Stroke

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

For each of these conditions, it is extremely important 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:

A stroke can have multiple causes:

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

1. Brain infarction or brain thrombosis

This is the most common cause of a 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 because of 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. The 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 of leak of the wall of an artery in the brain. On the one hand, this is the cause of 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. In the initial phase, controlling blood pressure is of great importance to try and avoid an increase in bleeding. Underlying vascular abnormalities must be detected since they sometimes require treatment. Sometimes, we also need to treat coagulation issues (e.g. using blood thinners).

3. Subarachnoid hemorrhage (subarachnoid bleeding)

In this type of stroke, bleeding occurs in between the membranes enveloping the brain (meninges). This is usually accompanied by extremely severe and extremely 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, also in the days following the start of the brain hemorrhage. 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 is a rather exceptional type of stroke where there is a blockage in the arteries (draining blood vessels) of the brain and not in the arteries. Very sudden headache may be a symptom too. Due to the decrease in blood drained from the brain, the pressure in the brain areas involved may increase, leading potentially to blood flow issues, oxygen deprivation and eventually, infarction. The causes, required tests and treatment of venous sinus thrombosis mostly differ from those for classic brain thrombosis.

Process in the hospital

Almost everybody who is admitted with (suspected) stroke, does so 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 or 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. With a brain or meninges bleed, a neurosurgeon is consulted to see if it should be treated surgically. Afterwards, the patient is admitted to a specialised ward for continuous observation 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, that has a multidisciplinary treatment team (see below) and that offers the possibility of continued monitoring of the functionality of brain, heart and lungs. It works closely together 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. The follow-up may therefore be very diverse, and the treatment plan is therefore tailored to the individual, in consultation with the patient and their loved ones. The complete multidisciplinary treating team consists of a neurologist, neurological nurse, rehabilitation physician, social worker, physiotherapist, speech therapist, dietician, psychologist, and pastoral colleague. An estimation is made of what the recuperation options are in the mid-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 help 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, 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 always available for consultation and reassessment.

More information

• Brain Damage League
• Belgian Stroke Council

Latest publication date: 09/02/2024
Supervising author: Dr Aers Isabelle