CVA has become a true pandemic. Figures suggest that it is one of the leading causes of death worldwide and the major cause of disability in the adult population. This article aims to provide information about what a stroke is, what types of stroke exist and what the possible sequelae are.

What is a cerebrovascular accident or CVA?

According to the World Health Organization, a cerebrovascular accident (CVA), also called stroke, is the interruption of blood flow to the brain. It is usually caused by the rupture or obstruction of a vessel that cuts off the supply of oxygen and nutrients, producing brain damage that, temporarily or permanently, alters the functioning of one or more areas of the brain.

In recent years, the prevalence of mortality has increased; however, the disability generated is greater than the deaths caused by this entity. A high percentage of these cases is preventable, with early incidence of modifiable risk factors. Some of the risk factors are: age, arterial hypertension (AHT), diabetes mellitus (DM), obesity, transient ischemic attacks (TIA) and sedentary lifestyle. Among these, age is the most frequent risk factor, with adults over 50 years of age being the most vulnerable population. It is then followed by HTN (Carnés-Vendrell, Deus-Yela, Molina-Seguin, Pifarré-Paredero, & Purroy, 2016) .

In this regard, there is a group of people with a special predisposition to develop this cardiovascular disease. Therefore, self-care, early diagnosis, and appropriate treatment can help prevent stroke and reduce the damage caused by the injury.

Types of cerebrovascular accident

CVAs can be divided into two major types based on the nature of the brain lesion:

• Ischemic strokes: occur when an artery becomes blocked, preventing blood from reaching a specific area of the brain. This is the most common cause of stroke, especially in older populations. Arteries become blocked or narrowed due to the accumulation of blood clots, fat deposits, or other debris traveling through the bloodstream, lodging in the brain’s blood vessels. Depending on its evolution within the first few hours, it can be distinguished whether it is a transient ischemic attack (TIA) or a cerebral infarction. The former does not cause permanent damage, while the latter has a longer duration and causes permanent damage.

• Hemorrhagic strokes: occur when a blood vessel in the brain ruptures, leading to a buildup of blood that damages the affected area of the brain. This is the most common type of CVA among young people. There are also two subtypes – intracerebral hemorrhage and subarachnoid hemorrhage. Intracerebral hemorrhage, usually associated with hypertension, is responsible for 80% of hemorrhagic strokes. Subarachnoid hemorrhage is usually caused by an aneurysm and is less common but often associated with vascular tissue malformations.

According to the Argentine Federation of Cardiology, statistics suggest that ischemic events predominate in our country, representing approximately 85% of cases, while hemorrhagic strokes constitute approximately 15%.

As mentioned earlier, a stroke can cause temporary or permanent disabilities depending on how long the brain is deprived of blood flow and the affected brain area.

Consequences or sequelae of cerebrovascular accident

One possible complication of a CVA is hemiplegia or loss of muscle movement. In these cases, a person experiences paralysis on one side of the body or may lose control of certain muscles. Swallowing capacity can also be affected if specific mouth and throat muscles are compromised. This can cause difficulties in speaking.

Cognitive sequelae of CVA

At the cognitive level, there may appear a difficulty in language, aphasia, deficit to communicate through words, mimicry or writing. As well as, memory loss, agnosia, apraxia, difficulties in the ability to reason, issue opinions and / or understand concepts. There are usually changes in habitual behavior, problems in performing personal care tasks (Aguilar-Palomino, Olivera-Pueyo, Benabarre-Ciria, & Pelegrín-Valero, 2009). People may become more withdrawn, dependent, needing extra help to maintain their personal and home hygiene. A deficit arises in the performance of basic tasks and activities of daily living.

It can be said that there is a decline that primarily affects attention, higher executive functions, and the emergence of neuropsychiatric manifestations such as depression, confusion syndromes, anxiety, psychomotor agitation, psychotic symptoms, and sleep disorders. Since the primary neurocognitive symptom after a CVA is not memory impairment, the term “vascular dementia” has been questioned, and these sequelae have been proposed to be included under the concept of “vascular cognitive impairment” (Luna-Matos, Mcgrath, & Gaviria, 2007).

