Stroke - Choosing treatments

The treatment for ischaemic and haemorrhagic strokes - that is, strokes caused by either an interruption of bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. to the brain, or a bleed within or around the brain - is very different. Because of this, it is very important that anyone who has had a stroke has images of their brain taken as a matter of urgency, to ascertain the underlying cause and determine what further treatment is needed.[1]

A considerable advance in stroke care has been the establishment of stroke care units, where people who have had a stroke receive focused professional care. These are now routine in several countries.[2]

These pages will discuss:

Therapy for ischaemic stroke

  • Thrombolysis - the administration of clot-busting drugs, which are also called thrombolyticsA medication that breaks up blood clots.. This is the definitive treatment for ischaemic stroke, although the benefits lessen over time. While it was originally believed that thrombolyticsA medication that breaks up blood clots. must be given within 3 hours of the onset of stroke symptoms in order to have any value, more recent research has suggested that there is a continuing benefit n taking them from 4.5 to even 6 hours after the onset of symptoms. This period of time is often called the 'therapeutic window'. Learn more about thrombolysis.
  • General medical care - includes high-flow oxygen, the correction of high bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. glucoseA simple sugar that is an important source of energy in the body. and the management of severely raised bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. pressure. However, caution must be exercised in blood pressure management, and sudden drops in blood pressure should be avoided.[3,4] This is because a sudden lowering of blood pressure can sometimes reduce the bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. supply to the brain[3,5]
  • Aspirin - is an antiplatelet drug, a medicine that stops platelets from clustering together, helping to prevent the formation of bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. clots. Aspirin has been shown to have a modest benefit if it's taken within 48 hours of a stroke. Even though the benefit is small, aspirin is easy to take, costs little and has few adverse effectsUndesirable side-effects of medication.[2,3]
  • Anticoagulants - may also be helpful in some circumstances, for instance, in cases of stroke caused by a bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. clot originating in the heart. Examples of anticoagulants include heparinA substance produced by the body, or given as medication, that reduces the likelihood of the blood to clot, coagulate. and warfarin. As always, the benefits of anticoagulantA medication that prevens blood from clotting, or which reduces the likelihood of the blood to clot. therapy need to be balanced against the risk of adverse effectsUndesirable side-effects of medication. - namely, bleeding[4]
  • Decompressive surgery - may be of benefit in a small proportion of people who have had an ischaemic stroke. This is surgery specifically aimed at relieving the pressure from oedemaThe accumulation of excess fluid in the tissues of the body., the collection of fluid around the brain. Although it seems that only a very few patients may benefit from decompressive surgery after an ischaemic stroke, in those that it does help, surgery appears to show a clear benefit. It is thought that surgery is most appropriate for those who have had an ischaemic stroke located in a specific area in the brain - called the middle cerebral arteryA blood vessel that carries blood away from the heart. Apart from the pulmonary artery and umbilical artery, all arteries carry oxygenated blood. territory - as well as brain oedemaThe accumulation of excess fluid in the tissues of the body.. However, it is not to be undertaken lightly; surgery in people who are acutely unwell in the aftermath of a stroke can pose significant risks.[2]

