Stroke (apoplexy): causes, treatment and consequences

Around 270,000 people suffer a stroke in Germany every year. Therefore, stroke is a well-known and, at the same time, feared clinical picture that should always be treated as an emergency. Rapid therapy is essential to avoid complications and long-term effects. Read here what happens in the body during a stroke, how to recognize apoplexy and its precursors in good time and how it affects life expectancy.

What is a stroke? Definition and types of apoplexy

A stroke (also apoplexy or stroke) is a sudden onset of bleeding-related disorders in the brain, which leads to a sudden impairment of various bodily functions.

Depending on the cause, two types of apoplexy are distinguished.

In about 80 per cent of the cases of a stroke, a vessel that is required for cerebral blood flow narrows or occludes. As a result, there is a functional failure of the muscles or sensitivity. According to the definition, one then speaks of an ischemic stroke. Ischemic means deficient or non-perfused.

In about 20 per cent of cases, a neurological abnormality does not occur due to a circulatory disorder but due to bleeding in the brain, which is referred to in medical jargon as a hemorrhagic stroke.

 

What happens in the event of a stroke?

In an ischemic stroke, the blood flow to the brain is disrupted. The arteries typically carry the necessary oxygen and nutrients to the brain with the bloodstream. For example, in an ischemic stroke, a blood clot blocks an artery, and there is a shortage of the nutrients brain cells need in the area that previously supplied blood to the “blocked” artery. As a result, the cells in the affected brain area die off.

The different areas of the brain have different tasks. For example, they are responsible for seeing or moving certain body parts. The corresponding brain function fails if the brain cells die in an area. For example, vision is impaired if there is an infarction in the back of the brain (posterior infarction).

A hemorrhagic stroke occurs when a blood vessel ruptures and bleeds inside the brain (intercerebral haemorrhage) or between the meninges (subarachnoid haemorrhage). In this form of apoplexy, the escaping blood puts pressure on the surrounding brain tissue. Often, there is also an accumulation of water (cerebral oedema) near the cerebral haemorrhage, exerting pressure on the brain mass. This pressure damages the nerve cells in the corresponding brain area.

Causes and risk factors: What can trigger a stroke?

The vascular occlusion in an ischemic stroke can be triggered, for example, by a blood clot (thromboembolism). A vascular calcification ( arteriosclerosis ) can also result in vascular occlusion and cause not enough blood to get through the artery.

Several risk factors can lead to a stroke. Which includes:

• increased blood pressure (arterial hypertension )
• increased blood fats (hyperlipidemia)
• Atrial fibrillation (a heart rhythm disorder )
• Diabetes mellitus
• Lack of exercise and overweight ( obesity )
• Smoking
• alcohol abuse
• increased incidence of stroke in the family

Atrial fibrillation is a cardiac arrhythmia in which the heart beats irregularly and not regularly. The clinical picture affects about one to two per cent of the German population. If the arrhythmia occurs intermittently or continuously, a blood clot can form in the heart, which is finally washed out through the bloodstream into the brain and closes a vessel there. Ischemic stroke occurs.

A burst blood vessel in a hemorrhagic apoplexy is often the result of vessels already damaged by arteriosclerosis, which is why most of the risk factors mentioned can also promote this form of stroke. However, the most critical risk factor for hemorrhagic stroke is high blood pressure. In addition, infections, a ruptured aneurysm, short circuits between arteries and veins (arteriovenous malformations), brain tumours or injuries to the skull can also cause cerebral haemorrhage.

 

How can you recognize an apoplexy?

The symptoms associated with a stroke depend either on which vessel in the brain is blocked or on where the bleeding is located in the brain. The symptoms do not distinguish an ischemic stroke from a hemorrhagic one.

The most common signs of a stroke include:

• One-sided paralysis: The arms and legs on one side of the body can suddenly no longer be moved or only to a limited extent. Sensitivity, for example, feeling touch, can also fail on the affected side.
• A hemiplegia of the facial muscles: Here, for example, when smiling, one corner of the mouth hangs down on one side. The halves of the face are not mirrored.
• Difficulty speaking: Those affected only speak with difficulty and haltingly.
• A limited understanding of language: Those affected talk a lot but must answer questions meaningfully.
• Visual disturbances: Part or even half of the standard field of vision is lost in both eyes.

TIA as a precursor or mild stroke?

A stroke must be distinguished from a TIA, a transient ischemic attack, i.e. a short-term reduced blood flow to the brain. In this case, the symptoms mentioned recede within 24 hours. The symptoms often only last a few minutes and can be interpreted as a harbinger of an ischemic stroke. Colloquially, the TIA is sometimes also referred to as an insidious stroke.

If there is only a slight functional impairment after a stroke, then according to the definition, one speaks of a “minor stroke”. The sign of a stroke, the TIA, is sometimes referred to in the literature as a “minor stroke”.

