Introduction.2. What Is a Stroke?.5. Types of Stroke.8. Ischemic Strokes.8. Hemorrhagic Strokes..9. Stroke Signs & Symptoms.11. Stroke Treatment...

Transcription

1 Patient Education

2 Introduction.2 What Is a Stroke?.5 Types of Stroke.8 Ischemic Strokes.8 Hemorrhagic Strokes..9 Stroke Signs & Symptoms.11 Stroke Treatment Stroke Risk Factors Vaccinations. 21 Notes...22 Stroke Care at University of Mississippi Medical Center

3 Stroke victims and those close to them should know the signs of stroke, its causes, risk factors, treatments to help prevent future strokes, what to do when a stroke occurs, and how to follow up with health care providers. This guide offers basic stroke information and education. If you have additional questions, please check with a member of your Stroke Care team. Your Stroke Care Team Your UMMC Stroke Care team is dedicated to your healing and prevention of future stroke. As a patient, you will have several tests that will help your health care team better understand the type, location and cause of your stroke. The results of these tests will help guide your care while in the hospital and in therapy and decrease risks of future strokes. If you do not fully understand something, always ask questions of your doctors, nurses or other health care provider. Your team may include: Doctors who specialize in: Emergency Medicine, Neurology, Neurosurgery, Neuro-Intensive Care, Radiology (x-ray), General Medicine, Other specialties Nurses who work in the many specialty and patient care areas Technicians who assist the doctors and nurses Technologists who specialize in certain procedures Dieticians to help with your nutrition needs Physical therapists to help with your walking, leg movement, and balance Occupational therapists to help with arms, hands, and self-care needs Speech pathologists to work with swallowing and language needs Case managers, social workers, and rehabilitation specialists to help you plan your discharge and continued recovery Pharmacists to help you and your team with medicines A host of personnel from other departments Because University of Mississippi Medical Center helps to prepare future health care providers, students may also work with your team. Stroke Care at University of Mississippi Medical Center 2

4 Medications In addition to this guide, you will receive other materials before you leave the hospital. A nurse or pharmacist will give you a list of all medicines that your doctor has prescribed, tell you what they are for, and how to take them. Feel free to ask any questions that you have about why some medicines have been changed or stopped and others have been started during your stay. Rehabilitation The effects of stroke usually improve some over time, depending upon the nature, size and location of the stroke. After a stroke, rehabilitation therapy helps people reach higher levels of function and helps them adjust to the changes that have taken place. Your doctor(s), case manager(s), social worker(s), and rehabilitation specialist(s) will discuss this with you and help make arrangements when therapy (rehabilitation) is needed after you leave the hospital. Follow-up Appointments You will have follow-up appointments with your doctor(s). You likely will need to see your family doctor and may need to see the neurologist or neurosurgeon who took care of you at UMMC. Keeping appointments is very important. Your doctors are interested in how you are recovering from your stroke. They also want to make sure that you are doing what is needed to help prevent complications and future strokes. Sometimes all of the results from special tests are not back by the time of hospital discharge and will need follow-up attention. If you are not able to keep appointments, please call to change to an appointment time that works for you. Stroke Care at University of Mississippi Medical Center 3

5 Questions? If you need to talk with a doctor after you are discharged, you may contact your family doctor, or you may use the number on the appointment card to contact the doctor with whom you will have follow up care at UMMC. You can also call and ask to be connected to your doctor s office. Resources For more information, visit any of the following websites for reliable stroke information. If you do not have Internet access at home, check your local library as most have several computers with Internet available for public use. American Heart Association American Stroke Association National Institute of Health Mayo Clinic Stroke Health Center National Stroke Association Centers for Disease Control and Prevention Stroke Care at University of Mississippi Medical Center 4

