A stroke (also stroke , stroke , apoplexy , cerebral insult , apoplectic insult , apoplexia cerebri , ictus apoplecticus , outdated stroke flow (even older also Middle Latin gutta , "drop", and Middle High German gutt ), colloquial stroke , often also apoplexy in medical slang or insult ) is a suddenly occurring cerebrovascular disease of the brain , which often leads to a prolonged failure of functions of the central nervous system and is caused by critical disturbances in the blood supply to the brain .
The terminology of stroke has not been and is not used consistently. The English terms stroke , cerebrovascular accident (CVA) and cerebrovascular insult (CVI) are synonymous with the term stroke . These terms are often used as a generic term for different neurological diseases, the most important thing in common is sudden symptoms after a circulatory disorder limited to the brain , whereby the loss of function must not be due to primary disorders of the excitability of nerve cells ( convulsive disorder , see epilepsy ).
It is estimated that there are around 270,000 new stroke cases in Germany each year. Annual frequencies in Germany:
- primary ischemic cerebral infarctions due to insufficient blood flow ( incidence 160–240 events / 100,000 population)
- Cerebral hemorrhage (24 / 100,000)
- Bleeding into the CSF surrounding the brain, so-called subarachnoid hemorrhage (6 / 100,000)
- Strokes of unknown cause (8 / 100,000)
Stroke is one of the most common serious illnesses in Germany, has a 1-year mortality of 20 to 30% and is also a frequent cause of death in Germany: In 2015, the Federal Statistical Office found 56,982 deaths from cerebrovascular diseases, which corresponds to a proportion of 6 2% corresponds.
In addition, stroke is the most common cause of moderate and severe disability with a disability rate of 30 to 35%.
51% of all strokes affect the over 75 age group. The risk of stroke increases disproportionately with age.
Stroke is the fifth leading cause of death in the United States. Stroke is one of the most common causes of disability worldwide. In the GDB 2016 (Global Burden of Disease 2016 Lifetime Risk of Stroke) a lifetime risk for stroke of 24.9% was determined worldwide. Men had a slightly lower risk (24.9%) than women (25.1%). The global risk of ischemic stroke was 18.3%, and that of hemorrhagic stroke was 8.2%. The highest lifetime risk was in East Asia (38.8%), Central Europe (31.7%) and Eastern Europe (31.6%). The lowest risk was in eastern sub-Saharan Africa (11.8%).
Forms of a stroke - reduced blood flow or bleeding
The stroke is caused by a sudden lack of oxygen and other substrates in the nerve cells . A rough distinction can be made between sudden reduced blood flow ( ischemic stroke or cerebral infarction) and acute cerebral hemorrhage ( hemorrhagic infarction or insult), which also leads to ischemia secondarily due to its space-occupying effect or due to the lack of blood in subordinate regions . In primary ischemic infarctions, secondary bleeding can also occur in the infarct area (hemorrhagic infarction).
The distinction between reduced blood flow and bleeding is only reliably possible with imaging methods such as computed tomography (CT) or magnetic resonance tomography (MRI, English MRI), whereby in the first few hours both imaging methods can still be normal, especially in primary ischemic cerebral infarction. The suspected diagnosis of subarachnoid hemorrhage , which arises as a result of a ruptured artery (for example due to an aneurysm ), can be confirmed by the detection of blood components in the nerve water during the lumbar puncture - especially if the symptoms are only mild (e.g. headache alone) .
Reduced blood flow, which lasts less than 24 hours and is invisible to the naked eye, was formerly known as a transitory ischemic attack (TIA). In the guidelines of the German Society for Neurology from 2005 it is pointed out that the classic differentiation between transient ischemic attacks (TIA) and completed ischemic strokes is considered outdated. However, the difference is still mentioned in some textbooks. Two reasons for this are that morphological brain injuries can be detected in many patients with a so-called TIA and that the risk of a re-infarction after TIA and a completed stroke is approximately equally increased. Apart from the question of lysis , both completed strokes and conditions previously known as TIA should be treated equally. The term (prolonged) reversible ischemic neurological deficit (RIND / PRIND) for findings lasting longer than 24 hours but less than three weeks should also no longer be used, as this already corresponds to a manifest stroke. The same applies to the description of a partially reversible ischemic neurological syndrome (PRINS).
