Stroke

Stroke

1. Definition
   Stroke is a sudden loss of brain function caused by interruption of the blood supply to a part of the brain. It is an emergency that must be recognised and treated without delay.

2. Synonyms Cerebrovascular accident – the term used to stress that the event is vascular in origin.
   Brain attack – a popular phrase to convey the urgency, similar to a heart attack.

3. Causes / Etiology
   • Thrombosis – a clot forms in a cerebral artery, usually on a background of atherosclerotic plaque; the clot blocks the lumen and stops flow.
   • Embolism – a clot or debris originates elsewhere (often the heart in atrial fibrillation, or a carotid plaque) and travels to the brain, lodging in a distal artery.
   • Hemorrhage – rupture of a small artery or an aneurysm leads to bleeding into the brain tissue (intracerebral) or into the subarachnoid space; hypertension and vascular malformations are common precursors.
   • Small‑vessel disease – chronic hypertension causes lipohyalinosis of penetrating arterioles, producing lacunar infarcts.
   • Other rare causes – vasculitis, arterial dissection, hypercoagulable states, drug‑induced vasospasm; each can produce an acute vascular occlusion.

4. Types / Classification
   Ischemic stroke (≈ 80 % of cases) – loss of blood flow due to blockage.
    a. Thrombotic – clot forms in situ on an atherosclerotic plaque; often presents with progressive weakness.
    b. Embolic – clot comes from a distant source; onset is abrupt and may affect multiple territories.
    c. Lacunar – small deep infarcts caused by occlusion of penetrating arteries; present with pure motor or pure sensory deficits.

Hemorrhagic stroke (≈ 20 % of cases) – bleeding into or around the brain.
 a. Intracerebral hemorrhage – blood collects within the brain parenchyma; common in basal ganglia, cerebellum, brainstem.
 b. Subarachnoid hemorrhage – blood enters the subarachnoid space, often after rupture of a berry aneurysm; presents with sudden “thunderclap” headache.

Acute forms last minutes to hours and require emergency care; chronic sequelae develop over weeks to months and include permanent deficits or recovery.

5. Pathophysiology / Pathology – step by step
   Ischemic stroke
6. Occlusion of a cerebral artery reduces perfusion pressure.
7. Within seconds the penumbra (area of reduced flow) becomes hypoxic; ATP depletion stops ion pumps.
8. Neuronal membranes depolarise, calcium influx triggers excitotoxicity and free‑radical formation.
9. If flow is not restored within 4–6 hours, the core tissue undergoes irreversible infarction.

Hemorrhagic stroke

1. Vessel wall rupture releases blood into brain tissue or subarachnoid space.

2. The expanding hematoma compresses adjacent neurons and raises intracranial pressure.

3. Blood breakdown products provoke inflammation and vasospasm, further compromising perfusion.

4. Secondary injury may continue for days as edema and hydrocephalus develop.

5. Clinical Features
   General – sudden appearance of focal neurological deficit, often with altered consciousness.

Specific –
• Motor: unilateral weakness or paralysis, facial droop, gait disturbance.
• Sensory: loss of touch, pain, temperature on one side.
• Vision: loss of half visual field (homonymous hemianopia) or double vision.
• Speech: expressive or receptive aphasia, dysarthria.
• Cranial nerves: eye movement palsy, dysphagia.

Acute – rapid onset (seconds to minutes), may be accompanied by severe headache (especially hemorrhagic), vomiting, hypertension, and loss of consciousness.

Chronic – persistent weakness, spasticity, gait instability, cognitive decline, mood disorders; these reflect the permanent loss of neuronal tissue.

7. Complications
   Acute – increased intracranial pressure, brain herniation, seizures, aspiration pneumonia, deep‑vein thrombosis. Early recognition and control of pressure can prevent fatal herniation.

Chronic – post‑stroke dementia, depression, spasticity, contractures, chronic pain, urinary incontinence; rehabilitation and psychosocial support reduce long‑term disability.

