WHAT IS A STROKE?
A stroke occurs when the blood supply to a part of the brain is reduced or cut off. As a result, the nerve cells in that part of the brain cannot function. When this happens, the part of the body controlled by these nerves cannot function normally. The result of a stroke may be weakness, loss of sensation or feeling, paralysis on one side of the body, and difficulty with vision, walking, speaking and understanding. Strokes, cerebrovascular accidents (CVA) or ‘‘Brain Attacks’’ are very individual; rarely are two alike even though the causes may be similar.
WHAT CAUSES A STROKE?
There are three major medical causes of stroke:
Thrombotic Stroke: A clot or thrombus forms inside an artery in the brain or neck. It may be related to atherosclerosis or abnormal thickening of inner arterial walls.
Embolic Stroke: A wandering blood clot. It may result from heart damage or be a small piece of a larger clot in the neck. Blood carries the clot to the brain where it blocks a small artery.
Cerebral Hemorrhage: A blood vessel in the brain bursts, flooding surrounding tissue with blood. It may be related to high blood pressure and atherosclerosis. It may be caused by a head injury, a bursting aneurysm, or long-standing high blood pressure.
For more complete information, see ‘‘Strokes: A Guide for the Family,’’ an American Heart Association pamphlet.
WHAT ARE THE TYPICAL RESULTS OF A STROKE?
The site and extent of the stroke determines the results or deficits. In general, the brain is divided into right and left hemispheres. The brain stem and cerebellum are at the base.
You may see or experience some of the following:
Right Hemisphere Injury: Left-side paralysis (hemiplegia or hemiparesis); excessive talking; short attention span; impulsive, quick behavioral style; memory problems; spatial-perceptual problems.
Left Hemisphere Injury: Right-side paralysis (hemiplegia or hemiparesis); speech and language deficits (aphasia); slow, cautious behavioral style; memory deficits.
Brain Stem: Coma or low level consciousness; unstable vital signs; nausea and vomiting; impaired swallowing; bilateral paralysis.
Cerebellum: Coordination and balance problems (ataxia); dizziness, nausea and vomiting; abnormal reflexes of head and trunk.
For more complete information, see: “How Stroke Affects Behavior,” “Caring for a Person with Aphasia,” “The One-Handed Way,” American Heart Association pamphlets.
WHAT HAPPENS DURING HOSPITALIZATION?
The diagnosis of stroke is made through a variety of procedures: Angiogram, CT Scan, EEG, EKG, and MRI (see Glossary). Appropriate treatment, medication, or surgery may then be administered.
HOW LONG WILL REHABILITATION TAKE?
While some recovery of function is spontaneous during the first six months following a “Brain Attack,” most experts now agree that major recovery occurs for two to three years. Many now believe recovery is life-long. Successful recovery depends on the extent of brain damage, the survivor’s attitude, the cooperation of family and friends, and the skill of the rehabilitation team.
The rehabilitation team may consist of a number of specialists: physiatrist, neurologist, neuropsychologist, occupational therapist (OT), physical therapist (PT), speech-language pathologist (ST or SP), case manager, and recreational therapist (RT). In addition, your regular doctor, sometimes referred to as a PCP or primary care provider, may coordinate overall care. Refer to the Glossary at the end of this directory for further information about these specialists.
HOW DO I KNOW THE EXTENT OF BRAIN DAMAGE?
Multidisciplinary evaluations by a rehabilitation team will help determine the extent of neurological injury and help plan strategies for recovery. Physical Therapy (PT), Occupational Therapy (OT), Speech-Language-Swallowing Therapy (SP or ST), and neuro-psychological assessments will help you understand specific strengths and limitations in the areas of mobility, self-care, speech, language, cognition, behavior and mood. An initial or baseline evaluation can be useful in setting realistic goals and tracking progress over time. Re-evaluation may be appropriate as recovery progresses over a number of years.
HOW DO I ARRANGE FOR AN ASSESSMENT?
