Stroke, its Risk and how to deal with it

STROKE

th_Stroke_Illustration_Final.jpg?t=13293Blood Suppply to the Brain

The major portion of the blood supply to the brain flows through main arteries arising from the arch of the aorta (see chapter one on anatomy of the heart). On the right side, one large artery arises from the aortic arch called the brachiocephalic trunk. After a short distance, it divides into the right subclavian artery (which supplies the right arm and other structures) and the right common carotid artery. On the left side, the subclavian and left common carotid arteries arise independently from the aortic arch (Figure 1). Therefore, except for the origins of these arteries, the arterial supply is generally symmetrical and identical on both sides.

                                                    th_Blood_to_Brain.jpg?t=1329318888

Figure 1 Schematic diagram of the blood supply to the brain, Ao = aortic arch, LSA
left subclavian artery, LCC = left common carotid, BCT = brachiocephalic trunk, RSA right subclavian artery, RCC right common carotid, 1 = right common carotid, 2 = left common carotid, 3 = left external carotid, 4 = left internal carotid, 5 = basilar artery, 6 = vertebral artery, 7 = ophthalmic artery

The right and left subclavian arteries supply blood to the right and left arms, while the right and left carotid arteries supply blood to the head and neck.

Each common carotid artery, passes somewhat lateral to the midline of the neck. About midpoint between the root of the neck and the base of the skull, the carotid artery divides into two branches: the external carotid artery and the internal carotid artery.

The internal carotid artery continues straight up to the base of the skull without giving off any branches. It enters the skull, and its first branch is an artery called ophthalmic artery that supplies blood to the eye. It further gives numerous branches to supply the remainder of the brain. The external carotid artery, on the other hand, provides blood to the structures of the head and neck except for the eyes and the brain. The entire system of internal and external carotid arteries is actually intercommunicating by small arteries, which play a very important
role. In case of narrowing in one of the major arteries, they become thecomponents of the collateral circulation to the brain (Figure 2).

                                      th_Internal_Carotid.jpg?t=1329318889

Figure 2 Internal carotid artery and its first branch, the ophthalmic artery. Intercommunicating branches play an important role in collateral circulation, 1 = common carotid artery, 2 = external carotid artery, 3 = internal carotid artery, 4 = ophthalmic artery

Although the subclavian artery supplies primarily the upper limbs, it also supplies the head and neck. One such artery is the vertebral artery. This artery travels in the neck and eventually enters the skull to join with the vertebral artery of the opposite side to become the basilar artery. This artery supplies blood to the posterior portion of the cranial cavity. Furthermore, the internal carotid arteries from the opposite side also meet to form an important structure called the circle of Willis, which also supplies the posterior of the brain
(Figure 3).

As  demonstrated, the carotid artery is the only link to the brain. If an area of this artery narrows because of atherosclerosis, and if the narrowing is severe, brain tissues will be damaged, resulting in a stroke. The most frequently affected location by atherosclerosis is the carotid bifurcation—in particular, the origin of the internal carotid. A large number of patients with cerebral ischemia have narrowing or stenosis at the bifurcation area. Other sites are also affected, but it is not the purpose of this book to elaborate on detailed information on the anatomy of the blood supply to the brain and the most frequent affected sites.

                                          th_Vertebral_Artery.jpg?t=1329318891

Figure 3, Vertebral arteries of opposite sides meet to form the basilar artery. Also, internal carotid arteries meet with the basilar artery to form the Circle of Willis, 1 = left and right vertebral arteries, 2 = basilar artery, 3 = left and right internal carotid arteries, 4 =ophthalmic artery, 5 = Circle of Willis.

