Manage a stroke

How to Manage a Stroke?

(Note: A glossary has been mentioned below)

The management of a stroke includes certain medications, lifestyle modifications, rehabilitation, and sometimes surgery.

 

What are the medications?

Thrombolytic drugs

Thrombolysis is indicated when the brain scan suggests that it might help. Alteplase should be given within three hours from the beginning of stroke symptoms.

Anti-platelet drugs and anticoagulants

Ischaemic stroke,

  • The patient should be given Aspirin as soon as possible (at least within 24 hours) and continue for two weeks or until the patient leave the hospital, whichever sooner.
  • If the patient has an allergy to Aspirin, he or she should be offered another anti-platelet drug instead of Aspirin.
  • If the patient has had dyspeptic symptoms, a proton pump inhibitor (such as Omeprazole, Rabeprazole, Esomeprazole, Pantoprazole, and Lansoprazole) should be given with Aspirin.
  • With a risk of developing venous thromboembolism: The patient should be given anticoagulants and monitored closely.
  • With deep-vein thrombosis (DVT), or pulmonary embolism: The patient should be offered anticoagulants instead of Aspirin.
  • If the patient has had an ischaemic stroke known as cerebral venous sinus thrombosis (with or without bleeding), the patient should be given anticoagulants, unless he or she has any contraindication.
  • If the patient was already taking anticoagulants for prosthetic valves in the heart and has a risk of bleeding in the brain,
      • Need to stop anticoagulant treatment.
      • The patient should be offered Aspirin instead of anticoagulants.
      • The patient can restart anticoagulant treatment after one week.
  • With atrial fibrillation: The patient should be offered Aspirin for two weeks and consider anticoagulant treatment later.

 

Haemorrhagic stroke,

  • With deep-vein thrombosis or pulmonary embolism, he or she should be offered anticoagulants or treated with a caval filter.
  • If the patient was taking anticoagulants before the haemorrhagic stroke, anticoagulant treatment should be stopped, and he or she should have medications to reverse the effect of anticoagulants.

 

Statins

If the patient was taking statins before the stroke, it should be continued. Otherwise, the healthcare professional will not start statins immediately after a stroke.

Examples for statins,
Atorvastatin, Simvastatin, Rosuvastatin

 

Management of difficulty swallowing

Swallowing should be assessed by a trained healthcare professional before feeding the patient. Otherwise, feeding, drinking water, or giving medication by mouth may lead to aspiration pneumonia. If the patient has difficulty swallowing, the healthcare professionals will insert a tube (nasogastric/NG tube) through the nose into the stomach within 24 hours. Food and medication should be given by the tube.

A specialist should assess the patient with difficulty swallowing usually within a day, at least within three days. If the patient can swallow, he or she should be given food and liquids, which they can swallow safely. The healthcare professionals will assess the hydration daily, the level of nutrition, weekly, and they will give nutritional supplements orally or through the feeding tube, if the patient is malnourished.

 

Blood pressure and sugar

Blood pressure and sugar should be monitored throughout the hospital stay. The healthcare team will offer treatments before thrombolysis, if the stroke patient has high blood pressure. The blood-sugar level should be within normal range and managed with Insulin (for high blood glucose/hyperglycaemia) and glucose (for low blood glucose/hypoglycaemia).

 

Moving around

The healthcare team will help the patient move around. The post-stroke rehabilitation begins, when the patient is stable. Physicians, physical therapists, rehabilitation nurses, speech-language pathologists, vocational therapists, occupational, and recreational therapists belong to the post-stroke rehabilitation team. They will help stroke survivors achieve skills, which have been lost due to the stroke.

 

Surgical management of stroke

Surgical management depends on the health before the stroke, age, and stability of the patient after the stroke.

Occlusion of the middle cerebral artery (a major blood vessel of the brain) can cause cerebral oedema (swelling of the brain). Therefore, the healthcare team may offer an operation known as decompressive hemicraniectomy. If the patient has all the following, this operation can be done.

  • Severe symptoms of stroke
  • The involvement of a large area of the brain, which receives blood supply from the middle cerebral artery.
  • The patient’s age is 60 years or below.
  • Deterioration of consciousness or significant loss of the level of consciousness

 

These patients should be referred within 24 hours and should have the decompressive hemicraniectomy within 48 hours.

If the patient has significant occlusion in the carotid arteries of the neck (major blood vessels of the brain), the healthcare team may do a surgery called carotid endarterectomy to cut the risk of TIA or stroke. Atheromatous plaques (fat deposits in the arterial wall) will be removed by the surgeon during this procedure.

If the symptoms of stroke are deteriorating, and the patient has an intracranial haemorrhage (bleeding into the brain), they should be offered an urgent brain scan.

If the patient has the following, an operation may be offered.

  • The patient has had a haemorrhagic stroke.
  • The patient is fit for surgery before and after the stroke.
  • The patient has increased intracranial pressure (pressure in the brain) due to bleeding. This condition is known as hydrocephalus.

 

Surgeries for haemorrhagic stroke

  • Evacuation of blood in or around the brain
  • Craniotomy – Repairing the bleeding aneurysm of the cerebral artery (thinning and dilatation of the artery wall)
  • Endovascular coil embolisation – Blocking the bleeding aneurysm by inserting a coil
  • Removal of arteriovenous malformations (abnormal blood vessels)

 

Glossary

      • Anticoagulants: The drugs, which cut blood clotting (such as Warfarin, and Heparin).
      • Anti-platelet drugs: The drugs, which prevent platelet cell aggregation and clot formation (such as Aspirin, Dipyridamole, and Clopidogrel).
      • Atrial fibrillation: A condition characterised by an irregular and/or fast heart beat.
      • Caval filter: A device, which can be implanted in the inferior vena cava (a major vein, which carries blood to the heart). It prevents pulmonary embolism.
      • Cerebral venous sinus thrombosis: This condition, which is a type of stroke occurs due to occlusion of a vein of the brain by a blood clot.
      • Deep-vein thrombosis: Occlusion of a vein by a blood clot, usually a vein in the leg.
      • Proton pump inhibitor: A drug, which prevents the acid production in the stomach.
      • Pulmonary embolism: Occlusion of an artery in the lung by a blood clot, which dislodge from a large blood clot in another part of the body.
      • Statins: The drugs, which lower the cholesterol level in the blood.
      • Thrombolytic drugs: The drugs used to do thrombolysis.
      • Thrombolysis: Treatment with a drug, which dissolves blood clots.
      • Venous thromboembolism: A blood clot, which travels in the blood. It can cause deep-vein thrombosis, and pulmonary embolism.

 

(Photo courtesy: A Health Blog)

 

Related Links:

Stroke and Transient Ischaemic Attack (TIA)
Stroke & TIA: Clinical Assessment
Management of Transient Ischaemic Attack (TIA)
How to Prevent a Stroke?
How to Detect a Stroke Early?

About the author
Dr. Nalaka Priyantha is the founder and author of 'DRN Health'. He currently works at the Ministry of Health, Sri Lanka as a senior medical officer. He is blogging about healthy living since 2012.
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