What is a stroke?

A stroke is when a clogged or burst artery interrupts blood flow to the brain. This interruption of blood flow deprives the brain of needed oxygen and causes the affected brain cells to die. When brain cells die, function of the body parts they control is impaired or lost.

A stroke can cause paralysis or muscle weakness, loss of feeling, speech and language problems, memory and reasoning problems, swallowing difficulties, problems of vision and visual perception, coma, and even death.

What physical and emotional problems occur after a stroke?

Common warning signs of a stroke include the following:

• sudden numbness or weakness of the face, arm and/or leg
• sudden confusion, trouble speaking, or difficulty understanding speech
• sudden difficulty seeing in one or both eyes
• sudden trouble walking, dizziness, loss of balance, or loss of coordination
• sudden severe headache with no known cause

If you or anyone you know experiences any of the above warning signs, call your doctor or go to an emergency room immediately.

Because of the organization of our nervous system, an injury to one side of the brain affects the opposite side of the body. Often the person loses movement and/or feeling in the arm and/or leg opposite the side of the brain affected by the stroke. So, if a person has a stroke on the left side of the brain, he or she may have weakness or paralysis in the right arm and leg. This makes it difficult for the person to perform activities of daily living (e.g., dressing, feeding, bathing, tying shoes, etc.). It is also common for survivors of stroke to tire easily.

After a stroke, a person may be able to see objects in only certain parts of his or her field of vision. Visual perception of everyday objects may also change. Objects may look closer or farther away than they really are, causing the person to spill at the table or bump into things while walking. Some people may lose awareness of their weaker side and ignore or forget about it. As a result, they may have trouble reading because they only see half of the page. They may only dress one side of their body thinking they are fully dressed. This one-sided neglect is most common when there is damage to the right hemisphere of the brain.

Stroke survivors often show inappropriate emotions and extreme mood fluctuations. They may laugh when something isn't funny or cry for no apparent reason. This is particularly common early on in the recovery process.

Persons who have had a stroke may seem very self-absorbed. They may demonstrate an intense need for a structured, unchanging routine. They may be very frustrated with their inability to communicate effectively, and this may lead to anger and depression.

What communication problems occur after a stroke?

After a stroke, some people experience language deficits (aphasia) that significantly impair their ability to communicate. These deficits vary depending on the extent and location of the damage. Read a detailed discussion of aphasia.

Deficits in social communication skills (pragmatics) may result in the following:

• Difficulty sequencing thoughts together to tell a story
• Switching topics without warning, or seeming to "go off on tangents" without informing the listener
• Difficulty taking turns in conversation
• Problems maintaining a topic of conversation
• Trouble using an appropriate tone of voice
• Difficulties interpreting the subtleties of conversation (e.g., sarcasm, humor)
• Problems "keeping up" with others in a fast-paced interaction
• Reacting inappropriately; seeming overemotional (overreacting), impulsive, or "flat" (without emotional affect)
• Having little to no self-awareness of inappropriate actions or responses

Oral motor functioning is sometimes affected by a stroke. The following problems may occur:

• Muscles of the lips and tongue may be weaker (dysarthria) or less coordinated (apraxia).
• Speech may not be clear.
• Breathing muscles may be weaker, affecting the patient's ability to speak loudly enough to be heard in conversation.

Muscles may be so weak that the person is unable to speak; consequently, he or she may need augmentative or alternative communication aids to help express ideas (e.g., a communication board).

Weak muscles may also limit the ability to chew and swallow effectively (dysphagia). Read a detailed discussion of swallowing problems.

What cognitive problems occur after a stroke?

Cognition refers to thinking skills. Cognitive difficulties are common in people who have had a stroke on the right side of the brain, and they vary in seriousness depending on the location and severity of the damage. The following problems may occur:

• Not being aware of one's surroundings
• Poor attention to tasks
• Memory difficulties
• Poor reasoning skills
• Poor problem solving skills
• Poor executive functioning (e.g., goal setting, planning, initiating, self-awareness, self-inhibiting, self-monitoring and evaluation, flexibility of thinking)
• Trouble concentrating when there are internal and external distractions (e.g., carrying on a conversation in a noisy restaurant, dividing attention among multiple tasks/demands)
• Slower processing of new information
• Recent memory is affected in some people, making new learning difficult. For example, some people may have trouble learning the new things they are being taught, such as how to get in and out of their wheelchair safely.

How is a stroke diagnosed?

