Am I Having a Stroke?
A "stroke" or cerebral vascular accident (CVA) is an injury to the brain caused by an interruption in the blood supply. CVA's are characterized by a sudden onset of weakness, numbness or paralysis to all or part of one side of the body. Sometimes they are accompanied by an excruciating headache. They range in seriousness from a short duration transient ischemic attack (TIA) to lifelong paralysis, to sudden death.
Why one side? That is because you really have two brains linked by a bridge. The left side of your brain controls the right side of your body and vise-versa. It's rare but not impossible for a stroke to have a global effect on your body. Most strokes will manefest on only one side.
Strokes can be loosely characterized by two things. First is where the location of the deficit is within the brain. Generally, the deeper within the brain the injury occurs, the more serious it is. The outside of the brain contains memories, your personality, your speech, language, and those things that, on an evolutionary scale, have developed rather recently. Injuries that arise in deeper portions of the brain can affect the basic machinery that keeps your lungs breathing and your heart beating, causing death.
The second descriptor of the stroke has to do with whether it is caused by a blood clot, a burst blood vessel, or a temporary spasm of a blood vessel. It's important to quickly figure out which one of these things is happening because the treatment for them is very different and not at all interchangeable. If someone is having stroke caused by a blood clot, you want to give them a "clot buster" to break it up before the parts of the brain behind the clot die from oxygen starvation. If you give those clot busters to someone who has a "bleed" in the brain, you have sentenced them to death in very short order. The simplest treatment of all is for the TIA. They are frequently caused by either a spasming blood vessel (like a spasming leg) or a decreased blood supply due to hardening of the arteries in the neck or generally poor circulation. TIA's are characterized by rapidly improving symptoms. The patient may initially complain of weakness on one side of the body, a face that droops on one side, and slurred speech. Within an hour or two the symptoms will be totally gone. Treating this condition mostly centers around determining its cause and decreasing the likelyhood of a worse episode in the future.
So what can you expect to happen if you think you are having a stroke? You have a sudden onset of weakness on one side of your body. You can speak but only nonsense is coming out of your mouth. You slump to the ground in the kitchen because your left leg is made of rubber. The time is one in the afternoon. Your husband calls 911.
When the ambulance arrives, the paramedics immediately assess your symptoms and come to the conclusion that you could be having a stroke. They ask your family to gather your medicines and put them in a bag. You are taken to the local ER where they have a stroke program. The enemy is time. It's one fifteen PM. The doctors and nurses at the ER must determine what type of stroke you are having. Is it a hemmoragic stroke (bleed) or thrombogenic stroke (blood clot)? If it's a TIA, it may already be improving. You are whisked off to the CT scanner almost the moment you arrive. The doctors ask you a few questions, mainly about what time the symptoms started and what medicines and history you have and before the nurse can get you a blanket, you getting scanned. Things are happening fast. Blood is drawn, an IV is started, a chest x ray, and an EKG are all performed within just a few minutes. The time is two PM, one hour after the onset of your symptoms.
If you are having a thrombogenic CVA, it will not show up on the CT scan. However, a hemorrhagic stroke will. You are in luck. Your symptoms aren't improving but there is no evidence of a bleed. The doctors come in to tell you the news and they want your permission to give you a clot buster. They tell you that you are within the three hour window of opportunity where the medicine may mean the difference between a total recovery and life long paralysis. As long as you are within the window, there is a portion of your brain that has not died and can be revived to full function if blood flow is restored. Time equals brain. Every minute's delay means dead brain cells. You give them permission to start the medicine. The nurses have started two IV's. They ask you if you have had surgery recently or a head injury, or problems with bleeding. These questions are important because if you have recently had surgery or any problems with bleeding, giving you a medicine that breaks down blood clots in your body can kill you. The medicine does not know the difference between the clot holding back the blood to your brain or the clot mending your gallbladder surgery.
Everything is OK and the clot buster is administered at three PM, just two hours after the onset of your symptoms and well within the three hour window of opportunity.
