Sudden cerebral infarction: a widespread disease that is often serious
Apoplex, commonly known as stroke, is an acute circulatory disorder in the brain that is most commonly caused by vasoconstriction or occlusion. Bleeding from the brain or other diseases are less common. If symptoms are recognizable, quick action is the most important prerequisite to prevent possible consequential damage to those affected. The acute treatment and any long-term therapies are individually very different and depend on the shape, the severity, the course and the respective disorders. As the third leading cause of death, every stroke is a serious emergency.
A brief overview
In order to be able to provide quick help yourself in an emergency, you need basic knowledge of stroke. The following summary provides a first overview of the most important facts. Detailed information can be found in the following article.
- definition: A stroke or cerebral infarction (apoplex) is an acute undersupply of the brain with oxygen and other nutrients due to a circulatory disorder. It is a life-threatening event.
- Symptoms: Typical first signs include unilateral paralysis, speech and vision disorders, severe headache and dizziness (also associated with nausea and vomiting). But these common symptoms do not appear in all cases. Possible consequential damages are long-term or permanent neurological dysfunctions, which can lead to different physical and mental impairments.
- causes: The most common cause of stroke is reduced blood flow due to narrowing of the vessels or constipation from a blood clot. Bleeding from the brain or other diseases are less common. Vascular calcifications (arteriosclerosis), high blood pressure or cardiac arrhythmias or atrial fibrillation) are often already present and can be counted among the triggering factors.
- Risk factors: In addition to the risk factors of age (especially over 75 years) that cannot be influenced, and genetic predisposition, unhealthy lifestyles favor the development of a stroke, such as high-fat nutrition, little exercise, smoking, alcohol and drug consumption. Diabetes also increases the risk by two to three times.
- diagnosis: A quick diagnosis is essential for survival and crucial for the first acute treatment. In the best case, the clinical examination in a specialized hospital unit (stroke unit) is supplemented with imaging procedures and a blood test. In the further course, other diagnostic methods, for example to determine the cause, may become important.
- treatment: The treatment options always depend on the individual situation. In acute treatment, thrombolysis therapy for the medicinal resolution of the vascular blockage or thrombectomy for removal of the vascular plug by means of a catheter can be used under certain circumstances. Rarely, and only with major bleeding into the brain, it may be necessary to surgically remove the leaked blood. In the aftermath, depending on the extent and the consequences of the event, there is usually a rehabilitation with various longer-term therapeutic measures.
- Naturopathic treatment: A variety of alternative and naturopathic methods can support rehabilitation after the acute phase. In addition to tried and tested methods from exercise therapy, phytotherapy, homeopathy (e.g. arnica) or acupuncture, newer approaches such as hyperbaric oxygen therapy are also used. In addition, nutritional concepts (with sufficient antioxidants) or the practice of tai chi can be useful supplements for physical and mental stabilization and strengthening.
- research: The aim of many specialist groups and expert centers is to improve knowledge about the causes and treatment options and to be able to offer those affected better help in the future.
Other names for a stroke include cerebral infarction and stroke or, in medical terminology, apoplexy (apoplexy) and cerebral insult. All terms refer to a sudden ("sudden") disease of the brain due to a disorder in the blood supply and thus the supply of the brain with oxygen and other nutrients. Subsequently, long-term neurological failures often occur, such as numbness and paralysis, as well as disorders in consciousness, speech and vision.
A cerebral infarction is an acute and often life-threatening event and is considered the main cause of acquired and persistent moderate to severe disabilities in adulthood. There are an estimated 270,000 new strokes per year in Germany, with around 20 to 30 percent of those affected dying from the serious illness and its consequences within a year. This makes stroke, after the heart attack and cancer, one of the most common causes of death in Germany.
Approximately half of all strokes occur from the age of 75. However, this life-threatening illness can also affect younger people, even children and newborns. There are various studies on the frequency in men and women, with the risk ratio generally differing only slightly. However, women are usually older than men (approximately 68 years) at the time of the event (on average 75 years), which means that the consequences are usually more serious for women affected.
