Stroke

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.

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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.”  Please leave your comments on this post in the space provided below.