STROKE: SYMPTOMS, CAUSES AND TREATMENTS - NEUROPSYCHOLOGY - 2025

A stroke or cerebrovascular accident is any alteration that occurs temporarily or permanently, in one or more areas of the human brain as a consequence of a disorder in the cerebral blood supply (Martínez-Vila et al., 2011).

Currently, in the scientific literature we find a wide variety of terms and concepts that refer to this type of disorders. The oldest term is stroke, which was used in a generalized way when an individual was affected by paralysis, however, it did not imply a specific cause (National Institute of Neurological Disorders and Stroke, 2015).

Among the most used terms, recently we can find: cerebrovascular disease (CVD), cerebrovascular disorder (CVD), cerebrovascular accident (CVA), or the generic use of the term stroke. These terms are generally used interchangeably. In the case of English, the term used to refer to cerebrovascular accidents is “stroke”.

Definition of stroke

A cerebrovascular accident or disorder occurs when the blood supply to an area of ​​the brain is suddenly interrupted or when a blood spill occurs (National Institute of Neurological Disorders and Stroke, 2015).

The oxygen and glucose that circulate through our bloodstream are essential for the efficient functioning of our brain, since it does not accumulate its own energy reserves. Furthermore, cerebral blood flow passes through the cerebral capillaries without coming into direct contact with neuronal cells.

In basal conditions, the necessary cerebral blood perfusion is 52ml / min / 100g. Therefore, any reduction in blood supply below 30ml / min / 100g will seriously interfere with brain cell metabolism (León-Carrión, 1995; Balmesada, Barroso and Martín and León-Carrión, 2002).

When areas of the brain stop receiving oxygen (anoxia) and glucose due to inadequate blood flow or massive blood inflow, many of the brain cells will be seriously damaged and may die immediately (National Institute of Neurological Disorders and Stroke, 2015).

Types of stroke

The most widespread classification of diseases or cerebrovascular accidents is made according to their etiology, and is divided into two groups: cerebral ischemia and cerebral hemorrhage (Martínez-Vila et al., 2011).

Cerebral ischemia

The term ischemia refers to the interruption of the blood supply to the brain as a consequence of a blockage of a blood vessel (National Institute of Neurological Disorders and Stroke, 2015).

It is usually the most common type of stroke, ischemic attacks represent 80% of the total occurrence (National Institute of Neurological Disorders and Stroke, 2015).

Depending on the extension, we can find: focal ischemia (affects only a specific area) and global ischemia (which can simultaneously affect different areas), (Martínez-Vila et al., 2011).

In addition, depending on its duration we can distinguish:

• Transient ischemic attack (TIA): when the symptoms disappear completely in less than one hour (Martínez-Vila et al., 2011).
• Cerebral infarction: the set of pathological manifestations will last longer than 24 hours and will be the consequence of tissue necrosis due to the deficiency of blood supply (Martínez-Vila et al., 2011).

The blood supply through the cerebral arteries can be interrupted by several causes:

• Thrombotic cerebrovascular accident: an occlusion or narrowing of a blood vessel occurs due to an alteration of its walls. The alteration of the walls may be due to the formation of a blood clot in one of the arterial walls that remains fixed reducing the blood supply or due to a process of arteriosclerosis; narrowing of the blood vessel due to an accumulation of fatty substances (cholesterol and other lipids) (National Institute of Neurological Disorders and Stroke, 2015).
• Embolic cerebrovascular accident: the occlusion occurs as a consequence of the presence of an embolus, that is, a foreign material of cardiac or non-cardiac origin, which originates in another point of the system and is transported by the arterial system until it reaches an area smaller in that it is able to impede blood flow. The embolus can be a blood clot, an air bubble, fat, or tumor-like cells (León-Carrión, 1995).
• Hemodynamic cerebrovascular accident: it can be caused by the occurrence of a low cardiac output, arterial hypotension or a phenomenon of “flow theft” in an arterial area due to an occlusion or stenosis (Martínez Vila et al., 2011).

Cerebral haemorrhage

Brain hemorrhages or hemorrhagic strokes account for between 15 and 20% of all strokes (Martínez-Vila et al., 2011).

When blood accesses intra- or extra-cerebral tissue, it will disturb both the normal blood supply and the neural chemical balance, both essential for brain function (National Institute of Neurological Disorders and Stroke, 2015).