Mechanism of Brain Damage

A stroke disrupts the flow of blood to the brain damaging its tissue. There are
two major types of brain damage in stroke patients:

  1. Stroke caused by ischemia is the most common
  2. Stroke caused by hemorrhage is the result of bleeding due to a rupture blood vessel

Stroke Caused by Ischemia

About 90 percent of strokes are ischemic in nature,
they occur when the formation of a clot within an artery obstructs blood flow
to one or more blood vessels. Usually, the lumen (the space in the interior of
an artery or vein) of the vessel is narrowed because of changes occurring in
the wall of that vessel due to atherosclerosis and the formation of plaques.

Ischemia (deficiency of blood flow) to brain tissue
could also be the result of diminished blood perfusion due to poor cardiac
activity because of coronary artery disease and/or heart attack.

The severity of brain ischemia depends on the location
and duration of poor perfusion and the ability of collateral circulation to
provide an adequate supply of oxygen and nutrients to the affected region. The
most common ischemic strokes are;

  • Thrombotic stroke. This type of stroke is the result of blood clots
    (thrombus) formed in one of the arteries that supply blood to the brain. A
    blood clot usually forms in areas already damaged by atherosclerosis. The
    location greatly varies but the carotid artery is mostly affected.
  • Embolic stroke. Embolic stroke occurs when a blood clot or other
    debris from a blood vessel away from the brain ‑ most likely from the heart is
    swept by the bloodstream to lodge itself in the smaller blood vessels of the brain.
    This type of clot is called an embolus. One such cause of clots is due to an
    irregular heart rhythm causing the pooling of the blood in the heart that
    prompts the formation of clots. This rhythm is called atrial fibrillation.

Stroke Caused by Hemorrhage

Hemorrhage is the medical term for bleeding. It could
be the direct result and most often originates from rupture of aneurysms
(ballooning in the wall of an artery because of a weak spot), flooding the
surrounding brain tissue with blood. The accumulated blood can cause an
excessive increase in pressure, whereas bleeding from other sources is usually
slower and at a much lesser pressure.

When hemorrhage starts directly into the brain
substance, the cause is most often hypertension, blood leaks from small
arterioles damaged by high blood pressure. The severity of the damage will
depend largely on the location of the bleeding, rapidity of the bleeding,
volume, and pressure of bleeding (Figure 4). There are two types of hemorrhagic stroke;

  • Intracerebral hemorrhage. This type of stroke is the result of a blood vessel
    that bursts in the brain and spills into the surrounding brain tissue, damaging
    brain cells. In addition, brain cells beyond the point of leakage are deprived
    of blood are damaged. Hypertension is the most common cause of this type of
    hemorrhagic stroke. Over time, high blood pressure can cause damage to the
    small vessels that eventually becoming brittle and rupture easily.
  • Subarachnoid hemorrhage. This type of stroke is when the bleeding starts on, or near the surface of the brain. Blood spills in the space between the brain and the skull. This bleeding prompts the sudden onset of pain, severe headache, and causes damage to the surrounding brain tissue.

                                              th_Thrombus_Artery.jpg?t=1329318890

Figure 4, A = Thrombus causes total occlusion of the artery, B = Embolism: small fragments dislodge to totally obstruct smaller arteries distally, C = Hemorrhage, D = Aneurysm

Warning Signals

It is quite often that certain warning signals do manifest themselves prior to the
onset of a stroke for example:

  • Sudden, temporary weakness or numbness of the face, arm, and/or leg on one side of the body
  • Sudden confusion and temporary loss of speech, difficulty speaking, or difficulty understanding speech
  • Dizziness, loss of balance, and falling down
  • Problems with vision, including double vision, blurriness, or total loss of sight
  • Sensation changes such as to heat, affinity to distinguish or feel pain or lose the feeling of touch
  • Hearing changes
  • Sudden, severe headache with no known cause
  • Change of personality moods and/or emotional changes
  • Loss of memory
  • Changes in taste
  • Problems reading or writing
  • Difficulty walking and becoming very clumsy

Usually, miniature strokes precede a major stroke; these are known as transient ischemic attacks or TIA.

