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Stroke - Questions & Answers
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This information leaflet is presented by kind permission of the C.H.S.A.
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What is stroke?

A stroke is an illness in which part of the brain is suddenly severely damaged or destroyed. The result is loss of function of the affected part of the brain. It usually causes weakness, paralysis of the arm and leg on either the left or right side of the body, twisting of the face, and in some cases other effects which may include loss of balance, and difficulty in swallowing. In very severe cases, there is a loss of consciousness or confusion of thought. The damage in the brain is caused by a blood clot or haemorrhage. If the clot is very big or if it affects a vital part of the brain, the patient may die. In less severe cases partial or complete recovery occurs.

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What is a Transient Ischaemic Attack?

A transient ischaemic attack or TIA is very like a stroke except that it passes quickly: the symptoms of weakness of one side of the body, tingling and twisting of the mouth or loss of speech or disturbance of vision last only for a few minutes and then disappear. TIAs occur because, for a short time, not enough blood reaches part of the brain. They can be treated and anyone who experiences a TIA should see his doctor immediately.

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What causes a stroke?

Most strokes occur in the second half of life and are caused by damage to the blood vessels - and sometimes to the heart - which has been building up slowly for many years. The actual stroke takes place either when a blood clot forms in a damaged vessel and blocks the flow of blood to part of the brain, or when a damaged blood vessel in the brain bursts and blood pours from the brain itself.

In at least half of all strokes the reason why the blood vessels become damaged in the first place is because they have been exposed to high blood pressure. If in addition the patient smokes, drinks heavily, is overweight, takes too much salt in his diet, or has heart disease or diabetes the risk of stroke is increased. A number of other factors are suspected, but there is no single cause of stroke.

Unfortunately anyone can suffer a stroke at any time, although the risks can be substantially reduced by a healthy life style, including the avoidance of smoking, and especially by having blood pressure checked and if it is too high, ensuring that it is kept under control by treatment.

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Is stroke due to overwork or stress?

No. Almost everyone who has ever had a stroke could be said to have been under stress or to have been overworking at some time before the onset of the stroke. So could almost anyone who has not had a stroke. It is natural to think of stroke and stress as being related -they even sound alike- but this is not so, and indeed many strokes occur during sleep. However, there is a relationship between stress and high blood pressure. It is almost impossible to take the stress out of life, but it is possible to reduce high blood pressure.

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Is the brain affected by stroke?

Yes. A stroke is to the brain what a coronary thrombosis is to the heart, and the brain is always damaged in a stroke, just as the heart is always damaged in a coronary. All the symptoms of a stroke are due to brain damage. But this does necessarily mean that patients with a stroke lose their 'brains' in the ordinary sense of the word. If the brain damage is very extensive or affects special areas there may be impairment of memory, concentration and learning ability or some confusion of thought. Control of the bladder and bowels may be lost. Patients may be slower to grasp new ideas and relatives have to learn to make allowances for these changes. Some patients are vague or unrealistic, or have impaired judgement in their assessment of their own capabilities or in their relationships with other people. But in most cases, even when paralysis is severe, there is no discernible effect on the intellect and memory, and the patient's 'brain power' is as good as ever.

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Is the heart affected by stroke?

No. The stroke itself has no effect on the heart, but patients who suffer a stroke may have had heart disease already, which they may or may not have known about before the stroke.

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Will recovery occur and how long will it take?

Partial recovery is very usual, but total recovery less so. After a stroke four things may happen:

  1. The brain cells which were badly damaged at the onset die and never recover.
  2. Other cells which were only partially damaged, due to swelling of the brain, recover and start working again. This process takes place during the first few weeks after the onset of the stroke.
  3. Parts of the brain which are unaffected by the stroke begin to take over the functions of the dead parts. This can occur only to a limited extent, but may continue for a long time.
  4. The patient adapts to the loss of function and learns new ways of living with the damaged brain.

Patients with strokes should never abandon hope of continuing, if limited, recovery. They should not, however, be unrealistic in their expectations and go on 'hoping against hope', because most of their recovery occurs relatively early. However, there are always exceptions.

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What are the risks of a second stroke?

