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Stroke is considered as a leading cause for acquired brain injury among Australians causing morbidity and mortality, while being a leading cause for disability among adults worldwide(AIHW, 2018). Several resources highlight(AIHW, 2018; Urden, Stacy, & Lough, 2017), although there is a decrease in number of deaths related to stroke worldwide within last few decades, more than 65% of stroke survivors suffered disability which affected their quality of life in several ways. Stroke occurs when blood supply to the brain cells get hindered causing ischemia and cell death. It is a syndrome characterised by rapid, onset neurological deficits which represent the affected area of brain(Lindley, 2017). Several literatures(Lindley, 2017; Urden et al., 2017), highlight the importance of early recognition of symptoms and restoration of normal blood circulation to the brain through early hospitalisation to minimise the disability. This paper critically analyses the contributing factors, pathophysiology and clinical manifestations of stroke. Furthermore, this illustrates evidence based preventative measures and management plan for stroke to minimize the risks and manage caused disability.
Understanding contributing risk factors critical in planning and providing care for an individual potential for stroke or management of stroke patient. These factors can be categorised as modifiable and non-modifiable risk factors(Liu, Wang, Wong, & Wang, 2011). Age and gender are two non-modifiable risk factors identified causing stroke. According to Australian Bureau of statistics (ABS, 2017) in 2015, out of estimated 394,000 individuals who had had a stroke in some part of their life, males show slightly higher tendency for having a stroke than females. However, Australian Institute of Health and Welfare(AIHW, 2018) provides evidences for higher mortality rate from stroke among females over 75 years than males over 75 years between 2003-2015.Among Australian statistics for hospitalisations due to stroke, more than 72% were for people above 65 years old(AIHW, 2018). Atrial fibrillation (AF), hypertension, diabetes, hyperlipidaemia, obesity and smoking can be highlighted as modifiable risk factors for stroke(Liu et al., 2011). Several studies(Hsieh & Chiou, 2014; Liu et al., 2011), provide evidences for the prevalence of a prolonged uncontrolled hypertension condition among majority of patients hospitalised due to haemorrhagic stroke. Increased intravascular pressure within arteries of brain due to high blood pressure increases the risk for arteries to rupture and leak. Prolonged hypertension causes narrowing of blood vessels in brain which increases the risk of accumulation of thrombus within arteries and making clots. This can increase the risk for Ischaemic stroke. Hypertension also considered as one of the main causing agent of Ischaemic stroke among AF patients secondary to TIA(Transient Ischaemic Attack)(McArthur, Quinn, Dawson, & Walters, 2011). Diabetes can cause pathologic changes to the walls of blood vessels and can lead to stroke if cerebral vessels are affected. Also, according to Chen, Ovbiagele, & Feng, 2016, hypoglycemia can have several adverse effects on post stroke outcomes and treatment options. Hyperlipidaemia leads to a condition called cranial atherosclerosis, where exessive cholesterole in blood get deposited in inner walls of cranial atreries. This condition narrows cranial blood vessals increasing the risk of TIA and Ischaemic stroke(McArthur et al., 2011). Atrial fibrillation is considered as one of the major risks for stroke.In AF, due to inefficient quiverring of upper chambers of the heart which alters proper emptying of atrial emptying, blood pools within atria. This causes blood cells to stick together and form clots whichcan move to brain through blood stream and cause Ischaemic stroke(Kamel, Okin, Elkind, & Iadecola, 2016). Other contributing factors for stroke include obesity, lack of exercise, smoking and alchohol consumption.
Simillar to the other cells in the body, brain cells need oxygen(O2) and nutrients for producing energy through aerobic respiration, required for their survival(Urden et al., 2017). This oxygen and nutrients supply and waste removal for excretion is performed by blood. Stroke causes ischaemia to the cell of affected area of brain and as a result brain cells strat to produce energy through anaerobic respiration. This results in increased lactic acid formation and accumulation within brain cells (Kuklina, Tong, George, & Bansil, 2012). Elevated lactic acid levels and lack of oxygen and nutrients cause brain cell necrosis increasing toxic chemical levels in brain tissue (excitotoxicity) (Kuklina et al., 2012). Stroke can be categorised in to two forms as Ischemic stroke and Haemorrhagic stroke. Many studies (Jauch et al., 2013; McArthur et al., 2011), identify ischaemic stroke as the most common type of stroke (85%) where the ischemia caused by a clot blocking an artery supply blood to the brain tissue. Ischaemic stroke syndrome can be further identified in several forms depending on its varying causes such as cardioembolic, arterial embolic (large artery disease), cryptogenic, lacunar (small vessel disease) and due to other causes(McArthur et al., 2011). Severity of Ischaemic stroke can be transient (also known as TIA) where symptoms prevail for short period of time and severe (major ischaemic stroke), where symptoms persist more for more than 24 hours (Jauch et al., 2013). Haemorrhagic stroke occurs when a vessel carrying blood to brain bursts and leaks into the brain tissue or outer space of cranium(Hsieh & Chiou, 2014). Haemorrhagic stroke also can be recognised in two types, intracerebral (within the brain) haemorrhage or sub-arachnoid haemorrhage. During haemorrhagic stroke, brain damage occurs due to increased intercranial pressure (ICP), reduced cerebral perfusion and possible herniation (Morotti & Goldstein, 2016). Hypertension, aneurysms, bleeding disorders, AVMs (Arteriovenous malformations) and trauma are common identified causes for haemorrhagic stroke(Hsieh & Chiou, 2014). Early recognition of clinical manifestations and fast treatments critical for reducing the damage and disability in stroke patients. according to many resources, time plays a major role in stroke management and it determines the degree of disability and outcomes of stroke treatments. Initial phase of stroke is characterised by numbness or weakness, paralysis of face, arm, leg (on either one side or both sides of the body), slurred speech and blurred vision. Furthermore, within initial phase of stroke, patients can experience severe headache but many resources(AIHW, 2018; Hsieh & Chiou, 2014; ‘Stroke Symptoms,’ 2019), identify that it can be unnoticeable in some cases. Post-stroke signs and symptoms can include, drooping facial muscles, hypersalivation, vision loss, persisting paralysis of one side or both sides of the body, dysphagia and slurred speech (Kuklina et al., 2012).