The symptoms of a stroke are varied and depend on which area of the brain is affected and how severely. Typical is the sudden appearance of symptoms that, depending on the extent, subside in a few minutes or persist over a longer period of time and can also lead to serious sequelae.
The symptoms also differ from person to person and are not equally pronounced between the sexes. While men are more likely to show typical neurological disorders during a stroke, women are more likely to experience extremely severe headaches and dizziness, combined with nausea and vomiting.
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Recognize the first signs
Every stroke represents an emergency, which is why quick detection and action is vital to survival. The typical “sudden” symptoms associated with an insult include the following complaints:
- unilateral paralysis and numbness, usually on the right side and often on the face (drooping corner of the mouth) and arm,
- different language disorders and language comprehension disorders,
- Visual disturbances (limited field of vision, double vision)
- very severe headache, including nausea and vomiting,
- Dizziness and gait insecurity.
Even laypersons can quickly identify whether there are actually signals for a stroke by simply asking those affected. This type of rapid test is abbreviated to the letters FAST (face, arms, speech, time). If the person concerned has problems performing even one of the activities, the emergency call must be notified immediately.
Affected people should be encouraged to smile. This is usually not possible with paralysis on one side and the patient has problems with his facial expressions and grimaces. Raising your arms with your palms up would not work properly on one side if you were paralyzed by a stroke. An arm would turn in again and sink down. If the person is asked to repeat a very simple sentence, this is often associated with problems. Affected people may express themselves very slowly, hesitantly or washed out. They may twist words and parts of sentences. These symptoms are not mandatory, but are common in acute stroke.
Short or temporary and easily recognizable symptoms with no consequences, such as short-term unilateral visual disturbances or paralysis, were formerly referred to as transient ischemic attacks (TIA). The neurological deficits that occur only last a few minutes or completely disappear within twenty-four hours. A so-called RIND or PRIND denotes a (prolonged) reversible ischemic neurological deficit that lasts longer than one day but less than three weeks. There is also the name of a partially reversible ischemic neurological syndrome (PRINS). All of these terms should no longer be used because, according to recent findings, this is either a stroke that has already been manifested, or the resulting brain injuries can be detected and have a similar risk of recurrence as is the case after a classic stroke. So even if symptoms disappear relatively quickly, you should take them very seriously and get medical advice immediately.
In one of the most common forms of stroke, the so-called media infarction, there is usually an embolic occlusion of the cerebral artery. If the supply area of this middle cerebral artery is affected, a number of symptoms can occur, which can also be very serious in the aftermath:
- contralateral hemiparesis: incomplete paralysis of one side of the body on the opposite side of the damage (dominant in the arm and face),
- Hemiaesthesia (one-sided sensitivity disorder), such as numbness and tingling in the limbs,
- contralateral homonymous hemianopsia: visual disturbance with loss of visual field (scotoma), in which both eyes are affected with the equilateral part of the visual field,
- Dysarthria (speech disorder),
- Aphasia (speech disorder) when the dominant hemisphere has been damaged,
- Apraxia: impaired execution of targeted actions with intact motor function (e.g. facial expressions, gestures, use of objects) if the non-dominant hemisphere has been damaged,
- Neglect (attention deficit disorder) on the opposite side of the brain lesion in the non-dominant hemisphere.
Common symptom: hemiparesis
If hemiparesis occurs as a result of a stroke, those affected often suffer from hemiplegia with arm arches and unilateral facial paralysis (facial paralysis). This results in a drooping corner of the mouth in the face, whereby the mouth can often not be closed properly and therefore the liquid and food intake is difficult. The frown on the affected side does not work or only to a limited extent. Eyelid closure is also hampered. There are also symptoms, such as an inward shoulder and an inward rotating and bent arm. The fingers are also directed inwards and the thumb is drawn in. The lower extremities can also be affected. One leg is often brought forward in a semicircle while walking. The symptoms mentioned are more or less pronounced depending on the extent and severity.
