Stroke Management (ACNRC)

Speech therapy is often a part of stroke rehabilitation.

Stroke management depends on the type of stroke and can include a variety of treatments and care: 

• Ischemic stroke

The main priority is to restore circulation to the affected brain areas. This can be done with thrombolytic medications, also known as “clot-busting” drugs, or a catheterization procedure. If you arrive at the hospital within three hours of the first symptoms, you may be able to receive a thrombolytic. 

• Hemorrhagic stroke

Treatment depends on the severity and location of the bleeding. The main priority is often to reduce blood pressure to stop or slow the bleeding. Surgery may be necessary to relieve pressure on the brain. 

During a stroke, things move quickly once you get to the hospital. Your emergency team works to learn what type of stroke you’re having. You’ll likely have a CT scan or other imaging test soon after arrival. Healthcare professionals also need to rule out other possible causes of your symptoms, such as a brain tumor or a drug reaction.

Some of the tests you may have include:

• A physical exam. A healthcare professional does several tests, including listening to your heart and checking your blood pressure. A neurological exam looks at how a potential stroke is affecting your nervous system.
• Blood tests. You may need tests to check how fast your blood clots and whether your blood sugar is too high or low. You also may be tested to see if you have an infection.
• Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show bleeding in the brain, an ischemic stroke, a tumor or other conditions. You might have a dye injected into your bloodstream to view the blood vessels in the neck and brain in greater detail. This type of test is called a computerized tomography angiography.
• Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and a magnetic field to create a detailed view of the brain. The test can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. Sometimes a dye is injected into a blood vessel to view the arteries and veins and highlight blood flow. This test is called magnetic resonance angiography or magnetic resonance venography.
• Carotid ultrasound. In this test, sound waves create detailed images of the inside of the carotid arteries in the neck. A carotid ultrasound can show buildup of fatty deposits called plaques and blood flow in the carotid arteries.
• Cerebral angiogram. This test is less common, but it provides a detailed view of arteries in the brain and neck. A thin, flexible tube called a catheter is inserted through a small incision, usually in the groin. The tube is guided through the major arteries and into the carotid or vertebral artery in the neck. Then a dye is injected into the blood vessels to make the arteries visible under X-ray imaging.
• Echocardiogram. An echocardiogram uses sound waves to create detailed images of the heart. An echocardiogram can find a source of clots in the heart that may have traveled to the brain and caused a stroke.

Treatment

Emergency treatment depends on whether you’re having an ischemic or hemorrhagic stroke. During an ischemic stroke, blood vessels in the brain are blocked or narrowed. During a hemorrhagic stroke, there’s bleeding into the brain.

Ischemic stroke

To treat an ischemic stroke, blood flow must quickly be restored to the brain. This may be done with:

• Emergency IV medicine. An IV medicine that can break up a clot has to be given within 4.5 hours from when symptoms began. The sooner the medicine is given, the better. Quick treatment improves your chances of survival and may reduce complications.

An IV injection of recombinant tissue plasminogen activator (TPA) is the gold standard treatment for ischemic stroke. The two types of TPA are alteplase (Activas) and Tenecteplase (TNKase). An injection of TPA is usually given through a vein in the arm within the first three hours. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started.

This medicine restores blood flow by dissolving the blood clot causing the stroke. By quickly removing the cause of the stroke, it may help people recover more fully from a stroke. Your healthcare professional considers certain risks, such as potential bleeding in the brain, to determine whether TPA is appropriate for you.

• Emergency endovascular procedures. Healthcare professionals sometimes treat ischemic strokes directly inside the blocked blood vessel. Endovascular therapy has been shown to improve outcomes and reduce long-term disability after ischemic stroke. These procedures must be performed as soon as possible:
  • Medicines delivered directly to the brain. During this procedure, a long, thin tube called a catheter is inserted through an artery in the groin. The catheter is moved through the arteries to the brain to deliver TPA directly where the stroke is happening. The time window for this treatment is somewhat longer than for injected TPA but is still limited.
  • Removing the clot with a stent retriever. A device attached to a catheter can directly remove the clot from the blocked blood vessel in the brain. This procedure is especially helpful for people with large clots that can’t be completely dissolved with TPA. This procedure often is performed in combination with injected TPA.

