Truly, as indicated above, stabilization is the most important step such as giving oxygen by mask and starting mannitol to minimize swelling of the brain around the stroke area.
Especially, in the unconscious patient the physician needs to maintain an airway and aspiration precautions have to be in place.
Intensive care of acute stroke patient
Certainly, intensive one-on one nursing is required. Surely, in this type of stroke there is either a closure of a narrowed blood vessel or else an embolus from somewhere else 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. In the meantime, 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%.
Long-term follow-up of stroke patients
To demonstrate, 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. Notably, 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.
The FDA approved intravenous intra-arterial tissue plasminogen activator (TPA) treatment in selected patients. The FDA approved alteplase for this purpose. Indeed, the physician can give this for up to 6 hours following the onset of an ischemic stroke; it leads to a successful reopening of the blood vessel in 60% of patients. On the contrary, the down side is that there is a risk of developing hemorrhagic strokes in 5% of treated patients. It is important to realize that newer research has shown that tenecteplase, a genetically engineered mutant tissue plasminogen activator, has a better response rate than alteplase.
Another key point is that interventional therapies for clot removal were developed. If there is a proven clot in one of the brain vessels, the FDA approved the Merci clot retrieval system 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 followed patients 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 physician takes care of the patient in a stroke unit or in an intensive care unit. When the patient is stable, hospital staff transfers the patient 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.
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