A cerebrovascular accident, or stroke, is a sudden alteration in the blood circulation of the brain, due to the obstruction of an artery or the rupture of its walls. The symptoms of a stroke appear suddenly and can differ depending on the nature and site of the lesion: paralysis, vision and language problems (indistinct speech, difficulty finding words, or understanding others), sensitivity (numbness) or coordination (trembling, clumsiness) problems, vertigo, loss of consciousness, violent headache, convulsions, etc. Cerebral hemorrhage, which represents 20% of strokes, often takes the form of blood effusion inside the brain (intracerebral hemorrhage), caused by the rupture of a cerebral artery. Preventing cerebrovascular accidents lies mainly in detecting warning signs, obtaining rapid medical attention, and reducing risk factors. A poor diet (excessive consumption of salt and saturated fats), lack of exercise, stress, smoking and alcoholism are all other factors that predispose an individual to stroke by increasing the risk of arterial hypertension, atherosclerosis, hypercholesterolemia, diabetes, etc. A lumbar puncture (spinal tap) may be performed to examine cerebrospinal fluid for tumor cells, proteins, infection, and blood. Surgery is the treatment of choice for brain tumors that can be reached without causing major injury to vital parts of the brain. Clinical trials are research studies in which new treatmentsa€”drugs, diagnostics, procedures, and other therapiesa€”are tested in people to see if they are safe and effective.
Our specialists are capable of controlling many brain tumors with a combination of treatments, including chemotherapy, surgery, implant therapy (radiation seeds), radiosurgery, and whole brain radiotherapy.
Patients with aggressive tumors benefit from our Tumor Board, a weekly conference where doctors from multiple specialties review and discuss the diagnosis, condition, and best treatment plan for each patient. Advances in technology give Mayfield’s neurosurgeons unprecedented access to brain tumors. A stroke, sometimes referred to as a cerebrovascular accident (CVA), cerebrovascular insult (CVI), or colloquially brain attack is the loss of brain function due to a disturbance in the blood supply to the brain. Ischemia is caused by either blockage of a blood vessel via thrombosis or arterial embolism, or by cerebral hypoperfusion. Stroke was the second most frequent cause of death worldwide in 2011, accounting for 6.2 million deaths (~11% of the total).
In the 1970s the World Health Organization defined stroke as a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours", although the word "stroke" is centuries old. In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin); this constitutes 30-40% of all ischemic strokes.
Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further.
Proposed systems include FAST (face, arm, speech, and time), as advocated by the Department of Health (United Kingdom) and the Stroke Association, the American Stroke Association, the National Stroke Association (US), the Los Angeles Prehospital Stroke Screen (LAPSS) and the Cincinnati Prehospital Stroke Scale (CPSS). For people referred to the emergency room, early recognition of stroke is deemed important as this can expedite diagnostic tests and treatments. In addition to the above CNS pathways, the brainstem gives rise to most of the twelve cranial nerves. Loss of consciousness, headache, and vomiting usually occurs more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing the brain. If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke. Large vessel disease involves the common and internal carotids, vertebral, and the Circle of Willis. Small vessel disease involves the smaller arteries inside the brain: branches of the circle of Willis, middle cerebral artery, stem, and arteries arising from the distal vertebral and basilar artery.
Sickle-cell anemia, which can cause blood cells to clump up and block blood vessels, can also lead to stroke. An embolic stroke refers to the blockage of an artery by an arterial embolus, a traveling particle or debris in the arterial bloodstream originating from elsewhere. Because an embolus arises from elsewhere, local therapy solves the problem only temporarily. Emboli most commonly arise from the heart (especially in atrial fibrillation) but may originate from elsewhere in the arterial tree.
Cerebral venous sinus thrombosis leads to stroke due to locally increased venous pressure, which exceeds the pressure generated by the arteries. It generally occurs in small arteries or arterioles and is commonly due to hypertension, intracranial vascular malformations (including cavernous angiomas or arteriovenous malformations), cerebral amyloid angiopathy, or infarcts into which secondary haemorrhage has occurred.
A silent stroke is a stroke that does not have any outward symptoms, and the patients are typically unaware they have suffered a stroke. Micrograph showing corticalpseudolaminar necrosis, a findingseen in strokes on medical imagingand at autopsy. Ischemic stroke occurs because of a loss of blood supply to part of the brain, initiating the ischemic cascade. As oxygen or glucose becomes depleted in ischemic brain tissue, the production of high energy phosphate compounds such as adenosine triphosphate (ATP) fails, leading to failure of energy-dependent processes (such as ion pumping) necessary for tissue cell survival. Ischemia also induces production of oxygen free radicals and other reactive oxygen species.
These processes are the same for any type of ischemic tissue and are referred to collectively as the ischemic cascade. In addition to injurious effects on brain cells, ischemia and infarction can result in loss of structural integrity of brain tissue and blood vessels, partly through the release of matrix metalloproteases, which are zinc- and calcium-dependent enzymes that break down collagen, hyaluronic acid, and other elements of connective tissue. Stroke is diagnosed through several techniques: a neurological examination (such as the NIHSS), CT scans (most often without contrast enhancements) or MRI scans, Doppler ultrasound, and arteriography. A physical examination, including taking a medical history of the symptoms and a neurological status, helps giving an evaluation of the location and severity of a stroke. When a stroke has been diagnosed, various other studies may be performed to determine the underlying cause. The most important modifiable risk factors for stroke are high blood pressure and atrial fibrillation (although magnitude of this effect is small: the evidence from the Medical Research Council trials is that 833 patients have to be treated for 1 year to prevent one stroke).
No high-quality studies have shown the effectiveness of interventions aimed at weight reduction, promotion of regular exercise, reducing alcohol consumption or smoking cessation.
Oral anticoagulants such as warfarin have been the mainstay of stroke prevention for over 50 years.
