The risk of stroke for patients with TBI is at its highest in the first four months after injury and remains significant for up to five years, new research has revealed.
TBI patients have an 86 per cent increased risk of stroke, when compared to patients who have not experienced a TBI.
Stroke risk may be at its highest in the initial four months post-injury, but remains a potential risk for the following five years, the University of Birmingham-led research finds.
Significantly, the findings suggest that TBI is a risk factor for stroke regardless of the severity or subtype of the injury – statistics show that up to 90 per cent of TBIs are mild, which researchers highlight as showing the stroke risk applies to even those who had few symptoms and are fully recovered.
Traumatic brain injury affects over 60 million people a year globally and studies have revealed the long-term risk of neurological diseases including dementia, Parkinson’s and epilepsy. The topic has come under renewed scrutiny through the recent investigations into links between concussion in sport and lasting neurological consequences.
The new research brings together 18 studies from four countries and is the first of its kind to investigate post-injury stroke risk.
“Stroke is the second leading cause of death and third leading cause of disability worldwide, however, urgent treatment can prevent stroke related death and long-term disability,” says Dr Grace Turner, lead author of the study from the University of Birmingham’s Institute of Applied Health Research.
“As our review has shown, TBI patients should be informed of the potential for increased stroke risk and with the risk of stroke at its highest in the first four months post-injury, this is a critical time period to educate patients and their care givers on stroke risk and symptoms,” says Dr Turner.
“This initial four-month period should also be used by clinicians to administer stroke prevention medication and lifestyle advice to mitigate the excess risk of stroke associated with TBI.”
Researchers also found that the use of anti-coagulants, such as VKAs and statins, could help to reduce stroke risk post-TBI, while the use of some classes of anti-depressants are associated with increased stroke risk post-TBI.
However, more research is required to investigate the effectiveness of stroke prevention drugs post-TBI to help inform clinicians’ prescribing and facilitate shared decision making, adds Dr Turner.
“Our review found some evidence to suggest an association between reduced stroke risk post-TBI and the stroke prevention drugs VKAs and statins but, as previous studies have found, stroke prevention drugs are often stopped when an individual experiences a TBI,” she says.
The review, published in the International Journal of Stroke, was funded by the National Institute for Health Research’s Surgical Reconstruction and Microbiology Research Centre based at University Hospitals Birmingham NHS Foundation Trust.
What causes a stroke?
Over 100,000 people in the UK suffer a stroke each year, with there currently being around 1.2 million survivors living in the country.
Many people note that despite how common strokes are they remain unaware of what the actual causes of a stroke are.
Depending on which of the two types develops, causes and outcomes can differ.
What both have in common is they restrict blood flow to the brain. This leads to a reduction in the brain’s oxygen levels, which can cause tissue damage.
Here, NR Times breaks down why a stroke may occur and what risk factors there are behind each different type.
What are the different types of stroke?
There are two main types of strokes: ischaemic and hemorrhagic.
Ischemic strokes make up nearly 90 percent of all cases and they materialise when an artery which provides blood and oxygen to the brain becomes blocked.
A hemorrhagic stroke is much less common, but happens when an artery leading to the brain bursts and starts to leak blood around or in the brain.
Causes of an ischaemic stroke
The brain is only able to function properly when its arteries supply it with oxygen-rich blood, meaning any blockages can cause lasting damage.
With a lack of blood flow, the brain is unable to make enough energy to work. If this consists for more than a few minutes, brain cells will begin to die.
This is exactly what happens in an ischaemic stroke, but there are a range of reasons as to why these blockages develop.
One of the main causes is when the arteries around the head narrow, which makes it harder for the blood to pass through.
This can also lead to something called atherosclerosis, which is where substances in the blood (such as fat or cholesterol) stick to the sides of the arteries.
Blood can build up on these deposits, causing a further increase in pressure and a reduction to the brain’s oxygen supply.
There are a number of reasons for these blockages, with the most common ones being around a person’s lifestyle.
For example, smoking can increase the risk of a stroke by up to 50 percent.
This is because nicotine not only narrows the arteries, but it also makes the heart beat faster, causing an increase in blood pressure.
Excessive alcohol intake, obesity and high cholesterol levels are also all listed as major risk factors when it comes to ischaemic strokes.
Problems with the arteries around the heart can also lead to an ischaemic stroke.
Irregular heartbeats, heart attacks and other irregularities around this area can again limit the blood’s oxygen levels.
