Cerebrovascular Accidents

Stroke is the common term for a blocked or ruptured blood vessel in the brain.  What differentiates stroke from other neuropsychological conditions is its rapid onset.  Alzheimer’s Disease can manifest for years without much functional impairment, but a stroke is sudden and without definite rules.  Some people suffer with transient ischemic accidents, that are defined as transient neural vascular events without any lasting impairment.  The perception of no lasting impairment is made from brief conversations, and the observation that the patient is still ambulatory and functioning in their environment.  Over the last twenty years, every patient I have tested with a history of transient ischemic accidents possessed measurable cognitive impairment.

Many people wonder, especially if older, if they are experiencing a stroke, or question if they have suffered a stroke.  The most obvious sign of stroke is paralysis on one side of the body.  The paralysis evolves over a period of hours, and typically diminishes after the main damage has been realized.  It may take several months to regain strength in limbs, even longer to regain coordination, and longer still to recover visual-spatial skills affected by the stroke.  Unfortunately, most people are left with lasting impairment.  The primary question for the clinician and family is whether the patient can be made functional in their environment.  Many strokes do not present with hemiparesis.  These less common forms are often misdiagnosed and blamed on psychological distress or malingering.

For those people wondering if they are currently experiencing a stroke, there is not much firm research on early warning symptoms.  Family members often note periods of disorientation or even confusion prior to the onset of the stroke.  The patient often complains of headaches or visual disturbances, but rarely are they self-aware of clouded consciousness.  Long-term research into early warning signs has implicated depressive and anxious episodes occurring in an atypical fashion for up to two years before a stroke.  I have not interviewed a stroke patient in the last twenty years that talked about a depressive or anxiety disorder onset prior to their stroke.  Nearly all the hundreds of stroke patients I have tested denied any early warning sign(s) prior to the actual event.  While I used to question early warning signs actively as a young clinician, I rarely do so now.

Another big question is, if I have one stroke, will I have another?  The research available to this clinician suggests that the chance of having a second stroke after having only one stroke is no greater than the base rate in the general population.  A second stroke increases the statistical possibility of having a third or fourth stroke significantly.  As with so many medical conditions, high blood pressure and smoking cigarettes significantly increases the chance of stroke.  If you have endured one stroke, not two or more, do not smoke cigarettes, and keep your blood pressure under control, then you are at no greater risk for another stroke then anyone else you pass in the street.

What can be done to minimize the effect of a stroke?  The physician’s job is to keep the blood pressure down and observe the patient.  The neuropsychologist’s job is to establish a cognitive baseline, theorize about the patient’s premorbid level of functioning, and give behavioral recommendations regarding specific symptoms.  As a clinician, one has to keep in mind that brain scans performed on the day of the stroke will not display the full extent of the damage, and many scans that display brain damage are secondary to old strokes or a congenital malformation of the brain.  The neuropsychologist, therefore, is focused on the patient’s capabilities in the present, and how to maximize their functioning in all areas.  For example, I will place a greater clinical weight on a patient who is delirious after a stroke, who is not able to repeat three digits in a row, than a brain scan that reveals less damage than anticipated.  The brain scans are important, but the neuropsychologist will pay the most attention to current brain/behavior functioning.  The neuropsychologist is also focused on what factors in the patient’s life, especially medications, that could be slowing rehabilitation.  The rehabilitation research is clear that clinical depression slows the patient’s progress.

Neuropsychological treatment of stroke is heavily biased towards current cognitive and behavioral functioning.  We are focused on factors that could slow or halt progress in physical, occupational and speech therapy.  The main negative factors experienced by my patients are depression and medications.  The medications are likely helpful for most people, but may have unwanted effects in particular stroke patients.  Lastly, there is a strong outpatient planning in neuropsychology.  Often seemingly trivial relationship factors can sour a return to one’s home, such that mediating these troubles before a discharge is very desirable.  The neuropsychologist attempts to make the extended family a “treatment team.”