These TIAs can occur days, weeks, or even months prior
to a major stroke. Blood clots are usually responsible for occluding the artery
temporarily. TIAs can also occur when an artery of the brain goes into spasm,
causing temporary occlusion of the artery and, therefore, interrupting blood
flow. The resulting symptoms usually occur very rapidly and last for a
relatively short period. Some of these symptoms are similar to the ones
mentioned in the above section.

Whenever you, or an acquaintance  you know experiences any of the above
symptoms, it is very important that you seek medical help immediately so that a
major stroke can be prevented. Explain to your doctor the exact symptoms since
he has to determine whether you suffered from a TIA or another ailment that has
similar symptoms such as a seizure, fainting, or symptoms from a cardiac
condition. In any event, prompt medical attention is important since it might
prevent a fatal or disabling stroke from happening.

If you experience any of the above, or you are a
witness to someone you know that started to experience the symptoms,
immediately and without any hesitation call 9-1-1 or the Emergency Medical
Services (EMS) number so an
ambulance equipped with advance life support be sent
to your location. One very important fact, check the time when the symptoms
first appeared.

A clot busting drug called plasminogen activator (tPA)
if given within the first three hours of the start of the symptoms can greatly
reduce long-term disabling effects of a stroke.

Prevention and Risk Factors

Preventing a stroke is very important. It can result
in a much healthier life for both the patient and their families.

It is very unfortunate to find that most of the
population is unaware of stroke. Even though a stroke is the third-leading
cause of death in the United States, it has received much less attention than
many other more publicized diseases.

A survey of a large number of the population showed
that nearly half could not name any early warning signs of stroke. The survey results also included the following:

  1. Most were aware
    that stroke is among the three major causes of death in the United States.
  2. In answering to
    the question, “A stroke occurs when the blood supply is cut off to what part of the body? Twenty-nine percent failed to select the “brain” as the correct answer from the choices of “heart,” “brain,” or  “others.”
  3. About 7 percent thought that arthritis was a major cause of stroke.
  4. Only 44 percent identified weakness or loss of feeling in one arm or leg as a symptom of stroke.

Despite the lack of knowledge about stroke, there has
been a constant decline in stroke incidences. The public has become more health
conscious. Eating habits have changed, and there has been a reduction of
smoking and alcohol. Physicians are treating hypertension more aggressively,
and the availability of better diagnostic methods has led to better assessing
vascular disease in general.

Therefore, the best way to prevent stroke is to reduce
the risk factors involved. There
are two types of risk factors:

  1. Uncontrollable risk factors for stroke
  2. Controllable riskfactors for stroke

Uncontrollable Risk Factors For Stroke

Age

The incidence of stroke is greatly related to aging
and increases tremendously in each successive decade for people over fifty-five
years of age. The incidence of hemorrhage rises steadily with age. Stroke in
individuals less than forty-five years of age is frequently related to cardiac
in origin. This does not mean that only the elderly suffer from stroke because
a number of younger people are equally affected.

Sex

Men have 30 percent more risks of stroke than women
have; however, for people under the age of sixty-five, the difference is
slightly greater yet. In most age groups, more men than women will have a
stroke in a given year. However, more than half of total stroke deaths occur in
women. Use of birth control pills and pregnancy pose special stroke risks for
women.

Race

African-Americans
have a much greater risk of death and disability than whites do, and the reason
is black people have a higher incidence of high blood pressure, diabetes and
obesity  than white people.

Prior Strokes

The risk of having another stroke in an individual who already has a history of
prior ones, is greatly increased compared to an individual who never had a
history of strokes. TIAs (transient ischemic attacks) are a very strong
predictor of stroke and should be considered as a medical emergency.
Recognizing the signs and symptoms of TIAs will reduce the risk of a major
stroke.

Heredity

Your stroke risk is greater if a parent, grandparent, sister or brother has had a
stroke. Some strokes may be symptoms of genetic disorders like CADASIL
(Cerebral Autosomal Dominant Arteriopathy that causes  a gene mutation that leads to damage of blood vessel walls in the brain, blocking blood flow).

