Understanding a Brain Stem Stroke

Page Index

1 - What is a Brain Stem Stroke

2- Locked-in syndrome

3 - Emotional lability

4 -Atrial Fibrillation

5 - The noise that an MRI makes

6 - Passy-Muir Valve with Mechanical Ventilation, video

7 - TRACH SUCTIONING Video

8 - PEG Tube Insertion video

What is a Brain Stem Stroke

Brainstem Stroke

(Stroke, Brainstem)

by Rebecca J. Stahl, MA

Definition

The brainstem is located directly above the spinal cord. It helps controls involuntary functions like heartbeat, breathing, and blood pressure. Nerves that are used for eye movement, hearing, talking, chewing, and swallowing are also controlled by the brainstem. Normal brainstem function is vital to survival.

A brainstem stroke happens when the brain’s blood supply is interrupted in this area. This type of stroke can result in death, since the damaged brainstem can no longer control the body’s vital functions.

Brain Stem

Causes

There are two main types of stroke:

Ischemic
Hemorrhagic

An ischemic stroke (the more common form) is caused by a sudden decrease in blood flow to a region of the brain, which may be due to:

A clot that forms in another part of the body (eg, heart or neck) breaking off and blocking flow in a blood vessel supplying the brain (embolus)
A clot that forms in an artery that supplies blood to the brain (thrombus)
A tear in a blood vessel supplying a part of the brain (arterial dissection)

A hemorrhagic stroke is caused by a burst blood vessel that results in bleeding in the brain.

Risk Factors

Examples of risk factors you can control or treat include:

Certain conditions, like:

High blood pressure
High cholesterol
High levels of the amino acid homocysteine (may lead to blood clots)
Atherosclerosis (narrowing of the arteries due to build-up of plaque)
Atrial fibrillation (abnormal heart rhythm)
Obesity
Metabolic syndrome
Type 2 diabetes
Alcohol or drug abuse

birth control pills

Medicines (eg, long-term use of

Lifestyle factors

)

Smoking
Physical inactivity
Diet high in sodium and processed foods

Risk factors that you cannot control include:

History of stroke, heart attack, or other type of cardiovascular disease
History of transient ischemic attack (TIA)—With a TIA, stroke symptoms often resolve within minutes (and always within 24 hours). They may signal a very high risk of having a stroke in the future.
Age: 60 or older
Family members who have had a stroke
Gender: males
Race: Black, Asian, Hispanic
Blood disorder that increases clotting
Heart valve disease (eg, mitral stenosis)

Symptoms

The symptoms of a brainstem stroke can be severe and may include:

Problems with vital functions (eg, breathing)
Difficulty with chewing, swallowing, and speaking
Weakness or paralysis in the arms, legs, and/or face
Problems with sensation
Hearing loss
Vision problems
Vertigo (feeling of spinning or whirling when you are not moving)
“Locked-in syndrome” (only the eyes are able to move)
Coma

If you or someone you are with has stroke symptoms, get emergency medical care right away.

Diagnosis

Since this is an emergency, the doctor will make a diagnosis as quickly as possible. Tests may include:

Exam of nervous system
Computed tomography (CT) scan—a type of x-ray that uses a computer to make pictures of the brain
CT angiogram—a type of CT scan that evaluates the blood vessels in the brain and/or neck
Magnetic resonance imaging (MRI)—a test that uses magnetic waves to make pictures of the brain
Magnetic resonance angiography (MRA)—a type of MRI scan that evaluates the blood vessels in the brain and/or neck
Heart function tests (eg, electrocardiogram, echocardiogram)
Doppler ultrasound—a test that uses sound waves to examine blood vessels
Blood tests
Tests to check the level of oxygen in the blood
Kidney and liver function tests

Treatment

Immediate treatment is needed to potentially:

Dissolve a clot causing an ischemic stroke to allow blood flow to the brain
Stop the bleeding during a hemorrhagic stroke

The doctor and nurses will take steps to stabilize the functions of the heart and lungs. A tube may be placed into the windpipe to provide oxygen.