Therefore, with the term cerebral hemorrhage we refer to blood spilling within the cranial cavity as a consequence of the rupture of a blood, arterial or venous vessel (Martínez-Vila et al., 2011).

There are different causes of the appearance of cerebral hemorrhage, among which we can highlight: arteriovenous malformations, ruptured aneurysms, hematological diseases and creneoencephalic trauma (León-Carrión, 1995).

Among these, one of the most common causes are aneurysms; it is the appearance of a weak or dilated area that will give rise to the formation of a pocket in an arterial, venous or cardiac wall. These bags can weaken and even break (León-Carrión, 1995).

On the other hand, a rupture of an arterial wall may also appear due to the loss of elasticity due to the presence of plaque (arteriosclerosis) or due to hypertension (National Institute of Neurological Disorders and Stroke, 2015).

Among arteriovenous malformations, angiomas are a conglomeration of defective blood vessels and capillaries that have very thin walls that can also present ruptures (National Institute of Neurological Disorders and Stroke, 2015).

Depending on the place of appearance of the cerebral hemorrhage, we can distinguish several types: intracerebral, deep, lobar, cerebellar, brainstem, intraventricular and subarachnoid (Martínez-Vila et al., 2011).

Symptoms

Strokes usually come on suddenly. The National Institute of Neurologial Disorders and Stroke proposes a series of symptoms that appear acutely:

• Sudden lack of feeling or weakness in the face, arm, or leg, especially on one side of the body.
• Confusion, diction or language comprehension problem.
• Difficulty of vision in one or both eyes.
• Difficulty in walking, dizziness, loss of balance or coordination.
• Acute and severe headache.

Consequences

When these symptoms occur as a result of a stroke, urgent medical attention is essential. Identification of symptoms by the patient or close people will be essential.

When a patient accesses the emergency room presenting a stroke, the emergency and primary care services will be coordinated by activating the “Stroke Code”, which will facilitate the diagnosis and the start of treatment (Martínez-Vila et al., 2011).

In some cases, the death of the individual is possible in the acute phase, when a serious accident occurs, although it has been significantly reduced due to the increase in technical measures and the quality of medical care.

When the patient overcomes the complications, the severity of the sequelae will depend on a series of factors both related to the injury and the patient, some of the most important being the location and extent of the injury (León-Carrión, 1995).

In general, recovery occurs in the first three months in 90% of cases, however there is no exact time criterion (Balmesada, Barroso and Martín and León-Carrión, 2002).

The National Institute of Neurological Disorders and Stroke (2015) highlights some of the probable sequelae:

• Paralysis: frequently there is paralysis on one side of the body (Hemiplegia), on the side contralateral to the brain injury. A weakness may also appear on one side of the body (Hemiparesis). Both paralysis and weakness can affect a limited part or the entire body. Some patients may also suffer from other motor deficits such as problems in gait, balance and coordination.
• Cognitive deficits: in general, deficits can appear in different cognitive functions in attention, memory, executive functions, etc.
• Language deficits: problems in language production and understanding can also appear.
• Emotional deficits: difficulties may appear in controlling or expressing emotions. A frequent fact is the appearance of depression.
• Pain: Individuals may present with pain, numbness or strange sensations, due to the affectation of sensory regions, inflexible joints or incapacitated limbs.

Treatments

The development of new diagnostic techniques and life support methods, among other factors, has allowed the exponential growth in the number of survivors of stroke.

At present, there are a wide variety of therapeutic interventions designed specifically for the treatment and prevention of stroke (Spanish Society of Neurology, 2006).

Thus, the classic treatment of stroke is based on both pharmacological therapy (anti-embolic agents, anticoagulants, etc.) and non-pharmacological therapy (physiotherapy, cognitive rehabilitation, occupational therapy, etc.) (Bragado Rivas and Cano-de la Cuerda, 2016).

However, this type of pathology continues to be one of the leading causes of disability in most industrialized countries, essentially due to the enormous medical complications and deficits secondary to its occurrence (Masjuán et al., 2016).

The specific treatment of stroke can be classified according to the time of intervention:

Acute phase

When signs and symptoms compatible with the occurrence of a cerebrovascular accident are detected, it is essential that the affected person go to the emergency services. Thus, in a large part of the hospitals, there are already different specialized protocols for the care of this type of neurological emergency.

Specifically, the “stroke code” is an extra and intra-hospital system that allows rapid identification of the pathology, medical notification and hospital transfer of the affected person to the reference hospital centers (Spanish Society of Neurology, 2006).

