Stroke

Stroke is caused by an interruption of blood flow to the brain, leading to a lack of oxygen to brain cells which causes them to die. Strokes are divided into ischaemic strokes and haemorrhagic strokes:

• Ischaemic stroke happens because of a blockage to the blood flow inside the arteries. This can be a blood clot or rupture of a cholesterol plaque inside the artery.
• Haemorrhagic strokes are due to burst blood vessels leading to bleeding inside the brain.

Stroke is caused by an interruption of blood flow to the brain, leading to a lack of oxygen to brain cells which causes them to die. Strokes are divided into ischaemic strokes and haemorrhagic strokes. Ischaemic stroke happens because of a blockage to the blood flow inside the arteries. Haemorrhagic strokes are due to burst blood vessels leading to bleeding inside the brain.

All strokes happen suddenly and cause damage to the brain. Sometimes a clot interrupts the blood flow only for a short period of time and quickly enough that there is little or no damage to the brain, producing a transient ischaemic attack (TIA). These events rapidly recover, however they are a warning of increased risk of stroke in the next few weeks and require medical attention start a stroke prevention management plan as soon as possible.

In some people, treatment can be given quickly, within 4 and a half hours of the onset of stroke, which can break up or remove the clot of an ischaemic stroke, restoring the blood flow and minimising the area of brain affected. This treatment is called thrombolysis which uses a medication that breaks down the clot. In some circumstances, larger clots can be removed by a technique called endovascular clot retrieval (ECR) in which a mechanical device is fed through the artery in the groin up into the brain to capture and remove the clot. Both these treatments require specialist assessment and are available at The Alfred. 

Damage to the brain interrupts the function of that area of brain. This produces problems in the body such as weakness, numbness or altered sensation, incoordination, or walking problems, double vision or loss of vision. It can cause problems with comprehension of language and communication, including trouble talking. Some parts of the brain are very important for thinking and cognition, and damage to those areas causes confusion or difficulties with planning, organising, thinking, or behavioural or personality change. 

Everyone who has symptoms of a new stroke will have scans of the brain looking for signs of stroke with either a CT scan or MRI (Magnetic Resonance Imaging) scan and sometimes both. 

The same scans, with the help of an injection of radiological contrast (or dye) in a vein, can also help visualise the arteries in the neck and brain and give more information about the cause of stroke.

Other investigations often will be needed to look for treatable risk factors for stroke, allowing us to prevent further strokes. These include:

• Blood tests looking for signs of diabetes, cholesterol level, clotting problems or other illness which can lead you to being at risk of stroke or other illness.
• Ultrasound/ Doppler of the arteries feeding the brain (carotid, vertebral) looking for blockages/ cholesterol plaque which might need an operation to remove the plaque.
• Cardiac monitoring looking for an irregular heartbeat, atrial fibrillation (AF) which increases the risk of stroke( if this is done outside the hospital it is called a “holter monitor”).
• Transthoracic Echocardiogram (TTE); an ultrasound of the heart looking for structural problems with the heart function which can increase your risk of stroke.

Our stroke team, including highly trained physiotherapists, speech pathologists, occupational therapists and dieticians assess patients cared for by The Alfred Stroke Unit regularly throughout their hospital stay, providing early rehabilitation to help you improve. 

Physiotherapy assessment of movement and walking is provided to all patients at The Alfred with stroke, and will help determine your need for ongoing rehabilitation.

Occupational therapy assessment helps to determine if additional aids or assistance would be needed to help return you to your home and to your usual activities safely.

Speech pathologists assess swallowing and help with making sure the food can be swallowed safely. Swallowing safely is important to prevent food from going down the “wrong way” and causing pneumonia. They also assess communication and speech. 

Nutrition assessment by a dietitian may happen if you are not able to swallow safely and require a nasogastric tube for nutrition, as well as making sure that you are eating and drinking well enough to help with your recovery post-stroke.