As a sign of a stroke, several symptoms can appear suddenly, and depending on the severity, simultaneously:
- Disturbances in consciousness ( somnolence , coma ), disorientation
- Numbness of the face, one arm, leg or half of the body
- Paralysis or weakness of the face, one arm, leg, or half of the body
- Confusion , speech or word finding , writing or comprehension disorder
- Swallowing disorders ( dysphagia , four degrees of NOD = neurogenic oropharyngeal dysphagia)
- painless visual impairment in one or both eyes, unilateral dilation of the pupil , loss of visual field , double vision
- Dizziness , gait disorder , balance or coordination disorder ( ataxia )
- Severe headache with no apparent cause, possibly derailed (excessive) blood pressure , nausea, vomiting
- Lack of awareness of part of the environment or of one's own body ( neglect )
- arterial embolism due to blood clots
- Thrombosis of the venous drainage vessels
- Vascular constriction due to vascular spasms
- Vascular ruptures: either spontaneous or z. B. due to high blood pressure
- Spontaneous bleeding with impaired blood clotting
- Subarachnoid hemorrhage, sub- or epidural hematomas
Early detection of an increased risk of stroke
An ultrasound of the carotid arteries is offered as early detection, which is intended to detect deposits and thus help reduce the risk of stroke. The IGeL-Monitor of the MDS ( Medical Service of the Central Association of the German Health Insurance Funds ) rated this investigation as “generally negative”. In the systematic literature search, the IGeL-Monitor scientists did not find any studies on the question of whether ultrasound can reduce the incidence of illness and death from a stroke. Although the ultrasound scan can detect many narrowing of the carotid artery early, it is unclear whether the treatment will really lead to fewer people having a stroke. Damage, however, is possible through unnecessary further examinations and unnecessary treatments. The most important source is a review from 2014. In the "Guideline on Diagnostics, Therapy and Follow-Up Care of Extracranial Carotid Stenosis", several German specialist societies also advise against a serial examination due to the current study situation: "Routine screening for the presence of carotid stenosis should not be carried out." Four international guidelines also do not recommend a serial examination of people without symptoms and without special risk factors. If there is any suspicion or complaints that can be traced back to a narrowed vein, the ultrasound is covered by the health insurance.
The diagnosis of stroke is made clinically , usually by a neurologist . This makes use of different examination methods to check the numerous different functions of the brain. Often these studies are based on scoring systems such as the National Institutes of Health Stroke Scale (NIHSS), which enables a quantitative assessment of the severity of the stroke. Depending on the presumed location of the stroke in the brain, more specific examinations, e.g. B. the cerebellum or the cranial nerves, be indicated. If the suspicion of a stroke is confirmed or at least not ruled out with certainty, an imaging diagnosis is always carried out.
Imaging methods such as computed tomography (CT) or magnetic resonance tomography (MRI, English MRI) enable the immediate diagnosis of cerebral hemorrhage . In the case of ischemic stroke, on the other hand, a native (i.e. without contrast agent ) CT or MRI examination can provide normal images during the first few hours. Depending on the cause, location, and severity of the stroke, CT angiography (CTA) and CT perfusion can follow. Diffusion -weighted images (DW-MRI) make it possible to visualize the infarct area in the MRI examination just a few minutes after the start of the stroke.
A blood sample is mandatory if a stroke is suspected. In addition to a blood count, in particular the coagulation status is determined, as well as electrolytes, urea, creatinine, blood sugar, liver values, CRP, TSH and other laboratory values. Blood biomarkers (e.g. S-100B , NSE , GFAP ), which can indicate damage to the brain, can supplement the diagnosis, but are not specific for a stroke and are sometimes inconspicuous in the early phase.
The Cincinnati Prehospital Stroke Scale (CPSS) was developed in 1997 specifically for emergency medical services personnel . This is formed from three criteria of the NIHSS and is intended to serve as a simple instrument for diagnosing a stroke. In layperson training for first aid, too, the CPSS criteria are often conveyed using the English acronym FAST (Face, Arms, Speech, Time). This test consists of four steps:
- F ace (face): ask the person to For example, smile broadly or show your teeth as a paralyzed half of your face can be a symptom of a stroke. Another method is to let the affected person inflate their cheeks and apply slight resistance; affected individuals cannot inflate one side or keep it inflated against resistance.
- A rms (arms): The person is asked to stretch both arms forward with their palms open so that the arms are held at a 90 ° angle to the body axis without support. In the case of paralysis, one arm cannot be brought into the required position or held in it, it sinks or turns inwards.
- S peech (language): Pay attention to the pronunciation of the person. It may be fuzzy, slow, sound "slurred," or the person may seem difficult to put into words.
- T ime (time): If a stroke is suspected, the person concerned must be transported to a suitable clinic - preferably a stroke unit - by the ambulance service as quickly as possible . Lengthy on-site treatments (“stay and play”) should only take place if a mobile stroke unit is used on site - otherwise the “ load and go ” principle applies . In general, the treatment must be carried out within the shortest possible time in order to keep brain damage as low as possible. It is important to record the time when the symptoms began and the time course (deterioration or improvement).
The CPSS is limited in particular by its focus on symptoms of a cortical infarction. This means that she is able to detect a large number of severe strokes with a relatively high sensitivity, but may miss less frequent strokes in other areas. It was therefore proposed to expand the acronym to BE FAST , with the additional criteria:
- B alance: Sudden balance or gait disorders can be symptoms of a stroke.
- E yes (eyes): The person complains of sudden loss or impairment of vision in one or both eyes, double vision, blurred vision.