The more rare symptoms include, for example, urinary incontinence (bladder weakness) or apathy. Confusion associated with disorientation are also possible signs that occur less frequently. These areas usually affect the area of the anterior cerebral artery (anterior cerebral artery).
Long-term consequences of a stroke
Depending on the severity of the symptoms, a stroke can have long-term or even permanent consequences for life. In some cases, the first symptoms can resolve spontaneously or after the corresponding therapy success. But it should not be forgotten that stroke is the most common cause of long-term care and that serious consequences are relatively common.
All of the above symptoms and other complaints can, in different forms and duration, make everyday life more difficult for those affected. Depression often occurs after a stroke, especially with long-term consequences. Adapting to the changed life situation and living with the resulting restrictions and fears is not easy for many affected people to cope with. There is often the recommendation (temporarily) to get help for everyday life through outpatient care services and appropriate therapeutic measures.
In principle, a distinction is made between two types of stroke, which also have different causes. At around eighty to eighty-five percent, the most common form is an ischemic “white” stroke that triggers a cerebral infarction due to reduced blood flow (ischemia) in the brain. Rarely (about fifteen to twenty percent) there is a hemorrhagic "red" stroke, which is based on bleeding.
Vascular occlusion and constriction are the trigger for the occurrence of reduced blood circulation in a certain area of the brain. If the undersupply lasts too long, a limited part of the tissue dies and causes various functional losses, depending on the extent and the exact location.
Statistically, the most common cause of this circulatory disorder is a blood clot (embolus), which does not form at the actual site of the event but in the heart. This vascular plug then reaches the brain region via the bloodstream, where it ultimately leads to vascular blockage. This so-called cardioembolic infarction often occurs in those with atrial fibrillation (arrhythmia of the heart with uncoordinated atrial action). The reason for this is that this cardiac arrhythmia means that the blood is not pumped on by the heart in the normal rhythm and therefore remains there too long, which can lead to a clot formation. However, other places of origin of an embolism, such as a “calcified” carotid artery, are also possible (carotid stenosis).
One of the most common consequences after embolic occlusion is a so-called media infarction. With this form of ischemic stroke, there is a blockage of the cerebral artery (“middle brain artery”). This artery is one of the main vessels for the supply of the brain as a direct continuation of the internal carotid artery ("internal carotid artery").
Frequently, however, there are also vascular changes, mostly due to vascular calcification (arteriosclerosis) due to deposits on the inner artery wall (plaques). Such a narrowing (stenosis) can progress to such an extent that the brain is no longer adequately supplied with blood and that in the end the vascular flow comes to a complete standstill. Furthermore, the formation of a vascular plug (thrombus) at this point can lead to a complete vascular occlusion (thrombosis). If there is a change in the large vessels, such as the large brain artery or its other branches, this is called macroangiopathy. Microangiopathy affects smaller vessels and also leads to smaller so-called lacunar brain infarctions below the cerebral cortex.
In rare cases there are also other causes, such as vascular inflammation (vasculitis), splitting of the arterial wall (dissection) or haematological diseases (blood diseases). It is also possible that the cause cannot be determined at all or not clearly.
The information corresponds to the current, modified classification system (TOAST classification), which differentiates between the five cause groups for an ischemic stroke: macroangiopathy, microangiopathy, cardiac embolism, other etiology and unclear etiology.
If a stroke is due to bleeding, a distinction is made between intracerebral bleeding (bleeding in the brain) or less often subarachnoid bleeding (bleeding in surrounding tissue layers).
Intracerebral bleeding (cerebral hemorrhage in the narrower sense) usually arises from a vascular rupture in the brain. It is not uncommon for a tear in an already weakened vascular wall to occur, which, for example, is more common in chronic arterial hypertension (high blood pressure). In other cases, vascular changes (for example, aortic aneurysm) or malformations, trauma (traumatic brain injury) or other brain or blood disorders are the cause.