Those with atrial fibrillation have a 5% a year risk of stroke, and this risk is higher in those with valvular atrial fibrillation. In primary prevention however, antiplatelet drugs did not reduce the risk of ischemic stroke while increasing the risk of major bleeding. Carotid endarterectomy or carotid angioplasty can be used to remove atherosclerotic narrowing (stenosis) of the carotid artery. Screening for carotid artery narrowing has not been shown to be a useful screening test in the general population. Nutrition, specifically the Mediterranean-style diet, has the potential for decreasing the risk of having a stroke by more than half. A number of specific recommendations have been made for women including: taking aspirin after the 11th week of pregnancy if there is a history of previous chronic high blood pressure, blood pressure medications in pregnancy if the blood pressure is greater than 150 mmHg systolic or greater than 100 mmHg diastolic. If studies show carotid stenosis, and the person has residual function in the affected side, carotid endarterectomy (surgical removal of the stenosis) may decrease the risk of recurrence if performed rapidly after stroke.
Definitive therapy is aimed at removing the blockage by breaking the clot down (thrombolysis), or by removing it mechanically (thrombectomy). Tight control of blood sugars in the first few hours does not improve outcomes and may cause harm. Thrombolysis, such as with recombinant tissue plasminogen activator (rtPA), in acute ischemic stroke, when given given within three hours of symptom onset results in an overall benefit of 10% with respect to living without disability.
Its use is endorsed by the American Heart Association and the American Academy of Neurology as the recommended treatment for acute stroke within three hours of onset of symptoms as long as there are not other contraindications (such as abnormal lab values, high blood pressure, or recent surgery). Large territory strokes can cause significant edema of the brain with secondary brain injury in surrounding tissue.
People with intracerebral hemorrhage require neurosurgical evaluation to detect and treat the cause of the bleeding, although many may not need surgery.
Ideally, people who have had a stroke are admitted to a "stroke unit", a ward or dedicated area in hospital staffed by nurses and therapists with experience in stroke treatment. When an acute stroke is suspected by history and physical examination, the goal of early assessment is to determine the cause. Stroke rehabilitation is the process by which those with disabling strokes undergo treatment to help them return to normal life as much as possible by regaining and relearning the skills of everyday living. A rehabilitation team is usually multidisciplinary as it involves staff with different skills working together to help the patient.
Good nursing care is fundamental in maintaining skin care, feeding, hydration, positioning, and monitoring vital signs such as temperature, pulse, and blood pressure.
For most people with stroke, physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) are the cornerstones of the rehabilitation process. Patients may have particular problems, such as dysphagia, which can cause swallowed material to pass into the lungs and cause aspiration pneumonia.
Treatment of spasticity related to stroke often involves early mobilizations, commonly performed by a physiotherapist, combined with elongation of spastic muscles and sustained stretching through various positionings.
Stroke rehabilitation should be started as quickly as possible and can last anywhere from a few days to over a year. Some current and future therapy methods include the use of virtual reality and video games for rehabilitation.
Other novel non-invasive rehabilitation methods are currently being developed to augment physical therapy to improve motor function of stroke patients, such as transcranial magnetic stimulation (TMS) and transcranial direct-current stimulation (tDCS) and robotic therapies.
Some of the physical disabilities that can result from stroke include muscle weakness, numbness, pressure sores, pneumonia, incontinence, apraxia (inability to perform learned movements), difficulties carrying out daily activities, appetite loss, speech loss, vision loss and pain. Emotional problems following a stroke can be due to direct damage to emotional centers in the brain or from frustration and difficulty adapting to new limitations. Disruption in self-identity, relationships with others, and emotional well-being can lead to social consequences after stroke due to the lack of ability to communicate. 30 to 50% of stroke survivors suffer post-stroke depression, which is characterized by lethargy, irritability, sleep disturbances, lowered self-esteem and withdrawal.
Emotional lability, another consequence of stroke, causes the patient to switch quickly between emotional highs and lows and to express emotions inappropriately, for instance with an excess of laughing or crying with little or no provocation.
Cognitive deficits resulting from stroke include perceptual disorders, Aphasia, dementia, and problems with attention and memory. Cognitive and psychological outcome after a stroke can be affected by the age at which the stroke happened, pre-stroke baseline intellectual functioning, psychiatric history and whether there is pre-existing brain pathology. Up to 10% of people following a stroke develop seizures, most commonly in the week subsequent to the event; the severity of the stroke increases the likelihood of a seizure.
The incidence of stroke increases exponentially from 30 years of age, and etiology varies by age. Family members may have a genetic tendency for stroke or share a lifestyle that contributes to stroke. Men are 25% more likely to suffer strokes than women, yet 60% of deaths from stroke occur in women. Episodes of stroke and familial stroke have been reported from the 2nd millennium BC onward in ancient Mesopotamia and Persia.
In 1658, in his Apoplexia, Johann Jacob Wepfer (1620–1695) identified the cause of hemorrhagic stroke when he suggested that people who had died of apoplexy had bleeding in their brains. The term brain attack was introduced for use to underline the acute nature of stroke according to the American Stroke Association, who since 1990 have used the term, and is used colloquially to refer to both ischemic as well as hemorrhagic stroke.
Angioplasty and stenting have begun to be looked at as possible viable options in treatment of acute ischemic stroke. Removal of the clot may be attempted in those where it occurs within a large blood vessel and may be an option for those who either are not eligible for or do not improve with intravenous thrombolytics.
Drugs that scavenge reactive oxygen species, inhibit apoptosis, or inhibit excitatory neurotransmitters have been shown experimentally to reduce tissue injury caused by ischemia. Hyperbaric oxygen therapy has been studied as a possible protective measure, but is currently not thought to be beneficial.