6 If you are having any symptoms of heart attack, stroke, breathing problems, or other emergency, call 911 or the number to activate your local emergency services. Don t waste time calling your doctor or going to his/her office. Signs of Stroke 1. SUDDEN weakness or numbness on one side of the body 2. SUDDEN difficulty with vision in one or both eyes 3. SUDDEN difficulty speaking or understanding speech 4. SUDDEN unusually severe headache 5. SUDDEN dizziness or unsteadiness Signs of Heart Attack 1. Chest discomfort can feel like pressure, squeezing, fullness or pain 2. Discomfort in areas of the upper body arms, back, neck, jaw or stomach 3. Shortness of breath with or without chest discomfort 4. Other signs include breaking out in a cold sweat, nausea or lightheadedness A stroke is a brain attack. Stroke is the third leading cause of death in the United States and the number one cause of disability in American adults. Almost 800,000 people in America have a stroke each year. Most strokes could be prevented if Americans ate a healthier diet, exercised more, didn t smoke cigarettes, didn t overindulge in alcohol, didn t use street-drugs, and took care of chronic diseases, such as obesity, high blood pressure, diabetes, high blood fats, and heart disease. Stroke Care at University of Mississippi Medical Center 5

7 These drawings may be used to show problems with arteries and effects of stroke. Arteries that take blood to the brain Frontal View (looking into the face) LifeART Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Occipital Lobe Parietal Lobe Frontal Lobe Arteries that take blood to the brain Inferior View (looking from the bottom of the brain) Temporal Lobe LifeART Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Cerebellum LifeART Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Lateral view of brain showing lobes (looking from the side) LifeART Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Mid sagital view of brain (looking as though sliced down the middle from back to front) Stroke Care at University of Mississippi Medical Center 6

8 Strokes cause damage to specific areas of the brain due to problems with blood vessels and blood flow. The symptoms of stroke are seen in body functions that are controlled by the damaged areas of the brain. Most strokes are caused by low blood flow (ischemia) to a part of the brain, but some strokes occur because of a break in the wall of a blood vessel. These are called bleeding (hemorrhagic) strokes. About 85% of strokes are low blood flow (ischemic) and 15% are bleeding (hemorrhagic). Your healthcare team may use these images to show the location of your stroke. Coronal view of the brain at the level of the brain stem Coronal views are made by slicing side-toside and show slices from front to back. These views are often used in CT and MRI Scans. LifeART Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Coronal view of the brain in front of the thalamus Coronal view of the brain at the level of the pons and thalamus LifeArt Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD LifeART Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Stroke Care at University of Mississippi Medical Center 7

9 Ischemic Stroke Ischemic strokes happen when there is not enough blood supply to an area of the brain to support the life of the brain tissue. This type of stroke is usually the result of a complete blockage of an artery. In some cases a drop in blood pressure and/or narrowing of arteries may reduce the blood supply to brain tissue to the point of causing permanent injury. Common causes of low blood flow (ischemic) stroke: Large vessel disease (atherosclerosis) Small vessel disease (thickening walls of very small, deep vessels) Other blood vessel problems (Non-atherosclerotic vasculopathy) Cardioembolism (clot from heart) Watershed (low blood flow affecting areas between major blood vessels) Blood clotting problems (hypercoaguable states) Unknown (cryptogenic) An ischemic stroke occurs when a blood clot blocks an artery, disrupting the flow of blood to the brain. LifeArt Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Transient Ischemic Attack (TIA) If an artery to the brain is blocked for a short time, the patient will have symptoms of a stroke for a few minutes but may not have. lasting symptoms or damage to the brain. For example, if someone s speech becomes slurred, but a few minutes later speech has completely returned to normal, this person may have had a transient ischemic attack (temporary low blood flow attack), or TIA. A TIA is an important warning that a person may Stroke Care at University of Mississippi Medical Center 8