8. Investigations / Diagnosis
   Routine – complete blood count, electrolytes, glucose, coagulation profile, ECG (to look for atrial fibrillation).

Specific – non‑contrast CT brain within the first hour to differentiate hemorrhage from infarction; MRI diffusion‑weighted imaging for early infarct detection.

Confirmatory – carotid Doppler ultrasound to assess stenosis, trans‑cranial Doppler for intracranial flow, MR or CT angiography for vessel occlusion, digital subtraction angiography when endovascular therapy is considered. Each test helps to identify the cause and guide treatment.

9. Differential Diagnosis (key points)
   Seizure – post‑ictal weakness (Todd’s paresis) can mimic stroke but usually follows a witnessed seizure and resolves within hours.

Migraine with aura – visual phenomena and sensory changes are gradual and often reversible; headache is typically throbbing and lasts longer.

Brain tumour – deficits develop insidiously, often with raised intracranial pressure signs and progressive worsening, unlike the abrupt onset of stroke.

Each condition can be distinguished by the time course, associated symptoms and imaging findings.

10. Management / Treatment

General management – immediate airway, breathing, circulation assessment; maintain normoxia, normoglycaemia, and blood pressure within target range; monitor for cardiac arrhythmias; prevent aspiration and deep‑vein thrombosis. The aim is to preserve viable penumbra and avoid secondary injury.

Modern medicine treatment –
• Ischemic stroke: if within 4.5 hours, intravenous thrombolysis with tissue‑plasminogen activator (tPA) is given; mechanical thrombectomy up to 24 hours for large‑vessel occlusion; antiplatelet agents (aspirin) started after 24 hours if no bleed.
• Hemorrhagic stroke: rapid blood‑pressure lowering (target < 140 mm Hg systolic), reversal of anticoagulation, surgical evacuation of large hematomas, and nimodipine for subarachnoid bleed to prevent vasospasm.

Diet and lifestyle advice – low‑salt, low‑saturated‑fat diet to control hypertension and cholesterol; regular aerobic exercise improves cerebral perfusion; smoking cessation reduces atherothrombosis; moderate alcohol intake; maintain healthy weight; adequate hydration and balanced nutrition support recovery.

11. Homeopathic Therapeutics (7 remedies, each with 7‑8 bullet points)

Arnica montana

• Causation: trauma, sudden impact, bruising of brain vessels.
• Characteristic symptoms: intense soreness, feeling of “being struck,” fear of being touched.
• Modalities: better from rest, worse from pressure or motion.
• Mental state: anxious, fearful, anticipates further injury.
• Thirst and appetite: increased thirst, appetite may be reduced due to nausea.
• Discharges: no specific secretions, occasional mild headache with pulsation.
• Physical generals: bruised, sore, warm skin over affected area.
• Suitable constitution: persons who are active, outdoors, prone to accidents.
• How it helps: reduces bruising and inflammation of cerebral vessels, supports recovery of neurological function.

Belladonna

• Causation: sudden inflammatory insult, high fever, rapid rise in intracranial pressure.
• Characteristic symptoms: throbbing headache, red face, dilated pupils, neck stiffness.
• Modalities: worse from light, noise, motion; better in cool, quiet environment.
• Mental state: delirious, restless, frightened of darkness.
• Thirst and appetite: great thirst for cold water, appetite poor.
• Discharges: dry mouth, occasional thin nasal discharge.
• Physical generals: hot, sweaty skin, rapid pulse.
• Suitable constitution: individuals with acute, violent onset of symptoms, often after a fright.
• How it helps: eases sudden vascular inflammation and reduces headache intensity.

Cerebrum (Cerebrum officinale)

• Causation: cerebral congestion after prolonged mental strain or over‑exertion.
• Characteristic symptoms: heaviness in head, difficulty concentrating, occasional loss of speech.
• Modalities: better in open air, worse in warm rooms.
• Mental state: confused, forgetful, unable to follow simple commands.
• Thirst and appetite: desire for cold drinks, appetite moderate.
• Discharges: occasional thin, watery sputum.
• Physical generals: pale complexion, sluggish pulse.
• Suitable constitution: students, scholars, people with excessive mental work.
• How it helps: improves cerebral circulation and clears mental fog after a stroke.

