Stroke and Cerebrovascular Disease

Evaluation Procedures for Stroke

How is a stroke diagnosed?

In addition to a complete medical history and physical examination, diagnostic procedures for stroke may include the following:

Imaging tests of the brain

  • Computed tomography scan (Also called a CT or CAT scan.) — a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays; used to detect abnormalities and help identify the location or type of stroke.
  • Magnetic resonance imaging (MRI) — a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body; an MRI uses magnetic fields to detect small changes in brain tissue that helps to locate and diagnose stroke.
  • Radionuclide angiography — a nuclear brain scan in which radioactive compounds are injected into a vein in the arm, and a machine (similar to a Geiger counter) creates a map showing their uptake into different parts of the head. The images show how the brain functions rather than its structure. This test can often detect areas of decreased blood flow and tissue damage.

Tests that evaluate the brain’s electrical activity:

  • Electroencephalogram (EEG) — a procedure that records the brain’s continuous, electrical activity by means of electrodes attached to the scalp.
  • Evoked potentials — procedures that record the brain’s electrical response to visual, auditory, and sensory stimuli.

Tests that measure blood flow:

  • Carotid phonoangiography — a small microphone is placed over the carotid artery on the neck to record sounds created by blood flow as it passes through a partially blocked artery. The abnormal sound is called a bruit.
  • Doppler sonography — a special transducer is used to direct sound waves into a blood vessel to evaluate blood flow. An audio receiver amplifies the sound of the blood moving though the vessel. Faintness or absence of sound may indicate a problem with blood flow.
  • Ocular plethysmography — measures pressure on the eyes, or detects pulses in the eyes.
  • Cerebral blood flow test (inhalation method) — measures the amount of oxygen in the blood supply that reaches different areas of the brain.
  • Digital subtraction angiography (DSA) — provides an image of the blood vessels in the brain detect a problem with blood flow. The test involves inserting a small, thin tube (catheter) into an artery in the leg and passing it up to the blood vessels in the brain. A contrast dye is injected through the catheter and x-ray images are taken.

Rehabilitation for Stroke

The purpose of rehabilitation is to help the patient reach the highest level of function by preventing complications, reducing disability, and improving independence.

Rehabilitation is the process of helping an individual achieve the highest level of independence and quality of life possible — physically, emotionally, socially, and spiritually. Rehabilitation does not reverse or undo the damage caused by a stroke, but rather helps restore the individual to optimal health, functioning, and well-being. Rehabilitate (from the Latin “habilitas”) means “to make able again.”

The stroke rehabilitation team

The stroke rehabilitation team revolves around the patient and family. The team helps set short- and long-term treatment goals for recovery and is made up of many skilled professionals, including the following:

  • Physicians such as a neurologist (a physician who treats conditions of the nervous system such as stroke) and physiatrist (a physician who specializes in physical medicine and rehabilitation)
  • Internists and specialists
  • Rehabilitation nurses
  • Physical therapists
  • Occupational therapists
  • Speech and language pathologists
  • Dietitians
  • Social workers and chaplains
  • Psychologists, neuropsychologists, and psychiatrists
  • Case managers

The stroke rehabilitation program

The outlook for stroke patients today is more hopeful than ever due to advances in both stroke treatment and rehabilitation. Stroke rehabilitation works best when the patient, family, and rehabilitation staff works together as a team. Family members must learn about impairments and disabilities caused by the stroke and how to help the patient achieve optimal function again.

Rehabilitation medicine is designed to meet each person’s specific needs; thus, each program is different. Some general treatment components for stroke rehabilitation programs include the following:

  • Treating the basic disease and preventing complications
  • Treating the disability and improving function
  • Providing adaptive tools and altering the environment
  • Teaching the patient and family and helping them adapt to lifestyle changes

The success of stroke rehabilitation depends on many variables, including the following:

  • The cause, location, and severity of stroke
  • The type and degree of any impairments and disabilities from the stroke
  • The overall health of the patient
  • Family and community support

Areas covered in stroke rehabilitation programs may include the following:

Patient need: Example:
Self-care skills, including activities of daily living (ADLs) Feeding, grooming, bathing, dressing, toileting, and sexual functioning
Mobility skills Walking, transfers, and self-propelling a wheelchair
Communication skills Speech, writing, and alternative methods of communication
Cognitive skills Memory, concentration, judgment, problem solving, and organizational skills
Socialization skills Interacting with others at home and within the community
Vocational training Work-related skills
Pain management Medicines and alternative methods of managing pain
Psychological testing Identifying problems and solutions with thinking, behavioral, and emotional issues
Family support Assistance with adapting to life styles changes, financial concerns, and discharge planning
Education Patient and family education and training about stroke, medical care, and adaptive techniques

Choosing a rehabilitation facility

Rehabilitation services are provided in many different settings, including the following:

  • Acute care and rehabilitation hospitals
  • Subacute facilities
  • Long-term care facilities
  • Outpatient rehabilitation facilities
  • Home health agencies

When investigating rehabilitation facilities and services, some general questions to ask include the following:

  • Does my insurance company have a preferred rehabilitation provider that I must use to qualify for payment of services?
  • What is the cost and will my insurance company cover all or part of the cost?
  • How far away is the facility and what is the family visiting policy?
  • What are the admission criteria?
  • What are the qualifications of the facility? Is the facility accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF)?
  • Has the facility handled treatment for this type of condition before?
  • Is therapy scheduled every day? How many hours a day?
  • What rehabilitation team members are available for treatment?
  • What type of patient and family education and support is available?
  • Is there a physician onsite 24 hours a day?
  • How are emergencies handled?
  • What type of discharge planning and assistance available?