10 soon develop an ischemic stroke. Since the causes of TIAs are the same as causes of ischemic stroke, this is the time to see a doctor and get treatment to prevent a completed stroke that may lead to permanent problems. Hemorrhagic (Bleeding) Stroke A hemorrhagic or bleeding stroke occurs when an artery within the skull ruptures. Brain damage due to a bleeding stroke mainly happens because the brain is surrounded by the skull and there is very little room for the blood to build up or for the brain to swell when it is injured. Sudden bleeding within the skull causes pressure on the brain and may cause lasting damage. There are two main types of bleeding strokes: 1. Intracerebral Hemorrhage - bleeding into the brain tissue and 2. Subarachnoid Hemorrhage - bleeding around the brain. Intracerebral Hemorrhage (ICH) When an intracerebral hemorrhage (bleeding within the brain tissue) occurs, a small artery deep in the brain ruptures and causes direct pressure on a specific part of the brain. The most common cause is damage to the small arteries in the brain due to long-standing high blood pressure (hypertension). Many years of constant pounding by high blood pressure causes the walls of small brain arteries to become weak and, in some cases, to burst. The best way to prevent an intracerebral hemorrhage is to have your blood pressure checked and, if it s high, take the treatment that your doctor advises. LifeArt Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD An intracerebral hemorrhage occurs when a blood vessel bursts, damaging surrounding brain tissue. Stroke Care at University of Mississippi Medical Center 9

11 Subarachnoid Hemorrhage (SAH) In subarachnoid hemorrhage (bleeding around the brain) a large artery at the base of the brain ruptures. This usually results in a sudden, severe headache, neck stiffness, nausea and vomiting, and sleepiness. Most subarachnoid hemorrhages are due to the 8 rupture of an aneurysm. An aneurysm is an area of the artery wall that becomes weak and balloons out. This ballooning leads to thinning of the artery wall, and makes it more likely to burst. Doctors are not sure why some people have aneurysms (a weak place in a vessel wall that lets it balloon out). Some people have them all their lives and they never burst, but, if an aneurysm does burst, the results are usually very serious. Subarachnoid space Subarachnoid space Subarachnoid space LifeART Collection Images Copyright by Lippincott Williams & Wilkins, Arteries at base of brain Mid-sagital view of brain showing flow of spinal fluid in subarachnoid space and other areas These images may be used to show problems in arteries related to SAH. Stroke Care at University of Mississippi Medical Center 10

12 The symptoms of a stroke differ depending on where in the brain the stroke happens. Because a stroke is usually due to a sudden blockage or sudden rupture of an artery, the symptoms of a stroke usually happen very suddenly. Stroke may cause all or some of the usual symptoms. REMEMBER: Signs of Stroke Appear Suddenly 1. Weakness or numbness on one side of the body 2. Difficulty with vision in one or both eyes 3. Difficulty speaking or understanding speech 4. Unusually severe headache 5. Dizziness or unsteadiness Stroke Strikes Fast. You should too. Call 911 at the first sign of stroke. Stroke Care at University of Mississippi Medical Center 11

13 TIME IS BRAIN! For people who get medical help early, many strokes can be treated with medicine or other treatments to reduce damage. A blood-clot breaker medication has been used for many years to treat heart attack. It is now used for certain ischemic stroke patients. For this medicine to have the best chance to do the most good, it must be given within three hours of the first symptoms of stroke. In addition to offering a clot busting medication, University Hospital uses a clot retrieval technology that can be used up to eight hours after the onset of a stroke. TIME IS CRUCIAL. The sooner you act, the greater your chance of preventing permanent damage. Call 911 at the first sign of stroke symptoms. TAKE ACTION CALL 911 DO NOT ignore symptoms; Time lost is brain lost. While all care is not available at each hospital emergency room, every hospital should have a plan for giving basic care for a stroke and for getting patients to a qualified hospital when higher care is needed. Because an ambulance provides trained personnel, talks with the hospital in route, and gets to the hospital quickly, call 911 immediately when stroke symptoms are recognized. A stroke victim should never try to drive himself. To prevent future strokes, treat cause of stroke and treat risk factors. Stroke Care at University of Mississippi Medical Center 12

14 Risk factors are not the same as direct causes of stroke. Causes refer to the exact physical reason for the stroke. Risk factors increase the chances that body conditions are such that strokes happen. Some conditions are risk factors for more than one cause of a stroke. Example: High blood pressure is a risk factor for small vessel disease, large vessel disease, and cardioembosism. Some risk factors can be controlled; some cannot. Some risk factors cannot be changed: Age Genetics (family history) Race Sex (gender) Having had a heart attack, stroke, or TIA in the past There are many stroke risk factors that are directly related to lifestyle choices. These risk factors can be changed, treated or controlled. When people have risk factors that CANNOT be changed, it is even more important that they control the stroke risks that CAN be controlled. Stroke Care at University of Mississippi Medical Center 13