The brain is protected from bacterial invasion from the environment by the skull, the dura, the arachnoid membrane, the pia, and the glia limitans, which is a dense mesh of astrocytic processes on the surface of the brain. Bacterial meningitis is the infection of the arachnoid membrane, subarachnoid space, and cerebrospinal fluid by bacteria. The infection may spread to the meninges from an adjacent infected area such as sinusitis, otitis media, and mastoiditis or from the environment through a penetrating injury or congenital defect, such as a menigomyelocele. The organisms that cause bacterial meningitis colonize the nasopharynx and, from there, they get into the blood stream. MeningitisThe inflammatory exudate in the subarachnoid space is layered-neutrophils on top, fibrin in the deeper layer. A creamy purulent exudate covers the cerebral hemispheres and settles along the base of the brain, around cranial nerves and the openings of the fourth ventricle. Neutrophils in the subarachnoid space infiltrate and damage cranial nerves resulting in cranial nerve deficits, and invade leptomeningeal vessels causing phlebitis and arteritis with thrombosis and ischemic infarction. The glia limitans, a thick tight mesh of astrocytic processes, joined by dense junctions and covered by basement membrane, resists penetration by bacteria and neutrophils.
Brain damage in meningitis is caused not only by bacteria but probably more by host responses. This course was produced for the use of students, residents, and staff of NEOMED and affiliated hospitals. In national security, the national sport, and on the national highways, brains are getting banged. Eighty two years after dementia pugilistica was diagnosed in boxers, we should not be surprised that impacts in war, car accidents and high-intensity sports are taking a toll on the thinking organ, says Robert John Dempsey, chair of neurological surgery at the University of Wisconsin-Madison. The brain shrinkage seen in autopsies of former football players after multiple concussions is called chronic traumatic encephalopathy.
After the growing concern about traumatic brain injury among middle-aged football veterans who were paid to endure thousands of blows to the head, the discovery of such damage in the 21-year-old Penn player raised questions for young athletes and their parents, as Robert Stern, a professor of neurology at Boston University, explained to the New York Times. Chronic traumatic encephalopathy is marked by concentrations of tau protein, shown here as brown spots. A 2007 study by University of North Carolina scientists suggests that concussions can follow almost any type of head impact in football, regardless of its strength and location. Until recently, impact was considered less serious than contusions — brain injuries with obvious damage like bleeding and swelling, says Dempsey.
But when the brains of former pro football players were examined after death, massive damage was blamed for serious problems like depression, confusion and movement disorders. Today, concussion and contusion seem less like distinct things and more like stages of a continuum of brain injury, Dempsey says.
Hospital corpsman Anthony Thompson gets a medal while being treated for a traumatic brain injury caused by an improvised bomb in Iraq. What do some promising recent studies say about halting or treating traumatic brain injury in animals or people? Doctors have long worried that an injured brain often contains too much energy in the form of blood sugar, says David Hovda, a professor of neurosurgery and director of Brain Injury Research Center at the University of California at Los Angeles. Hovda says his studies in rodents suggest the brain has complicated fuel needs during recovery.
Hovda says UCLA is in the second year of a five-year project to test the optimum level of plasma glucose after a traumatic brain injury in 20 to 25 patients.
If the new approach has promise, Hovda hopes to start a larger trial that would treat traumatic brain injury patients with a variety of intravenous fuels. Brain injuries can affect small structures like the hippocampus, which is critical to memory and other higher thought processes. A 2007 study found that football impacts could reach more than 100 Gs (100 times the acceleration of gravity). The imbalance has been concealed because the hippocampus has two pools of the neurotransmitters, and only the smaller pools at synapses (where two brain cells make contact) appear to be altered after injury.
The team performed electrical tests on brain slices and got normal results if the amino-acid supplements were present. As Cohen searches for funding for a human trial, he notes that the mice received leucine, isoleucine and valine. The Why Files was intrigued by the notion that simple lenses could substantially reduce symptoms of traumatic brain injury, and Rosner recommended that we phone former patient Penelope Frenette, 31.
Frenette said that after a car accident four years ago, she made the rounds of treatments, and saw an immediate improvement while visiting Debby Feinberg, a Birmingham, Mich., optometrist.
Penelope Frenette describes how prism glasses reduced the symptoms of a brain injury after a car crash. Previously, Frenette says, her balance was so poor that her apartment “was filled with grease marks where I had to hold the walls.
It sounds too good to be true, but a Michigan research group has published a study showing that simple corrective lenses can reduce headache, neck ache, and dizziness — common symptoms of traumatic brain injury.
The problem seems to be rooted in a brain malfunction that prevents the eyes from converging, so one eye aims slightly above or below the other.
The resulting tug of war between the muscles that raises and lower the eyes causes tension and headaches, Rosner says. The divergence is subtle, but detectable, and in many cases, it can be cured with prismatic eyeglasses, Rosner contends. Like regular eyeglasses, the lenses are used continually; the goal is not to retrain the brain but to correct the misalignment. A published study of 43 patients1, for whom Rosner and his colleagues had complete records, found a 72 percent reduction in several symptoms of traumatic brain injury, based on a subjective scale.
The majority of the patients had had a motor vehicle accident, Rosner says, but falls, strokes or and blast injuries to veterans were also represented. As Rosner and colleagues struggle to get the word out on their simple treatment, he says prism glasses are helpful, but not a panacea. BibliographyIdentification of Binocular Vision Dysfunction (Vertical Heterophoria) in Traumatic Brain Injury Patients and Effects of Individualized Prismatic Spectacle Lenses in the Treatment of Postconcussive Symptoms: A Retrospective Analysis, Jennifer E.


Evaluation: Neuroimaging Other studies have shown that up to one-third of patients with initially normal scans developed CT scan abnormalities within the first few days after closed head injury O'Sullivan, MG, Statham, PF, Jones, PA, et al. In Western countries, strokes are the third greatest cause of death and the greatest cause of acquired handicaps (motor coordination, sensory and intellectual deficiencies).
When the symptoms of a stroke disappear spontaneously in less than 24 hours, it is a transitory ischemic accident.
It results in the destruction of nerve cells as well as the formation of a hematoma and sometimes edema. It is important to monitor these problems and treat them by adopting a healthier lifestyle.
Surgery can help to refine the diagnosis, remove as much of the tumor as possible, and release pressure within the skull. Chemotherapy for high-grade gliomas is usually taken as a pill daily for a set period of time called a cycle. Our affiliation with the University of Cincinnati Brain Tumor Center and the Precision Radiotherapy Center provides patients with care from a multidisciplinary team of doctors.