The essential objectives of all interventions launched in the acute phase are:

- Restore cerebral blood flow.

- Check the patient's vital signs.

- Avoid increasing brain injury.

- Avoid medical complications.

- Minimize the chances of cognitive and physical deficits.

- Avoid the possible occurrence of another stroke.

Thus, in the emergency phase, the most widely used treatments include pharmacological and surgical therapies (National Institute of Neurological Disorders and Stroke, 2016):

Pharmacotherapy

Most of the drugs used in cerebrovascular accidents are administered in parallel to their occurrence or after it. Thus, some of the most common include:

- Thrombotic agents: they are used to prevent the formation of blood clots that can lodge in a primary or secondary blood vessel. These types of drugs, such as aspirin, control the ability of blood platelets to clot and, therefore, can reduce the likelihood of stroke recurrence. Other types of drugs used include clopidogrel and ticoplidine. They are usually given in emergency rooms immediately.

- Anticoagulants: this type of medicine is responsible for reducing or increasing the blood clotting capacity. Some of the most commonly used include heparin or warfarin. Specialists recommend the use of this type of drug within the first three hours of the emergency phase, specifically through intravenous administration.

- Thrombolytic agents: these drugs are effective in restoring cerebral blood flow, since they have the ability to dissolve blood clots, in the event that this was the etiological cause of the stroke. Generally, they are usually administered during the occurrence of the attack or in a period not exceeding 4 hours, after the initial presentation of the first signs and symptoms. One of the most commonly used drugs in this case is tissue plasminogen activator (TPA), - Neuroprotectors: the essential effect of this type of drug is the protection of brain tissue against secondary injuries resulting from the occurrence of a cerebrovascular attack. However, most of them are still in the experimental phase.

Surgical interventions

Surgical procedures can be used both for the control of a cerebrovascular accident in the acute phase, and for the repair of injuries secondary to it.

Some of the procedures most used in the emergency phase may include:

- Catheter: if the drugs administered intravenously or orally do not offer the expected results, it is possible to opt for the implantation of a catheter, that is, a thin and thin tube, inserted from an arterial branch located in the groin to reach the brain areas affected, where drug release will occur.

- Embolectomy: a catheter is used to remove or extract a clot or thrombus lodged in a specific brain area.

- Decompressive craniotomy: in most cases, the occurrence of a stroke can cause cerebral edema and consequently an increase in intracranial pressure. Thus, the objective of this technique is to reduce the pressure through the opening of a hole in the skull or the removal of a bone flap.

- Carotid endarectomy: the carotid arteries are accessed through several incisions at the neck level, to eliminate possible fatty plaques that occlude or block these blood vessels.

- Angioplasty and stent: in algioplasty, a balloon is inserted to expand a narrowed blood vessel through a catheter. While in the case of the use of the stent, a clipping is used to prevent bleeding from a blood vessel or arteriovenous malformation.

Subacute phase

Once the crisis is controlled, the main medical complications have been resolved and, therefore, the patient's survival is assured, the rest of the therapeutic interventions are started.

This phase usually includes interventions from different areas and, in addition, to a large number of medical professionals. Although rehabilitative measures are usually designed based on the specific deficits observed in each patient, there are some common characteristics.

In almost all cases, rehabilitation usually begins in the initial phases, that is, after the acute phase, in the first days of hospitalization (Group for the Study of Cerebrovascular Diseases of the Spanish Society of Neurology, 2003).

In the case of cerebrovascular accidents, health professionals recommend the design of an integrated and multidisciplinary rehabilitation program, characterized by physical and neuropsychological therapy, occupation, among others.

Physical therapy

After the crisis, the recovery period should begin immediately, in the first hours (24-48h) with physical intervention through postural control or mobilization of paralyzed joints or limbs (Díaz Llopis and Moltó Jordá, 2016).

The fundamental objective of physical therapy is the recovery of lost skills: coordination of movements with hands and legs, complex motor activities, gait, etc. (Know Stroke, 2016).

Physical exercises usually include repetition of motor acts, use of affected limbs, immobilization of healthy or unaffected areas, or sensory stimulation (Know Stroke, 2016).

Neuropsychological rehabilitation

Neuropsychological rehabilitation programs are specifically designed, that is, they must be oriented towards working with the deficits and residual capacities that the patient presents.

