Stroke
Treatment Overview
Prompt treatment of stroke and medical problems related to stroke, such as high blood sugar and pressure on the brain, may minimize brain damage and improve the chances of survival. Starting a rehabilitation program as soon as possible after a stroke increases your chances of recovering some of the abilities you lost.
Initial treatment for stroke
Initial treatment for a stroke varies depending on whether it's caused by a blood clot (ischemic) or bleeding in the brain (hemorrhagic). Before starting treatment, your doctor will use a computed tomography (CT) scan of your head and possibly magnetic resonance imaging (MRI) to diagnose the type of stroke you've had. Further tests may be done to determine the location of the clot or bleeding and to assess the amount of brain damage. While treatment options are being determined, your blood pressure and breathing ability will be closely monitored, and you may receive oxygen.
Initial treatment focuses on restoring blood flow for an ischemic stroke or controlling bleeding for a hemorrhagic stroke. As with a heart attack, permanent damage from a stroke often occurs within the first few hours. The quicker you receive treatment, the less damage will occur.
Ischemic stroke
Emergency treatment for an ischemic stroke depends on the location and cause of the clot. Measures will be taken to stabilize your vital signs, including giving you medicines.
- If your stroke is diagnosed within 3 hours of the start of symptoms, you may be given a clot-dissolving medicine called tissue plasminogen activator (t-PA), which can increase your chances of survival and recovery. However, t-PA is not safe for everyone. If you have had a hemorrhagic stroke, use of t-PA would be life-threatening. Your eligibility for t-PA will be quickly assessed in the emergency room.
- You may also receive aspirin or aspirin combined with another antiplatelet medicine. However, aspirin is not recommended within 24 hours of treatment with t-PA.1 Other medicines may be given to control blood sugar levels, fever, and seizures. In general, high blood pressure won't be treated immediately unless systolic pressure is over 220 millimeters of mercury (mm Hg) and diastolic is more than 120 mm Hg (220/120, which is also called 220 over 120).1
Hemorrhagic stroke
Initial treatment for hemorrhagic stroke is difficult. Efforts are made to control bleeding, reduce pressure in the brain, and stabilize vital signs, especially blood pressure.
- There are few medicines available to treat hemorrhagic stroke. In some cases, medicines may be given to control blood pressure, brain swelling, blood sugar levels, fever, and seizures. You will be closely monitored for signs of increased pressure on the brain, such as restlessness, confusion, difficulty following commands, and headache. Other measures will be taken to keep you from straining from excessive coughing, vomiting, or lifting, or straining to pass stool or change position.
- Surgery generally is not used to control mild to moderate bleeding resulting from a hemorrhagic stroke. However, if a large amount of bleeding has occurred and the person is rapidly getting worse, surgery may be needed to remove the blood that has built up inside the brain and to lower pressure inside the head.
- If the bleeding is due to a ruptured brain aneurysm, surgery to repair the aneurysm may be done. Repair may include:
Whether these surgeries can be done depends on the location of the aneurysm and your condition following the stroke.
- Using a metal clip to clamp off the aneurysm to prevent renewed bleeding.
- Endovascular coil embolization, a procedure which involves inserting a small coil into the aneurysm to block it off.
Ongoing treatment
After emergency treatment for stroke, and when your condition has stabilized, treatment focuses on rehabilitation and preventing another stroke. It will be important to control your risk factors for stroke, such as high blood pressure, atrial fibrillation, high cholesterol, or diabetes.
Your doctor will probably want you to take aspirin or other antiplatelet medicines. If you had an ischemic stroke
(caused by a blood clot), you may need to take anticoagulants to prevent another stroke. You may also need to take medicines, such as statins, to lower high cholesterol or medicines to control your blood pressure. Medicines to lower high blood pressure include:
- Angiotensin-converting enzyme (ACE) inhibitors.
- Angiotensin II receptor blockers (ARBs).
- Beta-blockers.
- Diuretics.
- Calcium channel blockers.
Your doctor may also recommend carotid endarterectomy surgery to remove plaque buildup in the carotid arteries. For more information on this decision, see:
A relatively new procedure called carotid artery stenting is another option for some people who are at high risk of stroke. This procedure is much like coronary angioplasty, which is commonly used to open blocked arteries in the heart. During this procedure, a doctor inserts a metal tube called a stent inside your carotid artery to increase blood flow in areas blocked by plaque. The doctor may use a stent that is coated with medicine to help prevent future blockage.
