Symptoms and causes

If the functionality of part of the brain is inhibited by a change in the blood flow, this is termed a stroke or cerebro- (brain) vascular (blood flow) accident, a CVA.

For each of these conditions, it is vital that the correct tests and therapy are started as soon as possible. This is only possible in a hospital. The initial symptoms may vary widely; there are some warning signs to look out for:

  1. Sudden drooping of the mouth
  2. Sudden loss of sensation, strength or coordination on one side
  3. Sudden loss of speech/language (understanding or expression)
  4. Sudden tendency to fall to one side, serious dizziness
  5. Hyperacute (within one minute), extremely severe headache
  6. Sudden loss of vision on one side

A stroke may have multiple causes:

  1. Brain infarction or brain thrombosis
  2. Brain haemorrhage
  3. Subarachnoid haemorrhage
  4. Venous sinus thrombosis

1. Brain infarction or brain thrombosis

This is the most common cause of stroke. The brain is supplied with oxygen-rich blood through the arteries. If a brain infarction occurs, the blood can no longer reach part of the brain due to a blocked artery. If an area in the brain is deprived of any or sufficient oxygen and glucose, this area will die and stop functioning. An artery may be blocked through gradual, local blocking (hardening of the arteries or atherosclerosis) or because a small clot is transported in the blood and gets stuck in an artery that is too narrow in diameter (embolism). Other, rarer causes of blocked arteries are e.g. spasms of the vessel wall or an internal tear of the arterial wall (dissection).

Brain infarction is diagnosed with the aid of a CT scan or NMR scan. If we suspect or determine a brain infarction in A&E, we may try in some cases to remove the blockage by administering strong blood thinners (thrombolysis) or by removing the clot through the groin (thrombectomy). This will enhance the chance of recovery. Treatment of potential underlying risk factors for cardiovascular disease, heart rhythm abnormalities or structural heart abnormalities helps limit the risk of recurrence and is therefore very important. To this end, we collaborate closely with the Cardiology Department. To try and avoid subsequent thrombosis, patients are started on blood thinners.

2. Brain haemorrhage

Brain haemorrhage is caused by a tear or leak of the wall of an artery in the brain. On the one hand, this causes insufficient blood flow to some brain areas, and on the other hand, the suddenly released blood leads to increased pressure in the brain. Both factors may contribute to brain damage. The diagnosis is confirmed with the aid of a CT scan or NMR scan. Controlling the pressure in the brain sometimes requires surgical intervention by the neurosurgeon. During the initial phase, controlling blood pressure is extremely important to try and avoid increased bleeding. Underlying vascular abnormalities must be detected since they may require treatment. Sometimes, we also need to treat coagulation issues (e.g. by using blood thinners).

3. Subarachnoid haemorrhage (subarachnoid bleeding)

In this type of stroke, bleeding occurs in between the membranes enveloping the brain (meninges). This is usually accompanied by an extremely severe and sudden headache (thunderclap headache). As with brain haemorrhage, the pressure in the brain may increase to dangerous levels. Neurosurgery is sometimes required. Additionally, arterial spasms may occur and lead to additional brain damage, including in the days following the the start of the brain haemorrhage. The diagnosis is confirmed with the aid of a CT scan in A&E, sometimes complemented with a lumbar puncture to analyse cerebral fluid. Sometimes, an underlying arterial abnormality (e.g. aneurysm) is responsible for the haemorrhage and must be treated through the groin or through brain surgery.

4. Venous sinus thrombosis

In contrast to the previous conditions, this quite rare form of stroke involves blocked blood vessels (draining vessels) in the brain, and not blocked arteries. Very sudden headache may be a symptom as well. The reduced drainage of blood from the brain may increase the pressure in the brain areas involved, potentially leading to blood flow issues, oxygen deprivation and eventually, infarction. The causes, required tests and treatment of venous sinus thrombosis largely differ from those for classic brain thrombosis.

Diagnosis and treatment

Process in the hospital

Almost everybody who is admitted with a (suspected) stroke, enters the hospital via A&E. If stroke is suspected after history taking and clinical examination of the patient, a brain scan will be performed as soon as possible. Then, the neurologist, in consultation with the radiologist, will discuss the diagnosis and treatment options with the patient or his/her representative if they can be reached quickly enough. This is because the speed with which treatment is initiated is crucial to the chance of recovery. In case of brain haemorrhage or subarachnoid haemorrhage, the neurosurgeon is also involved in the discussion to assess whether surgical intervention is required. After that, the patient is admitted to a specialised ward for continuing supervision and monitoring. This may be in the Stroke Unit or (most often) in the Intensive Care Department. The Stroke Unit is a ward that is permanently staffed with specially trained nurses, has a multidisciplinary treatment team (see below) and offers the possibility of continued monitoring of the functionality of the brain, heart and lungs. It works together closely with the departments of Radiology and Cardiology. Patients can often leave this specialised department after 48 hours. Sometimes, patients are sufficiently recovered to be able to go home, and sometimes admission to the Neurology ward of Rehabilitation Department is necessary.

Aftercare and follow-up

Unfortunately, patients are not always fully recovered when they are discharged after having experienced a stroke. Therefore, the follow-up may be very diverse, and the treatment plan is tailored to the individual in consultation with the patient and their loved ones. The complete multidisciplinary treating team is involved, consisting of a neurologist, neurological nurse, rehabilitation physician, social worker, physical therapist, speech therapist, dietitian, psychologist, and Pastoral Care Service staff. An estimation is made of what the recovery options are in the medium term, as well as the possible intensity of rehabilitation, capabilities and abilities of caregivers at home. The GP may be involved in this too to help shape the home arrangements and estimate the possibilities at home.

Sometimes, further examinations may be required after discharge, especially imaging follow-ups of the brain and additional examinations of the heart. Appointments for these examinations, as well as a check-up with the neurologist will be arranged on discharge.

If a patient has very serious remaining disabilities and needs to be transferred to another care facility (care home, admission to other rehabilitation centre), often no follow-up appointments are arranged because that is not always necessary or desirable. However, patients may always arrange such appointments themselves or do so in consultation with the GP.

The GP has a very important role in the follow-up of the initiated medication, the risk factors for a new stroke and the monitoring of the physical and mental consequences of the stroke. Naturally, the neurologist remains available for consultation and reassessment.

More information

Treatment centres and specialisations

Neurology

Latest publication date: 05/08/2021
Supervising author: Dr Aers Isabelle