Stroke patients, including suspected cases, should be examined by a doctor immediately. The so-called "time-to-needle" (period within which any lysis treatment [see below] must be started) is a maximum of four and a half hours after the onset of the stroke. After an emergency call is made immediately , the patient should be observed and positioned with the upper body elevated. In addition, he should not be physically stressed and not eat or drink anything, as there is a risk of aspiration . Generally, an emergency transport is carried out by ambulance - possibly with an emergency doctor - to a stroke unit for the purpose of precise diagnosis and appropriate treatment, often using lysis therapy . In the countryside - with a correspondingly low density of stroke units - a rescue helicopter is often used, as it can be used for faster transport to a more distant, suitable hospital. In some cases, the distances to be covered are so great that even at night the use of an intensive care transport helicopter, which has a much longer lead time than a rescue helicopter, can be considered. Even Mobile stroke units (specially equipped ambulance) come here partly used.
Lysis treatment is not indicated in hemorrhagic strokes. In many ischemia cases, however, the intravenous administration of medication ( thrombolysis ) succeeds in dissolving the blood clot and protecting the brain from permanent damage. Early thrombolysis has been shown to improve patient prognosis.
A fairly new procedure, neurothrombectomy , mechanically removes the blood clot in the brain using a catheter (neuro thrombectomy catheter) . “More than 60 percent of patients with major strokes can lead an independent life after three months after catheter treatment. In drug therapy, this rate is only around 15 percent ”. Thrombectomy is particularly effective for patients in whom the blood clot blocks a large vessel in the brain. The vessel can be reopened in around 90 percent of cases. However, neurothrombectomy can only be used in around 10 to 15 percent of ischemic strokes. So far, this procedure has been offered in around 140 hospitals in Germany and is constantly being expanded to include new clinics (as of October 2017). In the course of 2015, five studies showed that the catheter was superior to drug therapy.
Personal lifestyle affects the risk of having a stroke. Normal blood pressure , good blood sugar levels and nicotine abstinence in particular can reduce the risk of stroke. A blood pressure in the normal range alone reduces the risk of stroke by 60 percent. Other aspects of a healthy lifestyle include physical activity, avoidance of obesity, normal cholesterol levels and a healthy diet. Studies have shown that consuming a lot of salt is a risk factor, while consuming potassium is a protective factor.
As part of the search for the cause and thus in the context of secondary prevention after a stroke, intermittent (paroxysmal) atrial fibrillation should also be looked for. An examination period of 24 to 72 hours is recommended. If atrial fibrillation is detected, even if only temporarily, anticoagulation should be carried out with phenprocoumon or direct oral anticoagulants (DOAC).
The medical rehabilitation of patients with cerebrovascular insufficiency ideally begins post-acute in a stroke unit . Rehabilitation approaches such as the Bobath concept require a high degree of interdisciplinary cooperation and, if carried out consistently, are largely responsible for the rehabilitation process. A new and scientifically validated approach is the "Constraint-Induced Movement Therapy" (CIMT), in which by immobilizing the healthy arm for the majority of the waking period the patient is "forced" to use the diseased hand, whereby pathological adaptation phenomena such as the " learned non-use ”can be prevented. This therapy method can also be used in severely affected patients and in the chronic stage. The method is also known in German-speaking countries as "Taubian motion induction" .
The focus of neurological rehabilitation is primarily on measures that promote the body awareness of the person concerned and, in the best case, lead to complete compensation for lost skills.
For example, gait patterns are practiced with physiotherapists to restore the ability to walk . Occupational therapists work specifically with patients to (partially) restore sensorimotor , cognitive and emotional abilities.
The importance of targeted speech therapy in the early phase and over a long period of time is often underestimated and only approached in an amateur way. For certain therapeutic areas, there is currently no adequate offer in the outpatient area, as in speech therapy v. a. in aphasia and dysarthria. In rehabilitation therapy, high-frequency, repetitive practice of certain tasks makes sense, while teletherapy enables supervised patient care. Intensive treatment cannot be provided in a resident setting. Only through the use of computer-aided procedures can the intensity be increased in such a way that the target values resulting from the specifications of the meta-study can be achieved. Feasibility studies show that teletherapy makes sense for around 50–60% of aphasic patients. In fact, the teletherapy study was able to show for the first time that the therapy frequency is increased by supervised teletherapy without any loss of quality so that patients can demonstrably benefit from it.
Modern approaches to neurorehabilitation try to influence pathological brain activity. In some patients there is uninhibited activity of the undamaged hemisphere, which disrupts the motor functions of the hemisphere affected by the stroke. A reduction in overactivity, for example with the help of transcranial magnetic stimulation (TMS), can lead to a better function of the paralyzed hand in some patients. A multicenter study on the effectiveness of magnetic stimulation therapy in combination with pharmacological stimulation with the dopamine preparation "Levo-DOPA" is currently underway at the National Institutes of Health (NIH) . The latter is intended to intensify the TMS effects. Other drugs from the group of monoaminergic substances such as paroxetine (serotonergic), fluoxetine (serotonergic) or reboxetine (adrenergic) can transiently improve stroke deficits , as has been shown in placebo-controlled studies. A new technical approach to the improvement of failures is the transcranial direct current treatment (transcranial direct current stimulation, tDCS), which is currently being examined in several clinics, including in Germany.
Studies have shown that after - especially repeated - strokes, the affected patients are at an increased risk of dementia .
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