If a vessel bursts in the brain, blood flow to certain areas of the brain is reduced and the escaping blood also causes pressure on the surrounding tissue, which can cause further damage.
With sudden subarachnoid hemorrhage, blood runs between the inner and middle layers of tissue that surround the brain. In most cases, this happens due to the rupture of a bulged artery wall (aneurysm). If bleeding in the subarachnoid space occurs due to a head injury, this is considered to be a traumatic disorder of its own and not a stroke.
The main causes such as high blood pressure together with arteriosclerosis, aneurysms, heart and blood disorders, there are a number of factors that promote a stroke or the pathological changes that can lead to a stroke. Some risks can be reduced by lifestyle changes and preventive measures, others cannot be influenced. There are fundamentally different risk factors for a "white" or a "red" insult.
The risks that cannot be changed include age and a certain genetic disposition. So the risk increases with age (especially over 75 years) and when a brain infarction has occurred in the family, especially due to inheritable diseases.
Other major risk factors for ischemic stroke are diabetes, smoking and high cholesterol. The latter can occur due to a fat metabolism disorder or due to improper and too high-fat nutrition. Taking the pill is only a very small additional risk. Diabetics have a two to three times higher risk, while smoking is even considered to be a two to four times higher risk.
Other general risk factors include excessive alcohol consumption, other substance dependencies (cocaine, amphetamines) and stress. Being overweight can also increase the risk of stroke, especially if the fat deposits are in the abdominal region. This often goes hand in hand with an unhealthy diet and insufficient physical activity.
With a red insult, however, especially blood clotting disorders pose a high risk of brain hemorrhage. Sometimes bleeding can also occur after an ischemic stroke. In principle, there is an increased risk of a hemorrhagic stroke for people who have already had a seizure.
Avoid risks and prevent stroke
Various, quite simple measures can already have a great positive impact on the health of the cardiovascular and vascular systems. For example, moderate physical exercise, a normal body weight, as little stress as possible and the absence of nicotine and alcohol have been shown to reduce the risks of a cerebral infarction (e.g. from arteriosclerosis or high blood pressure).
Every minute counts as soon as those affected, their relatives or first aiders notice signs of a stroke. The emergency services must be called immediately so that specialist medical care is ensured as quickly as possible. First of all, an exact diagnosis is pioneering for the subsequent acute therapy and the success of the treatment.
Ideally, the diagnosis and the first treatment will be carried out on a stroke special unit, the so-called “stroke unit”. But not all hospitals have this special care area. Comprehensive equipment examination and monitoring devices are available on these "acute wards". Together with a specially trained specialist staff, intensive medical care and the best possible diagnostic and therapeutic care of those affected is guaranteed.
First of all, a quick clinical examination takes place via a medical history (patient survey), if necessary also with the help of relatives. At best, the examination should be carried out with specialist neurological expertise. Various examination methods enable brain functions to be checked.
In any case, these initial examination results and any suspicion should be followed by imaging diagnostics using computer tomography (CT) or magnetic resonance imaging (MRI) of the head within a very short time. The blood vessels and structures in the brain can be made clearly visible using the slice images, often with contrast agents, so that a stroke can be localized precisely and the severity of the incident can be recognized. Triggers such as bleeding or vascular occlusion can also be identified in this way. A blood test is also part of a stroke diagnosis, for example to detect coagulation disorders. After these first, absolutely necessary examinations, a decision is usually made about a possible acute treatment.
Further examinations usually follow in the first days after a cerebral infarction and after the first therapeutic measures. These can be special ultrasound exams, such as duplex sonography, to measure blood flow in the brain. This can provide further important results, particularly in the case of circulatory disorders. A long-term ECG can show any irregularities and diseases of the heart, such as atrial fibrillation. This cardiac arrhythmia is often one of the causes. Ultrasound examination of the heart (cardiac echo) can detect possible blood clots. And a long-term blood pressure measurement can clarify whether the risk factor is hypertension.