Thus, with the objective of treating the most affected areas, which are usually related to orientation, attention or executive function, this intervention usually follows the following principles (Arango Lasprilla, 2006):

- Individualized cognitive rehabilitation.

- Joint work of the patient, therapist and family.

- Focused on achieving relevant goals at a functional level for the person.

- Constant evaluation.

Thus, in the case of care, training strategies for care, environmental support or external aids are usually used. One of the most used programs is the Attention Process Training (APT) by Sohlberg and Mateer (1986) (Arango Lasprilla, 2006).

In the case of memory, the intervention will depend on the type of deficit, however, it essentially focuses on the use of compensatory strategies and the enhancement of residual capacities through techniques of repetition, memorization, revisulization, recognition, association, environmental adaptations, among others (Arango Lasprilla, 2006).

In addition, on many occasions patients can present significant deficits in the linguistic area, specifically problems for articulation or expression of language. Therefore, the intervention of a speech therapist and the development of an intervention program may be required (Arango Lasprilla, 2006).

Occupational therapy

Physical and cognitive alterations will significantly impair the performance of activities of daily life.

It is possible that the affected person has a high level of dependency and, therefore, requires the help of another person for personal hygiene, eating, dressing, sitting, walking, etc.

Thus, there are a wide variety of programs designed for relearning all these routine activities.

New therapeutic approaches

Apart from the classical approaches described previously, numerous interventions are currently being developed that are showing beneficial effects in post-stroke rehabilitation.

Some of the newer approaches include virtual reality, mirror therapy, or electrostimulation.

Virtual Reality (Bayón and Martínez, 2010)

Virtual reality techniques are based on the generation of a perceptual reality in real time through a computer system or interface. Thus, through the creation of a fictitious scenario, the person can interact with it through the performance of different activities or tasks.

Normally, these intervention protocols usually last about 4 months, after which an improvement in the capacities and motor skills of those affected in the recovery phase has been observed.

Thus, it has been observed that virtual environments are capable of inducing neuroplasticity and, therefore, contributing to the functional recovery of people who have suffered a stroke.

Specifically, different experimental studies have reported improvements in the ability to walk, grip or balance.

Mental practice (Bragado Rivas and Cano-de La Cuerda, 2016)

The process of metal practice or motor imagery consists of making a movement at the mental level, that is, without physically executing it.

It has been discovered that through this process the activation of a good part of the musculature related to the physical execution of the imagined movement is induced.

Therefore, the activation of internal representations can increase muscle activation and, consequently, improve or stabilize movement.

Mirror therapy

The mirror technique or therapy consists, as its name indicates, in the placement of a mirror in a vertical plane in front of the affected individual.

Specifically, the patient must place the paralyzed or affected limb on the back side of the mirror and the healthy or unaffected limb in front, thus allowing the observation of its reflex.

The goal, therefore, is to create an optical illusion, the affected limb in motion. Thus, this technique is based on the principles of mental practice.

Different clinical reports have indicated that mirror therapy shows positive effects, especially in the recovery of motor functions and pain relief.

Electrostimulation (Bayón, 2011).

The transcranial magnetic stimulation (TMS) technique is one of the most widely used approaches in the area of ​​electrostimulation in stroke.

EMT is a non-invasive technique that is based on the application of electrical pulses to the scalp, over the areas of affected nervous tissue.

The most recent research has shown that the application of this protocol is capable of improving motor deficits, aphasia and even hemineglect in people who have suffered a stroke.

References

1. Balmesada, R., Barroso and Martín, J., & León-Carrión, J. (2002). Neuropsychological and behavioral deficits of cerebrovascular disorders. Spanish Journal of Neuropsychology, 4 (4), 312-330.
2. FEI. (2012). Spanish Federation of Ictus. Obtained from ictusfederacion.es.
3. Martínez-Vila, E., Murie Fernández, M., Pagola, I., & Irimia, P. (2011). Cerebrovascular diseases. Medicine, 10 (72), 4871-4881.
4. Stroke, NN (2015). Stroke: Hope Through Research. Retrieved from ninds.nih.gov.
5. Neurological disorders. (nineteen ninety five). In J. León-Carrión, Manual of Clinical Neuropsychology. Madrid: Siglo Ventiuno Editores.
6. WHO Cardiovascular Diseases, January 2015.
7. Stroke: a socio-sanitary problem (Ictus FEI).