This Stroke is Always Bad Luck

The term “stroke” is a fitting name for a sudden unexpected happenstance.  In medicine the term “stroke” applies to the sudden onset of symptoms after circulatory problems arise in the brain.  The movies typically portray the sudden devastation to one’s physical functioning; for example the paralyzed father in “Legends of the Fall.”  The slow insidious onset of symptoms from circulatory problems is neither as dramatic or pictorial as the sudden manifestation, but it may cause as much or more functional impairment.  The sudden classic middle cerebral artery stroke with left or right paralysis may be diagnosed by many non-professionals.  The slow manifestation is often overlooked or misidentified by professionals.

Neuropsychological and medical training instills the belief that the former type of stroke is much more common than the latter; that the sudden “stroke” is much more common than the slowly evolving cerebral damage from altered circulation.   Given the unique and dramatic symptoms of a stroke are much easier to diagnose than the slowly evolving, it is likely that the figures taught to doctors are less than accurate.  Slowly evolving symptoms of stroke are directly related to uncontrolled high blood pressure.  While one would think that a slowly evolving hemorrhagic stroke (leaking blood vessel) would be more common than a blockage, this does not appear to be the case.   Most hemorrhagic strokes are of sudden onset, and are often difficult to differentiate from a blockage in a cerebral artery.

Most slowly evolving events related to blood pressure present with decreased attention, a decreased level of arousal, and an overall slowing of thoughts and actions.  There may be signs often considered focal or localized; for example speech and visual deficits, but this is hardly universal.  Family history often identifies a day or two where the patient had been inattentive or even partially paralyzed, but the symptoms tended to abate.  I recently interviewed a man with many years of uncontrolled high blood pressure.  The man had refused treatment for high blood pressure because he was convinced the issue was touted by physicians to increase their income.  His family noticed a few days of poor attention and impaired speech a year or two back, but his apparent rapid recovery dissuaded them from seeking medical consultation.  The symptoms returned and abated over a course of years, but the overall picture was of functional decline.  Diagnostic imaging of the brain was not remarkable, yet his performance on neuropsychological tests was indicative of one or more strokes.  As is often the case, one of his arms was significantly stronger than the other, but not affected to the point it was noticeable to the patient or his family.  He lost the power to ambulate as both legs became progressively weaker; not just the one side typically associated with a blockage of a cerebral artery.  Notice that not only were both sides effected, but the damage increased over time.  This is at odds with what most people would consider a cerebral vascular accident.

Another difficulty in the diagnosis of slowly evolving strokes is the overlap with other conditions.  The sudden dramatic onset of focal paralysis is not present in any other physical condition known to this clinician.  The clinician must differentiate between a stroke and a psychological conversion reaction producing the symptoms, and the latter is fortunately very rare.  The slow onset of bilateral weakness in the legs, as in my patient above, may be secondary to a host of factors other than brain damage.  The unfortunate person may have generalized weakness due to malnutrition, dehydration, anemia, a systemic infection or metabolic/endocrine disorders.  Bilateral weakness in the legs may be secondary to damage in the spinal column, a muscular dystrophy, arthritis or even an unwillingness to walk.  Regardless of age, failure to bear weight on one’s hips and legs quickly leads to muscular atrophy.  The burden on the physician is much greater when the symptoms are not focal and slowly evolving.  It is no wonder that statistics regarding different kinds of strokes may be unavoidably inaccurate.

Given these hurdles experienced by trained professionals, what is an educated layman to do?  The most practical and effective measure is to watch one’s blood pressure.  Over the course of my training and twenty years of practice, I have observed many medical “facts” and “breakthroughs” fall by the wayside for a lack of evidence and efficacy.  The evidence favoring control of blood pressure and its positive effects on health and overall well-being has only increased over the years.  Regardless of age, if you are a female smoker and use birth control, I suggest close monitoring of your blood pressure.  If you are older than 50, I suggest checking your blood pressure regularly; especially important if one has episodes of feeling dizzy and flush.

