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The vast majority (80%) of all strokes are ischemic. The cause of ischemia, or cerebral infarction, is most often a significant narrowing or closure of the vessel that supplies blood to a specific area of the brain.
The reason may be a thrombus forming near the vessel wall, most often on the basis of atherosclerotic plaque, or an embolism arising from blood flow, from the heart or larger vessels, fragments of thrombi. Yet another cause of ischemia may be a critical reduction in blood flow to specific areas of the brain associated with a large drop in total blood pressure. Much less frequently, ischemia can be caused by prolonged contraction of cerebral vessels, their inflammation or excessive blood clotting.
The risk of ischemic stroke is much greater in people who have had some systemic diseases for many years, such as high blood pressure, diabetes or heart disease (ischemic heart disease, atrial fibrillation). Most patients admitted to hospital for a stroke have high blood pressure, and a quarter also have diabetes.
It was also proved that significant risk factors ischemic stroke are:
• obesity,
• lack of physical activity,
• a diet rich in fats,
• alcoholism and smoking.
People with high cholesterol and triglycerides also have a higher risk of developing the disease. All the above-mentioned factors determine not only the susceptibility to the disease, but also the course of the disease and the related treatment options.
Sometimes the symptoms of cerebral ischemia are temporary and resolve spontaneously. The condition in which the relief of symptoms occurs within the first 24 hours after falling ill is called transient ischemic attack. Transient ischemic attacks tend to recur and in some cases (in about 25% of people) precede the stroke. Therefore, the occurrence of such incidents requires proper diagnosis in order to find their cause, as well as to prevent a recurrent episode of cerebral ischemia.
People who have had a transient ischemic episode should take a drug that reduces the risk of repeated stroke events. Acetylsalicylic acid is recommended in most cases as it inhibits platelet function and thus reduces the formation of blood clots. Any type of stroke is a direct threat to life and therefore people suspected of having a stroke should be admitted to a hospital as soon as possible, preferably to a specialized stroke center. In such situations, all patients undergo a head CT scan as soon as possible, followed by many additional tests to find the cause of the stroke (blood chemistry, ultrasound of the arteries of the head, echocardiography).
Treatment of ischemic stroke
So far, there is no specific drug that can reverse ischemia and bring nerve cells back to life. They are very susceptible to oxygen and glucose deficiency and die within minutes after the blood supply is interrupted. The task of the treating team is to ensure the best possible conditions of cerebral circulation in the vicinity of the necrosis area, to prevent and treat stroke complications, and to introduce appropriate prevention of stroke recurrence as soon as possible (secondary prevention). Ischemia is a dynamic process dependent both on local (cerebral microcirculation) and systemic factors (arterial blood pressure, blood oxygenation, body temperature, blood glucose concentration). Too low blood pressure, its increased density and viscosity, or excess or deficiency of glucose lead to an enlargement of the focus of necrosis (infarction) caused by ischemia. Complications such as brain edema, circulatory failure, pneumonia, venous clots or pulmonary embolism significantly worsen the course of the disease.
Maintaining proper blood circulation conditions and preventing and treating the above-mentioned early complications are decisive for the patient’s survival. A drug that is used both in the treatment of ischemic stroke and later in secondary prophylaxis is acetylsalicylic acid. It increases the chance of surviving the current stroke and also reduces the risk of another ischemia. Therefore, it should be administered as soon as possible after falling ill and maintained as a treatment until the end of life.
In a large proportion of patients, the cause of stroke lies in the intensified carotid atherosclerosis causing their narrowing. Ultrasound of the intracerebral arteries, followed by angiography, detect narrowing of the intracerebral arteries. In some cases, the possibility of surgical (mechanical) removal of this narrowing is considered, and thus protection against its further build-up and recurrence of stroke.
Nursing care and early rehabilitation are very important issues influencing the outcome of stroke patients’ treatment. Patients should lie on a comfortable bed with an anti-bedsore mattress. Elastic stockings are also recommended to reduce blood stagnation in the veins of the lower extremities. Prevention of pressure ulcers and pneumonia consists in frequent turning of the sick, patting the chest and conducting respiratory gymnastics. From the first days of hospitalization, it is advisable to perform passive movements and encourage active people. As early as the patient’s general condition allows, it should be gradually started, and rehabilitation should become the main direction of therapy. Rehabilitation of left hemispheric stroke patients should also include speech. Appropriate exercises with a speech therapist prepared for this will allow for a much faster and more complete return of the ability to communicate through speech.
The final result of treatment, i.e. the degree of residual paresis, speech disorders and other functions, depends on many factors that are very difficult to assess in the early stages of a stroke. Full or significant improvement is more likely if the patient has no previous brain damage, both focal (previous stroke, also without clinical symptoms) and generalized (hypertension, diabetes, heart failure). The prognosis, which determines the intensity of the rehabilitation procedure, should be determined very carefully and individually by an experienced physician.
Prevention of ischemic stroke
Remember that as important as treatment is preventing a repeat stroke. Hence, it is so important to control the factors that increase the risk of stroke, such as treating high blood pressure, diabetes, following a low-fat diet, getting enough exercise and not smoking.
The significant reduction in mortality in stroke patients in the developed world in recent years is due to better and more professional care for patients in the early stages of stroke. More and more often, also in Poland, such specialized care for patients with stroke is taken over by specially prepared departments.
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