… or where we discuss what to do. Let’s begin small and first focus on the transient ischemic attacks, or TIAs. These as we saw were blockages of smaller vessels in the brain that the body manages to clear away before any permanent brain damage happens. Patients have symptoms of strokes but recover rapidly and in the period of evaluation do not show any evidence of a stroke on the variety of tests that are available.
TIAs are warnings that have to be heeded to prevent a major stroke in the following few months. Like the first drops of rain before a thunderstorm. The risk factors for stroke are very very similar to those of a heart attack. A bad lipid profile, diabetes, hypertension and smoking. These 4 horsemen herald the development of atherosclerosis and narrowing of the arteries in the body. Most evaluations of patients following a TIA focus on identifying and correcting these abnormalities. In addition, an important test is to look at the carotid arteries – the two main vessels that carry blood into the brain and are in front of the neck. And what every movie star checks to see is someone is alive. The carotids may gradually get narrowed by fat deposition within the vessels, also called an atheromatous plaque.
This not only reduces the amount of blood going into the brain, but can also break off and block an entire branch.
An ultrasound or an angiogram maybe done to see the extent of narrowing. A variety of very well conducted clinical trials in the past 3 decades have shown that for patients who have had a TIA and have significant narrowing of the carotid, surgery is extremely beneficial in preventing the occurrence of major strokes. This reduction is better than blood thinners like aspirin (ecosprin) or the placements of stents.
Surgery involves opening the carotid artery and removing the atheromatous plaque and closing the vessel often with a patch to widen it. This surgery is most beneficial if done within 3 months of the attack. Another option which is usually used when patients may not tolerate a surgery due to problems such as heart disease or uncontrolled diabetes, is the placement of a stent to open up the narrowed artery. Be it surgery or stenting, blood thinners are mandatory. There are now studies on with newer blood thinners to determine if they are as good, if not better, in preventing strokes when compared to surgery.
Other components of prevention include control of diabetes and/or hypertension and smoking cessation. Regular exercise and a healthy diet, like in most diseases, help substantially.
But what of those who are not as lucky and have had a major stroke? Stroke treatment like treatment of a heart attack is best when instituted early. The past few years have seen an increase in the number of dedicated stroke centres in urban India. These centres have a neurologist or neurophysican, an neurointervention specialist, a neurosurgeon and intensive care specialists that form the stroke team. The mainstay of both stroke and heart attack treatment in the past used to be ‘thrombolysis’. This is the injection of enzymes that attack and break down the clot thus opening up the arteries. These are given as an injection and have to travel through the blood stream to reach the clot. Then begin dissolving it. Needless to say there were severe time constraints within which this had to be done, giving rise to the famous pain-to-needle time metrics that cardiologists stress about. The knowledge of possible interventions in case of a heart attack is far more widespread than that of stroke interventions. Thus patients also seek specialized help when they think they are having a heart attack and the existing medical infrastructure is also tuned to respond with urgency.
Currently the standard of care in heart attacks is thrombolysis AND a possible angioplasty/stent insertion wherever appropriate or possible. Similarly, in strokes, the latest endovascular technology available which has shown spectacular results in a sizable subset of strokes is the stent retriever technology. This video shows how this technology works by removing the clot from within the artery and opening it up. Patients who have gotten to a stroke center within 4.5 hours of the onset of a stroke are candidates for thrombolysis with an injection called altepase or TPA and additional endovascular treatment if required. . Currently patients within 6 hours and rarely upto 24 hours of a stroke undergo initial CT/MRI imaging and are assessed if they are candidates for a possible stent retriever intervention. And with appropriate treatment the long term effects of the stroke including paralysis and even death can be averted.
The key however is not the technology, the availability of thrombolytic drugs, the trained staff and infrastructure but actually the time taken for most patients to get to a stroke facility. Some of the delay can be blamed on the varied symptoms of a stroke, some of it on lack of knowledge of where to go in such a situation, some of it on just not thinking it’s as serious as a heart attack.
