Brain Attack
A stroke is sometimes called a brain attack because, just like a heart attack, it happens when blood flow is interrupted. But how much do we know about the warning signs, and what can we do to reduce our risk?
Here, GP Dr Nick Dunn draws on his family’s experience of stroke and his time working on a stroke rehabilitation ward to explain why recognising the signs and getting medical help quickly can make such a difference.
It feels strange to say that I was a little afraid and apprehensive of my grandmother. But the truth is that my youngest memories of her were of a woman who needed help to get from her armchair to the toilet, who could not speak properly and struggled to be understood, and seemed to burst into tears without warning. Looking back, I would have been about 3 or 4 years old, and she would have been about the age I am now. Understanding the nature of stroke disease, I now have some comprehension of what she was likely going through, understanding what was going on around her but unable to express herself adequately or control her emotional outbursts. Which seems incredibly painful – being with her grandson but with an invisible barrier between us.
My mother was only 18 years old when her mother, my grandmother, had her first stroke. Following this she continued to have a series of increasingly disabling strokes. Presumably affecting the left side of her brain where the speech control centre called Broca’s area is situated resulting in inability to talk properly (expressive dysphasia), weakness down her right arm and leg and what we call emotional lability – expression of emotional behaviours such as crying which are poorly controlled and easily triggered. My grandmother died around ten years later having become increasingly disabled, unable to do very much for herself.
A few years after her death, at the age of 16, I started full-time work as an Auxiliary Nurse at my local hospital in Alexandria in the West of Scotland, where I spent a year before starting Medical School at Glasgow University. The first six months of that job I spent working in a dedicated stroke rehabilitation ward, which in 1988 was one of the first of its kind in the country. The ward was pretty much run by Physiotherapists with medical oversight from a Consultant in Old Age Medicine. Patients had daily one-to-one physiotherapy, with regular input from speech therapists and occupational therapists. Although at the time much of it was beyond me, I was aware that a lot of thought had gone into how things were organised to optimise their recovery from stroke. An example of this was that the bedside lockers were place on the patient’s affected side to force them to try to use their weakened arm and hand and, to reduce the risk of complete inattention to the affected side. This is a phenomenon in stroke where people sometimes completely ignore the affected side of their body.
As a young man suddenly placed amongst a large group of older disabled adults this was an initial culture shock, but I soon got to know each patient as an individual with their own story. Being part of the team who made their beds, helped them to the toilet, washed them and sometimes fed them it would have been hard not to. There were some real characters, and I still remember Alex, who in his day had been a champion figure skater, and Agnes, who had worked as private investigator for the stars. Helen at that time was 92 and told me how, at the age of 12 she had to leave home and “go into service” – living with the Blackie family who commissioned the building of the Hill House by Charles Rennie Mackintosh. I remember her telling me she was so small she had to stand on a box to wash the dishes.
I think these stories are important in Stroke Awareness Week as it illustrates not only the devastating damage which strokes can do, but more importantly the people behind the stroke victim. Strokes are just like heart attacks but affect the brain. Increasingly experts are encouraging doctors and the public to use the term “brain attack” to increase the sense of urgency if someone is suspected of having a stroke.
In simple terms, a stroke is when part of the brain has its blood supply interrupted, resulting in areas of cell death, permanent damage and scarring. These areas can be microscopic and unable to be seen on a scan, or they can be large. Under normal circumstances the brain consumes around about 25% of the body’s total metabolic needs and is composed of very delicate tissue. Which is why it is so vulnerable to damage. Blood supply can be affected either by blockage of blood vessels (ischaemia) or bleeding within the brain tissue (haemmorhage). Ischaemic strokes are by far the most common and usually result from narrowing and hardening of blood vessels which is accelerated by smoking, high blood pressure, high cholesterol and diabetes. A rather shocking fact is that although smoking is known to be very harmful, high blood pressure (hypertension) is the single biggest risk factor for stroke and heart disease.
The effect of stroke will vary depending on the severity of the damage and which areas of the brain have been affected. Classic stroke symptoms cause weakness or loss of power of the arm and leg on one side of the body. They can also cause visual loss, hearing loss, dizziness, speech problems or even difficulty processing and understanding language (receptive dysphasia). It is important to remember two important things about a stroke victim – they were usually a fully functioning person immediately before their stroke, and they are likely to have a much better understanding than they may appear.
As the commonest cause of disability in the UK, Stroke Awareness Week is designed to highlight the problem and encourage people to seek early help if they or others are displaying signs of a stroke.
Immediate hospital treatment is necessary to identify the cause with a medical examination and brain scan. Early treatment with clot-busting drugs (thrombolysis) can sometimes reverse early symptoms and provide almost complete recovery, and in specialist centres in the UK angioplasty is a technique where tiny tubes are passed into the brain circulation to open up blood vessels or remove clot to allow blood flow to return to the brain tissue.
Immediately after or during a stroke, careful control of blood pressure and hydration is essential and early assessment by physiotherapists and speech therapists to assess swallowing is required. Before going home patients will be started on “secondary prevention” medications to reduce the risk of a further and possibly more serious stroke, as happened to my grandmother. Drugs core to this include minor blood thinners such as Aspirin and Clopidogrel, statins such as Atorvastatin, and blood pressure lowering drugs such as Perindopril and Indapamide. It is important to remember that recovery of the brain following stroke lasts up to around 18 months and long-term stroke rehabilitation can be hard work but be very worthwhile.
I hope that over the next few years we will see numbers of strokes fall, as people live healthier lifestyles and treatments improve. In the meantime, though, remember to see your GP for regular blood pressure checks and bloods to check cholesterol and sugar levels, as prevention is always best. And don’t forget FAST – if in doubt call an ambulance rather than miss a brain attack.
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