Stroke

Stroke patients can be treated in many different settings, but the ideal place for treatment is a stroke unit, where the doctors, nurses, and therapists work together as a specialized unit. When a stroke patient arrives at the hospital, overall medical treatment includes maintaining blood pressure, reducing elevated temperature, and normalizing blood glucose levels. Specific measures performed by the stroke team include attempting to reopen closed blood vessels, protecting the brain, and preventing complications.

Maintaining blood pressure of the patient is important because after stroke, the brain may be unable to control its own blood supply (autoregulation). Blood supply depends on blood pressure, and if the blood pressure is not high enough to pump blood to the damaged area, brain cells will die. To prevent further damage to the brain after stroke, the medical team makes sure that blood pressure is maintained by measuring and medicating if necessary.

Temperature is another factor when treating a stroke patient. An increase in body temperature of even one degree centigrade will double the risk of death or disability in a stroke patient. In addition, patients with a high level of blood glucose at the time of a stroke are less likely to recover; therefore, reducing blood glucose in the acute situation benefits the patient.

The most common cause of stroke is the closing off of a blood vessel to the brain. Some studies have shown that giving the patient a clot-busting (thrombolytic) drug may reopen the closed blood vessels to the head. Thrombolytic drugs are effective only if given early in the onset of stroke and also carry a great risk of causing more bleeding to the head, thus causing more damage and possibly death. The drug in this classification that has been receiving much attention is tissue plasminogen activator (t-PA). It has been used with success in the treatment of heart attacks and is currently being used in treating stroke. The side effect of bleeding to the head may result in death, so it is important that thrombolytic drugs be researched and tested in centers where there are experts in stroke and facilities to deal with the possible consequence of bleeding into the head. With time and caution, thrombolytic treatment may play a more important role in the treatment of acute stroke.

Another type of drug works to protect the brain after stroke. In laboratory studies these drugs have protected the brain when blood deprivation occurred. They are now being tested in clinical studies.

Brain cell repair is the future of recovery after stroke. More is being learned about how the brain repairs injury and the potential of injecting engineered cells to help healing. It may be the case that a combination of drugs that open the blood vessels to the brain protect the brain from breakdown, and speed up the repair of the brain will be the ideal treatment of the future.

Surgery is not used in the acute treatment phase unless a blood clot is pressing on one of the vital parts of the brain or if an aneurysm has ruptured and there is bleeding around the brain (subarachnoid hemorrhage). Timing is important when dealing with a ruptured aneurysm. There are two approaches considered by the neurosurgeon: (1) to operate before the brain vessels go into spasm (vasospasm), or (2) to wait a for the vasospasm to disappear and then operate. Operating early has a higher rate of complication, but waiting allows vasospasm to cause further damage. Thus, early surgery is often chosen despite the overall risk.

Aneurysms that have been found by diagnostic testing and have not bled, do not necessarily require surgery. If the aneurysm is less than 10 mm in diameter, the patient usually will be monitored. If the aneurysm measures greater than 10 mm in diameter, surgery or treatment with balloons or coils delivered through a tube (catheter) in the blood vessel may be considered.

Preventing complications is a main concern of the stroke team. When a patient is bedridden for a long period of time, blood becomes stagnant and tends to pool, which may make the patient more prone to developing blood clots, resulting in further damage and even death. Lying in the same position for a long time can also cause painful bedsores and the shortening of muscles (contractures). Initially, the stroke team will move an immobilized patient and perform range of motion exercises to keep muscles limber. As the patient gains ability, he or she can take over some of these exercises to help prevent complications. Stroke patients are also at higher risk for infection, and are carefully monitored by the doctor and nurses to ensure that they remain as healthy as possible.

In the first few hours after a stroke, it can become fairly clear what the prognosis for the patient will be. In some cases the result of stroke can be more grievous than death, and the family will be told what they can expect. At a time when emotions are so highly charged, it may be difficult to make a decision that is best for the patient, especially if the patient is unable to communicate his or wishes. Situations like this can be avoided by having a living will or an advance health care directive in place. This document is prepared beforehand for emergency situations and lets the doctors and family know what the patient would like done in certain situations if he or she is unable to communicate. For example, an incapacitated patient who goes into cardiac arrest may not wish to be revived. This is something that can be established legally before a catastrophic event. Advance health care directives may have different names and different regulations governing them in the states and provinces. Having an advance health care directive in place makes the person’s wishes clear and removes the burden of not knowing what to do from the family.