Medications

For an ischemic stroke, medicines may be given to:

Dissolve clots and prevent new ones from forming
Thin blood
Control blood pressure
Treat an irregular heart rate
Treat high cholesterol

For a hemorrhagic stroke, the doctor may give medicines to:

Work against any blood-thinning drugs you may regularly take
Reduce how your brain reacts to bleeding
Control blood pressure

Surgery

These procedures may be done to treat an ischemic stroke:

Embolectomy—a catheter is used to remove the clot or deliver clot-dissolving drugs
Carotid endarterectomy—fatty deposits are removed from a carotid artery
Carotid angioplasty and stenting—carotid artery is widened and a mesh tube is placed to keep it open

For a hemorrhagic stroke, a clip or tiny coil may be placed on the aneurysm to stop it from bleeding.

Once your condition is stabilized, a feeding tube may be placed to deliver nutrients.

Rehabilitation

Brainstem strokes can lead to serious deficits. Therapy programs focus on regaining as much ability as possible:

Physical therapy—to work on improving movement
Occupational therapy—to assist in everyday tasks and self-care
Speech therapy—to improve swallowing and speech challenges
Psychological therapy—to provide support in adjusting to life after the stroke

Prevention

To help reduce your chance of having a stroke, take the following steps:

Exercise regularly.
Eat a healthy diet that includes fruits, vegetables, whole grains, and fish.
Maintain a healthy weight.
Drink alcohol only in moderation (1-2 drinks per day).
If you smoke, quit.
If you have a chronic condition, like high blood pressure or diabetes, get proper treatment.
If recommended by your doctor, take a low-dose aspirin every day.
If you are at risk for having a stroke, talk to your doctor about statin medicines.

Last reviewed May 2011 by Rimas Lukas, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

Locked-in syndrome

From Wikipedia, the free encyclopedia

basilar artery

denying blood to the

pons

, among other causes.

Locked-in syndrome can be caused by stroke at the level of the

Locked-in syndrome is a condition in which a patient is aware and awake but cannot move or communicate verbally due to complete paralysis of nearly all voluntary muscles in the body except for the eyes. Total locked-in syndrome is a version of locked-in syndrome where the eyes are paralyzed, as well.[1] The term for this disorder was coined by Fred Plum and Jerome Posner in 1966.[2][3] Locked-in syndrome is also known ascerebromedullospinal disconnection,[4] de-efferented state, pseudocoma,[5] and ventral pontine syndrome.

Locked-in syndrome usually results in quadriplegia and the inability to speak in otherwise cognitively intact individuals. Those with locked-in syndrome may be able to communicate with others through coded messages by blinking or moving their eyes, which are often not affected by the paralysis. The symptoms are similar to those of sleep paralysis. Patients who have locked-in syndrome are conscious and aware, with no loss of cognitive function. They can sometimes retain proprioception and sensation throughout their bodies. Some patients may have the ability to move certain facial muscles, and most often some or all of the extraocular eye muscles. Individuals with the syndrome lack coordination between breathing and voice.[6] This restricts them from producing voluntary sounds, though the vocal cords are not paralysed.[6]

Causes

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(October 2011)

This section

In children, the most common cause is a stroke of the ventral pons.[7]

Unlike persistent vegetative state, in which the upper portions of the brain are damaged and the lower portions are spared, locked-in syndrome is caused by damage to specific portions of the lower brain and brainstem, with no damage to the upper brain.

Possible causes of locked-in syndrome include:

Traumatic brain injury
Diseases of the circulatory system
Medication overdose
Damage to nerve cells, particularly destruction of the myelin sheath, caused by disease (e.g. central pontine myelinolysis secondary to rapid correction of hyponatremia)
A stroke or brain hemorrhage, usually of the basilar artery
Multiple Sclerosis
Lou Gehrig's disease

Treatment

Neither a standard treatment nor a cure is available. Stimulation of muscle reflexes with electrodes (NMES) has been known to help patients regain some muscle function. Other courses of treatment are often symptomatic.[8] Assistive computer interface technologies, such as Dasher in combination with eye tracking, may be used to help patients communicate. New direct brain interface mechanisms may provide future remedies; one effort in 2002 allowed a fully locked-in patient to answer yes-or-no questions.[9][10][11] Some scientists have reported that they have developed a technique that allows locked-in patients to communicate via sniffing.[12]

Prognosis

Extremely rarely does any significant motor function return. The majority of locked-in syndrome patients do not regain motor control, but devices are available to help patients communicate. Within the first four months after its onset, 90% of those with this condition die. However, some people with the condition continue to live much longer,[13] while in exceptional cases, like that of Kerry Pink[14] and Kate Allatt,[15] a full spontaneous recovery may be achieved.