Life is a risky business, and if we think about risks the whole time we will never cross the road or go up in an aeroplane. While there is no good reason for assuming that one stroke will automatically be followed by others, the conditions which have caused the first - namely, weakness of an artery wall or blood-clotting - can sometimes not be reversed, and the risk persists, but it can be lessened if the patient does not smoke, is not overweight, does not take too much salt in his diet and, most important of all, has his blood pressure checked regularly and if it is too high, keeps it under control by treatment.

It is best to train oneself to put the fear of a further stroke into the same category as the fear of a crash when buying an air ticket - it could happen but it probably will not, so why allow the slight risk to deprive life of its enjoyment?

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Do all stroke patients need to go to hospital?

People who have had a severe stroke should go to hospital, also those in whom the diagnosis is in doubt, so that tests can be done to make sure that they are not suffering from another disease which requires a different type of treatment. Patients with no one to care for them at home must also go to hospital. If the stroke is not too severe and there are relatives who are able to care for them, patients are often treated in their homes. There are obvious advantages in remaining within the family, but stroke patients need careful and skilled nursing and therapy from an early stage of their stroke if maximum recovery is to be achieved. In some areas this can be provided by domiciliary services, but some patients may be at a disadvantage if they are treated at home by the family without specialist care and advice.

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How is movement affected?

At the onset of the stroke the muscles of the face, trunk, arm and leg on either the left or right side of the body are weak and lax. In most cases the power gradually returns, first to the leg and then to the arm. However, unless the limbs are placed in the correct position and are frequently put through a range of movements, there is a danger that they may stiffen, so that, even if the power returns, the limbs could be practically useless. This is why so much importance is attached to maintaining the limbs in the correct position and allowing recovery to take place in the best way. The simple rule is to let the leg bend but to keep the arm straight. It is also vital to treat the body as a whole, not just the paralysed limbs in isolation.

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How is speech affected?

Speech is affected in two ways. In some patients it is slurred and indistinct or even completely absent, but the patient can read, write and understand perfectly what is said. This condition is called dysarthia, and it usually yields to treatment.

The other condition is much more complex. It is called dysphasia or aphasia and is due to damage to the part of the brain which controls all language processes. This can affect the patient's ability to speak, understand speech, read and write.

The condition occurs in nearly one half of patients who have paralysis of the right side of the body, but hardly ever occurs in those whose paralysis is on the left side. Some cases are mild, and the patient may only occasionally have difficulty in finding a familiar word. In others, language is painfully slow and halting and patients often give up their attempt to communicate with others. In the worst cases the patient can say nothing at all, or only the same word or phrase over and over again. Sometimes this is a swear word which the patient was not in the habit of using before the stroke, and this may cause great distress to him and his family. In other cases, speech is full of nonsense words and it is impossible to understand the patients meaning. Recovery from dysphasia can be rapid and complete, but is, in most cases, slow and incomplete, and patients and their relatives need a great deal of help from speech and language therapists and others.

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How is vision affected?

In most cases vision is not affected at all, and even in those patients who complain of visual difficulty the fault is not in the eyesight itself, but in the interpretation by the brain of what the eye sees. In normal people, the two sides of the brain each form a separate picture of half of what lies before it, and the two pictures are joined together, as it were, to give a total view. When part of the brain forming one of those half pictures is damaged by a stroke the patient sees only one half of the world depending on which half of the brain is affected. This can be perplexing for the patient and relatives, and is very disabling, but recovery, although slow, usually occurs.

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What is the medical treatment for a stroke?

Doctors watch carefully over the patient in the early stages to ensure accurate and complete diagnosis, management of fluids and nourishment, control of blood pressure and prevention of complications. A number of drugs have been tried in the hope of reducing the brain damage to the minimum, but it is not yet agreed that there is any medical way of doing this.

Once the first few days have passed the main role of the doctor is to work with the other members of the rehabilitation team -nurse, physiotherapist, occupational therapist, speech and language therapist and social worker- to encourage maximum restoration of function and self-confidence. Research is at present concentrated on drugs that prevent blood clotting in blood vessels of the body, or help to dissolve blood clots, and thereby prevent strokes or limit their damage.

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What is the rehabilitation treatment?

There are many ways of treating stroke patients, but the common ingredients of success are the confidence of the patient, the skill of the therapists and the co-operative working of the rehabilitation team.