Diagnosis

Once an individual has shown some signs or symptoms of
transient ischemic attack (TIA), or stroke, a physician must follow that
patient closely and gather all necessary medical history and physical
information to determine whether

Controllable Risk Factors For Stroke

High Blood Pressure

Hypertension, is a condition that affects a large number of the population and can start as early as age nine. However, high blood pressure weighs more heavily than any other risk factor for stroke; in fact, the risk of stroke varies directly with a person’s blood pressure. High blood pressure affects both sexes almost equally and is not very well tolerated. As described earlier, hypertension is a silent disease; it does not cause any pain or symptoms, and that is why in so many people it goes undetected without treatment. This is also, why so many people die from sudden death due to a stroke.

High blood pressure is easily controllable and thus has a direct relationship in the death rate reduction from strokes. Blood pressure must be checked regularly. If it remains high, consult your physician immediately.

Diabetes

Diabetes is a controllable disease. It affects a person and adds a tremendous stress on the metabolism,  and it becomes a risk factor for stroke. This is even truer for women than men. Diabetes also strongly correlates with high blood pressure, making the risk for stroke greater.

Cardiovascular Disease

Cardiovascular disease increases the risk of stroke, mainly because of two reasons the first since the heart fails as a pump, and the consistency of a failing pump will cause deficiencies in the circulation, which leads to poor oxygen supply to the brain. Secondly, a diseased heart is a source of emboli (blood clots), which are carried by the bloodstream, causing obstruction to certain arteries responsible for supplying blood to the brain; thus, a stroke occurs. Diseased blood vessels of the arms, legs, and carotid arteries are a pathway of debris
towards the brain. Atrial fibrillation or quivering of the heart is anothercause of clot formation.

High Red Blood Cell Count

An increase in the red blood cell count may cause a stroke because the red blood cells tend to stick to each other, causing the formation of clots. The administration of blood thinners may solve the problem, preventing stroke. Sickle cell disease is a genetic disorder that
affects mostly African-Americans and Hispanic children. Sickled red blood cells
are not able to carry the normal amount of oxygen to the tissues and organs.

Besides the above two groups of risk factors, there are a number of other factors that play a role in promoting stroke who should be mentioned. Although these factors play a smaller role, they could become major risks if they are in association with others.

These risks are:

  1. High cholesterol intake of fat in your food
  2. Elevatedcholesterol and triglyceride levels
  3. Cigarette smoking
  4. Excessive consumption of alcohol
  5. Lack of exercise
  6. Obesity
  7. Oral contraceptives
  8. Poor diet
  9. Suffice to mention that other factors such as; Geographic location,
    Socio-economic factors, alcohol abuse and drug abuse play a role in the onset of stroke.

Although these are minor risk factors for strokes, they are major factors for heart disease; and heart disease is a major risk factor for stroke.

Stroke can cause death. Certain people have described that death is better than the disabling condition  patient experiences after a stroke. Furthermore, it is a traumatic experience for the direct family members of patients; therefore, it is important to understand the causes of stroke, and the risk factors involved. Unfortunately, no one can prevent a stroke, from happening, but one should be able to control the risk factors. Following a good diet and participating in an exercise program will definitely reduce the chances of suffering a stroke. Regular visits to your doctor and controlling high blood pressure is a healthy way to prevent a stroke.

Diagnosis

Once an individual has shown some signs or symptoms of transient ischemic attack (TIA), or stroke, a physician must follow that patient closely and gather all necessary medical history and physical information to determine whether these symptoms are, in fact, those of a stroke, since they could be of a different non-related disease.

A careful review of the events that happen are very important. Once all the physical data, facts, and laboratory test results are completed, the physician will be able to determine and pinpoint the presence of any abnormality(s) causing the symptoms.