Notable cases

Jean-Dominique Bauby

Parisian journalist Jean-Dominique Bauby suffered a stroke in December 1995, and, when he awoke 20 days later, he found his body was almost completely paralyzed; he could control only his left eyelid. By blinking this eye, he slowly dictated one alphabetic character at a time and, in so doing, was able over a great deal of time to write his memoir, The Diving Bell and the Butterfly. Three days after it was published in March 1997, Bauby died of pneumonia.[16] The 2007 film The Diving Bell and the Butterfly is a screen adaptation of Bauby's memoir. Jean-Dominique was instrumental in forming the Association du Locked-In Syndrome (ALIS) in France.[17]

Kate Allatt

Kate Allatt is a mother-of-three from Sheffield, South Yorkshire. She has successfully recovered from locked-in syndrome. Now she runs Fighting Strokes, and devotes her life to assisting those with locked-in syndrome.[18]

Julia Tavalaro

In 1966, Julia Tavalaro, then aged 32, suffered two strokes and a brain hemorrhage and was sent to Goldwater Memorial Hospital on Roosevelt Island, New York. For six years, she was believed to be in a vegetative state. In 1972, a family member noticed her trying to smile after she heard a joke. After alerting doctors, a speech therapist, Arlene Kratt, discerned cognizance in her eye movements. Kratt and another therapist, Joyce Sabari, were eventually able to convince doctors she was in a locked-in state. After learning to communicate with eye blinks in response to letters being pointed to on an alphabet board, she became a poet and author. Eventually, she gained the ability to move her head enough to touch a switch with her cheek, which operated a motorized wheelchair and a computer. She gained national attention in 1995 when the Los Angeles Times published her life story. It was republished by Newsday on Long Island and in other newspapers across the country. She died in 2003 at the age of 68.[13][19]

Eddie Pleban

Lives in Norwich, Norfolk, and has successfully recovered from locked-in syndrome. Now he is a Volunteer Coordenator for 'Different Strokes' and his mission in life to assisting those recovering fom a stroke.

Emotional lability

EMOTIONAL ROLLER COASTER (emotional liability)

I have touched on how my emotions are affected by my stroke further on in my blog, it’s not uncommon, normally one can easily control ones emotions and only in exceptional circumstances where life throws some unexpected tragedy at you that causes some short or long term trauma, or you are touched by something funny which can cause some uncontrollable laughter. Normally whatever the circumstances our brains can control, filter, resolve many emotions but when the brain is damaged it’s not so easy.

Pseudo bulbar affect (PBA), emotional liability, labile affect or emotional incontinence refers to a neurologic disorder characterized by involuntary crying or uncontrollable episodes of crying and/or laughing, or other emotional displays.[1] PBA occurs secondary to neurologic disease or brain injury. Patients may find themselves crying uncontrollably at something that is only moderately sad, being unable to stop themselves for several minutes. Episodes may also be mood-incongruent: a patient might laugh uncontrollably when angry or frustrated.

I suffer with (PBA) or emotional liability as it’s called in the UK. There were many occasions when I would burst into tears for no reason and still do, it’s a strange feeling you know it’s going to happen but can’t stop it, however over the months laughing has become a major issue; yes I laugh at something funny just like everyone else but that laughter can become uncontrollable, there are time when trying to have a serious conversation I laugh this can be rather disturbing for me and the people I am with, but, I usually warn them that it may happen, however, they are not prepared for what happens especially when I turn blue in the face what I mean is I laugh so much I can’t take a breath its frightening for me so goodness knows how they feel. There is a funny side to this however that is once I start it’s not long before everyone else is laughing.

Understanding emotional lability

Brain injury can change parts of the brain that regulate or control emotional behaviour and feelings

Emotional lability refers to rapid, often exaggerated changes in mood, where strong emotions or feelings (uncontrollable laughing or crying, or heightened irritability or temper) occur. These very strong emotions are sometimes expressed in a way that is not related to the person’s emotional state.

What causes emotional lability?