Early aggressive rehabilitation may allow you to regain some normal functioning. Your rehabilitation will be based on the physical abilities that were lost, your general health before the stroke, and your ability to participate. Rehabilitation begins with helping you resume activities of daily living, such as eating, bathing, and dressing. For more information, see the topic Stroke Rehabilitation.
Changes in lifestyle may also be an important part of your ongoing treatment to reduce your risk of having another stroke. It will be important for you to exercise to the extent possible, eat a balanced diet, and quit smoking, if you smoke. Your doctor may suggest that you follow the Dietary Approaches to Stop Hypertension (DASH) diet if you have high blood pressure. If you have high cholesterol, you may need to follow the Therapeutic Lifestyle Changes (TLC) diet. These eating plans stress a diet that is low in fat (especially saturated fat) and contains more whole grains, fruits, vegetables, and low-fat dairy products.
If you take warfarin (such as Coumadin), see:
Treatment if the condition gets worse
Depression is common in people who have had a stroke. You may need medicines for depression and pain to help you cope.
If you get worse, it may be necessary for your loved one to move you to a care facility that can meet your needs, especially if your caregiver has his or her own health problems that make it difficult to properly care for you. It is common for caregivers to neglect their own health when they are caring for a loved one who has had a stroke. If your caregiver's health declines, the risk of injury to you and your caregiver may increase. For more information, see:
Palliative care
As your condition gets worse, you may want to think about palliative care. Palliative care is a type of care for people who have illnesses that do not go away and often get worse over time. It is different than care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.
Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.
If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.
For more information, see the topic Palliative Care.
End-of-life issues
Although stroke rehabilitation is increasingly successful at prolonging life, a stroke can be a disabling or fatal condition. People who have had a stroke may consider discussing health care and other legal issues that may arise near the end of life. Many people find it helpful and comforting to state their health care choices in writing with an advance directive while they are still able to make and communicate these decisions.
Advance directives can include the ability to refuse treatment in specific situations. The three main types of advance directives are:
- Do not resuscitate orders (DNRs).
- Living wills.
- Durable power of attorney for health care (DPA).
Do not resuscitate orders (DNRs) typically request that no extraordinary measures be used to save your life. Extraordinary measures include cardiopulmonary resuscitation (CPR), use of an electrical shock to stop a fatal abnormal heart rhythm (defibrillation), intubation (placement of a breathing tube down your throat), or the use of lifesaving drugs. People with DNR orders will only be given drugs that make them more comfortable in their last moments. You may request that you be identified as a DNR if you wish to avoid expensive, uncomfortable, or invasive medical care that probably will not improve your long-term prognosis and may increase your discomfort.
Living wills are written documents that contain specific instructions about the type of treatment you wish to receive at the end of your life. Unlike a DNR order, which applies to a specific moment when you require resuscitation, living wills apply to more general situations.
One of two broad conditions must be triggered:
- You have slipped into a permanent coma.
- You are unable to make decisions about the type of care you wish to receive.
Whenever two doctors agree that one of these conditions has been met, your doctor will deliver care based on the directions in your living will. Usually, living wills instruct doctors not to prescribe any treatment that would unnecessarily lengthen the process of dying.
A durable power of attorney (DPA) for health care document appoints a specific person (surrogate) to make decisions about your care if you are incapacitated. (A DPA can also be called the appointment of a health care agent or health care surrogate.) Unlike DNRs or living wills, DPAs allow an independent observer of your choice to assess your current health condition and to speak to your doctor before any decision about your care is made. DNRs and living wills do not allow for this type of dialogue, because your treatment is based on choices you made without knowing the exact nature of your condition.
For more information about these options, see the topic Care at the End of Life.
What To Think About
People who are unconscious immediately after a stroke have the least chance of a full recovery. Some people may have a poor recovery because of the location and extent of brain damage. However, many people do successfully recover.
It is not possible to predict precisely how much physical ability you will regain. The more ability you retain immediately after a stroke, the more independent you are likely to be when you are discharged from the hospital. After a stroke:
- People usually show the greatest progress in being able to walk during the first 6 weeks. Most recovery occurs within the first 3 months, but you may continue to improve slowly over the next few years.
- Speech, balance, and skills needed for day-to-day living return more slowly and may continue to improve for up to a year.
- About half of the people who suffer a stroke have problems with coordination, communication, judgment, or behavior that affect their work and personal relationships.3
After a person has had a stroke, family members can learn ways to provide rehabilitation support and encouragement to their loved one.
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| Author: | Robin Parks, MS | Last Updated: March 6, 2007 |
| Medical Review: | Anne C. Poinier, MD - Internal Medicine Richard D. Zorowitz, MD - Physical Medicine and Rehabilitation | |
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