Affective-cognitive complications

Regarding affective-cognitive complications, it is worth noting the central role that depression, known as post-stroke depression (PSD), plays in the evolution of these patients. PSD presents symptoms similar to depression without associated neurological disease, although with some differences. Sleep disorders, vegetative symptoms, and social withdrawal are more frequent. Despite its high prevalence, it is often underdiagnosed, negatively impacting patients’ quality of life.

Untreated emotional problems such as depression in individuals who have had strokes lead to a worse prognosis for recovery of daily functioning and cognitive capacity (Carnés-Vendrell, Deus-Yela, Molina-Seguin, Pifarré-Paredero & Purroy, 2016). Hence, it is crucial to pay close attention to these symptoms.

Post-CVA Depression

There is ongoing debate about the origin of depression following a CVA. Some authors propose that mood symptoms result from the location of the lesion caused by the underlying organic pathology. Others suggest that depressive symptoms are a psychological consequence of the functional and social impairment experienced by individuals due to the neuronal sequelae. Thus, the decline in the level of functioning is considered a predictive factor for post-CVA depression. It should not be overlooked that depressive symptoms also influence functional recovery (Aguilar-Palomino, Olivera-Pueyo, Benabarre-Ciria & Pelegrín-Valero, 2009). A third aspect to be taken into account has to do with cerebrovascular risk factors. It has been considered that these may generate a certain predisposition to the appearance of the mood disorder.

In relation to their treatment, evidence has been found showing that psychopharmacological treatment, together with neurocognitive therapy, is the therapy with the greatest benefits for this type of patients. The efficacy of antidepressants has been proven in people with symptomatology after a stroke, obtaining better results than in patients who start treatment in later stages. SSRIs are the first-line drugs, and no evidence has been found to suggest the superiority of a specific type over another of the same group. The pharmacological approach allows paving the way for cognitive stimulation for partial or total recovery of the functions impaired by the brain injury.

Conclusion

Emphasizing the prevalence of stroke worldwide and its possible sequelae, whether temporary or permanent, the need to prevent the onset of stroke by reducing risk factors, but also the importance of seeking treatment in the early stages of onset of post-injury symptoms, is evident.
Addressing the various manifestations from a comprehensive approach that combines medication and psychotherapy can positively influence the recovery of each person affected by this cardiovascular disease. Neurocognitive rehabilitation allows total or partial recovery of the affected functions, significantly improving the quality of life of the patient and his or her family.

Bibliography

• Aguilar-Palomino, H., Olivera-Pueyo, J., Benabarre-Ciria, S., & Pelegrín-Valero, C. (2009) Psicopatología del accidente cerebrovascular: el estado de la cuestión. Psicogeriatría, 1, 23-35.
• Carnés-Vendrell, A., Deus-Yela, J., Molina-Seguin, J., Pifarré-Paredero, J., & Purroy, F. (2016) Actualización de la depresión postictus: nuevos retos en pacientes con ictus minor o ataque isquémico transitorio. Revista Neurol, 62, 460-7.
• Díaz Alfonso, H., Sparis Tejido, M., Carbó Rodríguez, H. L., & Díaz Ortiz, B. (2015) Ictus isquémico en pacientes hospitalizados con 50 años o más. Rev. Ciencias Médicas, 19 (6), 1063-1074
• Espárrago Llorca, G., Castilla-Guerra, L., Fernández Moreno, M.C., Ruiz Doblado, S., Jiménez Hernández, M.D. (2015) Depresión post ictus: una actualización. Science DIrecte, 30 (1), 23-31.
• Luna-Matos, M., Mcgrath, H. & Gaviria, M. (2007). Manifestaciones neuropsiquiátricas en accidentes cerebrovasculares. Revista chilena de neuro-psiquiatría, 45(2), 129-140.

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