Stroke is the fifth leading cause of death and a leading cause of disability in the United States. The brain is divided into three parts: the brainstem, which controls most basic functions of the body such as breathing, blood pressure, swallowing, and pupil constriction; the cerebellum, which is just behind the brainstem and is responsible for tasks involving muscles like playing the piano; and the cerebrum, which is located above the cerebellum and is divided down the middle into the right and left cerebral hemispheres. The front part controls emotions and thought (must not be that important if that is in the front). The middle part controls sensations and movement, and the back part processes sight. In most people, speech is controlled on the left side of the brain. Messages sent to and from the brain travel through nerves. Twelve pairs of cranial nerves run directly from the brain to various parts of the body.
One of the most common complaints is a headache. What is interesting is the brain and skull do not have pain receptors; pain of the head is felt from the surrounding areas of the face, scalp, meninges (membranes that cover the brain and spinal cord), larger blood vessels, and muscles of the head, neck, and face. One type of headache is called a tension headache, which is caused by muscle contractions in the head and neck and is attributed to stress. The pain is squeezing, dull, or achy. Next, there are migraine headaches, which are changes in blood vessel size at the base of the brain. Pain is pounding, throbbing, and pulsating; there is typically nausea and vomiting, visual warning signs (flashing lights or partial vision loss), and it can last for several hours to days. There are also sinus headaches, which are caused by pressure that is a result of fluid accumulation in the sinus cavities. The last headache type is cause for concern and is a hemorrhagic stroke, which is caused by bleeding in the brain. Brain tumors and meningitis are serious neurologic conditions that may include headache as a symptom, with a sudden onset. A severe headache has associated symptoms and is often described as the worst headache of their life. Headaches accompanied by a fever, stiff neck, seizures, altered mental status, or following head trauma are potentially life-threatening and require a complete assessment and transport to the hospital.
A cerebrovascular accident (CVA), or stroke, is an interruption of blood flow to an area within the brain that results in the loss of brain function. The brain cells will develop ischemia, a reduction in blood supply that results in inadequate oxygen being supplied to the brain cells. There are two main types of stroke: ischemic, when blood flow through the cerebral arteries is blocked, and hemorrhagic, when a blood vessel ruptures and the accumulated blood causes increased pressure in the brain.
An ischemic stroke occurs when blood flow through the cerebral arteries is blocked by a blood clot. Patients have dramatic symptoms, including loss of movement on the side of the body opposite the side where the occlusion has occurred. Blockage may be due to thrombosis, where a clot forms at the site of blockage, or an embolus, where the blood clot forms in a remote area (such as a diseased heart) and then travels to the site of the blockage. Patients with atrial fibrillation (a heart rhythm where the atria shake rather than squeeze) are prone to ischemic strokes caused by an embolus and often take blood thinners to reduce the risk. Coronary artery disease and atherosclerosis in the blood vessels often cause ischemic stroke. Atherosclerosis is where calcium and cholesterol build up, forming plaque inside the wall of the blood vessels.
A hemorrhagic stroke occurs when a blood vessel ruptures and the accumulated blood causes increased pressure in the brain. The compression due to bleeding prevents oxygenated blood from getting into the area, and brain cells begin to die. People at high risk are those with extremely high blood pressure. An aneurysm is the swelling or enlargement of the wall of an artery resulting from a defect or weakness. It is often described as the worst headache someone has had in their life.
With a transient ischemic attack (TIA), in a patient with coronary artery disease, blood flow to the heart muscle may be obstructed, causing chest pain (angina), which is considered a warning sign of a potential myocardial infarction. When blood flow to the brain is obstructed due to atherosclerosis or a small blood clot, the patient may exhibit signs of a stroke. These symptoms resolve on their own in less than 24 hours. These are sometimes called mini strokes. As with angina, no actual death of tissue occurs with a TIA.
Some signs of a stroke are facial drooping; sudden weakness or numbness in the face, arm, leg, or one side of the body; decreased or absent movement and sensation on one side of the body; lack of muscle coordination (ataxia) or loss of balance; sudden vision loss in one eye; blurred or double vision or abnormal eye movements; difficulty swallowing; decreased level of responsiveness; speech disorder; aphasia; slurred speech (dysarthria); sudden and severe headache; confusion; dizziness; weakness; combativeness; restlessness; tongue deviation; and coma.
When the left side is affected by a stroke, the patient may exhibit a speech disorder called aphasia, an inability to produce or understand speech. Some patients will have trouble understanding speech. It can also cause paralysis on the right side of the body. Right hemisphere strokes involve patients who have trouble moving the muscles on the left side of the body. They normally have the ability to understand language, but words will be slurred and hard to understand. They may be completely oblivious to their problems. If you ask them to lift their left arm, however, they cannot, but it is almost like they have forgotten this portion of the body exists. Lack of pain may prevent the patient from seeking help until someone tells them.
Some conditions that may mimic stroke include hypoglycemia, the postictal state (period following a seizure that lasts between 5 and 30 minutes), and subdural or epidural bleeding.
