What to do if you suspect a loved one may be having a stroke
Understanding Stroke (CVA) and the diagnostic role of Carotid Duplex Doppler and Computed Tomography.
Face drooping, Arm weakness, Speech difficulty … Time to call 10177. Act FAST, you are seeing someone having a stroke.
A stroke occurs when a portion of the brain does not receive adequate blood supply and is unable to function. Stroke is regarded as an acute syndrome1. It is a major cause of death, rated as the third leading cause of death globally2.
Transient ischaemic attack (TIA), also called a ‘ministroke’, occurs when an area in the brain is deprived of normal blood flow for a short period of time. Symptoms settle reverse completely without treatment as blood flow goes back to normal on its own3.
A transient ischaemic attack may be recognised by the following signs and symptoms4:
- Sudden numbness / weakness in your arms or legs
- Diffculty in speaking / slurred speech
- Temporary loss of vision in one eye
- Drooping facial muscles
However, a TIA is a warning to take action because it is often the forerunner to a stroke if left untreated5.
Stroke is caused by two different mechanisms. It can either occur when a part of the brain loses blood flow (Ischaemic stroke) or when bleeding occurs (Haemorrhagic stroke). 85% of strokes are caused by ischaemia2. 80% of cerebral ischaemic strokes are caused by atherosclerosis of the of the intra and extra carotid arteries3.
The two mechanisms of stroke (Top Neuro Docs. 2020).
Ischaemic Stroke – Carotid Duplex Doppler
The carotid arteries are located at both sides of your neck. It is the vessels through which oxygen rich blood travels from the heart to the brain. Carotid artery disease, referring to atherosclerotic changes, occurs when there is a build-up of fats, cholesterol and other substances causing atheromatous plaque adhering to the wall of the carotid arteries6.
The atherosclerotic changes in the carotid arteries can cause the arteries to narrow, hampering blood flow to the brain. A small portion of unstable plaque can break off, consequently lodging in one of the smaller arteries of the brain, blocking flow. Blood clots can also form in the carotid artery, which blocks blood flow7.
Extracranial vascular imaging (carotid duplex doppler ultrasound)
is a relatively cost-effective, accurate, easily accessible and non-invasive evaluation used to identify extracranial insufficiency or cholesterol plaque build-up. Duplex sonography combines high-resolution two-dimensional imaging and Doppler spectrum to evaluate the development of atherosclerotic plaque, intima media thickening or hemodynamically significant stenosis in a quick and effective way in order to determine your risk of having a stroke3. Kadian-Dodov, Papolos and Olin8 states that ultrasonography carries a high sensitivity and specificity to point our carotid artery disease.
Risk factors for developing atherosclerotic disease include: smoking, too little exercise, high cholesterol levels in the blood, being overweight, diabetes, certain genetic factors and high blood pressure6.
It is important to remember that atherosclerosis develops gradually. Symptoms usually present when the disease is advanced, causing inadequate blood supply to organs or tissues resulting in stroke or heart attack. It is important see your physician if you present with any signs or symptoms indicating towards atherosclerosis. The sooner you diagnose atherosclerosis, the better your chances of preventing disease progression and eliminating stroke, heart attack or medical emergencies are5.
The treatment plan can be determined as soon as the cause of the ischaemic attack is found. Anticoagulant medication can be given to reduce tendency of blood, or alternatively, surgical intervention to prevent complete occlusion of arteries may be necessary5.
Haemorrhagic Stroke – Computed Tomography
Haemorrhagic stroke is a critical disease usually leading to severe disability or death. Hypertensive changes or other vascular malformations causes small penetrating arteries in the brain to rupture or leak.
Hypertension (high blood pressure) is the most important risk factor of haemorrhagic stroke. Anticoagulant medication, cerebral aneurysms, substance abuse, family history of strokes, etc. are amongst other risk factors9. As stated by Muir & Santosh10, a Non-contrast CT evaluation is the modality of choice to diagnose and determine severity of intracranial haemorrhage in acute stroke.
Signs and symptoms include the following:
- Sudden weakness or numbness in the face, arm, leg (typically on one side)
- Sudden confusion. Trouble speaking, trouble understanding
- Sudden trouble seeing in one or both eyes
- Sudden difficulty walking, dizziness, loss of balance, loss of coordination
- Sudden severe headaches with no known cause11.
Unfortunately, there is no primary treatment option for haemorrhagic stroke. The ongoing bleeding in the brain must be stopped. Medication can be used to lower high blood pressure. Alternatively, surgical intervention may be necessary or even life support in sever cases9.
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- What is a Stroke? [Internet]. William C. Shiel; 2016 Janurary 8. Available from: https://www.medicinenet.com/stroke_pictures_slideshow/article.htm
- Masuka, TD, Wilton BW, Traboulsi M, Hill M. Diagnosis and management of acute ischemic stroke: speed is critical. CMAJ. 2015 September 8; 187(12): 887-893.
- Fernandes M, Keerthiraj B, Mahale AR, Kumar A, Dudekula, A. Evaluation of carotid arteries in stroke patients using color Doppler sonography: A prospective study conducted in a tertiary care hospital in South India. Int J Appl Basic Med Res. 2016 Jan-Mar; 6(1): 38-44. Available from: http://www.ijabmr.org/article.asp?issn=2229-516X;year=2016;volume=6;issue=1;spage=38;epage=44;aulast=Fernandes. DOI: 10.4103/2229-516X.174007.
- Medical News Today [Internet]. United Kingdom: James McIntosh; 2004. Everything you need to know about stroke; 2020 March 4. Available from: https://www.medicalnewstoday.com/articles/7624#treatment.
- Mayo Clinic [Internet]. Arizona: Mayo Clinic Staff; 1998. Arteriosclerosis / atherosclerosis; 2018 April 24. Available from https://www.mayoclinic.org/diseases-conditions/arteriosclerosis-atherosclerosis/symptoms-causes/syc-20350569.
- Healthline [Internet]. United States of America: Moores D; 2005. Carotid Duplex Scan; 2016 January 13. Available from https://www.healthline.com/health/carotid-duplex#procedure.
- VeryWellHealth [Internet]. New York: Eure MA; 2019. What is a Carotid Doppler Test?; 2019 November 27. Available from https://www.verywellhealth.com/carotid-doppler-2967718.
- Kadian-Dodov D, Papolos A, Olin JW. Diagnostic utility of carotid artery duplex ultrasonography in the evaluation of syncope: a good test ordered for the wrong reason. EHJ. 2015 February 10; 16:621-625. Available from: https://academic.oup.com/ehjcimaging/article/16/6/621/2397473. DOI: 10.1093/ehjci/jeu315.
- TorpyJM, Burke AE, Glass RM. Hemorrhagic Stroke. JAMA. 2010 June 9; 303(22): 2312. Available from https://jamanetwork.com/journals/jama/fullarticle/186039. DOI: 10.1001/jama.303.22.2312.
- An SJ, Kim TJ, Yoon B. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Haemorrhage: An Update. JoS. 2017 January 31; 19(1): 3-10. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5307940/. DOI: 10.5853/jos.2016.00864.
- Muir KW, Santosh C. Imaging of acute stroke and transient ischaemic attack. JNNP. 2005; 76(Suppl III): iii19-iii28. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765698/. DOI: 10.1136/jnnp.2005.075168.