By Tedler D. Depaynos, MD
(Note: We are reprinting this article because in last week’s issue, a portion of it supposedly at the jump page disappeared when it (the page) was “scrambled” to accommodate an article that came in at the last minute Friday night when we were getting ready to email the whole issue for out of town as the first step in the production process.)
The 78 years old male patient has been suffering from “severe arthritis” resulting in difficulty and painful ambulation. Recently, his relatives observed that his right leg and right arm appeared to have weakened. This was just interpreted as worsening of his “severe arthritis”. Because they live in a distant mountainous community in Benguet reachable only by private vehicles capable of negotiating rough roads, he was not brought to any medical personnel immediately. His anti-arthritic medicines were just doubled. Because of no improvement, he was eventually brought to a medical center when they called a son who is working in the city.
Except for his limping ambulation aided by his relatives alternating as human canes and his difficulty of hearing which is expected at his age, he appeared “alright”. They were surprised however, when he was diagnosed to have a “mild stroke” which they never expected. This was confirmed by a head CT Scan.
He never complained of headaches, dizziness or other symptoms related to his “stroke” but probably this was masked by his arthritic pains and hard in hearing. His blood pressure however, is severely elevated and he forgot the last time he took his Amlodipine.
Stroke has something to do with the brain. The brain is divided into two hemispheres, the left and the right. Each side has a specific blood supply with branches to be able to supply its respective areas. The blood carries oxygen to the brain and when this is cut off even just for three minutes, the area of the brain deprived of oxygen necroses. The dying brain will initially swell compressing the adjacent brain tissues depriving them likewise of the much needed oxygen. It would eventually shrink and become a scar tissue with time and this may be appreciated in the CT Scan. Hence, even though a very small blood vessel is involved a wide area of the brain could be involved. This may have happened in this elderly patient.
Depending on the severity of the injury, the patient will initially complain of headache, nausea and vomiting, dizziness and even loss of consciousness. If the patient survives, the manifestations will depend on what area of the brain is involved. Since the widest area is responsible for the muscular and sensual areas, the most common manifestation is permanent paralysis and loss of senses.
In the majority of individuals, they are right sided. If you are then right sided, the predominating brain hemisphere is the left. And likewise if you are left sided the opposite right brain hemisphere also predominates. Hence if the paralysis is on the right side, the affected brain is the left hemisphere. The nerves from the brain going to the lower parts of the body somehow crosses at the area of the neck going down the opposite side.
Deprivation of oxygen would mean that the blood supply is cut off. There could be blockage of the blood vessel or rupture causing leakage. The blockage could be due to clotted viscous blood. It could occur somewhere else like the heart especially when the heart beats are irregular and may be thrown into the cerebral blood supply as an embolus.
A rupture causing leakage of blood is called intra cerebral hemorrhage. This may be due to excessive hypertension (HPN) and could be associated with weakness of a portion of the blood vessel due to age or due to a congenital defect called aneurysm. This may be the cause of this patient’s “stroke”. In younger individuals, intra-cerebral hemorrhages are usually associated with congenital aneurysms.
Depending on the amount of blood leakage, the patient may undergo surgical drainage. Most of the time, however, if drainage is contemplated the hemorrhage is profuse and the patient is in coma and the prognosis is poor.
The blocking of the blood vessel may also be due to lipid deposits made up of cholesterol, triglycerides and high density lipoproteins (LDL) along the inner walls of the vessel. The accumulation obviously may take years and even decades. It does not happen overnight. The lumen will gradually decrease in size reducing the much needed blood supply causing ischemia. In some studies, it is found out that smoking would cause vascular spasm worsening the ischemia.
Depending on the size of the blood vessels, they may eventually be obstructed. The deposits or plaques may also get dislodged and they may block suddenly the blood vessel. Hence, abnormal level of lipids should also be treated.
Other diseases that may affect the cholesterol or lipids level like diabetis mellitus should also be included in the treatment.
In this patient, treatment and monitoring of the HPN was emphasized. It’s good that the patient does not smoke and retired from taking alcoholic beverages because both are taboo in stroke patients. When he was advised to avoid fatty foods, the son smiled because he thinks that it is too late for his father to stop what he enjoys considering his age. Besides being an elderly in their remote community, his father is always invited in occasions where he is requested to offer and lead the eating of special parts of the butchered animals with the surrounding but unseen “spirits”. It is rumored that only he could easily feel their presence and closeness.
One of his attending MDs with greying hair likewise smiled.**
