copyright 2008 Cheryl K. Hosken, BSN, MS Psych.
Pastor Harvey Cole was in his church office preparing his Easter sermon for the next morning when the telephone rang. It was his oldest child, calling from the hospital. "Something is wrong with Mom!" he shouted, sounding very upset. Mrs. Cole had been rushed to the hospital after complaining of a violent headache, followed by dizziness, difficulty speaking, and numbness in one arm - all distinct signs of stroke.
Pastor Cole, a Presbyterian minister, drove quickly to the hospital. There he learned that his 40-year-old wife had suffered massive brain hemorrhages and was in a deep coma. The emergency room doctor said that cases like these have a poor prognosis and the patient usually dies after 48 hours. The minister and his family could only wait.
Pastor Cole says that in a blink of an eye his whole family life changed. He was intensely angry. He went home at night and pounded on the bed and prayed, asking why this had happened to him. When he woke up the next morning, it was Easter - the day Jesus "woke up", but his wife did not wake up.
The first week, he lived at the hospital, then as his wife's condition did not improve, he developed a routine of visiting her. He had trouble believing what had happened to her. It was surreal.
Meditate Word By Word On These Verses:
John 9:1-7.
Cerebrovascular stroke and traumatic brain injury (TBI) mainly occur at opposite ends of the age spectrum. Stroke is the foremost disabler of the elderly. TBI or head injury is responsible for many deaths of persons between the ages of 1-45 years. TBI occurs from an external source - perhaps hitting one's head in contact sports or on the windshield of a car. A stroke happens because of an internal source.
What Happens in a Stroke?
One fourth of the blood pumped from the heart goes to the brain via the carotid arteries on either side of the head. From these arteries, there is a branched artery system that carries blood within the brain. Should any of these arteries rupture or develop a blockage, stroke occurs.
Most strokes are ischemic which means that an artery carrying blood is obstructed or constricted. This is similar to what happens in a heart attack. The brain cells are deprived of oxygen and die within minutes unless the arteries nearby re-route the blood back to the brain. Because the cerebrovascular and cadiovascular system belong to the circulatory system, stroke and heart attack have almost the same causes. High blood pressure and atherosclerosis or decreased size of the lumen of the artery are the culprits in these two diseases.
Atherosclerosis scars the inner walls of the arteries and over time the lumen of the artery decreases because fatty deposits (cholesterol) build up on these scars. The smaller opening becomes a place for a blood clot to form. Stroke usually happens early in the morning or late at night when a person's blood pressure is low.
About 15% of strokes are cerebral embolisms that get to the brain and plug and artery. Usually what happens is that a clot from the heart is swept along the bloodstream to the brain where it plugs a small artery and stops blood flow. Blood pressure is the leading cause of stroke. Family history is also significant in predicting a stroke as well as age, weight, excessive drinking, smoking, inadequate exercise and diabetes.
Question 1: What similar causes do cardiovascular disease and cerebrovascular disease have in common?
(Only one of the following answers is correct.)
obstructed arteries.
high blood pressure and atherosclerosis.
cholesterol in the arteries.
Symptoms of Strokes
Knowing the symptoms of stroke can be helpful since swift medical attention is necessary. As with the heart attack, when a stroke occurs in the brain, the brain tissue dies almost immediately. The area around the stroke site may also be further injured due to lack of oxygen. The longer the oxygen-deprived area of the brain must wait for blood to bring oxygen, the more widespread is the brain damage. There is a very fine line between giving medication to increase blood supply to the brain and trying to decrease the size of the clot in a blood vessel.
The most common sign of a stroke is numbness and weakness or paralysis on one side of the body. Other symptoms are:
- sudden blurred vision or decreased vision in one or both eyes,
- difficulty speaking or understanding simple statements,
- dizziness or loss of balance,
- unusual confusion, disorientation, or loss of consciousness.
Transient Ischemic Attack
A transient ischemic attack is usually a forewarning of a stroke. It can occur weeks or months ahead of time. It is a "little stroke" and is a temporary disturbance in the circulation of the brain. It stops normal brain functioning because of decreased blood flow to the brain. The signs are similar to a permanent stroke. They come quickly and then disappear after 10-15 minutes. The little stroke symptoms disappear because sometimes the body's system of dissolving clots activates quickly and restores normal blood flowing in the brain. Although a TIA leaves little permanent damage, it is a significant event and often a prelude to a stroke.
Question 2: What is the difference between a stroke and a transient ischemic attack?
(Only one of the following answers is correct.)
A stroke is lack of oxygen to the brain causing death to the brain tissue.
A transient ischemic attack occurs over a long time period.
A stroke is temporary.
