Stroke

How do I recognize a stroke and what should I do?

FAST

F – A – S – T stands for Face (face), Arms (arms), Speech (speech) and Time (time).

• Face: Ask the person to smile.
  Is the face distorted on one side?
• Arms: Ask the person to stretch their arms forward and turn their palms upwards.
  Can the arms be raised? Do they sink or do the palms turn inwards?
• Speech: Have the person repeat a simple sentence.
  Is she unable to do this or does her voice sound washed out?
• Time: Call 144 immediately and describe the symptoms and onset of symptoms.

What is a stroke?

There are two different types of stroke: an ischemic stroke, i.e. reduced blood flow to the brain, and a hemorrhagic stroke, i.e. a cerebral hemorrhage. Both forms can lead to impairments throughout the body, depending on the area of the brain in which the stroke has occurred. This is because each brain region controls different bodily functions.

What is a stroke?

A stroke often does not announce itself to those affected, but occurs abruptly – like a sudden blow. This is why this dramatic dysfunction in the brain is also known as a stroke. In around 85 percent of cases, it occurs because a blood vessel in the brain is blocked; this is known as an ischemic stroke. If the blood supply to a certain area is interrupted, this leads to a reduced supply to this area. This results in functional limitations in the affected body regions, which can manifest themselves as neurological deficits such as paralysis, speech disorders, dizziness or visual disturbances. If the blood vessel is not reopened within a few hours, these disorders persist. In about 15 percent of cases, however, it is a hemorrhage in the brain: a blood vessel has burst, which increases the pressure in this area; this form is called a hemorrhagic stroke.

Strokes mostly affect older people, around four-fifths of whom are over 60 years old. But younger people, even children, can also have a stroke.

Stroke: causes and risk factors

Both forms of stroke, the more common ischemic stroke and the hemorrhagic stroke, have different causes.

Ischemic stroke

In an ischemic stroke, a blood vessel in the brain is blocked. As a result, the underlying tissue is more or less cut off from the blood supply, and oxygen and sugar are no longer sufficiently available. If this condition lasts longer, the undersupplied area dies off. In addition to various rare causes, there are two common mechanisms for vascular congestion:

• Often, arteriosclerosis has been present for years. A blood clot (thrombus) can form at a narrow point in the vessel and block the bloodstream (local thrombotic occlusion) or the blood clot can break loose (embolus) and then block a smaller vessel further distally (=in the direction of blood flow) (arterio-arterial embolism).
• A clot forms in the heart, which then travels via the bloodstream to the brain and blocks a vessel there (cardioembolism). This can occur with cardiac arrhythmias such as atrial fibrillation.

Hemorrhagic stroke

The most common cause of a hemorrhagic stroke is high blood pressure. The blood vessels are permanently overloaded by the high blood pressure and can tear. If this happens in the brain, a cerebral hemorrhage occurs. The escaping blood exerts mechanical pressure on the surrounding area. The surrounding nerve cells are damaged. In addition to high blood pressure, there are rare causes of cerebral hemorrhage, such as vascular malformations in the brain.

Risk factors for a stroke

There are various factors that significantly increase the risk of a stroke. You cannot influence two of them. These are:

• Age: Most of those affected are over 60 years old.
• Family predisposition: If one or even several of your relatives have already had a stroke, your own risk may also be increased.

However, there are four times as many other known risk factors for which you can reduce the risk of a stroke yourself with medical support:

• Smoking: Tobacco consumption is one of the most important preventable risk factors.
• High blood pressure (hypertension): Permanently high blood pressure damages the blood vessels and promotes strokes.
• Diabetes mellitus: A poorly controlled blood sugar level can damage the blood vessels and increase the risk.
• Elevated blood lipid levels (e.g. LDL cholesterol): promote hardening of the arteries (atherosclerosis).
• Overweightespecially abdominal fat: severe obesity is associated with other risk factors such as high blood pressure and diabetes.
• Lack of exercise: An inactive lifestyle increases the risk on several levels.
• Excessive alcohol consumption: Regular high alcohol consumption damages blood vessels and organs.
• Chronic stress: Persistent psychosocial stress can have a negative impact on cardiovascular disease.

Symptoms of a stroke

There are a number of signs that can indicate a stroke. They are so different because they depend on which area of the brain is affected by the stroke and which bodily functions are impaired by the resulting deficiency. These are mostly neurological deficits.

