Rehabilitation after Stroke

Rehabilitation after Stroke is one of the most important phases in recovery after stroke. It is also one of the most neglected aspects of stroke care in India. Annual estimated stroke incidence is 135 to 145 per 100,000, with early death rates ranging from 27% to 41%. This corresponds to ~1.5 million people having a stroke each year, leading to a further 500,000 people, each year, living with stroke-related disability. Hence, every patient being treated for stroke should have access to rehabilitation services. 

The long term goal of rehabilitation is to improve function so that the stroke survivor can become as independent as possible. This can be achieved by regaining the lost function as well as retraining other areas of the brain to take up the lost function (brain plasticity).

When does rehabilitation begin?

Rehabilitation should begin as soon as the treating doctor determines that the patient is medically stable. Depending upon the severity of stroke, rehabilitation may be undertaken in 

• Rehabilitation unit in the hospital
• At home, through home health personnel
• Outpatient rehabilitation facilities
• Long term care facilities such as nursing home

What are the different components of rehabilitation after stroke?

• Psychological - Depression and anxiety are the most common sequelae after stroke. Timely consultation with a psychiatrist and a psychologist will prevent interference with recovery process.
• Cognitive retraining - The psychiatrist and psychologist can also help in improving communication, spatial awareness, concentration and memory.
• Physiotherapy helps in improving muscle strength and overcoming walking difficulties.
• Occupational therapy involves adapting your home or using equipment to make everyday activities easier, as well as trying to find alternative ways of carrying out tasks that the patients have problems with.
• Speech and Language therapist works with improving difficulties with speech and communication.
• Swallowing difficulty - Some patients may have difficulty swallowing and require a feeding tube to prevent aspiration of food into the lungs. In long term, the speech and language therapist also works with the patient in starting oral feeds in a way to prevent aspiration.
• visual problems such as not being able to see one half of the visual fields may require eye movement exercises and can be addressed by simple ways by the physiotherapist or the ophthalmologist.
• Bladder and bowel problems are not uncommon after stroke and can be effectively be treated with retraining exercises, medications, pelvic floor exercises and the use of special products for incontinence.
• Erectile dysfunction can be a problem after stroke and there are many ways to overcome it.
• Not being able to drive is another major problem that may prevent the stroke survivor from returning to work. It should be borne in mind that the patients should start driving only after obtaining clearance from the doctor. If needed, specific training should be sought.
• Changes should be made in the lifestyle to prevent further strokes.

The ATTEND (Family-Led Rehabilitation After Stroke In India) trial aims to determine whether stroke recovery at home given by a trained family member is an effective, affordable strategy for those with disabling stroke in India when compared to usual care. Considering the cultural and family structure in India, this trial if it is positive it holds promise for a major change in practice in stroke rehabilitation both in developed and developing countries.

Vein of Galen Malformation

Vein of Galen Malformation (VOGM) is a rare condition in which there is an abnormal malformation involving one of the important veins in the brain that returns blood to the heart.

What causes VOGM?

The exact cause of VOGM is unknown. It is seen most often in infants and children. It can be detected as early as during pregnancy during routine ultrasound examination. The condition is not inherited and is not transmitted in the family. Rarely, it can be seen in older individuals.

Signs and Symptoms

The abnormal communication between arteries and veins in the brain leads to increased blood flow into the veins and to the heart. All the symptoms are as a result of this increased blood flow. the most common signs and symptoms are

• heart failure, often in the first few days of life
• abnormally increased head size and circumference due to excessive fluid accumulation within the brain
• prominent veins on the veins and scalp
• developmental delay
• failure to thrive
• seizures
• headache
• rarely, brain bleed
• if untreated, the condition may be life threatening

Diagnosis

• the condition may be detected on antenatal ultrasound
• CT scan, MRI may be required if there is a suspicion of VOGM
• cerebral angiography is the definitive test to confirm the diagnosis

Treatment

• A Neurosurgeon and neurointerventionist should be consulted to assess the extent and location of VOGM and plan management
• A Cardiologist should be consulted to assess heart function
• The neonatologist or pediatrician takes care of general health of the child
• Embolization is performed to close the abnormal connections. The procedure involves inserting a catheter through one of the arteries in the groin and navigating all the way into the tiny abnormal connections. Coils (metal threads) and glue are used to close the abnormal connections.
• Multiple sessions of embolization are often needed to close all the abnormal connections
• Open surgery for VOGM is never required. However, shunt surgery may be required to drain the fluid from accumulating in the brain.