Nux vomica

• Causation: vascular spasm after excess stimulants (caffeine, alcohol) or over‑work.
• Characteristic symptoms: sharp, stabbing headache, nausea, irritability.
• Modalities: worse after midnight, better after coffee or warm drink.
• Mental state: irritable, impatient, feels “on edge.”
• Thirst and appetite: thirst for hot drinks, appetite reduced.
• Discharges: dry mouth, occasional bitter taste.
• Physical generals: tense muscles, rapid pulse, constipation.
• Suitable constitution: workaholics, night‑shift workers, those who over‑indulge in stimulants.
• How it helps: relaxes vascular smooth muscle, reduces spasm and improves flow.

Phosphorus

• Causation: prolonged weakness of vessel walls, often in thin, emaciated persons.
• Characteristic symptoms: burning headache, dizziness on standing, faintness.
• Modalities: better in cool, open air; worse in warm, stuffy rooms.
• Mental state: anxious, fearful of death, easily startled.
• Thirst and appetite: great thirst for cold water, appetite poor.
• Discharges: thin, watery nasal discharge, occasional cough.
• Physical generals: cold extremities, weak pulse, tendency to bleed easily.
• Suitable constitution: frail, thin individuals, often with a history of chronic illness.
• How it helps: strengthens fragile vessels and reduces risk of further bleed.

Gelsemium

• Causation: sudden loss of power after emotional shock or over‑exertion.
• Characteristic symptoms: heaviness of limbs, drooping eyelids, sluggish speech.
• Modalities: better when lying down, worse on mental effort.
• Mental state: apathetic, indifferent, “as if in a fog.”
• Thirst and appetite: little thirst, appetite diminished.
• Discharges: dry mouth, occasional thin sputum.
• Physical generals: slow, weak pulse, low blood pressure.
• Suitable constitution: persons who become exhausted after grief or disappointment.
• How it helps: restores tone to weakened nerves and improves motor response.

Aconitum napellus

• Causation: sudden onset after fright, exposure to cold wind, or rapid change in temperature.
• Characteristic symptoms: severe, stabbing headache, feeling of impending doom, restlessness.
• Modalities: worse from heat, better in cool, fresh air.
• Mental state: panic, fear of death, hyper‑alert.
• Thirst and appetite: thirst for cold water, appetite minimal.
• Discharges: dry mouth, occasional thin nasal discharge.
• Physical generals: rapid, thready pulse, flushed face.
• Suitable constitution: individuals who react violently to sudden stress or cold exposure.
• How it helps: calms the sudden surge of sympathetic activity and eases vascular constriction.

12. Prognosis
    Outcome varies widely; small lacunar infarcts often recover with minimal deficit, whereas large middle‑cerebral‑artery strokes or deep intracerebral hemorrhages carry higher mortality. Early reperfusion, control of risk factors, and intensive rehabilitation improve functional recovery. Age, baseline health, size of lesion, and speed of treatment are the main determinants of final outcome.

13. Prevention
    Primary – control hypertension (target < 130/80 mm Hg), manage diabetes, maintain lipid profile, quit smoking, limit alcohol, regular aerobic exercise, and adopt a low‑salt, high‑fiber diet. These measures reduce the incidence of both ischemic and hemorrhagic strokes.

Secondary – after a first stroke, antiplatelet therapy (aspirin or clopidogrel) for ischemic type, anticoagulation for atrial fibrillation, carotid endarterectomy if > 70 % stenosis, and strict blood‑pressure control to prevent recurrence.

14. Diet
    Recommended – fresh fruits, vegetables, whole grains, lean protein (fish, legumes), nuts, and olive oil; these provide antioxidants, fibre, and omega‑3 fatty acids that protect vessels.

Avoided – foods high in saturated fat, trans‑fat, excess salt, and refined sugars; they promote atherosclerosis, raise blood pressure, and increase clot‑forming tendency.