Since the carotid arteries are the only link of blood supply to the brain, a careful examination of these arteries is appropriate and should be conducted, particularly if a bruit (unusual noise) is heard in the carotid artery region. An ultrasound examination is completely safe,
non-invasive, and painless, and it will show if any plaques are present in the artery that could possibly cause a significant reduction of blood flow to the brain.

If this test is positive, an arteriogram should be conducted in which a dye is injected into the blood at the site of the plaque, and digital images are recorded. These pictures will show the exact location and percentage of narrowing, if any is present. Upon the final interpretation
of the arteriogram, your physician will be able to make the decision regarding a method of treatment. If the narrowing is not important , the patient will be put on medication and watched very carefully. On the other hand, if the narrowing is significant, surgical intervention might be necessary. This is known, as carotid endarterectomy.
Your physician will determine the course of treatment. Similar to coronary  arteries stenting described in the Cardiac catheterization chapter, carotid artery stenting is feasible if the location and type of obstruction are favorable, thus preventing a surgical intervention.

The carotid arteries are not the only vessels responsible for causing a stroke; vessels present within the brain could also cause a stroke. An arteriogram of the brain is conducted to determine the presence of any disease. An arteriogram will also reveal the presence of a
brain tumor, that produces symptoms similar to those of a stroke. Cat Scan or computerized axial tomography scanner is another technique to diagnose the presence of tumors, and injury to the brain. If a lesion is found in the arteries of the brain, intervention can be performed to correct the problem. These aggressive techniques are not within the scope of this book. If a lesion is found in the arteries of the brain, intervention can be performed
to correct the problem.

Treatment of Stroke

Emergency treatment for stroke depends on whether you are having an ischemic stroke blocking an artery — the most common kind — or ahemorrhagic stroke involving bleeding into the brain.

            Ischemic stroke. To treat an ischemic stroke, doctors must quickly restore blood flow to your brain.

            Emergency treatment with medications. Therapy with clot-busting drugs must start within three hours — and the sooner, the better. Quick treatment not only improves
your chances of survival, but may also reduce the complications from your
stroke. You may be given: blood-thinning drugs such as Coumadin, heparin or others.
Aspirin is the best-proven immediate treatment after an ischemic stroke to
reduce the likelihood of having another stroke.

Several methods and techniques are available for the treatment of stroke:

  1. The surgical removal of plaques in arteries and tumors surgically, this    requires hospital admission and fullanesthesia.
  2. Drug therapy is administered aggressively through an intravenous (IV) of the most promising treatment by injecting the FDA-approved tPA (tissue plasminogen activator) that can significantly reduce the effects of stroke and reduce permanent
    disability. Generally, 3-5 percent of those who suffer a stroke reach the hospital in time to even be   considered for the treatment.
  3. Acute hospital care
  4. Rehabilitation
  5. Stenting could also be utilized to open an obstructive lesion similar to   the method described for coronary stenting (see: cardiac catheterization).

In many occasions, treatment of the heart can mean treatment of the stroke since
many forms of valvular diseases (diseases of the heart valves) may cause the
formation of clots that dislodge, travel in the blood stream, and end up in the
brain, causing a stroke.

We have outlined very briefly the method of treatments. Since treatment of stroke
is a very personalized matter, your physician should be able to give you
additional information regarding this matter. You can contact the stroke
division of your local American Heart Association for more information. The
Internet has a vast library dealing with stroke, stroke patients, recovery, and
much more.

Coping with Stroke Patients

In the next few pages, we will describe briefly and give you general guidelines as to why stroke patients behave the way they do and some helpful hints in their rehabilitation . The following quotes are often heard from family members of stroke patients.

I understand why my wife has difficulty using her arm and leg following her stroke, but why does she cry so much?

My father has learned to walk since he had his stroke, but why does he keep bumping into things?

Mom used to be such a good housekeeper before her stroke, and now she is sloppy.

My husband had a stroke, and now nothing I do seem to please him.

th_Brain_Opposite_Side.jpg?t=1329318888Figure 5 Brain damage affects opposite side of the body.