Nearly 3.5 million people in the US have epilepsy, which is a common cause of seizures. Seizures are classified as either generalized or focal. A generalized seizure results from abnormal electrical discharges from large areas of the brain, involving both hemispheres. It is typically characterized by unconsciousness and generalized severe twitching of the body’s muscles that lasts several minutes or longer. In generalized motor seizures (tonic-clonic), almost all the muscles in the body are contracting at the same time. In other cases, there is a brief lapse of consciousness where the patient stares and does not respond to anyone. Seizures typically last less than 5 minutes and are followed by a lengthy period (5 to 30 minutes) called a postictal state. Once a seizure has stopped, the patient’s muscles relax, becoming almost flaccid or floppy, and breathing becomes labored to compensate for the buildup of acids in the bloodstream. It takes time for the body to balance again, and the longer the seizure, the more unresponsiveness and confusion. In some situations, the postictal state may be characterized by hemiparesis, or weakness on one side of the body. If a patient’s symptoms do not improve, consider other possible underlying conditions such as hypoglycemia or infection.
A focal seizure begins in one part of the brain. Focal-onset seizures are classified as either aware or impaired-awareness, and either type can be motor or nonmotor. There may be no change in the patient’s level of consciousness. The patient may report visual changes and unusual smells or tastes. It may also cause twitching of muscles that may spread slowly from one part of the body to another. They may also experience brief paralysis. A warning sign that patients may experience is an aura, flashing lights, blind spots in the field of vision, or hallucinations.
Status epilepticus is a seizure that lasts more than 5 minutes and describes seizures that continue every few minutes without the person regaining consciousness or that last longer than 30 minutes. This is a life-threatening situation that requires immediate medical attention. ALS has potential medications that can help stop these seizures.
There are multiple causes of a seizure. They could be epileptic and congenital in origin. The seizure could be due to a structural problem where there exists a tumor, infection, scar tissue, head trauma, or a stroke. It could also be metabolic in cause, such as hypoxia, abnormal blood chemical values, hypoglycemia, poisoning, drug overdose, or sudden withdrawal from alcohol or medications. The seizure could also be caused by a high fever.
Syncope and seizures are often mistaken for each other. Fainting generally happens when standing, whereas seizures may occur in any position. Fainting is not associated with a postictal state.
An altered mental status has a number of possible causes. There could be a wide range of issues including hypoglycemia, hypoxemia, intoxication, delirium, drug overdose, unrecognized head injury, brain infection, body temperature abnormalities, brain tumors, overdoses, and poisonings. Hypoglycemia can mimic conditions in the brain associated with stroke and may cause hemiparesis. The principal difference is that a patient who has experienced a stroke may be alert and attempting to communicate normally, whereas a patient with hypoglycemia almost always has an altered or decreased level of consciousness. They may also experience seizures, and you may find a patient in a postictal state. Symptoms are not likely to improve after several minutes.
Use AEIOU-TIPS when assessing an altered mental state:
A – Alcohol
E – Epilepsy, endocrine, electrolytes
I – Insulin
O – Opiates and other drugs
U – Uremia (kidney failure)
T – Trauma, temperature
I – Infection
P – Poisoning, psychogenic causes
S – Shock, stroke, seizure, syncope, space-occupying lesion, subarachnoid hemorrhage
When treating someone, always start with the XABCs. A patient lying on the ground in an unnatural position is more likely to have a potentially life-threatening condition than one sitting up in bed. Most likely, the seizure will be over by the time you arrive, but if they are still seizing, they may be in a condition called status epilepticus. First, determine level of consciousness using the AVPU scale. Focus on the patient’s airway and breathing on arrival. Stroke affects how the body functions in many ways, including difficulty swallowing and risk of choking on saliva. Prepare to provide suction and position the patient to prevent aspiration. Potentially place the patient in the recovery position to help prevent secretions from entering the airway. Evaluate for trauma, which is more likely in a seizure patient than a stroke patient. If a patient is experiencing a stroke, provide rapid transport to an appropriate facility. Prompt treatment is a critical action to minimize the disability caused by an ischemic stroke.
To evaluate neurological conditions, use the following approaches:
BE FAST Stroke Assessment
B – Balance
E – Eyes – change in vision, loss of vision, double vision, no side or top vision
F – Facial droop – one side of the patient’s face droops when he or she smiles
A – Arm drift – does the patient demonstrate weakness or inability to move one arm
S – Speech – is the patient slurring words or using words that do not make sense
T – Time – when did the symptoms first appear? Rapid transport
LA adds checking the blood glucose level. To test speech, ask them to repeat “you can’t teach an old dog new tricks” and ask them to smile.
There is the LAG scale, where more than >4 is likely to indicate a stroke.
LOC – Normal = 0, mild dysfunction = 1, severe dysfunction (unconscious) = 2
Arm drift (hemiparesis) – Normal function = 0, mild dysfunction = 1, severe dysfunction = 2
Gaze – Normal (follows pen/finger to left and right side) = 0, mild = 1, severe = 2
Glasgow Coma Scale
Eye Opening – Spontaneous = 4, sound = 3, pressure = 2, none = 1
Verbal Response – Oriented conversation = 5, confused conversation = 4, inappropriate words = 3, incomprehensible sounds = 2, none = 1
Best Motor Response – Obeys commands = 6, localizes pressure = 5, withdraws from pressure = 4, abnormal flexion = 3, abnormal extension = 2, none = 1
Score 13–15 indicates mild dysfunction, 9–12 may indicate moderate dysfunction, and 8 or less indicates severe dysfunction.
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