Outcome

It is often possible to cure the malformation. The extent of brain and heart damage at the time of diagnosis and treatment determines the outcome.

Support Group

VOGM Patents' Alliance http://vogmparents.org/

The Road to Recovery after Brain Aneurysm Treatment - Emotional Effects

"I know all about time and wounds healing, but even if I had all the time in the world, I still don’t know what to do with all this hurt right now.” 
                                                   ------------― Nina Guilbeau, Too Many Sisters

It is impossible for others to understand the suffering that a patient with an illness goes through simply because the experience is unique to the person. The life-changing experience that one goes through after brain aneurysm treatment puts the patient through great emotional stress. Even though no one may truly understand the emotional effects following brain aneurysm treatment, all patients should know that help and support is available. Maintaining a positive attitude, healthy diet and following doctor's advice will help the patient overcome the emotional sequelae.

Common emotional disturbances following brain aneurysm treatment are

Depression: Many brain aneurysm survivors suffer from depression. Symptoms include mood swings, feeling of sadness, anxiety, emptiness, hopelessness, decreased energy and fatigue, difficulty concentrating, forgetfulness, lack of sleep, decreased appetite, loss of interest in pleasure or activities including sex and suicidal thoughts. 

The patients need to openly share their feelings with someone close to them and also to the treating doctor. Consultation with a psychiatrist or a psychologist may help. The patients should understand that patience and time are required to overcome some of these sequelae. The most important thing that the patients and their families should understand and keep in mind that having a brain aneurysm is not the end of the road and that help is available to face the emotional and physical disturbances. 

Loss of Emotional Control: Many patients experience increased anger, sadness or apathy. The anger or frustration of not being able to go back to the pretreatment state can be difficult to understand. In these circumstances, counselling should be sought.

Loneliness: Many patients feel lonely as they do not have someone to share their suffering. In such circumstances, sharing their feelings with the doctor and seeking appropriate counselling often helps.

Sleep Disturbances: Many patients experience decreased or excessive sleep due to prolonged stay in the hospital or the ICU. In most circumstances, the treating doctor is able to help.

Decreased Self-esteem: Many patients feel less capable of doing their work. In many patients, it is the lack of right attitude rather than physical incapability. Appropriate and timely treatment by a psychiatrist or a psychologist is very helpful.

Family and financial issues: Disputes in the family or financial insecurity may crop up and play a major role in worsening the above mentioned emotional effects. The patient and his/her family should understand that having a brain aneurysm is not the end of the road and, with appropriate and timely treatment, the physical and emotional effects can be minimized.

The Road to Recovery after Brain Aneurysm Treatment - Physical Effects

Having a brain aneurysm and undergoing treatment is a life changing event. Recovery is more difficult and longer in older patients, following brain aneurysm rupture and chronic medical problems. Patients recovering after treatment of brain aneurysm often have physical, emotional and psychological issues. Besides the patient, the family also suffers from many issues, one of the most important being financial burden in Indian scenario. In the coming few posts, I will discuss the issues faced by patients and family and how to get over them

Neurological

• weakness of arm, leg
• speech problems
• memory problems
• visual problems
• loss of smell or taste
• difficulty walking or balance problems
• seizures
• fatigue and generalized weakness
• sleep problems
• back pain

Many of these problems gradually improve over time. Evaluation by a physiotherapist and occupational therapist is recommended in patients with arm or leg weakness and balance problems. Speech therapy can help many patients with difficulty understanding and speaking. Appropriate neuropsychological testing and therapy can help patients with memory and behavioral problems to cope with the frustration. Some of the common memory problems include absorbing, storing and recalling information. The memory problem may be from the bleed or stroke during the acute period after aneurysm rupture. Organizing one's daily activities and writing down information is helpful.

