in the recovery process. Physical therapy generally starts within four or five days after the stroke.

The rehabilitation process becomes more active as the patient becomes medically stable (usually within a day or two). Passive range-of-motion exercises, in which a family member, nurse, or physical therapist performs most of the movement, are replaced by active range-of-motion routines, in which the patient strives to regain strength in the affected limbs. The efforts of the rehabilitation team also must focus on the mental aspects of recovery-not only to help patients overcome deficits in knowledge or memory, but also to help prepare them for the long recovery process and encourage them to lead lives as full as possible with the abilities they retain.

It is important to keep in mind that many people have fought their way back from a stroke and continued to lead useful and fulfilling lives. Patients with the ability to make decisions should be included in family decision-making. No program can succeed without a strong desire by the patient to be independent. Nevertheless, family involvement is also a key ingredient in a successful rehabilitation program. The family can provide a positive environment for the patient, nurturing the desire to be independent while reassuring the patient that he or she is still wanted, needed, and loved. Often giving a patient something to do, and to live for, is half the battle.

The family is also important because although most patients are able to leave rehabilitation facilities to return to their families, often they continue to have some problems and their recovery process must continue at home. Family members should take as much of the responsibility for physical therapy at home as is practical. A nurse or physical therapist visiting the home for a few hours a week cannot alone provide the sustained encouragement and the level of activity needed to facilitate recovery. Beyond the patient and family, rehabilitation is a team effort with input from physiatrists (rehabilitation physicians), neurologists, nurses, physical therapists, occupational therapists, speech therapists, and social workers. Their common goal is to help the patient and family achieve the maximal level of functioning possible. Most stroke patients will need several types of therapy, described below, but the mix and amount of each will be tailored to the patient’s needs and symptoms.

Although symptoms of brain damage vary widely, some generalizations can be made. A common way of characterizing stroke injury is by the side of the brain affected. An injury to the right side of the brain that results in paralysis—temporary or permanent—will affect the left side of the body. Conversely, right-sided paralysis is the result of injury to the left side of the brain. Certain language problems and changes in behavior are also associated with leftor right-side damage.

PHYSICAL THERAPY
The primary objective of physical therapy is to help patients who are partially paralyzed learn to walk again. Starting slowly, the therapist will first work with the patient on simple exercises to increase range of motion and muscle tone. Once the patient is able to turn over and sit up unsupported, the therapist usually will have the patient try to start walking. A patient learns to walk while holding on to a bar for support, and then with the aid of a quadruped cane (one with a sturdy four-footed base) and, usually, ankle- foot braces for stability. An estimated 75 percent of all stroke survivors are eventually able to walk independently and will regain most of their ability by the end of the first month.

OCCUPATIONAL THERAPY
Although the ultimate goal is to help the patient resume some sort of employment, if possible, occupational therapy encompasses all aspects of everyday life. Occupational therapists help patients regain the muscular coordination necessary to perform basic activities such as dressing, bathing, and using the toilet. A patient who is paralyzed on one side is taught how to maneuver clothing using the able side of the body, and is advised about clothing styles-such as pullover rather than buttoned shirts-that are easiest to maneuver. Patients are taught how to use a wheelchair, and how to transfer from bed to wheelchair and vice versa. The occupational therapist will also advise the family about changes that can make a patient’s move back home easier and safer: handrails in the bathtub and by the toilet, a raised toilet seat, and ramps in place of stairs, and widened doorways to accommodate a wheelchair, if one is still necessary.

SPEECH THERAPY
Two disorders that may occur after a stroke are aphasia (difficulty with language) and dysarthria (difficulty with articulation). Aphasia and dysarthria are not necessarily associated with a loss of the ability to think or understand. Dysarthria is caused by weakness or paralysis of muscles in the face, mouth, neck, or throat. It can result in slow, labored speech, slurring of words, or a change in voice quality. Often the paralysis of the face muscles causes drooping of one side of the face and perhaps drooling.

Most stroke patients with left-brain injury have some degree of aphasia. It manifests itself in different ways in different patients; there may be difficulty making oneself understood, comprehending others’ words, or reading, writing, or doing arithmetic. The complexity of the problem mirrors the complexity of the communication process, which involves on the one hand organizing thought, finding the words to express it, and producing the words, and on the other hand perceiving that someone wants to say something to you, following the words as they are spoken, and then comprehending the message in its entirety. Aphasia may be equally frustrating for the patient and the family and friends, who may feel they can no longer communicate with the patient. Imagine waking up into a world where you mean to say one thing and something completely different comes out of your mouth, or one where your family seems to be speaking a foreign language that you cannot comprehend. This is what an aphasic patient may experience. But with the help of a speech therapist and a cooperative family, a stroke survivor has an excellent chance of regaining communication skills. If the patient is not able to produce speech specifically, that does not mean he or she cannot use and comprehend language in the larger sense of the word, which encompasses other communication tools such as gestures, movements, facial expressions, and noises.

A speech therapist should lay the groundwork while the patient is in the hospital, first working to obtain from the patient reliable (verbal or nonverbal) yes or no responses to questions. Then the therapist uses a variety of techniques, including repetition and pointing to pictures, to reestablish the fundamentals of language. In most cases, the knowledge of language hasn’t been eradicated, and patients just need to regain their ability to recall what they have learned in the past. As with other memory losses, the patient will often regain ability to remember events that happened in the distant past, but will not be as able to remember things that happened in the very recent past—where he or she left a hat ten minutes ago.


 


 
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