Please enable JavaScript.
Coggle requires JavaScript to display documents.
STROKE, REFERENCES - Coggle Diagram
STROKE
PATHOGENESIS
thrombotic is when a blood forms in one of the arteries, this could be from atherosclerosis - the buildup of plaque constricts the vascular chamber and forms clots
embolic strokes are when a blood clot or other debris break off from a different place in the body and travels to be logged to an artery in the brain that blocks blood flow - decreased blood flow causes and embolism which leads to severe stress which leads to cell death/necrosis, then follows plasma membrane function, organelle swelling and leaking into extracellular space and loss of neuronal function
about 85% are ischemic strokes, which can be either thrombotic or embolic
hemorrhagic strokes are from bleeding or leaky blood vessels, where the blood that leaked causes too much pressure on the brain cells and damages them, making up 10-15%
intracerebral hemorrhages happen when a blood vessel inside of the brain ruptures, and bleeds into surrounding tissue - this can be because of hypertension, aneurysms, excessive use of anticoagulants/thrombolytic agents, or vascular malformations
ischemic strokes are from deficient blood and oxygen supply to the brain, when blood clots or other particles block vessels
subarachnoid hemorrhages involve bleeding in the space between the brain and arachnoid tissue - usually because of a ruptured aneurysm or head injury
blood flows to brain via two internal carotids and two vertebral arteries
transient ischemic attacks, aka mini strokes, are warning signs for strokes in the future - often caused by blood clots
strokes happen from either a blocked or ruptured artery
any interference of blood flow getting to the brain will deprive the brain of getting the oxygen and nutrients it needs causing cell death that can lead to neurologic deficits
hemorrhagic strokes can be either intracerebral or subarachnoid hemorrhages
in both types of stroke, the deprivation of oxygen and nutrients and release of toxic substance leafs to the death of the neurons and glial brain cells
apoptosis and necrosis pathways get activated and further contribute to brain tissue being lost
penumbra is the irreversibly injured brain tissue around the ischemic core, the cells here die slowly via inflammation and neurovascular perturbations; blood flow deficits and hemorrhagic lesions in core areas cause brain cells to die
depending on what area of the brain was affected we can see different manifestations from motor function, balance, swallowing/eating, speech/language, vision, cognition/memory, emotional function, or bladder bowel control
damage to the motor area of the brain is what causes the weakness/paralysis to one side of the body, hemiplegia/paresis; affecting body movement and fine motor skills, brainstem damage can lead to dysphagia
stroke can also cause difficulty with speaking and language, causing aphasia, having issues reading or writing depending on the location
INCIDENCE/PREVALENCE
stroke risk increases with age, doubling after the age of 55, but can happen at any age, average age of incidence was 69.2 years, last year 38% of admitted stroke patients were less than 65
high income countries also have lower incidence rates of scored compared to lower income countries, almost double, because of healthcare differences and lack of access to preventative/lifestyle change
stroke risk is almost twice as high in non-hispanic black adults compared to white adults, and non-hispanic black and pacific islander adults have the highest death rates due to stroke
strokes have been slightly more common in men compared to women, but he age gap has narrowed over recent years
incidence varying by age, race, sex, and ethnicity
cardioembolic strokes are more severe, and more prevalent in women
about 185,000, about 1 in 4, are in people who have had a previous stroke
the prevalence of stroke is the highest in developing countries, mostly ischemic infarctions, but has decreased overall
every year in the US more than 795,000 people have a stroke, 610,00 being new/first strokes, and is the second leading cause of death and a major contributor to disability worldwide
RISK FACTORS
NON-MODIFIABLE
race/ethnicity, african americans, hispanics americans, american indians, alaska natives have higher rates compared to caucasians
sex, men are at higher risk
TIA
age, they can occur at any age but risk significantly increases after 55 and doubling after each successive decade
family history/genetics
MODIFIABLE
smoking
obesity/physical inactivity
high cholesterol
diabetes
hypertension
diet
atrial fibrillation/other heart disease
excessive alcohol consumption
drug abuse
sleep apnea
CLINICAL MANIFESTATIONS
trouble walking, dizziness, losing balance/coordination
severe headache
confusion, trouble speaking/understanding what people are saying
facial drooping
numbness or weakness in face, arm, or leg(affecting one side of the body)
FAST; face, arms, speech, time
sudden onset of neurological symptoms
DIAGNOSTICS
CT scan, similar to x-ray but uses several images to make a 3D picture of the brain; sometimes injection dye will be used to help see the blood vessels in imaging; CT scans can help differentiate between ischemic and hemorrhagic strokes
MRI scans, use magnetic field and radio waves to make a detailed picture of the body; longer than a CT scan, but shows brain tissue in greater detail allowing smaller or harder to identity areas, a dye can also be used with this scan