However, these and some other special procedures, like the FAST rapid test, do not always manage to identify a stroke. In particular, the rare forms and minor incidents are sometimes not recognized and the causes cannot always be proven despite extensive investigations.
The first hours after a stroke and the treatment that has been given are decisive for the extent of the permanent damage. In order to maintain as much quality of life as possible for those affected, quick and correct acute treatment is required and, in the more severe cases, subsequent individual rehabilitation and long-term therapy.
At the very beginning of every treatment is the adjustment of the vital functions in order to stabilize those affected as best as possible. In the case of an ischemic insult, thrombolysis (abbreviated: lysis) is only possible in the first four and a half hours after the first symptoms appear and under certain conditions. A medication is administered to dissolve the clot and to preserve the underserved area as much as possible. The faster such treatment begins, the greater the success to be expected.
A hemorrhagic stroke should not be lysed under any circumstances, as this may cause further bleeding aggravation, which may have triggered the cerebral infarction, or additional dangerous bleeding may occur. In the case of major bleeding in particular, it may be necessary to surgically remove the blood in order to reduce the pressure on the brain and relieve the tissue at risk. Such interventions are rarely carried out.
Another, less frequently used, method for a "white" insult is thrombectomy. This is primarily used for larger blood clots. The seal is pierced by a catheter and the clot is aspirated.
Rehabilitation and long-term treatment measures
In many cases, an inpatient rehabilitation measure directly follows the hospital stay to further treat the consequences of a stroke. Mostly they are admitted to a neurological specialist clinic. A geriatric clinic can also be recommended for older people with certain previous illnesses. In some cases, if those affected can take good care of themselves and a corresponding center is located in the immediate vicinity of the place of residence, outpatient rehabilitation can also take place.
As a rule, the cost bearers (health insurance companies) undertake rehabilitation for around three weeks and, if requested, a longer period of time. The therapy plan is basically comparable in the individual facilities, but differs according to the individual clinical pictures and the symptoms present. As a rule, individual treatment units from the areas of physiotherapy, occupational therapy, speech therapy, neuropsychology and nutritional advice are put together. In addition to individually tailored individual sessions, group therapies can also take place.
The aim of the rehabilitation is to restore the remaining functional disorders as far as possible and to learn compensation measures in order to find your way back to your everyday life as independently as possible. Prevention in order to avoid another stroke if possible is also part of the rehabilitation.
In many cases, outpatient therapies follow after discharge from rehabilitation, and one's own daily training is also of great importance for further recovery. Depending on their severity, those affected have to learn to live long-term or forever with certain restrictions. This is often a major psychological burden and it is not uncommon for depression to occur due to the difficult new life situation and fears of a new stroke. If this is the case, psychological counseling or psychotherapy can also be useful.
In addition to regular primary care, further specialist treatment may be necessary, depending on the cause and state of health.
Naturopathic and alternative treatments
In addition to conventional medical treatment, there are several naturopathic and alternative procedures that can support treatment after the acute phase of a stroke. One of the newer therapeutic approaches is hyperbaric oxygen therapy (HBO therapy), in which patients inhale medically pure oxygen under increased ambient pressure. An Israeli study showed that this treatment can reactivate damaged cells in the affected areas of the brain, but more in a later phase after a stroke.
On the other hand, the routine administration of oxygen in a stroke, regardless of the oxygen saturation, is now classified as questionable and possibly also harmful, as reported in the Ärzteblatt. Recent developments and tests with brain stimulation and neurorobots also show possibilities for a new therapy that activates unused nerve pathways and thus improves the quality of life.