Is Your Dementia Clean or Dirty?

Is it possible to find someone with a “clean” dementia?  While this sounds like a misnomer, it is intended to describe people who suffer with a specific dementing pathology, and no other complications are known to exist.  It is a form of progressive cognitive deterioration that corresponds perfectly with its diagnostic category.  Only symptoms of this particular dementia are present, uncontaminated by other forms of physical or mental illness.  Hypothetically, such a “clean” dementia should readily conform to existing treatment protocols.  When a patient consults a neuropsychologist, they expect some sort of diagnosis with treatment recommendations, and not “well, it might be this, or it might be that.”  Families often vacillate between different factors to explain the changes in behavior and cognition, such that they expect definitive answers from a professional.  It is not unusual for the patient to become agitated when the doctor invariably, stereotypically, calls for more tests before they can arrive at a definitive diagnosis.  Why can’t we just do our job?

Here is where I frustrate my audience by reporting that diagnoses are rarely simple and clear cut, and that it’s typically a disservice to the patient to arrive at a quick and dirty diagnosis.  For example, a new patient came into the office yesterday with an old severe closed head injury.  This person exhibited classic signs of a severe traumatic brain injury.  Their personality and mental functioning were permanently altered in a way that is very consistent with the pathology of TBI that I was taught in school.  The easiest route is to dazzle the family with my knowledge of traumatic brain injury, make some behavioral and medication recommendations, and then sit back until they return in two weeks.  During the course of the interview with the family and patient, it became apparent that the patient endured a cerebral vascular accident immediately subsequent to the closed head injury.  Unfortunately, this is not an uncommon occurrence after severe closed head injury, though rare in mild to moderate injuries without a period of coma.  There are aspects of the patient’s balance and overall ambulation that would be uncommon in a “clean” closed head injury.  While the patient is walking in a functional manner, they often trip and fall into objects.  Weakness in one of their arms makes it difficult to perform tasks that require two hands.  Functional impairment from the stroke is as or more important than the impairment secondary to the closed head injury.  Formulating recommendations based on one or the other diagnosis would be unsafe and unwise.  Only by thinking in terms of the patient’s holistic or overall functioning would I be able to make their life safer and more stimulating.  Stated another way, diagnoses are typically less important than the obvious difficulties the patient confronts in their environment every day.

How is a physician able to prescribe the correct medication without the correct diagnosis?  Since the Food and Drug Administration does not allow direct comparison between drugs, physicians cannot be confident that they are using the single best medication for a given illness.  While certain medications are believed by professionals to be better for organic conditions than psychiatric conditions, there is only modest support in the research for using one medication over the other.  The best clinicians tend to prescribe by side-effect; that is there are many medications that claim to do the same thing, but the risk of unwanted and possibly deleterious effects of any given medication are uppermost in their mind.  For example, the physician is weighing the benefit of two tranquilizers.  The med they typically prescribe for most neurologically intact patients causes memory and attentional impairments, and the other tranquilizer is known to have few cognitive side-effects, but may cause trouble with ambulation.  Most of us, physician or not, would avoid using the first medication in someone recovering from a closed head injury, and avoid the second for someone recovering from a stroke or movement disorder.  While this appears to make good sense, and even smacks of common sense, one has to keep in mind that common sense is anything but common.

The common sense approach to treatment of damage to the central nervous system is driven by symptoms and their expression in the patient’s unique environment.  A diagnosis helps alleviate the anxiety of family members and the insurance industry, but in isolation, does little to assist the patient.  Medications prescribed for their main effect rather than by their side-effect may help in one area and cause problems in another, rendering little to no net gain for the patient.  Clinicians that need to find neat categories and rapid solutions will please the family shopping for confidence more that the family looking for real gains.  Lastly, even the best of treatment protocols needs adjustment.  People change over time, and the cognitively impaired are no exception.  Any intervention that has positive results for a year or more should be considered a success-even if there is a subsequent decline.  Consider periodic adjustments to behavioral and medication protocols to be necessary and expected.