It is important to understand that stroke affects the brain. Some areas of the brain are damaged, and this damage is probably permanent; the behavior of these patients has completely changed their personality. Stroke will not affect all areas of the brain, nor is intelligence affected equally; as a result, all stroke patients are not affected alike. Each stroke patient will behave and act differently depending on the type and severity of the affected area.

The brain is made of two halves: the right and left side. If an injury occurs on the left side of the brain, the right side of the body is affected. On the other hand, if the right side of the brain is injured, the left side of the body is affected (Figure 5).

Right-Sided Paralysis

A right-side paralysis, or right hemiplegia, means the left side of the brain is damaged or
injured. A stroke patient with right hemiplegia is likely to have speech and
language problems. This is called aphasia. Aphasia (apha’sia) is defined as “A weakening or loss of the faculty of transmission of ideas by language in any of its forms, reading, writing,
speaking or failure in the appreciation of the written, printed or spoken word”
(Stedman’s Medical Dictionary) (Figure 6).

th_Left_Sided_Stroke.jpg?t=1329318889Figure 6 Left side of Brain damaged causing right-sided paralysis

Language and Memory Problems

Aphasia is a condition, that follows brain injury, but not everyone who suffers from a stroke becomes aphasic. That person begins to
experience a life of scrambled communication. For every word, he attempts to say, another one comes out, no matter how hard he tries. When he speaks, it sounds like complete nonsense.

In our society, a great deal of emphasis is placed upon speech and communication. When a person cannot speak or cannot be understood, we have the tendency to regard him as a disabled person. Because an
aphasic person cannot speak properly with others, it does not mean that he is unable to communicate. Along with speech difficulty, there is also a difficulty in reading, writing, or using numbers.

It is an error to isolate the aphasic patient in a world of no communication simply because his language is gone. Many other activities can be carried out daily without the use of speech.

At times, an aphasic patient may describe an item or object with a word that we do not understand. For example, he might use the word BAK to describe a table or chair; therefore, we can use his word if that term is being consistently used. Insisting on using the correct terminology can generate a great deal of frustration and anger. Many aphasic patients will quickly develop a way of communication without the use of speech. They develop an effective language by supplementing gestures, sounds, or nonsense words. If you treat the patient, as if he cannot communicate and do not respond to his “language,” he may stop
completely from trying to communicate with you.

The aphasic patient needs to recover the use of language that he possessed before his stroke. It is believed that he has not lost his language but rather the ability to recall it, and how to use it. So recovery does not mean he has to learn the language like a child, but rather
recalling what has already been learned.

One of the most common errors made when dealing with an aphasic patient is to overestimate his understanding of speech. At first, you may be dismayed at his inability to speak or understand speech. You may think that he cannot communicate or use language in any form, but then you discover signs that look as if he understands. Therefore, it is easy to jump to the conclusion that he understands much more than he actually does.

It is a good idea to check he level of understanding of an aphasic patient. This can be done easily by saying one thing and pointing to another. For example, if it was summer, you smile, look out the window, and say, “It is snowing today, isn’t it?” If the patient smiles or indicates yes, then you have evidence that he is responding to the sound of your voice rather
than the spoken words.

It is important to use small and simple sentences rather than long and complicated ones. You might find yourself speaking louder to a person who seems not to understand. Remember that there is nothing wrong with the patient’s hearing. Always maintain the same tone of voice and speak normally with small and simple phrases.

The most frequent physical problem accompanying aphasia is weakness or paralysis of the right side of the body. Usually, only the leg, one arm, a hand, and a portion of the face are affected.

In time, the use of both the arm and leg are regained, but weakness lingers in the arm more than the leg and in the hand longer than the arm.

Aphasic patients may have severe headaches, and at times, convulsions. They also may experience visual disturbances such as seeingobjects off to the right or left.