Hemorrhagic Stroke
Hemorrhages are far less common than ischemic infarctions. However they are far more deadly. Here a defective artery in the brain bursts open and spills blood into the brain tissue. Hemorrhages do double damage. The cells die from lack of oxygen and the escaped blood presses on the neighboring brain tissue and interferes with brain function. Half of all cerebral hemorrhage patients die from this increased pressure. Once the pressure bought on by the hemorrhage is relieved, surrounding brain tissue may recover.
The cause of a hemorrhage is chronic high blood pressure, which weakens the walls of the arteries until one bursts open. Frequently, the cause is an aneurysm. An aneurysm is thought to be a congenital defect in the artery.
The symptoms of a brain hemorrhage are like the ischemic stroke. The hemorrhagic stroke comes without warning. The most telling sign is a sudden , excruciating headache, nausea, vomiting, and loss of consciousness.
Traumatic Brain Injury
A driver hitting his head on the windshield of a car, a woman slipping on the ice and hitting the back of her head on the sidewalk, and a boxer hit in the jaw with a left hook can all suffer a cerebral hemorrhage as a result of these occurrences. There may also be substantial brain damage. A severe head injury patient is someone who comes into the emergency room in a coma and does not respond to any stimuli. Usually a head injury means permanent disability and ongoing care and attention. A small percentage of head injuries will result in a persistent vegetative state or prolonged coma.
Question 3: A hemorrhagic stroke is different from a brain injury because:
(Only one of the following answers is correct.)
a hemorrhagic stroke cannot be controlled, but a brain injury can be controlled by living inside at all times.
a hemorrhagic stroke is caused by bleeding inside the brain and brain injury is caused by damage from outside the head.
there is no difference, both conditions cause brain injury.
Automobile accidents that cause head injury are all too common and are responsible for almost half of the head injuries. Usually, head injuries are acceleration /deceleration injuries. This means that the brain rocks back and forth on its stem and ricochets off the interior of the bony skull. There are often brain bruises from this action inside the head. The force of the brain hitting the skull can also cause blood vessels to tear and cause bleeding in the brain or between the brain and the layers of the protective covering of the brain. These types of injuries are called forcal injuries because we know where they are located in the brain. However, there may also be diffuse injuries where cells have been temporarily or permanently distorted by all the movement inside the head. The most serious brain injury is damage to the brain and the brain stem. The brain stem is responsible for breathing, heartbeat, and swallowing reflexes. These patients are often in a comatose state for a long time and when they waken, they have severe deficits in intelligence, sensation, and movement.
The second type of head injury is open head injury that causes direct brain damage such as a bullet wound. The amount of damage depends on the size, force, and path of a penetrating object.
Diagnosis and Treatment of Stroke and Traumatic Brain Injury
The computerized tomography scan is the preferred diagnostic tool for patients who may have suffered a stroke. If there is a cerebral hemorrhage, it can be diagnosed 97% of the time. If there is no evidence of hemorrhage, it is assumed that a blood vessel has a thrombis. A Doppler ultrasound may also be done to detect blockages in the carotid arteries. Once the cause is discovered, the doctors have 4 hours to return sufficient blood flow to the brain and stop permanent cell damage. This is done through surgery, drug therapy or both.
Question 4: The best diagnostic tool for brain trauma is:
(Only one of the following answers is correct.)
x-ray.
surgery.
computerized tomography.
The types of surgery done are craniotomy for removing hematomas, carotid endarterectomy to remove plaque from the inside of the artery, and repair of an aneurysm. Drugs that are given are those that dissolve blood clots - tissue plasminogen activator, and neuroprotective agents such as antioxidants and glutamate inhibitors. These agents safeguard neighboring cells from damage. The other drugs are anti-hypertensive drugs. They are used to bring the blood pressure under control, though not too low so that the brain does not get enough oxygen.
The acute complications of stroke and head injury are these:
- Increased intracranial pressure due to swelling of the brain and/or hematoma - treated by medications and monitoring
- Impaired respiration or cessation of breathing treated by ventilation
- Heart Attack
- Difficulty swallowing treated by nasogastric feedings
- Pulmonary embolism treated by medication, elastic stockings, and exercise
- Incontinence due to a neurogenic bladder, meaning that the nerve stimulation to hold urine has been interrupted treated by a bladder program that helps persons go to the bathroom at frequent intervals. If this fails, amitrypyline, a drug with anticholinergic properties will help. This medication stops the urinary bladder from contracting and losing urine.
The Long-Term Effects of Stroke and Brain Injury
Once a person has been stabilized from a stroke or brain injury, relief that the person is alive can turn to foreboding about what the future holds. The magnitude of the after effects may be enormous. It is not unusual for the person to have neurological defects. The location and severity of the injury is the key to the deficits a person will have.