The more proven and common alternative measures in prevention and rehabilitation include, above all, exercise therapy, which also has positive cognitive effects, and certain nutritional concepts or nutritional supplements. For example, free radicals in the organism are considered harmful molecules that can also be involved in the development of a stroke. In order to protect the body cells from this, a diet with sufficient antioxidants can be a useful addition. This can be achieved through a rich selection of appropriate foods in the daily diet (superfood). This includes various types of vegetables, fruits, seedlings, wild plants, natural oils and fats and nuts. It is not clearly proven whether and under what conditions an additional intake of folic acid can reduce the risk of stroke. Drinking enough water, at least two liters a day, is part of a healthy, preventive diet.
From the area of homeopathy and phytotherapy, arnica should be mentioned above all, also known as wolf flower or mountain wellness rental. This medicinal plant has been used medicinally in many ways for a long time and even with a stroke, symptoms can be alleviated.
The Far Eastern martial art of tai chi is said to be carried out on a regular basis to prevent various illnesses and to provide relief from certain symptoms. In connection with a stroke, an improvement in the balance has positive effects. This not only reduces the risk of falling, especially in the elderly, but can also improve permanent balance problems.
Acupuncture, as a method of traditional Chinese medicine (TCM), affects mobility and promotes the healing of damaged nerve cells as well as the interaction between nerves and muscles. Auch wenn diese Methode relativ häufig Anwendung findet und es viel positive Resonanz gibt, besteht bislang kein hinreichender Beleg für den Nutzen in der Rehabilitation nach einem Schlaganfall (Ärzteblatt 2010).
Da ein Schlaganfall, trotz des heutigen Wissens, noch immer häufig schwere gesundheitliche Folgen hat oder sogar einen tödlichen Verlauf nimmt, steht die Krankheit im Fokus vieler Untersuchungen. Allgemeines Ziel ist es, die Kenntnisse über die Ursachen zu erweitern und neue Therapiemöglichkeiten zu entwickeln, um somit mehr Menschen helfen zu können. Zwei wichtige Forschungszentren in Deutschland stellen das Centrum für Schlaganfallforschung Berlin (CSB) und das Kompetenznetz Schlaganfall. (sw, cs)
Author and source information
This text corresponds to the specifications of the medical literature, medical guidelines and current studies and has been checked by medical doctors.
Dr. rer. nat. Corinna Schultheis
- Stiftung Deutsche Schlaganfall Hilfe: https://www.schlaganfall-hilfe.de (Abruf 17.04.2019), Stiftung Deutsche Schlaganfall-Hilfe
- Deutsche Gesellschaft für Neurologie (DGN): Leitlinie Akuttherapie des ischämischen Schlaganfalls, Stand 09/2012 , in Überarbeitung (Abruf: 17.04.2019), dgn.org
- Deutsche Gesellschaft für Neurologie (DGN): Akuttherapie des ischämischen Schlaganfalls – Rekanalisierende Therapie, Ergänzung 10/2015 (Abruf: 17.04.2019), dgn.org
- Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin (Hrsg.): DEGAM-Leitlinie Nr. 8: Schlaganfall, Stand 02/2012, in Überarbeitung, publiziert bei AMWF-online (Abruf: 17.04.2019), AWMF-online
- Berufsverband Deutscher Internisten e.V. (Hrsg.): www.internisten-im netz.de (Abruf: 15.04.2019), internisten-im-netz: Hirninfarkt
- Giraldo, Elias A.: Überblick über den Schlaganfall, Stand 02/2018 (Abruf: 16.04.2019), msdmanuals.com
- National stroke association: https://www.stroke.org (Abruf 12.04.2019)
- Powers, William J. et al.: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke, in: Stroke, Ausgabe 49/3 (2018), AHA/ASA Journals
- Kraft, Peter (Hrsg.): ELSEVIER ESSENTIALS: Schlaganfall, Elsevier, 2018
ICD-Codes für diese Krankheit:I63ICD-Codes sind international gültige Verschlüsselungen für medizinische Diagnosen. You can find yourself e.g. in doctor's letters or on disability certificates.