This story plays out every day in our ER. Sometimes it has a good ending, and sometimes it doesn't. When you have a stroke, you are at death's door. Only a well trained ER team with a strong stroke program can save brain function. If you are outside the three hour window but within six hours, you may be whisked off to a special area where "interventional radiology" is performed. Using special wires and catheters, guided into your brain under fluoroscope, the clot can sometimes be removed if it's in a place that's accessible.
If your stroke is caused by a bleed or burst blood vessel, there are still some things that can be done to improve your outcome. You can be given medicine to help your body clot off the bleeding. You can be given medicine to adjust your blood pressure to help your brain get more oxygen. You may have to have a "bolt" or tube inserted into your skull to either monitor the pressure or actually drain off cerebral spinal fluid to decrease it. In any of these cases, your prognosis is rarely good. The problem is that your brain lives within a box that has no opening for extra pressure to escape. The high pressure blood contained within the muscular arteries, if unleashed on the soft matter of the brain, will easily crush and displace it causing massive damage.
Here is a CT scan showing a catastrophic brain injury. You are looking at a slice through the brain just above the ears. The white matter is fresh blood spilling into the cranial cavity. It has totally obliterated the ventricle on the right side of the brain (screen left) and is pushing the right side of the brain over into the left side (mass shift). It is displacing live brain tissue with blood. This is what you don't want to see. Unfortunately, CVA's are a part of being a human. They are just one of many many things that go wrong with the human body.
Age, high blood pressure, smoking, diet, and genetic predisposition, all factor into this disease. As we age, our brain shrinks within its cavity and basically floats around in there, loosely anchored to the skull by small blood vessels. This is why, when the elderly fall, it can be much more serious then when a younger, tightly packaged brain does. The normal weakening of the connective tissue and muscular arterial walls can also lead to stroke in the elderly. As we age the heart can (and often does) become less efficient at pumping blood, causing blood clots to form in the heart that may suddenly dislodge and move to the lungs or brain.
Smoking causes your blood vessels to contract for up to six hours. This decreases the blood supply to the brain, causing very small blood clots to form. The chemicals put in cigarettes by the tobacco companies to increase the absorption of nicotine into your blood stream only worsen the effects. The good news is that within six months of quitting smoking, your chances of dying from any smoking related illness approach those of a non smoker (but never completely go away.)
Your diet, if rich in fat, as most American's is, packs on the pounds. This extra mass means your heart has to work harder to do everything. Pushing blood through that vast network of fat laden capillary bed is hard work. The fat builds up on the artery walls and in addition to blocking blood vessels in the heart, clogs up the vessels in your neck and brain as well. These rough patches of fat on arterial walls cause inflammatory responses which lead to calcium deposition and blood clots which then either break off and move downstream to your heart, brain, or lungs, or cause a blood clot to form right there leadng to "claudication" or the closing of the blood vessel. You can see the effects of hardening of the arteries or "arthrosclerosis" in this picture of the left leg of an elderly person. This person has an artificial hip, probably due to the weakening of the large bone of the leg which then broke. But what is really interesting about this x ray study is the femoral artery. It has almost as much calcium lining it's walls as the femur! Talk about hardening of the arteries.
Of course genetic predisposition is something that you can't change. However you can do your best to get your other risk factors under control. Quitting smoking will make you feel better and have more energy. If you are overweight, your body is a prison instead of a temple exalting the brilliance of your brain. But you know all of this and are probably already working to improve your life and by doing so, improving the life of those around you. That's why it's important for you to survive this stroke.
Fortunately, your brain injury is contained and even reversed by a medicine that broke up the blood clot. You had an almost miraculous recovery just thirty minutes after you got the clot buster. Your feeling returned in your left side. You can now speak normally and your beautiful smile has returned to normal. Your husband and children are beside themselves with relief. The doctors will admit you for a few days of observation to make sure you don't have any bleeding problems. You will be discharged on a regimen of aspirin and maybe another blood thinner to keep you from suffering from another stroke. However the primary key to your recovery is yourself. You are the one who will take the bull by the horns and create an environment of healing and health for your most important organ, your brain.