Therapy for haemorrhagic stroke

  • Stabilisation measures - these include maintaining an open airway and assessing breathing. Sometimes intubationProcedure involving passing a tube into part of the body. Examples include endotracheal intubation to maintain an airway, and gastric intubation to empty the stomach. (passing a tube down the airway, or tracheaThe windpipe.) is needed, to maintain a clear airway[5] and to reduce the risk of aspiration pneumoniaInfection of the lungs owing to inhalation of a foreign body, usually food particles, through the windpipe (trachea). - infectionInvasion by organisms that may be harmful, for example bacteria or parasites. resulting from the inhalation of foreign material into the lungs
  • Reversal of the effects of thrombolyticsA medication that breaks up blood clots., antiplatelet drugs or anticoagulants - this may be needed if any such medication has prompted bleeding. For example, the effects of heparinA substance produced by the body, or given as medication, that reduces the likelihood of the blood to clot, coagulate. can be reversed by taking protamine sulphate; meanwhile, vitamin K can help to reverse the effects of warfarin.[5] Reversal of the effects of these medications can help to prevent continuing bleeding
  • Antifibrinolytic agents - are substances that help to prevent the breakdown of fibrinA product of blood coagulation that forms the basis of a blood clot. in clots. Several of these drugs are available, and it is thought that one in particular - recombinant Factor VII - may be helpful in treating people who have experienced a haemorrhagic stroke[5]
  • Blood pressure management - may be necessary in some cases. Blood pressure is elevated in around half of all patients who experience a haemorrhagic stroke. While it is not clear whether high blood pressure directly increases the extent of bleeding, it is associated with worse outcomes after a stroke. However, it is not always best to treat high bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. pressure, as bringing down the blood pressure too much or too quickly can reduce the bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. supply to the brain and actually worsen brain injury[5]
  • Simple measures to lower the pressure inside the skull (intracranial pressureThe pressure within the skull.) - such as elevating the head of the bed, taking certain medications and breathing more deeply and more rapidly. These are holding measures until a neurosurgical procedure can be carried out - for example, craniotomySurgical removal of a part of the skull.[5]
  • Placement of a ventricularRelating to a ventricle (either in the brain or the heart) drain - this can help to remove excess fluid collected round the brain, a condition called hydrocephalusExcess levels of fluid within the brain..[5] When hydrocephalusExcess levels of fluid within the brain. is present, doctors may drain the excess fluid by placing a very small tube within the skull, which drains to the outside. This is called a ventricularRelating to a ventricle (either in the brain or the heart) drain and it may help to restore normal neurological function by lowering the intracranial pressureThe pressure within the skull. - that is, the pressure within the skull.[6] The procedure is done under general anaestheticAny agent that reduces or abolishes sensation, affecting the whole body.. Prior to placement, a small area of the scalp is shaved; a small incision is then made in the skin and the skull, through which the drain is passed. Stitches hold the drain in place; bed rest is usually needed until the drain is removed.
  • Anticonvulsants - may be needed to treat seizures after a haemorrhagic stroke; sometimes, seizures are the initial symptom of this kind of stroke. Although supportive evidence is lacking, some people are given anti-epileptic treatment for a month as a preventative measure; this is then discontinued if they do not have any seizures[5,6]
  • Surgical treatment - this is sometimes needed to remove a collection of bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. and may be life-saving if the bleed is around the cerebellumThe part of the brain that regulates muscle tone and balance. area of the brain. Surgical resection of the haemorrhageThe internal or external loss of blood from a blood vessel. is recommended for people who are drowsy or have poor vital signs, or those who have large bleeds.[6] Other surgical options are available; for example, the surgical clipping of any bleeding arteries or ruptured aneurysms within or around the brain.[2]

Care common to both ischaemic and haemorrhagic strokes

Multidisciplinary care following a stroke is paramount. This means that the care team should include not only physicians and nurses, but also physiotherapists, speech and language therapists and dietitians, as well as other healthcare professionals.

General measures for everyone who has had a stroke include pain relief and the treatment of fever, as well as identifying and giving antibiotic treatment for any sources of infectionInvasion by organisms that may be harmful, for example bacteria or parasites. such as urinary tract infections or pneumoniaInflammation of one or both lungs..[3-5]

Equally important are measures taken to avoid the development of complications - such as rigorous nursing care with regular turning to prevent the development of bed sores - and the initiation of steps to help prevent another stroke.[4]

If someone has difficulty swallowing, it may be necessary to try alternative forms of feeding, for example, through a nasogastric tubeA tube passed through the nose into the stomach. - a tube passed through one of the nostrils and down the gullet (oesophagusThe gullet, the part of the gastrointestinal system that extends down from the mouth cavity to the stomach.), into the stomach. Other methods of assisted feeding include PEG feedingPassing a tube into the stomach for feeding. PEG stands for percutaneous endoscopic gastrostomy., which involves feeding via a tube that passes through the skin and into the stomach.[6]

References: 
  1. Lees KR. Stroke: success for extending acuteHas a sudden onset. treatment.  Lancet Neurol 2009; 8: 2-4.
  2. Donnan GA, Fisher M, Macleod M et al. Stroke. Lancet 2008; 371: 1612-23.
  3. Khaja AM and Grotta JC. Established treatments for acuteHas a sudden onset. ischaemic stroke. Lancet 2007; 369: 319-30.
  4. Goldstein LB. Acute ischemic stroke treatment in 2007. Circulation 2007; 116; 1504-14.
  5. Sahni R and Weinberger J. Management of intracerebralWithin the brain. hemorrhage. Vasc Health Risk Manag 2007; 3: 701-9.
  6. Link. Last accessed November 20, 2009.