Behavior Problems

In addition to language problems, right hemiplegic patients have a tendency to be slow and cautious in their actions. This behavior will surprise friends and family members that knew the patient to be quite different before his stroke.

Because of brain injury, the individual has less control over his emotions than before his illness. The aphasic patient tends to become very frustrated by not being able to make himself understood. These patients become easily irritable and cry, laugh, and act impulsively at times.

The right hemiplegic patient is likely to need frequent, and plenty of feedback that his performance is correct. It is better to give more feedback than too little. If he performed correctly, give him some positive reinforcement immediately. It has to be the correct feedback; otherwise, you will be insulting his intelligence. If he commits an error, wait
for him to correct it; if he continues in error, show him it is incorrect, give him a hint, and indicate success thereafter.

The right hemiplegic patient needs more indications of success than failures; therefore, always keep your comments positive rather than negative or critical. Just remember that if he acts the way, he does it, is not because he wants to, but because his handicap makes him do so.

Recovery from Aphasia

Recovery from aphasia is a continuous process, and it is difficult to predict with any accuracy how a patient will improve over a specific period. Most of the progress will be made before the end of the first year, but progress will continue forever even over a lifetime. Some make great recoveries in short period of times; others recover in varying degrees. It is important that family members work steadily with the patient. The family should not count on the patient recovering without assistance. Help is necessary and should be given in every possible way. Speech control usually returns gradually.

Besides his loss of communication and his limitation in movement, (paralyzed arm or leg), the aphasic patient will feel as if he is enclosed behind a fence with very limited means to get out. His main goal is to move from behind that fence and overcome his speech problem and physical disability (if he has one). The family by his side has a unique opportunity to help him meet these needs.

Summary

Right paralysis or right hemiplegia means left brain damage.

Right hemiplegics will often have difficulty with speech and language. They are cautious, anxious, and disorganized when performing new tasks.

  1. Do not underestimate the ability of an aphasic patient to communicate, even if he has lost his speech.
  2. If he cannot speak, use a different form of communication such as hand language.
  3. Do not shout or use special voices. Keep a normal tone of voice and use  simple and short sentences.
  4. Any tasks given to aphasic patients should be given in simple steps.
  5. Always give feedback and encouragement when he performs correctly.

Left-Sided Paralysis

A left-sided paralysis, or left hemiplegia, means the right side of the brain has been damaged
(Figure 8-7). The stroke patient with right brain damage will often show difficulty with spatial-perceptual tasks. The patient will have difficulty judging distance, size, place, rate of movement, form, and the relation of certain parts of an object to the whole object. A stroke patient with right brain damage has more difficulty learning to care for himself than the patient with equally severe aphasia.

th_Right_Sided_Stroke.jpg?t=1329318889Figure 7 Right side of the Brain is damaged causing left side paralysis

Almost all normal people have experienced at one point
or another minor deficit of spatial-perceptual ability; for example, when you expect to have another step when there is none, you will be “jarred” when you find it is not there, or when you place an object on the table to find that you missed the table completely.

The left hemiplegic patient has exactly the same problems but extremely
magnified, consistent, and severe. A patient might put all his concentrations into achieving a certain act, and yet he would still miss. He may also confuse the inside and outside of his clothes and the left from the right.

He might have some difficulty differentiating, whether he is sitting or standing and difficulty estimating the distance of objects. He might have difficulty reading the newspaper or even adding a simple column of numbers because he keeps losing his place in the paper. He will miss buttons when buttoning his shirt, making it uneven. A female patient may put her
lipstick on crooked.

Behavior Problems

A left hemiplegic patient behaves in ways, which promote overestimation of his ability. He tends to be impulsive and fast; he behaves as if he is unaware of his problem and will comment that he can do anything. He will always try to do things that are beyond his
ability and are unsafe. He will try to walk without his walker just to fall within the first few steps. Do not take the word of left hemiplegic patients (since they will tell you that
they are capable of performing anything) unless they can demonstrate toyou that they really can.