A Tumor Board review includes the opinions of medical oncologists (chemotherapy), neurosurgeons (surgery), radiation oncologists (radiation), and neuroradiologists (diagnosis). Image-guided systems enable us to navigate precisely in remote areas and to remove tumors with minimum impact to our patients. Hemorrhagic stroke is caused by bleeding of blood vessels of the brain, either directly into the brain parenchyma or into the subarachnoid space surrounding brain tissue. An ischemic stroke is occasionally treated in a hospital with thrombolysis (also known as a "clot buster"), and some hemorrhagic strokes benefit from neurosurgery. Approximately 17 million people had a stroke in 2010 and 33 million people have previously had a stroke and were still alive.
Ischemic strokes are caused by interruption of the blood supply, while hemorrhagic strokes result from the rupture of a blood vessel or an abnormal vascular structure.
This definition was supposed to reflect the reversibility of tissue damage and was devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. The Oxford Community Stroke Project classification (OCSP, also known as the Bamford or Oxford classification) relies primarily on the initial symptoms; based on the extent of the symptoms, the stroke episode is classified as total anterior circulation infarct (TACI), partial anterior circulation infarct (PACI), lacunar infarct (LACI) or posterior circulation infarct (POCI).
A distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the brain). Different findings are able to predict the presence or absence of stroke to different degrees. A scoring system called ROSIER (recognition of stroke in the emergency room) is recommended for this purpose; it is based on features from the medical history and physical examination. Depending on the part of the brain affected, the defect in the brain is usually on the opposite side of the body.
Since blockage of the artery is gradual, onset of symptomatic thrombotic strokes is slower.
Diseases that may form thrombi in the large vessels include (in descending incidence): atherosclerosis, vasoconstriction (tightening of the artery), aortic, carotid or vertebral artery dissection, various inflammatory diseases of the blood vessel wall (Takayasu arteritis, giant cell arteritis, vasculitis), noninflammatory vasculopathy, Moyamoya disease and fibromuscular dysplasia. Diseases that may form thrombi in the small vessels include (in descending incidence): lipohyalinosis (build-up of fatty hyaline matter in the blood vessel as a result of high blood pressure and aging) and fibrinoid degeneration (stroke involving these vessels are known as lacunar infarcts) and microatheroma (small atherosclerotic plaques). A stroke is the second leading killer of people under 20 who suffer from sickle-cell anemia.
In paradoxical embolism, a deep vein thrombosis embolizes through an atrial or ventricular septal defect in the heart into the brain. It is most commonly due to heart failure from cardiac arrest or arrhythmias, or from reduced cardiac output as a result of myocardial infarction, pulmonary embolism, pericardial effusion, or bleeding. Infarcts are more likely to undergo hemorrhagic transformation (leaking of blood into the damaged area) than other types of ischemic stroke. Despite not causing identifiable symptoms, a silent stroke still damages the brain, and places the patient at increased risk for both transient ischemic attack and major stroke in the future. However, brain tissue is especially vulnerable to ischemia since it has little respiratory reserve and is completely dependent on aerobic metabolism, unlike most other organs. SPECT documents cerebral blood flow and PET with FDG isotope the metabolic activity of the neurons. With the current treatment and diagnosis options available, it is of particular importance to determine whether there is a peripheral source of emboli. Primary prevention is less effective than secondary prevention (as judged by the number needed to treat to prevent one stroke per year).
Other modifiable risk factors include high blood cholesterol levels, diabetes, cigarette smoking (active and passive), heavy alcohol consumption and drug use, lack of physical activity, obesity, processed red meat consumption and unhealthy diet.
Nonetheless, given the large body of circumstantial evidence, best medical management for stroke includes advice on diet, exercise, smoking and alcohol use. Blood pressure reduction of 10 mmHg systolic or 5 mmHg diastolic reduces the risk of stroke by ~40%. While intensive control of blood sugar has been shown to reduce microvascular complications such as nephropathy and retinopathy it has not been shown to reduce macrovascular complications such as stroke. However, several studies have shown that aspirin and antiplatelet drugs are highly effective in secondary prevention after a stroke or transient ischemic attack.
Depending on the stroke risk, anticoagulation with medications such as warfarin or aspirin is useful for prevention. Further studies are needed to investigate a possible protective effect of aspirin against ischemic stroke in women. Studies of surgical intervention for carotid artery stenosis without symptoms have shown only a small decrease in the risk of stroke. It does not appear that lowering levels of homocysteine with folic acid affects the risk of stroke.
In those who have previously had preeclampsia other risk factors should be treated more aggressively. The philosophical premise underlying the importance of rapid stroke intervention was crystallized as Time is Brain!
High blood pressure is also not typically lowered as this has not been found to be helpful. This position for tPA is based upon the findings of two studies by one group of investigators which showed that tPA improves the chances for a good neurological outcome.
This phenomenon is mainly encountered in strokes of the middle cerebral artery territory, and is also called "malignant cerebral infarction" because it carries a dismal prognosis. Anticoagulants and antithrombotics, key in treating ischemic stroke, can make bleeding worse.
It has been shown that people admitted to a stroke unit have a higher chance of surviving than those admitted elsewhere in hospital, even if they are being cared for by doctors without experience in stroke. Treatment varies according to the underlying cause of the stroke, thromboembolic (ischemic) or hemorrhagic. It also aims to help the survivor understand and adapt to difficulties, prevent secondary complications and educate family members to play a supporting role. These include physicians trained in rehabilitation medicine, clinical pharmacists, nursing staff, physiotherapists, occupational therapists, speech and language therapists, and orthotists. The condition may improve with time, but in the interim, a nasogastric tube may be inserted, enabling liquid food to be given directly into the stomach. Gaining initial improvement in range of motion is often achieved through rhythmic rotational patterns associated with the affected limb. Most return of function is seen in the first few months, and then improvement falls off with the "window" considered officially by U.S. These forms of rehabilitation offer potential for motivating patients to perform specific therapy tasks that many other forms do not. Stroke can affect peoples physically, mentally, emotionally, or a combination of the three. If the stroke is severe enough, or in a certain location such as parts of the brainstem, coma or death can result. Post-stroke emotional difficulties include anxiety, panic attacks, flat affect (failure to express emotions), mania, apathy and psychosis.