Most stroke survivors go through an initial period of rehabilitation following discharge from the acute hospital, either in an acute rehab hospital, a skilled nursing facility with an active rehab team, a home health agency, or an outpatient clinic. Multidisciplinary evaluation and family training in post-stroke issues are generally part of this rehabilitation. If you require an evaluation, your primary physician can generally make a referral, either to a specific practitioner or to a rehabilitation team. Going through your primary physician for a referral also maximizes the possibility that the cost of the evaluation will be covered by insurance.
NEUROPSYCHOLOGICAL EVALUATION
A neuropsychologist is a licensed clinical psychologist with special expertise in brain function. Neuropsychological assessment can provide more in-depth evaluation of a variety of cognitive skills such as memory (verbal and visual), sequencing, and reasoning (both verbal and visuo-spatial). Neuropsychological assessment also looks at the behavioral, emotional and social consequences of brain injury. This in-depth look at verbal and non-verbal thinking skills can be of particular value in setting realistic goals and assessing employment potential if one is considering returning to work. Neuropsychological assessment may not routinely be a part of a multidisciplinary evaluation, but most rehabilitation facilities have staff neuropsychologists or can recommend one. Your primary physician may also be able to make a referral. The California Employment Development Department (Department of Vocational Rehabilitation) may provide some neuropsychological assessment at no cost if the stroke survivor is a client.
WHAT AFFECTS THE SURVIVOR’S ATTITUDE?
This is complex. Some of the factors include life stage, gender, previous medical history, pre-stroke personality and attitude, quality of family and social relationships.
Altered brain function may initially result in frequent tearfulness or laughter that is not always appropriate to the situation. Family members who understand the origin of changed behavior will be able to learn how best to respond in order to maintain the stroke survivor’s motivation.
The survivor has sustained numerous losses — mobility, income, speech, thinking ability, independent functioning, and social role — in a very short time. The sense of who one is in the world and the sense one has made of the world may no longer hold true. The experience of being a patient may be frustrating or frightening for someone used to managing his/her own life. At this time of crisis, an essential aspect of the self may clearly reveal itself. Whatever comes forward must be met with interest, curiosity and care to convey belief that a whole person still exists amidst all the wounds.
WHAT HELPS FAMILIES COOPERATE?
Initially, the primary caregiver will be the person most involved in making the necessary medical decisions. Clear, honest communication between family members is usually helpful. Hospital social workers may be able to facilitate communication between family members or between family and medical staff if there are areas of conflict. The rehabilitation team should include and educate family and extended family about progress made and discharge planning.
WHAT ARE SOME COMMON PROBLEMS FAMILIES AND CAREGIVERS ENCOUNTER?
During the acute phase, typically family and friends rally. The primary caregiver is often completely focused on the patient, forgetting about himself or herself. The caregiver needs as much support and acknowledgment as the stroke survivor. The transition from hospital to home may be an especially difficult time for everyone. Anxiety, depression and social isolation are common. Colleagues, friends, and even some family often stop calling or visiting in the months to come because of their own discomfort. Caregivers may need to establish new support networks to maintain their own mental, physical and spiritual well-being. Even if it feels uncomfortable, caregivers should be willing to ask for and accept help from family and friends.
WHAT MAY HELP COMMUNICATION?
Communication will be a challenge for families if speech and language processing are affected by the stroke. The person who has had a stroke may have difficulty speaking, or use inaccurate or inappropriate words to communicate, without being aware that he or she is doing so. It is important to be as patient and honest as possible. If the caregiver doesn’t understand what is being said, it is important to let the person know. Look for alternative ways for the stroke survivor to express himself or herself, such as pointing or gesturing. Try to ask questions that permit a yes/no or headshake answer. The caregiver may also want to encourage the person to speak more slowly, or take a deep breath to reduce stress and frustration.
WHAT SUPPORTS MOBILIZATION?
