Stroke

Definition

A stroke, also known as a cerebrovascular accident (CVA), occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. There are two main types of stroke: ischaemic (caused by a blockage) and haemorrhagic (caused by bleeding).

Aetiology

Strokes can be caused by:

• Ischaemic stroke: Blockage of an artery due to a blood clot or atherosclerosis.
• Haemorrhagic stroke: Rupture of a blood vessel in the brain due to hypertension, aneurysm, or arteriovenous malformation.
• Transient ischaemic attack (TIA): A temporary blockage that resolves within minutes to hours without causing permanent damage.

Pathophysiology

In ischaemic stroke, a clot blocks blood flow to a part of the brain, leading to ischaemia and cell death. In haemorrhagic stroke, bleeding causes increased intracranial pressure and reduced blood flow to the brain tissue. Both types result in loss of brain function corresponding to the affected area.

Risk factors

• Hypertension
• Diabetes
• High cholesterol
• Smoking
• Obesity
• Physical inactivity
• Family history of stroke
• Age (risk increases with age)
• Cardiovascular diseases (e.g., atrial fibrillation, heart failure)
• Excessive alcohol consumption

Signs and Symptoms

• Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body
• Sudden confusion, trouble speaking, or difficulty understanding speech
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause

Red Flags

• Rapid onset of neurological symptoms
• Severe headache with sudden onset
• Loss of consciousness or altered mental state
• Severe hypertension

Investigations

• Clinical history and physical examination, focusing on neurological deficits
• Imaging studies: Non-contrast CT scan of the head to differentiate between ischaemic and haemorrhagic stroke
• MRI of the brain for detailed imaging of brain tissue
• Blood tests to assess glucose levels, coagulation status, and other relevant parameters
• ECG to check for atrial fibrillation or other cardiac conditions
• Echocardiography to evaluate cardiac function and identify sources of emboli

Management

Primary Care Management:

• Immediate referral to emergency services for suspected stroke
• Stabilisation of airway, breathing, and circulation
• Rapid transport to a stroke unit or emergency department with stroke capabilities

References:

1. NICE. (2019). Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Retrieved from https://www.nice.org.uk/guidance/ng128
2. NHS. (2023). Stroke. Retrieved from https://www.nhs.uk/conditions/stroke/
3. NICE. (2023). Scenario: Suspected acute stroke. Retrieved from https://cks.nice.org.uk/topics/stroke-tia/management/suspected-acute-stroke/
4. Ropper, A. H., & Samuels, M. A. (2019). Adams and Victor's Principles of Neurology. 11th ed. McGraw-Hill Education.
5. O'Sullivan, S. B., & Schmitz, T. J. (2016). Physical Rehabilitation. 6th ed. F.A. Davis Company.