When brain cells die because of a stroke, they swell and can cause a person to be drowsy for a few days. Sometimes when people have a stroke, they also develop other problems. The muscles in the throat can be weak and can result in saliva entering the lungs, causing a chest infection and sometimes pneumonia. When you are not able to move properly because of a stroke, you can have interruption of normal bladder and bowel emptying which may lead to an infection in the bladder.

The nursing team will assess your bladder and bowel continence and help you prevent complications. You will also be given pneumatic compression stockings or blood thinning injections to prevent clots forming in the leg veins causing a deep vein thrombosis ( DVT). The Alfred Stroke Unit doctors will assess for these problems daily, and provide early treatment when needed. 

Soon after a stroke there is a risk of a second stroke occurring, producing more damage to the brain. This risk is reduced by starting medication that controls the risk factors for stroke. The need for these medications is determined by the doctors of the stroke unit, depending on the type of stroke, other medical problems you may have, and possible side effects of medications. These medications can include:

• Blood thinners - used to reduce the risk of repeated ischaemic strokes, but cannot be used if there has been a haemorrhagic stroke. These medications are in two major groups - medications which alter the function of platelets, which normally produce small clots in our blood allowing us to stop minor bleeding from cuts and bruises; and medications that alter the clotting factors in the blood. These medications include aspirin and clopidogrel (which both affect platelets); Warfarin and other anticoagulants are used in more significant clotting factor disorders or when there is atrial fibrillation. 
• Blood pressure medication - high blood pressure (hypertension) is a strong risk factor for stroke and can also worsen initially after stroke, often requiring treatment with tablets. This is particularly important in haemorrhagic strokes in which the blood pressure can be very high, sometimes requiring infusions of medication via a drip for the first 1-2 days. The need for blood pressure tablets is assessed daily during the hospital and rehabilitation stay, and is then reviewed in the follow up clinic and with your GP.
• Cholesterol lowering treatments - high cholesterol is associated with an increased risk of stroke and heart problems, and lowering this quickly often requires medication. The long term need for these medications is reassessed overtime.
• Smoking cessation treatment - cigarette smoking is a strong risk factor for stroke, and assistance to stop smoking is provided for all patients at The Alfred. After discharge you will be offered follow up support in the Smokefree Clinic.

Strokes are always at their worst over the first few days, when the brain is swollen. After the swelling reduces, the brain will then try to learn new ways to achieve the tasks that were previously done by the area of damaged brain.

Rehabilitation can be helpful in improving this new learning, and is particularly important when there is significant injury to the brain resulting in problems walking or speaking. How much recovery you make depends on the site and size of damage there is to the brain and how much therapy you are able to do, based on your overall health.

Recovery can be very difficult to predict early on but most patients with stroke do improve with time – although not all are able to make a full recovery. 

You will stay at The Alfred under the care of the Stroke Unit until you are either well enough to go home or to rehabilitation.

Rehabilitation is particularly important when there is injury to the brain resulting in problems with daily living. How much recovery you make depends on the site and size of damage there is to the brain and how much therapy you are able to do, based on your overall health. 

Many people with stroke will require more extensive rehabilitation to help recovery, and this is usually undertaken at the Caulfield Hospital neurorehabilitation unit, or at private rehabilitation hospitals in Melbourne or regional rehabilitation services if appropriate. If you require further rehabilitation after your stroke, we will arrange this for you. 

The Stroke Unit team, including the doctors, nurses and allied health, are able to provide information about your stroke, medications and treatment, and expected recovery.

You will have a personalised record of your stroke in a folder produced by the Stroke Foundation called ‘My Stroke Journey’.

If you have concerns about your treatment you can ask to speak with the doctors of the stroke team or contact the 7 West Nurse Unit Manager on (03) 9076 3672.

Further information about stroke, life after stroke and prevention of further strokes is also available at the Stroke Foundation.