Stroke Statistics

  • Stroke is third largest cause of death, ranking behind diseases of the heart and all forms of cancer.
  • Strokes kill about 160,000 Americans each year.
  • Almost every minute in the United States, a person experiences a stroke.
  • About 33 percent of people who have had a stroke and survived will have another stroke within five years.
  • The risk of having a stroke increases with age.
  • Seventy-two percent of all strokes occur in people over the age of 65.
  • Of all the stroke deaths that occur each year, women account for approximately 60 percent.
  • African-Americans are twice as likely to experience a stroke than Caucasian-Americans.

Effects of Stroke

What are the effects of stroke?

The effects of stroke vary from person to person based on the type, severity, and location of the stroke.

The brain is extremely complex and each area of the brain is responsible for a special function or ability. When an area of the brain is damaged, which typically occurs with a stroke, an impairment may result. An impairment is the loss of normal function of part of the body. Sometimes, an impairment may result in a disability, or inability to perform an activity in a normal way.

The brain is divided into three main areas, including the following:

  • cerebrum (consisting of the right and left sides or hemispheres)
  • cerebellum
  • brain stem

Depending on which of these regions of the brain the stroke occurs, the effects may be very different.

What effects can be seen with a stroke in the cerebrum?

The cerebrum is the part of the brain that occupies the top and front portions of the skull. It is responsible for control of such abilities as movement and sensation, speech, thinking, reasoning, memory, sexual function, and regulation of emotions. The cerebrum is divided into the right and left sides, or hemispheres.

Depending on the area and side of the cerebrum affected by the stroke, any, or all, of the following body functions may be impaired:

  • movement and sensation
  • speech and language
  • eating and swallowing
  • vision
  • cognitive (thinking, reasoning, judgment and memory) ability
  • perception and orientation to surroundings
  • self-care ability
  • bowel and bladder control
  • emotional control
  • sexual ability

In addition to these general effects, some specific impairments may occur when a particular area of the cerebrum is damaged.

Effects of a right hemisphere stroke:

The effects of a right hemisphere stroke may include the following:

  • left-sided weakness (left hemiparesis) or paralysis (left hemiplegia) and sensory impairment
  • denial of paralysis or impairment and reduced insight into the problems created by the stroke (this concept is called “left neglect”)
  • visual problems, including an inability to see the left visual field of each eye (homonymous hemianopsia)
  • spatial problems with depth perception or directions such as up/down and front/back
  • inability to localize or recognize body parts
  • inability to understand maps and find objects such as clothing or toiletry items
  • memory problems
  • behavioral changes such as lack of concern about situations, impulsivity, inappropriateness, and depression

Effects of a left hemisphere stroke:

The effects of a left hemisphere stroke may include the following:

  • right-sided weakness (right hemiparesis) or paralysis (right hemiplegia) and sensory impairment
  • problems with speech and understanding language (aphasia)
  • visual problems, including the inability to see the right visual field of each eye (homonymous hemianopsia)
  • impaired ability to do math or to organize, reason, and analyze items
  • behavioral changes such as depression, cautiousness, and hesitancy
  • impaired ability to read, write, and learn new information
  • memory problems

What effects can be seen with a stroke in the cerebellum?

The cerebellum is located beneath and behind the cerebrum towards the back of the skull. It receives sensory information from the body via the spinal cord and helps to coordinate muscle action and control, fine movement, coordination, and balance.

Although strokes are less common in the cerebellum area, the effects can be severe. Four common effects of strokes in the cerebellum include the following:

  • inability to walk and problems with coordination and balance (ataxia)
  • dizziness
  • headache
  • nausea
  • vomiting

What effects can be seen with a stroke in the brain stem?

The brain stem is located at the very base of the brain right above the spinal cord. Many of the body’s vital “life-support” functions such as heartbeat, blood pressure, and breathing are controlled by the brain stem. It also helps to control the main nerves involved with eye movement, hearing, speech, chewing, and swallowing. Some common effects of a stroke in the brain stem include problems with the following:

  • breathing and heart functions
  • body temperature control
  • balance and coordination
  • weakness or paralysis in all four limbs
  • chewing, swallowing, and speaking
  • vision
  • coma

Unfortunately, death is common with brain stem strokes.