physical exam, head to toe assessing neurological function, vital signs, weakness, difficulty speaking, assessing medical history, looking at brain scans, blood tests, looking specifically at blood sugar and cholesterol levels
swallow test, used to make sure the ability to swallow isn’t impaired after a stroke so that there’s no aspiration risk which could lead to pneumonia, referred to speech and language therapist for further assessment if test is failed
carotid ultrasounds, uses a transducer to send waves through the body and the bounce back creates an image, shows if there’s any narrowing or blockages in the neck that lead to the brain
heart and blood vessel tests to identify what caused the stroke
echocardiography, shows image of heart to see if there are any issues related to stroke, a probe is passed through the esophagus and placed behind the heart imagine any possible clots or abnormalities
TREATMENTS
HEMORRHAGIC
blood pressure management to prevent further bleeding or strokes
surgery to remove blood and repair broken vessels in craniotomy, or to treat hydrocephalus with a shunt
require more supportive treatments like nutrition focused, feeding tubes, fluids, supplemental oxygen, compression stockings
REHAB
physical, occupational, or speech therapy to address deficits in mobility, strength, coordination, swallowing cognition
lifestyle changes, to prevent strokes from happening again; smoking cessation, exercise, health eating, diabetes/blood pressure management, taking the antiplatelet/coagulant meds
ISCHEMIC
antiplatelet medications, aspirin, helps decrease risk of clot formation by inhibiting thromboxane synthesis in platelets/suppresses platelet activation anticoagulants, also reduce risk of clot formation, such as heparins and warfarin that inhibit clotting factors
thrombectomy, procedure using a catheter to remove the clot from large arteries in the brain
thrombolysis, “clot busting medication”, tissue plasminogen activator, alteplase dissolves clots to restore blood flow to the brain, but is time sensitive because it can increase bleeding risk
anticoagulants, also reduce risk of clot formation, such as heparins and warfarin
blood pressure medication, statins to lower cholesterol levels and diminish sympathetic outflow from the vasomotor center
carotid endarterectomy, unblocks arteries in stenosis, could be an incision to remove fatty deposits
endovascular therapy , using a catheter to deliver those clot busting meds to the clot and physically remove it with a stent or aspirator, and mostly for larger blockages
LIVED EXPERIENCE
physical challenges can include one-sided weakness or paralysis, difficulty keeping balance, changes in sensation and coordination, all which have major impact on ADLs and can make independent living and regular tasks very difficult
depending on the area of the brain that was affected, strokes can also have an effect on cognitive function, issues with expression, speaking, memory, or processing information
depending on the severity of a stroke there can be many challenges to accompany day to day life going forward
these sudden changes can also take a toll on the patients mental health, many have feelings of depression and frustration with their loss of independence or not seeing significant improvements within therapy
SOCIAL DETERMINANTS OF HEALTH
A lower socioeconomic status is connected to higher risk for having a stroke due to several factors such as limited access to health foods, healthcare, resources, and education that can inform people about the risk factors of stroke, especially the modifiable ones. Financial burdens can also be barriers to finding time or gaining access to the same treatments and preventative measures that people in better conditions don’t have. The star issue of lower socioeconomic status is seen through lack of sufficient nutrition, limited healthcare access, unsafe environments that don’t promote physical activities. Addressing these social determinants of health would play a leading role in increasing prevention measures and earlier treatments for those affected.
REFERENCES
National Center for Biotechnology Information. (2011). Mechanisms of ischemic brain damage. Neuroscience, 158(3), 972–982.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3037909/#:~:text=The%20pathophysiology%20of%20stroke%20is,%2C%20cytokine%2Dmediated%20cytotoxicity%2C%20complement
Cuddy, S. (2021). The importance of addressing social determinants of health in stroke care. Today's Geriatric Medicine, 14(1), 18. Retrieved from
https://www.todaysgeriatricmedicine.com/archive/MJ21p18.shtml#:~:text=Social%20determinants%20of%20health%20(SDOH,frustrating%20barrier%20to%20patient%20care
.
National Health Service. (n.d.). Stroke - Treatment. Retrieved from
https://www.nhs.uk/conditions/stroke/treatment/
National Center for Biotechnology Information. (2020). Understanding the pathophysiology of ischemic stroke. Critical Care Nursing Quarterly, 33(4), 318–330.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7589849/
Centers for Disease Control and Prevention. (n.d.). About stroke. Retrieved from
https://www.cdc.gov/stroke/about.htm#Ischemic
Centers for Disease Control and Prevention. (2021). Stroke facts. Retrieved from
https://www.cdc.gov/stroke/facts.htm#:~:text=Stroke%20statistics&text=Every%20year%2C%20more%20than%20795%2C000,are%20first%20or%20new%20strokes
.
National Health Service. (n.d.). Stroke - Diagnosis. Retrieved from
https://www.nhs.uk/conditions/stroke/diagnosis/#:~:text=If%20a%20stroke%20is%20suspected,to%20receive%20appropriate%20treatment%20sooner
.