Causes of a hemorrhagic stroke
Hemorrhagic strokes are most common in people ages 45 to 70, but they affect a lot more younger people than an ischaemic stroke.
These are caused after the arteries around the brain burst and cause bleeding.
Depending on where the artery is can affect the outcome of the hemorrhagic stroke.
If the bleeding occurs within the brain, blood shooting out at high pressure can kill some cells.
Bleeding on the surface increases the pressure in the protective layer between the brain and the skull, potentially causing more cell loss.
This bleeding is normally caused by chronically high blood pressure. In many cases, the increased pressure can cause the arteries to expand and weaken, meaning a split in them is more likely to take place.
A rarer cause of hemorrhagic stroke is where the blood vessels around the brain are connected abnormally, causing further stress on the brain. These are congenital (present at birth) but the reason for their occurrence is currently unknown.
Again, the best way to reduce the risk of an hemorrhagic stroke is to make healthy lifestyle choices.
‘Healthcare and individuals can both tackle stroke risk’
“Stroke is a challenging, complex and difficult condition to treat and manage, and it requires both the healthcare and public to play a part in preventing, treating and managing it.”
Elizabeth Muchechetere, head of therapies (neuro rehabilitation) at neurological care centre British Home, shares her insight on a series of points around stroke and recovery, to help highlight the condition during Stroke Awareness Month.
Anyone can be affected
British Home is a neurological care home with 80 residents – 34 per cent of our residents have been affected by stroke, and they all present differently, and therapy is tailored to suit presentation.
These are people who never thought a stroke could happen to them and they are all from different walks of life.
Engaging in rehabilitation can be challenging for our residents as they realise life has changed and they are required to put in a lot of work in their rehabilitation with the help and support of our dedicated therapy and care staff, and family input.
I have seen how devastating this could be as at times during rehab, it is important to stop a session and give emotional support and explanation why rehabilitation is important as some may lose hope as the effects of stroke will have caused big changes in their lives.
I have also noticed that those who have previously lived an active lifestyle tend to see more improvement than those who have not.
Anyone can be affected by stroke!
The effects of stroke affect not only the person who has had a stroke, but families at times struggle to come to terms with the sudden vast changes and the teams supporting can also go through many challenges in giving treatment and rehabilitation.
Timing is everything
With one in four people being affected by stroke, these numbers are too high and we need to get them down. I believe stroke is still such a big issue within the UK due its complexity.
We know it is an issue and we know the information is out there, but we are not ready, and if we are not ready, it can be detrimental.
It can be disabling and is known to be one of the leading causes of death if one does not receive immediate and timely medical attention in the UK.
Treatment and rehabilitation in my experience is slow and challenging and many take some time recover, but there is always hope.
I have also noticed that those who have previously lived an active lifestyle tend to see more improvement than those who have not.
One big issue is that there can be long waiting lists for rehabilitation following discharge from hospital and discharge from follow up early supported discharge (ESD) rehabilitation in the community.
Frustratingly some patients still require more rehabilitation, but may not be able to access it. As a result, 65 per cent of stroke survivors leave the hospital with a disability (The National Report – Stroke Association).
According to Blood Pressure UK, stroke is a major cause of death in the UK and the largest cause of disability, but six out of 10 strokes could be prevented by managing blood pressure to a healthy level.
However, for every 10 people diagnosed with high blood pressure, seven remain undiagnosed and untreated, and this is more than 5.5 million people in England (NCVIN, 2016), meaning, not all cases are tracked so can’t be prevented.
We now know the treatment of HBP significantly reduces the risk of strong among other conditions (Stroke statistics, 2017), however the number of people diagnosed as having HBP has consistently increased since 2005, (NHS Digital, 2016) and is not slowing down.
To tackle stroke and its effects, both the public and healthcare must have a part to play.
Healthcare continues to speak about stroke and how it affects individuals, but the public need to listen and be more aware of the vast information around stroke, its effects, symptoms, management of risks like high blood pressure, diabetes to mention a few.
Diabetes is reported to double the risk of stroke (a paper on Cardiovascular Disease Outcome Strategy by the Department of Health, 2013).
High cholesterol can increase the risk in developing a blood clot which can lead to a stroke therefore it is important to treat and manage it.
Alcohol consumption in large quantities increases the risk of having a stroke while smoking doubles the risk of death from stroke.
With all that in mind, the best way to help prevent a stroke is manage those underlying conditions, avoid smoking and alcohol, and eat a healthy diet, not forgetting regular exercise.