The time window when these procedures can be considered has been expanding due to newer imaging technology. Perfusion imaging tests done with CT or MRI help determine if that someone may benefit from endovascular therapy.

Hemorrhagic stroke

Emergency treatment of hemorrhagic stroke focuses on controlling the bleeding and reducing pressure in the brain caused by excess fluid.

Emergency measures

If you take blood-thinning medicines to prevent blood clots, you may be given treatment to counteract the blood thinners’ effects. These treatments include medicines or a transfusion of blood products. Medicines also can lower the pressure in your brain, lower blood pressure, prevent spasms of the blood vessels and prevent seizures.

Surgery

If the area of bleeding is large, you may need surgery to remove the blood and relieve pressure on your brain. Surgery also may be used to repair blood vessel damage associated with hemorrhagic strokes.

Your healthcare professional may recommend one of these procedures if an aneurysm, arteriovenous malformation (AVM) or other blood vessel condition caused the stroke.

• Surgical clipping. A surgeon places a tiny clamp at the base of an aneurysm to stop blood flow to it. An aneurysm is a bulge at a weak spot in a blood vessel. The clamp can keep the aneurysm from bursting. Or the clamp can keep an aneurysm that has recently burst from bleeding again.
• Coiling, also known as endovascular embolization. A catheter is inserted into an artery in the groin and guided to the brain. Using the catheter, a surgeon places tiny coils into the aneurysm to fill it. This blocks blood flow into the aneurysm and causes blood to clot.
• Surgical removal of a tangle of thin-walled blood vessels, known as an AVM. Surgeons may remove a smaller AVM if it’s in an area of the brain that’s easy to access. This removes the risk of rupture and lowers the risk of hemorrhagic stroke. However, it’s not always possible to remove an AVM if it’s deep within the brain or if it’s large. It also may not be possible to remove if the procedure would impact brain function.
• Stereotactic radiosurgery. This procedure uses multiple beams of highly focused radiation to repair blood vessel malformations. Stereotactic radiosurgery is an advanced treatment that’s not as invasive as other procedures.

After emergency treatment, you’re closely monitored for at least a day. After that, stroke care focuses on helping you recover as much function as possible and to return to independent living. The impact of the stroke depends on the area of the brain involved and the amount of tissue damaged.

If the stroke affected the right side of the brain, movement and feeling on the left side of your body may be affected. If the stroke damaged the left side of the brain, movement and feeling on the right side of your body may be affected. Brain damage to the left side of the brain also may cause speech and language disorders.

Most people who have had a stroke go to a rehabilitation program. Your healthcare professional can recommend the therapy program that is right for you. A program is recommended based on your age, overall health and degree of disability from the stroke. Your lifestyle, interests, priorities and whether you have help from family members or caregivers are considered.

Rehabilitation may begin before you leave the hospital. After discharge, you might continue the program in a rehabilitation unit of the same hospital. Or you may go to another rehabilitation unit or to a skilled nursing facility as an outpatient. You also might have rehabilitation at home.

Every person’s stroke recovery is different. Depending on your condition, your treatment team may include:

• Doctor trained in brain conditions, known as a neurologist.
• Rehabilitation doctor, known as a physiatrist.
• Rehabilitation nurse.
• Dietitian.
• Physical therapist.
• Occupational therapist.
• Recreational therapist.
• Speech pathologist.
• Social worker or case manager.
• Psychologist or psychiatrist.
• Chaplain.

Treatment outcomes

One way to evaluate the care of patients diagnosed with stroke is to look at the percentage of patients receiving the timely and effective care measures that are appropriate.

The graphs below display the percentage of eligible Mayo Clinic patients diagnosed with stroke receiving all of the appropriate care measures.

Written by
Sumon Ghosh (Founder & managing director, MCAF)