The most common symptoms are

• A feeling of weakness (paresis) or total loss of muscle strength (plegia). Typically, these symptoms only occur in one half of the body, as the stroke usually only affects one half of the brain. The opposite side of the body is then affected by the feeling of weakness. Example: The stroke affects the right side of the brain, paresis or plegia occur in the left arm and leg.
• Sensory disturbances such as numbness, affecting one half of the face and one arm
  Slurred speech, slurred speech and difficulties with communication show the range of speech and language disorders.
• Dizziness and unsteady gait: This can manifest as a sudden spinning or swaying sensation, accompanied by difficulty maintaining balance, which can lead to an unsteady, staggering gait or even falls.
• Swallowing disorders (dysphagia): Those affected may have difficulty swallowing saliva, liquids or food. This can be manifested by frequent choking, coughing or gagging during or after eating and drinking, or by the feeling that something is stuck in the throat.
• Visual disturbances: These can take many forms, such as suddenly seeing double vision, blurred vision, temporary blindness in one eye or a restricted field of vision (as if part of the visual area is covered
• Confusion: Sudden disorientation. Those affected appear restless and unfocused, can no longer assess situations correctly or answer simple questions adequately.
• Drowsiness to unconsciousness: This can range from severe drowsiness and apathy to a state in which the person no longer reacts to external stimuli. Deep unconsciousness is less common in strokes, but is a very serious sign.
• Very severe, sudden onset of headache and vomiting

The symptoms usually occur suddenly. An exception to this is the so-called wake-up stroke, where those affected wake up in the morning with symptoms. They were therefore unable to notice when exactly they had started, as this happened during sleep.

But it doesn’t matter whether you notice these symptoms from one minute to the next or only in the morning, whether they are dramatic or mild: You should always call the emergency services (144) immediately or have them call you. Because every minute counts when treating a stroke. A stroke can be life-threatening. And the more time that passes before treatment begins, the greater the risk of permanent damage.

Stroke: Diagnosis with us

In the event of neurological deficits, the ambulance service usually takes the patient immediately to a specialized center (stroke unit, stroke center). As a stroke center, the USZ offers all the possibilities of modern stroke care at any time of day or night. Specialists from neurology, neuroradiology and neurosurgery work closely together on an interdisciplinary basis. Other hospitals with a stroke unit carry out the necessary diagnostics and transfer patients to the stroke center if necessary. The diagnosis must be made very quickly and consists of a neurological examination to clarify the symptoms in more detail: Computed tomography or MRI. The CT scan helps to determine whether it is ischemia or a cerebral hemorrhage, i.e. whether a blood vessel is blocked or has burst. This distinction is important because the acute treatment of these two forms of stroke is very different.

In the further course, the cause of the stroke must then be clarified with the help of:

• Ultrasound examination of the neck vessels
• Ultrasound examination of the heart
• Cardiac waveform (over at least 48 hours) to detect whether cardiac arrhythmia is present.

Stroke: gender-specific aspects

Although the classic signs of a stroke – such as sudden paralysis on one side, speech disorders or loss of vision – generally apply to all genders, there are important gender-specific differences in both the symptoms and the risk factors that need to be taken into account in women. Awareness of these differences is crucial as they can influence timely diagnosis and treatment.

Differences in the symptoms

While men more frequently show the “classic” focal deficits, women can also experience additional or sometimes more superficial so-called atypical or non-specific symptoms. These include, for example:

• Sudden, severe and unusual tiredness or general weakness
• Nausea and vomiting
• Shortness of breath or shortness of breath
• Pain, for example in the chest, neck, jaw or limbs (which can be mistaken for a heart attack or other illness)
• Sudden confusion, disorientation or loss of consciousness
• Hiccups or sudden changes in behavior

These non-specific symptoms can make diagnosis more difficult, as they are not always immediately associated with a stroke. It is important to emphasize that women can also suffer the classic symptoms.