I’d encourage anyone who is reading to locate hospitals in their city that have a stroke program with a neurointervention specialist (these maybe radiologists, or neurosurgeons or neurologists, all who have had special training in neurointervention). And also remember the FAST acronym and perhaps realize that no matter what Shakespeare said, the brain is more fragile than the heart.
Some lucky few may seek such help and get it in time to walk away from a stroke. Literally. But most stroke patients get to a hospital after that narrow window and usually, most commonly have weakness of one side of the body and a varying degree of speech and consciousness alteration (depending on the side, previous post, etc.). The acute care phase in most hospitals in established strokes is aimed at preventing further brain injury. It involves making sure blood and oxygen get to the brain normally, that there is mitigation of threat to life if any, and preparing the patient for the subsequent rehabilitation phase.
The rest of this article has been written with the assistance of my colleague Dr Pavan Nagendra, who heads the neuro-rehabilitation unit in the hospital. He can be reached at [email protected].
Rehabilitation plays a vital role in overcoming the deficits following a stroke and improving the quality of life post stroke. These deficits may be motor – limb weakness, speech related or cognitive. Rehabilitation is a team effort consisting of physiotherapists, speech and language trainers, occupational therapists, orthotics and prosthetics specialists, and psychologists.
In the acute phase, immediately following a stroke, the physiotherapists play a vital role in preventing complications of prolonged a stay in a hospital bed. They ensure that there are no respiratory infections by providing chest physiotherapy. This involves techniques like vibration, percussion, shaking, deep breathing exercises, chest clearance techniques, and assisted cough techniques. A patient who is confined to a bed has a high risk of developing bed sores and contractures. The therapist will assist and guide the patient and caretakers in proper positioning in bed, train the patient or the caretaker to turn in bed to either side, and perform passive movements to maintain joint mobility and prevent stiffness and deformity.
Current research indicates that early mobilization off the bed into the upright position improves the long term functional outcome. This involves getting patients who are bed bound to initially sit up on arm chairs (yes, our patients get La-Z boys) or wheelchairs even when in the intensive care units.
Rehabilitation proceeds in a sequential manner and once the patients are out of an acute sitting they benefit from intensive physiotherapy in dedicated in-patient rehabilitation units. These are medical facilities that can admit patients and whilst giving them the required medical care, focus more intently on rehabilitation of the patient.
The recovery plan starts with moving in the bed, and then the focus shifts to attain sitting control followed by standing control. These tasks are initially assisted but the patient taught and encouraged to get from lying to sitting and standing independently or with minimal support. This bolsters confidence and further eggs the patients towards achieving some form of functional independence – the ability to do some activities of daily living without assistance.
This moves on to training of the individual in specific tasks like reaching and manipulation of objects, walking, stair climbing, dressing, eating etc. The tasks are broken down into components and each part is repeatedly practiced in different scenarios. This kind of functional training is far superior to passive exercises in bed and is the greatest advantage of rehabilitation in specialized facilities rather than at home. The focus of physiotherapy in neurological patients is gradually moving towards a functional, patient centric approach where treatment goals are directed by the patient. The initiation of movement and efforts are primarily from the patient rather than the caregiver or physiotherapist.
In addition to motor skills, which are the most obvious deficits, focus of rehabilitation extends to various other aspects. These can be cognitive – memory and thinking, emotional, speech and language, swallowing, adjusting to visual deficits, and most importantly self-care.
This flowchart below summarizes this post and fills more space to make things look good.
The brain, historically, was believed to be an organ that once developed could never regenerate from an injury. While this is true at a cellular level, what was not accounted for was the amount of redundancy in the brain and its ability to reroute connections. This is termed plasticity and is the primary reason for recovery from a stroke. This plasticity is driven by external stimuli, effort and movement. And evidently more stimulation means better recovery.
But not all patients recover. And most patients with a major stroke never go back to how they were prior to the event. The intention of any treatment is to preserve brain function and then encourage recovery and plasticity. Current research is aimed towards multiple targets – prevention, reducing damage, encouraging recovery, assisting life. The future alone holds the answers.