15 Some risk factors can be controlled by diet, activities, and medicines: Atherosclerosis Hypertension (high blood pressure) High fats in the blood (cholesterol and triglyceride) Cigarette smoking Coronary artery and other heart diseases Diabetes mellitus (sugar diabetes) Lack of exercise (physical inactivity) Overweight and obesity Peripheral arterial disease Irregular heart rhythms Sickle cell disease Certain drugs The more uncontrolled risk factors one has, the greater the risk of stroke. A combination of two or more of these risk factors multiplies one s risk and demands even more attention. Luckily, there are many good treatments and programs to help people deal with these risk factors. Talk with your doctor or nurse about ways to help deal with these risk factors. Continue reading to see how many risk factors work together to set up conditions that lead to stroke. How Blood Clots Form There are two main ways that blood clots form: 1. through platelets. 2. through clotting factors. LifeArt Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Everyone has small blood cells called platelets. Platelets, like velcro, stick to rough or bumpy areas, clump together, and form blood clots. Platelets are important when there is a cut in a vessel wall that needs to clot and stop bleeding. Platelets are not good when they stick to the rough bumpy surface of an artery that has atherosclerosis. Clotting factors are chemicals that are dissolved in blood and keep blood from clotting too easily and help blood clot when needed. They work with platelets to form helpful clots and slow bleeding from an injury or cut Stroke Care at University of Mississippi Medical Center 14 14

16 vessel. These clotting factors may contribute to form harmful clots when blood pools in arteries, veins, damaged heart chambers, or when the heart beat is not regular and the heart does not pump well. A blood clot stuck to the inside of an artery is called a thrombus. A thrombus may narrow or close off the vessel at the point of atherosclerosis or the thrombus may break off and float down-stream until it lodges in a small vessel and stops blood flow. A thrombus moving through the blood stream is called an embolus. When a thrombus (blood clot sitting in a vessel) or embolus (blood clot moving in a vessel) plugs up an artery that feeds the heart muscle, it is called a heart attack. When this happens in an artery that takes blood to the brain, it is called a stroke. In this case, it is called an ischemic stroke (low-blood-flow stroke). The good news is that there are medicines that work to lower the risk of stroke for people with atherosclerosis. Talk to your doctor about drugs that work to keep platelets from sticking to rough artery walls and he/she can best decide if you need any of these medications. Step 1 Formation of a thrombus within a blood vessel. Step 3 LifeART Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Step 2 When the levels of clotting factors are not normal, people may have either bleeding (hemorrhage) or clots (thrombus) when they should not. Some people are born with clotting factor levels that are not normal; in other people, faults in clotting come about due to infection, inflammation or other reasons. When blood clots happen because of abnormal Stroke Care at University of Mississippi Medical Center 15 15

17 clotting factors or because of slow movement in the heart or blood vessels, blood-thinning medicines are needed to help prevent clots from forming. Atherosclerosis The inner lining of the walls of arteries is normally very smooth and stretchy to help blood flow smoothly, but over the years this wall can be damaged and become bumpy and hard. This process is called atherosclerosis, or hardening of the arteries. Atherosclerosis can happen in any or all of the arteries of the body. The three main places that atherosclerosis causes problems are the arteries to the legs (causes peripheral artery disease [PAD]), the arteries to the heart (causes heart attack), and the arteries that feed the brain (causes stroke). It may take many years for atherosclerosis to become severe enough to cause symptoms. It is the leading cause of both stroke and heart attack. Although atherosclerosis (hardening of the arteries) happens as a part of aging, many people live long lives without any problems. Other people have problems from atherosclerosis during middle or even young ages. Atherosclerosis happens earlier and more severely in persons with a family history of atherosclerosis at a young age or with any one of the following risk factors: high blood pressure (hypertension) cigarette smoking diabetes mellitus (sugar diabetes) high cholesterol (high fats in the blood) It is very important that you work to control anything that puts you at risk of atherosclerosis. Each of these diseases can be treated by eating a better diet, being more active, and taking your doctor s advice. If you have a family history of atherosclerosis, it is even more important to reduce risks that you can control. Stroke Care at University of Mississippi Medical Center 16