Special risk factors for women

Women have some gender-specific risk factors for stroke, and certain common risk factors may put them at a higher relative risk:

• Hormonal factors: Taking the contraceptive pill (especially in combination with smoking), pregnancy (and complications such as pre-eclampsia) and hormone replacement therapy during the menopause can increase the risk.
• Atrial fibrillation: This cardiac arrhythmia is associated with a higher risk of stroke in women and is often more severe than in men.
• Diabetes mellitus: Women with diabetes tend to have a higher risk of stroke than men with diabetes.
• Migraine with aura: This type of migraine affects women more frequently and is a known risk factor for ischemic strokes.
• Older age of onset: On average, women often suffer strokes at an older age than men, which can be associated with an increase in other comorbidities and a potentially more complex initial situation.

Knowledge of these gender-specific differences is of great importance both for prevention and for responding quickly and correctly in an emergency in order to optimize treatment outcomes for all those affected.

Preventing and recognizing strokes at an early stage

The risk of a stroke can be reduced if you control and treat the common risk factors in particular. We can advise and help you with this as part of our specialized stroke consultation hours:

1. Prevent high blood pressure from developing – and if it doesn’t, it should at least be well controlled. This means that, in consultation with us, you can lower your blood pressure by taking the right dose of medication and adopting a healthy lifestyle.
2. Protect yourself from high blood lipid or sugar levels with a healthy diet, exercise and, if necessary, medication, which we will work with you to optimize.
3. Stop smoking.
4. Make sure you exercise regularly.
5. If you sometimes have palpitations or other pulse irregularities, please have them checked by a cardiologist.
6. Avoid stress.

In addition, an ultrasound examination of the blood vessels, such as the carotid artery, can show whether the blood vessels are in good condition or whether the innermost layer of the vessel wall has changed – an important indication of arteriosclerosis. Of course, regular blood pressure checks complement the stroke prevention program.

Course and prognosis of a stroke

Ultimately, a stroke can be life-threatening. In industrialized nations such as Switzerland, stroke is the third leading cause of death. It can lead to lifelong disabilities, but also to dementia. This results in enormous costs for the healthcare system (direct healthcare costs alone amount to over CHF 700 million per year).

A stroke is therefore always a medical emergency and treatment should start as soon as possible. Every minute counts. If therapy is started as soon as the first symptoms appear and only a small area of the brain is affected, the stroke can, in the best case scenario, have no consequences.

Unfortunately, sometimes the therapy does not work quite as quickly, and more or less impairing functional disorders remain – such as speech disorders and partial paralysis. However, with the appropriate neurorehabilitation, these can disappear or at least be alleviated over time. The brain develops the ability for intact areas to learn and take over the tasks that were lost with the damaged areas. However, this often requires a lot of time, but also the strength, will and motivation of those affected.

Self-help groups

The exchange with people who are affected by the same disease can be a great support in coping with the disease. Advice on finding a suitable self-help group is available from Selbsthilfe Zürich. Self-Help Zurich and the University Hospital Zurich are cooperation partners in the national project “Health literacy thanks to self-help-friendly hospitals”.

Stroke: Treatment - the sooner the better

Depending on whether it is an ischemic stroke (caused by a blocked blood vessel) or a hemorrhagic stroke (caused by a cerebral hemorrhage), the therapies differ fundamentally. In each individual case, however, the time factor is absolutely critical. Immediate, precise diagnosis, usually by means of imaging procedures such as computer tomography (CT) or magnetic resonance imaging (MRI), is therefore essential. This makes it possible to quickly identify the type of stroke and thus initiate the appropriate, often very different, acute treatment without delay.

In the case of an ischemic stroke, the main aim is to restore the blood supply to the affected area of the brain as quickly as possible (reperfusion). This can be done with medication by dissolving the blood clot (systemic thrombolysis) or mechanically by removing it using a catheter procedure (thrombectomy).

In haemorrhagic strokes, on the other hand, the focus of acute therapy is on stopping the bleeding, controlling the often increased intracranial pressure and stabilizing vital functions. This may, for example, require blood pressure regulating measures, the administration of medication for blood clotting or, in certain cases, neurosurgical intervention.

Regardless of the cause, the immediate transfer of the patient to a specialized department (stroke unit or stroke center) is of crucial importance. Continuous monitoring and a rapid response to possible complications can be guaranteed there. However, the primary goal of all these rapid and targeted measures is always to save as much brain tissue as possible, to minimize or restore as much neurological function as possible as a result of the stroke and to set the course for subsequent rehabilitation and secondary prevention at an early stage.