Patients with visual problems and seizures should be careful not to drive and should avoid working near heavy machines that can cause injury. evaluation by an ophthalmologist is advised for visual rehabilitation.

Fatigue and generalized weakness is a common complaint in many patients. The patients should understand that it is normal to be sleepy and not interested in outdoor activities for a few weeks. The bleeding in the brain takes a few weeks to resolve. Eat well and engage your mind in activities to keep you busy. Trouble sleeping in the night is also very common and should get better with time.

Back pain may occur in some patients due to lying in the bed for many days or if the bleeding extended into the spine. The headache may also be from spinal tap in some patients. The pain usually resolves in a few weeks as the patients involve themselves in activities.

Common problems following surgery for brain aneurysms are

• incision site pain and numbness - may patients complain of local pain at the site of incision in the scalp following surgery. Some may have numbness over the incision site. The pain and numbness usually goes away with time.
• jaw pain - many patients may have jaw pain on the side of surgery, especially while eating or chewing hard food. For this reason, it is advisable to eat soft food immediately after the surgery. The jaw pain occurs due to manipulation of muscles during surgery and resolves slowly after surgery in about a month.
• clicking sound in the head - some patients may notice a click in the head following surgery. It is also a normal phenomenon and usually resolves in a few weeks
• headache - some patients may have intermittent mild headache that disturbs their daily activity. The pain usually resolves with pain pills or by itself. If headache is severe, associated with vomiting or blurring of vision, consult your doctor immediately.

Common problems following coiling or stenting for brain aneurysms are

• groin pain - there may be bruising or pain in the groin for a few days after the procedure. Please consult your doctor immediately if there is sudden bleeding from the puncture site or painful swelling.
• hair loss - is seen in some patients secondary to radiation. It is more common when the procedures last longer than about 3 hours. The hair loss is temporary in most of the patients.
• headache - may occur in some patients and is usually due to the bleed that occurred following aneurysm rupture. it resolves gradually on its own.
• general bruises over the body - may occur in some patients who take blood thinner pills following stenting. Try not to get hurt or cut yourself inadvertently. If you notice a bad bruise, contact your doctor immediately.

Carotid Stenosis (Carotid artery disease)

Carotid stenosis (stenosis = narrowing) is the narrowing of carotid arteries in the neck. Carotid arteries carry oxygen-rich blood to a large part of the brain. Gradual narrowing of these arteries causes decrease blood flow to the brain leading to stroke. There are no community based studies describing the incidence and prevalence of carotid artery disease in India. The increasing prevalence of heart disease, diabetes and other risk factors such as obesity only indicates that the incidence of carotid stenosis in India is on the rise. Hence it is important for family doctors and people to be aware of this condition and seek appropriate treatment.

What is carotid stenosis?
Progressive narrowing of carotid arteries in the neck occurs due to the formation of plaque consisting of fat, cholesterol and calcium. Over time, this plaque gradually prevents adequate amount of blood going to the brain. People with carotid stenosis have an increased risk of having a stroke in one of the three ways:

• The plaque may grow larger and larger and may eventually completely block the carotid artery.
• Due to decreased blood flow through the carotid arteries, there is an increased risk of forming blood clots in the carotid artery. These blood clots may go into the brain and block one of the major arteries.
• The plaque may break and block one of the arteries in the brain.

What are the risk factors for carotid stenosis?

• Age
• Smoking
• High blood pressure
• High 'bad' Cholesterol (LDL)
• Diabetes
• Obesity
• Family history of heart disease and stroke

What are the symptoms?

Unfortunately, many people with carotid artery disease do not have symptoms until the late stage and, in many patients stroke may be the first indication of carotid stenosis. Transient ischemic attack (TIA) or 'Warning Stroke' may be another indication of underlying carotid artery disease. Common symptoms of TIA include

Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body. 