18 High Blood Pressure/Hypertension Blood pressure is measured using two numbers the top number is called the systolic blood pressure and the bottom number is called the diastolic number. Generally speaking, the top number (systolic blood pressure) should be less than 120 mm/hg, and the bottom number (diastolic blood pressure) should be less than 80 mm/hg. High blood pressure (hypertension) is usually described as a top number or systolic blood pressure of 140 mm/hg or above or bottom number (diastolic blood pressure) of 90 mm/hg or above. Top numbers between 120 mm/hg and 139 mm/hg or bottom numbers between 80 mm/hg and 89 mm/hg is defined as pre-hypertension. These levels should be watched very closely and perhaps treated to prevent high blood pressure (hypertension). Sometimes when certain blood vessels are already narrow from atherosclerosis, your doctor may advise that a higher blood pressure than normal is needed soon after stroke to help push blood past the narrowed areas. Keeping the blood pressure in the range prescribed by your doctor will decrease the risk of stroke in most people. In people with hypertension, blood pressure stays too high most the time. Hypertension is often called the silent killer because many times it causes no symptoms until it is too late. A stroke or heart attack may be the first and only symptom, even though hypertension has been present for several years. Longstanding high blood pressure damages blood vessel walls (arteriosclerosis). The small blood vessels deep in the brain, heart, and kidneys are especially prone to this type of damage. The earlier you catch and treat high blood pressure, the better chance you have to avoid a stroke or heart attack. Even older patients who treat and control their blood pressure can decrease their risk of stroke or heart attack. Many times high blood pressure (hypertension) is related to certain behaviors in a person s life. Things such as being overweight or obese, not exercising (sedentary lifestyle), eating foods high in salt (sodium), and drinking too much alcohol may lead to high blood pressure. The first steps one can take to keep a normal blood pressure should be to eat a diet low in salt and fat, maintain a healthy weight, be active, and limit alcohol intake. Talk with your doctor about starting an exercise or weight reduction plan. He/she can make suggestions to help. Stroke Care at University of Mississippi Medical Center 17

19 There are many recipe books available today with low-fat, low-salt foods that also taste good. (Check with the American Heart Association or American Stroke Association for recipes.) Sound: (silence) tapping swishing crisp blowing silence 120 Systolic Category Normal Prehypertension Diastolic High Blood Pressure Stage I Stage 2 Systolic (Top Number) Less than or Higher Diastolic (Bottom Number) Less than or Higher LifeART Collection Images Copyright by Lippincott Williams & WWilkins, Baltimore, MD Alcohol Alcohol intake of more than two ounces per day is not good for blood pressure, heart or brain health. Two ounces of alcohol equals one beer, one glass of wine, or one jigger of whiskey. If you cannot limit you alcohol to this amount, then don t drink at all. Cigarette Smoking Smoking causes damage to blood vessel walls (arterosclerosis) over time and greatly raises the risk of stroke, heart attack, and other diseases. The more cigarettes one smokes each day, the greater the risk of stroke. It is never too late too quit. After quitting, your risk of stroke due to smoking will reduce significantly over time. There are prescription medicines and over-the-counter products and other programs to help people stop smoking. Talk with your doctor, nurse, pharmacist, or other health care provider about your need to stop smoking. Stroke Care at University of Mississippi Medical Center 18