Emotional lability occurs because of damage to parts of the brain that control:

• Awareness of emotions (ours and others)
• Ability to control how emotions are expressed, so ability to inhibit or stop emotions emerging

When a person is emotionally labile emotions can be out of proportion to the situation or environment the person is in. For example, a person may cry, even when they are not unhappy – they may cry just in response to strong emotions or feelings, or it may happen “out of the blue” without warning.

A person may have little control over the expression of these strong emotions, and they may not be connected to any specific event or person.

Following a brain injury an individual may also lose emotional awareness and sensitivity to their own and others emotions, and therefore their capacity to control their emotional behaviour may also be reduced.

They may overreact to people or events around them – conversations about particular topics, sad or funny movies or stories. Weaker emotional control and lower frustration tolerance, particularly with fatigue and stress can also result in more extreme changes in emotional responses.

The person may express their emotions in situations where previously they would have been able to control (in quiet situations, in church, listening to a concert).

These behaviours can be confusing, embarrassing, and difficult to understand for the person with brain injury and for others.

Emotional responses after Acquired Brain Injury - become aware of triggers

• Be aware of triggers for emotional lability and try to avoid these when you can. Triggers can include: excessive fatigue or tiredness
• Stress, worry or anxiety
• High stimulation (too demanding, too noisy, too many people) and too much pressure
• Strong emotions and demands from others
• Very sad or funny situation (such as jokes, movies, certain stories or books)
• Discussing certain topics (e.g. driving, loss of job, relationships, death of a family member)
• Speaking on the telephone or in front of a group or where a person feels under pressure.

Have a break

Have a short break away from the situation so the person can regain control of emotions, and to give the opportunity for emotions to settle.

Sometimes a break for a few minutes or longer period is enough to regain control of emotions – taking a short walk, doing a different activity all can help to cope with these strong emotions.

Ignore the behaviour

Try to ignore the emotional lability as much as possible. Try to get others to ignore it too and continue on with the conversation or task.

Focussing on the lability, or giving the person too much attention when it is happening, can reinforce the problem. It is important that other people don’t laugh too, as this will also reinforce and increase the behaviour.

Change the topic or task

Changing the topic or activity (redirection and distraction) can reduce stimulation or stress (particularly if the topic was a trigger). Try to distract or divert the person’s attention by engaging them in a different activity or task.

Provide information and education

Uncontrolled crying or laughing can be upsetting frightening or confusing for other people if they don’t understand so:

Provide simple explanations of information to other people about the lability e.g. “I cry a lot since I had my stroke….don’t worry about it” or “Sometimes when I am nervous I get the giggles”.

Tell people what they should do e.g. just ignore me and it will stop”.

Plan ahead

When there is severe emotional lability, one-to-one, brief and fun activities in a quiet environment will be better. Try to avoid putting the person in stressful situations or environments e.g. noisy, busy, high levels of activity or a too demanding.

Plan activities that are within the person’s ability, and plan more demanding activities or appointments after rests, or when the person has the most energy. Plan for rests between activities.

Use cognitive techniques

Some simple cognitive strategies can also assist in managing emotional lability:

• Relaxation and breathing exercises to reduce tension and stress
• Use distraction e.g. thinking of something else, imagining a peaceful image or picture, counting
• Do an activity (going for a walk)
• Discuss cognitive and behavioural strategies (e.g. ‘thought stopping’|) with a psychologist.

Counselling and support

Sometimes a person has had many losses and changes to cope with after the brain injury – loss of work, ability to drive, independence, changes in relationships or finances, and lower quality of life. These changes can happen suddenly with little chance to prepare for them.

These feelings of sadness, grief, anger, frustration, disappointment, jealousy or depression after an injury are common and may be difficult to cope with.

If there are other emotional adjustment and coping issues, referral to a councillor such as a psychologist, social worker or psychiatrist may be helpful. Families (parents, siblings, partners, children), friends and carers may also benefit from support and care to help them understand and to cope with these changes.

Atrial Fibrillation

Atrial Fibrillation (AF)

I have been diagnosed to have Atrial Fibrillation which contributed to my stroke, to try and explain this condition please read the info below. I have been told that this is a lifelong condition to which I will have to take medication for the rest of my time to control it.

What is Atrial Fibrillation (AF)?