Many patients who experience communication impairments after a stroke find it more difficult to cope with the social issues rather than physical impairments.
Depression can reduce motivation and worsen outcome, but can be treated with antidepressants. While these expressions of emotion usually correspond to the patient's actual emotions, a more severe form of emotional lability causes patients to laugh and cry pathologically, without regard to context or emotion. A stroke sufferer may be unaware of his or her own disabilities, a condition called anosognosia. In the United States stroke is a leading cause of disability, and recently declined from the third leading to the fourth leading cause of death. Higher levels of Von Willebrand factor are more common amongst people who have had ischemic stroke for the first time. Since women live longer, they are older on average when they have their strokes and thus more often killed (NIMH 2002). Hippocrates (460 to 370 BC) was first to describe the phenomenon of sudden paralysis that is often associated with ischemia. Wepfer also identified the main arteries supplying the brain, the vertebral and carotid arteries, and identified the cause of ischemic stroke [also known as cerebral infarction] when he suggested that apoplexy might be caused by a blockage to those vessels. Its use is now discouraged by a number of neurology textbooks, reasoning that the connotation of fortuitousness carried by the word accident insufficiently highlights the modifiability of the underlying risk factors.
Intra-cranial stenting in symptomatic intracranial arterial stenosis, the rate of technical success (reduction to stenosis of <50%) ranged from 90-98%, and the rate of major peri-procedural complications ranged from 4-10%. A spinal epidural abscess arises when organisms from osteomyelitis or tuberculosis of the vertebral column spread to this space. The subdural space is traversed by bridging arteries and veins but has no vascular network of its own.
The subarachnoid space is bounded externally by the arachnoid membrane and internally by the pia, and dips into the brain along blood vessels in the perivascular (Virchow-Robin) spaces. They enter the subarachnoid space by passing through endothelial cells (transcytosis), getting across the porous choroid plexus capillaries, or being carried by granulocytes. Bacterial toxins cause neuronal apoptosis, and cell wall lipopolysaccharide (endotoxin), released from bacteria, activates clotting causing disseminated intravascular coagulation (DIC). The inflamed spinal structures are sensitive to stretch, and pain can be elicited by maneuvers that stretch the spine, such as bending the leg with an outstretched knee (Kernig sign) or bending the neck (Brudzinski sign). The CSF in meningitis shows hundreds, even thousands of neutrophils and is teeming with organisms. The MRI shows enhancement and high FLAIR signal intensity in the meninges, corresponding to the pathology. Less than 5% of such cases are due to bacterial meningitis and the rest are due to viral (aseptic) meningitis (see viral infections). Undamaged, it provides an effective barrier that prevents the infection from spreading into brain tissue.
These responses have a protective purpose (to eliminate bacteria) but are excessive and indiscriminate and set in motion destructive cascades that damage everything in their way, mostly host tissues. The bacteria that cause brain abscess spread from adjacent air sinuses or the middle ear, or via the blood stream from the lungs (bronchiectasis, lung abscess), or from the heart (bacterial endocarditis). Hypervascularity and vascular leakage account for the "ring enhancing" pattern after contrast injection, which gives abscess its characteristic radiological image (necrotic tumors may have a similar appearance). 12, two Philadelphia Eagles stayed on the field, despite signs of concussion visible to millions of viewers. This disturbing shrinkage of the brain is linked to severe, deadly brain abnormalities, including memory loss, confusion, paranoia, depression, dementia and Parkinsonism. Beyond glucose, he will also test other fuels that might support recovery while reducing harm in other parts of the brain. In a mouse model of brain injury, Akiva Cohen, an associate professor of pediatrics and neurology at the University of Pennsylvania School of Medicine, has found that dietary supplements may help the hippocampus work after injury.
Many patients even notice their headache and neck ache start to subside during a 20-minute trial period in the office. Role of intracranial pressure monitoring in severely head-injured patients without signs of intracranial hypertension on initial computerized tomography. They affect all ages, but the risk increases after 60 years of age and in the event of arterial hypertension, atherosclerosis, diabetes, or aneurysm. This type of accident, caused by a brief interruption of the blood irrigation of the brain, constitutes a warning signal since it often precedes cerebral infarction.
In the case of thrombosis, the obstruction is caused by a blood clot (thrombus) that forms directly in a cerebral artery, at an atheromatous plaque. The main cause of intracerebral hemorrhage is arterial hypertension, which weakens the blood vessels. Cerebral edema leads to headaches and neurological problems (language problems, hallucinations, blindness, amnesia, decrease in strength and sensitivity, loss of consciousness). People who have already suffered from a transitory ischemic accident should be particularly careful.
Small biting instruments remove bits of tumor for the pathologist to examine and determine the exact tumor cell type. The radiation beams are shaped to match the tumor and minimize exposure to normal brain tissue.
The drug circulates through the bloodstream to the brain where it crosses the blood-brain-barrier to the tumor. Information about current clinical trials, including eligibility, protocol, and locations, are found on the Web. This information is not intended to replace the medical advice of your health care provider. As a result, the affected area of the brain cannot function normally, which might result in an inability to move one or more limbs on one side of the body, failure to understand or formulate speech, or a vision impairment of one side of the visual field.
Risk factors for stroke include old age, high blood pressure, previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, tobacco smoking and atrial fibrillation. Treatment to recover any lost function is termed stroke rehabilitation, ideally in a stroke unit and involving health professions such as speech and language therapy, physical therapy and occupational therapy. Between 1990 and 2010 the number of strokes decrease by approximately 10% in the developed world and increased by 10% in the developing world. The 24-hour limit divides stroke from transient ischemic attack, which is a related syndrome of stroke symptoms that resolve completely within 24 hours.
These four entities predict the extent of the stroke, the area of the brain that is affected, the underlying cause, and the prognosis. Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system).