20 Diabetes Mellitus (Sugar) Diabetes often acts silently, like hypertension, in that a person can go many years with this disease but notice no symptoms. Over time, a higher blood sugar level causes damage to blood vessel walls (arterosclerosis) and increases risk of stroke and heart attack. Diet changes, weight control, medication, and insulin shots are all treatments for diabetes and can lower stroke risk. Your doctor will decide which options are best for you. High Cholesterol (Hypercholesterolemia) Cholesterol is a kind of fat that is carried in the blood. Cholesterol is a very important part of cell walls and a certain amount is good for a healthy body. However, if the cholesterol level becomes too high in the blood for a long period of time, it can lead to a build-up of the bumpy, hard material lining artery walls atherosclerosis. Just like high blood pressure and high blood sugar, high blood cholesterol usually does not cause any symptoms until there is already damage. In some people this can be treated with diet and exercise alone, but most people will need a cholesterol-lowering medication (the so-called statin drugs). There are two types of cholesterol in your blood: LDL is the bad cholesterol and HDL is the good cholesterol. The goal is to lower the LDL and raise the HDL. The best way to lower your LDL is to eat a lowfat diet, keep your weight down, and/or take a statin drug as directed by your doctor. The best way to raise your HDL is through regular exercise at least 20 minutes of exercise at least three days per week. Some medications can also help. Usual Cholesterol Targets After Stroke LDL (bad cholesterol) should be less than 100 HDL (good cholesterol) should be greater than 40 Stroke Care at University of Mississippi Medical Center 19

21 Irregular Heart Rhythms/Other Heart Diseases There are two common causes of clots forming in the heart and moving through the blood vessels to the brain to cause stroke. The first is an abnormal heartbeat where the upper chambers of the heart do not have a regular rhythm and allow blood to form small pools (atrial fibrillation). The other cause is damage to heart muscle from heart attack, high blood pressure, and other reasons that allow blood to stagnate or pool in the main pumping chamber of the heart. Cardioembolism Cardio = heart Embolism = moving clot or plug Sickle Cell Disease (Sickle Cell Anemia) People with Sickle Cell Disease are prone to clumping of the abnormal blood cells, resulting in blocking of arteries and stroke. This is much more likely to happen when the person is dehydrated (not enough water in the body) and when the percent of abnormal (sickle) cells is high, compared to the normal cells. Those with Sickle Cell Disease can reduce their risks of stroke by drinking plenty of fluids, and having transfusions when the percent of abnormal cells is high. Stroke experts disagree on whether those with sickle cell trait (meaning the person is a carrier but does not have the disease) have a higher risk of stroke than those with neither the trait nor the disease. Normal Red Blood Cells Erythrocytes (Red Blood Cells) Normal Cellular Structure of Red Blood Cells Sickle Cell Red Blood Cell as viewed from the side LifeART Collection Images Copyright by Lippincott Williams & Wilkins, Baltimore, MD Stroke Care at University of Mississippi Medical Center 20

22 Drugs Drugs that cause blood vessels to constrict, blood pressure to rise, and heart rate to increase can cause strokes, especially when they are used incorrectly or abused by using more than the recommended amount. Many over-the-counter drugs, such as antihistamines and diet pills, have been taken off the market because of stroke and other problems. Prescription drugs that cause these responses should be used only as prescribed. However, most drug-induced strokes are caused by use of street drugs. Both cocaine and methamphetamine can cause stroke and heart attack. UMMC participates in a national program to screen patients for pneumonia and flu vaccines. Before you leave the hospital, your nurse will ask you about your vaccination history. If you are eligible for either the pneumonia or flu vaccine, you will be asked to consent to receive the vaccine(s). Because many people are at greater risk of getting these illnesses after a stroke, you should receive the vaccines, unless there is a medical reason for you not to receive it. While pneumonia vaccinations are given year round, the flu vaccine is given only during the flu season. INFORMATION SOURCES: Coalition Initiatives. Retrieved May 13, 2009, from Brain Attack Coalition website: Diseases and Conditions. Retrieved June 1, 2009, from Centers for Disease Control and Prevention website: Learn About Stroke, Warning Signs. Retrieved June 1, 2009, from American Stroke Association website: Website information and patient information content compiled by the Stroke Care Team at University of Mississippi Medical Center. Stroke Care at University of Mississippi Medical Center 21

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