Paralysis/Weakness
3 in 4 stroke survivors experience partial paralysis on one side of the body. Motor dysfunction might affect the whole hemisphere of the brain or just a part of it. Jackie Cole, the lady at the beginning of this lecture, had quadraparesis or paralysis of all four extremities. When she was discharged from the hospital after five months, she was still unable to stand or walk. Quadreparesis is associated with widespread, deep internal damage to the brain.
Question 5: The effects of brain injury and stroke cause neurological problems such as paralysis, speech problems, impaired memory, and loss of vision.
true /
false.
Here is a list of potential impairments people can suffer:
- LEFT CEREBRAL DAMAGE
Right side paralysis, right side vision loss, right side sensation loss, right side neglect
Aphasia, impaired memory, reasoning, logical thinking
Inappropriate emotional responses- RIGHT CEREBRAL DAMAGE
Left side paralysis, left side vision loss, left side sensation loss, left side neglect,
Problems with perception and judgment of spatial relationships
Impaired short-term memory
Impulsivity and inappropriate emotional responses- CEREBELLAR INJURY
Poor balance and coordination
Inappropriate emotional responses- BRAIN STEM INJURY
Slurred speech, difficulty swallowing, impaired breathing, unstable blood pressure
Impaired vision and hearing, full or partial paralysis on one or both sides of the body
Inappropriate mental responses
Question 6: These effects of brain injury and stroke always occur.
true /
false.
Contracture
Paralysis causes muscles to shrink in size and lose their ability to stretch. Within 24 hours of Jackie Cole's stroke, her hands began to curl up like claws. This caused painful cramping as the joints angled inward toward the center of her body. If the joints stay like that for too long, the patients may have permanent disablement.
The management of contracture is passive range of motion exercises. The likelihood of forestalling contracture from affecting the joints and muscles improves if these exercises are begun shortly after the stroke or brain injury. These exercises are not difficult to learn and you can teach them to the family so they can help their loved one.
Hemispheric Neglect
Damage to the right brain, particularly from stroke can bring a curious phenomenon called left side neglect. This person fails to acknowledge objects, people that are located to the left, and sometimes his own left side.
If asked to draw a clock, the numbers on the clock will all be crowded to the right side and the left side will be entirely empty. Or the person may eat only the food on the right side of the plate. At times, such persons may hit their left arm or leg because it does not obey the rest of the body or they may not think their left side is even their own body. Not surprisingly, this deficit leaves such persons accident prone and dependent on others.
To help this person, place objects on the side he sees. For example, turn his plate as he eats or put the plate slightly to the right of him. Put clothes on the right side of a closet or drawer. Most of all, you can use your own verbal skills to remind the person to turn his head to the left to see things or shave and put on cosmetics.
Speech/Language Loss (Aphasia)
One person in five loses his ability to communicate through stroke. This cognitive (thinking) disorder can also jumble the faculties necessary for reading, listening, or writing. For example, people with aphasia may have any of the following problems:
- Producing proper sounds to be understood (apraxia)
- Using appropriate words (dysnomia)
- Putting words in correct order
- Interpreting conversational cues such as knowing when to let another person speak
- Inability to listen attentively
- Inability to understand the meaning of a sentence even though they hear and understand the individual words
- Recall of information recently learned
- Grasp of jokes, wordplays, or sarcasm
People with brain injury have deficits in areas of learning, comprehension, and speaking so that their affected abilities resemble those of stroke victims. One of the results of severe brain injury is dysarthria. A person may be able to think well, but the neurofibers that control the muscles of the tongue and mouth are damaged.
Question 7: If a person has a vision deficit, you can help him by:
(One or more of the following answers may be correct.)
asking him to turn his head to see objects.
touch the side of his head so that he turns to see things.
put food, clothes and other equipment on the side where he sees best.
put his hand on the object.
Changes in Behavior and Personality
Brain trauma may cause an alteration of intellect, memory, and personality which is the essence of their being and our knowing them. For example, Jackie Cole lost her history. It is the usual pattern for the brain damage to wipe out sections of recent memory and keep the past memory intact. But Jackie's long-term memory had so many blank spots that she had to learn her own history from her husband.
Cognitive or thinking processes are most affected in stroke. Perception of words, ideas and visual cues may be lost. Communication verbally and visually may have to be learned or is permanently changed. However, personality changes are most apparent in brain injured. These changes are hard to describe, but the person is changed from his usual self.
A common characteristic of either injury is apathy. Their emotions are blunted and they may seem indifferent to life. Others have trouble with emotional lability. They may erupt with anger, tears, or laughter at inappropriate moments. These outbursts can end as abruptly as they began. With frontal lobe injury, there is a loss of self control, social skills, and inhibition.