To answer the initial question, it is rare, indeed, to find a “clean” dementia.  Even if the initial stages of the dementia are uncomplicated and according to protocol, the illness rarely remains so orderly for its entire course.  Patients and family members often gain confidence from hurried and decisive experts; tending to view their curt behavior as a sign of social importance.  A clinician who is unsure and vacillating about treatment options exudes less confidence to others, but may ultimately be the most concerned and helpful.

Arteriosclerotic Dementia

Vascular dementia is a progressive loss of cognitive skills over time, secondary to a blockage or rupture of a blood vessel in the brain. This term used to be called “multi-infarct dementia”, and other classification systems refer to it as an “arteriosclerotic dementia.” The primary form is atherosclerosis, in which the plaques of fatty deposits form in the innermost layer of the cerebral artery. It is almost exclusively a problem of the older adult. Very young children are prone to arteriovenous malformations, which are congenital defects of the cerebral vascular system. Most of these AVM’s are located in the brain stem, and do not result in the sort of symptoms observed in the older adult.

The primary deficit of multiple strokes is an impairment of memory. The impairment may be the ability to recall old information or learn new information. It is rare that someone forgets old information, yet learns new information at an average level. The most common scenario is a decreased ability to retain new information, with increasing impairment of long-term personal information that declines with every subsequent stroke. The specific deficit regarding loss of old personal information is called “episodic memory”, and it may be affected in isolation of other memory impairments. A specific deficit of this type of memory is exceedingly rare, such that an impairment of new learning is much more common.

Vascular dementia is not limited to memory impairment alone. The diagnostic criteria stipulates that a patient must have a memory impairment, as well as one other cognitive deficit, in order to be appropriately diagnosed with “Vascular Dementia”. The most common cognitive impairment from stroke is difficulty with motor control; not just unilateral paralysis, but an impaired ability to carry out motor routines, despite a functional motor system. Many stroke victims have difficultly recognizing and utilizing objects, despite having an intact sensory system. Lastly, many stroke suffers have difficulty switching between mental tasks, making plans, and organizing the steps necessary to accomplish a plan.

Patients with a vascular dementia are impaired in work and/or social functioning. If one performs well at work and socially, despite having multiple strokes, the diagnosis of “Vascular Dementia” would not be appropriate. Usually, there are hard neurological signs of the multiple strokes; e.g., unilateral paralysis, gait disturbance (difficulty walking), unilateral weakness and lesions that appear on brain images. It is also common to suffer with a delirium in the acute phase, which is an altered mental state where a person is incapable of focusing their attention. Immediate attention is often impaired after a stroke, but tends to resolve over several months.

Psychological problems are common after suffering one or more strokes. It is not common to have delusions of persecution or grandiosity after a stroke. Some forms of progressive dementia affecting the right prefrontal-temporal area exhibit delusions as an early symptom of the disease. Neglect of the right or left visual space should not be mistaken for a delusion. It is frequently the case that the patient suffered with a Delusional Disorder prior to the onset of the stroke. The most common psychological symptom of “Vascular Dementia” is depression. The depression may arise from difficulty with psychological adjustment to their declined condition, or a general psychomotor retardation without any awareness as to their own psychological condition. This takes the form of a significantly reduced reaction time, both simple and complex. The person appears chronically fatigued, laconic, and wanting to be left alone. This type of depression is often deemed to be “organic” in nature.

The neuropsychological treatment of “Vascular Dementia” is to first determine the exact nature of the deficits through testing. If the patient is experiencing psychological symptoms of depression or delusions, the clinician must determine if the patient is aware of their abnormal state. For example, psychotherapy is appropriate for an adjustment problem in a self-aware person, but inappropriate for a severely depressed person with no awareness of their symptoms. Neuropsychologists use the patient’s remaining cognitive strengths to compensate for their deficits.

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