The more extensive the area of brain affected, the more functions that are likely to be lost. However, since these pathways also travel in the spinal cord and any lesion there can also produce these symptoms, the presence of any one of these symptoms does not necessarily indicate a stroke. The hematoma enlarges until pressure from surrounding tissue limits its growth, or until it decompresses by emptying into the ventricular system, CSF or the pial surface. Conversely, those who have suffered a major stroke are also at risk of having silent strokes. The loss of vascular structural integrity results in a breakdown of the protective blood brain barrier that contributes to cerebral edema, which can cause secondary progression of the brain injury. Hemorrhagic strokes arise from bleeding within the brain parenchyma or intraventricular spaces, and are classified based on their underlying pathology.
Test selection may vary, since the cause of stroke varies with age, comorbidity and the clinical presentation.
Alcohol use could predispose to ischemic stroke, and intracerebral and subarachnoid hemorrhage via multiple mechanisms (for example via hypertension, atrial fibrillation, rebound thrombocytosis and platelet aggregation and clotting disturbances). Medication or drug therapy is the most common method of stroke prevention; carotid endarterectomy can be a useful surgical method of preventing stroke. Lowering blood pressure has been conclusively shown to prevent both ischemic and hemorrhagic strokes. Since earlier meta-analyses of other lipid-lowering drugs did not show a decreased risk, statins might exert their effect through mechanisms other than their lipid-lowering effects. Except for in atrial fibrillation, oral anticoagulants are not advised for stroke prevention —any benefit is offset by bleeding risk. Endarterectomy for a significant stenosis has been shown to be useful in the prevention of further strokes in those who have already had one. Among people with nonvalvular atrial fibrillation, anticoagulation can reduce stroke by 60% while antiplatelet agents can reduce stroke by 20%. When administered within the first three hours thrombolysis improves functional outcome without affecting mortality. Relief of the pressure may be attempted with medication, but some require hemicraniectomy, the temporary surgical removal of the skull on one side of the head. People are monitored for changes in the level of consciousness, and their blood pressure, blood sugar, and oxygenation are kept at optimum levels.
Some teams may also include psychologists and social workers, since at least one third of the people manifest post stroke depression. If swallowing is still deemed unsafe, then a percutaneous endoscopic gastrostomy (PEG) tube is passed and this can remain indefinitely. After full range has been achieved by the therapist, the limb should be positioned in the lengthened positions to prevent against further contractures, skin breakdown, and disuse of the limb with the use of splints or other tools to stabilize the joint. Many clinics and hospitals are adopting the use of these off-the-shelf devices for exercise, social interaction and rehabilitation because they are affordable, accessible and can be used within the clinic and home. A systematic review found that there are inadequate long-term data about the effects of exercise and training on death, dependence and disability after a stroke. Other difficulties may include a decreased ability to communicate emotions through facial expression, body language and voice.


Broader aspects of care must address the emotional impact speech impairment has on those who experience difficulties with speech after a stroke. In a condition called hemispatial neglect, a patient is unable to attend to anything on the side of space opposite to the damaged hemisphere.
Geographic disparities in stroke incidence have been observed, including the existence of a "stroke belt" in the southeastern United States, but causes of these disparities have not been explained.
95% of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65. The results of this study found that the only significant genetic factor was the person's blood type. Apoplexy, from the Greek word meaning "struck down with violence," first appeared in Hippocratic writings to describe this phenomenon. Until recently, human clinical trials with neuroprotective agents have failed, with the probable exception of deep barbiturate coma.
Bacteria can penetrate into the brain from the environment if there is a break in the continuity of these protective layers. It extends from the optic chiasm to the cauda equina and surrounds the brain and spinal cord completely. The most common organisms of bacterial meningitis in children and adults are Streptococcus pneumoniae and Neisseria meningitidis. The CSF is an ideal medium for the spread of bacteria because it provides enough nutrients for their multiplication and has few phagocytic cells, and low levels of antibodies and complement. Yet, to play it safe, physicians admit such patients to hospital and treat them with antibiotics. The thick fibrinopurulent exudate in the subarachnoid space organizes into fibrous tissue that blocks the exits of the fourth ventricle and impairs CSF circulation around the cerebral convexities. Modulating these reactions, in addition to killing bacteria, can reduce the morbidity and mortality of meningitis. Patients with brain abscess present most frequently with headache and may also have symptoms of infection, focal neurological deficits due to destruction of brain tissue, and seizures. But ironically, better protection is part of the reason why so many soldiers are returning with brain injuries — body and vehicle armor keeps them alive without always protecting the head. The blood effusion may not occur in the brain, but between the meninges that cover it (meningeal bleedings). It may cause intracranial hypertension as well as compression of the brain and is a common cause of death.
Malignant tumors have an irregular border that invades normal tissue with finger-like projections making surgical removal more difficult. Prevention of recurrence may involve the administration of antiplatelet drugs such as aspirin, control of high blood pressure, and the use of statins. With the availability of treatments which can reduce stroke severity when given early, many now prefer alternative terminology, such as brain attack and acute ischemic cerebrovascular syndrome (modeled after heart attack and acute coronary syndrome, respectively), to reflect the urgency of stroke symptoms and the need to act swiftly. The TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification is based on clinical symptoms as well as results of further investigations; on this basis, a stroke is classified as being due to (1) thrombosis or embolism due to atherosclerosis of a large artery, (2) embolism of cardiac origin, (3) occlusion of a small blood vessel, (4) other determined cause, (5) undetermined cause (two possible causes, no cause identified, or incomplete investigation). The main types of extra-axial hemorrhage are epidural hematoma (bleeding between the dura mater and the skull), subdural hematoma (in the subdural space) and subarachnoid hemorrhage (between the arachnoid mater and pia mater). Also, symptoms may be transient as the embolus is partially resorbed and moves to a different location or dissipates altogether. Because the reduction in blood flow is global, all parts of the brain may be affected, especially "watershed" areas - border zone regions supplied by the major cerebral arteries. In a broad study in 1998, more than 11 million people were estimated to have experienced a stroke in the United States. Embolic infarction occurs when emboli formed elsewhere in the circulatory system, typically in the heart as a consequence of atrial fibrillation, or in the carotid arteries, break off, enter the cerebral circulation, then lodge in and occlude brain blood vessels. The concentration of glutamate outside the cells of the nervous system is normally kept low by so-called uptake carriers, which are powered by the concentration gradients of ions (mainly Na+) across the cell membrane. In fact, many antioxidant neuroprotectants such as uric acid and NXY-059 work at the level of the endothelium and not in the brain per se.