Moderate exercise can reduce one’s risk of stroke by up to 27 per cent (Lee CD et al., 2003), while inactivity and a sedentary lifestyle increases risks of an ischaemic stroke by 50 per cent (WHO).
While there is hope as innovation in the healthcare industry is increasing and improving, there is still a need in the public balancing the stroke risk factors; high blood pressure (HBP), diabetes, high cholesterol, increased alcohol intake, smoking and lack of physical activity (Stroke statistics, 2017), which pose more challenges in stroke occurring and recovery.
We all know what we need to do to help prevent stroke, so it is important we start practicing it.
Sadly some people leave home for work daily, possibly have a stroke at work and never return home. With stroke, life can vastly change without a warning and we all need to do better to change this. It is everyone’s duty, where possible, to take ownership of our health and well-being.
‘I’ll be forever grateful’
After 88-year-old Philip Haines had a stroke and lost mobility in his left side, his bespoke rehabilitation enabled him to regain his independence. Here, to mark Stroke Awareness Month, he shares his story of recovery
“I’ll be forever grateful.”
For 88-year-old Philip Haines, who lost mobility in his left side following a stroke, his thanks to those who helped him regain it are limitless.
Philip, former secretary to the Anglican Diocese of Peterborough, admits being “hit for six” after his stroke, which was caused by a blood clot in his brain.
His cerebral infarct left him with dense left hemiplegia, meaning he was unable to move his left arm and leg. While the blood clot was successfully removed, the stroke left Philip with cognitive challenges and difficulty in swallowing.
Philip was admitted to Askham Rehab from Peterborough City Hospital in November, where he was assessed by the multidisciplinary team and set clear goals, before being put on a specialist four-month programme specific to his needs.
And now, to mark Stroke Awareness Month, Philip is sharing his gratitude for the team at the specialist neurorehab community near Doddington, as well as to help show the life-changing effects such rehab can offer.
“The stroke knocked me for six and changed my life dramatically, but every day I was met with a group of very enthusiastic physiotherapists who were trying to bring some life back into my left side,” says Philip, who returned home last month.
“This whole journey has been a completely new experience, it’s almost like a rebirth. You always try to be positive, but it’s inevitable that you go through periods of feeling low.
“The team’s enthusiasm helped pick me up during those low points. We got on fine, they were very helpful, and it was a real group effort in trying to bring life back into my muscles.”
When asked if he had any final words for the team that looked after him throughout his rehabilitation, Philip says simply: “Keep up the good work. I’ll be forever grateful.”
During his time at Askham Rehab, Philip was able to make use of the family-run community’s robotics and sensor assisted technology, with it being one of a small number of providers in the UK to offer a specialist robotic-led rehabilitation service.
He used the MYRO table, a sensor-based surface with interactive applications, to aid upper limb movement and focus on balance, coordination, and cognitive training.
With strokes being a specialist area at Askham Rehab, Philip also performed mirror therapy, hands-on therapy and functional tasks as part of his tailored programme, which soon led to a significant improvement in his mobility.
“Philip had access to all four of our disciplines; clinical psychology, physiotherapy, occupational therapy, and speech and language therapy,” says Sara Neaves, clinical lead and outpatients service manager at Askham Rehab.
“It was clear from day one that Philip knew exactly what he wanted to achieve. This enabled us to set patient-centred goals with him, ensuring he was part of the process throughout his journey with us.
“Philip was fully independent before his stroke and enjoyed walking into Peterborough city centre every day for his lunch, so he was determined to get back on his feet.
“He swiftly improved the mobility of his left upper limb through the use of our robotics and mirror therapy, and was soon able to transfer using a Molift with the assistance of two.
“He also improved his swallowing through oral motor techniques and no longer needed thickening in his fluids.
“It has been extremely rewarding to see Philip come this far. He had a positive outlook on his rehabilitation journey with us from the offset.
“His sister has also been an excellent support to him and due to our patient-centred care, his individualised programme has worked to his goals.
“We’re delighted he’s now able to get back out and head into town again for his lunch outings with friends.”
Aliyyah-Begum Nasser, director at Askham, adds: “Philip’s journey at Askham encompasses what Stroke Awareness Month is all about; highlighting the strategies to improve the quality of life for persons recovering from the condition.
“Our family-run community, which has more than 30 years’ experience, including 10 years of neurological rehabilitation expertise, prides itself on having comprehensive and specialist programmes in place to ensure those undergoing rehabilitation with us receive structured, high-quality care with a holistic approach.”
For more information on Askham Rehab, visit https://askhamrehab.com/.
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