The traditional definition of stroke, devised by the World Health Organization in the 1970s, is a “neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours”. This definition was supposed to reflect the reversibility of tissue damage and was devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. The 24-hour limit divides stroke from transient ischemic attack, which is a related syndrome of symptoms that resolve completely within 24 hours. With the availability of treatments that, when given early, can reduce stroke severity, many now prefer alternative concepts, such as brain attack and acute ischemic cerebrovascular syndrome (modeled after heart attack and acute coronary syndrome respectively), that reflect the urgency of stroke symptoms and the need to act swiftly.
Strokes can be classified into two major categories: ischemic and hemorrhagic. Ischemic strokes are those that are caused by interruption of the blood supply, while hemorrhagic strokes are the ones which result from rupture of a blood vessel or an abnormal vascular structure. About 87% of strokes are caused by ischemia, and the remainder by hemorrhage. Some hemorrhages develop inside areas of ischemia (“hemorrhagic transformation”). It is unknown how many hemorrhages actually start as ischemic stroke.
In an ischemic stroke, blood supply to part of the brain is decreased, leading to dysfunction of the brain tissue in that area. There are four reasons why this might happen:
Thrombosis (obstruction of a blood vessel by a blood clot forming locally)
Embolism (obstruction due to an embolus from elsewhere in the body, see below),
Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)
Stroke without an obvious explanation is termed “cryptogenic” (of unknown origin); this constitutes 30-40% of all ischemic strokes.
CT scan showing an intracerebral hemorrhage with associated intraventricular hemorrhage.
Intracranial hemorrhage is the accumulation of blood anywhere within the skull vault. A distinction is made between intra-axial hemorrhage (blood inside the brain) and extra-axial hemorrhage (blood inside the skull but outside the brain). Intra-axial hemorrhage is due to intraparenchymal hemorrhage or intraventricular hemorrhage (blood in the ventricular system). The main types of extra-axial hemorrhage are epidural hematoma (bleeding between the dura mater and the skull), subdural hematoma (in the subdural space) and subarachnoid hemorrhage (between the arachnoid mater and pia mater). Most of the hemorrhagic stroke syndromes have specific symptoms (e.g., headache, previous head injury).
Signs and symptoms
Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage.
Various systems have been proposed to increase recognition of blood flow to the brain problems by patients, relatives and emergency first responders. A systematic review, updating a previous systematic review from 1994, looked at a number of trials to evaluate how well different physical examination findings are able to predict the presence or absence of stroke. It was found that sudden-onset face weakness, arm drift (i.e., if a person, when asked to raise both arms, involuntarily lets one arm drift downward) and abnormal speech are the findings most likely to lead to the correct identification of a case of stroke (+ likelihood ratio of 5.5 when at least one of these is present). Similarly, when all three of these are absent, the likelihood of brain disorder is significantly decreased. While these findings are not perfect for diagnosing stroke, the fact that they can be evaluated relatively rapidly and easily make them very valuable in the acute setting.
For people referred to the emergency room, early recognition of stroke is deemed important as this can expedite diagnostic tests and treatments. A scoring system called ROSIER (recognition of stroke in the emergency room) is recommended for this purpose; it is based on features from the medical history and physical examination.
One of the challenges in the treatment, after diagnosis and treatment of the acute incident, is the time frame to addressing the underlying penumbra and restoring function as quickly as possible. As all medical approaches are time sensitive with brain function, post stroke a number of options exist. Remember that stabilization of function is essential prior to beginning any therapy for rehabilitation.
During the last number of years there has been a substantial effort to begin rehab as quickly as possible. In the conventional settings however the use of “experimental” techniques has been limited. One example is the use of hyperbaric oxygen to use oxygen under pressure to return function to damaged areas. Clearly there is a body of evidence to suggest this should be a primary intervention, for a number of patients. Its limited by the availability and cost as insurances will not pay for “experimental” services.
In a similar light is the use of stem cells to seed the brain with new neurological potentials. In many neurological disorders it has been clearly seen as the necessary step to reestablish both lost connections and function. There is a misconnection that in order to achieve this phenomenon stem cells need to be surgically placed in the damaged areas. With proper adjuvant therapies, at the time of stem cell infusion, along with stimulation utilizing growth factors one can safely begin a neurological rehabilitation program. We do place the cells in the spinal canal and our comprehensive protocols enhance blood brain permeability allowing for increased seeding.
At World Stem Cells, LLC we have developed a set of protocols to address the patients post stroke needs, including modifications to utilize many adaptive aid, coupled with ongoing physical and occupational therapy, under the supervision of a board certified neurologist and staff.
Due to the nature of this disorder it is essential to address the stroke as soon as possible and make certain that you’re released and stable to fly. Only your neurologist should make this determination.
There is now a significant amount of published data that clearly indicates this therapy as appropriate and potentially life saving.
The studies have confirmed that an increased blood flow, in the ischemic areas, occurs within a few days after stroke and is associated with neurological recovery. The induction of new blood vessel formation (angiogenesis) has been reported with transplantation of stem cells, from the amplified growth factors in the damaged area.
A neuroprotective effect occurs by the secretion of cytokines, chemical messengers stimulated by the new stem cells. Reductions in lesion size have been noted in a number of studies. Also reduced inflammation coupled with inhibition of an overactive immune response has been seen.
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