Treatment for Stroke

Investigation of acute stroke is to confirm the vascular nature of the lesion, distinguish cerebral infarction from haemorrhage and identify the underlying vascular disease and risk factors.

Initial investigations includes simple blood tests, an electrocardiogram and brain imaging. When there is uncertainty about the nature of stroke, further investigations are carried out. This usually applied to younger patient who are less likely to have atherosclerotic disease.

Brain imaging using CT scan or MRI should be carried out in all patients with stroke. CT  is widely available and the most practical method of imaging the brain. It will usually exclude non-stroke lesions like subdural haematomas and brain tumours. CT scan is used to look for bleeding within the brain that may cause symptoms that mimic a stroke, but are not treated with thrombolytic therapy with TPA.

MRI is not as widely available as CT, scanning times are longer and it cannot be used in some individuals with contraindications. However, MRI diffusion weighted imaging can detect ischaemia earlier than CT and other MRI sequences can also be used to demonstrate abnormal perfusion. MRI is more sensitive than CT in detecting strokes that affects the brain stem and cerebellum. An MRI scan can also be used to specifically view the blood vessels non-invasively (without using tubes or injections), a procedure called an MRA (magnetic resonance angiogram).

Stroke can also be investigated by computerised tomography with angiography. This can be done by using dye and inject it into a vein in the arm. Images of the blood vessels in the brain can give information regarding aneurysms or arteriovenous malformations. Besides, other abnormalities of brain blood flow may be evaluated.

Tissue plasminogen activator (TPA). Alteplase (TPA) is used  to dissolve the blood clot that is causing the stroke. The earlier it is given, the better the result. TPA must be given within four and a half hours after the onset of symptoms. For patients who waken from sleep with symptoms of stroke, it counts when they were last seen in a normal state.TPA is injected into a vein in the arm but the time frame for its use may be extended to six hours if it is dripped directly into the blood vessel that is blocked requiring angiography, which is performed by an interventional radiologist. This technology is not availble in all hospitals.TPA may reverse stroke symptoms in most patients but it may also cause bleeding in some patients, causing stroke to become worse.

Heart tests are often performed in stroke patients to search for the source of an embolism. Electrocardiograms (EKG or ECG) can be used to detect abnormal heart rhythms .

Blood tests are done to check for kidney and liver function, electrolyte abnormalities, blood clotting function and anaemia.

Heparin

Formal anticoagulation with heparin has been widely used in treating stroke in the past. This does improve the patient’s recovery. However, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes.

Aspirin

Aspirin should be started immediately after an ischaemic stroke unless  rt-PA has been given, in which case it should be withheld for at least 24 hours. Aspirin reduce the risk of early recurrence and has a small but measurable effect on long-term outcome.

Corticosteroids, haemodilution, vasodilators and ‘neuroprotective’ agents

Routine use of these agents should be avoided because they may have adverse effects. None of it has been shown to improve patient outcomes.

Managing other Medical Problems

• Patient will be given fluids because if the patient is having a stroke, he or she may often be dehydrated.
• Patients who have difficulty in breathing will be assessed and treated.
• Oxygen may be given to make sure that the brain is getting the maximal amount.
• Patients are not allowed to eat or drink until his or her ability to swallow is assessed.
• Medicine including pills, nitroglycerin paste or IV injections can be used to lower the blood pressure. However,  blood pressure should not be too low so that the brain can get enough oxygen. If the blood pressure is very high, patients would be placed on a continuous IV flow of medication.
• The blood sugars level of patients with diabetes is often elevated after a stroke. The glucose level in patients should be controlled to minimise the size of strokes.
• Patients who have ischemic attacks  may undergo  blood pressure and cholesterol medications even if the blood pressure and cholesterol levels are within acceptable levels.
• No smoking .

Management is aimed at minimising the volume of brain that is irreversibly damaged, preventing complications , reducing the patient’s disability and handicap through rehabilitation, and reducing the risk of recurrent episodes.

The rehabilitation process is shown in the following:

1. occupational therapy - To regain the  function in the arms and hands .
    
2. physical therapy-  To improve strength  and help in walking.
3. speech therapy -  To relearn talking and swallowing. 
4.  family education - To help them in facing and coping with types of challenges in life.

However, total recovery is not really possible in many cases but  many stroke patients can return to their independent lives.

Patients who have more severe stroke are transferred from the acute care hospital setting to a skilled nursing facility to be monitored and continue physical and occupational therapy.

Reducing the risk of further strokes and other vascular problems

The average risk of having a further stroke is 5-10% within the first week of stroke or TIA, perhaps 15% in the first year and 5% per year thereafter.  Patients with ischaemic events should be put on long-term antiplatelet drugs and statins to lower down cholesterol level. The risk of recurrence after strokes can be reduces by blood pressure reduction,even for those with blood pressure in the normal range.

Posted in: Stroke