Sudden vision changes. A special type of TIA is amaurosis fugax. Transient blindness in one eye occurs because debris from a narrowed carotid artery clogs the artery (ophthalmic artery) that supplies blood to the retina of the eye. 

Sudden trouble speaking. 

Sudden confusion or trouble understanding simple statements. 

Sudden problems with walking or balance.

How is carotid stenosis diagnosed?
Every doctor should be aware of this condition and should refer the patient to the appropriate specialist when in doubt. A Stroke Neurologist is the best person to diagnose and  manage carotid artery disease initially. Other than a thorough clinical examination, some of the common tests used to diagnose carotid stenosis and plan treatment are

• Carotid doppler ultrasound
• CT angiography
• MR angiography
• Digital Subtraction Angiography

How is carotid stenosis treated?

• Lifestyle modification slows the growth of the plaque. This is the most important step in treatment of carotid stenosis
• Depending upon the associated medical conditions, your doctor may prescribe blood thinners such as aspirin, clopidogrel and warfarin. Statins have a major role to play in the medical management of carotid artery disease. High blood pressure, diabetes and heart disease, if present, should be treated appropritely
• Carotid Endarterectomy: In selected patients, surgery may be required to remove the plaque. Surgery involves making an incision in the neck, opening the carotid artery, removing the plaque and sewing the artery back to restore blood flow to the brain

                                           

• Carotid angioplasty and stenting: In patients with severe uncontrolled heart disease in whom surgery may carry a high risk, opening the artery from inside and placing a stent by inserting a catheter through the groin may be an option.

Lifestyle Changes to Prevent Stroke

The annual incidence of stroke in the country has increased from 13 per 100,000 in 1969 to 145 per 100,000 in 2006. The costs of acute care and managing these patients in long term are astounding. In another study, the overall DALYs (Disability Adjusted Life Years) lost due to stroke were 795.57 per 100,000 person years. This means that if 100,000 people were to live for one year, about 800 people will be disabled due to stroke and will not be able to go to work.

As individuals, we should be aware of the healthy ways of living to prevent a stroke. In this article, I will discuss some of the lifestyle changes that we can adopt in order to decrease the risk of having a stroke and heart attack.

How to make lifestyle healthier?

• Do not smoke. Smoking is one of the strongest predisposing factors for stroke and heart attack. Passive smoking is harmful as well. Ideally, it's best to not start smoking in the first place, but if you're a current smoker, no matter what your age, quitting can be extremely beneficial. For example, if you quit smoking before the age of 50, you cut your risk of dying in the next 15 years in half compared to those who keep smoking.
• Eat healthy. Eat foods low in saturated fat, trans fat, cholesterol, sodium and added sugars. Some of the nutrients sources for vegetarians are
• Proteins - chickpeas, lentils, green peas, soybeans and kidney beans, beans, nuts, nut butters, peas, and soy products (tofu). Milk products and eggs are also good protein sources for lacto-ovo vegetarians. Calcium-fortified nondairy substitutes, such as soy milk and soy yogurt, are also excellent sources of protein. A cup of milk or soy milk provides about 8 grams, and 1 cup of low-fat yogurt contains about 13 grams of dietary protein. Paneer, a fresh cheese common in Indian cuisine, contains about 7 grams of protein per ounce
• Iron - iron-fortified breakfast cereals, spinach, kidney beans, black-eyed peas, lentils, turnip greens, whole wheat chappati, peas, and some dried fruits (dried apricots, raisins)
• Calcium - calcium-fortified milk, calcium-fortified breakfast cereals and orange juice, tofu made with calcium sulfate, and some dark-green leafy vegetables (collard greens, turnip greens, bok choy, mustard greens). Milk products are excellent calcium sources for lacto vegetarians.
• Zinc - beans (white beans, kidney beans, and chickpeas), zinc-fortified breakfast cereals, wheat germ, and pumpkin seeds. Milk products are a zinc source for lacto vegetarians.
• Vitamin B12 - milk products, eggs, and foods that have been fortified with vitamin B12. These include breakfast cereals, milk and nutritional yeast.
• Avoid foods like egg yolks, fatty meats, butter and cream, which are high in fat and cholesterol.
• Eat moderate amounts of food and cut down on saturated fat, trans fat, sugar and salt.
• Bake, broil, roast and boil foods instead of frying.
• Read nutrition labels on packaged meals. Many are very high in sodium.
• Limit alcohol to one drink a day for women; two drinks per day for men.
• Eat more fruit, vegetables, whole-grains, dried peas and beans, pasta, fish, poultry and lean meats.
• Ask your doctor, nurse or a nutritionist or dietician for help.