Why one side? That is because you really have two brains linked by a bridge. The left side of your brain controls the right side of your body and vise-versa. It's rare but not impossible for a stroke to have a global effect on your body. Most strokes will manefest on only one side.
Strokes can be loosely characterized by two things. First is where the location of the deficit is within the brain. Generally, the deeper within the brain the injury occurs, the more serious it is. The outside of the brain contains memories, your personality, your speech, language, and those things that, on an evolutionary scale, have developed rather recently. Injuries that arise in deeper portions of the brain can affect the basic machinery that keeps your lungs breathing and your heart beating, causing death.
The second descriptor of the stroke has to do with whether it is caused by a blood clot, a burst blood vessel, or a temporary spasm of a blood vessel. It's important to quickly figure out which one of these things is happening because the treatment for them is very different and not at all interchangeable. If someone is having stroke caused by a blood clot, you want to give them a "clot buster" to break it up before the parts of the brain behind the clot die from oxygen starvation. If you give those clot busters to someone who has a "bleed" in the brain, you have sentenced them to death in very short order. The simplest treatment of all is for the TIA. They are frequently caused by either a spasming blood vessel (like a spasming leg) or a decreased blood supply due to hardening of the arteries in the neck or generally poor circulation. TIA's are characterized by rapidly improving symptoms. The patient may initially complain of weakness on one side of the body, a face that droops on one side, and slurred speech. Within an hour or two the symptoms will be totally gone. Treating this condition mostly centers around determining its cause and decreasing the likelyhood of a worse episode in the future.
So what can you expect to happen if you think you are having a stroke? You have a sudden onset of weakness on one side of your body. You can speak but only nonsense is coming out of your mouth. You slump to the ground in the kitchen because your left leg is made of rubber. The time is one in the afternoon. Your husband calls 911.
When the ambulance arrives, the paramedics immediately assess your symptoms and come to the conclusion that you could be having a stroke. They ask your family to gather your medicines and put them in a bag. You are taken to the local ER where they have a stroke program. The enemy is time. It's one fifteen PM. The doctors and nurses at the ER must determine what type of stroke you are having. Is it a hemmoragic stroke (bleed) or thrombogenic stroke (blood clot)? If it's a TIA, it may already be improving. You are whisked off to the CT scanner almost the moment you arrive. The doctors ask you a few questions, mainly about what time the symptoms started and what medicines and history you have and before the nurse can get you a blanket, you getting scanned. Things are happening fast. Blood is drawn, an IV is started, a chest x ray, and an EKG are all performed within just a few minutes. The time is two PM, one hour after the onset of your symptoms.
If you are having a thrombogenic CVA, it will not show up on the CT scan. However, a hemorrhagic stroke will. You are in luck. Your symptoms aren't improving but there is no evidence of a bleed. The doctors come in to tell you the news and they want your permission to give you a clot buster. They tell you that you are within the three hour window of opportunity where the medicine may mean the difference between a total recovery and life long paralysis. As long as you are within the window, there is a portion of your brain that has not died and can be revived to full function if blood flow is restored. Time equals brain. Every minute's delay means dead brain cells. You give them permission to start the medicine. The nurses have started two IV's. They ask you if you have had surgery recently or a head injury, or problems with bleeding. These questions are important because if you have recently had surgery or any problems with bleeding, giving you a medicine that breaks down blood clots in your body can kill you. The medicine does not know the difference between the clot holding back the blood to your brain or the clot mending your gallbladder surgery.
Everything is OK and the clot buster is administered at three PM, just two hours after the onset of your symptoms and well within the three hour window of opportunity.
