A stroke is a major life-threatening emergency that requires rapid diagnosis and management. This can go a long way in helping to reduce permanent disability and even preventing death. The therapeutic approach to the two major types of stroke, ischemic stroke and hemorrhagic stroke, differs and therefore proper diagnosis at the earliest possible time is essential. Treatment and management involves a combination of medication, rehabilitation and education for both the patient and caregivers.
Firstly, proper diagnosis depends upon stroke assessment tools which are useful in evaluating a patient, either on the scene or in the emergency room, prior to diagnostic investigations. This will indicate, with fair degree of accuracy, whether a stroke has occurred or not. Then diagnostic investigation like a CT scan or MRI will confirm the diagnosis and further indicate the extent of the infarct. The approach to diagnosis is discussed in detail under suspected stroke.
Treatment of Ischemic vs Hemorrhagic Stroke
Ischemic stroke is the most common type of stroke andoccurs due to a blockage of an artery to a specific area of the brain. Most of the time this is by a blood clot. An acute ischemic stroke needs immediate reperfusion - restoration of blood flow to the brain. The best results are obtained by initiating intravenous fibrinolytic therapy – treatment where drugs are used to break down the clots – within 3 hours of onset of symptoms.
A transient ischemic attack (TIA), also known as a mini-stroke, is a short-lived episode caused by temporary blockage of an artery. Iit needs to be treated as an emergency because it is not possible to predict the severity of the outcome.
Hemorrhagic stroke accounts for the remaining 15% of all strokes. This is caused by rupture of a blood vessel in the brain, resulting in bleeding into the surrounding brain tissue. Fibrinolytics used for an ischemic stroke are contraindicated which means it should never be used for a hemorrhagic stroke. Anticoagulants are drugs that prevent blood from clotting and should also be avoided. These drugs can exacerbate bleeding in the brain.
The initial noncontrast CT scan is the most important test for an acute stroke patient since it helps to differentiate ischemic from hemorrhagic stroke. Aspirin, heparin, or tPA should not be given until the CT scan has ruled out intracranial hemorrhage.
General Care for Stroke Patients
- Admission in a stroke unit for constant blood pressure and neurological monitoring.
- Support of airway.
- Maintaining nutrition.
- Intravenous fluids if necessary.
- Hypertension treatment, where indicated.
- Blood sugar treatment if blood glucose is above 200 mg/dL.
- Treatment for fever.
- If the patient’s neurologic status deteriorates, a repeat CT scan should be done to determine the cause, such as cerebral edema or hemorrhage (swelling of or bleeding in the brain).
Tissue Plasminogen Activator (tPA)
For ischemic stroke, fibrinolytic therapy should be started as soon as possible. Fibrinolysis, or clot break down, is done by use of tissue plasminogen activator (tPA). It gives maximum benefit if used within 3 hours of the onset of stroke symptoms. For patients who awake with symptoms of stroke, being previously normal, tPA must be given within 4 ½ hours of onset of symptoms. Only in case of posterior circulation strokes that involve the vertebrobasilar system (arteries running up the back of the neck), tPA treatment may be started within 18 hours.
tPA may cause some side effects, the most important of which is intracranial hemorrhage. The potential adverse effects of tPA need to be weighed against the potential benefit and should be discussed with the patient and family before starting treatment. Blood pressure control, in hypertensive patients, is necessary before starting fibrinolytic therapy to lower the risk of intracerebral hemorrhage following administration of tPA.
Heparin may sometimes be used as an anticoagulant for the treatment of stroke. Its role in improving the outcome remains doubtful, although it does help in preventing further strokes.
Administration of aspirin after onset of symptoms may have a positive outsome in some patients but it should not be given as a routine procedure, where it can cause more harm than good. In some cases, due to medical reasons, where tPA cannot be given, aspirin may be used. Aspirin may be given within 48 hours of a stroke.
Plaque /Clot Removal
Carotid artery surgery may be needed in case of carotid artery disease (the carotid artery runs up the front of the neck on either side). Either carotid endarterectomy or carotid artery angioplasty may be conducted.
- Carotid endarterectomy is a surgical procedure that ‘cleans’ out plaques and opens up the narrowed carotid arteries.
- Carotid angioplasty and stenting (CAS) may be an alternative to carotid endarterectomy in some patients, such as those with severe stenosis. A thin catheter is inserted into an artery in the groin, which is then threaded through the blood vessels to reach the site of blockage in the carotid artery. The clot may be broken up or a tiny balloon is inflated against the walls of the blood vessel (angioplasty). A circular wire mesh (stent) is left inside the vessel to keep it open.
For a hemorrhagic stroke, emergency surgery may be required to remove blood from around the brain and to repair the damaged blood vessels. This may be done by means of a surgical procedure known as craniotomy, where a small section of the skull is cut away so that the surgeon can reach the bleeding site.
If an aneurysm (a balloon-like bulge in the artery) is the cause of stroke, aneurysm clipping or coil embolization may be done.
- In aneurysm clipping, the surgeon makes an incision in the brain. The aneurysm is then blocked off from blood vessels in the brain by means of a tiny clamp.
- In coil embolization, a catheter is inserted in an artery in the groin, which is threaded to the site of the aneurysm. A tiny coil is pushed into the aneurysm through the catheter. The coil will cause a blood clot to form in the aneurysm, thus preventing blood flow through it.
If an arteriovenous malformation (AVM) is the cause of stroke, an AVM repair may be done, either by means of :
- surgery to remove the AVM.
- blocking blood flow by injecting a substance into the blood vessels.
- radiation to shrink the blood vessels of the AVM.
The aim of long-term treatment will be to improve function as well as prevent further strokes. The rehabilitation process may include :
- Speech therapy
- Occupational therapy
- Physical therapy
- Family education
Prevention may include :
- Reducing risk factors, such as smoking, hypertension, diabetes, and high cholesterol.
- Use of anticoagulants, such as heparin and warfarin.
- Use of antiplatelet drugs like aspirin and clopidogrel which decrease blood clotting by stopping platelets from clumping together .
- Use of a statins to lower LDL (bad cholesterol) level.
- Carotid endarterectomy may be considered for a narrowed carotid artery that may lead to future strokes.