If a stroke goes wholly unnoticed and causes no or only a few symptoms, it is also referred to as a silent stroke. This can also be a precursor to a severe stroke.

What to do with hemiplegia or speech disorders?

If one or more of the above symptoms suddenly occur, the emergency services (telephone number 112) should be called immediately.

This takes the affected person to a nearby hospital, where the diagnosis and, if necessary, the therapy should be started immediately.

 

Diagnosis: How is a stroke detected?

After transport to a hospital, an imaging of the head, known as computed tomography (CT), is first made.

A distinction is first made between a hemorrhagic stroke, i.e. bleeding, and an ischemic stroke. In some cases, an ischemic stroke can be detected after just a few hours based on early signs in the CT. A more considerable bleeding can usually be detected earlier in computed tomography. The distinction between bleeding and ischemic infarction is essential for further therapy.

In most cases, an additional depiction of the vessels supplying the brain is achieved in the CT by administering a contrast agent via the vein. In the further course, the arteries are, in many cases, also shown with the help of an ultrasound examination. In addition, additional magnetic resonance imaging ( MRT ) is often carried out to examine the exact extent of the infarction.

How is apoplexy treated?

Stroke therapy depends on how quickly the affected person arrives at the hospital after the symptoms appear. To achieve the most effective treatment possible, the person should be taken to the hospital as quickly as possible.

Within the first four and a half hours after the onset of symptoms, initiating so-called lysis therapy  (also thrombolysis) can be considered in the case of an ischemic apoplexy. Here, a robust blood-thinning drug is administered via the vein to open the blocked vessel again. However, there are also some situations in which lysis should not be carried out, for example, when those affected regularly take blood-thinning medication such as Marcumar® or Eliquis®.

Catheter intervention (mechanical thrombectomy or endovascular therapy) can be considered as an alternative or in addition to lysis therapy. A long tube is pushed through the inguinal artery to the vessels in the brain. Man tries to find and remove the blood clot that caused the stroke. The therapy takes place in sedation, which means that the person concerned is asleep during this time.

A common problem when deciding on acute therapy is that many patients wake up with the symptoms explained above, and it is unclear how long the symptoms have existed. In such cases, the therapy must be decided on an individual basis.

If a cerebral haemorrhage is the cause of apoplexy, the treatment depends on the type and location of the bleeding. Blood pressure-lowering drugs or a puncture can help reduce the pressure on the brain tissue. Rarely, emergency surgery may be required to stop the bleeding or to repair the ruptured vessel.

What happens after a stroke?

Regardless of whether one of the above-mentioned acute therapies could still be carried out, after a stroke, you are admitted to a particular stroke unit (“stroke unit”) and monitored there.

The most important thing now is to identify and reduce the above risk factors as causes of stroke to prevent recurrence.

 

What are the consequences of a stroke?

Strokes often lead to physical disabilities due to the dead nerve cells. Up to 40 per cent of people who suffer a stroke have chronic disabilities. These include, for example:

• Swallowing and speaking disorders ( aphasia )
• Paralysis (often unilateral), spasticity (stiffness of the muscles) and other motor disorders
• Memory disorders or other impairments in intellectual functioning, personality changes
• Sensory disorders such as vision, hearing or balance.

That is why staying in a rehabilitation clinic after a stroke is significant. Targeted training can, for example, improve the mobility of arms and legs as well as that of the mimic facial muscles.

What complications occur after a stroke?

Various complications can occur after a stroke. The following examples show which complications occur comparatively frequently after a stroke:

• Difficulty swallowing is common after a stroke. “Swallowing” can also cause pneumonia.
• The brain damage can lead to epileptic seizures (convulsions) either as a direct consequence within the first few days or as a late consequence after more than two weeks.
• Due to the lack of exercise in the hospital, a leg vein thrombosis can occur. As a result, a pulmonary artery embolism, i.e. the expulsion of a blood clot in a pulmonary artery, is often accompanied by shortness of breath and chest pain.

There is also an increased risk of another stroke. A stroke can also be fatal: it is still one of the most common causes of death in Germany.

What is the life expectancy after a stroke?

Life expectancy after a stroke depends on the age of the person affected. On average, more than 75 per cent survive the first year after a stroke, i.e. three out of four sufferers.

After five years, just over half are still alive. The average age at the time of the stroke is between 70 and 75 years. The prognosis is much better in younger years, with almost 100 per cent of those under the age of 45 surviving the stroke.

 

How can you prevent another apoplexy?

The best way to prevent stroke is to identify the factors that increase your risk of stroke and eliminate them. Statins (for example, atorvastatin or simvastatin ) can lower blood lipids, and there are also some treatment options for high blood pressure. If such drugs are already being taken and a stroke has occurred despite this, then increasing the dosage should be considered. It is also essential to stop smoking. By implementing these measures, you can prevent the occurrence of a (re)stroke.