Although we treat all forms of cardiac arrhythmia, atrial fibrillation is the commonest and most confusing for patients so here is some more information:

Overview of Atrial Fibrillation (AF)

The anatomy of the heart

The heart is a pump which is divided into two sections, the atria and ventricles, and into two halves the left and right. This means that the heart is divided into 4 chambers. The atria pump blood into the ventricles and thus have a relatively small job to do, and the ventricles pump blood around the body and thus take on most of the work. The atria are therefore thinner and smaller than the muscular ventricles. The right heart pumps blood through the lungs to get oxygen into it and the left heart pumps blood around the body including the brain.

Figure: The anatomy of the heart

The electrical system of the heart

Normally the atria pump blood into the ventricles before the ventricles pump blood around the body, therefore the atria and ventricles are working in sequence. The heart normally beats 60-80 times a minute however this gets faster if you need your blood to move through your body more quickly, for example during exercise. To allow the chambers to pump in sequence and for the heart to go faster and slower it has an electrical timing system.

It is this system that is faulty when people have abnormal heart rhythms, also known as ‘arrhythmias’. A small bunch of cells situated at the top of the heart, the sinus node, sends an electrical impulse out at about 60 to 80 times a minute (hence your heart rate is 60 to 80). This electrical impulse then washes like a wave across the atria from right to left being conducted from cell to cell and making the cells contract causing the atria to squeeze. The atria and the ventricles are insulated from one another (black line) so when the electrical wave hits this insulation it dies out and the cells await the next impulse from the sinus node.

The atria is electrically connected to the ventricle by the atrioventricular node and bundle branches which are electrical “motorways” that spread the electrical wave very quickly through the ventricles causing them to contract. The wave therefore washes through the heart from top to bottom before dying out, until the next impulse from the sinus node.

Figure: The electrical system of the heart

Key: SN sinus node, AVN atrioventricular node, BB bundle branches

Atrial fibrillation (AF)

In AF the sinus node has lost control of the heart. Rather than a single electrical wave emerging from the sinus node, there are many groups of rogue cells which are generating their own electrical waves. Hence there are lots of smaller waves which are continuously and chaotically wandering around the atrium. These rogue cells are usually found in the left atrium, most often at the junction of the pulmonary veins (the veins which bring blood back to the heart from the lungs).

To see a recording of atrial fibrillation in a human click here. This is a recording made over a period of a 10th of a second with a mapping system called non-contact mapping and is of a human left atrium. The video shows 2 views of the left atrium (front and back) with electrical waves as white and coloured areas passing over the surface of the atrium (coloured purple when not being activated). In this recording, which is slowed down to help the viewer see a bit of what is going on, one can see how complex atrial fibrillation is.

In the presence of these chaotic electrical wavefronts, the atria do not contract but appear to shiver or fibrillate. This causes 2 important problems. The first is that the atria do not squeeze blood out of the atria properly allowing it to stagnate and clot. If clots form in the left atrium then they may be dislodged and fly off into the circulation, reach the brain and cause a stroke. The risk of stroke is dramatically reduced by taking warfarin or aspirin hence these drugs are very important in patients who have AF. Clicjk here for a guide to which patients with AF should be taking aspirin or warfarin.

The second problem is that the lack of atrial contraction reduces the pumping efficiency of the heart. The atria can be likened to a turbo-charger on a car. If your car is sitting at the traffic lights it does not use the turbo. The effect of the atrial contraction is similarly minimal when someone is resting, because all the blood flows into the ventricle on its own without the atrium. However when the traffic lights go green and the driver puts their foot on the pedal they will notice immediately that the turbo is not working because the car will be much slower than normal. The same is true for the heart, particularly in active people.

Many patients notice that they are in AF because they cannot do as much as they could when they were in normal rhythm. Because AF is a chronic condition, patients get used to this lack of function and forget what it was like when they were in normal rhythm. It is not uncommon for patients to be surprised at what they can do when restored to normal rhythm and feel worse if they return to AF because they have been reminded what it is like to be in normal rhythm.

The atria are connected to the ventricle via the electrical connection the AV node (see figure). The AV node will respond to the chaotic electrical signals in the atrium and try to keep up. The ventricle (and therefore the heart beat and pulse) will contract irregularly, rapidly and with a varying intensity, because for each contraction of the ventricle will pump out a different volume of blood.

What is AF?

Atrial Fibrillation (AF) is the most common, abnormal rhythm of the heart.