If you have some difficulty teaching a task to a left hemiplegic patient, try to talk him through the task rather than using signs and gestures to teach him that particular task. It is not a bad sign if the left hemiplegic starts to talk to himself about how to accomplish certain tasks. He needs a great deal of feedback when attempting to complete a task, and he also needs to be encouraged, and every completed step needs to be checked.

Feedback should be in the form of encouragement rather than criticism. Do not nag; it tends to make them extremely angry and upset, and most definitely, their performance will drop. Left hemiplegic patients have difficulty understanding with visual cues since they misjudge distance. A cluttered room is very disturbing because it becomes distracting. Sudden and
fast-moving people or objects will just add to their confusion. Provide them with clearly marked reference points, such as doorframes or a standing full mirror. A well-lit room and simpleobjects are very important.

Summary

A left hemiplegic patient has right brain damage. He will be unable to judge size and distance. He will always talk better than he actually can perform. He is impulsive and careless. However:

  1. Do not overestimate his abilities
  2. Use language if he has difficulty with demonstration
  3. His tasks should be given in small steps; give plenty of feedback
  4. Check his action rather than taking his word for it
  5. Keep his effects neat and avoid clutter
  6. Minimize any sudden and fast movements
  7. Pinpoint visual reference points

Stroke in General

Stroke in general is damage to the brain. Some patients will show no evidence of paralysis, and yet they will give intellectual deficits. Others will show paralysis but not intellectual
problems. However, usually stroke patients will demonstrate some kind of behavioral deficits—an indication of brain damage.

It is important that a stroke patient should be able to guide and check his own behavior. This means doing the “right” thing at the “right” time. This could also be called social judgment. This kind of control is best identified by those closest to the patient, since they can see and
identify the changes that might be completely missed by friends and relatives who are not with the patient at all times.

The quality of life and the changes that occur to stroke patients are enormous and obvious. The meticulous person might become very sloppy and care little about his appearance. He may say the wrong thing at the wrong time. The quiet person may become noisy. The shy person may become immodest and very aggressive. The previously talented conversationalist may become boring and repetitive, and the prudent and cautious person with his money may start spending on impulse.

These enormous changes in the quality of life are very obvious and annoying to others because these changes are quite often not well-understood. They are mistaken for psychological problems, and patients with visible deficits are called sloppy or lazy. Patients with minor speech deficits are called depressed or disinterested because they do not talk. Patients with a memory deficit are sometimes called dirty old men because they forget to zip
their pants.

Conclusion

While stroke patients have significant emotional problems and might need professional help, it is very important to recognize these deficits and not make things more severe by ignoring these problems. These patients lack control of the quality of life they lead, and they will
undoubtedly need all the help they can get from the environment. They will need more encouragement and feedback than just psychotherapy alone. The stroke patient who fails to bathe or change his shirt may well have the ability to dress himself independently and groom adequately. Unfortunately, because of his intellectual deficit, he forgets or cannot see his errors.

Remember that the purpose of feedback is to help him recognize his bad behavior and to let him practice a better way. Do not nag at stroke patients, since they will become very angry and things might become worse. Your feedback should be prompt; otherwise, its effect is lost. Most importantly, you will need plenty of patience.

As previously mentioned stroke is a very large subject. A complete book can be devoted to it; however, we have outlined the general information about stroke patients and briefly described how to recognize some of their actions and behavior. If the reader requires more
detailed information, contact your physician or your local chapter of the American Heart Association (AHA), or the American Stroke Association (ASA), and they will supply you with more information regarding the subject.

Stroke is a disease of the cardiovascular system, it affects a large number of the population and its mai causes and risk factors are similar to those of Heart Disease. A new book is now available for everyone to learn and describes many topics about the prevention of both heart attack as well as stroke.

You can obtain a copy of the book at the following link;

http://www.tatepublishing.com/bookstore/book.php?w=9781613468449