Stroke I: acute neurological injuries vascular originated

Accidente cerebrovascula

I have been working as a paramedic volunteering of the Spanish Red Cross until relatively recently. The other day I found one of my colleagues and we remembered few anecdotes from our common past in the organisation. He remind me an alert that we had together, in the middle of the night, in which we should go to evaluate an elderly woman, because his family was alert the 112 emergency service stating she looks different as usual.

When we finally arrived at her home, lost in an old village in the middle of the Madrid’s mountains, two men came to meet us attracted by the sound of the warning siren, which identified themselves as husband and son of the patient.

There was not much light at the entrance, so we pass through a small hall to the living room. The lady was sitting near a heater, and we could observe at first sight her face, asymmetrical and with a twisted lip commissure, with which we were alarmed immediately. We asked the woman some questions like what was her name and location, but she replied us with an unintelligible language. When we also interrogated the family how long was the patient like that, they replied she was for years, as suffering dementia (maybe vascular) and it was not unusual to hear her saying nonsense words or moving things to a different places. But they had called us because she had fainted a while ago and now her face was not as always.

With a score on the Glasgow scale of 11 points (4 of ocular response, 3 of verbal response and 4 of a motor response), we had to notify the Emergency Coordinator Centre that the patient should be assessed by an advanced life support (ALS), because this situation was out of our limits of assistance. The response from them was that there were none available at that moment and we have to drive the patient immediately to hospital… O.K., one possibly cerebrovascular accident (CVA) in a basic life support unit (BLS)? Obviously it was not optimal, but to be honest, it was the best option available.

AmbulanceAs I remembered, we took the patient into the ambulance, sat her at the stretcher and one of my colleagues and I assist her in the back part. While he was busy putting her nasal cannula (her saturation was not good at all), I tried to finish the neurological exam. Hemiparesis was evident, but the rest of the points were not really objective. The patient had cataract, so was complicated to do the pupil assessment, although a slight anisocoria and low reactivity was appreciated (in that situation, it was not all bad). The patient was uncooperative with strength tests, so we only could check at that moment that her sensitivity was not affected, since both members were retreated to a painful stimulus. She had a lightly high blood pressure, which reaffirmed the possible neurological diagnosis. My colleague also made her a glucose test that showed it was within normal limits.

ANUNCIO

While the patient was transferred to the hospital by ambulance, she became gradually drowsier, so we fought to keep her entertained and to maintain her level of consciousness. I must confess that this alert was one of the first that I made from Red Cross Services, and at that time I had few experience in the area of outpatients. Moreover, as a BLS, there were many things we could not do (electrocardiograms, cannulate to give IV…) so the only way for us at that moment was to follow the American model “scoop and run”.

Arriving to the hospital was a high relief. When we left the patient in the observation area (in the A&E unit) and transferred the personal details and paramedical notes to the staff which had to take care of her, they made us a gesture like “Holy crap! what kind of gift you had bring us.”

After this story, I would like to think together about the situation and the actions taken in it. Do you think that the healthcare action was developed correctly? Do you recognise any of the above symptoms mentioned? What kind of pathologies might fit with the patient’s clinic?

Let us start from the beginning what is an Acute Cerebrovascular Accident or Stroke?

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brain injuryStroke is the most common serious central nervous system disease. It concerns to sudden onset disorders belonging to cerebral circulation that are caused by occlusion or rupture of a blood vessel supplying the brain. This difference between clogging and haemorrhages will determine the cause of the stroke (ischemic or haemorrhagic) and definitive treatment. However, the initial treatment in an emergency is very similar in both cases.
There are two classifications for stroke based on the aetiology that has caused the injury or the evolution of patient’s disease pattern.