• Be physically active
• Look for small chances to walk or exercise. Take the stairs instead of the elevator
• Brisk walking or running for at least 2-3 hours a week is good for health
• Consult your doctor before starting any exercise if you have a medical condition
• Get regular blood pressure checks. Don't be afraid of high blood pressure. Work with your doctor to control the blood pressure
• Maintain a healthy weight. A basal metabolic index (BMI) of less than 25 is acceptable
• Take your medicines as directed by the doctor
• Reduce the stress level in your daily life. Meditation helps
• Have regular medical check-ups. Do not ignore warning signs

'Transient Ischemic Attack' or 'Mini-Stroke'

A 'Transient Ischemic Attack' (TIA) or 'Mini-stroke' is a condition in which the person experiences the symptoms of a stroke for a few minutes. The symptoms completely resolve within a few minutes. About 1 in 3 persons experiencing TIA will eventually develop a full blown stroke. This is the reason why TIA is also called 'Warning Stroke'. It also gives the person time to act and prevent permanent stroke.

TIA occurs because the blood flow to a part of the brain stops temporarily due to a clot. When the body dissolves the clot, blood flow is restored and the symptoms resolve. Decreased blood flow due to narrowing of an artery supplying a part of the brain may also lead to TIA in situations where the demand increases.

The common symptoms of TIA are exactly the same as that of stroke.

• Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body.
• Sudden vision changes. A special type of TIA is amaurosis fugax. Transient blindness in one eye occurs because debris from a narrowed carotid artery clogs the artery (ophthalmic artery) that supplies blood to the retina of the eye.
• Sudden trouble speaking.
• Sudden confusion or trouble understanding simple statements.
• Sudden problems with walking or balance.

Most symptoms of TIA disappear in a few minutes to hours.

Risk factors for TIA are the same as that for stroke

• strong family history of stroke
• smoking
• high cholesterol
• high blood pressure
• heart disease
• diabetes

Tests that your doctor may perform

• Tests that show pictures of your brain and blood vessels, such as a CT scan, an MRI, a magnetic resonance angiogram (MRA), or an angiogram.
• A test that uses sound to check your blood flow (Doppler ultrasound).
• An echocardiogram (echo) to check your heart's shape and its blood flow.
• An electrocardiogram (EKG, ECG) to measure your heart rhythm.
• Blood tests, including a complete blood count and a fasting blood test to check for problems that could be causing your symptoms.

The goal of TIA treatment is to prevent a full blown stroke. Treatment depends on the exact cause of the TIA. In addition to lifestyle changes such as diet, physical activity, limiting alcohol intake, and not smoking, the doctor may recommend medications to treat high blood pressure, high cholesterol, or heart disease. These changes may reduce your risk of further TIA or stroke. There are many medications that help prevent blood clots from forming, thus, reducing the risk of full-blown stroke.

If a TIA is caused by blockage in the main artery in the neck that supplies blood to the brain, called the carotid artery, surgeries may be required to open the artery, and prevent a stroke. These procedures are known as endarterectomy and stenting.

If TIAs are appropriately treated on time, one can prevent stroke and major disability. Hence, it is essential for people to be aware of this condition and seek treatment as soon as possible.