The most favoured method of treatment is based on treating the whole body, indeed the whole patient, and not just the affected arm or leg. A lot of time is spent at the outset in obtaining a correct position of the body and of the limbs while the patient is in bed or in a chair. Each time the patient is moved, whether this is to turn him in bed or to transfer him out of bed on to a chair or a commode, or any other movement, it has to be done according to a carefully worked out pattern, and the limbs must always be placed in the correct position. Walking practice is delayed until the patient has acquired good posture and balance.

This method takes more time and effort than the older methods which depended on getting the patient walking as soon as possible, but the final results appear to be better. Relatives must expect a severely affected patient to take anything from one to six months to regain skill, confidence and security in walking after a severe stroke.

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Should the patient be helped to do everyday tasks or left to get on with it?

The aim of treatment is to restore the patient to independence within the limits of his disability. Most disabled patients set a high store on being independent, and want to be left to 'get on with it'. Others, especially the older ones, find such everyday tasks as learning to dress themselves daunting and a number give up the attempt, or they may take so long about them that someone feels an irresistible urge to help. Once the patient is given help he will expect it again, and he will soon find it easier to give in and become dependent than to struggle on. Once he has become accustomed to dependence, efforts towards self-help cease, and he becomes demanding and difficult.

Patients should, therefore, in general be left to 'get on with' self care tasks; but it is the responsibility of the people around them to see that these tasks are within their capability. A patient with only very limited dressing skills should not be left half naked to put on all his clothes. It is better to assist him to do those tasks he cannot tackle unaided and leave him the final task which is within his capability. Once he has mastered this skill he should be given a little more to do within his increased capability and again left 'to get on with it', so that gradually he becomes as fully independent as his disabilities permit.

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Why does stroke illness tend to make some patients aggressive?

There is usually an initial spurt of optimism when a stroke patient returns home from hospital, but, unless recovery is complete or almost complete, there comes a realisation that the patient will not be able to regain the position in life which he held before the stroke. During this difficult period, emotions may be experienced by patients and relatives which they dare not express, because they recognise their unfairness, yet they cannot control them.

The patients thoughts may be concentrated on what they cannot yet do, and he may resent the cheerful comments from well intentioned friends about how well he looks, and how independent he is. These problems are common to all disabled people, but they are particularly difficult to endure when the illness, as in a stroke, comes suddenly and devastatingly and at a mature stage in life. Relatives may reflect on how their lives have been changed for the worse by the patient's stroke, and may feel guilty at allowing such a selfish thought to replace, even temporarily, the compassion which they know they ought to feel all day every day.

It is possibly not the existence of these feelings but their suppression that is responsible for much of the frustration, anguish and aggression which creeps into the world of some stroke patients and their relatives as time goes by. Everything is to be gained by expressing these views to others. The hospital medical social worker knows of these feelings and can be a sympathetic listener and guide. Stroke clubs and relative groups offer to families the opportunity of mixing with others who face problems similar to their own and this can be of inestimable help.

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What about sexual relations?

Couples who have enjoyed sexual relationships before the stroke are often fearful of resuming them in case a further stroke should result. The fear is groundless and relationships can be safely resumed.

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What can relatives do to help?

While the patient is in hospital relatives should keep in close contact with the staff. Most hospitals welcome the participation of relatives in therapy sessions and, before discharging a patient, may arrange for them to return to their home on short visits to test their ability to care for themselves in their family environment. No matter how good the education of relatives has been in hospital unexpected problems may arise when the patient comes home and further guidance will then be needed.

Living with a recovering stroke patient is a great test of personal qualities, and constant patience and understanding are required. Patients are bound to experience moments of depression and despair and at such times the tactful encouragement and patience of the relatives are most required. Encouragement must always stop well short of pressure. Relatives have to recognise that patients sometimes need a holiday from their stroke and ceaseless enthusiastic encouragement can be fatiguing.

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Where can patients' families get more information about stroke illness?

Medical and nursing guidance are available from the General Practitioner and Public Health Nurse. The hospital in which the patient was treated is often able to give such help. The hospital or area social worker can put relatives in touch with many voluntary bodies that will fulfil specific needs

Stroke Clubs are an excellent source of help. Unfortunately not every county in Ireland has one. Check out the Contact Details to find your nearest Stroke Club.