Some examples of hemorrhagic stroke are hypertensive hemorrhage, ruptured aneurysm, ruptured AV fistula, transformation of prior ischemic infarction, and drug induced bleeding.
There is yet no commonly used blood test for the stroke diagnosis itself, though blood tests may be of help in finding out the likely cause of stroke. In those who are otherwise healthy aspirin does not appear beneficial and thus is not recommended.
Thienopyridines (clopidogrel, ticlopidine) "might be slightly more effective" than aspirin and have a decreased risk of gastrointestinal bleeding, but they are more expensive. Even then, for 100 surgeries, 5 patients will benefit by avoiding stroke, 3 will develop stroke despite surgery, 3 will develop stroke or die due to the surgery itself, and 89 will remain stroke-free but would also have done so without intervention.
However, a recent meta-analysis suggests harm from anti-coagulation started early after an embolic stroke.
Years later, that same idea, that rapid cerebral blood flow restoration results in fewer brain cells dying, has been proved and quantified. 6.4% of people with large strokes developed substantial brain hemorrhage as a complication from being given tPA thus part of the reason for increased short term mortality.
This decreases the risk of death, although some more people survive with disability who would otherwise have died. Validated instruments such as the Barthel scale may be used to assess the likelihood of a stroke patient being able to manage at home with or without support subsequent to discharge from hospital. PT and OT have overlapping areas of expertise, however PT focuses on joint range of motion and strength by performing exercises and re-learning functional tasks such as bed mobility, transferring, walking and other gross motor functions. Cold in the form of ice wraps or ice packs have been proven to briefly reduce spasticity by temporarily dampening neural firing rates.
However, patients have been known to continue to improve for years, regaining and strengthening abilities like writing, walking, running, and talking. However, cardiorespiratory training added to walking programs in rehabilitation can improve speed, tolerance and independence during walking. The word stroke was used as a synonym for apoplectic seizure as early as 1599, and is a fairly literal translation of the Greek term.
This data suggests that a randomized controlled trial is needed to more completely evaluate the possible therapeutic advantage of this preventative measure. However, more recently NXY-059, the disulfonyl derivative of the radical-scavengin phenylbutylnitrone, is reported to be neuroprotective in stroke.
Such a discontinuity may be due to congenital defects (encephalocele, meningomyelocele) or may be caused by trauma or a shunt. However, a cranial epidural abscess may develop when bacteria colonize a traumatic epidural hematoma, or when infection from air sinuses extends in the plane between the dura and bone. Initially, bacteria multiply uninhibited and can be identified in smears, cultures, or by ELISA detection of their antigens before there is any inflammation. Cells of the innate immune system of the brain, located in the BBB, choroid plexus, and ependyma, detect bacteria and secrete cytokines, chemokines, and complement, which attract circulating granulocytes into the CSF. These complications are due to HIE, increased intracranial pressure, and a toxic metabolic encephalopathy. Unnecessary hospitalizations can be avoided if a standard set of criteria are taken into account. Right: The brain of former NFL linebacker John Grimsley, who died of a gunshot at age 45 after nine concussions.
In the case of embolism, the obstruction is created by a foreign body having migrated to the brain, often a blood clot that formed in the heart or detached itself from an atheromatous plaque. More frequent in women, meningeal bleeding is generally caused by the rupture of an aneurysm.
Users of stimulant drugs such as cocaine and methamphetamine are at a high risk for ischemic strokes.
While these findings are not perfect for diagnosing stroke, the fact that they can be evaluated relatively rapidly and easily make them very valuable in the acute setting.
A watershed stroke refers to the condition when blood supply to these areas is compromised. ICH has a mortality rate of 44 percent after 30 days, higher than ischemic stroke or subarachnoid hemorrhage (which technically may also be classified as a type of stroke).
Approximately 770,000 of these strokes were symptomatic and 11 million were first-ever silent MRI infarcts or hemorrhages. Since blood vessels in the brain are now occluded, the brain becomes low in energy, and thus it resorts into using anaerobic metabolism within the region of brain tissue affected by ischemia. However, stroke cuts off the supply of oxygen and glucose which powers the ion pumps maintaining these gradients. Free radicals also directly initiate elements of the apoptosis cascade by means of redox signaling.
They result in tissue injury by causing compression of tissue from an expanding hematoma or hematomas. In people who have had a myocardial infarction or those with a high cardiovascular it provides some protection against a first stroke. Even patients older than 80 years and those with isolated systolic hypertension benefit from antihypertensive therapy. Patients are selected for surgery based on age, gender, degree of stenosis, time since symptoms and patients' preferences.
A 2014 review found a 5% increase in the number of people living without disability at three to six months; however, there was a 2% increased risk of death in the short term. Additionally, it is the position of the American Academy of Emergency Medicine that objective evidence regarding the efficacy, safety, and applicability of tPA for acute ischemic stroke is insufficient to warrant its classification as standard of care.Intra-arterial fibrinolysis, where a catheter is passed up an artery into the brain and the medication is injected at the site of thrombosis, has been found to improve outcomes in people with acute ischemic stroke. Physiotherapists can also work with patients to improve awareness and use of the hemiplegic side. Electrical stimulation to the antagonist muscles or vibrations has also been used with some success. Bacteria can also spread to the brain from infected adjacent air sinuses, the middle ear and the mastoids. Granulocytes and macrophages have powerful lysosomal enzymes and free radicals, which they use to kill bacteria, but have a short life span. These complications take time to develop and may appear after the inflammation has subsided.
