Stroke

The management of stroke has two distinct phases : immediate treatment, and longterm management.

Treatment in the immediate situation is aimed at:

• Resuscitation
• Diagnosing the type/cause of the stroke
• Starting the appropriate treatment

Resuscitation follows the standard pattern of attending to Airways, Breathing, Circulation etc. Once stable, the next urgent step is to determine what type of stroke has occurred, because the treatment differs vastly.

The recognized types of stroke are:

1. Ischaemic: this may be due to:
   (a) cerebral artery thrombosis (clots formed in the artery)
   (b) cerebral embolism ( a clot or piece of atheroma from somewhere else in the body lodges in the cerebral artery)

   85% are due to clots of some form, and these qualify for special treatment.

2. Haemhorragic: this means a bleed into tissues, usually due to a ruptured vessel (c) Intracerebral bleed ( into the brain tissue) (d) Subarachnoid bleed ( into the membranes around the brain)
   

It is also important to localise where in the brain the stoke has happened, and to assess the severity : both of these factors are relevant to the management and outcome of the stroke. The level of consciousness and severity are assessed clinically according to accepted criteria, eg on the Glasgow scale.

Immediate treatment
The most important factor here is time: any suspected stroke victim must receive emergency attention, preferably at an Emergency Casualty where they can be admitted.

Speed is necessary because clot-dissolving treatment will be successful only if used within 3 hours of the onset of symptoms. Also, reversible risk factors, such as extreme hypertension, if identified and treated early enough, can limit the extent of damage to the brain tissues.

Basic resuscitation, including attention to airways, fluid requirements etc must be given. In some cases, it may be necessary to insert a breathing tube, and use a ventilator. Once the patient is stable, appropriate investigation is begun to determine the type and cause of the stroke.

Most important is a non-contrast CT scan : this will identify whether or not the stroke is due to a bleed. There are other more sophisticated techniques available eg MRI scans, or even cerebral angiograms, and the choice of technique will be made by the specialist involved.

Further treatment will depend on the cause : eg if there is a bleed in the membranes or a ruptured brain artery (aneurysm) surgery may be needed. Whilst treatment is begun, bedridden patients are given physiotherapy to prevent lung complications and muscle contractures, and are also turned regularly to prevent bedsores and infections.

Specialised treatment
Once the site, severity and underlying contributing causes have been identified, specialised treatment aimed at dealing with these can be started. Any identified risk factors must be dealt with.

If the patient has a non-haemhorragic stroke and meets certain criteria, s/he may be a candidate for thrombolytic (clot-busting) therapy. Usually about 10% of patients will qualify for this treatment, which is administered only by specialists, preferably in a stroke unit, because of the significant risks involved.

Ischaemic stroke is most commonly due to the blocking off of a cerebral artery by a clot from elsewhere, so the source of this must be found and dealt with.

Cardiac problems
Many heart problems are possible sources of clots leading to stroke, and these must be identified and treated. A very useful investigation is an echocardiogram, which is a form of ultrasound. This can be done externally, with a probe placed on the chest wall, or internally, using a Trans Esophageal Echo (TEE).

The TEE consists of a specialised tiny probe which is inserted into the patient’s esophagus or stomach, much like “swallowing the camera” for a gastroscopy. This probe then lies directly behind the heart, and provides very clear and accurate information about heart function, as well as clear pictures of the chambers and valves.

Heart problems associated with stroke include:

• Valve abnormalities
• Endocarditis – infection of the abnormal valve
• Rhythm disturbances - often associated with valve lesions, and predisposing to the formation of clots within the heart.

Heart problems associated with stroke require specialist treatment, and should thus be managed by a cardiologist. Eg. some rhythm disturbances will require anticoagulation with Warfarin, but this may pose a great risk (of brain bleeding) to a patient who has already had a stroke.

Carotid artery disease
Narrowing of the neck arteries (carotids) due to atheroma is a common cause of stroke. One or both arteries may be affected, and the narrowing may be partial or complete. Often, the patient’s symptoms will suggest carotid disease as a cause of the stroke, or s/he may have had previous Transient Ischeamic attacks (TIAs).

