Ictus

ISCHEMIC STROKE / STROKE / CEREBRAL EMBOLISM / CEREBRAL INFARCTION

GENERAL ASPECTS

Cerebrovascular diseases are disorders of the cerebral blood vessels that cause an alteration in the normal blood flow, resulting in brain injury.

The term ictus (“stroke” in Latin) describes the sudden and abrupt nature of the symptoms due to cerebral vascular lesion. Depending on the type of lesion, they are classified as hemorrhagic strokes if there is arterial rupture (10-15%) and ischemic strokes if the artery is obstructed (85-90% of the total), a situation that we will deal with in this section.

Transient ischemic attack (TIA) is defined as an episode of brief neurological dysfunction caused by a temporary flow disturbance.

CAUSES OF ISCHEMIC STROKE

1. Atherosclerosis: arteries with fatty plaques that become obstructed or fragmented and move to a more distant region (embolism). The most important vascular risk factors are high blood pressure, cholesterol, diabetes, smoking and a sedentary lifestyle.
2. Cardiac: the abnormal contraction of the heart that occurs in some arrhythmias, or the existence of valvular prostheses, can favor the creation of embolisms that go to the brain.
3. Lacunar: lesion of small blood vessels due to arterial hypertension.
4. Inhabitual: more frequent in young people, including carotid artery dissection (splitting of the arterial wall) or patent foramen ovale (cardiac alteration from birth).

SYMPTOMS

A stroke causes a sudden neurological alteration, which depending on the type and blood territory affected may be:

1. Visual disturbance: loss of total vision or on one side of the visual field in one or both eyes, as well as double vision.
2. Loss of sensation or weakness of the face, arm or leg, usually on one side of the body, and may also deviate the head to the opposite side.
3. Difficulty articulating words or understanding or uttering language.
4. Inability to walk while maintaining balance.
5. Severe and sudden (“thunderclap”) headache.

DIAGNOSIS

It is a medical emergency, which requires the activation of the stroke code, a set of procedures that allow rapid diagnosis and treatment in less than 24 hours from the onset of symptoms. The patient is initially stabilized (blood pressure, temperature, heart rate) and a blood test and electrocardiogram are performed. Subsequently, a neuroimaging study of the brain and blood vessels is performed to identify the type of damage (hemorrhage or ischemia).

Subsequently, once the patient is stabilized, a series of complementary tests will be required to find the specific cause of the cerebral flow alteration. Among other studies, advanced cerebral neuroimaging, blood tests, ultrasound of extra and intracranial arteries (to assess arteriosclerosis plaques), echocardiography and electrocardiographic monitoring including 24-hour or longer cardiac holter (to assess heart problems or arrhythmias) are assessed.

TREATMENT

In acute ischemic stroke, the patient should be admitted to a stroke or critical care unit with close monitoring and supervision by specialized professionals, where the clinical situation will be controlled and the indicated antithrombotic treatments will be started. There are different treatments that can be applied at the beginning to try to eliminate the arterial thrombus and reverse the symptoms and the damage it is causing to brain tissue. For this purpose, there are:

• Intravenous fibrinolysis, which may be indicated in ischemic strokes with less than 4.5 hours from symptom onset.
• Mechanical thrombectomy, which is the treatment that uses devices that are introduced into the obstructed arteries with sufficient caliber to aspirate or dilate their interior.

After the acute phase, long-term treatment should be personalized, including strict control of vascular risk factors and modification of lifestyle habits. Depending on the cause of the stroke, antiplatelet treatment with statins (more commonly used in those with atherothrombotic causes) such as acetylsalicylic acid or clopidogrel, or anticoagulant treatment (usually if there are cardiac embolisms) with drugs such as acenocoumarol (sintrom) or direct-acting anticoagulants may be considered. Invasive interventions are also considered in selected cases of severe narrowing of the carotid arteries or repairable cardiac alterations.

When should I suspect that someone is suffering a stroke?

You should ask the person to smile (and assess facial asymmetry), to raise his/her arms (observe whether he/she cannot raise them or tends to fall) and to speak (assess whether he/she speaks strangely or cannot be understood). If any of these instructions are not carried out correctly, or if there is any other sudden alteration in vision, sensitivity, strength or balance, you should suspect that the patient may be suffering a stroke.

When to go to the emergency room for a stroke?

You should call the emergency service or go to the emergency room of a hospital immediately whenever there is an abrupt alteration compatible with a stroke. You should not wait for the symptoms to disappear, and even if the alteration is transient, you should also go without delay for a possible transient ischemic attack.