Brainstem Stroke

Definition

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

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

Brainstem

There are two main types of stroke ischemic and hemorrhagic. An ischemic stroke is the most common type of stroke.

Causes

An ischemic stroke is caused by a blockage of the blood flow, which may be due to:

A clot from another part of the body like the heart or neck. The clot breaks off and flows through the blood until it becomes trapped in a blood vessel supplying the brain.
A clot that forms in an artery that supplies blood to the brain.
A tear in an artery supplying blood to the brain. Called an arterial dissection.

A hemorrhagic stroke is caused by a burst blood vessel. Blood spills out of the broken blood vessel and pools in the brain. This interrupts the flow of blood and causes a build up of pressure on the brain.

Risk Factors

Factors that may increase your risk of stroke include:

Sex: Men are more likely to have strokes than women but women are more likely to die of strokes than men
African American, Hispanic or Asian/Pacific Islander descent
Age: Risk of stroke increases with age particularly after 55 years of age.
Family history of stroke

Medical conditions that can increase your risk of stroke include:

High blood pressure (the number one risk factor for ischemic stroke)
High blood homocysteine level
Atherosclerosis
High cholesterol levels—specifically high-LDL "bad" cholesterol
Diabetes mellitus or impaired glucose tolerance
Atrial fibrillation
Blood disorders such as sickle cell disease and polycythemia
Disease of heart valves, such as mitral stenosis
Prior stroke or cardiovascular disease, such as heart attack
Peripheral artery disease
Transient ischemic attack (TIA) —a "warning stroke" with stroke-like symptoms that go away shortly after they appear
Conditions that increase your risk of blood clots such as:
- Cancer
- Pregnancy
- Certain autoimmune diseases
Having a blood vessel abnormality

Lifestyle factors that can increase your risk of stroke include:

Drug abuse (heroin, cocaine, amphetamines)
Smoking
Use of birth control pills, especially if you are over 35 years old and smoke
Long-term use of hormone replacement therapy
Physical inactivity
Alcohol abuse

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 know has any of these symptoms, call for medical help right away. Brain tissue without blood flow dies quickly.

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
Angiogram —a test that uses a catheter (tube) and x-ray machine to assess the heart and its blood supply
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:

Dissolve or remove a clot (for ischemic stroke)
Stop bleeding (for hemorrhagic stroke)

If needed, steps may be taken to help support your heart and lungs. A tube may be placed into the windpipe to provide oxygen.

Medications

For an ischemic stroke, medication 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 medication 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
Vertebrobasilar 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

Many of the risk factors for stroke can be changed. Lifestyle changes that can help reduce your chance of getting a stroke include:

Exercise regularly.
Eat more fruits, vegetables , and whole grains . Limit dietary salt and fat .
Stop smoking .
Increase your consumption of fish.
Drink alcohol only in moderation (1-2 drinks per day).
Maintain a healthy weight.
Check blood pressure frequently . Follow your doctor's recommendations for keeping it in a safe range.
Take aspirin if your doctor says it is safe.
Keep chronic medical conditions under control. This includes high cholesterol and diabetes.
Talk to your doctor about the use of a statins. These types of drugs may help prevent certain kinds of strokes in some people.
Seek medical care if you have symptoms of a stroke, even if symptoms stop.
Stop the use of recreational drugs such as cocaine.

RESOURCES

American Heart Association http://www.americanheart.org/

National Stroke Association http://www.stroke.org/

CANADIAN RESOURCES

Heart and Stroke Foundation of Canada http://www.heartandstroke.com/

Stroke Survivors Association of Ottawa http://www.strokesurvivors.ca/

References

Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke . 2010 October 21. Available at: http://stroke.ahajournals.org/cgi/reprint/STR.0b013e3181f7d043v1 . Updated October 21, 2010. Accessed September 4, 2012.

Hemorrhagic stroke. American Heart Association American Stroke Association website. Available at: http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/HemorrhagicBleeds/Hemorrhagic-Strokes-Bleeds%5FUCM%5F310940%5FArticle.jsp. Accessed June 6, 2013.

Hemorrhagic stroke. National Stroke Association website. Available at: http://www.stroke.org/site/PageServer?pagename=HEMSTROKE . A Accessed September 4, 2012.

Intracerebral hemorrhage. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php. Updated March 21, 2013. Accessed June 6, 2013.

Ischemic stroke. American Heart Association American Stroke Association website. Available at: http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/IschemicClots/Ischemic-Strokes-Clots%5FUCM%5F310939%5FArticle.jsp. Accessed June 6, 2013.

Long term management of stroke. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php. Updated April 30, 2013. Accessed June 6, 2013.

Mena F, Fruns M, Contreras A, Soto F, Mena I. Acute brainstem infarct: multidisciplinary management. Alasbimn Journal website. Available at: http://www.alasbimnjournal.cl/revistas/5/mena5.htm . Published October 1999. Accessed June 6, 2013.

Stroke (acute management). EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php. Updated May 2, 2013. Accessed June 6, 2013.

Nueroimaging for acute stroke. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php. Updated May 15, 2013. Accessed June 6, 2013.

Signs and symptoms. National Stroke Association website. Available at: http://www.stroke.org/site/PageServer?pagename=SYMP . A Accessed September 4, 2012.

Stroke (acute management). EBSCO Publishing DynaMed website. Available at: http://www.ebscohost.com/dynamed . Updated August 30, 2012. Accessed September 4, 2012.

Subarachnoid hemorrhage. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php. Updated January 22, 2013. Accessed June 6, 2013.

Jensen M, St. Louis E. Management of acute cerebellar stroke. Archives of Neurology website. Available at: http://archneur.ama-assn.org/cgi/reprint/62/4/537.pdf . Published April 2005. Accessed June 11, 2013.

Revision Information

Reviewer: Rimas Lukas, MD
Review Date: 05/2013 -
Update Date: 06/11/2013 -

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