Motivation is essential for mobilization. The more the stroke survivor is involved in deciding important goals in collaboration with the rehab team, the more likely he or she is to be motivated to persist in the hard work of recovery. Support groups offer members praise, encouragement, understanding, and often reinforce behavioral change. They provide new social connections during a period that is often lonely.
ARE THERE PREDICTABLE STAGES OF RECOVERY?
Everyone touched by stroke is grieving the loss of the pre-stroke person, while the survivor is simultaneously regaining function and rebuilding a sense of self. Recovery involves both letting go of the old identity and reconstructing a new one which may include some diminished capacities.
· SHOCK, the first stage of recovery, may be accompanied by numbness, fear and helplessness.
· DENIAL is the second stage. Refusal to face the effects of the stroke may protect the survivor and the family from feeling overwhelmed and provides time for adjustment to new realities.
· ANGER/DEPRESSION, both of which are typical responses to loss, may be complicated by damage to the brain. If these persist, clinical intervention and even antidepressant medication may be beneficial. Participation in a stroke support group may also help.
· MOBILIZATION, the fourth stage, brings an interest in setting and accomplishing goals.
· COPING is the final stage. This involves adaptation to a life with new limitations, priorities, and interests.
WHAT CAN I HOPE FOR?
Unfortunately, 25% of stroke patients do not survive the first year, and many who do survive are unable to return to work. A small percentage of stroke survivors, particularly those who are young (one third of all stroke survivors are under age 65), may fully recover. Even with some degree of disability, many survivors do resume active and meaningful lives. Resilience, resources and newly discovered skills may enable survivors and families to adapt and meet the challenge of multiple losses and changed expectations, to recreate meaning and purpose in their lives.
© Recovery requires persistent hard work.
WILL IT HAPPEN AGAIN?
This is a major concern, because the risk of stroke for someone who has already had one is much greater than for someone who has not. Therefore, it is important for the stroke survivor, family members, and friends to recognize the symptoms of stroke and Transient Ischemic Attack (TIA).
WHAT ARE THE SYMPTOMS OF STROKE
AND TIA (Transient Ischemic Attack)?
If the symptoms come and go, or fade rapidly (in minutes to hours), then a TIA may have occurred. Both stroke and TIA may begin with these symptoms:
- Sudden weakness or numbness of the face, arm and/or leg.
- Sudden double-vision or loss of vision or blurred vision in one or both eyes.
- Sudden, severe headache.
- Trouble speaking or understanding.
- Sudden difficulty swallowing.
- Unexplained dizziness, unsteadiness or sudden falls, especially along with any of the above.
QUICK TEST FOR A STROKE – SAS
- Smile – note facial paralysis
- Arms raised overhead – note weakness of one side
- Say a sentence – note speech or language problems
WHAT SHOULD YOU DO?
Call 911 and have someone call your doctor immediately.
Do Not Ignore the Symptoms. New, available medications may minimize the damage from a stroke.
© REMEMBER: Time is Brain!
WHAT CAN YOU DO TO REDUCE RISK OF STROKE?
- Maintain a regular schedule of medical check-ups, especially if you have heart disease, abnormal heart rhythms, hypertension, take oral contraceptives, smoke or are diabetic.
- Monitor your blood pressure, eat a healthy diet, maintain the proper weight, exercise and, if necessary, take medication.
- Stop smoking! Your risk of stroke from smoking can be eliminated in one year.
- Monitor blood or urine glucose and acetone levels if you are diabetic.
- Get frequent medical monitoring if you take oral contraceptives and smoke.
- Regular aerobic exercise maintains a healthy cardiovascular system. Walking and swimming are good ways to keep fit. Consistency and enjoyment are important aspects of any exercise program.
- Learn and practice stress reduction techniques
- Monitor blood cholesterol and lipids. Learn about nutrition and your health; modify diet as recommended by your physician or nutritionist.
- Learn about your body, what it likes and what creates feelings of well-being, such as music, dance, and fresh air.
“It is part of the cure to wish to be cured.”
Seneca (3 B.C. – A.D. 65)