A stroke is diagnosed by medical professionals. Special tests that allow doctors to look at the person's brain (CT scan, MRI) are often used to determine where the stroke occurred and how severe it is.

A speech-language pathologist (SLP) works with other rehabilitation and medical professionals and families to provide a comprehensive evaluation and treatment plan for stroke survivors. The team may include:

• doctors
• nurses
• neuropsychologists
• occupational therapists
• physical therapists
• social workers
• employers/teachers (when applicable)

What other organizations have information about a stroke?

This list is not exhaustive and inclusion does not imply endorsement of the organization or the content of the Web site by ASHA.

• Aphasia Facts
• Aphasia Hope Foundation
• National Stroke Association
• American Academy of Neurology
• American Heart Association
• Pediatric Stroke Network
• Hemikids
• National Aphasia Association

What causes a stroke?

Blockage of blood vessels in the brain

• Clots can travel from the blood vessels of the heart or neck and lodge in the brain.
• Small vessels in the brain can become blocked, often due to high blood pressure or damage from diabetes.
• Clots can form in the blood vessels of the brain due to arteriosclerosis (hardening of the arteries).

Bleeding into or around the brain

• Weak spots on brain arteries (aneurysms) burst, covering the brain with blood.
• Blood vessels in the brain break because they have been weakened by damage due to high blood pressure, diabetes, or aging.

How common is stroke?

Information about the incidence and prevalence of stroke is available in the ASHA report, Communication Facts: Special Populations: Stroke – 2004 Edition.

How effective are treatments for a stroke?

ASHA has written a treatment efficacy summary for aphasia resulting from left hemisphere stroke [PDF] and for cognitive communication disorders resulting from right hemisphere brain damage [PDF] that describe evidence about how well treatment works. These summaries are useful not only to individuals with stroke and caregivers, but also to insurance companies considering payment for much needed services for stroke.

What does a speech-language pathologist do when working with individuals with a stroke?

The treatment program focuses on improving the skills that have been affected by the stroke, depending on what the areas are affected.

For expressive and/or receptive language skills , the SLP will work on specific drills and strategies to improve them, such as the following:

• Participating in group therapy sessions to practice conversational skills with other stroke survivors
• Holding structured discussions, focusing on improving initiation of conversation, turn-taking, clarification of ideas, and repairing of conversational breakdowns
• Role-playing common communication situations that take place in the community and at home, such as talking on the telephone, ordering a meal in a restaurant, and talking to a salesperson at a store

If cognitive skills are affected, some activities may include:

• Using a memory log to keep track of daily happenings to help with memory
• Using an organizer to plan tasks
• Using checklists
• Increasing awareness of deficits in order to help self-monitoring in the hospital, home, and community

Eventually, persons are taken on individual and group community outings to practice their use of compensatory strategies outside of the hospital. They are asked to plan, organize, and carry out these trips using the compensatory strategies they have learned. For example, persons may practice using daily planners and checklists to plan the outing. They may practice functional reading and writing skills by using a telephone book to find the phone number of a restaurant and to writing it down. They may practice telephone skills by calling the restaurant and making a reservation. They may practice reading maps, taking public transportation to the restaurant, and counting the change needed to purchase a ticket. They may practice their functional conversational skills by ordering their food in the restaurant.

Later on in the recovery, the SLP may work with a vocational specialist to help transition the person back into work or school, if applicable. The SLP may also work with employers and/or educational specialists to implement the use of compensatory strategies in these settings. The SLP may work with them to modify the patient's work/school environment to meet language and/or cognitive needs.

If speech muscles are weak, the SLP may teach exercises to strengthen these muscles. The person will practice the exercises at home and in therapy. The person may also be taught strategies to make speech more intelligible and to compensate for the muscle weakness.

If swallowing is a problem, the SLP may teach exercises to strengthen or improve the coordination of swallowing muscles, or strategies to compensate for muscle weakness and improve the safety of swallowing. The SLP works closely with doctors, nurses, and the dietitian to recommend the food consistencies that are safest and most appropriate for the patient's needs. As the person gains more strength and coordination in swallowing muscles, the SLP works with these professionals to "upgrade" the person's diet. For example, the SLP may recommend upgrading the diet from a pureed/blended consistency to a chunky consistency.

If the person is learning how to use an augmentative or alternative communication aid, treatment will focus on teaching use of the aid in structured conversation, with other stroke survivors, with family, and eventually in the community.