Goals of stroke prevention include early recognition of acute syndrome, identifying contributing risk factors, making lifestyle changes and treating and managing underlying disorders which can cause stroke (Rost & Black-Schaffer, 2015). FAST (Face, Arms, Speech, Time) tool is a worldwide accepted approach for recognising someone at risk of having a stroke(SF, 2019). Many resources (McArthur et al., 2011; Rost & Black-Schaffer, 2015) identify the importance of increasing public awareness of this tool to minimise the adverse effects of strokes within the community. Lifestyle modifications such as smoking cessation, balanced diet, regular exercises and avoiding alcohol consumption can prevent stroke by controlling hyperlipidaemia, obesity, diabetes and AF conditions(Liu et al., 2011). regular monitoring of blood pressure, blood sugar levels and blood tests can influence in understanding health status and potential risks for stroke and initiate lifestyle changes(Goldstein, 2014). Many organisations and institutions have introduced several guideline and management plans to manage stroke and support affected patients and their family/caregivers due to secondary adverse outcomes of stroke. Aims of plans and interventions of those management plans include, reducing risks for death and dependency, reducing secondary complications, rehabilitation, facilitating self-management and providing psychological and emotional support for patient and family(Hsieh & Chiou, 2014; Warburton, Alawneh, Clatworthy, & Morris, 2011). TIAs (Transient Ischaemic Attacks) which are recognised as temporary minor strokes considered as warning signs for major stroke. According to Guidelines of Stroke Foundation Australia(SF, 2019), patients who are admitted with TIAs should undergo thorough investigations and assessments to ensure patient safety from risk if stroke. Investigations include complete assessment on medical and family history, blood tests (full blood count, blood cholesterol, ESR-Erythrocyte Sedimentation Rate, renal function, BGL, electrolytes) and brain imaging (Jauch et al., 2013). These imaging tests include MRI, CT and carotid angiograms. Furthermore, for patients who experienced stroke, tests such as catheter angiograms, ECGs, vasculitis screen and prothrombotic screen should be performed onset to determine the treatment options(Goldstein, 2014). Aspirin is considered as the initial treatment option after onset of stroke symptoms. Patient and family education at early stages ensures adherence to pharmacological therapy, supports and motivates self-management and provides psychological/emotional support. Series of pharmacological treatments can be used to prevent, manage symptoms and relieve secondary complications. Antihypertensives, antiplatelet (aspirin), anticoagulants, satins (cholesterol lowering) are commonly used medications in stroke management(Goldstein, 2014; Rost & Black-Schaffer, 2015).
Managing a patient after a stroke with post stroke complications needs a multidisciplinary approach. Post stroke complications include persisting disabilities leading to dependency, inability to perform ADLs, social isolation and psychological decline (Urden et al., 2017). Rehabilitation of stroke patients with the involvement of multidisciplinary team is essential when transferring stroke patient from hospital care to community. During rehabilitation patient is thoroughly assessed by multidisciplinary team to determine needs of care, support needed and available, necessary aids, availability of support services and need for follow-up services(Clarke & Forster, 2015; SF, 2019). It is critical to ensure family/carer participation in decision making and care planning process. During hospital care nursing staff can ensure patient adherence and understanding of the medication management. Physiotherapists and occupational therapists play a critical role in rehabilitation process by assessing patients ability to self-manage daily activities and identifying support and aids required (Rost & Black-Schaffer, 2015). Also, if the patient is affected with paralysis post stroke, physiotherapists can assist in reversing the paralysis through continuous exercises. Many resources(Clarke & Forster, 2015; Lindley, 2017), highlight the importance of the involvement of social worker to the care process of a stroke patient to enable access to necessary support services and financial support. Community rehabilitation can be long term for stroke patients. This highlights the importance of follow-up services to provide support and education(Clarke & Forster, 2015). One main aspect of stroke management is to provide psychological and emotional support for the patient and family/carers. Counselling services and psychiatrist support can be included in to care plan to minimise the stress, fear and anxiety on post-stroke patients regarding their disabilities, sexuality and treatments(Hackett, Köhler, T O’Brien, & Mead, 2014). Furthermore, many literatures(Salter, Foley, & Teasell, 2010; Warburton et al., 2011) have identified the need of a tailored information and support services to the family/carers during all phases of recovery of the patient.
Stroke is a syndrome which result in mortality and disability worldwide and considered as a major health concern in Australia. Stroke patients are not only affected physically, but also psychologically and emotionally. Therefor awareness within the community about signs and symptoms can ensure early recognition and interventions. Healthy lifestyle and controlling underlying disorders mostly related to cardiovascular system can reduce potential for stroke. Finally, stroke and its secondary complications affect patients and carers thus, a collaboratively tailored management plan is imminent for stroke prevention and disability management.
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