This story plays out every day in our ER. Sometimes it has a good ending, and sometimes it doesn't. When you have a stroke, you are at death's door. Only a well trained ER team with a strong stroke program can save brain function. If you are outside the three hour window but within six hours, you may be whisked off to a special area where "interventional radiology" is performed. Using special wires and catheters, guided into your brain under fluoroscope, the clot can sometimes be removed if it's in a place that's accessible.
If your stroke is caused by a bleed or burst blood vessel, there are still some things that can be done to improve your outcome. You can be given medicine to help your body clot off the bleeding. You can be given medicine to adjust your blood pressure to help your brain get more oxygen. You may have to have a "bolt" or tube inserted into your skull to either monitor the pressure or actually drain off cerebral spinal fluid to decrease it. In any of these cases, your prognosis is rarely good. The problem is that your brain lives within a box that has no opening for extra pressure to escape. The high pressure blood contained within the muscular arteries, if unleashed on the soft matter of the brain, will easily crush and displace it causing massive damage.
Here is a CT scan showing a catastrophic brain injury. You are looking at a slice through the brain just above the ears. The white matter is fresh blood spilling into the cranial cavity. It has totally obliterated the ventricle on the right side of the brain (screen left) and is pushing the right side of the brain over into the left side (mass shift). It is displacing live brain tissue with blood. This is what you don't want to see. Unfortunately, CVA's are a part of being a human. They are just one of many many things that go wrong with the human body.
Age, high blood pressure, smoking, diet, and genetic predisposition, all factor into this disease. As we age, our brain shrinks within its cavity and basically floats around in there, loosely anchored to the skull by small blood vessels. This is why, when the elderly fall, it can be much more serious then when a younger, tightly packaged brain does. The normal weakening of the connective tissue and muscular arterial walls can also lead to stroke in the elderly. As we age the heart can (and often does) become less efficient at pumping blood, causing blood clots to form in the heart that may suddenly dislodge and move to the lungs or brain.
Smoking causes your blood vessels to contract for up to six hours. This decreases the blood supply to the brain, causing very small blood clots to form. The chemicals put in cigarettes by the tobacco companies to increase the absorption of nicotine into your blood stream only worsen the effects. The good news is that within six months of quitting smoking, your chances of dying from any smoking related illness approach those of a non smoker (but never completely go away.)
Your diet, if rich in fat, as most American's is, packs on the pounds. This extra mass means your heart has to work harder to do everything. Pushing blood through that vast network of fat laden capillary bed is hard work. The fat builds up on the artery walls and in addition to blocking blood vessels in the heart, clogs up the vessels in your neck and brain as well. These rough patches of fat on arterial walls cause inflammatory responses which lead to calcium deposition and blood clots which then either break off and move downstream to your heart, brain, or lungs, or cause a blood clot to form right there leadng to "claudication" or the closing of the blood vessel. You can see the effects of hardening of the arteries or "arthrosclerosis" in this picture of the left leg of an elderly person. This person has an artificial hip, probably due to the weakening of the large bone of the leg which then broke. But what is really interesting about this x ray study is the femoral artery. It has almost as much calcium lining it's walls as the femur! Talk about hardening of the arteries.
Of course genetic predisposition is something that you can't change. However you can do your best to get your other risk factors under control. Quitting smoking will make you feel better and have more energy. If you are overweight, your body is a prison instead of a temple exalting the brilliance of your brain. But you know all of this and are probably already working to improve your life and by doing so, improving the life of those around you. That's why it's important for you to survive this stroke.
Fortunately, your brain injury is contained and even reversed by a medicine that broke up the blood clot. You had an almost miraculous recovery just thirty minutes after you got the clot buster. Your feeling returned in your left side. You can now speak normally and your beautiful smile has returned to normal. Your husband and children are beside themselves with relief. The doctors will admit you for a few days of observation to make sure you don't have any bleeding problems. You will be discharged on a regimen of aspirin and maybe another blood thinner to keep you from suffering from another stroke. However the primary key to your recovery is yourself. You are the one who will take the bull by the horns and create an environment of healing and health for your most important organ, your brain.
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