A simple ultrasound of the neck arteries will make the diagnosis, whilst an angiogram can provide incontrovertible proof of the degree of obstruction. Treatment of this condition is aimed at opening the narrowing and keeping it open, to restore proper blood flow to the brain.

Surgery can be done to widen the narrowed section : this is a risky procedure, and should only be done by experienced vascular surgeons.

An alternative nowadays is that of carotid Stenting. In this procedure, a catheter is threaded into the narrow section of the artery, and, when in position, a balloon is inflated to stretch open the narrowed part. Once dilated to normal size, a stent (a dilatable metal mesh tube) is inserted to keep the artery open.

This is the same procedure used for stents in the heart arteries. This procedure also has its risks, and is done only by cardiologists in a specially equipped catheterisation theatre.

Heamorrhagic stroke
The commonest cause for a bleed within the brain (Intracerebral) is uncontrolled hypertension: the obvious treatment is thus to lower and keep under control,the blood pressure.

Bleeding into the membranes around the brain (Subarachnoid bleeds) are usually due to rupture of small aneurysms (little blowouts of the artery wall, like a weak car tyre) near the base of the brain, or to bleeds from abnormal vessels on the surface of the brain’s membrane.

Once identified, surgery may be needed to stop the bleed and prevent recurrences. Investigations may show other abnormal arteries also needing to be sealed off before they rupture. Some success has been had with catheter embolisation, in which a catheter is threaded into the artery concerned, and the artery is then sealed from within – almost like glueing it shut from inside.

Both surgery and catheter ablation are risky procedures, and only undertaken by experienced specialists at well-equiped centres.

Other factors
Other unusual causes of stroke, such as vasculitis and neurofibromatosis will need managing, but may be less successful. Anticoagulants such as Warfarin are only of use when there is a clear indication, eg atrial fibrillation associated with stroke.

Modifiable risk factors must be dealt with, and carefully controlled:
If risk factors are not treated, many patients with an established stroke will have a second, usually fatal, stroke within a few months of the first one.

The important conditions which can be treated are:

• TIAs
• Hypertension
• Diabetes
• Cardiovascular disease of all types
• Hypercholesterolaemia
• Heart rhythm disturbances
• Smoking
• Use of oral contraceptives
• Obesity
• Sickle cell anaemia and migraines

Rehabilitation
Rehabilitation has two aims:

1. Restoring function to as near normal as possible (ie to pre-stroke abilities)


2. Preventing further strokes.

Restoring function begins immediately after admission at the time of the stroke. Physiotherapy, including passive exercise, is used to keep muscles supple. Also, as soon as the patient can cooperate, gentle exercise is begun to improve residual function, and possibly learn new techniques to make up for lost abilities.

Occupational and speech therapy are important, and should also be started as soon as possible. Recovery can be a very slow process, and many patients never return to their pre-stroke levels. Patients and their families must therefore be fully informed about the prospects in a realistic way.

An important aspect of rehabilitation is the psychological impact on the patient and the family. Apart from the expected, and normal, reaction to becoming suddenly physically disabled to some degree, stroke victims may be left with a range of emotional problems such as : uncontrollable crying, severe depression, inappropriate responses, lack of awareness of their physical disabilities, or even complete lack of awareness of the half of their body affected by the stroke.

This can be a management problem for caregivers, who are usually family members, so they have a double burden. – physical and psychological care. Support groups for stroke victims and their care-givers can be of value here. Community resources are important, and a social worker may be helpful in organizing access to these.

An often forgotten aspect of stroke management is the fact that some conditions or risk factors have a familial tendancy. If such factors are identified – eg hypercholesterolaemia – other family members should be informed, and encouraged to go for testing.

Preventing further strokes is accomplished by careful attention to underlying risk factors, as outlined in the section on treatment.

Reviewed by Dr A.G. Hall (B.Soc.Sc.(SW), MB,Ch.B) Last updated: 2008/02/08

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