As indicated above, stabilization is the most important step such as giving oxygen by mask, starting mannitol to minimize swelling of the brain around the stroke area.
In the unconscious patient an airway has to be maintained and aspiration precautions have to be in place.
Intensive one-on one nursing is required. In this type of stroke there is either a closure of a narrowed blood vessel or else an embolus from somewhere else that got caught in a brain blood vessel, so that there is a sudden closure of it. In about half of the patients there might be an indication to attempt to dissolve this clot through the use of an infusion of TPA as mentioned above. Ref. 1 explains that this can be safely given 3 to 7 hours after the stroke started without fear of ending up with a worse scenario, a hemorrhagic stroke. A German study (Ref. 2) has shown that if thrombolytic therapy is done in strict accordance with the American Heart Association guidelines, a good outcome is achieved with ischemic stroke patients. When rechecked one year after the stroke, complete or almost complete neurological recovery was achieved in 41%.
Only 6.6% had another stroke, 3.3% had transient ischemic attacks and 4% died from other causes than a stroke. The authors felt encouraged to continue using thrombolytic therapy for selected ischemic stroke patients. Another study from England (Ref. 3) describes that 49% of severely disabled stroke patients aged 47 to 60 can learn how to walk again, even 3 to 11 months following the stroke. This had a profound positive effect on them and their families as they maintained a degree of independence. This in turn affected further speech- and other neurorehabilitation positively with better than average results.
In selected patients intravenous intra-arterial tissue plasminogen activator (TPA) treatment is approved by the FDA. Alteplase has been approved for this purpose, is given for up to 6 hours following the onset of an ischemic stroke and leads to a successful reopening of the blood vessel in 60% of patients. The down side is that there is a risk of developing hemorrhagic strokes in 5% of treated patients. Newer research has shown that tenecteplase, which is a genetically engineered mutant tissue plasminogen activator, has a better response rate than alteplase.
Interventional therapies for clot removal have also been developed. If there is a proven clot in one of the brain vessels, the Merci clot retrieval system
is approved by the FDA for up to 8 hours following the onset of a stroke. The use of the Solitaire FR revascularization device is demonstrated in this YouTube.
Another system to remove clots is the Penumbra system. See this YouTube presentation . Another area where surgery can be of benefit is a carotid endarterectomy when there is a significant narrowing of the carotid artery near the bifurcation. Ref. 13 points to a study where patients were followed up after carotid endarterectomy; at the two year point of follow-up the stroke risk has been reduced to 9% in the surgical group compared to a control group that was only on aspirin prevention and developed strokes in 26%.
In the beginning of treatment the patient is cared for in a stroke unit or in an intensive care unit. When the patient is stable, the patient is transferred to a hospital that specializes in stroke care.
When a person has a completed stroke, it is important to concentrate on rehabilitation, which includes physical therapy, speech therapy and occupational therapy. Some people may need counselling as the change from before the stroke to after can be so overwhelming that it takes some effort to readjust to the new situation. Counselling will help to reestablish a new balance.
Stem cells for stroke treatment
The newest approach to treating severe stroke patients comes from London, England. These clinical investigators have succeeded in separating stem cells from the bone marrow of stroke victims with severe strokes as they reported in their August 2014 study. The key is to offer this stem cell therapy early (within the first 7 days after the stroke). See details under this link.
1. KH Lee et al. Arch Neurol 2000 Jul 57(7): 1000-1008.
2. S Schmulling et al. Stroke 2000 Jul 31(7): 1552-1554.
3. D Jackson et al. Clin Rehabil 2000 Oct 14(5): 538-547.
4. ML Hackett et al. Neurology 2000 Sep 12; 55 (5): 658-662.
5. K Tsutsumi et al. J Neurosurg 2000 Oct 93( 4): 550-553.
6. IS Spetzler Surg Neurol 2000 Jun 53(6): 530-540.
7. G Lot et al. Acta Neurochir (Wien) 1999; 141(6): 557-562.
8. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 174.
9. Noble: Textbook of Primary Care Medicine, 3rd ed.,2001, Mosby Inc.
10. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.
11. Rakel: Conn’s Current Therapy 2004, 56th ed., Copyright 2004 Elsevier
12. Ferri: Ferri’s Clinical Advisor 2013, 1st ed. Copyright 2012 Mosby, An Imprint of Elsevier. Acute Ischemic Stroke, Hemorrhagic Stroke and Subarachnoid hemorrhage.
13. Cleveland Clinic: Current Clinical Medicine, 2nd ed. Copyright 2010 Saunders, An Imprint of Elsevier. Section 10. Neurology. Stroke treatment.
14. http://www.ncbi.nlm.nih.gov/pubmed/21911621 : Zhang Y, Tuomilehto J, Jousilahti P, Wang Y, Antikainen R, Hu G. Lifestyle factors on the risks of ischemic and hemorrhagic stroke. Arch Intern Med. 2011 Nov 14;171(20):1811-8. Epub 2011 Sep 12.
15. David Perlmutter, MD: “Grain Brain. The Surprising Truth About Wheat, Carbs, And Sugar-Your Brain’s Silent Killers.” Little, Brown and Company, New York, 2013.