The infarction causes the interruption of the blood flow to the brain, and, to a varying extent, the destruction of its tissues. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage.
Blood flow to these areas does not necessarily stop, but instead it may lessen to the point where brain damage can occur. Silent strokes typically cause lesions which are detected via the use of neuroimaging such as MRI. Anaerobic metabolism produces less adenosine triphosphate (ATP) but releases a by-product called lactic acid. As a result the transmembrane ion gradients run down, and glutamate transporters reverse their direction, releasing glutamate into the extracellular space. In those who have previously had a stroke, treatment with medications such as aspirin, clopidogrel and dipyridamole be beneficial. The available evidence does not show large differences in stroke prevention between antihypertensive drugs —therefore, other factors such as protection against other forms of cardiovascular disease should be considered and cost. Ticlopidine has more skin rash, diarrhea, neutropenia and thrombotic thrombocytopenic purpura. Surgery is most efficient when not delayed too long —the risk of recurrent stroke in a patient who has a 50% or greater stenosis is up to 20% after 5 years, but endarterectomy reduces this risk to around 5%.
The most widely used anticoagulant to prevent thromboembolic stroke in patients with nonvalvular atrial fibrillation is the oral agent warfarin while a number of newer agents including dabigatran are alternatives which do not require prothrombin time monitoring. Rehabilitation involves working on the ability to produce strong movements or the ability to perform tasks using normal patterns. Complete recovery is unusual but not impossible and most patients will improve to some extent: proper diet and exercise are known to help the brain to recover.
Unfortunately, after producing favorable results in one large-scale clinical trial, a second trial failed to show favorable results. They can reach the brain either directly through the bone, especially in areas where the bone plate is thin, or through veins (diploic veins, dural venous sinuses, intracerebral veins).
If they are large enough, they compress the brain and spinal cord, resulting in loss of function and increased intracranial pressure. In newborns, the most common organisms are beta hemolytic Streptococcus group B (Streptococcus agalactiae) and Eschericia coli. The toxic metabolic encephalopathy is probably caused by unknown diffusible substances (perhaps cytokines) that have a neurotoxic action.
Bacteria in the blood seed this necrotic nidus and spread around it causing brain necrosis and acute inflammation (cerebritis).
Since the infection is contained within brain tissue, the CSF usually shows only a few mononuclear cells with normal protein and glucose. It can also cause the formation of a cerebral edema or develop into intracerebral hemorrhage.
Lactic acid is an irritant which could potentially destroy cells since it is an acid and disrupts the normal acid-base balance in the brain. Glutamate acts on receptors in nerve cells (especially NMDA receptors), producing an influx of calcium which activates enzymes that digest the cells' proteins, lipids and nuclear material.
In addition, the pressure may lead to a loss of blood supply to affected tissue with resulting infarction, and the blood released by brain hemorrhage appears to have direct toxic effects on brain tissue and vasculature. The routine use of beta-blockers following a stroke or TIA has not been shown to result in benefits. Dipyridamole can be added to aspirin therapy to provide a small additional benefit, even though headache is a common side effect.
The number of procedures needed to cure one patient was 5 for early surgery (within two weeks after the initial stroke), but 125 if delayed longer than 12 weeks. The various protective layers may also help contain infections within certain spaces or planes. In babies, group B sreptococcal infection is frequently acquired during passage through the birth canal but meningitis may also develop a few days or weeks after birth. In infants, meningitis may present with nonspecific signs such as a depressed state, apneic spells, changes in heart rate, and atypical seizures. Alternatively, viral PCR of CSF, which has a turnaround time of a few hours, can confirm aseptic meningitis. The effects of HIE and cerebral infarction are especially devastating in newborn babies in whom the brain can literally melt away.
CSF cultures are positive in a minority of cases, however lumbar puncture should be avoided because of the risk of herniations.
The risk of silent stroke increases with age, but may also affect younger adults and children, especially those with acute anemia. Calcium influx can also lead to the failure of mitochondria, which can lead further toward energy depletion and may trigger cell death due to apoptosis. Preventive Services Task Force (USPSTF) recommends against screening for carotid artery stenosis in those without symptoms.
Low-dose aspirin is also effective for stroke prevention after sustaining a myocardial infarction.
There is no reliable way to determine who will have an intracranial hemorrhage post treatment versus who will not. One example physiotherapists employ to promote motor learning involves constraint-induced movement therapy.
This damage is followed by formation, in the subdural space, of a vascularized inflamed connective tissue and then a fibrous scar.
Nosocomial sources of meningitis include craniotomy, internal and external ventricular shunts, penetrating cranial fractures, closed head injuries with CSF-leaking basilar skull fractures, external lumbar catheters, and rarely lumbar puncture. The necrotic center cavitates while, at the periphery, a vascular zone of brain tissue with macrophages, mononuclear cells, and reactive astrocytes contains the infection. Through continuous practice the patient relearns to use and adapt the hemiplegic limb during functional activities to create lasting permanent changes. Histologically, acute subdural empyema shows a layer of neutrophils overlying the arachnoid membrane. So, brain damage in bacterial meningitis is caused in part by the direct action of bacteria and in part by the antibacterial inflammatory response.
In 4-5 weeks, collagen (derived from vascular cells) is laid down in this reactive zone forming a thick capsule that walls off the infection. OT is involved in training to help relearn everyday activities known as the Activities of daily living (ADLs) such as eating, drinking, dressing, bathing, cooking, reading and writing, and toileting. The inflammatory cells may infiltrate the arachnoid membrane and extend into the subarachnoid space. The brain has elaborate mechanisms for controlling inflammation but, in some cases, unbalanced defense reactions can cause severe injury.
Thus, the treatment of chronic abscess requires drainage or surgical excision in addition to systemic antibiotics.
The most dangerous complication of bacterial meningitis is increased intracranial pressure from cerebral edema.
Cerebral edema may be vasogenic, from increased vascular permeability, cytotoxic from cerebral hypoxia, interstitial, from increased CSF volume, or a combination of all.



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