If we follow the etiological way, we can find two aspects:

Ischemic:

  1. Atherothrombotic: although the origin is usually atherosclerosis, immediate injury arises from occlusion or stenosis of an intra / extracranial artery (especially in the carotid bifurcation)
  2. Lacunar: infarcts resulting from occlusion of subcortical arteries (supplying deep brain structures)
  3. Cardioembolic: affects mainly young people (under 40 years), these type of ischemic stroke occur due to cardiac embolism from atrial fibrillation (AF), acute myocardial infarction (AMI), rheumatic heart diseases, cardiomyopathies or mitral valve prolapse.
  4. Other causes: vasculitis, hypercoagulability, pregnancy, contraception…

Haemorrhagic:

  1. Intracerebral haematoma: collection of blood in the brain parenchyma as a result of a vascular rupture. If it is derived from high blood pressure (hypertension), it may be located in the basal ganglia, pons, cerebral lobes or cerebellum. It can also be generated by drug abuse, tumours, aneurysms …
  2. Subarachnoid haemorrhage: caused by the rupture of a saccular aneurysm (also known as berry aneurysm)

Halfway between ischemia and haemorrhage we can find the haemorrhagic-infarct stroke, where there is an extravasation of blood into the ischemic territory.

Depending on the evolution of stroke we can classified it in:

  1. Transient ischemic attack (TIA): neurological recovery of the patient is complete in the following 24 hours of the symptoms’ outbreak. Usually it has an abrupt onset and takes a few minutes until it disappear. It is the most important predictor of stroke.
  2. Reversible ischemic neurological deficit (RIND): the neurological deficit disappears from 7 to 14 days
  3. Evolving stroke/progressive: patient shows new symptoms or worsening thereof after hours of evolution
  4. Established stroke: neurological deficit is permanent, no signs of progression. Initially it involves little risk of progression

unconsciousnessAfter viewing the classification, we should talk about how to recognize signs and symptoms of someone who is suffering a stroke. Well, both could change depending on the damaged area, although we will suspect of transient loss of consciousness, confusion, syncope or seizures in patients susceptible to suffer a stroke.

Risk factors for this disease are similar to those of any cardiovascular disease: metabolic syndrome (hypertension, diabetes, dyslipidaemia), obesity, smoking, heart disease, family history of stroke, previous TIA, etc…

We are going to divide the symptoms into three sections to make it easier to visualize and integrate it:

  • Carotid circulation alteration: monocular blindness (affecting the same side of the damaged artery), visual impairment, paralysis and numbness (all contralateral side damage); speech disorder (aphasia, alexia and agraphia)
  • Vertebrovasilar circulation alteration: dizziness, impaired visual fields, diplopia, paralysis and numbness (half-body or four limbs); ataxia and dysarthria.
  • Brain Haemorrhage: the most common symptom is the sudden high-intensity headache. Usually it triggered by an effort and reaches the maximum intensity quickly. Its appearance is holocraneal, and often could be irradiated to the neck and face. We must be alert if it is also accompanied by transient loss of consciousness. It can also be associated with other symptoms such as nausea, vomiting, photophobia and noise intolerance.

Despite of this, it is difficult to formulate a proper differential diagnosis between an ischemic or haemorrhagic stroke when you are unable to any screening test, as symptomatology often overlaps itself. However it is true that haemorrhagic stroke patients have a worse prognosis and headaches are usually more intense. While there is also a possibility of suffering an asymptomatic stroke (and sadly I can assure that I have suffered it with a beloved family member).

If you liked the post and would like to know more about how to assess a patient with this disease correctly and its treatment, you should visit the second part here. See you soon!

Bibliography:

  1.  Morillo Rodríguez, F. J; Abad Esteban, F; Acebedo Esteban, F. J; Aranda Fernández, A; Barrado Muñoz, L; Cabezas Moreno, A. et al. Manual de enfermería en la Asistencia Prehospitalaria Urgente. Elselvier. Madrid 2007. Págs: 177 – 179
  2. Iza Stoll, A. Tratamiento de la hipertensión arterial primaria. Acta méd. peruana v.23 n.2 Lima mayo/agos. 2006
  3. Gimeno Orna, J. A; Lou Arnal, L. M; Molinero Herguedas, E; Boned Julián, b; Portilla Córdoba, D. P. Influencia del síndrome metabólico en el riesgo cardiovascular de pacientes con diabetes tipo 2. Revista Española de Cardiología, Vol. 57, Nº 6, Págs: 507-513

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